CaliforniaChoice

Understanding Your Rx Choices

IMPORTANT: Benefit information applies only to CaliforniaChoice^® members whose
group enrolled or renewed 1/1/12 or after. The Evidence of Coverage (EOC) and plan contract should be consulted for a detailed description or coverage benefits and limitations. Please call the health plan directly to confirm the accuracy of the information provided. Health plan phone numbers appear on "Listing of Plans" page.

CaliforniaChoice Rx Benefits

Standard HMO Rx Benefits: CaliforniaChoice features several different HMO benefit levels. Each HMO offers copay benefits for prescriptions. Each health plan maintains a different formulary listing of prescription drugs that they will cover. Our Formulary Information is provided to assist you in looking up some of the more commonly prescribed drugs. Standard HMO prescription benefits for brand and generic drugs for employees of
groups enrolling or renewing on or after 1/1/12:

Standard HMO Rx Benefits
Benefit Plan	Participating Health Plans	Generic^*	*Formulary Brand^{ †}**
CalChoice^® HMO 15¹	All Carriers	$10	$20
CalChoice HMO 25¹	Anthem Blue Cross, Health Net, Western Health Advantage, Sharp	$15	$100 Ded - $30
CalChoice HMO 25¹	Kaiser Permanente	$10	$25
CalChoice HMO 25 Value	Anthem Blue Cross	$15	$200 Ded- $30
CalChoice HMO 25 Value	Health Net	$15	$100 Ded - $30
Elect Open Access 25 Plus	Health Net	$15	$100 Ded - $30
Elect Open Access	Health Net	$15	$100 Ded - $30
Salud HMO y mas (Salud Network Only)	Health Net	$15	$25
CalChoice HMO 30¹	Anthem Blue Cross, Health Net, Western Health Advantage, Sharp	$15	$150 Ded - $30
CalChoice HMO 30¹	Kaiser Permanente	$15	$30
CalChoice HMO 30 Value	Health Net	$20	$200 Ded - $30
CalChoice HMO 40¹	Anthem Blue Cross, Health Net, Western Health Advantage, Sharp	$20	$200 Ded - $30
CalChoice HMO 40¹	Kaiser Permanente	$15	$30
CalChoice HMO 40 Value	Anthem Blue Cross	$15	$250 Ded - $30
CalChoice HMO 40 Value	Health Net	$20	$200 Ded - $30
CalChoice HMO 40 Value	Western Health Advantage	$20	$250 Ded - $30
Elect Open Access 40 Plus	Health Net	$20	$250 ded - $30
Non-Formulary Brand Drugs - See below for specific information
Mail Order -See below for plan specific information
^*Per 30 day supply or 100 unit dose, HCSP is allowed to use a generic for formulary brand
¹ Copayment shall be the designated amount, or 50% of the provider's contracted rate, whichver is less
^†All brand drugs may be subject to pre-authorization

Glossary of Terms

Standard PPO Rx Benefits: CaliforniaChoice features 8 different Anthem Blue Cross PPO benefit levels. The following PPO prescription benefits are available for employees of groups enrolling or renewing on or after 1/1/12. PLEASE NOTE: Prescription drugs from any retail pharmacy are covered (no mail order). Both the plan deductible and the coinsurance (member pays 20%) apply. The chart below outlines the Rx benefits for the 8 PPO benefit levels:

	Standard PPO Rx Benefits
	Prescription Costs
Outpatient Prescription Drugs¹ (Not subject to deductible, includes oral contraceptives)	Participating Pharmacy		Non-Participating Pharmacy
	PPO 750/750 GenRx/1000/1000 GenRx/3000/4000*	Lumenos HSA 1800²/2500²	PPO 750/750 GenRx/1000/1000 GenRx/3000/4000*	Lumenose HSA 1800²/2500²
	Prescription Costs		Up to 30 day supply
Generic Drugs	$15	$15	50% of drug limited fee schedule when filled in California	50% of drug limited fee schedule when filled in California
Formulary Brand Drugs †	PPO 750/1000/3000/4000 - $30 PPO 750 GenRx/PPO 1000 GenRx - Not Covered	$30	PPO 750/1000/3000/4000 - 50% of drug limited fee schedule when filled in California PPO 750 GenRx/PPO 1000 GenRx - Not Covered	50% of drug limited fee schedule when filled in California
Non-Formulary Brand Drugs †	PPO 750/1000/3000/4000 - $50 PPO 750 GenRx/PPO 1000 GenRx - Not Covered	$50	PPO 750/1000/3000/4000 - 50% of drug limited fee schedule when filled in California PPO 750 GenRx/PPO 1000 GenRx - Not Covered	50% of drug limited fee schedule when filled in California
* A separate $150 per individual deductible applies to formulary and non-formulary brand drugs.
** A separate $200 per individual deductible applies to formulary and non-formulary brand drugs.
*** A separate $250 per individual deductible applies to formulary and non-formulary brand drugs.
¹ Copayments for services do NOT count toward the copayment maximum and continue to be charged after it is reached.
² Prescription drugs are subject ot the medical deductible. The submission of a prescription drug claim is required for reimbursement for out-of-network pharmacies.
† All brand drugs may be subject to pre-authorization

Plan Specific Non-Formulary & Mail Order Rx Benefits
An Rx Formulary is an approved list of drugs which has been reviewed for safety, quality, effectiveness and cost by the physicians and pharmacists on a health plan's Rx review panel. A non-formulary drug refers to a drug which is not included on the approved Rx list for a health plan. Each health plan has their own formulary or approved drug list, which is reviewed on a regular basis.

Experimental, non-FDA approved, not medically necessary and over-the-counter drugs are not covered under the Non-Formulary benefit of any health plan. As always, please confirm all information directly with the health plan prior to making an enrollment decision or accessing coverage.

Health Plan

Non-Formulary
Rx Benefit

Mail Order
Rx Benefit

Anthem Blue Cross PPO

PPO 750
$50 non-formulary copay applies at network participating pharmacies.
50% of drug limited fee schedule when filled in California for non-participating pharmacies. A separate $150 per individual deductible applies to formulary and non-formulary brand drugs

PPO 750
90 day supply:
	Generic	$15
	Formulary Brand	$60
	Non-Formulary Brand	$100
A separate $150 per individual deductible applies to formulary and non-formulary brand drugs

PPO 1000
$50 non-formulary copay applies at network participating pharmacies.
50% of drug limited fee schedule when filled in California for non-participating pharmacies.
A separate $200 per individual deductible applies to formulary and non-formulary brand drugs

PPO 1000
90 day supply:
	Generic	$15
	formulary brand	$60
	Non-Formulary Brand	$100
A separate $200 per individual deductible applies to formulary and non-formulary brand drugs

PPO 3000 & PPO 4000
$50 non-formulary copay applies at network participating pharmacies.
50% of drug limited fee schedule when filled in California for non-participating pharmacies. A separate $250 per individual deductible applies to formulary and non-formulary brand drugs

PPO 3000 & PPO 4000
90 day supply:
	Generic	$15
	Formulary Brand	$60
	Non-Formulary Brand	$100
A separate $250 per individual deductible applies to formulary and non-formulary brand drugs.

PPO 750 GenRx & PPO 1000 GenRx
No non-formulary benefit

PPO 750 GenRx & PPO 1000 GenRx
90 day supply:
	Generic	$15
	Brand	Not Covered
	Non-Formulary Brand	Not Covered

Lumenos HSA 1800/2500
$50 non-formulary copay applies at network participating pharmacies.
50% of drug limited fee schedule when filled in California for non-participating pharmacies.

Lumenos HSA 1800/2500
90 day supply:
	Generic	$15¹
	formulary brand	$60¹
	Non-Formulary Brand	$100¹

Anthem Blue Cross HMO

CC15: $40
CC25: $50
CC25 Value: $50
CC30: $50
CC40: $50
CC40 Value: $50

90 days supply:
CC15:
	Generic	$10
	Brand	$40
	Non-Formulary	$80
CC25:
	Generic	$30
	Brand	$100 Deductible - $60
	Non-Formulary	$100 Deductible - $100
CC 25 Value:
	Generic	$15
	Brand	$200 Deductible - $60
	Non-Formulary	$200 Deductible - $100
CC30:
	Generic	$15
	Brand	$150 Deductible - $60
	Non-Formulary	$150 Deductible - $100
CC40:
	Generic	$20
	Brand	$200 Deductible - $60
	Non-Formulary	$200 Deductible - $100
CC40 Value
	Generic	$15
	Brand	$250 Deductible - $60
	Non-Formulary	$250 Deductible - $100

Kaiser Permanente

If deemed medically necessary by Kaiser Permanente physician

Up to a 100 day supply:
CC15:
	Generic	$20
	Brand	$40
CC25:
	Generic	$20
	Brand	$50
CC30:
	Generic	$30
	Brand	$60
CC40:
	Generic	$30
	Brand	$60
No Mail-Order benefits for non-formulary

Health Net

$50 non-formulary copay applies
Prior authorization may be required for certain medications

90 days supply:
CC15:
	Generic	$20
	Brand	$40
	Non-Formulary	$100
CC25:
	Generic	$30
	Brand	$100 Deductible - $60
	Non-Formulary	$100 Deductible - $100
CC25 Value:
	Generic	$30
	Brand	$100 Deductible - $60
	Non-Formulary	$100 Deductible - $100
Elect Open Access 25 Plus:
	Generic	$30
	Brand	$100 Deductible - $60
	Non-Formulary	$100 Deductible - $100
Elect Open Access:
	Generic	$30
	Brand	$100 Deductible - $60
	Non-Formulary	$100 Deductible - $100
Salud HMO y mas (Salud Network Only)
	Generic	$30
	Brand	$50
	Non-Formulary	$100
CC30:
	Generic	$30
	Brand	$150 Deductible - $60
	Non-Formulary	$150 Deductible - $100
CC30 Value:
	Generic	$40
	Brand	$200 Deductible - $60
	Non-Formulary	$200 Deductible - $100
CC40:
	Generic	$40
	Brand	$200 Deductible - $60
	Non-Formulary	$200 Deductible - $100
CC 40 Value:
	Generic	$40
	Brand	$200 Deductible - $60
	Non-Formulary	$200 Deductible - $100
Elect Open Access 40 Plus:
	Generic	$40
	Brand	$200 Deductible - $60
	Non-Formulary	$200 Deductible - $100

Sharp Health Plan

Double the formulary brand copay
Prior authorization maybe required, see "Standard CaliforniaChoice Rx Benefits" above

90 days supply:
CC15:
	Generic	$20
	Brand	$40
	Non-Formulary	$80
CC25:
	Generic	$30
	Brand	$100 Deductible - $60
	Non-Formulary	$100 Deductible - $120
CC30:
	Generic	$30
	Brand	$150 Deductible - $60
	Non-Formulary	$150 Deductible - $120
CC40:
	Generic	$40
	Brand	$200 Deductible - $60
	Non-Formulary	$200 Deductible - $120

Western Health Advantage

CC10:	$35
CC25:	$100 Ded - $50
CC30:	$150 Ded - $50
CC40:	$200 Ded - $50
CC40 Value:	$250 Ded - $50

90 days supply:
CC15:
	Generic	$20
	Brand	$40
	Non-Formulary	$70
CC25:
	Generic	$30
	Brand	$100 Deductible - $60
	Non-Formulary	$100 Deductible - $100
CC30:
	Generic	$30
	Brand	$150 Deductible - $60
	Non-Formulary	$150 Deductible - $100
CC 40:
	Generic	$40
	Brand	$200 Deductible - $60
	Non-Formulary	$200 Deductible - $100
CC40 Value:
	Generic	$40
	Brand	$250 Deductible - $60
	Non-Formulary	$250 Deductible - $100

¹Prescription drugs are subject to the medical deductible. The submission of a prescription drug claim is required for reimbursement for out-of-network pharmacies

GLOSSARY OF TERMS

Coinsurance - The arrangement by which both the insured and the insurer share, in a specific ratio, the covered losses under a policy. (i.e. An insurer pays 80%, while patient pays 20%).

Copay/Copayment - A designated dollar amount that an insured must pay to a contracted provider or hospital for eligible service rendered instead of submitting claims or paying a co-insurance percentage. It usually applies to HMO or PPO plans.

Deductible - A flat amount the insured must pay before the insurance company will make any benefit payments under a policy.

Evidence or Explanation of Coverage (EOC) or Explanation of Benefits (EOB) - A booklet provided by the carrier to the insured summarizing benefits under an insurance plan.

Formulary - A list of approved prescription drugs; a list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and therapeutics committee. In HMO's, physicians are often required to prescribe from the formulary.

HMO (Health Maintenance Organization) - An institution that offers prepaid medical care to subscribing members. For a set fee, participants receive all their health care from the HMO's own facilities and doctors, or from independents contracted by the HMO. No benefits are provided if the insured goes out of the network. The HMO may be sponsored by the government, employer, school, hospital, credit union, insurance company or hospital-medical plans.

Medically Necessary - Medical Necessity - Services or supplies which meet the following tests: They are appropriate and necessary for the symptoms, diagnosis, or treatment of the medical condition; They are provided for the diagnosis or direct care and treatment of the medical condition; They meet the standards of good medical practice within the medical community in the service area; They are not primarily for the convenience of the plan member or plan provider; and They are the most appropriate level or supply of service which can safely be provided.

PPO (Preferred Provider Organization) - Similar to an indemnity plan, but with a network of physicians, the insured is allowed to choose a doctor or hospital from a preferred provider list, which are doctors and hospitals who have agreed to group pricing and will follow the procedures and policies of the plan, or any other non-network provider. Lower fees are arranged with the network or providers, giving a financial incentive to stay within the network. A higher cost or co-pay is generally required for medical services obtained from outside sources.

Prior Authorization - A formal process requiring a provider to obtain approval to provide particular services or procedures before they are done. This is usually required for non-emergency services that are expensive or likely to be abused or overused. A managed care organization will identify those services and procedures that require prior authorization.

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