Benefits Description Table

Outpatient Services Benefits

Pediatric/Well- Child Care

including periodic office visits, diagnostic services, immunizations, and the testing and treatment of phenylketonuria (PKU).

Copayment

$0 Copayment

Adult Periodic Health Examinations

including immunizations, diagnostic services, Pap smears, Prostate Specific Antigen (PSA) tests, and all generally medically accepted cancer screening tests.

org Preventive Services Without CostSharing for Specified Services:

rated A or B by the US Preventive Services Task Force, recommended immunizations, preventive care for children and adolescents, additional preventive care and screenings for women. Physical Examinations for Routine Care including diagnostic services and the testing and treatment of phenylketonuria (PKU). Vision and hearing screening examinations to determine the need for vision or hearing correction as provided by your PCP. Well-Woman Examinations including diagnostic services, a pelvic and breast examination, and Pap smear. Annual cervical screening includes PAP tests, a human papillomavirus screening that is approved by the federal Food and Drug Administration, and the option of any cervical cancer screen test approved by the FDA (i.e.

Mammography Screening for Routine Care including radiological procedures and interpretation of the results. $0 Copayment

$0 Copayment

$0 Copayment

$0 Copayment

How to Obtain Covered Services

Call to schedule an appointment with your child’s VHP Network PCP. Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan.

liquid based prep test).

Call to schedule an appointment with your VHP Network PCP. Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan.

org Limitations & Exclusions

The age, health status, and medical needs of the child determine the frequency of these examinations.

Frequency is based on Medical Necessity, age, and demographic characteristics.

Call to schedule an appointment with your VHP Network PCP. Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan.

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Call to schedule an appointment with your VHP Network Provider. Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan.

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The age, health status, and medical needs of the Member determine the frequency of these examinations.

You may self-refer to an OB/ GYN within the VHP Network for a well-woman examination once every Calendar Year.

Your Plan Physician will order when Medically Necessary. Frequency is based on Medical Necessity, age, and demographic characteristics.

Coverage for mammography screening is limited to once every Calendar Year. Diagnostic mammograms will be covered under the “Diagnostic Laboratory Services” benefit.

Outpatient Services, continued Benefits Copayment

Allergy Testing and Treatment

including allergy serum and injection services. $0 Copayment

Dermatology Services for Routine Care $0 Copayment

Diagnostic Laboratory Services

including outpatient diagnostic

Exclusions

written referral from your PCP and Prior Authorization from VHP. Services from a VHP network dermatologist. X-ray, nuclear medicine, and laboratory services (including tests performed on an outpatient basis at your Plan Facility or Hospital).

HIV, AIDS, or Other Infectious Diseases Testing and Treatment

including HIV testing regardless if related to a primary diagnoses.

Immunizations and Injections

includingflu shots, tetanus and diphtheria boosters, AIDS vaccines, Hepatitis A and B vaccines, pneumococcal pneumonia vaccines, and immunizations as required by Immigration and Naturalization Services Department (INS), or as recommended by the US Preventive Services Task Force or as recommended from the Advisory Committee on Immunization Practices of the Centers for Disease Control Travel Immunizations as recommended by the U.S. Preventive Services Task Force. $0 Copayment

$0 Copayment

$0 Copayment

$0 Copayment

How to Obtain Covered Services

Your PCP will refer you to a Plan Specialist. To obtain care you must receive a

Call your Plan network office to schedule Covered

Your Plan Physician will make arrangements when Medically Necessary.

Limitations &

(CDC).

Your VHP Network Provider will make arrangements when Medically Necessary.

Your VHP Network Provider will make arrangements when Medically Necessary.

You may call Santa Clara County Public Health Travel Clinic to obtain travel immunizations at 408.792.5200 or, as available, from a VHP Plan Provider.

Outpatient Services, continued Benefits Copayment How to Obtain Covered Services

Optometry Services for vision screening, including a wide range of diagnostic testing, which include screening for cataracts, diabetes, and Glaucoma. As needed you will be referred to the Ophthalmology. Coverage includes special contact lenses for aniridia and aphakia. Note: Your employer may offer a vision benefit plan that provides optometry services including eye refraction examinations for eyeglass/ lens prescription. $0 Copayment Call your Plan network office to schedule Covered Services from a VHP network optometrist. Refer to Limitations and Exclusions.

If your employer offers a vision benefit e.g. Vision Service Plan (VSP) or Vision Plan of America (VPA), refer to that carrier’s provider list and coverage detail. Your employer vision benefits allow you to make an appointment(s) for Eye Refraction examinations at several locations in your area. Eyeglasses and lenses benefits may also be purchased through your vision carrier at that same location(s).

Limitations & Exclusions

Refraction examinations are limited to one (1) per year. Eyeglass lenses, frames, and contact lenses including fitting and dispensing (except for special contact lenses to treat aphakia or aniridia) non-implant low vision aides, and correction of visual acuity or refractive errors are excluded from your Benefit Plan. For treatment of aniridia (missing iris) coverage is limited to up to two Medically Necessary contact lenses per eye (including fitting and dispensing) in any 12-month period, whether provided by the Plan during the current or a previous 12 month contract period. For treatment of aphakia (absence of the crystalline lens of the eye) coverage is limited to up to six Medically Necessary aphakic contact lenses per eye (including fitting and dispensing) per calendar year for Members through age 9, whether provided by the Plan during the current or a previous 12 month contract period. VHP does not cover any copayments or costs through your employer vision plan(s).

Ophthalmology Services

including visits, examinations, and outpatient surgery at a Plan Hospital or Plan outpatient facility.

Podiatry Services for the treatment of injuries and diseases of the feet, such as diabetes, systemic foot disease, trauma, or accidental injury to the foot, requiring care by a medical professional. $0 Copayment

$0 Copayment Your VHP Network Provider will refer you to a Plan Specialist. To obtain outpatient surgery care you must receive Prior Authorization from VHP. Your PCP will refer you to a Plan Specialist. To obtain care you must receive a written referral from your PCP and Prior Authorization from VHP. Radial keratotomy is excluded from your Benefit Plan.

Orthotic appliances must be Medically Necessary devices to restore bodily functions essential to activities of daily living, prevent significant physical disability or serious deterioration of health or alleviate severe pain. Orthotic appliances are limited to one (1) per year, unless Medically Necessary with Prior Authorized. Refer to the “Durable Medical Equipment (DME)” section of this Benefits Description Table. Surgery is limited to Reconstructive Surgery. Routine/cosmetic foot care and Cosmetic Surgery is excluded from your Benefit Plan.

Outpatient Hospital Services Benefits Copayment How to Obtain Covered Services Therapy Services

including Physical, Occupational, Speech, and Respiratory Therapy Services are provided as necessary, which includes maintaining or preventing deterioration of a patient’s chronic physical or mental condition, including Severe Mental Illness. $0 Copayment Your VHP Network Provider will refer you to a Plan Specialist. To obtain care you must receive a written referral from your Network Provider and Prior Authorization from VHP.

Limitations & Exclusions

Outpatient physical, occupational, and speech therapies, and/or other rehabilitative services are limited to treatment provided in the amount, frequency, or duration, as the Plan Physician deems Medically Necessary.

Outpatient Hospital or Surgical Center

Services including outpatient surgery and procedures in a hospital or outpatient centers such as, but not limited to, angiograms and bronchoscopies; chemotherapy and medically appropriate materials.

Outpatient services also include surgical assistant and anesthesiologist, drugs, X-ray, lab, supplies and blood, blood derivatives, and transfusions (blood bank). $0 Copayment Your VHP Network Provider will make arrangements when Medically Necessary to a Plan Provider that most appropriately meets your medical needs.

To obtain outpatient surgery care you must receive Prior Authorization from VHP. You must have Prior Authorization for outpatient hospital or Surgical Center services from VHP, or you may be financially responsible for all charges.

Hospitalization Services (Non-Emergent or Scheduled Admissions) Benefits Copayment How to Obtain Covered Services Limitations & Exclusions

Inpatient Hospital $0 Your VHP Network Provider will Arrangements for a private room are Services at your primary Copayment make arrangements when Medically excluded from your Benefit Plan unless Plan Hospital, provides Necessary to a Plan Hospital that Medically Necessary and ordered by your Hospital Services most appropriately meets your Plan Physician. including physician and surgeon care, semiprivate room and board, intensive care, operating room, inpatient drugs, medical needs. Rehabilitation services are provided as Medically Necessary. Limits on habilitative and rehabilitative services and devices shall not be combined. X-ray, lab, supplies, All non-emergent scheduled anesthesia, acute admissions at hospitals must be Prior rehabilitation, dialysis, Authorized by VHP or you may be radiation therapy, cathode financially responsible for all charges. ray scanning, and blood, blood derivatives, and transfusions (blood bank).

Skilled Nursing Services Benefits Copayment

Skilled Nursing Care - $0 Inpatient provided in a Copayment Skilled Nursing Facility (SNF) or a skilled nursing bed in a Plan Facility, including semi-private bed and board, general and skilled nursing, social services, drugs, X-ray, lab, supplies, blood, blood derivatives, and transfusions (blood bank), rehabilitation services, speech/ language pathology, and durable medical equipment and/or other services necessary to the health of Members ordinarily furnished by the SNF.

How to Obtain Covered Services

To obtain care you must receive a written referral from your VHP Network Provider and Prior Authorization from VHP to a Plan Facility

Limitations & Exclusions

Coverage is limited to a maximum of 100 days per Calendar Year. If you request a private room, you must pay the difference between the Plan Facility or Hospital’s charge for a private room and a semi-private room. Coverage is limited to care which:

is skilled and required on a daily basis; is not Custodial Care; and as a practical matter, can only be provided on an inpatient basis. Conditions which are:

long-term; or chronic in nature, and require ongoing inpatient skilled nursing care are excluded from your Benefit Plan after you receive 100 days of care each Calendar Year. Rehabilitation services are provided in the amount, frequency, or duration, as the Plan Physician deems medically appropriate.

Rehabilitation Services Benefits Copayment

Rehabilitation Care - $0 Inpatient provided at a Copayment Plan Facility, which offers a physician directed plan of rehabilitation care including Physical Therapy (PT), Occupational Therapy (OT), Speech and DME. Benefits include a semiprivate bed and board, nursing, social services, drugs, X-ray, lab, supplies, provided on an inpatient basis.

blood, blood derivatives, and transfusions (blood bank), and Durable Medical Equipment ordinarily furnished by the

How to Obtain Covered Services

To obtain care you must receive a written referral from your VHP Network Provider and Prior Authorization from VHP to a Plan Facility.

Limitations & Exclusions

Rehabilitation services are provided in the amount, frequency, or duration, as the Plan Physician deems Medically Necessary. If you request a private room, you must pay the difference between the Plan Facility or Hospital’s charge for a private room and a semi-private room. Coverage is limited to care which: • is not Custodial Care; and • as a practical matter, can only be rehabilitation center.

Emergency Services Benefits Copayment

Emergency Services at any $0 facility or hospital worldwide, Copayment which are required to treat a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and Active Labor), and the time required to reach your Plan Facility or Hospital is such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the delay to result in:

serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or places your health or psychological wellbeing in serious jeopardy. Emergency Services also includes additional screening, examination, and evaluation by a physician, or other personnel to the extent, permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a Psychiatric Emergency Medical Condition exists, and the care and treatment necessary to relieve or eliminate the Psychiatric Emergency Medical Condition, within the capability of the facility.

How to Obtain Covered Services

If you think you have an Emergency medical condition, call 911 or go to the nearest hospital. You will be evaluated by Emergency medical professionals. Once your emergency condition is stabilized, if it is determined that you are to be admitted to a non-contracted hospital, VHP must be contacted by the provider for Authorization of Services. If able, present your VHP ID Card and ask the provider or someone acting on your behalf to call VHP.

Limitations & Exclusions

Once your emergency medical condition is stabilized VHP must be contacted by the provider before your admission or as soon as reasonably possible. Once your condition stabilizes, you may be transferred to a Plan Hospital.

Ambulance and Medical Transportation Services Benefits Copayment How to Obtain Covered Services Ambulance Services

includes emergency transportation to the closest hospital. $0 Copayment If able, present your VHP ID Card and ask the provider or someone acting on your behalf to call VHP. Call 911 for emergency ambulance transportation.

Medical Transportation

including inter-facility transfers. $0 Copayment Your Plan Physician or VHP will make arrangements for non-emergency medical transportation when Medically Necessary.

Limitations & Exclusions

Emergency medical and psychiatric transport is covered when medically necessary.

Non-Emergency medical and psychiatric transport is covered when medically necessary.

Urgently Needed Services

form of ID and your VHP ID Card when seeking services.

Benefits Copayment

Urgently Needed Services $0 Copayment

provided by your VHP

Network Provider include Medically Necessary services for an illness or injury which, if left untreated for a period in excess of 48 hours, in the view of a prudent layperson or physician, is likely to lead to a serious deterioration in the patient’s health or significant disability.

Urgently Needed Services provided at non-VHP

Network Providers, when you are out of your Service Area (Santa Clara County), include Medically Necessary services for an illness or injury which, if left untreated for a period in excess of 48 hours, in the view of a prudent layperson or physician, is likely to lead to a serious deterioration in the patient’s health or significant $0 Copayment

How to Obtain Covered Services

Call 1.866.682.9492 (toll-free) for medical advice, a nurse will assess your condition and direct you to the appropriate care. Valley Health Plan offers several Urgent Care Clinics; some require an appointment; some are walk-in clinics.

For a complete list of Plan urgent care clinics, including the walk-in clinic locations, visit the VHP website at www.valleyhealthplan.org or call Member Services at 1.888.421.8444 (toll-free) for assistance. Present a disability

Call 1.866.682.9492 (toll-free). An advice nurse will assess your condition and direct you to the appropriate care; or go directly to a Plan walk-in clinic; or go directly to the nearest urgent care center, present your VHP ID Card and ask the provider or someone acting on your behalf to call VHP.

Limitations & Exclusions

Urgent care services at non-Plan Providers within the Service Area must be Prior Authorized before services are rendered or you may be financially responsible for all charges.

If you are temporarily outside our Service Area and the care you receive from a non–Plan Provider is not an Urgently Needed Service, you may be financially responsible for all charges.

Prescription Drugs, Medications, and Pharmacy Services Benefits Copayment How to Obtain Covered Services Limitations & Exclusions

Prescription Drugs $0 When you have received a prescription Prescription drugs and supplies are including outpatient Copayment from your Plan Physician, you must limited to prescriptions written by Planprescription drugs, have it filled at your Plan Pharmacy. authorized providers when deemed diaphragms, birth control, insulin, glucagon, and Provide your VHP ID Card and the prescription to the Plan Pharmacy. Medically Necessary and in accordance with professionally recognized standards of care. other prescriptive medications for the treatment of diabetics Prescription Fill Options: Plan Pharmacies: Medically Necessary prescription drugs are limited to: at Plan Pharmacies from the Plan’s drug You have the option to contact your Plan Pharmacy to have your prescription • drugs approved by the FDA, Formulary. Birth refilled. Information regarding your • generic equivalents approved as control includes prescription is on your prescription label. substitutable by the FDA, any FDA approved Mail Service Pharmacy: • drugs approved by the FDA as contraceptive or You have the option of using our Mail Treatment Investigational New Drugs, medically appropriate Service Pharmacy, which only offers or prescribed contraceptive methods. Prescription Drugs also include premature infant prescriptions to be mailed to your home. Once a prescription is filled by the Mail Service Pharmacy, the prescription cannot be transferred to another Plan Pharmacy. Contact the Plan’s Pharmacy Benefit Manager at 1.866.333.2757 • drugs classified as Group C cancer drugs by the National Cancer Institute to be used only for the purposes approved by the FDA or the National Cancer Institute. formulas for up to (toll-free). For additional information Medications, not Medically Necessary, three (3) months go to www.valleyhealthplan.org including travel patches, cosmetics, and reimbursement or contact VHP Member Services herbal products and treatments, dietary for the purchase of Department at 1.888.421.8444 (toll- supplements, health or beauty aids, are formulas or special free). excluded from the Benefit Plan. food products that are required for the treatment of PKU. Out-of-Network: Should you need to obtain a prescription associated with Out-of-Network For most oral medications, a Prescription Unit represents a single course of treatment or up to a 90 day supply for Emergency Services or Urgently chronic illness. Needed Services, take your prescription to a Plan Pharmacy. If a Plan Pharmacy You may be financially responsible for lost is not available, VHP will cover the or misplaced medications. The PBM or prescription filled at an Out of Network pharmacist will advise you of all charges. Pharmacy. You or the provider may PKU formula and special food product submit your claim to PBM or VHP for reimbursement is limited to the amount payment. and duration that the Plan Physician Formulary: deems Medically Necessary. For Formulary information, call VHP’s Special formulas for allergy, e.g. cow’s PBM at 1.866.333.2757 (toll-free) or milk, soy, or lactose intolerance milk are visit www.valleyhealthplan.org not a Covered Service under your Benefit Plan.

Over the counter (OTC) drugs and supplies are excluded from your benefit plan.

Durable Medical Equipment - Medical Supplies and Equipment Benefits Copayment How to Obtain Covered Limitations & Exclusions Services

Medical Supplies and $0 Your Plan Physician will prescribe Medical supplies are limited to equipment and Equipment including Copayment or arrange for Prior Authorization devices which: Durable Medical Equipment (DME) and supplies which: • primarily serve a medical purpose; and when Medically Necessary. Your Plan Physician or VHP will advise you where to obtain the supplies at the Plan Provider of DME. • • are intended for repeated use over a prolonged period; are not considered disposable, with the exception of ostomy bags and diabetic supplies; • are appropriate for use in the home. • do not duplicate the function of another piece of equipment or device covered by VHP; and DME also includes corrective appliances, • are generally not useful to you in the absence of illness or injury. Prosthetic Devices and Medically Necessary repair or replacement orthotic devices, oxygen of medical supplies or equipment must be and oxygen equipment prescribed by your Plan Physician, but is which are Medically excluded from your Benefit Plan when caused by Necessary. misuse or loss. Refer to the “Benefits Description” section under “Durable Medical Equipment - Medical Supplies and Equipment.” Any purchase or customization of living environment or automobile (e.g. home ramps, swimming pools/ hot tubs, doorway enlargements, air conditioners, waterbeds, or any other equipment which could be used in the absence of an injury or illness) are excluded from your Benefit Plan. Braces or other devices primarily for use in athletic competition or recreational activities are excluded from your Benefit Plan. Prescribed hearing aid benefits are limited to once every 36 months and up to a coverage maximum of $1,000.00, regardless of the number of hearing aides or devices prescribed. Shoe inserts and over the counter (OTC) medical supplies and equipment are excluded from your Benefit Plan. OTC items include but are not limited to garter belts, and similar devices, experimental or research equipment and devices not Medically Necessary. Orthotic and prosthetic appliances are limited to Medically Necessary devices to restore bodily functions essential to activities of daily living, prevent significant physical disability or serious deterioration of health or alleviate severe pain.

Mental Health Services Benefits Copayment

Outpatient Mental Health $0 Copayment

and Behavioral Health Treatment Provided by Non-Physician Providers

– Outpatient Mental Health includes, but are not limited to assessment, diagnosis, individual and group psychotherapy. Behavioral Health Treatment is covered by the Plan and includes professional services and treatment programs including applied behavior analysis and evidence-based behavior intervention programs that develop or restore, to the maximum extent practical, the functioning of an individual with Pervasive Developmental Disorder or Autism.

These services are provided by Psychologists (PhD), Marriage and Family Counselors (MFCC/ MFT) and Licensed Clinical Social Workers (LCSW), or other health professionals permitted by California law. In some instances your PCP may be able to provide Mental Health Services.

Outpatient Mental Health and Behavioral Health Treatment Services Provided by a

Psychiatrist for evaluation and treatment including prescribed psychological and neuropsychological testing, crisis intervention, and partial hospital services. Services include Medically Necessary treatment for Severe Mental Disorders and Serious Emotional Disturbances of a Child or Adolescent.

How to Obtain Covered Services

No Prior Authorization is required for Outpatient Mental Health and Behavioral Health Treatment provided by a non-physician Mental Health Provider; however, you may contact VHP’s Utilization Department at 408.885.4647 for assistance in obtaining care or you may contact a Mental Health Plan Provider directly. To obtain a list of VHP’s Mental Health Providers, call VHP Member Services Department at 1.888.421.8444 (toll-free), or visit the VHP website www.

valleyhealthplan.org

You must obtain Prior Authorization before receiving Outpatient Mental Health and Behavioral Health Treatment Services provided by a Psychiatrist. These exclusions or limitations do not apply to medically necessary services to treat severe mental illnesses (SMI) or serious emotional disturbances of a child (SED). The scope of treatment services for mental health conditions that VHP must cover varies depending on whether the condition is defined as a Severe Mental Illness (SMI), a Serious Emotional Disturbance of a Child (SED), or another type of mental or substance use disorder that is not an SMI or SED. Notwithstanding any exclusions or limitations described in this EOC, all treatment services for an SMI or SED mental health condition shall be covered as medically necessary. To obtain prior authorization call VHP’s Utilization Department at 408.885.4647 or contact your PCP for a referral.

If you think you have a psychiatric Emergency, call 911 or go to the nearest hospital.

Limitations & Exclusions

Outpatient mental health services are limited to Medically Necessary treatment of a mental health condition. Such treatment is covered in the amount, frequency, or duration required to ensure the Member no longer medically requires treatment, or to the time where it is determined that benefit, or further benefit from treatment is unlikely. Mental health services for Members who are incarcerated, or that are court ordered, or as a condition of parole or probation are excluded from your Benefit Plan, unless determined Medically Necessary by the Medical Director. If you seek outpatient mental health services from an Out-ofNetwork Mental Health Provider without Prior Authorization, you may be financially responsible for all charges.

Mental Health Services (continued) Benefits Copayment How to Obtain Covered Services

In some instances your PCP may be able to provide Mental Health Services.

Prescription Drugs for Mental Health Conditions

Services include prescription drugs, medications, and pharmacy services. Prescription drugs must be written by a Plan Psychiatrist or Primary Care Physician (PCP).

Inpatient Mental Health Services and Behavioral

Health Treatment for evaluation, treatment, crisis intervention and Inpatient Mental Health residential treatment.

Post hospitalization outpatient treatment services are available. (Refer to the “Emergency and Urgently Needed Services” section under “Post- Stabilization.” $0 Copayment Your VHP mental health Plan Provider will make arrangements when Medically Necessary. If you think you have a psychiatric emergency, call 911 or go to the nearest hospital. Prior Authorization from VHP is required.

Limitations and Exclusions

Inpatient mental health services are limited to Covered Services as described in the “Hospitalization Services” section of this Benefits Description Table. Mental health services for Members who are incarcerated, or that are court ordered, or as a condition of parole or probation are excluded from your Benefit Plan, unless determined Medically Necessary by the Medical Director.

Chemical Dependency Services (Alcoholism and Drug Abuse) Benefits Copayment How to Obtain Covered Services Limitations & Exclusions

Substance Abuse $0 Call the Gateway Program at If you or your condition does not respond Services - Outpatient Copayment 1.800.488.9919 (toll-free) for to therapeutic management, outpatient includes includes access to information, referral and substance abuse counseling and medical Medically Necessary treatment services, or call your PCP. treatment may be excluded from your evaluation and treatment Benefit Plan. of alcohol and/or drug dependency and medical treatment for withdrawal symptoms. Residential ancillary services (defined as any program without on-site treatment services being provided, and intended primarily as a residence, e.g. Sober Living Medically Necessary Environment (SLE) or SLE housing) are methadone maintenance excluded from your Benefit Plan. services are included. Detoxification $0 Your VHP Network Provider will Inpatient (hospital-based) substance Substance Abuse Copayment make arrangements for Medically abuse services are limited to Covered Services, i.e. Hospital Necessary Covered Services Services under the “Hospitalization based – Inpatient at a Plan Hospital that most Services” section of this Benefits including Medically appropriately meets your medical Description Table. Necessary detoxification for alcohol and/or drug dependency. needs. Residential ancillary services (defined as any program without on-site treatment services being provided, and intended primarily as a residence, e.g. Sober Living Environment (SLE) or SLE housing) are excluded from your Benefit Plan. Residential $0 Call the Gateway Program at Residential recovery services are (intermediate-term) Copayment 1.800.488.9919 (toll-free) for limited to Medically Necessary, shortRecovery Services access to information, referral and term alcohol or drug detoxification and including short-term, treatment services, or call your PCP. transitional recovery treatment. non-hospital based detoxification services, and transitional substance abuse residential treatment for alcohol and/ or drug dependency that are Medically Necessary. Residential ancillary services (defined as any program without on-site treatment services being provided, and intended primarily as a residence, e.g. Sober Living Environment (SLE) or SLE housing) are excluded from your Benefit Plan.

Home Health and Hospice Services Benefits Copayment How to Obtain Covered Services

Home Health Care $0 Your Plan Physician will prescribe including Medically Copayment or make Prior Authorized Necessary health care arrangements when Medically services and supplies Necessary. provided in your home. Services include drugs, medicines, and supplies administered by a visiting health care professional; rehabilitation, and laboratory services; and Medically Necessary intermittent skilled nursing If, at the time of enrollment, you are receiving on-going home health care, it is your responsibility to notify VHP to arrange for continuation of services through Plan Providers. Contact Member Services at 1.888.421.8444 (toll-free) for assistance and home health aide Should you fail to inform us of your services. need for such services and not obtain Prior Authorization from VHP for continuation of care through non-Plan Providers, you will be financially responsible for the cost of such services. Dialysis Services for $0 Your PCP or Plan Physician will acute renal failure and Copayment make arrangements when Medically chronic renal disease, Necessary with an authorized Plan including equipment, Provider training, and supplies. Hospice Care provided $0 Your PCP or Plan Physician will by licensed hospice Copayment make arrangements when Medically programs as certified Necessary with an authorized Plan by the Centers for Provider when you elect Hospice Medicare and Medicaid Care. Services (CMS). Hospice Services include physician services, nursing care, therapy, medical social services, home health aide and homemaker services, drugs, medical supplies and DME, care for pain control and symptom management, counseling and bereavement services, and services of volunteers.

Limitations & Exclusions

Coverage is limited to services that may not be appropriately provided in Plan Provider’s office, hospital or Skilled Nursing Facility. Coverage is limited to homebound Members under a doctor’s supervision. Custodial Care is excluded from your Benefit Plan.

Your Plan Physician will determine the amount, frequency, or duration of Medically Necessary in-home physical, occupational, and speech therapies, and/ or other rehabilitative services.

Medicare enrollment is required once you meet the Medicare eligibility requirements.

Coverage is limited to Members who have been given a prognosis of 12 months or less to live and VHP determines hospice care to be Medically Necessary. Coverage is limited to a maximum of 366 days of hospice care including five (5) consecutive days of inpatient respite care (to provide relief for family members or others who might be caring for you). Other Benefits for the terminal illness are excluded while your hospice election is in effect.

Acupuncture Services Benefits Copayment

Acupuncture Services $10 are provided for the Copayment treatment of nausea or as per visit part of a comprehensive pain management program for the treatment of chronic pain.

How to Obtain Covered Services

Call your PCP to request a referral for Acupuncture Covered Services

Limitations and Exclusions

Coverage is limited to a maximum of 20 Prior Authorized visits per calendar year. Beyond 20 prescribed visits require justification from Plan Provider. If you seek care without Prior Authorization from VHP, you may be financially responsible for all charges. Services that are not acupuncture related, such as herbal medicines or other treatments will be your financial responsibility.

Chiropractic Services Benefits Copayments

Chiropractic Services $10 includes visits, Copayment examinations, procedures per visit performed in the office to prevent, modify, or alleviate severe, persistent, or chronic pain.

How to Obtain Covered Services

Call your PCP to request a referral for Chiropractic Covered Services.

Limitations & Exclusions

Coverage is limited to a maximum of 20 Prior Authorized visits per calendar year. Beyond 20 prescribed visits require justification from Plan Provider. If you seek care without Prior Authorization from VHP, you may be financially responsible for all charges. Services that are not chiropractic related, such as x-rays or nutritional counseling will be your financial responsibility.

Cancer Clinical Trial or Other Life-Threatening Services Benefits Copayment How to Obtain Covered Services Limitations & Exclusions

Cancer Clinical Trial $0 Copayment Your Plan Physician or VHP The clinical trial’s: Services include routine health care services associated with your participation in a cancer will order or arrange for Prior Authorization of Covered Services. i. endpoints must not be defined exclusively to test toxicity, but have a therapeutic intent, and clinical trial, Phase I through ii. treatment must either V. (a) be approved by the National Covered Services are only Institute of Health, the Federal Food available if: and Drug Administration, or the • you have been diagnosed Veterans Administration or with cancer or other life- (b) involve a drug that is exempt under threatening disease or the federal regulations from a new condition; drug application. • you are accepted into a Coverage is limited to routine patient care

Phase I through V clinical Covered Services in accordance with trial for cancer; and state and federal Regulations. • your Plan Physician has recommended your participation in the trials because it will have a meaningful potential benefit to you.

Family Planning Services Services

Benefits Copayment

Artificial Insemination

Services includes the intrauterine sperm placement procedure only for the treatment of infertility when determined Medically Necessary by a Plan Physician. Evaluation and work-up should be completed within six (6) months or (6) six Cycles. Semen analysis and sperm washing for conception procedures will be covered only in conjunction with artificial insemination procedures covered by your Benefit Plan.

Refer to “Infertility Diagnosis and Treatment” section in this Benefits $0 Copayment

How to Obtain Covered

Description Table.

Your PCP will make arrangements when Medically Necessary to a Plan Provider.

Limitations & Exclusions

Treatment of infertility due to prior tubal ligation or tubal reanastomosis and complex artificial insemination procedures are excluded from your Benefit Plan.

Conception by artificial means, such as in-vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), and gamete intrafallopian transfer (GIFT) or any other process that involves the harvesting or manipulation (physical, chemical, or by any other means) of the human ovum to treat infertility are excluded from your Benefit Plan.

Any service, procedure, or process which prepares you to receive conception by artificial means that is not a Covered Benefit, such as prescription drugs, donor sperm, sperm preservation, sperm storage, or direct intra uterine placement, are excluded from your Benefit Plan.

Family Planning Services (Continued) Benefits Copayment How to Obtain Covered Services

Family Planning $0 Call to schedule an appointment Services including Copayment with your VHP Network Provider. contraceptive counseling, prescribed birth control pills, fitting and/or inserting birth control devices Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan. org (e.g. diaphragms), and examination, insertion, and removal of an IUD.

Family services also include familyplanning counseling, pre-abortion and post- abortion counseling, and information on birth control.

Medical services in a Plan Provider’s office for diagnosis and treatment of involuntary infertility are covered under your Benefit Plan

Infertility Diagnosis

and Treatment includes Covered Services to evaluate, diagnose, and provide Medically Necessary treatment. $0 Copayment Your PCP will order or make arrangements with a Plan Provider when Medically Necessary.

Limitations & Exclusions

Non-prescription (i.e. over the counter) contraceptive supplies and devices are excluded from your Benefit Plan

Treatment of infertility services due to tubal ligation, tubal reanastomosis, or vasectomy procedures are excluded from your Benefit Plan. Refer to the “Family Planning Services” section in this Benefits Description Table. Limitations include:

i. The Member must provide the sperm and pay any sperm bank or preparation costs. Two (2) semen analyses are covered in conjunction with the Artificial

Insemination procedures. ii. Artificial Insemination is the actual basic insemination procedure. iii. Sperm washing only in connection with the Artificial Insemination procedures.

Maternity Services Benefits Copayment

Maternity Care includes prenatal care, delivery, and antepartum and postpartum care. You and your newborn child are entitled to 48 hours of inpatient hospital care following a normal vaginal delivery or 96 hours following a delivery by Cesarean section. Prenatal and newborn support classes are available, by calling the VHP Health Education Department at

408.885.3490.

$0 Copayment

How to Obtain Covered Services

It is important to receive early care when you are pregnant. If you think you are pregnant, call to schedule an appointment with a Plan OB/GYN: Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan.

org

Enrollment of your Eligible Dependent is required within 31 days of the birth; contact your employer/ human resources to obtain enrollment information.

Limitations & Exclusions

If you travel outside of the Service Area to obtain Medical Services related to care and/or delivery of the newborn, you may be financially responsible for all charges, except for those expenses related to Emergency Services. Amniocentesis, ultrasounds, or any other procedure performed solely for the purpose of sex determination are excluded from your Benefit Plan. Should you give birth while a Member and your newborn meets the definition of an Eligible Dependent, he/she is eligible for Coverage under the Benefit Plan for the first 31 days after the birth. • Except in the event of an emergency or urgently needed required Covered

Services, during this grace period, your

Plan Physician must provide care. • The appropriate membership premium will be charged from the date of the birth.

• For continuous Coverage of your newborn beyond 31 days, the

Subscriber must complete and submit the appropriate paperwork to enroll your newborn as an Eligible Dependent within 31 days of the birth. Enrollment materials must be submitted to your employer’s Human Resources office. If you are enrolled as a Subscriber to a Group that does not offer dependent coverage, Coverage of your newborn child will be excluded 31 days after the birth.*

If you are enrolled as an Eligible Dependent child when you give birth, newborn care is excluded from your Benefit Plan. (Please refer to the “Eligible Dependent” definition for details.) * Note: For information on continuous health coverage for your newborn, contact the Children’s Health Initiative (CHI) at 1.888.244.5222 (toll-free).

A CHI representative can give you information about free or low cost health insurance.

Maternity Services (Continued) Benefits Copayment How to Obtain Covered Services

Circumcision $0 Copayment Ask your Plan Pediatrician to arrange the circumcision within two (2) weeks of the birth of your newborn.

Genetic Counseling $0 Copayment Services includes Medically Necessary risk Benefit Plan and the circumcision must be performed within two (2) weeks of the birth.

assessment for Family Planning and diagnosis.

Sterilization Services

is excluded from your Benefit Plan.

Benefits Copayment

Sterilization Services $0 Copayment include vasectomy and tubal ligation procedures. Your VHP Network Provider will determine the scope of services based on Medical Necessary

How to Obtain Covered Services

Your Plan Provider will make arrangements if you elect to have a vasectomy or tubal ligation at a Plan Provider.

Abortion Services Benefits Coverage

Abortion Services $0 Copayment includes examination, counseling, and procedure.

Benefits Copayment

Health Education and $20 Health Promotion Copayment Services includes for Weight VHP Health Education Watchers classes and materials in Session(s) childbirth preparation, may apply. prenatal education, CPR, smoking cessation, weight management, and exercise and fitness education. A fee for classes, materials, and supplies may be charged

How to Obtain Coverage

Call VHP’s Utilization Department at 408.885.4647 or your Plan Provider can make arrangements at a Plan Facility.

How to Obtain Covered Services

Contact your VHP Health Education Department at 408.885.3490 or e-mail healtheducation@vhp. sccgov.org to register and obtain information on class availability, schedule(s), and fees. Visit VHP’s website at www. valleyhealthplan.org for a list of Plan authorized health education classes.

Limitations & Exclusions

Circumcision is done on an outpatient basis only if the newborn meets the definition of an Eligible Dependent. Your newborn must be enrolled in the

Limitations & Exclusions

A hysterectomy exclusively for voluntary sterilization purposes is excluded from your Benefit Plan. The reversal of sterilization procedures

Health Education Services

Limitations & Exclusions

Covered Services must be provided by a VHP Network Provider.

Limitations & Exclusions

Coverage is limited to Plan authorized health education classes and programs. Unless otherwise noted in the VHP Health Education class booklet, prior to attending any VHP health education classes or programs, you must contact the VHP Health Education Department for pre-registration. Weight Watchers benefit is limited to one (1) session per calendar year. Weight Watchers session(s) are available in some work places or Weight Watchers session coupons are available from VHP. A second session or second set of coupons may be requested if you provide documentation of continuous Weight Watchers meeting attendance. There is no reimbursement for the $20.00 Copayment.

Dental Services Benefits

Dental Services include services:

for treatment or removal of tumors,

Plan Physicians’ services or X-ray exams for the treatment of accidental injury to natural teeth, surgery on the maxilla or mandible that is Medically

Necessary to correct temporomandibular joint (TMJ) disease or other medical disorders, or • services in connection with accidental fractures of the jaw.

Temporomandibular Joint (TMJ) Disorders

Services includes the evaluation and treatment of TMJ dysfunction, including the provision of intra- oral appliances.

Copayment

$0 Copayment

$0 Copayment

Dental Services – Plan Hospital or Surgery

Center Services include general anesthesia and associated facility charges for dental procedures rendered in a hospital or surgery center, when the clinical status or underlying medical condition of the patient requires such Covered Services $0 Copayment

How to Obtain Covered Services

Your Plan Physician or VHP will make Prior Authorized arrangements when Medically Necessary in a Plan Hospital or Plan surgery center.

Limitations & Exclusions

VHP DOES NOT OFFER DENTAL INSURANCE. Charges for the dental procedures that are not related to the treatment of a Medically Necessary condition are excluded from your Benefit Plan.

Routine dental or any dental services or X-ray exams involving one (1) or more teeth, the tissue or structure around them, the alveolar process or the gums are excluded from your Benefit Plan. Medically Necessary medications (i.e. medications for pain, antibiotics) prescribed by your dentist must be filled by your Plan Pharmacy. Other prescriptions written by dentists are not covered by VHP.

Your Plan Physician or VHP will make Prior Authorized arrangements when Medically Necessary. Submit your request for reimbursement for intra-oral devices and related services to VHP within 90 days of the date of service. Coverage is limited to a maximum of $800.00 lifetime benefit for Member reimbursement toward intra-oral devices and the fitting of such appliances. Charges for the dental procedures that are not related to the treatment of a Medically Necessary condition are excluded from your Benefit Plan. Charges for the dental procedure itself, including but not limited to, the professional fee(s) of the dentist, and X-rays are excluded from your Benefit Plan.

Your Plan Physician or VHP will make Prior Authorization arrangements when Medically Necessary in a Plan Hospital or Plan surgery center. VHP DOES NOT OFFER DENTAL INSURANCE. Charges for the dental procedures that are not related to the treatment of a Medically Necessary condition are excluded from your Benefit Plan.

Covered Services are only available if the Member’s health is compromised and general anesthesia is Medically Necessary. Prior Authorization is required from VHP for Medically Necessary Covered Services in a Plan Hospital or Plan surgery center.

Reconstructive and Cosmetic Surgery Services Benefits Copayment How to Obtain Covered Services

Reconstructive Surgery $0 Your VHP Network Provider will includes plastic surgery to Copayment make arrangements when Medically correct or repair abnormal Necessary at a Plan Provider. structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function; (2) To create a normal appearance, to the extent possible when Medically Necessary.

Transplant Services Benefits Copayment

Human Organ, Tissue, and Bone Marrow Transplantation Services

for Non-Experimental Procedures include:

• Preoperative evaluation;

• surgery; • follow-up care only provided at centers that have been designated by

VHP; and • the reasonable medical of a donor or individual identified as a prospective donor if such expenses are directly related to the transplant, other than corneal transplants. Benefits also include Medically Necessary ambulance services.

Applicable pharmacy Plan Benefit applies for Immunosuppressive drugs prescribed after a covered transplant. Prescriptions are covered when obtained from a Plan pharmacy. $0 Copayment

How to Obtain Covered

Services

Your Plan Physician will refer you a Plan Provider for transplant services when Medically Necessary and Prior Authorized by VHP.

Limitations & Exclusions

Surgery that is defined as strictly Cosmetic Surgery is excluded from your Benefit Plan. Implants that are cosmetic, experimental, or investigational are excluded from your Benefit Plan. Reconstructive surgery is covered only when a Plan Physician determines that surgery is necessary to improve function, or create a normal or uniform appearance, to the extent possible.

Limitations & Exclusions

Transplantation Services are limited to those that are Medically Necessary, Prior Authorized, and performed in a Plan Facility or Hospital. The patient-selection committee of the designated center will select recipients. If VHP physicians or the referral facility determines that you do not satisfy the patient selection Medical Criteria for the transplant, tissue and organ transplant procedures, services will be excluded. VHP will pay only for the services you received before that and hospital expenses

decision is made.

Donor searches and recipient or donor transportation costs to the transplantation center are excluded from your Benefit Plan. The medical and hospital Covered Services of a donor are covered up to 12 months from the date of surgery when related to the transplant. Services related to non-human or artificial organs and their implantation are excluded from your Benefit Plan. Anti-rejection drugs, biological products, and other procedures are limited to Non-Experimental Procedures.

Experimental procedures are excluded from your Benefit Plan.

Certain definitions of terms used to describe your Benefits can be found in the “Definitions” section. These defined terms will be Capitalized throughout the document. For example: Covered Services, Plan Physicians. VHP offers you and your Dependent(s) a comprehensive range of Benefits. This section describes the Covered Services that are available through your Benefit Plan. Please take a few moments to read these descriptions, the “Emergency and Urgently Needed Services” section, the “Benefits Description Table,” and the “Exclusions and Limitations” section of this EOC to fully understand your Benefits. Your Copayment responsibility and the particular exclusions and limitations that apply to a specific Benefit are listed in the “Benefits Description Table.” Except for Emergency Services, Urgently Needed Services, Prior Authorized, or Member selfreferral services, Covered Services must be: • provided, prescribed, arranged for, and/or directed for Authorization by your PCP or a PlanPhysician

Provider; • obtained from Plan Provider(s) within the VHP Network; and • rendered to a Member for the treatment of illness or injury, (unless specifically covered as preventive or routine health services). Mid-Level Practitioners and resident physicians may be involved in your care through VHP. These providers will participate in your care under the direct supervision of an attending physician and all health care decisions will be made by consultation with the attending physician. You will be informed of the involvement of any Mid-Level Practitioners by the individuals themselves at the Plan Provider site.

Valley Health Plan believes this Coverage is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your Coverage many not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. Questions regarding VHP’s grandfathered health plan status can be directed to VHP Member Services. If you have additional questions about your Covered Services, please call a VHP Member Services Representative at 1.888.421.8444 (toll-free).

Professional Services

Professional physician services are covered under your Benefit Plan. Covered Services include: • Primary Care Physician (PCP) Services; • Plan Specialist Care; • Inpatient Hospital Plan Physician Services; • Outpatient Plan Physician Care; and • Outpatient Hospital Plan Physician Services.

Outpatient Services

Your Benefit Plan covers Outpatient Care by Plan Providers. Routine Care or urgent care is arranged or provided through your PCP or Plan Physician and includes many of the common preventive and diagnostic services you will need, such as evidence based preventive services rated A or B by the US Preventive Services Task Force, recommended immunizations by the Centers of Disease Control, preventive care for children, adolescents, and adults, plus additional preventive care and screenings for women. There is no limit to the number of visits (except for defined limitations and exclusions). You may self-refer directly for OB/GYN. VHP believes that preventive services are important in maintaining your health and the health of your Dependents. Outpatient Covered Services include: • Pediatric/Well-Child Care; • Adult Periodic Health Examinations; • Physical Examinations for Routine Care; • Well-Woman Examinations; • Mammography Screening; • Allergy Testing and Treatment; • Dermatology Services; • Diagnostic Laboratory Services; • HIV, AIDS, or Other Infectious Diseases Testing and Treatment; HIV testing is covered regardless if related to a primary diagnoses; • Immunizations and Injections; • Travel Immunizations; • Optometry Services; • Ophthalmology Services; • Podiatry Services; • Therapy Services; • Outpatient Hospital or Surgical Center Services; • Urgently Needed Services.

Facilities - Inpatient Services Hospitalization Services

Inpatient Hospital Services include physician and surgeon care, semi-private room and board, intensive care, operating room, inpatient drugs, X-ray, lab, supplies, anesthesia, acute rehabilitation, dialysis, radiation therapy, cathode ray scanning, and blood, blood derivatives, and transfusions (blood bank). Rehabilitation services are provided in the amount, frequency, or duration, as the Plan Physician deems Medically Necessary. There is no limit to the number of inpatient days, when provided at a Plan Hospital by Plan Providers when your care is deemed Medically Necessary.

Skilled Nursing Services

Skilled Nursing Care (Inpatient) provided in a Skilled Nursing Facility (SNF) or a skilled nursing bed in a Plan Facility, including semi-private bed and board, general and skilled nursing, social services, drugs, X-ray, lab, supplies, blood, blood derivatives, and transfusions (blood bank), and durable medical equipment ordinarily furnished by the SNF. Coverage is limited to a maximum of 100 days per calendar year. Rehabilitation services are provided in the amount, frequency, or duration, as the Plan Physician deems Medically Necessary.

Rehabilitation Services

Rehabilitation Care (Inpatient) provided in a Plan Facility that offers a physician directed plan of rehabilitation care including Physical Therapy (PT), Occupational Therapy (OT), Speech and Durable Medical Equipment. Benefits include a semi-private bed and board, nursing, social services, drugs, X-ray, lab, supplies, blood, blood derivatives, and transfusions (blood bank), and durable medical equipment ordinarily furnished by the rehabilitation center.

Ambulance Services

In the event of an emergency medical condition that requires an emergency response, you are encouraged to use appropriately the “911” emergency response system in areas where the system is established and operating. In the event of an emergency where no “911” response service is available, go to the nearest hospital by the most appropriate means available to you.

Medical Transportation Services

Medically necessary non-emergency medical transport will be arranged by your PCP and VHP. Prior Authorization is required.

Prescription Drugs, Medications and Pharmacy Services

When you receive a prescription from your Plan Physician you must have it filled at a Plan Pharmacy. YourPlan Physician coordinates your health care to determine when you need medication and the proper dosage from VHP’s Formulary. Medically Necessary medications (i.e. medications for pain, antibiotics) prescribed by your dentist must be filled by your Plan Pharmacy. Other prescriptions written by dentists are not covered by VHP. Over the counter (OTC) drugs, medications, and supplies are not a Covered Benefit, except as specified in this Membership Agreement and Evidence of Coverage & Disclosure Form.

Plan Pharmacies

When filling a prescription at a Plan Pharmacy, present your VHP ID Card and the prescription to the pharmacist. The Pharmacy will dispense up to but no more than a 90 day supply for Serious Chronic Conditions. You may be required to pay a Prescription Unit copayment. The Pharmacy will advise you of all charges. All prescriptions must be filled by Plan Pharmacies. Your pharmacy Benefit is limited to prescriptions filled at a Plan Pharmacy. Only prescriptions for emergent or urgent care services will be covered at an outside pharmacy when a Plan Pharmacy is not available. Formulary drug prescriptions obtained from non-VHP providers and filled at non-Network Plan Pharmacies are subject to the Authorization process. Upon review by the Medical Director, reimbursement may be denied. Routine Medically Necessary medications prescribed by your dentist are a Covered Benefit only when authorized and filled at a Plan Pharmacy.

Over the counter (OTC) drugs, medications, and supplies are not a Covered Benefit except for all FDA-approved contraceptive drugs, devices, and products available over the counter at no charge, when prescribed by your Plan Physician and filled at a Plan Pharmacy. You may choose to have your prescription mailed to your home. You will not be charged for this mail order service, however if your request for mail order cannot be filled the pharmacy may need to contact you. It is important that your phone numbers and mailing address are up to date in the Plan Pharmacy and VHP records. For more information go to VHP’s website at www.valleyhealthplan.org or call VHP Member Services at 1.888.421.8444 (toll-free).

Prescription Fill Options Plan Pharmacies:

You have the option to contact your Plan Pharmacy to have your prescription refilled. Information regarding your prescription is on your prescription label.

Mail Service Pharmacy:

You have the option of using our Mail Service Pharmacy, which only offers prescriptions to be mailed to your home. Once a prescription is filled by the Mail Service Pharmacy, the prescription cannot be transferred to another Plan Pharmacy. Contact the Plan PBM at 1.866.333.2757 (tollfree). For addition information go to www.valleyhealthplan.org or contact VHP Member Services Department at 1.888.421.8444 (toll-free).

VHP Formulary

Plan Physicians use a comprehensive drug Formulary that includes both FDA-approved drugs (brand name and generic). Your Plan Physician coordinates your health care to determine when you need medication and the proper dosage. Although a drug may be on the Formulary, it does not guarantee that your Plan Physician will prescribe the drug. If the Plan Physician specifies “Do Not Substitute” and a generic equivalent drug is available the prescription is subject to the Authorization process. Upon review by the Medical Director, the generic equivalent drug may be dispensed by the Plan Pharmacies. Valley Health Plan delegates the Formulary drug selection process to its Pharmacy and Therapeutics Committee (P&T). The VHP Formulary has been prepared as a reference for all health professionals who share the responsibility for the management of patient care, including VHP Members. The Formulary is prepared for publication by VHP’s Pharmacy Benefits Management Provider under the direction of the P&T. The Formulary is published online. Additions and deletions to the Formulary, which occur throughout the year by action of the P&T conveyed to the PBM. The PBM advises the Plan Providers and Members as appropriate. Records of these changes are maintained in the P&T minutes. To identify whether a specific drug(s) is on the Formulary or to obtain a copy of the Formulary, speak to the Plan PBM at 1.866.333.2757 (toll-free). For information go to www.valleyhealthplan.org or call VHP Member Services at 1.888.421.8444 (toll-free).

Non-Formulary, Urgent, or Emergent Prescriptions

Medically Necessary non-formulary drugs may be covered if your Plan Physician obtains Authorization from VHP or the PBM. New non-formulary prescriptions will be authorized within five (5) business days. Urgent or emergency non-formulary prescriptions will be authorized within