Valley Health Plan Benefits and Coverage Handbook

Valley Health Plan Benefits and Coverage Handbook Combined Evidence of Coverage and Disclosure Form

Important Information THIS BOOKLET PROVIDES AN EXPLANATION OF YOUR RIGHTS, BENEFITS, SERVICES, AND RESPONSIBILITIES AS A MEMBER. IT ALSO EXPLAINS VALLEY HEALTH PLAN’S HEALTH MAINTENANCE ORGANIZATION RESPONSIBILITIES TO YOU. RECORD IMPORTANT INFORMATION BELOW AND USE THIS PAGE AS A QUICK REFERENCE GUIDE FOR YOU AND YOUR FAMILY. Subscriber (Your) Social Security Number

Your Child’s Name

Your Name

VHP ID Number

VHP ID Number

Primary Care Physician

Your Effective Date of Coverage

Your Child’s Name

Your Primary Care Physician

VHP ID Number

Your Self Referral Physician

Primary Care Physician

Your Spouse’s Name

Your Child’s Name

VHP ID Number

VHP ID Number

Primary Care Physician

Primary Care Physician

Self Referral Physician

Your Child’s Name

Important Telephone Numbers

VHP ID Number

Valley Health Plan’s 24-hour Medical Advice Line: 1.866.682.9492 (toll-free) Your VHP Network PCP/Appointment #:

Primary Care Physician

Emergency: 911 Your contract for membership includes the Agreement, this Combined Evidence of Coverage and Disclosure Form (EOC), any materials distributed in the packet with your EOC, your enrollment application and any information submitted by you in applying for coverage, attachments, addenda, and any amendments that may be added in the future.

VHP does not discriminate in the employment of staff or in the provision of health care services on the basis of race, disability, sex, religion, age, color, sexual orientation, creed, family history, marital status, veteran status, national origin, handicap, or condition in accordance with applicable State and federal law.

Telephone numbers listed in this document are subject to change, as needed, contact a VHP Member Services Representative at 408.885.4760 to obtain revised telephone numbers or go to the VHP website at www. valleyhealthplan.org

1 ■ VALLEY

HE ALTH

PLAN

EVIDENCE

OF

COVERAGE

AND

DISCLOSURE

FORM

Welcome to Valley Health Plan!

Dear Member, Thank you for choosing Valley Health Plan (VHP) to manage your health care needs. VHP is a state licensed health care service plan owned and operated by the County of Santa Clara. We care about the health and well- being of you and your family. VHP’s staff is committed to ensuring that you receive quality care and service at the right time, at the right place and by the right provider. We believe that health care is highly personalized and that you receive the best health care when you make informed decisions about your treatment in partnership with your Primary Care Physician (PCP).

To help you understand your coverage and responsibilities as a Valley Health Plan member, this Combined Evidence of Coverage (EOC) and Disclosure Form booklet will provide you with a detailed explanation of VHP services, benefits, limitations and exclusions. We welcome you to carefully read through the information in this booklet and the accompanying literature about your Covered Services so you know how and where you can access health care services. This Combined Evidence of Coverage and Disclosure Form is only a summary of your Benefit Plan. The Group Service Agreement must be consulted to determine the exact terms and conditions of your Covered Services. For your easy reference, a schedule of benefits matrix is located in the “Benefits Description Table” section. If you have special health care needs, we recommend that you read those sections of the EOC that apply to your needs.

Even after you have read the EOC, you may still have questions. Please remember you have someone you can count on, your Member Advocate, who can help you manage the details of your health care like paperwork, referrals and even selecting a personal physician. And, if you would like help in another language, our helpful staff will make sure you are speaking with us in your language of choice, at no cost to you. Simply call our VHP Member Services Representatives at 1.88.421.8444 (toll-free) during regular business hours 9:00am – 5:00pm or send us an email any time of the day or night to memberservices@vhp. sccgov.org For the hearing and speech impaired, call the California Relay Service (CRS), by simply dial 711 or the 800 CRS number of your modality.

To help you find commonly used health care services, VHP has created an “Access to Services & Network Providers” booklet. This booklet along with updated benefit changes, events, provider listings, and general information can be found at www.valleyhealthplan.org The staff at Valley Health Plan (VHP) appreciates your membership and look forward to serving you.

Well wishes, Valley Health Plan

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Table of Contents Important Information .........................................1 Welcome to Valley Health Plan!..........................2 About This Evidence of Coverage and Disclosure Form............................................4 General Information - English.............................6 General Information - Spanish............................8 General Information - Vietnamese....................11 Eligibility & Enrollment......................................13 Choice of Physicians & Providers....................18 Access to Care....................................................20 Emergency & Urgently Needed Services.........28 Benefits Description Table................................31 Benefit Descriptions......................................... 56 Limitations & Exclusions...................................71 Payment & Reimbursement Responsibility.....75 Member Services Assistance........................... 80 Termination of Benefits.................................... 84 Individual Continuation of Coverage............... 89 Retiree Continuation of Coverage................... 96 General Information.......................................... 99 Definitions.........................................................102 Index.................................................................. 113 Helpful Contact Information............................ 116

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About This Combined Evidence of Coverage and Disclosure Form This booklet is designed as a reference guide to help you understand your Benefits through VHP (the Plan) and how to use them. It is called a Combined Evidence of Coverage and Disclosure Form (EOC).

It contains guidelines on how to get the most from your VHP Benefits, you should read it carefully as certain limitations and conditions affect your Benefit Plan. The following is a brief outline of the major sections included in this booklet. This outline together with the Table of Contents and the Index will help you better understand where you can go to find the information you need.

Multi-Language General Information These pages provide a brief overview about VHP health plan in English, Spanish, and Vietnamese.

Eligibility and Enrollment This section outlines the eligibility requirements, walks you through the enrollment process, explains the Open Enrollment Period, and provides information relating to your Effective Date of Coverage.

Choice of Physicians & Providers – Access to Care This section provides information on some of the choices you will need to make, including which Plan Providers you will be using and how to select your Primary Care Physician (PCP). You will also learn about your identification card, how to change your PCP, what happens when you need to see your doctor, and how to obtain a referral to a specialist for care.

Emergency & Urgently Needed Services This section will help you understand the difference between Emergency and Urgently Needed Services. You will also identify who to call if your condition is urgent but not a medical emergency, what to do in the case of an emergency situation, as well as what to do should you need follow-up care after receiving Emergency or Urgently Needed Services.

Benefits Description Table The Benefits Description Table or schedule of benefits explains the specifics of your Benefit Plan, including information on how to obtain Coverage and any Copayment that you may be charged for Covered Services. It outlines the benefits, services, limitations, and exclusions of your Benefit Plan.

Benefit Descriptions For a more comprehensive explanation of the Covered Services contained in the “Benefits Description Table” refer to this “Benefits Descriptions” section. In this section, you will find detailed information on such things as what happens when you need to be hospitalized, the difference between health education and health promotion services, and how to get a prescription filled.

Limitations & Exclusions This section lists the benefits and services not covered under the Agreement as well as certain limitations and exclusions that were not included in the “Benefits Description Table.” Many of the services listed in this section pertain to more than one benefit.

Payment & Reimbursement Responsibility In this section find information about your premium, other Member charges and what happens when you reach your Copayment Maximum. The section also explains how VHP pays its Plan Providers and the procedure for sending VHP any Covered Services billings you may have received or how to file a Member Claim should you have to pay the bill or furnish a deposit for covered expenses due to an Emergency or Urgently Needed Service. In addition, you can find out your responsibilities when there is a Coordination of Benefits or third party reimbursement.

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About This Combined Evidence of Coverage and Disclosure Form Member Services Assistance For information on how to obtain medical care, interpret your covered health benefits, change your Primary Care Physician, add dependents, request a new VHP ID card, submit claims, file a Grievance, or to assist you with any other service issues, refer to this section.

Termination of Benefits You may choose to end your membership in the Benefit Plan through voluntary Disenrollment; or your Coverage may be terminated through loss of employment, cancellation or termination of the Agreement, or for reasons of cause as explained in this section.

Individual Continuation of Coverage Should you become disabled, lose your job, or retire, optional coverage may be available for you or your Eligible Dependent(s). Refer to this section for information on the various options available for you and your family.

Retiree Continuation of Coverage This section is dedicated to retiree continuation of coverage. Here you will learn how to become a VHP Retiree Member, who is eligible, what retiree covered services are available and about retiree termination.

General Information This section provides additional information on VHP’s responsibilities to you, your medical records, and your rights and responsibilities as a VHP Member.

Definitions To help you better understand defined terms, we have provided an explanation of the major words and terms.

Defined terms are identified by their initial capitalization. Example: Covered Services; Plan Provider.

Table of Contents Refer to the Table of Contents to locate the sections included in this Combined Evidence of Coverage and Disclosure Form (EOC).

As you read this booklet, you may have questions. For information, call a Valley Health Plan Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free). For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number from your modality.

Visit our website at www.valleyhealthplan.org for additional information.

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General Information - English Where Can I Go To Get Healthcare?

In Case of an Emergency: In the event of an Emergency, call 911 or seek care at the closest hospital. It is an emergency if waiting to get care could be dangerous to your life or a part of your body.

Primary Care Doctors: Your doctor or Primary Care Physician (PCP) plays a key role in your health care and will be your regular personal doctor. Valley Health Plan has a number of health centers and individual provider offices that provide the health care services you need. These doctors are located throughout Santa Clara County. These visits are covered 100% through VHP. To find a PCP, visit the VHP website at www. valleyhealthplan.org and use the Provider Search function, or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free). For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality.

Urgent Care Services: Urgent care is care you need within 24 to 48 hours. If you need Urgent Care Services, call the 24-hour medical advice line at 1.866.682.9492 (toll-free), schedule an appointment or go to a VHP Network Walk-in Urgent Care Clinic. In the event you are out of the Service Area and cannot safely go to your Plan Providers, go to the closest urgent care provider. All follow-up care must be received through Network Plan Providers or authorized by VHP. VHP Network Hospitals: VHP is contracted with several hospitals throughout its Service Area. Except in the case of an emergency, Hospital Services must be authorized by the Plan.

How To Choose A Doctor

Your Primary Care Doctor: Your doctor or Primary Care Physician (PCP) plays a key role in your health care and will be your regular personal doctor. Your doctor may refer you to other doctors/specialists when necessary.

Choosing My Doctor: You can choose your own doctor (PCP) from within the VHP Network. If you do not choose a doctor, you will be assigned one by VHP. To find a PCP, visit the VHP website at www.valleyhealthplan.org and use the Provider Search function, or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

Changing My Doctor: You can change your doctor at anytime by calling VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

Who To Call

Member Services: Call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) if you have any questions about your health plan benefits or if you need help with any other health plan matter. For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality.

Appointments: To schedule an appointment with your PCP, call the appointment phone number listed for their office. For Provider office appointment phone numbers, visit the VHP website at www.valleyhealthplan. org and use the Provider Search function, or call Member Services at 408.885.4760 or 1.888.421.8444 (tollfree).

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General Information – English Medical Advice: Call 1.866.682.9492 (toll-free) to speak with an “Advice Nurse.” Advice Nurses are available 24 hours a day, seven (7) days a week. They can give you medical advice and direct you to the care you need.

Language Services: “We’ve Got You Covered.In Your Preferred Language.” Call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) if you would like to talk to us in your language about any questions, comments or concerns. VHP in coordination with Plan Providers offers over-the-telephone language assistance at no cost to you. You can also get an interpreter to talk to your doctor by contacting VHP Member Services. In addition, as required by the Department of Managed Health Care (DMHC), VHP can provide written translation of vital documents, such as applications, Grievance or consent forms, or other important membership materials. If you have questions about language services, call our Member Services Department.

Member Grievances

At Valley Health Plan (VHP) we take pride in being a member-focused health plan. Our Member Services Representatives are able to help you in resolving your concerns by calling 408.885.4760 or 1.888.421.8444 (toll-free), Monday through Friday between 9:00am - 5:00pm. You may request that a Grievance be filed on your behalf or you can complete a Grievance form and submit it to VHP. Grievance forms are available through VHP and at your provider’s office. Forms are available in English, Spanish, or Vietnamese. You also have the right to request this vital document to be translated in the language of your choice; the Plan has 21 days to translate the Grievance form for you. Send your Grievance to Valley Health Plan, Attention: Grievances, 2480 N. First Street, Suite 200, San Jose, CA 95131. Alternatively, you may also submit your Grievance online in English, Spanish, or Vietnamese at www.valleyhealthplan.org. You have 180 days from the date of the event, which caused a Grievance, to file your Grievance. As needed, the 180 days starts on the date the Plan provides you with a Grievance form, translated into the language of your choice other than English, Spanish or Vietnamese.

Department Of Managed Health Care (DMHC) Consumer Help-Line

“The California Department of Managed Health Care is responsible for regulating health care service plans.

If you have a Grievance against your health plan, you should first telephone your health plan at 408.885.4760 or 1.888.421.8444 (toll-free) and use your health plan’s grievance process before contacting the Department (for the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality). Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a Grievance involving an emergency, a Grievance that has not been satisfactorily resolved by your health plan, or a Grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1.888.HMO.2219) and a TDD line (1.877.688.9891) for the hearing and speech impaired. The Department’s Internet website http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.”

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General Information - Spanish ¿Dónde Puedo Ir Para Recibir Atencion Medica?

En caso de Emergencia: En el caso de una Emergencia, llame al 911 o busque ayuda en el hospital más cercano.

Es una emergencia si esperar para obtener cuidado de salud pudiera ser peligroso para su vida o para una parte de su cuerpo.

Doctores de Cuidado Primario: Su doctor o su médico de Cuidado Primario (PCP) juega un papel importante en el cuidado de su salud y será su doctor personal regular. Valley Health Plan (VHP) tiene varios centros de salud y oficinas de proveedores individuales para brindarle los servicios de de salud que usted necesita. Estos doctores están ubicados en todo el Condado de Santa Clara. Las visitas están cubiertas en un cien por ciento (100%) a través de VHP. . Para encontrar un doctor de cuidado primario visite el sitio de internet www.valleyhealthplan.org de VHP y use la función búsqueda de proveedor, o llame a Servicios para miembros al 408.885.4760 o a la línea gratuita 1.888.421.8444. Las personas con discapacidad de audición y del habla, pueden llamar a California Relay Service (CRS) simplemente marcando el 711 o el número CRS 800 de su modalidad.

Servicios de Cuidados Urgentes: Cuidado urgente es el que usted necesita en un plazo de 24 a 48 horas.

Si usted necesita Servicios de Cuidados Urgentes llame a la línea de consejo médico las 24 horas al 1.866.682.9492, haga una cita o vaya sin cita a la Clínica de Cuidados Urgentes de la red de Valley Health Plan. En el caso que usted esté fuera del área de servicio y no pueda ir en forma segura a los proveedores de su plan, vaya al proveedor de cuidados urgentes más cercano. Todo el cuidado de seguimiento debe ser recibido a través del Plan de Proveedores de la red o ser autorizado por Valley Health Plan.

Hospitales de la red de Valley Health Plan: VHP ha contratado los servicios de varios hospitales en toda su área de servicios. Con la excepción de servicios de hospital en el caso de una emergencia, estos deben ser autorizados por el plan.

Cómo Elegir Un Doctor

Su Doctor de Cuidado Primario: Su doctor o Médico de Cuidado Primario (PCP) juega un papel importante en el cuidado de su salud y será su doctor personal regular. Su doctor lo puede referir a otros doctores o especialistas cuando sea necesario.

Elección de su doctor: Usted puede elegir a su propio doctor (PCP) de la red de Valley Health Plan. Si no elige un doctor, Valley Health Plan le asignará uno. Para encontrar un doctor de cuidado primario visite el sitio de internet www.valleyhealthplan.org de VHP y use la función búsqueda de proveedor, o llame a Servicios para Miembros al 408.885.4760 o a la línea gratuita 1.888.421.8444.

Cambio de doctor: Usted puede cambiar de doctor en cualquier momento llamando a Servicios para Miembros de Valley Health Plan al 408.885.4760 o a la línea gratuita 1.888.421.8444.

A Quién Llamar

Servicios para miembros: Si tiene alguna pregunta acerca de los beneficios de su plan de salud o si necesita ayuda con cualquier otro asunto del plan de salud, llame a Servicios para Miembros de Valley Health Plan al 408.885.4760 o a la línea gratuita 1.888.421.8444 (número gratuito). Las personas con discapacidad de audición o del habla, pueden llamar a California Relay Service (CRS) simplemente marcando el 711 o el número CRS 800 de su modalidad.

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General Information – Spanish Citas: Haga una cita con su doctor de Cuidado Primario, llamando directamente al teléfono de citas de su oficina. Para obtener los números de teléfono de citas de las oficinas de los proveedores visite el sitio de internet www.valleyhealthplan.org de Valley Health Plan y use la función búsqueda de proveedor, o llame a Servicios para Miembros al 408.885.4760 o a la línea gratuita o a la línea gratuita 1.888.421.8444.

Consejo Médico: Llame a la línea gratuita 1.866.682.9492 para hablar con una “Enfermera Consejera.” Las Enfermeras Consejeras están disponibles las veinticuatro (24) horas del día, los siete (7) días de la semana.

Ellas le pueden dar consejo médico y guiarle a recibir el cuidado que usted necesite.

Servicios de Intérprete: “Lo tenemos cubierto…en el idioma de su preferencia.” Llame a Servicios para Miembros de Valley Health Plan al 408.885.4760 o a la línea gratuita 1.888.421.8444 si quisiera hablar con nosotros en su idioma por alguna pregunta, comentario o preocupación. Valley Health Plan, en coordinación con todos los proveedores del plan le ofrecen servicios de intérprete por teléfono sin costo para usted. Para hablar con su doctor, usted también puede conseguir un intérprete contactando a Servicios para Miembros de Valley Health Plan. Adicionalmente, como lo requiere el Departamento de Cuidado de Salud Administrado Department of Managed Health Care (DMHC), Valley Health Plan puede proporcionar traducción escrita de documentos vitales, como solicitudes, formularios de quejas o de consentimientos u otros materiales importantes de membresía. Si tiene alguna pregunta acerca de los servicios de intérprete, llame a nuestro Departamento de Servicios para Miembros.

Quejas De Los Miembros

En Valley Health Plan (VHP) nos sentimos orgullosos de tener un plan de salud dirigido a los miembros.

Nuestros Representantes de Servicios para Miembros pueden ayudarle a resolver sus preocupaciones llamando al 408.885.4760 o a la línea gratuita 1.888.421.8444, de lunes a viernes de 9:00 a.m. a 5:00 p.m. Usted puede solicitar que se presente una Queja a su nombre o puede completar un formulario de Quejas y presentarlo a Valley Health Plan. Los formularios de quejas están disponibles en inglés, español y vietnamita a través de Valley Health Plan y en la oficina de su proveedor. Usted también tiene el derecho de solicitar que este documento vital sea traducido al idioma de su elección; el Plan tiene 21 días para traducir el formulario de Quejas para usted. Envíe su Queja a Valley Health Plan, Attention: Grievances, 2480 N. First Street, Suite 200, San José, CA 95128. Usted también puede presentar su Queja en inglés, español o vietnamita en el sitio del Internet www.valleyhealthplan.org Usted tiene 180 días desde la fecha del evento que ocasionó la Queja para presentarla. Según sea necesario los 180 días se cuentan a partir de la fecha en la que el Plan le proporciona el formulario de Quejas, traducido al idioma de su elección, además de los formularios en inglés, español y vietnamés.

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General Information – Spanish Línea De Ayuda Al Consumidor Del Departamento De Cuidado De Salud Administrado (DMHC)

El Departamento de Cuidado de Salud Administrado de California, el “California Department of Managed Health Care” es responsable de regular los planes de servicio de cuidado de salud. Si usted tiene una Queja contra su plan de salud, primero tiene que llamar a su plan de salud al 408.885.4760 o a la línea gratuita 1.888.421.8444 y usar el proceso de quejas de su plan de salud antes de contactar al Departamento (las personas con discapacidad de audición y del habla deben llamar a “California Relay Service” (CRS) simplemente marcando el 711 o el número CRS 800 de su modalidad). La utilización de este procedimiento de presentación de quejas no prohíbe ningún derecho legal potencial o acciones que pudieran estar disponibles para usted. Si necesita ayuda con una Queja que involucra una emergencia; con una Queja que no ha sido satisfactoriamente resuelta por su plan de salud; o con una Queja que ha permanecido sin resolver por más de treinta (30) días, puede llamar al Departamento para pedir ayuda. Usted también puede ser elegible para una Revisión Médica Independiente (IMR). Si usted es elegible para una IMR, el proceso de IMR le proporcionará una revisión imparcial de decisiones médicas hechas por un plan de salud relacionado a la necesidad médica de un servicio o tratamiento propuesto; decisiones de cobertura para tratamientos que son de tipo experimental o de investigación, y disputas sobre pagos por servicios médicos de emergencia o de urgencia. El Departamento también tiene un número de teléfono de llamada gratuita (1.888.HMO.2219) y una línea TDD (1.877.688.9891) para las personas con discapacidades de audición y del habla. El sitio del Internet del Departamento http://www.hmohelp.ca.gov tiene formularios de quejas, formularios de solicitud de Información Médica Independiente (IMR) e instrucciones.

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General Information - Vietnamese Tôi Có Thể Đi Đến Đâu Để Chăm Sóc Sức Khỏe?

Trong Trường Hợp Khẩn Cấp: Trong trường hợp khẩn cấp, gọi 911 hoặc đến bệnh viện gấn nhất. Trường hợp khẩn cấp là khi phải chờ đợi để được điều trị mà có thể nguy hiểm đến tính mạng hoặc một phần của cơ thể.

Bác Sĩ Chính: Bác sĩ gia đình hoặc Bác Sĩ Chính (PCP) có nhiệm vụ chủ yếu trong việc chăm sóc sức khỏe cho quý vị và là bác sĩ thường lệ của quý vị. Valley Health Plan (VHP) có nhiều trung tâm y tế và văn phòng bác sĩ cung cấp dịch vụ chăm sóc sức khỏe cần thiết cho quý vị. Các bác sĩ này làm việc tại nhiều địa điểm trong khắp Quận Hạt Santa Clara. Các lần khám bệnh được VHP tài trợ 100%. Để tìm một bác sĩ, xin vào trang mạng VHP ở www.valleyhealthplan.org và tìm ở mục Tìm Kiếm Bác Sĩ (Provider Search), hoặc gọi Dịch Vụ Hội Viên ở số 408.885.4760 hoặc 1.888.421.8444 (số miễn phí). Cho những người có khuyết tật về nghe và nói, xin gọi California Relay Service (CRS) bằng cách gọi 711 hoặc số 800 CRS theo thể thức của quý vị.

Dịch Vụ Điều Trị Cấp Tính: Điều trị cấp tính là sự điều trị mà quý vị cần trong vòng 24 đến 48 giờ. Nếu cần Dịch Vụ Điều Trị Cấp Tính, quý vị có thể gọi đường dây cố vấn y khoa 24 giờ ở số 408.885.4760 hoặc 1.866.682.9492 (số miễn phí), để làm hẹn, hoặc đi đến các Khoa Cấp Tính không cần làm hẹn trước trong mạng lưới VHP. Trong trường hợp quý vị đang ở xa, ngoài vùng hoạt động của mạng lưới này, và không thể đến Bác Sĩ của VHP thì quý vị nên đi đến khoa điều trị cấp tính nào gần nhất. Tất cả những sự điều trị tiếp theo sau đó phải được cung cấp bởi các bác sĩ hoặc y viện trong mạng lưới của VHP hoặc được sự chấp thuận của VHP. Các Bệnh Viện Trong Mạng Lưới VHP: VHP có hợp đồng với nhiều bệnh viện trong toàn khu vực. Ngoại trừ trường hợp khẩn cấp, những dịch vụ bệnh viện phải được sự chấp thuận của chương trình bảo hiểm.

Cách Thức Chọn Bác Sĩ

Bác Sĩ Chính: Bác sĩ của quý vị hoặc Bác Sĩ Chính (PCP) có nhiệm vụ chủ yếu trong việc chăm sóc sức khỏe cho quý vị và là bác sĩ thường lệ của quý vị. Bác sĩ của quý vị có thể giới thiệu quý vị đến một bác sĩ/ bác sĩ chuyên khoa khác khi có nhu cầu điều trị cần thiết.

Chọn Bác Sĩ: Quý vị có thể chọn một Bác Sĩ Chính (PCP) trong mạng lưới VHP. Nếu không tự chọn bác sĩ thì quý vị sẽ được VHP chỉ định một bác sĩ. Để tìm một bác sĩ, xin vào trang mạng VHP ở www. valleyhealthplan.org và tìm ở mục Tìm Kiếm Bác Sĩ (Provider Search), hoặc gọi Dịch Vụ Hội Viên ở số 408.885.4760 hoặc 1.888.421.8444 (số miễn phí).

Thay Đổi Bác Sĩ: Quý vị có thể đổi một bác sĩ khác bất cứ lúc nào bằng cách gọi Dịch Vụ Hội Viên, số 408.885.4760 hoặc 1.888.421.8444 (số miễn phí).

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General Information – Vietnamese Gọi Ai

Dịch Vụ Hội Viên: Gọi Dịch Vụ Hội Viên, số 408.885.4760 hoặc 1.888.421.8444 (số miễn phí) nếu quý vị có câu hỏi về quyền lợi bảo hiểm sức khỏe hoặc nếu quý vị cần sự trợ giúp bất cứ việc gì liên quan đến bảo hiểm sức khỏe. Những người có khuyết tật về nghe và nói có thể gọi California Relay Service (CRS) bằng cách gọi 711 hoặc số 800 CRS theo thể thức của quý vị.

Làm Hẹn: Muốn làm hẹn với Bác Sĩ Chính (PCP), xin gọi thẳng số điện thoại của văn phòng bác sĩ của quý vị. Để tìm số điện thoại của văn phòng bác sĩ của quý vị, xin vào trang mạng VHP ở www.valleyhealthplan.org và tìm ở mục Tìm Kiếm Bác Sĩ (Provider Search), hoặc gọi Dịch Vụ Hội Viên ở số 408.885.4760 hoặc 1.888.421.8444 (số miễn phí).

Cố Vấn Y Khoa: Quý vị có thể gọi số 408.885.4760 hoặc 1.866.682.9492 (số miễn phí) để nói chuyện với “Y Tá Cố Vấn.” Có các y tá này sẳn 24 tiếng mỗi ngày, 7 ngày mỗi tuần. Các y tá này có thể cố vấn về y khoa và chỉ dẫn quý vị đi đến nơi nào để nhận được sự điều trị cần thiết.

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Eligibility andEnrollment Enrollment Eligibility and Becoming a VHP Member

Before applying for VHP membership you and/or your Eligible Dependent(s) must meet certain eligibility and enrollment requirements. After you have enrolled in VHP you must continue to meet these requirements.

This section outlines who is eligible to enroll, how to enroll, how to renew and retain membership, and when coverage begins. If you have any questions regarding eligibility, enrollment, or changes to your enrollment contact your employer.

To review a copy of the Group Service Agreement, contact your employer or VHP. In the event of conflicts between the Group Service Agreement and the EOC, the provisions of the EOC will be binding upon the Plan even if provisions in the Group Service Agreement are less favorable to Subscribers or their Dependents.

You must report any changes in employment, any change that would affect your eligibility or the eligibility of your dependents to your employer within 31 days of the change in status.

Eligibility

You are eligible to apply for Coverage under the Benefit Plan as long as you meet the definition of Eligible Employee or Eligible Dependent and you: • live or work in Santa Clara County, • satisfy the Group’s waiting period requirements, and • meet the Group’s eligibility requirements. Your employer determines your eligibility.

Please see the “Definitions” section for definitions of Eligible Employee and Eligible Dependent.

You are also eligible to apply for Coverage under the Benefit Plan as long as you meet the definition of an Eligible Retiree. Your employer determines your eligibility. If you are an Eligible Retiree, you must reside within the Service Area, San Francisco County, or any adjacent counties to the Service Area. Adjacent counties include: San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties.

Please see the “Definitions” section for the definition of Eligible Retiree.

VHP may verify eligibility, employee status and dependent status. Services are not covered prior to the Member’s Effective Date of Coverage or after the Member’s Coverage Termination date.

Members who are terminated, retired, or separated from employment with the Group may be eligible for continued coverage. (Please refer to the “Individual Continuation of Coverage” section for details.)

Enrolled Eligible Retirees and their dependents who reside outside the Service Area, may be eligible for Coverage, but will only be covered for Emergency or Urgently Needed Services outside of Santa Clara County. All follow-up or Routine Care must be received in Network through the Member’s PCP. Enrolled Eligible Dependent children under the age of 26, who reside outside the Service Area, may be eligible for Coverage, but will only be covered for Emergency or Urgently Needed Services outside of Santa Clara County. All follow-up or Routine Care must be received in Network through the Member’s PCP.

For Eligibility & Enrollment Information, call 408.885.4760.

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Eligibility and Enrollment Prior to January 1, 2014, the Plan may exclude eligibility if the adult dependent is eligible to enroll in an employer plan. Contact your employer to verify if your dependent is eligible for Group Benefits.

Except for Eligible Retirees, in the event that a Subscriber works and resides outside the Service Area for more than 90 consecutive days (with no intention of returning) he/she is not eligible, or is no longer eligible for Coverage under the Benefit Plan.

You or any one of your dependents may not be eligible to enroll, if you or your dependents have ever been terminated by VHP for a reason stated in the “Termination of Benefits-Cancellation of Members for Cause” and/ or “Termination for Nonpayment” section.

Children of your Dependent(s) are not eligible to enroll unless they meet your employer’s eligibility requirements. If you or your Dependent(s) are subsequently found to be ineligible, VHP will not provide Benefits during the period of ineligibility and will be entitled to reimbursement from you for any services rendered and claims paid during such period you were not eligible for membership.

Uninsured young adult Dependent(s), aged 19 through 25, with a pre-existing condition may face a preexisting condition exclusion. The exclusion is up to six (6) months if they were uninsured for 63 days or more prior to gaining Coverage. In this case, VHP can exclude coverage of pre-existing conditions to the extent that is allowed by California state laws. Starting in 2014, pre-existing condition exclusions will no longer be permitted through Group Coverage. Contact Member Services or your employer for more information.

If you and your Dependent(s) are otherwise eligible to enroll, VHP will not refuse to enroll you or your Eligible Dependent(s) because of a pre-existing health condition.

Enrollment

VHP must receive a completed and signed enrollment form for you and/or your Eligible Dependent(s) to apply for Coverage. Your employer will distribute an application form and other VHP materials for enrollment and reference. Upon your request, your employer will provide a copy of the VHP Combined Evidence of Coverage and Disclosure Form or Valley Health Plan Benefits and Coverage Handbook. Your employer is responsible for submitting a properly completed membership application and applicable premiums to the Plan. Following receipt, VHP will process all eligible enrollments and distribute a Member packet and Identification Card(s) to your current address in VHP records. As part of the application process, you will be asked to provide personal information including name, address, race, ethnicity, and language written and spoken.

At the time you enroll, you may be eligible to continue receiving treatment from your non-VHP Provider. Please refer to the “Access to Care” section under “Continuity of Care” to determine if you may continue with a former provider.

Enrolling Initially You must apply for membership for you and your Eligible Dependents by submitting an application to your Group within the Initial Eligibility Period. Contact your employer for information about the application process; when you are eligible to enroll; and your Effective Date of Coverage.

If you or your Dependent(s) do not enroll when you first become eligible, you may enroll only during the next Open Enrollment Period.

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Eligibility and Enrollment Adding Dependents You must submit an enrollment or status change request to your employer to add a new spouse or dependent(s). VHP must receive the request within 31 days after they became your Eligible Dependent(s). You must provide proof of dependent status (e.g. birth or marriage certificate) when you add Eligible Dependents to your Coverage.

If you must provide coverage for a non-custodial child due to a court order for medical support, you must complete enrollment within 31 days of the court order. You must provide proof of legal status or court order.

You must notify your employer and VHP of any changes in status that affect your own or your enrolled Dependent’s eligibility. If you do not enroll your Eligible Dependents when they are first eligible, you will not be able to enroll them until the next Open Enrollment Period.

This section does not apply if your employer group does not offer Dependent coverage.

Coverage for Eligible Dependents Who are Disabled Dependents who meet the Dependent eligibility requirements, except for the age limit, are eligible as disabled dependents if they meet all of the following requirements; • Your Group permits enrollment of Dependent children; • They are your or your Spouse’s children, your or your Spouse’s adopted children, children placed with you or your Spouse for adoption, or children for whom you or your Spouse is the legal guardian; • They are incapable of self-sustaining employment because of a physically or mentally disabling injury, illness, or condition that occurred before they reached the age limit for Dependents; • They receive support and maintenance chiefly from you or your Spouse; and • VHP receives proof of their incapacity and dependency.

If the Dependent is a Member at the time the child turns age 26, Coverage will only continue if the Subscriber notifies the Group prior to the Dependent turning age 26. The Subscriber must provide the proof of their incapacity and dependency within the Group’s required timelines. If the Group determines that the Dependent is eligible as a disabled Dependent, there will be no lapse in Coverage.

If the Dependent is not a Member and the Subscriber is requesting enrollment, the Subscriber must provide documentation of the Dependent’s incapacity and dependency at the time of enrollment.

Enrolling Late or During Open Enrollment Late enrollment occurs when you or your Eligible Dependent(s) do not enroll when you first become eligible.

If you do not enroll when you first become eligible, you may enroll only during the next Open Enrollment Period. Your employer will announce the dates of the Open Enrollment Period.

If you decline enrollment for you or your Eligible Dependents because of other health insurance coverage but that insurance ceases, you may enroll yourself or your Eligible Dependent(s) within 31 days after such coverage ends.

For Member Services, call 408.885.4760.

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Eligibility and Enrollment If you do not enroll when you first become eligible, the late enrollment rule will not apply if: • You never received a form from the employer.

• You never signed a form explaining the consequences of the employee’s decision.

• Your signed form exists but cannot be produced as evidence of the employee’s informed decision.

Coverage for Eligible Retirees

You and your Eligible Dependent(s) may be eligible for Valley Health Plan Group Coverage if you are retired.

To continue or obtain Coverage as a retired Subscriber: • You must be an Eligible Retiree from a Group that offers VHP as a benefit to its retired employees; • You and your Eligible Dependent(s) must be enrolled in VHP and VHP must receive prepayment fees or premiums from the Group; • You must meet the Group’s eligibility criteria and the Group’s applicable waiting period requirements; • You must reside continuously within the Service Area, San Francisco County, or any adjacent counties to the Service Area. Adjacent counties include: San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties; and • If you are eligible for Medicare, you must enroll in Medicare and contact your Group and VHP Member Services.

To enroll in Valley Health Plan as an Eligible Retiree, contact your employer. Your employer will give you the necessary paperwork, including the VHP application form. Your employer will advise you of your responsibility for any portion of VHP monthly membership fees or premiums.

Refer to the “Retiree Continuation of Coverage” section of this EOC.

When Coverage Begins

Covered Services begin on the Effective Date of Coverage established by your employer if you enroll: • When you or your Eligible Dependent(s) first became eligible; or • At an Open Enrollment Period; or • Within 31 days of a late enrollment. (Refer to the “Enrolling Late or During Open Enrollment” section.)

Covered Services begin for your Dependent: • Newborn natural child—at the moment of birth; or • Adopted child—on the date you obtain adoptive custody or when you receive the legal right to control the adopted Eligible Dependent child’s health care; or • Ward who is an Eligible Dependent child—on the commencement date of legal guardianship.

To ensure continued Coverage, you must enroll your newly Eligible Dependent(s) within 31 days after birth, custody, or legal guardianship. If you fail do to so, you must wait until your employer’s next Open Enrollment Period to enroll them.

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Eligibility and Enrollment Continuing Group Coverage for Dependents

Health Coverage may continue for your Eligible Dependent(s) as follows: 1. Physically or mentally handicapped Eligible Dependent(s) who is incapable of sustaining employment and is dependent upon you for support and maintenance may continue Coverage if the child was handicapped on the day before reaching age 26. The child can be covered under the Plan through age 25 or until the child recovers from the handicap or the date the child is no longer chiefly dependent on you for support and maintenance.

Verification of disability and dependency may be required as often as deemed necessary by VHP. However, the Plan will not request verification more often than once a year.

2. Newborn, newly adopted, or new legal ward child can continue Coverage after the first 31 days when you enroll your child within the first 31 days following the child’s birth, adoption, or guardianship.

After this period, you must wait until your employer’s next Open Enrollment Period to enroll your child.

3. Your or your spouse’s natural child, step-child, legally adopted child, or a child under your court-ordered legal guardianship, can be covered under the Plan through the age of 25. Contact your employer regarding continuing Group Coverage for your Dependents.

Renewal Provisions

The Agreement renews automatically as long as premiums have been properly paid. You do not need to reapply, at the time of Open Enrollment or renewal unless changes are needed. Monthly premiums may change upon Open Enrollment or at the time of renewal. If Coverage for you or your Dependent(s) is terminated, you must submit a new application for membership to be reinstated.

Contract Period of This Evidence of Coverage

The Agreement is revised when the contract between your Group and VHP is changed. Any future changes to the Agreement may affect this Combined Evidence of Coverage and Disclosure Form (EOC). The description of Benefits discussed in this Valley Health Plan Benefits and Coverage Handbook is applicable after August 2012. VHP makes revisions to its EOC annually but may not print and distribute it. VHP also distributes member communications regarding Benefits or changes. These communications act as changes and will supersede the current EOC in effect.

It is important to keep all Benefit information or changes mailed to you with the most current EOC. If you would like copies of the EOC, or of recent Member communications, such as the VHP Member newsletter “Perspectives,” visit www.valleyhealthplan.org or call the VHP Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free).

Need Assistance? Call 408.885.4760.

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Choice of Physicians & Providers Please read the following information so you will know from whom or what group of providers health care may be obtained.

Valley Health Plan is a non-profit health plan that contracts with Plan Providers who provide and coordinate Covered Services for Members. As a Member of Valley Health Plan, you must receive all of your Covered Services from these Plan Providers except in the event of an Emergency, Urgently Needed Services or if VHP has preauthorized the services. Refer to the “Liability of Subscriber or Enrollee for Payment” section under “Payment and Reimbursement Responsibility.”

Each Member can select a Primary Care Physician (PCP) upon enrollment. If a PCP is not selected, VHP will assign you a PCP. Your PCP provides all basic medical care, and coordinates any Prior Authorized specialty and Hospital Services you may need.

Your Member packet contains information about VHP’s Primary Care Physicians, facilities, pharmacies, clinics, and laboratories. Although the list(s) of VHP Plan Providers is subject to change, we recommend that you keep this information with this Combined Evidence of Coverage and Disclosure Form. For updated Plan Provider information, visit www.valleyhealthplan.org or call a Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free).

To understand the meaning of important definitions, such as Plan Providers and Service Area, refer to the“Definitions” section of this EOC.

Choosing Your Primary Care Physician

VHP encourages you and your Dependent(s) to choose a VHP Primary Care Physician (PCP). If you do not select a PCP, VHP will assign one to you and your enrolled Dependent(s). For updated Plan Provider information, visit www.valleyhealthplan.org or call a Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free).

To choose a PCP: 1. Include the name of the Primary Care Physician of your choice on your Enrollment Application when enrolling initially.

2. Select a Primary Care Physician who is located near your home or work. You may choose a different PCP for each Dependent.

VHP will make every effort to assign you to the PCP of your choice, however, if this is not possible, VHP will contact you to make another selection.

VHP encourages you to identify your baby’s Primary Care Physician during the last few months of Pregnancy. If you need any assistance in selecting a VHP PCP, please call a Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free) who will be happy to assist you.

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Choice of Physicians & Providers Changing Your Primary Care Physician

You can change your PCP at any time by calling the Member Services Department or by requesting the change in writing. The effective date of the change will be first of the next month after your request is received, provided you are not receiving hospital or other institutional care at the time of your request. In the event you are institutionalized, discuss your effective date with the Member Services Department.

If needed, a new VHP Identification Card (VHP ID Card) will be mailed to you.

In the event your PCP terminates his/her relationship with VHP, you will be notified by VHP and will be assigned a new PCP.

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Access To Care As a Member of VHP, you are selecting our health plan to provide you and/or your family health care. You must receive all Covered Services from Plan Providers inside our Service Area, except as described in the “Emergency and Urgently Needed Services” section. Through our health plan, you have convenient access to all of the Covered Services you may need such as Routine Care with your Primary Care Physician, hospital care, mental health, laboratory and pharmacy services and other Benefits listed in the “Benefits Description Table” and in the “Benefit Descriptions” section.

Scheduling Appointments

VHP offers a wide section of Primary Care Physicians (PCPs) throughout its Service Area. To schedule an appointment with your PCP, call your PCP’s appointment line. For your PCP’s appointment line, go to www. valleyhealthplan.org or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for assistance.

VHP provides a free 24-hour Medical Advice line at 1.866.682.9492 (toll-free).

Language services are available to you at no cost through your Plan Provider.

If you are a female Member, you may obtain Covered Services through direct access (self-refer) from a Plan OB/GYN and/or through direct access from a Plan family practice physician and surgeon (Plan Provider).

VHP recommends you call in advance to schedule your routine doctor’s appointments. Be prepared to provide your name, the VHP ID number on your VHP ID Card, a daytime telephone number where you can be reached, and the reason for the visit (so that adequate time can be scheduled for your appointment).

For more immediate or urgent care attention, tell the office of the urgency of your call and request the next available appointment.

If you need to cancel an appointment, be sure to call your Primary Care Physician’s appointment number immediately so another patient can be scheduled. Whenever possible, you should give at least 24 hours notice when canceling an appointment.

At the time of your doctor’s appointment, you will be asked to show your VHP ID Card and another form of identification. VHP suggests that you carry your VHP ID Card at all times.

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Access To Care Receiving Primary Health Care

The PCP you or your Dependent(s) have chosen will provide or arrange for the majority of your general medical, pediatric, and OB/GYN Covered Services from VHP Plan Providers. To ensure quality health care, you should regularly schedule general checkups and office visits.

Receiving Specialty Care and Referrals

Your PCP will coordinate all specialty care or other Covered Services: • Before you receive specialty services from a VHP Physician, (such as general surgery, orthopedic surgery or cardiology), you must receive a referral from your PCP. Certain self-referred care is an exception.

• Your PCP will obtain Authorization for specialty services. Your PCP will instruct you how to make an appointment to see the Plan Specialist. Making an appointment will be your responsibility. Services received by specialists with no Prior Authorization could result in your financial responsibility. Some specialty referrals may require additional review by the VHP Medical Director.

When all necessary referral information has been provided, VHP will inform you and your PCP of its decision within five (5) business days.

Your Primary Care Physician provides any other special instructions for your specialty visit.

• If you have a Serious Chronic Condition your PCP can request a standing referral to your Plan Specialist.

Your PCP must request the standing referral and must continue to coordinate these services. You will be advised of VHP’s decision within two (2) business days.

• If you require mental health or chemical dependency services, refer to the “Benefits Description” section under “Mental Health Services” or “Chemical Dependency Services.”

To receive more information about referrals and Authorizations, call a VHP Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free), or refer to the “Authorization and Denial of Services” section.

Receiving Self-Referral Services

VHP contracts with its Plan Providers. Based on a Primary Care Physician’s Network, you may self-refer to some specialists. Please contact your PCP’s office directly.

OB/GYN Self-Referral Services Any female Member may self-refer to a Plan OB/GYN. Call a Plan OB/GYN to make an appointment. To find a Plan OB/GYN, go to www.valleyhealthplan.org and use the Provider Search function or contact VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for assistance.

Lock-In Provision You should be aware that the “Lock-In” provision of your Benefit Plan requires you to obtain all Covered Services from Plan Providers in your Network. Except in the case of an Emergency Services or out-of-area urgent care, if you seek and receive services outside of your Plan Network without Authorization you may be responsible for the charges.

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Access To Care Timely Access to Care

VHP provides and arranges for the provision of Covered Services in a timely manner appropriate for the nature of the Member’s condition and consistent with professionally recognized standards of practice. VHP has Timely Access to Care standards. These services are described in this VHP EOC and include: • A “24-hour Medical Advice Line” that Members can call at any time to obtain triage or screening for the purpose of determining the urgency of the Member’s need for care.

• An Authorization system in place that allows for Members to self-refer to OB/GYN or through obtaining standing referrals to Plan Specialists. This Authorization system includes timely referrals for other Medically Necessary Covered Services through the Plan Provider Network.

• A process to schedule or reschedule health care appointments. VHP has a website www.valleyhealthplan.org that directs Members to VHP Providers or to locations. The website directs you to Plan Providers, including emergency and urgent care. The website details provider telephone numbers and gives you the Urgent Care Clinic’s hours of operation. Many of our Urgent Care Clinics offer self-referral/walk-in same day urgent care services. Appointments are not necessary but it may save you time if you call ahead.

• A Member Services Department, with English, Vietnamese, and Spanish speaking representatives, who offer assistance in obtaining covered health care services and resolving Members health care issues. Additional interpreter services are available, as needed, at the time of the appointment or in the interpretation of critical documents, such as needed during the Plan’s Grievance Process.

• Professionally recognized standards of practice used to determine wait times when scheduling appointments that meet legislative requirements. Such standards do not prohibit the Plan or the Plan Providers from accommodating a Members’ preference to wait for a later appointment from a specific Plan Provider.

For more information on timely access to care, including language services, contact VHP Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free).

Receiving Hospital or Other Facilities Care

Valley Health Plan is contracted with several hospitals throughout its Service Area. Except in the case of an emergency, Hospital Services must be authorized by the Plan.

Medical advice services are available 24 hours a day by calling 1.886.682.9492 (toll-free). To receive any Medically Necessary hospital or facilities Covered Services: • Your Primary Care Physician will arrange for all Covered Services, including inpatient, transitional, and/or care provided in a sub-acute or Skilled Nursing Facility. Authorization is required for all facilities care and VHP should be notified of any such care either prior to admission or, as in the event of an emergency, as soon as possible thereafter.

• In the rare event Covered Services are not available at a Plan Facilities, your Primary Care Physician will arrange with VHP for a Prior Authorized referral. If you receive services without a Prior Authorization, or if you receive services outside of the VHP Provider network, you may be responsible for the charges.

• In the event of an Emergency and you cannot safely come to a Plan Hospital, you should call 911 or seek care at the closest hospital. Please refer to the “Emergency Services” section.

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Access To Care Receiving Care While Out of Network/Service Area

Before leaving the Service Area, it’s important that you obtain any care (such as Routine Care or foreseeable care for Serious Chronic Conditions) that you know will be needed before you return. For example, if you require routine dialysis or oxygen therapy and know that you will require a treatment during your absence, you should either make arrangements to obtain the necessary therapy prior to leaving the Service Area or work with your Primary Care Physician and VHP to obtain Prior Authorization for this care from a Non-Plan Provider while you are Out of Network/Service Area.

Services that you receive while Out of Network/Service Area that can be foreseen and have not been Prior Authorized, are not considered Urgently Needed Services or Emergency Services. If you delay receiving or arranging for this care until you are Out of Network/Service Area, VHP will not pay for your care and you will be financially responsible for the full cost of such services.

In the event of Urgently Needed Services, call the 24-hour Medical Advice line at 1.866.682.9492 (toll-free). The advice nurse will assess your condition and direct you to the appropriate care. The telephone number is also printed on your VHP ID Card. You should also notify Valley Health Plan at 408.885.4760 or 1.888.421.8444 (toll-free) and as needed, leave a message. Refer to the “Emergency and Urgently Needed Services” section under “Urgently Needed Services.”

In the event of an Emergency, call 911 or go to the nearest emergency room. Refer to the “Emergency and Urgently Needed Services” section.

Receiving Health Care as a Dependent While Out of Network/Service Area

Enrolled Dependents residing Out of Network/Service Area will only be covered for Emergency or Urgently Needed Services when out of the Service Area. All follow-up or Routine Care must be received in Network through the Member’s PCP.

Authorization and Denial of Services

Valley Health Plan contracts with Primary Care Physicians and Plan Providers who are responsible for providing and coordinating Covered Services for its Members. Except in the event of an emergency, Urgently Needed Services, or if VHP has authorized the services in advance, you must receive all of your care from these Plan Providers. Services not received from the Member’s PCP require a referral (unless such services are eligible for self-referral as defined in this EOC).

All Covered Services are provided, arranged for, or coordinated by your PCP. For Members to receive Covered Services that requires an Authorization: •

a VHP PCP must initiate such a referral to a specialist on behalf of the Member;

•

as needed, the referral is submitted for approval or Denial; and

•

in the event that the referral requires Prior Authorization, VHP’s Medical Director must approve Authorization prior to a Member receiving Covered Services.

If you would like more details regarding the Authorization process of your Benefit Plan, contact VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

For 24-hour Medical Advice, call 1.866.682.9492 (toll-free).

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Access To Care Members are notified of Authorizations and Denials by VHP in writing. Except for Emergency Services or Urgently Needed Services (Refer to the “Emergency and Urgently Needed Services” section), if you receive services without an Authorization, or if you receive services outside of the VHP Network, you may be responsible for the charges.

If you believe that your Primary Care Physician or other VHP Provider has improperly denied a request for treatment or services, you may file a Grievance by calling Member Services 408.885.4760. You should file this Grievance within 30 days of the initial Denial. If the service you requested is still denied and you have followed the VHP Member Grievance process described in the “Member Grievances” section; you may contact the DMHC Consumer Help-line at 1.888.HMO.2219 (toll-free) or visit the Department’s Internet website http://www. hmohelp.ca.gov Requests involving an imminent and serious threat to your health will receive an expedited review, as may be required by the urgency of the situation.

In the event that you are dissatisfied with any action or adjustment by your Plan Provider or VHP, you should follow the “Member Grievances” procedure as outlined in this EOC. In addition, you may also contact the California Department of Managed Health Care. Refer to the “Department of Managed Health Care Consumer Help-Line” section for more details.

Second Medical Opinions

A second medical opinion is a medical evaluation that you seek from a provider other than your current VHP treating provider. Second medical opinions within the VHP Network are a Covered Service. Second medical opinions outside the VHP Network are not covered unless VHP’s Medical Director or Utilization Department has given Authorization. You have the right to request and receive a second medical opinion.

Request a second opinion: • If you question the reasonableness or necessity of recommended surgical procedures; •

If you question a diagnosis or plan of care for a condition that threatens substantial impairment or loss of life, limb, or bodily function, or, a Serious Chronic Condition;

•

If the clinical indications are not clear or are complex and confusing,

•

If a diagnosis is in doubt due to conflicting test results, or your Plan Provider is unable to diagnose the conditions, and you request an additional evaluation;

•

If your treatment is not improving your condition within an appropriate period of time given the diagnosis and plan of care, and you request a second opinion regarding the diagnosis or continuance of the treatment; or

•

If you have attempted to follow the plan of care or discussed your serious concerns about the diagnosis or plan of care with your Provider.

If you request a second opinion about care from a specialist, the second opinion shall be provided by any provider of your choice within the Plan Physician network of the same or equivalent specialty. If you want to request a second medical opinion, your PCP, your VHP Provider, or VHP Member Services Representative can help you make the necessary arrangements. As needed, they can help you select which VHP Plan Provider to call. Decisions regarding second medical opinions will be made and the Member and Provider will be notified within the following time frames: • Emergency Services requests — within 2 – 6 hours •

Urgently Needed Services requests — within 24 hours

•

Routine requests — within 5 business days

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Access To Care If you are seeking an Emergency Services second medical opinion after normal business hours, call the 24-hour Medical Advice Line at 1.866.682.9492 (toll-free). Please call 408.885.4647 on the next business day and advise the VHP Utilization Department of your request.

Providers will render services for second medical opinions within 30 calendar days. When needed, providers will provide an expedited second medical opinion within 72 hours.

If you are not satisfied with the way your request or the determination of a second medical opinion has been handled, you can call a Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free). VHP representatives will help resolve your concern or, if necessary, assist you in filing a Grievance as outlined in the “Member Grievances” section. You may also contact the California Department of Managed Health Care’s Health Plan Division; refer to the “DMHC Consumer Help-Line” section for more details.

Continuity of Care

If you or your Dependent(s) have an Acute Condition, a Serious Chronic Condition, a Pregnancy, a terminal illness, or your newborn child between birth and age 36 months is under medical care, and at the time of new enrollment, you may be eligible to continue to receive treatment from your provider (e.g. physician or hospital) if the following apply: • if your treating Plan provider terminates as a VHP Plan Provider, or •

if you are receiving care from a non-participating provider at the time of your enrollment in Valley Health Plan.

This section describes the Covered Services of this continuity of care. You have the right to request a copy of the Plan’s Continuity of Care policy. To request a copy of this policy, call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

Continuity of care Covered Services will be provided to qualified Members from their provider. Treatment will be provided in a timely and appropriate basis as determined by the Plan Physician. In the case that the Member is Pregnant, continuum of care Covered Services will be provided until postpartum services related to the delivery are complete or until such time as it is deemed appropriate. Plan Providers will consult with the Member’s provider to determine when it is safe to transfer.

Completion of Covered Services following termination of a Plan Provider or enrollment in the Plan: 1. for an Acute Condition shall be provided for the duration of the Acute Condition.

2. for a Serious Chronic Condition shall be provided for a period of time necessary to complete the course of treatment and to arrange for a safe transfer to a Plan Provider. Completion of Covered Services shall not exceed 12 months.

3. for a Pregnancy shall be provided for the duration of the Pregnancy.

4. for a terminal illness shall be provided for the duration of the terminal illness. Terminal illness for continuity of care is defined as an incurable or irreversible condition that has a high probability of causing death within one (1) year or less. Completion of Covered Services shall be provided for the duration of a terminal illness, which may exceed 12 months from the Plan Provider contract termination date or 12 months from the effective date of Coverage for a new Member.

5. for the care of a newborn child between birth and age 36 months. Completion of Covered Services shall not exceed 12 months.

In an emergency, call 911.

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Access To Care 6. for the performance of a surgery or other procedure that is authorized by the Plan as part of a documented course of treatment and has been recommended and documented by the current provider at the time of enrollment or Plan Provider termination. Completion of such surgical Covered Services must occur within 180 days.

To receive continuation of care from your provider or terminated Plan Provider, you must obtain a written Prior Authorization from VHP. This Authorization shall state the predetermined amount of time you will be able to continue to receive care from your current provider.

A written referral for continuity of care is only provided if you are a new Enrollee or your provider is a terminated VHP Provider, when: 1. the delay in the services will result in loss of continuity of care, 2. the services are Medically Necessary Covered Services under the terms of your Group Coverage with VHP when provided by Plan Providers; 3. the services are provided within the Service Area, 4. your Coverage with VHP is in effect, 5. the terminated Provider or Out-of-Network Provider signs a new temporary contract with VHP, and the terminated Provider was not terminated by VHP for reasons other than medical disciplinary cause, criminal activity, or the provider’s voluntary termination.

Your Coverage with VHP does not include an Out-of-Network option.

To apply for this continuity of care coverage, call Member Services at 408.885.4760 or 1.888.421.8444 (tollfree) within 30 days from your Effective Date of Coverage with VHP, or within 30 days from the date you received notice from VHP that your Plan Provider has terminated or when your Plan Provider notifies you that he/she is terminating from VHP. For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality.

Independent Medical Review

One of VHP principal exclusions is service that is not Medically Necessary. The determination whether a service or supply is Medically Necessary is made by the Plan Medical Director based on an objective review.

All decisions are subject to the Plan Grievance procedures. If VHP denies you health care services because it is not Medically Necessary, you, your designee, or your doctor can request an Independent Medical Review (IMR). Before initiating an IMR, you must have completed the VHP Grievance process or have participated in the Grievance process regarding a Disputed Covered Service for at least 30 days.

The Department of Managed Health Care’s HMO Help Center operates the Independent Medical Review Program, which is a review process conducted by health care professionals who are not associated with Valley Health Plan. These doctors and other health care professionals outside VHP make an independent decision about your health care.

You must submit a request for an Independent Medical Review to the DMHC within six (6) months of receiving a Denial from the Plan. You may only request a review for a service that is a Covered Benefit. You can obtain more information on the Independent Medical Review process on the Department of Managed Health Care’s website www.dmhc.ca.gov (Questions and Answers about IMR) or by calling a Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free).

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Access To Care If services are denied because they are Experimental or Investigational Treatment(s), which are non-Covered Benefit(s), you have the right to request an IMR from the DMHC without first participating in the VHP’s Grievance process. The IMR request for review of Experimental or Investigational Treatments must be based on the following requirements that the Member’s Plan Physician certifies that the disease or condition is: a) Life-Threatening and Seriously Debilitating, or b) due to a terminal condition that has a high probability of causing death within two (2) years and that your Plan Physician certifies that standard therapies used have not been effective to improve the condition, would not be medically appropriate, or for which there is no other beneficial standard therapy covered by the plan than the proposed drug, device, procedure or therapy, and c) the specific drug, device, procedure, or other therapy recommended by the Plan Physician would be a Covered Benefit, except for the Plan’s determination that the therapy is Experimental or Investigational.

Nothing in this section shall preclude a Member from seeking assistance directly from the Department in cases involving imminent or serious threat to the health of the Member or where the Department determines an earlier review is warranted. In such cases, the Department may require the Plan and contracting Plan Providers to expedite the delivery of information.

For additional information on the “Department of Managed Health Care Consumer Help-Line” or the Plan’s “Grievance process” refer to the “Member Services Assistance” section.

VHP Website: www.valleyhealthplan.org

The Valley Health Plan website address is www.valleyhealthplan.org This site provides information about Covered Services/Benefits, VHP Providers and their locations, and health education information and classes.

There is also a listing of phone numbers to call for appointments, to reach a VHP Network Pharmacy, for appointments with a self-referral clinic (OB/GYN and some specialists based on your PCP network), or to reach VHP Member Services.

VHP Newsletter – Perspectives

Valley Health Plan publishes the “Perspectives” newsletter twice a year. It includes articles on how to access to care, health and wellness advice, health tips, physician profiles, and other information important to VHP members. For a copy of Perspectives, contact the VHP Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free). You may also visit VHP’s website at www.valleyhealthplan.org to view the most recent newsletters.

Using Your VHP ID Card

After enrolling, you will receive a VHP ID Card for yourself and each covered Dependent. Keep your VHP ID Card handy when you call to make an appointment, or go to a medical facility for care.

Please note: Your VHP ID Card is for identification only. To receive Covered Services, you must be an Eligible Member. Anyone who is not a VHP Member will be charged for any services received. If you let someone else use your card, your membership may be terminated.

For Member Services, call 408.885.4760.

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Emergency & Urgently Needed Services Emergency Services are available within or outside of your Service Area 24 hours a day, 7 days a week.

Urgently Needed Services are available through Plan Providers or through Non-Plan Providers while out of the Service Area.

Although all necessary care is available in your Network, VHP also covers you for all Emergency and Urgently Needed Services received from Non-Plan Providers: • when your condition is so emergent that you cannot safely come to a Plan Hospital, and •

when you are out of the Service Area and require urgent medical care and you cannot safely go to a Plan Provider.

Be sure to carry your VHP ID Card with you at all times to access care.

Emergency Services

In an emergency, call 911 for assistance, go to the nearest emergency room.

Emergency Services are covered when furnished by: • Plan Providers or •

Non-Plan Providers when a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, Active Labor, and psychiatric condition) is such that the absence of immediate medical attention could reasonably expect the delay to result in: serious impairment to your bodily functions; serious dysfunction of any bodily organ or part; or serious jeopardy to your health or psychological well-being.

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. Psychiatric Emergency Medical Condition means a mental disorder where there are acute symptoms of sufficient severity to render either an immediate danger to yourself or others, or you are immediately unable to provide for or use, food, shelter, or clothing due to the mental disorder.

Emergency Services do not require Prior Authorization, however should it be necessary to receive Emergency Services from a Non-Plan Provider, present your VHP ID Card.

Refer to the “Post-Stabilization” section.

Covered Services are considered to be an Emergency Service only until your condition has stabilized sufficiently to permit either discharge or transfer.

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Emergency & Urgently Need Services Urgently Needed Services

Valley Health Plan offers extended hours at several Urgent Care Clinics, some require an appointment, some are walk-in clinics. Call the VHP Medical Advice line at 1.866.682.9492 (toll-free) for medical advice. A nurse will assess your condition and direct you to the appropriate care. 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 408.885.4760 or 1.888.421.8444 (toll-free) for assistance. For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality. Present a form of ID and your VHP ID card when seeking services.

Should it be necessary to receive Urgently Needed Services outside the Service Area, you can call VHP at 408.885.4760 or 1.888.421.8444 (toll-free) to answer any questions you may have. If you unable to reach VHP, call the advice nurse at 1.866.682.9492 (toll-free), explain the situation, and follow his/her instructions. As needed, contact the closest provider to receive treatment. Present your VHP ID Card and call VHP within 48 hours to advise VHP of your urgent care visit. Failure to notify VHP within this time frame may result in the Denial of your claim.

Urgent care services are covered by VHP if: • your condition meets the definition of Urgently Needed Services, and •

you can contact an advice nurse by calling 1.866.682.9492 (toll-free), or

•

you obtain urgent care services through your VHP Network Provider, or

•

you obtain Urgently Needed Services, while outside the Service Area and the medical care could not be delayed until you return to the Service Area.

If you seek routine or elective medical services that are not Urgently Needed Services from Non-Plan Providers without a Prior Authorization, VHP will not pay for your care and you will be required to pay for the full cost of such services.

Follow-Up Care After Emergency or Urgently Needed Services

Your Coverage includes Medically Necessary follow-up care after Emergency and Urgently Needed Services if that care cannot be delayed without adverse medical effects.

Follow-up care after any Emergency or Urgently Needed Service should be obtained through your Primary Care Physician. Should it be necessary to obtain follow-up care, after an Emergency or Urgently Needed Service, from a Non-Plan Provider, call VHP to receive Prior Authorization before you access care.

If you seek follow-up care after an Emergency or Urgently Needed Services from Non-Plan Providers without an Authorization, VHP will not pay for your care and you will be required to pay for the full cost of such services.

Call 911 in the case of an emergency.

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Emergency & Urgently Need Services Post-Stabilization

Once your emergency medical condition is stabilized, your treating health care provider may believe that you require additional Medically Necessary Services prior to your being safely discharged. If the hospital is not part of VHP’s contracted network, the hospital will contact your PCP or the Plan to obtain timely Prior Authorization for these post-stabilization services. Should the Plan not provide timely Prior Authorization, within the timelines as required by law, for post-stabilization care at the Non-Plan Hospital, then Plan shall be financially responsible for such care.

If VHP determines that you may be safely transferred to a Plan Hospital, and you refuse to consent to the transfer, the non-Plan hospital must provide you written notice that you will be financially responsible for 100% of the cost for services provided to you once your Emergency condition is stable.

If the non-Plan hospital is unable to determine your name and contact information at VHP in order to request Prior Authorization for services once you are stable, the non-Plan hospital may bill you for such services.

IF YOU FEEL THAT YOU WERE IMPROPERLY BILLED FOR SERVICES THAT YOU RECEIVED FROM A NON-CONTRACTED PROVIDER, PLEASE CONTACT VHP AT 408.885.4760 or 1.888.421.8444 (TOLL-FREE).

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Benefits Description Table

Benefits Description Table Table of Contents Professional Services.................................... 34 Primary Care Physician (PCP) Services Plan Specialist Care Outpatient Services....................................... 35

Prescription Drugs, Medications, and Pharmacy Services................................. 43 Prescription Drugs Durable Medical Equipment Medical Supplies and Equipment................. 44 Medical Supplies and Equipment

Pediatric/Well-Child Care Adult Periodic Health Examinations Physical Examinations Well-Woman Examination Mammography Screening Allergy Testing and Treatment Dermatology Services Diagnostic Laboratory Services HIV, AIDS, or Other Infectious Diseases Testing Immunizations and Injections Travel Immunizations Optometry Services Ophthalmology Services Podiatry Services Therapy Services

Mental Health Services.................................. 45

Outpatient Hospital Services........................ 38

Home Health Care Dialysis Services Hospice Care

Outpatient Hospital or Surgical Center

Mental Health Services and Behavioral Health Treatment Services - Outpatient Outpatient Mental Health and Behavioral Health Treatment Services Provided by a Psychiatrist Prescription Drugs for Mental Health Conditions Mental Health Services and Behavioral Health Treatment - Inpatient Chemical Dependency Services (Alcoholism and Drug Abuse)....................... 47 Substance Abuse Services - Outpatient Detoxification Substance Abuse Services, i.e. Hospital based - Inpatient Residential (intermediate-term) Recovery Services Home Health and Hospice Services............. 48

Hospitalization Services (Non-Emergent or Scheduled Admissions)................................. 38

Cancer Clinical Trial Services

Inpatient Hospital Services

Chiropractic Services.................................... 49

Skilled Nursing Services............................... 39

Chiropractic Services

Skilled Nursing Care - Inpatient

Acupuncture Services................................... 50

Rehabilitation Services.................................. 40

Acupuncture Services

Rehabilitation Care - Inpatient Emergency Services and Ambulance.......... 41

Cancer Clinical Trial Services....................... 49

Dental Services ............................................. 50

Emergency Services Ambulance Services

Dental Services Temporomandibular Joint (TMJ) Disorders Services Dental Services - Plan Hospital or Surgery Center

Medical Transportation Services.................. 42

Family Planning Services.............................. 51

Medical Transportation Urgently Needed Services............................. 42 Urgently Needed Services - VHP Network Urgently Needed Services - Non-VHP Network V A L L E Y

H E A L T H

P L A N

Artificial Insemination Services Family Planning Services Infertility Diagnosis and Treatment

B E N E F I T S

D E S C R I P T I O N

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Benefits Description Table Maternity Services ........................................ 53 Maternity Care Circumcision Genetic Counseling Services Sterilization Services..................................... 54 Sterilization Services Abortion Services.......................................... 54 Abortion Services Health Education Services............................ 54 Health Education and Health Promotion Services Reconstructive and Cosmetic Surgery Services............................................ 55 Reconstructive Surgery Transplant Services....................................... 55 Human Organ, Tissue, and Bone Marrow Transplantation Services

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H E A L T H

P L A N

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T A B L E

Benefits Description Table THIS BENEFITS DESCRIPTION TABLE (MATRIX) IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND TO HELP YOU UNDERSTAND VALLEY HEALTH PLAN (VHP) COVERED BENEFITS. THE TABLE IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND DISCLOSURE FORM/VALLEY HEALTH PLAN BENEFITS AND COVERAGE HANDBOOK OR GROUP SERVICE AGREEMENT (PLAN CONTRACT WITH YOUR EMPLOYER) SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERED BENEFITS AND LIMITATIONS. COPAYMENT MAXIMUM (No Deductibles) Individual: $1,000 per Calendar Year Family: $2,000 per Calendar Year Maximum Lifetime Benefit: Unlimited

Professional Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Primary Care Physician (PCP) Services including visits, examinations, diagnostic, and surgical procedures performed in the office of a VHP Network PCP.

$0 Copayment

Your PCP will provide, arrange, and/or coordinate all your routine medical care.

If you seek Routine Care from an Out-ofNetwork provider, you may be financially responsible for all charges.

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 If you are a female Member you may obtain Covered Services through direct access (self-refer) from Plan OB/GYN and/or through direct access from a Plan family practice physician and surgeon (Plan Provider).

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

V A L L E Y

$0 Copayment Your PCP will refer you to a Plan Specialist.

H E A L T H

To obtain care, you must receive a written referral from your PCP and Prior Authorization from VHP.

You must have Prior Authorization for specialty services from a VHP Network Provider or the Plan Medical Director, or you may be financially responsible for all charges

Direct access to Plan Specialist and standing referrals are available when coordinated by your PCP.

P L A N

B E N E F I T S

D E S C R I P T I O N

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Benefits Description Table Outpatient Services Benefits

Copayment

How to Obtain Covered Services Limitations & Exclusions

Pediatric/Well- Child Care including periodic office visits, diagnostic services, immunizations, and the testing and treatment of phenylketonuria (PKU).

$0 Copayment

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.org

$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.

Call to schedule an appointment with your VHP Network PCP.

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 VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan.org

Preventive Services Without Cost-Sharing for Specified Services 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).

$0 Copayment

Call VHP Member Services for the telephone number, or visit VHP’s website at www.valleyhealthplan.org

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.

$0 Copayment

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. liquid based prep test).

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Call to schedule an appointment with your VHP Network PCP.

H E A L T H

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.org

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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.

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Benefits Description Table Outpatient Services, continued Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

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

$0 Copayment

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.

Allergy Testing and $0 Copayment Treatment including allergy serum and injection services.

Your PCP will refer you to a Plan Specialist.

Dermatology Services for Routine Care

$0 Copayment

Call your Plan network office to schedule Covered Services from a VHP network dermatologist.

Diagnostic Laboratory Services including outpatient diagnostic X-ray, nuclear medicine, and laboratory services (including tests performed on an outpatient basis at your Plan Facility or Hospital).

$0 Copayment

Your Plan Physician will make arrangements when Medically Necessary.

HIV, AIDS, or Other Infectious Diseases Testing and Treatment including HIV testing regardless if related to a primary diagnoses.

$0 Copayment

Your VHP Network Provider will make arrangements when Medically Necessary.

Immunizations and $0 Copayment 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 (CDC).

Your VHP Network Provider will make arrangements when Medically Necessary.

Travel Immunizations as recommended by the U.S. Preventive Services Task Force.

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.

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$0 Copayment

H E A L T H

To obtain care you must receive a written referral from your PCP and Prior Authorization from VHP.

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Benefits Description Table Outpatient Services, continued Benefits

Copayment

How to Obtain Covered Services Limitations & Exclusions

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.

$0 Copayment

Call your Plan network office to Refraction examinations are limited to one (1) schedule Covered Services from a VHP per year. network optometrist.

Eyeglass lenses, frames, and contact lenses Refer to Limitations and Exclusions. including fitting and dispensing (except for special contact lenses to treat aphakia or If your employer offers a vision benefit aniridia) non-implant low vision aides, and e.g. Vision Service Plan (VSP) or correction of visual acuity or refractive errors Vision Plan of America (VPA), refer to are excluded from your Benefit Plan. that carrier’s provider list and coverage detail. Your employer vision benefits For treatment of aniridia (missing iris) coverage allow you to make an appointment(s) is limited to up to two Medically Necessary for Eye Refraction examinations contact lenses per eye (including fitting and at several locations in your area. dispensing) in any 12-month period, whether Eyeglasses and lenses benefits may provided by the Plan during the current or a also be purchased through your vision previous 12 month contract period. carrier at that same location(s).

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.

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.

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.

$0 Copayment

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

Your VHP Network Provider will refer you to a Plan Specialist.

Radial keratotomy is excluded from your Benefit Plan.

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.

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.

Therapy Services including $0 Copayment 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.

Your VHP Network Provider will refer you to a Plan Specialist.

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

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.

For Benefit Information, call 408.885.4760.

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Benefits Description Table Outpatient Hospital Services Benefits

Copayment

How to Obtain Covered Services Limitations & Exclusions

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.

$0 Copayment

Your VHP Network Provider will make arrangements when Medically Necessary to a Plan Provider that most appropriately meets your medical needs.

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

To obtain outpatient surgery care you must receive Prior Authorization from VHP.

Outpatient services also include surgical assistant and anesthesiologist, drugs, X-ray, lab, supplies and blood, blood derivatives, and transfusions (blood bank).

Hospitalization Services (Non-Emergent or Scheduled Admissions) Benefits

Copayment

How to Obtain Covered Services Limitations & Exclusions

Inpatient Hospital Services at your primary Plan Hospital, provides Hospital Services including physician and surgeon care, semiprivate 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).

$0 Copayment

Your VHP Network Provider will make arrangements when Medically Necessary to a Plan Hospital that most appropriately meets your medical needs.

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Arrangements for a private room are excluded from your Benefit Plan unless Medically Necessary and ordered by your Plan Physician.

Rehabilitation services are provided in the amount, frequency, or duration, as the Plan Physician deems Medically Necessary.

All non-emergent scheduled admissions at hospitals must be Prior Authorized by VHP or you may be financially responsible for all charges.

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B E N E F I T S

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Benefits Description Table Skilled Nursing Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

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), rehabilitation services, speech/ language pathology, and durable medical equipment and/ or other services necessary to the health of Members ordinarily furnished by the SNF.

$0 Copayment

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

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.

For 24-hour Medical Advice, call 1.866.682.9492 (toll-free).

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Benefits Description Table Rehabilitation Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Rehabilitation Care Inpatient provided at a Plan Facility, which offers a physician directed plan of rehabilitation care including Physical Therapy (PT), Occupational Therapy (OT), Speech and DME.

$0 Copayment

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

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:

Benefits include a semi-private bed and board, nursing, social services, drugs, X-ray, lab, supplies, blood, blood derivatives,

• is not Custodial Care, and • as a practical matter, can only be provided on an inpatient basis.

and transfusions (blood bank), and Durable Medical Equipment ordinarily furnished by the rehabilitation center.

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Benefits Description Table Emergency Services and Ambulance Benefits

Copayment

How to Obtain Covered Services Limitations & Exclusions

Emergency Services at any facility or hospital worldwide, 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

$0 Copayment

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.

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.

If able, present your VHP ID Card and ask the provider or someone acting on your behalf to call VHP.

• 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.

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.

Transportation that is not of an emergency nature or that is not Medically Necessary and Prior Authorized is not covered under your Benefit Plan.

Call 911 for emergency ambulance transportation.

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Benefits Description Table Medical Transportation Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Medical Transportation including inter-facility transfers.

$0 Copayment

Your Plan Physician or VHP will make arrangements for non-emergency medical transportation when Medically Necessary.

Transportation that is not of an emergency nature or that is not Medically Necessary and not Prior Authorized is excluded under your Benefit Plan.

Urgently Needed Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Urgently Needed Services 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.

$0 Copayment

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.

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.

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 disability

$0 Copayment

V A L L E Y

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 408.885.4760 or 1.888.421.8444 (toll-free) for assistance.

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

H E A L T H

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.

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B E N E F I T S

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.

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Benefits Description Table Prescription Drugs, Medications, and Pharmacy Services Benefits

Copayment

Prescription Drugs $0 Copayment including outpatient prescription drugs, diaphragms, birth control, insulin, glucagon, and other prescriptive medications for the treatment of diabetics at Plan Pharmacies from the Plan’s drug Formulary.

Birth control includes any FDA approved contraceptive or medically appropriate prescribed contraceptive methods.

Prescription Drugs also include premature infant formulas for up to three (3) months and reimbursement for the purchase of formulas or special food products that are required for the treatment of PKU.

How to Obtain Covered Services

Limitations & Exclusions

When you have received a prescription from Prescription drugs and supplies are limited your Plan Physician, you must have it filled to prescriptions written by Plan-authorized at your Plan Pharmacy. providers when deemed Medically Necessary and in accordance with professionally Provide your VHP ID Card and the recognized standards of care. prescription to the Plan Pharmacy.

Medically Necessary prescription drugs are Prescription Fill Options: limited to: Plan Pharmacies: • drugs approved by the FDA, You have the option to contact your Plan Pharmacy to have your prescription refilled. • generic equivalents approved as substitutable Information regarding your prescription is by the FDA, on your prescription label.

• drugs approved by the FDA as Treatment Mail Service Pharmacy: Investigational New Drugs, or You have the option of using our Mail • drugs classified as Group C cancer drugs by Service Pharmacy, which only offers the National Cancer Institute to be used only prescriptions to be mailed to your home. for the purposes approved by the FDA or the Once a prescription is filled by the Mail National Cancer Institute.

Service Pharmacy, the prescription cannot be transferred to another Plan Medications, not Medically Necessary, Pharmacy. Contact the Plan’s Pharmacy including travel patches, cosmetics, herbal Benefit Manager at 1.866.333.2757 (tollproducts and treatments, dietary supplements, free). For additional information go to health or beauty aids, are excluded from the www.valleyhealthplan.org or contact Benefit Plan.

VHP Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free). For most oral medications, a Prescription Unit represents a single course of treatment or up Out-of-Network: to a 90 day supply for chronic illness.

Should you need to obtain a prescription associated with Out-of-Network Emergency You may be financially responsible for lost Services or Urgently Needed Services, take or misplaced medications. The PBM or pharmacist will advise you of all charges. your prescription to a Plan Pharmacy. If a Plan Pharmacy is not available, VHP will PKU formula and special food product cover the prescription filled at an Out of reimbursement is limited to the amount Network Pharmacy. You or the provider and duration that the Plan Physician deems may submit your claim to PBM or VHP for Medically Necessary. payment.

Special formulas for allergy, e.g. cow’s milk, Formulary: soy, or lactose intolerance milk are not a For Formulary information, call VHP’s Covered Service under your Benefit Plan.

PBM at 1.866.333.2757 (toll-free) or visit Over the counter (OTC) drugs and supplies www.valleyhealthplan.org are excluded from your benefit plan.

For Health Education Information, call 408.885.3490.

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Benefits Description Table Durable Medical Equipment - Medical Supplies and Equipment Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Medical Supplies and Equipment including Durable Medical Equipment (DME) and supplies which:

$0 Copayment

Your Plan Physician will prescribe or arrange for Prior Authorization when Medically Necessary.

Medical supplies are limited to equipment and devices which:

• primarily serve a medical purpose, and

Your Plan Physician or VHP will advise you where to obtain the supplies at the Plan Provider of DME.

• are appropriate for use in the home.

• are intended for repeated use over a prolonged period, • are not considered disposable, with the exception of ostomy bags and diabetic supplies, • do not duplicate the function of another piece of equipment or device covered by VHP, and

DME also includes corrective appliances, Prosthetic Devices and orthotic devices, oxygen and oxygen equipment which are Medically Necessary.

• are generally not useful to you in the absence of illness or injury.

Medically Necessary repair or replacement of medical supplies or equipment must be prescribed by your Plan Physician, but is excluded from your Benefit Plan when caused by 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.

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Benefits Description Table Mental Health Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Outpatient Mental Health 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.

0 Copayment

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.

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.

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.

To obtain a list of VHP’s Mental Health Providers, call VHP Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free), or visit the VHP website www.valleyhealthplan. org

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.

You must obtain Prior Authorization before receiving Outpatient Mental Health and Behavioral Health Treatment If you seek outpatient mental health services from an Out-of-Network Services provided by a Psychiatrist.

Mental Health Provider without To obtain prior authorization call VHP’s Prior Authorization, you may be Utilization Department at 408.885.4647 financially responsible for all charges. or contact your PCP for a referral.

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

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.

For Benefit Information, call 408.885.4760.

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Benefits Description Table Mental Health Services (continued) Benefits

Copayment

How to Obtain Covered Services

Limitations and Exclusions

Your VHP mental health Plan Provider will make arrangements when Medically Necessary.

Inpatient mental health services are limited to Covered Services as described in the “Hospitalization Services” section of this Benefits Description Table.

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 $0 Copayment Services and Behavioral Health Treatment – Inpatient 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 “PostStabilization.”

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H E A L T H

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

Prior Authorization from VHP is required.

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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.

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Benefits Description Table Chemical Dependency Services (Alcoholism and Drug Abuse) Benefits

Copayment

How to Obtain Covered Services Limitations & Exclusions

Substance Abuse Services - Outpatient includes includes Medically Necessary evaluation and treatment of alcohol and/ or drug dependency and medical treatment for withdrawal symptoms.

$0 Copayment

Call the Gateway Program at 1.800.488.9919 (toll-free) for access to information, referral and treatment services, or call your PCP.

If you or your condition does not respond to therapeutic management, outpatient substance abuse counseling and medical treatment may be excluded from your Benefit Plan.

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.

Medically Necessary methadone maintenance services are included.

Detoxification Substance Abuse Services, i.e.

Hospital based – Inpatient including Medically Necessary detoxification for alcohol and/or drug dependency.

$0 Copayment

Residential (intermediateterm) Recovery Services including short-term, nonhospital based detoxification services, and transitional substance abuse residential treatment for alcohol and/ or drug dependency that are Medically Necessary.

$0 Copayment

Your VHP Network Provider will make arrangements for Medically Necessary Covered Services at a Plan Hospital that most appropriately meets your medical needs.

Inpatient (hospital-based) substance abuse services are limited to Covered Services under the “Hospitalization Services” section of this Benefits Description Table.

Call the Gateway Program at 1.800.488.9919 (toll-free) for access to information, referral and treatment services, or call your PCP.

Residential recovery services are limited to Medically Necessary, short-term alcohol or drug detoxification and transitional recovery treatment.

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 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.

For 24-hour Medical Advice, call 1.866.682.9492 (toll-free).

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Benefits Description Table Home Health and Hospice Services Benefits

Copayment

How to Obtain Covered Services Limitations & Exclusions

Home Health Care $0 Copayment including Medically Necessary health care services and supplies 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 and home health aide services.

Your Plan Physician will prescribe or make Prior Authorized arrangements when Medically Necessary.

Coverage is limited to services that may not be appropriately provided in Plan Provider’s office, hospital or Skilled Nursing Facility.

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 408.885.4760 or 1.888.421.8444 (toll-free) for assistance

Coverage is limited to homebound Members under a doctor’s supervision.

Dialysis Services for acute renal failure and chronic renal disease, including equipment, training, and supplies.

Your PCP or Plan Physician will make arrangements when Medically Necessary with an authorized Plan Provider

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

Your PCP or Plan Physician will make arrangements when Medically Necessary with an authorized Plan Provider when you elect Hospice Care.

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.

$0 Copayment

Hospice Care provided by licensed hospice programs as certified by the Centers for Medicare and Medicaid 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.

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Should you fail to inform us of your 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.

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.

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.

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Benefits Description Table Cancer Clinical Trial or Other Life-Threatening Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Cancer Clinical Trial Services include routine health care services associated with your participation in a cancer clinical trial, Phase I through V.

$0 Copayment

Your Plan Physician or VHP will order or arrange for Prior Authorization of Covered Services.

The clinical trial’s: i. endpoints must not be defined exclusively to test toxicity, but have a therapeutic intent, and ii. treatment must either (a) be approved by the National Institute of Health, the Federal Food and Drug Administration, or the Veterans Administration or

Covered Services are only available if: • you have been diagnosed with cancer or other lifethreatening disease or condition,

(b) involve a drug that is exempt under the federal regulations from a new drug application.

• you are accepted into a Phase I through V clinical trial for cancer, and

Coverage is limited to routine patient care Covered Services in accordance with State and Federal Regulations.

• your Plan Physician has recommended your participation in the trials because it will have a meaningful potential benefit to you.

Chiropractic Services Benefits

Copayments

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

How to Obtain Covered Services

Limitations & Exclusions

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

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.

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Benefits Description Table Acupuncture Services Benefits

Copayment How to Obtain Covered Services

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

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.

Dental Services Benefits

Copayment How to Obtain Covered Services

Limitations & Exclusions

Dental Services include services:

$0 Copayment Your Plan Physician or VHP will make Prior Authorized 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.

• for treatment or removal of tumors, • Plan Physicians’ services or X-ray exams for the treatment of accidental injury to natural teeth,

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.

• surgery on the maxilla or mandible that is Medically Necessary to correct temporomandibular joint (TMJ) disease or other medical disorders, or

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.

• 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.

$0 Copayment Your Plan Physician or VHP will make Prior Authorized arrangements when Medically Necessary.

Coverage is limited to a maximum of $800.00 lifetime benefit for Member reimbursement toward intra-oral devices and the fitting of such appliances.

Submit your request for reimbursement for intra-oral devices and related services Charges for the dental procedures that are to VHP within 90 days of the date of not related to the treatment of a Medically service.

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.

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Benefits Description Table Dental Services (Continued) Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

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

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.

Family Planning Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

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.

$0 Copayment

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

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.

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 Des Table.

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.

For Benefit Information, call 408.885.4760.

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Benefits Description Table Family Planning Services (Continued) Benefits

Copayment

How to Obtain Covered Services Limitations & Exclusions

Family Planning Services including contraceptive counseling, prescribed birth control pills, fitting and/ or inserting birth control devices

$0 Copayment

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.org

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

(e.g. diaphragms), and examination, insertion, and removal of an IUD. Family services also include familyplanning counseling, pre-abortion and postabortion 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 $0 Copayment and Treatment includes Covered Services to evaluate, diagnose, and provide Medically Necessary treatment.

Your PCP will order or make arrangements with a Plan Provider when Medically Necessary.

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.

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Benefits Description Table Maternity Services Benefits

Copayment How to Obtain Covered Services

includes prenatal care, delivery, and antepartum and postpartum care.

$0 Copayment It is important to receive early care when If you travel outside of the Service Area to you are pregnant. obtain Medical Services related to care and/ or delivery of the newborn, you may be If you think you are pregnant, call to financially responsible for all charges, except schedule an appointment with a Plan for those expenses related to Emergency OB/GYN: Services.

Call VHP Member Services for the Amniocentesis, ultrasounds, or any other telephone number, or visit VHP’s procedure performed solely for the purpose website at www.valleyhealthplan.org of sex determination are excluded from your Benefit Plan.

Enrollment of your Eligible Dependent is required within 31 days of the birth; Should you give birth while a Member and contact your employer/ human resources your newborn meets the definition of an to obtain enrollment information.

Eligible Dependent, he/she is eligible for Coverage under the Benefit Plan for the first 31 days after the birth.

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.

Limitations & Exclusions

• 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.

For Member Services, call 408.885.4760.

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Benefits Description Table Maternity Services (Continued) Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Circumcision.

$0 Copayment

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

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 Benefit Plan and the circumcision must be performed within two (2) weeks of the birth.

Genetic Counseling Services includes Medically Necessary risk assessment for Family Planning and diagnosis.

$0 Copayment

Your VHP Network Provider will determine the scope of services based on Medical Necessary

Sterilization Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Sterilization Services include vasectomy and tubal ligation procedures.

$0 Copayment

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

A hysterectomy exclusively for voluntary sterilization purposes is excluded from your Benefit Plan.

The reversal of sterilization procedures is excluded from your Benefit Plan.

Abortion Services Benefits

Coverage

How to Obtain Coverage

Limitations & Exclusions

Abortion Services includes examination, counseling, and procedure.

$0 Copayment

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

Covered Services must be provided by a VHP Network Provider.

Health Education Services Benefits

Copayment

How to Obtain Covered Services

Limitations & Exclusions

Health Education and Health Promotion Services includes VHP Health Education classes and materials in childbirth preparation, prenatal education, CPR, smoking cessation, weight management, and exercise and fitness education.

$20 Copayment for Weight Watchers Session(s) may apply.

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.

Coverage is limited to Plan authorized health education classes and programs.

A fee for classes, materials, and supplies may be charged

Visit VHP’s website at www. valleyhealthplan.org for a list of Plan authorized health education classes.

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.

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Benefits Description Table Reconstructive and Cosmetic Surgery Services Benefits

Copayment How to Obtain Covered Services

Limitations & Exclusions

Reconstructive Surgery includes plastic surgery to correct or repair abnormal 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.

$0 Copayment Your VHP Network Provider will make arrangements when Medically Necessary at a Plan Provider.

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.

Transplant Services Benefits

Copayment

How to Obtain Covered Services

Human Organ, Tissue, and Bone Marrow Transplantation Services for Non-Experimental Procedures include:

$0 Copayment Your Plan Physician will refer you a Plan Provider for transplant services when Medically Necessary and Prior Authorized by VHP.

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 decision is made.

• Preoperative evaluation, • surgery, • follow-up care only provided at centers that have been designated by VHP, and • the reasonable medical and hospital expenses of a donor or individual identified as a prospective donor if such expenses are directly related to the transplant, other than corneal transplants.

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.

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.

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 NonExperimental Procedures.

Experimental procedures are excluded from your Benefit Plan.

For Health Education Information, call 408.885.3490.

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Benefit Descriptions 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 self-referral services, Covered Services must be: • provided, prescribed, arranged for, and/or directed for Authorization by your PCP or a Plan Physician/ 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 408.885.4760 or 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.

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Benefit Descriptions 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.

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Benefit Descriptions 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.

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Benefit Descriptions Over the counter (OTC) drugs, medications, and supplies are not a Covered Benefit except for all FDAapproved 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 408.885.4760 or 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 (toll-free). For addition information go to www.valleyhealthplan.org or contact VHP Member Services Department at 408.885.4760 or 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 408.885.4760 or 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 24 hours or one (1) business day. If you are completely out of your prescription, call your Plan Pharmacy, Plan Provider, or VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

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Benefit Descriptions If the request for Authorization is denied, VHP will notify you and your Physician in writing, within two (2) business days, of the reason for the Denial. You will be referred back to your Plan Physician for alternative treatment and/or to contact VHP or PBM Customer Care for further assistance. The notice will also inform you of your right to dispute the Denial. If you have questions, speak with your Plan Pharmacist, Plan Provider, a PBM Customer Representative (1.866.333.2757 toll-free), or a VHP Member Services Representative.

In the event Member needs to file a Grievance with the Plan, the Member must contact VHP Member Services. If VHP denies the Member Grievance, VHP will notify the Member in writing of the reason for denial. The notice shall also inform the Member of their right to dispute the decision.

Emergency prescription drugs are filled according to the provider’s prescription. Should you need to obtain a prescription associated with out-of-area Emergency Services or Urgently Needed Services, take your prescription to a Plan Pharmacy. If a Plan Pharmacy is not available, VHP will cover the prescription filled at an Out of Network Pharmacy. Refer to the “Payment and Reimbursement Responsibility” section under “Reimbursement Provisions (Claims)” for reimbursement procedures.

At the Time of Your Enrollment If you are taking prescription drugs at the time you enroll, please make an appointment with your Primary Care Physician for evaluation of your current medication and your continuing care. If your Plan Provider determines that you need a prescription, you will receive either a prescription for your current medication or a new prescription for a drug(s) from the Formulary that is equally effective.

Inpatient Pharmacy Services For inpatient care, Covered Services include drugs, supplies, and supplements. Inpatient hospital and other facility drugs and supplements are provided in accordance with your Plan Physician’s prescription and Plan Formulary. Applicable Copayments and other Member charges apply. Refer to the “Benefits Description Table” for additional Covered Services information.

Durable Medical Equipment - Medical Supplies & Equipment

Medical Supplies and Equipment are covered under your Benefit Plan through Durable Medical Equipment (DME) Plan Providers. Coverage is limited to the basic Medically Necessary item of equipment that adequately meets your medical needs. Deductibles, Coinsurance, and Copayments may apply. Refer to the Summary of Benefits and Coverage at the front of this booklet. Note: The dollar amount of Deductibles, Coinsurance, and Copayments can be $0 (no charge).

Your Plan Physician will prescribe when Medically Necessary. If Prior Authorization is required (e.g. DME and prosthetic devices) your PCP or Plan Physician will arrange it. Covered Services include: • Durable Medical Equipment; •

Corrective appliances;

•

Prosthetic Devices;

•

Prescription Orthotic Devices; and

•

Oxygen and oxygen equipment.

VHP or your Plan Provider will determine whether to repair, rather than to replace prosthetic devices.

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Benefit Descriptions Durable Medical Equipment for Home Use Inside our Service Area, we cover the durable medical equipment specified in this “Durable Medical Equipment for Home Use” section for use in your home (or another location used as your home) in accord with our durable medical equipment formulary guidelines. Durable medical equipment for home use is an item that is intended for repeated use, primarily and customarily used to serve a medical purpose, generally not useful to a person who is not ill or injured, and appropriate for use in the home. Cost Sharing may apply.

Coverage is limited to the standard item of equipment that adequately meets your medical needs. Covered durable medical equipment (including repair or replacement of covered equipment) is provided at. We decide whether to rent or purchase the equipment, and we select the vendor. You must return the equipment to us or pay us the fair market price of the equipment when we are no longer covering it.

Inside our Service Area, we cover the following durable medical equipment for use in your home (or another location used as your home): • For diabetes blood testing, blood glucose monitors and their supplies (such as blood glucose monitor test strips, lancets, and lancet devices) •

Infusion pumps (such as insulin pumps) and supplies to operate the pump (but not including insulin or any other drugs)

•

Standard curved handle or quad cane and replacement supplies

•

Standard or forearm crutches and replacement supplies

•

Dry pressure pad for a mattress

•

Nebulizer and supplies

•

Peak flow meters

•

IV pole

•

Tracheostomy tube and supplies

•

Enteral pump and supplies

•

Bone stimulator

•

Cervical traction (over door)

•

Phototherapy blankets for treatment of jaundice in newborns

Prosthetic and Orthotic Devices Prostheses incidental to surgery, include, but are not limited to the following: • Prosthetic devices and installation accessories to restore a method of speaking following the removal of all or part of the larynx (this coverage does not include electronic voice-producing machines, which are not prosthetic devices).

•

Artificial limbs and eyes;

•

Supplies necessary for the operation of prostheses; and

•

Initial fitting and replacement after the expected life of the item.

For surgically implanted and other Prosthetic Devices provided to restore and achieve symmetry incident to a mastectomy, see the “Reconstructive Surgery” section under “Reconstructive, Cosmetic, and Bariatric (weight loss) Surgery Services.” The Plan covers up to three brassieres, required to hold a prosthesis, every 12 months as required for Medically Necessary mastectomy.

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Benefit Descriptions VHP does not cover most prosthetic and orthotic devices, but we do cover devices as described in this “Prosthetic and Orthotic Devices” section if all of the following requirements are met: • The device is in general use, intended for repeated use, and primarily and customarily used for medical purposes •

The device is the standard device that adequately meets your medical needs

•

You receive the device from a Plan Provider

Coverage includes fitting and adjustment of these devices, their repair or replacement (unless due to loss or misuse), and Services to determine whether you need a prosthetic or orthotic device. If we cover a replacement device, then you pay the Cost Sharing that you would pay for obtaining that device.

Medical Supplies, Equipment, and other External Devices Medical Supplies are limited to equipment and devices which: are intended for repeated use over a prolonged period, are not considered disposable (with the exception of ostomy bags and diabetic supplies), are ordered by your Plan Physician, do not duplicate the function of another piece of equipment or device covered by VHP, are generally not useful to you in the absence of illness or injury, primarily serve a medical purpose, and are appropriate for use in the home.

VHP covers the following external prosthetic and orthotic devices: Prosthetic devices and installation accessories to restore a method of speaking following the removal of all or part of the larynx (this coverage does not include electronic voice-producing machines, which are not prosthetic devices)

•

•

Prostheses needed after a Medically Necessary mastectomy, including:

o Custom-made prostheses when Medically Necessary o Up to three brassieres required to hold a prosthesis every 12 months •

Podiatric devices (including footwear) to prevent or treat diabetes-related complications when prescribed by a Plan Physician or by a Plan Provider who is a podiatrist

•

Compression burn garments and lymphedema wraps and garments

•

Enteral formula for Members who require tube feeding in accord with Medicare guidelines

•

Prostheses to replace all or part of an external facial body part that has been removed or impaired as a result of disease, injury, or congenital defect

Formulas and special food products for the treatment of phenylketonuria (PKU) are Covered Services provided that such items are part of a diet prescribed by Plan Physician who specializes in the treatment of metabolic disease. The diet must be deemed Medically Necessary to avert the development of serious physical or mental disabilities or to promote normal development or function as a consequence of PKU. Prior Authorization is required.

Any customization of living environment or automobile are excluded from your Benefit Plan. Coverage is limited to the basic Medically Necessary item of equipment that adequately meets your medical needs.

Ostomy and Urological Supplies Coverage includes ostomy and urological supplies as prescribed in accordance with our Plan Formulary guidelines. We select the Plan Provider, and coverage is limited to the standard supply that adequately meets your medical needs. Cost Sharing may apply.

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Benefit Descriptions Ostomy and urological supplies used for comfort, convenience, or luxury equipment or features are excluded.

Our formulary guidelines allow you to obtain nonformulary ostomy and urological supplies (those not listed on our soft goods formulary for your condition) if they would otherwise be covered and the Plan Provider determines that they are Medically Necessary.

Note: The Plan’s soft goods formulary lists ostomy and urological supplies in a variety of types and materials. Generic categories for those supplies are as follows: • Adhesives – liquid, brush, tube, disc or pad •

Adhesive removers

•

Belts – ostomy

•

Belts – hernia

• Catheters •

Catheter Insertion Trays

• Cleaners •

Drainage Bags/Bottles – bedside and leg

•

Dressing Supplies

•

Irrigation Supplies

•

Lubricants

• Miscellaneous Supplies – urinary connectors; gas filters; ostomy deodorants; drain tube attachment devices; soma caps tape; colostomy plugs; ostomy inserts; irrigation syringes, bulbs, and pistons; tubing; catheter clamps, leg straps and anchoring devices; penile or urethral clamps and compression devices • Pouches – urinary, drainable, ostomy • Rings – ostomy rings • Skin barriers • Tape – all sizes, waterproof and non-waterproof.

Mental Health Services

Outpatient Mental Health and Behavioral Health Treatment provided by Non-Physician Providers Outpatient Mental Health provided by non-physician providers includes, but are not limited to assessment, diagnosis, individual and group psychotherapy. Behavioral Health Treatment is provided by the Plan and includes professional services and treatment programs, including applied behavior analysis and evidencebased behavior intervention programs that develop or restore, to the maximum extent practicable, 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. Refer to the “Benefits Description Table” for additional Covered Services information.

For Member Services, call 1.888.421.8444 (toll-free).

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Benefit Descriptions Outpatient Mental Health and Behavioral Health Treatment Services provided by a Psychiatrist Outpatient Mental Health and Behavioral Health Treatment Services provided by a psychiatrist are available through VHP Mental Health Plan Providers. Coverage includes evaluation and treatment, prescribed psychological and neuropsychological testing, crisis intervention, and partial hospital services, short-term hospital-based intensive outpatient care (partial hospitalization) and short-term multidisciplinary treatment in an intensive outpatient psychiatric treatment program; including treatment for Severe Mental Illness, for Members of any age, and Serious Emotional Disturbances of a Child or Adolescent. 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 practicable, the functioning of an individual with Pervasive Developmental disorder or Autism. In some instances your PCP may be able to provide Mental Health Services. Services include prescription drugs, medications, and pharmacy services; prescription drugs must be written by an authorized Psychiatrist or Primary Care Physician (PCP). Services are limited to Medically Necessary treatment in the amount, frequency, or duration up to the point in which you are no longer clinically determined to require treatment. Prior Authorization from VHP is required.

Inpatient Mental Health and Behavioral Health Treatment Services Covered Services for Inpatient Mental Health and Behavioral Health Treatment Services are available when authorized to Plan Provider. Hospital alternative treatment services are available if a Member would benefit from treatment in a structured multidisciplinary Mental Health Program as an alternative to inpatient hospitalization. Post-hospitalization Outpatient Mental Health Services treatment(s) only as authorized by a Plan Provider at a Plan Facility.

VHP covers inpatient psychiatric hospitalization in a Plan Hospital. Coverage includes room and board, drugs, and Services of Plan Physicians and other Plan Providers who are licensed health care professionals acting within the scope of their license.

VHP covers the following Intensive psychiatric treatment programs at a Plan Facility: • Inpatient Mental Health residential treatment • Crisis residential treatment • Short-term treatment in a crisis residential program in licensed psychiatric treatment facility with 24-hour-a-day monitoring by clinical staff for stabilization of an acute psychiatric crisis • Psychiatric observation for an acute psychiatric crisis Inpatient Mental Health Services that are court ordered, or as a condition of parole or probation are excluded from your Benefit Plan, unless determined Medically Necessary by your Plan Physician.

Chemical Dependency Services (Alcohol & Drug Abuse)

Outpatient evaluation and treatment for alcohol or drug dependency and medical treatment for withdrawal symptoms are Covered Services when authorized by VHP and arranged through a Plan Provider. Short term authorized inpatient detoxification services for alcohol and drug addictions are available when provided in a Plan Facility. Intensive Outpatient Program is considered an inpatient hospitalization alternative treatment when authorized by VHP. Coverage includes Medically Necessary prescribed methadone maintenance services when approved by VHP and provided by a Plan Provider. Chemical Dependency Services that are court ordered, or as a condition of parole or probation are excluded from your Benefit Plan, unless determined Medically Necessary by your Plan Physician.

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Benefit Descriptions Home Health & Hospice Services

Home Health Care When you are confined to your home for medical reasons, your Benefit Plan covers authorized home health care services from Plan Providers. Home health care will be provided under the direct care and supervision of a Plan Physician and administered by visiting Plan Provider health care professionals. Refer to the “Benefits Description Table” for additional Covered Services information.

Dialysis Services Dialysis services for acute renal failure and chronic renal disease, including equipment; training and medical supplies required for home dialysis are covered under your Benefit Plan. Plan Providers must render Covered Services. Prior Authorization must be received before evaluation and treatment.

Hospice Care Should you be diagnosed with a terminal illness and have a life expectancy of 12 months or less, you may elect home-based hospice care. Such care will be arranged through a certified hospice program with Authorization from VHP and your Plan Physician. Hospice care is provided within the Service Area.

You may change your decision to receive hospice care at any time, however, once you have elected hospice care, you are not entitled to any curative treatments for the terminal illness while your hospice election is in effect, however you are entitled to Covered Services not related to the terminal illness.

Coverage is limited to five (5) consecutive days of inpatient respite care (to provide relief for family members or others who might be caring for you) and a maximum of 366 days of hospice care.

Other Benefits for the terminal illness are excluded while your hospice election is in effect.

For additional Covered Services or Copayments information, refer to the “Benefits Description Table.”

Acupuncture Services

Acupuncture services are available through the Plan’s Acupuncture network through referral by your PCP or VHP. Acupuncture services are typically provided only for the treatment of nausea or as part of a comprehensive pain management program for the treatment of chronic pain. . Coverage is limited to a maximum of 20 prescribed visits per Calendar Year. Beyond 20 prescribed visits require justification from Plan Provider.

Applicable Copayments apply. Visit the VHP website www.valleyhealthplan.org or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for Plan Acupuncture Providers. For additional Covered Services or Copayments information, refer to the “Benefits Description Table.”

Cancer Clinical Trial Services

Cancer Clinical Trial Services include routine health care services associated with your participation in a cancer clinical trial, Phase I through V. Covered Services are only available if: • You have been diagnosed with cancer, • You are accepted into a Phase I through V clinical trial for cancer, and • Your Plan Physician has recommended your participation in the trials because it will have a meaningful potential benefit to you.

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Benefit Descriptions Chiropractic Services

Chiropractic Services are available through the Plan’s Chiropractic Network through referral by your PCP. Coverage is limited to a maximum of 20 visits per Calendar Year. Beyond 20 prescribed visits require justification from Plan Provider. Applicable Copayments apply. Visit the VHP website www. valleyhealthplan.org or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for Plan Chiropractic Providers. For additional Covered Services or Copayments information, refer to the “Benefits Description Table.”

Dental Services

Dental Services are limited to Medically Necessary Covered Services. Services must be Prior Authorized by VHP at a Plan Provider.

Valley Health Plan does not provide dental insurance services such as those dental services covered through your employer dental plan or as purchased through a dental plan carrier.

Outpatient Dental Services Dental Services include Prior Authorized Covered Services rendered in an outpatient setting as provided by Plan Provider for: • treatment or removal of tumors, •

Plan Physicians’ services or X-ray exams (not in a dentist office) 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,

•

services in connection with accidental fractures of the jaw, or

•

prescribed drugs obtained at a Plan Pharmacy.

Limitations and Exclusions apply. Routine general dental services are not covered. Charges for the dental procedure itself, including, but not limited to, the professional fee of the dentist, are excluded. Items and services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth are not covered.

Temporomandibular Joint (TMJ) Disorders Services Temporomandibular Joint (TMJ) Disorders Services includes the evaluation and treatment of Medically Necessary TMJ dysfunction, including the provision of prescribed intra-oral appliances. Prior Authorization

by VHP is required for all Covered Services including consultations, diagnosis, and medical or surgical treatment for disorders of the TM joint. A lifetime limitation of $800.00 applies to the cost of any intra-oral positioning devices and related services. You will be financially responsible for services and all costs over the lifetime $800.00 limit for intra-oral appliances and related services.

VHP will provide Prior Authorized TMJ Covered Services provided the: • diagnosis of the TMJ Syndrome is made by a Plan PCP and the Member has completed a three (3) to six (6) month trial of continuous conservative management; and •

placement of intra-oral appliance prior to surgery. Intra-oral appliances are limited to one (1) oral splint or appliance, lifetime limits apply.

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Benefit Descriptions •

surgical Coverage is limited to:

(1) services for treatment or removal of tumors; (2) physicians’ services or X-ray exams for the treatment of accidental injury to natural teeth; (3) surgery on the maxilla or mandible that is Medically Necessary to correct temporomandibular joint disease or other medical disorders; or

(4) services in connection with accidental fractures of the jaw.

Upon Prior Authorization, Member may elect to seek care at VHP dentist consultant office. Exclusions include routine dental services and dental treatment; more than one (1) intra-oral positioning device or prosthesis (these are considered dental); hypnosis or biofeedback, and bruxism appliances.

Dental Services - Plan Hospital or Surgery Center Dental services in a Plan Hospital or Plan surgery center include general anesthesia and associated Plan facility charges for dental procedures rendered in a Plan Hospital or Plan surgery center, when the clinical status or underlying medical condition of the Member requires such Covered Services.

Inpatient Plan Hospital services may be covered if furnished in connection with a dental procedure if the patient has impairments that are so severe that they require hospitalization or if the severity of the dental procedure requires hospitalization and as authorized by a VHP Medical Director. Hospitalization will only be covered if Medically Necessary and if provided in a VHP Plan Hospital.

Family Planning Services

Your Benefit Plan offers a wide selection of family planning services through your Plan Physician.

• Family Planning service Benefits include family planning services, genetic counseling services, and some authorized artificial insemination services.

• Procedures for prenatal diagnosis of fetal genetic disorders including test for specific genetic disorders for which genetic counseling is available.

• Sterilization services must be Prior Authorized.

• Abortion services and abortion procedures must be authorized by VHP to a Plan Provider, call the VHP Utilization Management Department at 408.885.4647.

Some Plan Hospitals and other Plan Providers do not provide one (1) or more of the following services that may be covered under your plan benefits and that you or your Eligible Dependent(s) might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your prospective Plan Provider or call Valley Health Plan Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) to ensure that you can obtain the health care services that you need.

Refer to the “Benefits Description Table” for additional Covered Services information.

Maternity Services

Maternity Care Maternity care is provided through your Plan Physician. Maternity services include maternity care, newborn care, and newborn circumcision. Procedures for prenatal diagnosis of fetal genetic disorders including tests for specific genetic disorders for which genetic counseling is available. For additional Covered Services information, refer to the “Benefits Description Table.”

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Benefit Descriptions To assure the good health for you and your baby, keep your prenatal appointments, make healthy lifestyle changes, and follow the advice of your physician. You are entitled to Alpha Feto Protein (AFP) testing and as desired, can participate in the Expanded AFP program, which is a statewide prenatal testing program administered by the State Department of Health Services.

You and your newborn child are entitled to at least 48 hours of inpatient hospital care following a normal vaginal delivery or 96 hours following a Cesarean section.

If your baby remains in the hospital after you are discharged, it is considered a separate hospital admission, be sure your newborn is enrolled in VHP. An earlier discharge may be arranged when you and your physician agree. If you are released from the hospital early, you and your baby are entitled to a follow-up visit within 48 hours of discharge. You and your Plan Physician will determine whether the visit will occur at your Plan Facility or your Plan Physician’s office.

Circumcision Services Circumcisions are performed on an outpatient basis. Upon discharge from the Hospital, you will be given a notice, which includes instructions on how to make an appointment for your newborn’s circumcision. To ensure coverage of this service, you must make your appointment within the time limits written on this notice, usually two (2) weeks from the date of birth. Also, your newborn must be enrolled in the Benefit Plan within 30 days of the date of birth to ensure ongoing coverage.

Genetic Counseling Services Genetic Counseling Services includes Medically Necessary risk assessment for family planning and diagnosis.

Infertility Diagnosis & Treatment Infertility diagnosis and treatment means procedures consistent with established medical practices by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medications and any Medically Necessary surgery. For additional information, refer to the “Benefits Description Table.”

Artificial Insemination Services Artificial insemination services include the intrauterine sperm placement procedure only for the treatment of infertility when determined Medically Necessary by a Plan Physician. Semen analysis and sperm washing for conception procedures will be covered only in conjunction with artificial insemination procedures covered by your Benefit Plan. For additional information, refer to the “Benefits Description Table.”

Sterilization Services

Sterilization services include vasectomy and tubal ligation procedures. For additional information, refer to the “Benefits Description Table.”

Abortion Services

Abortion services and abortion procedures must be authorized by VHP to a Plan Provider. To obtain an Authorization, call the VHP Utilization Management Department at 408.885.4647. Services include examination, counseling and procedure. For additional information, refer to the “Benefits Description Table.”

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Benefit Descriptions Health Education Services

VHP is committed to promoting and enriching the health of our Members. The primary purpose of providing health education and health promotion is to help you live a healthy lifestyle. Health education programs and materials related to disease management are available. Contact your PCP or the VHP Health Education Department at 408.885.3490 to discuss your needs for this service. Topics include asthma, diabetes and more.

Health promotion services are designed to improve your health as well as to prevent illness. Classes include childbirth preparation, prenatal education, tobacco cessation, CPR, first aid, fitness, and more. These heath education and promotion classes are offered to Members at low or no cost. VHP maintains an updated list of health education classes available throughout Santa Clara County. These classes are sponsored by VHP, Santa Clara Valley Health and Hospital System, various community organizations, hospitals, health centers, and voluntary health agencies.

VHP provides “Tobacco Cessation” classes; these two 2-hour classes will teach you how to understand and address your smoking history and routine. You will learn about the benefits of quitting, different ways to quit, withdrawal symptoms, smoking “triggers”, helpful medicines and the importance of selecting a quit date. You will create a personal quit plan and review coping techniques in a small group setting.

After completing these classes, you will receive a Certification of Completion that will allow you to request medicines such as Nicotine Replacement Therapy (including the nicotine patch, the nicotine gum or the nicotine lozenge) to help with withdrawal symptoms. These classes and all FDA-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a Plan Provider are preventive services offered at no cost sharing to enrollees and without needing prior authorization.

The VHP Perspectives Newsletter provides information on different health topics, new classes, and programs that are available to you. This publication is sent twice a year to all members and is also available online at www.valleyhealthplan.org Please contact the VHP Health Education Department for information on class availability, schedules, and any applicable fees. Coverage is limited to program design and class availability. For additional Covered Services information or Copayments, refer to the “Benefits Description Table.”

VHP Health Education Department contact information: Phone: 408.885.3490 E-mail: healtheducation@vhp.sccgov.org Website: www.valleyhealthplan.org

Reconstructive, Cosmetic, & Bariatric (Weight Loss) Surgery Services

Reconstructive Surgery Reconstruction Surgery includes surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, if a Plan Physician determines that it is necessary to improve function, or create a normal or uniform appearance, to the extent possible. Reconstructive Surgery is a Covered Benefit following Medically Necessary mastectomy surgery (including breast implants), which resulted from disease, illness, or injury, and is for internal breast prosthesis required incidental to a mastectomy. Refer to the “Mastectomies and Lymph Node Dissections” section.

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Benefit Descriptions Cosmetic Surgery Cosmetic Surgery is not a Covered Benefit. Reconstructive Surgery that, in the judgment of a Plan Physician specializing in reconstructive surgery, offers only a minimal improvement in appearance is excluded as it is Cosmetic Surgery. Surgery that is performed to alter or reshape normal structures of the body in order to improve appearance is also considered Cosmetic Surgery. Cosmetic services that are intended primarily to change or maintain your appearance, except for Covered Services covered under “Reconstructive Surgery” are also excluded.

Mastectomies & Lymph Node Dissections Your coverage includes Medically Necessary mastectomies and lymph node dissections including hospitalization, office visits, and physician and surgeon costs. Covered Services include Prosthetic Devices and Reconstructive Surgery, including devices or surgery to restore and achieve symmetry incident to the mastectomy. When necessary, your Plan Physician will make arrangements for you to receive Covered Services.

Bariatric (Weight Loss) Surgery Bariatric surgery provided for the treatment of morbid obesity is a Covered Benefit when Medically Necessary, is Prior Authorized by VHP and performed by a Plan Provider. Reconstructive surgery deemed Medically Necessary under the reconstructive surgery benefit and otherwise approved, other than Cosmetic Surgery, to improve appearance is a Covered Benefit. The Plan may review requests for other specific procedures/surgery based upon Plan professional guidelines consistent with professional practice; such Covered Services require Prior Authorization.

Travel Services

Valley Health Plan covers worldwide Emergency and Urgently Needed Services. When out of the Service Area all Coverage must be authorized by VHP. Refer to the “Authorization and Denial of Services” section.

Travel Immunizations as recommended by the U.S. Preventive Services Task Force are available. To obtain travel immunizations, you may call the Santa Clara County Public Health Department Travel Clinic at 408.792.5200 to schedule an appointment or contact your VHP Plan Provider or VHP Member Services for information.

Transplant Services

Human Organ, Tissue, and Bone Marrow Transplantation Services Your Benefit Plan includes Covered Services for organ, tissue, and bone marrow transplants subject to the limitations and exclusions as outlined on the “Benefits Description Table” and the “Limitations and Exclusions” sections.

Your Plan Physician will determine that you meet certain Medical Criteria for patients needing transplants, and refer you, in writing with the approval of the VHP Medical Director, to a transplant facility selected by VHP. The transplant facility must determine that you satisfy the patient selection criteria for the transplant. If denied, Covered Services include those services received before such decision(s) is made.

Donor Services Donor services include donation-related Covered Services for a donor, or an individual identified by the authorized transplant facility to be a potential donor, even if the donor is not a VHP member. These Covered Services must be directly related to a covered transplant and are covered up to 12 months from the date of the surgery.

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Limitations & Exclusions This section describes the limitations and exclusions to your Benefit Plan. For specific Benefit limitations and exclusions please also refer to the “Benefits Description Table.”

VHP is not financially responsible for services that exceed the limitation or are excluded. Service refers to any item, drug (unless listed in the VHP Formulary and a prescription is written by a VHP Provider), supply, equipment, device, service, treatment, benefit, or therapeutic or diagnostic procedure. When a particular service is excluded, any service necessary to that excluded service is also excluded, even if it would otherwise be covered.

Principal Limitations

The following items, procedures, benefits, services, drugs, supplies, and equipment are limited under your Benefit Plan: 1. Covered Services are available only through Plan Providers in the Network (unless such care is rendered as Emergency Services, Out-of-Network Urgently Needed Services, or is Prior Authorized); 2. Covered Services provided by Non-Plan Providers are limited to those services rendered as Emergency or Out-of-Network Urgently Needed Services or for which you have obtained Prior Authorization before services are rendered; 3. If you seek Routine Care, elective medical services or follow-up care from Non-Plan Providers without an Authorization, VHP will not pay for your care and you will be required to pay for the full cost of such services; 4. In the event of major disasters, epidemic, labor disputes, war, and other circumstances beyond our control, VHP Providers will provide benefits to the extent practical, according to their best judgment within the limitations of available facilities and personnel. We will have no liability for delay or failure to provide services under such conditions; 5. You may refuse to accept procedures or treatment recommended by your Plan Physician. If you refuse to follow a recommended treatment or procedure, your Plan Physician will inform you whether or not your Plan Physician believes there is an acceptable alternative treatment. You may seek a second medical opinion from another VHP Provider. If you still refuse the recommended treatment or procedure, as required by law, VHP will still be responsible to provide all Medically Necessary Covered Services not refused by you; 6. VHP reserves the right to Coordination of Benefits Reimbursement as outlined in the Agreement. Your Benefits are limited to such extent. As a member, you have an obligation to cooperate and assist us to coordinate Benefits by providing information to all health service providers on any other coverage you and your Dependent(s) have; 7. VHP reserves the right to seek Third Party Reimbursement as outlined in the Agreement. Your Benefits are limited to such extent. As a Member, you have the obligation to cooperate fully in our efforts by signing any forms necessary to assist us in obtaining this recovery; 8. Acupuncture services are limited to 20 visits per Calendar Year; 9. Chiropractic services are limited to 20 visits per Calendar Year; 10. 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; 11. Orthotic appliances are limited to one (1) per year, unless Medically Necessary with Prior Authorization.

12. 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.

For Benefit Information, call 408.885.4760.

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Limitations & Exclusions Principal Exclusions

The following items, procedures, benefits, services, drugs, supplies, and equipment are excluded under your Benefit Plan: 1. Services furnished by a facility which is primarily a place for rest, a place for the aged, a nursing home or any facility of like character, except as specifically provided as Covered Services; 2. Services not Medically Necessary as determined by the treating physician. Upon utilization review, the Medical Director can then approve/deny services, subject to Grievance procedures; 3. Services rendered by Non-Plan Providers except in an Emergency, Out of Network/Service Area Urgently Needed Services, or upon Prior Authorization by the Medical Director; 4. Services rendered when not an Eligible member, prior to the effective date or after the termination date; 5. Services that are court ordered or as a condition of incarceration, parole or probation; 6. Services which exceed the limitations or fail to meet the conditions of Covered Services; 7. Charges for any treatment for addiction to, or dependency on, tobacco or tobacco products, except for the smoking cessation programs that are Benefits of the health education and health promotion services; 8. Charges for services for which the Member would not be obligated to pay in the absence of the Agreement or which are provided to the Member at no cost; 9. Acupuncture services except as specifically listed as a Covered Service; 10. Administration of prescription Legend Drugs or injectable insulin; 11. Anorectics or any other drug used for the purpose of weight control, unless Medically Necessary; 12. Artificial Insemination - any service, procedure, or process which prepares the Member to receive conception by artificial means (except as specified as a Covered Service), such as services related to prescription drugs not on Plan Formulary, donor sperm, sperm preservation, or washing or concentration procedures; 13. Hypnotherapy, vision therapy, and sleep therapy; 14. Cancer clinical trial services except as specifically listed as a Covered Service; 15. Chiropractic services except as specifically listed as a Covered Service; 16. Cosmetic Surgery or plastic surgery except as specified as a Covered Service; 17. Cosmetics, herbal products and treatments, dietary supplements, health or beauty aids; 18. Custodial or Domiciliary Care except as required under Hospice; 19. Dental Services except authorized: (1) services for treatment or removal of tumors; (2) physicians’ services or physician X-ray exams for the treatment of accidental injury to natural teeth; (3) surgery on the maxilla or mandible that is Medically Necessary to correct temporomandibular joint disease (TMJ) or other medical disorders; and/or (4) services for intra-oral devices and associated services for the treatment of TMJ within the limitations of $800.00; or (5) services in connection with accidental fractures of the jaw; 20. Dependent coverage for Groups with Subscriber Coverage only;

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Limitations & Exclusions 21. Devices or appliances except Medically Necessary Diabetic, Prosthetic, and Orthotic Devices. Specifically excluded devices include, but are not limited to, the following: over the counter items, garter belts and similar devices; experimental or research equipment; devices not medical in nature; modifications to a home or automobile; deluxe equipment, non-standard equipment, more than one (1) piece of equipment that serves the same function; more than one (1) device for the same part of the body; and electronic voice producing machines. Unless Medically Necessary, with Prior Authorization, Orthotic Devices are limited to one (1) device per year; 22. Educational services, which a Member might be eligible under State law, including Lanterman Developmental Disabilities Services Act, California Early Intervention Services Act, and services delivered as part of an individualized education program for individuals with exceptional needs, 23. Emergency room services for non-emergency care; 24. Classes and equipment that are solely for exercise, recreation, self-help, hygiene, and beautification, except as specifically listed as a Covered Service; 25. Experimental or Investigational Treatment except as expressly provided as a Covered Service (Cancer Clinical Trial Services or a Member with a Life-Threatening or Seriously-Debilitating condition may request an Independent Medical Review as described in the “Independent Medical Review” section); 26. Gastric bubble, gastroplasty, gastric bypass, bariatric surgery, Laparoscopic Gastric Band (lap-band) surgery, and gastric stapling except when determined to be Medically Necessary by the VHP Medical Director; 27. Hearing aids and hearing aid services, including the furnishing, fitting, installing, or replacing of hearing aid, unless specifically listed as a Covered Service; 28. Hearing examinations to determine the need for hearing correction for Members over 18 years unless Medically Necessary; 29. Human Chorionic Gonadotropin (HCG) Injections; 30. Human Growth Hormone (HGH), except for members with confirmed HGH deficiency; and Covered Services are recommended by a Plan Specialist; 31. Infertility services expect as specifically listed as a Covered Service; 32. Liposuction; 33. Massage therapy; 34. Mental Health Services and Chemical Dependency Services that are court ordered, or as a condition of incarceration, parole or probation, except if a Plan Physician determines that the services are Medically Necessary Covered Services; 35. Military service connected disability care for which a Member is covered or is eligible for such care through another group, whether insured or self-insured; 36. Organ, tissue and bone marrow transplants considered Experimental or Investigational Treatment; 37. Organ, tissue and bone marrow transplants treatment, including medical and Hospital Services for a Member who is a donor or prospective donor when the recipient of an organ, tissue or bone marrow transplant is not a Member. Covered Services for a non-member donor must be directly related to a covered transplant of a Member and are covered up to 12 months from the date of the transplant surgery;

For Member Services, call 1.888.421.8444 (toll-free).

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38. Out-of-Network opinions, except as a Covered Benefit. Independent Medical Review of Denial of coverage by a Plan Provider for Experimental and Investigational Treatment is available; refer to the “Independent Medical Review” section; 39. OTC drugs, medications, and supplies are not a Covered Benefit, except as specified in this Membership Agreement and Evidence of Coverage & Disclosure Form; 40. Penile implants and services related to the implantation of penile prostheses, except as Medically Necessary to treat direct physical trauma, tumor, or physical disease to the circulatory system or the nerve supply; 41. Personal lodging, meals, travel expenses and all other non-medical expenses; 42. Personal or comfort items which are non-medical, environmental enhancements or environmental adaptations, modifications to dwellings, property or motor vehicles, adaptive equipment and training in operation and use of vehicles; 43. Physical exams, evaluations and reports including those for employment, insurance, licensing, school, sports, recreation, premarital purposes, or required for or by court proceedings, unless timing and scope coincide with covered periodic health appraisal exams; 44. Prescription drugs and accessories not Medically Necessary or in accordance with professionally recognized standards of care; non-prescription drugs or medications, including over the counter drugs; non-FDA Approved Drugs; Generic equivalents not approved as substitutable by the FDA; non-FDA approved Treatment Investigational New Drugs; National Cancer Institute Group C cancer drugs that are used for purposes other than those purposes approved by the FDA or the National Cancer Institute; 45. Reversal of voluntary sterilization or of voluntary induced infertility; 46. Routine foot care, including trimming of corns, calluses and nails, unless Medically Necessary; 47. Temporomandibular Joint (TMJ) Disorders Services that are not Medically Necessary. Intra-oral appliances related to TMJ are limited to one (1) oral splint or appliance and are limited to an $800.00 maximum lifetime benefit. Intra-oral appliance and placement services which cost more than the lifetime limit of $800.00, for intra-oral positioning devices and related services, are not covered.

48. Transportation services unless Medically Necessary and authorized by the Medical Director or unless necessitated by an Emergency; 49. Vision care except as specified as Covered Benefits; 50. Vocational Rehabilitation; 51. Weight control, weight loss treatments, weight loss surgery, or related supplies unless Medically Necessary, except as specifically provided as Covered Benefits.

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Payment & Reimbursement Responsibility Prepayment Fees (Premiums)

Your employer is responsible for paying your membership premiums. Your employer will notify you if you are responsible for any portion of these charges. If you have questions regarding information about the method, amount, or frequency of your contribution (if any), please contact your employer.

If the Group no longer employs you and you wish to continue receiving VHP Benefits, VHP must receive your premiums. Continued Coverage is only available for the period when premiums are received and if you are covered under: • COBRA or the Consolidated Omnibus Budget Reconciliation Act - you will be required to make monthly prepayment premiums directly to the Group. The Group will be responsible for distributing these fees to VHP (Note: Group may designate a Group COBRA Administrator to administrate and submit premiums directly to VHP).

•

Cal-COBRA or the California Continuation Benefits Replacement Act - you will be required to make monthly prepayment premiums directly to the Plan. (Note: Plan may designate a Cal-COBRA administrator or Group to administrate and submit premiums directly to VHP.) to administrate and submit premiums directly to VHP.)

•

VHP Individual Conversion Benefit Plan - you will be required to make payments directly to the VHP office at 2480 N. First Street, Suite 200, San Jose, CA 95131.

•

Continuation of Coverage for Totally Disabled Members - you will be required to make payments directly to the Group. The Group will be responsible for distributing these fees to VHP.

Changes in Fees, Benefits, and Charges

VHP may change the premiums and benefits, to the extent permitted by law, during the term of the Agreement. If there are changes or modification to your Benefits, to other charges, such as Copayments, or to the cost of contribution to your membership premiums your employer will notify you of the change and reason(s) why.

Other Charges

When you receive medical care, you may be responsible for paying certain Copayments. A Copayment is a minimal charge made at the time of service. For your information and convenience a schedule of the Covered Services and applicable Copayment is included in this booklet. Refer to the “Benefits Description Table.”

Annual Copayment Maximum

There is a limit to the Copayments and other charges that you must pay in any Calendar Year. The Copayment limit per Calendar Year is: • $1,000.00 for an individual, or •

$2,000.00 for a family.

You should keep a record of all Copayments you have paid during the year. When the limit has been reached, contact VHP. Once you have demonstrated that you have reached the limit, you will not be required to pay any additional copayments or other charges for the remainder of the Calendar Year.

If you have any questions regarding your Copayment and annual maximum limits, call a Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free).

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Payment & Reimbursement Responsibility Maximum Lifetime Benefit

There is no Maximum Lifetime Benefit (on essential benefits) that applies to the Covered Services described in this booklet. The only maximum benefit limits are those specifically mentioned in this booklet.

Premiums & Health Care Benefits Ratio

Beginning January 1, 2011, regulations require that VHP spends on average at least 85 percent of premiums on health care benefits, this requirement is known as a “Medical Loss Ratio” or “Minimum Loss Ratio” (MLR). VHP is also required to report the “MLR” to specified individuals and Small Groups. The bill defines “health care benefits” to include, but not be limited to: health care services that are either provided or reimbursed by the plan or its contracted providers as Covered Services; the costs of programs or activities, including training and the provision of informational materials determined through regulation to improve the provision of quality care, improve health care outcomes, or encourage the use of evidence-based medicine; disease management expenses; payments to providers as risk pool payments of pay-for-performance initiatives; plan medical advice by telephone; and, prescription drug management programs. MLR is the ratio of administrative costs vs medical costs.

Premiums are adjusted on an annual basis and are outlined in the Agreement. VHP spends 91% of its premiums or MLR for the geographic area of Santa Clara County. Santa Clara County is the Service Area for the Plan.

Provider Payments

The Valley Health Plan contracts with its Plan Providers to provide Covered Services to its Members.

Plan Providers currently include Palo Alto Medical Foundation (PAMF), San Jose Medical Group (SJMG), Santa Clara County Independent Physician Association (SCCIPA), and Santa Clara Valley Hospital and Health System (SCVHHS). These Networks include clinics and urgent care centers. VHP also contracts with other Service Area providers including several community clinics and independent physicians, a Pharmacy Benefits Management (PBM) company, and a 24-hour Medical Advice provider. Under the terms and conditions of your membership with VHP, you must obtain services from these Plan Providers unless you are authorized to receive services elsewhere or in the event of an Emergency Service.

VHP’s financial arrangements with our physicians and providers are reviewed and approved by the DMHC. No financial incentives are offered to any provider.

All Plan Providers are paid based on the terms and conditions of their agreements with VHP. Plan Providers are paid 100% for Covered Services, therefore except for Copayments, the Members do not pay any additional fees to VHP Providers.

For additional information regarding provider payments, contact your provider or VHP Provider Relations Department at 408.885.2221 or 1.888.421.8444 (toll-free).

For information regarding Claims processing and other reimbursement responsibilities, refer to other sections in this “Payment and Reimbursement Responsibilities” section.

Reimbursement Provisions (Claims)

VHP has designed coverage in a way to minimize the need for you to file a Member Medical or Pharmacy Claim. If for some reason you are billed or have paid for services that are Covered Services, submit the itemized bill and/or your original receipt showing proof of payment with your request for reimbursement within 90 days after (or as soon as possible thereafter) you receive those Covered Services.

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Payment & Reimbursement Responsibility For Medical Claims submit your claim to:Valley Health Plan Valley Health Plan Claims Department P.O. Box 26160 San Jose, CA 95159-6160 To obtain a Member Claim form (Medical Claim Reimbursement Form) contact VHP’s Member Services or go online to our website at www.valleyhealthplan.org under “Members - Forms.”

Be sure your name, the Subscriber/employee’s Social Security Number, date and type of service, your PCP’s name, and any other pertinent information (such as original receipts, doctor notes, etc.) are included in your request. VHP will process the request for reimbursement within 45 working days of receiving complete information.

You may obtain information about reimbursement by writing or visiting the VHP office at 2480 N. First Street, Suite 200, San Jose, CA 95131 or by calling our Member Services at 408.885.4760 or 1.888.421.8444 (toll-free). To obtain a Medical Claim Reimbursement Form contact VHP’s Member Services or go online to our website at www.valleyhealthplan.org For Pharmacy Claims submit your claim to: Navitus Health Solutions Operations Division - Claims P.O. Box 999 Appleton, WI 54912-0999 To obtain a Pharmacy Claim Form go online to our website at www.valleyhealthplan.org under “Members - Forms.” You may also obtain claim forms at www.navitus.com or by calling Navitus Customer Care, 24 hours/ daily, at 1.866.333.2757 (toll-free).

To submit a pharmacy claim for reimbursement, you must provide specific information about the prescription, the reason you are requesting reimbursement, and any payments made by you or on your behalf. (You must fill out the reimbursement claim form completely.)

VHP may reimburse you or the Plan Provider, less any copayment, for the Covered Services. If a request for reimbursement is denied or partially denied, you will receive written notice specifying the reason for the Denial.

VHP reviews all services received outside of the Network for appropriateness of care. If the services are from a Non-Plan Provider for either an Emergency, Out-of-Network Urgently Needed Services, or for authorized services, VHP will reimburse you or the provider for those Covered Services, less any required Copayment(s). If the services from the Non-Plan Provider are non-Covered Services or you have exceeded the Benefits limits, VHP will deny your request for reimbursement.

In the event that VHP fails to pay a Plan Provider, you will not be liable to the Plan Provider for any sums owed by VHP. As required by California law, every contract between VHP and a Plan Provider contains a provision to this effect. However, in the event that VHP fails to pay a Non-Plan Provider because the claim was denied, you could be liable to the Non-Plan Provider for the cost of service.

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Payment & Reimbursement Responsibility Liability of Subscriber or Enrollee for Payment

Plan Members are not liable for charges for Covered Services authorized by their PCP or VHP. A Copayment may be required for some services. The specific Copayment or other charges for your Benefit Plan can be found in the “Benefits Description Table” and in the Group Service Agreement available from your employer.

If you receive care that is not performed by your PCP or authorized by VHP, you will be financially responsible for the cost of care provided. (This does not apply if you receive Emergency Services or Out of Network/ Service Area Urgent Services that are Covered Services and you have notified your PCP or VHP.) If you receive care that is a non-Covered Service or if you receive services of a non-VHP Provider that have not been authorized by VHP, you will be financially liable for such services. Non-Covered Services are listed in the “Exclusions and Limitations” section, “Benefits Descriptions” section and in the “Benefits Description Table.”

Members may be responsible for charges by a provider for appointments that are missed without notice to the provider.

Coordination of Benefits Reimbursement

The Covered Services under this EOC are subject to Coordination of Benefits (COB) rules. You must notify VHP if you have health care coverage with another health plan or insurance company, VHP will coordinate benefits for Members who are covered under two (2) or more health plans. When there is a Coordination of Benefits, health care plans share the costs of authorized services. Members may be able to receive up to one hundred percent (100%) coverage. Valley Health Plan will pay for Covered Services provided by Plan Providers and authorized by VHP. If appropriate, you should submit claims to VHP for review.

You must notify VHP if you or your enrolled Dependent(s) are covered under another health care plan, including government health care programs such as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), Medi-Cal, and Medicare. VHP will not cover Benefits that duplicate the other benefits to which a Member is entitled.

VHP has the right to recover any overpayments made for Covered Services. In certain circumstances, Members may be required to assist VHP with the necessary documentation.

Third Party Reimbursement / Liability

In cases of injuries caused by any act or omission of a third party (including, without limitation, motor vehicle accidents and injuries, and illnesses covered by Workers’ Compensation) and complications incident thereto, Plan will furnish Covered Services. However, you must inform VHP or your Provider when services performed are covered through workers’ compensation laws, automobile, accident, or other liability coverage. The Plan will not duplicate coverage for such services.

When a legitimate dispute exists as to third party liability, Plan will furnish Covered Services until the dispute is resolved. You must agree to supply all information and sign the appropriate documents necessary to carry out the Plan’s right to recover its costs of the services provided or for VHP to obtain a lien.

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Payment & Reimbursement Responsibility Otherwise VHP may deny coverage for such reimbursement. As necessary, VHP and/or its Providers will seek reimbursement up to the amount VHP has paid for any duplicate services. In the case of a monetary award, VHP or its Plan Providers must be reimbursed immediately after the award is received. You are responsible for notifying VHP of any duplicate payment made for such services. VHP also has the option to be subrogated to your rights to the extent of the cost of Benefits provided by the Plan; meaning that VHP has the right to collect directly from any third party who is responsible for such liability when payment has been made by VHP for services.

If you wish to release a third party from liability or settle a claim against a third party for which you received compensation for medical care provided through VHP, you must obtain prior written consent from VHP if such acts would limit VHP’s right to reimbursement.

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Member Services Assistance Member Services Representative

Valley Health Plan’s top priority is to provide quality service and health care to its Members. Everyone at VHP shares responsibility for assuring your satisfaction. Our Member Services Representatives will be happy to assist you with your questions, complaints or to hear how VHP and its Plan Providers are doing.

Member Services is available to assist you over the phone Monday through Friday from 9:00am to 5:00pm at 408.885.4760 or 1.888.421.8444 (toll-free). For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality. If you need language assistance, VHP’s Member Services offers over-the-telephone language assistance at no cost to you. Walkin office hours are Monday through Friday 8:00am – 5:00pm. Valley Health Plan is located at 2480 N. First Street, Suite 200, San Jose, CA 95131.

You can ask our representatives how to obtain medical care, how to interpret your covered health benefits, what to do if you move, how to add dependents, obtain a new VHP ID Card, submit Member Claims, file Grievances, or to help you with any other service issues. You can also request Plan materials, including an updated EOC or VHP Primary Care Physician List, which includes clinic address and telephone numbers.

If a representative is not available, please leave a message, a representative will return your call on the next business day. Call VHP at 408.885.4760 or 1.888.421.8444 (toll-free), to leave a message 24 hours a day.

If you need to notify VHP of an emergency or urgent care situation, please leave a telephone number where you can be reached.

Membership Records/Information

Your VHP Membership record contains eligibility and other information about you and your Eligible Dependent(s). This information is important because it identifies you as a Member and determines where you and your enrolled Dependent(s) can receive services. Incorrect records can delay medical care, create problems in Coverage, and possibly cost you money.

It is important to keep your Member records updated with current information. It is your responsibility to keep your membership records updated. Contact your employer and call the VHP Member Services office at 408.885.4760 or 1.888.421.8444 (toll-free).

Membership Records – Employer Responsibilities

Your employer provides VHP with updated eligibility/enrollment information; including effective dates of Coverage, name, address, telephone numbers, dependent status, and other carrier benefits information. Your employer is also responsible for notifying VHP of status changes including marriage, death, termination of employment, reduction in hours, or entitlement to Medicare. Therefore, it is necessary for you to notify your employer or employer’s human resources department of any changes you may have to your eligibility and membership information.

It is important to keep your Member records updated with current information. It is your responsibility to keep your membership records updated. Contact your employer or VHP if you have questions regarding your VHP membership records/information.

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Member Services Assistance Member Grievances

At Valley Health Plan (VHP) we take pride in being a member focused health plan. We suggest that you allow our Member Services Department to assist you in resolving your concerns. You may call a VHP Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free); they are available Monday through Friday between 9:00am – 5:00pm. For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality. You can also reference our website at www.valleyhealthplan.org for recent updates, provider listings, and general information.

You may request that a Grievance be filed on your behalf or you can complete a Grievance form and submit it to VHP. Grievance forms are available through VHP, at your provider’s office and on our website at www. valleyhealthplan.org under Members – Grievances. Grievance forms are available in English, Spanish and Vietnamese at no cost to you. Grievance forms, translated into other languages, are also available free of cost to you. For more information regarding these forms and other VHP’s language services, contact a VHP Member Services Representative.

Send your Grievance to Valley Health Plan, Attention: Grievances, 2480 N. First Street, Suite 200, San Jose, CA 95131. Alternatively, you may also submit your Grievance online at www.valleyhealthplan.org. You have 180 days from the date of the event, which caused a Grievance, to file the Grievance. As needed, the 180 days starts on the date the Plan provides you with a Grievance Form translated into the language of your choice.

It would be helpful to include all pertinent information from your VHP ID Card and the details and circumstances surrounding your concern or problem. Providing as much information as possible may eliminate the time required to collect such data. Pertinent information should include any medical records or physician opinions in support of your Grievance; otherwise your medical records may need to be obtained from your Plan Physician or you may need to obtain them from a Non-Plan Physician. Your Grievance will be acknowledged within five (5) calendar days of receipt. VHP will notify you in writing of the outcome within 30 calendar days of receiving your Grievance.

If the Grievance involves an imminent and serious threat to your health or the health of your Dependents, including but not limited to, severe pain, psychological well-being, potential loss of life, limb or major bodily function you will be entitled to an expedited review. The Grievance must state that you are requesting an expedited review. You will be notified of the outcome or status within three (3) days of receipt of the Grievance.

If you are not satisfied with the Grievance decision, you may contact the California State Department of Managed Health Care (DMHC) by following the procedures outlined in the “DMHC Consumer Help-Line” section.

The Plan does not have a requirement that the Member must first participate in the Plan’s Grievance process before requesting the Department to review a Grievance. Refer to the “Access to Care” section under “Independent Medical Review.”

For Benefit Information, call 408.885.4760.

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Member Services Assistance Department of Managed Health Care (DMHC) Consumer Help-Line

“The California Department of Managed Health Care is responsible for regulating health care service plans.

If you have a Grievance against your health plan, you should first telephone your health plan at 408.885.4760 or 1.888.421.8444 (toll-free), and use your health plan’s Grievance process before contacting the Department.

For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number of your modality. Utilizing this Grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.

If you need help with a Grievance involving an emergency, a Grievance that has not been satisfactorily resolved by your health plan, or a Grievance that has remained unresolved for more than thirty (30) days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1.888.HMO.2219) and a TDD line (1.877.688.9891) for the hearing and speech impaired. The Department’s Internet website www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online.”

Public Policy Committee

You may assist VHP to establish public policy through VHP’s Public Policy Committee, the VHP Advisory Board. The findings and recommendations of this Advisory Board are regularly reported to VHP’s governing body. A minimum of 51% of the committee must be Members of VHP. “Public Policy” means acts performed

by VHP and its employees to assure the comfort, dignity, and convenience of Members who rely on VHP providers to provide services. Please contact a VHP Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free) if you are interested in becoming an Advisory Board member or would like more information.

Advance Health Care Directive - Your Health Care Choices

An Advance Health Care Directive is a formal document, signed by you in advance of a severe illness or injury, which will guide your physician(s) when providing treatment. Not withstanding this document, you still have the right to make medical and other health care decisions for yourself so long as you can give informed consent regarding the particular decision. As long as you can speak for yourself, Plan Providers will honor your wishes. But, if you become so incapacitated that you cannot make an informed decision, this directive will guide your health care treatment based on the directions you set out in the Advance Health Care Directive.

There are two (2) basic types of Advance Health Care Directives in California that provide guidance to your physicians if there is a disagreement results about your wishes. They are: • Durable Power of Attorney for Health Care Decisions (DPAHCD), and •

Natural Death Act Declaration.

The preferred document is the DPAHCD. A VHP Member Services Representative can help you obtain one.

The policies involving your right to make medical treatment decisions may vary from facility to facility. For example, operating rooms typically suspend Advance Health Care Directives and provide all appropriate resuscitative and life-prolonging treatment during surgery and recovery.

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Member Services Assistance It is your responsibility to inquire about and comply with the policies of your hospital or other health care facility about Advance Health Care Directives. Give copies of your completed Advance Health Care Directive to your physician, your representative (if designated), and your family. Be sure to keep a copy for yourself and take one with you when you are hospitalized.

You are not required to have an Advance Health Care Directive. If you do not have an Advance Health Care Directive, you can and will still be treated.

If you have any questions regarding your health care choices or need more information, please contact your Primary Care Physician or a Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free).

Call Member Services at 408.885.4760.

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Termination of Benefits Once enrolled, your coverage may be canceled only for the Disenrollment and Termination of Benefits reasons identified below. To voluntarily disenroll, contact your employer and complete and sign the appropriate paper- work. Your employer will notify you of your effective date of termination. If you or your Dependent(s) coverage is terminated involuntarily, you will receive notice of the date of termination. Until the effective date of your Disenrollment or Termination, you will remain a VHP Member and are responsible to: • continue to receive all Covered Services from Plan Providers (except in the event of an Emergency or Out of Network/Service Area Urgently Need Services), •

pay for all applicable membership premiums, and

•

continue to adhere to all requirements of your VHP membership.

Once your Disenrollment or Termination from the Benefit Plan becomes effective, your VHP Identification Card will no longer be valid.

You may not be reinstated automatically if coverage is canceled or terminated.

Fraudulent use of your VHP Identification Card, the services or facilities of VHP or its Plan Providers, and/or fraud or misrepresentation on the enrollment application form will result in an investigation and appropriate legal action.

If you have additional questions about the Disenrollment or Termination process, please review the following sections and/or call your employer or a VHP Member Services Representative at 408.885.4760 or 1.888.421.8444 (toll-free).

Cancellation of Group Service Agreement

Your employer may terminate your coverage upon written notice to VHP. If your employer terminates or does not renew the Group Service Agreement for any reason, or if VHP terminates the Agreement, your Coverage will cease on the date the Agreement terminates. You will not be able to convert to Individual Conversion unless you are disabled and eligible for continued coverage. Refer to “Continuation of Coverage for Totally Disabled Members.”

Loss of Eligibility

Recent health care reform requires VHP and its Groups to continue to offer Coverage to dependent children until the child turns 26 years of age (through age 25). Extended Coverage to Dependents will occur at the time of the Group’s renewal of their Agreement or as determined by the Group. For more information regarding the health care reform’s extension of Dependent Coverage, contact your employer or VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

If you cease to meet VHP and/or your Group eligibility requirements, then your and your Dependent’s coverage will involuntarily terminate. (Subject to the provisions for continuation of coverage or conversion of benefits.) You and your employer must notify VHP immediately if you or your Dependent(s) cease to meet the eligibility requirements. (Refer to the “Eligibility” section.)

You lose eligibility if: • you no longer work or reside within Santa Clara County and you have no intention of returning to the Santa Clara County for an uninterrupted period of more than 90 consecutive days.

• you

are an Eligible Retiree and you reside outside the Service Area, adjacent or contiguous counties to the Service Area, or San Francisco County with no intention of returning for an uninterrupted period of more than 90 consecutive days. Adjacent counties include San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties.

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Termination of Benefits Your legal spouse loses eligibility: • upon dissolution of the marriage, Coverage for a Subscriber’s spouse will automatically terminate. In addition, the enrollment of all of the spouse’s Dependent(s) who are not also Eligible Dependents of the Subscriber will terminate. Coverage will terminate on the last day of the month/pay period of the dissolution of marriage.

•

if he/she moves out of the service area, he/she is eligible for Emergency Services only.

Your domestic partner (as defined by the Group Service Agreement or as in accordance with State and federal requirements) loses eligibility: • upon dissolution of the relationship as certified by your employer, Coverage for a Subscriber’s domestic partner will automatically terminate as defined by your Group. In addition, the enrollment of all of the domestic partner’s Dependent(s) who are not also Eligible Dependents of the Subscriber will terminate.

Coverage will terminate on the last day of the month/pay period of the dissolution of relationship as certified by your employer.

• if

he/she moves out of the service area, he/she is eligible for Emergency Services only.

Your Eligible Dependent child(ren) lose eligibility and coverage automatically terminates when they: age 26 (contact your employer regarding your Dependent’s extension of Coverage); or

• reach

• become

employed and they are eligible to enroll in an employer plan - applies to adult children aged 19 through age 25.

• if

he/she moves out of the Service Area, he/she is eligible for Emergency or Urgently Needed Services only.

For Eligible Dependent child(ren) who were incapable of self-sustaining employment by reason of mental retardation or physical handicap prior to age 26 and are chiefly dependent on you for support and maintenance, coverage will discontinue: • at

age 26 if the child is no longer disabled; or

• if

the child is older than 26, the earlier of the date the child recovers from the handicap or the date the child is no longer chiefly dependent on you for support and maintenance.

Your Dependent(s) may also lose eligibility in the event of your death. If the Subscriber dies, Dependent Member(s) must contact the Group for details on Disenrollment or continued Coverage for Members.

Loss of eligibility does not affect any rights to continue Group Coverage under COBRA, as described in the“Individual Continuation of Coverage” section.

Disenrollment by Member

If you or your Dependent(s) elect coverage under another health benefits plan offered by or through your employer, then your Coverage terminates automatically at the time and date the alternate coverage becomes effective. You and your employer agree to notify VHP immediately that you or your Dependent(s) have elected coverage elsewhere. You or your Dependent(s) may voluntarily disenroll from VHP at any time and for any reason. You may disenroll by notifying VHP and/or your employer in writing of your intent to cancel your membership. Your Coverage terminates at midnight on the last day of the pay period/month in which you provide notice to VHP of your intent to disenroll or at midnight on the effective date as determined by your employer.

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Termination of Benefits Cancellation of Members for Cause

VHP may terminate your membership and the membership of your Dependent(s) if: You or your Dependent(s) commit fraud or deception in connection with membership, Plan, or a Plan Provider, then Plan may terminate Member within 30 days notice. Some examples of fraud or deception include: • Intentional failure or with willful misrepresentation to furnish material information required in connection with the enrollment under the Agreement, such as knowingly misrepresenting eligibility or enrollment information, or intentionally giving us incorrect or incomplete material enrollment information in any document, or if you fail to intentionally notify us of material changes in your family status (e.g. dependent changes) or Medicare coverage that may affect eligibility for membership or Benefits. The Plan may terminate Member with 30 days notice.

• Engage in deception in the use of the services or facilities of VHP, Plan Providers, or Non-Plan Providers.

• Unauthorized use of a Plan identification card by permitting a non-Member to use a Member identification card to obtain Benefits.

Cancellation of a Dependent for cause will solely apply to the Dependent involved and will not affect the enrollment of the Subscriber or any other Dependent(s).

You may use the Grievance procedure to contest an involuntary Disenrollment or Termination for cause.

(Refer to the “Member Grievance” section.)

Termination for Nonpayment

VHP may terminate your and/or your Dependent(s) membership if payment is not made in the amounts due within the time VHP specifies in writing, subject to compliance with a 30 day grace period notice requirement. If you receive notice that your coverage is being canceled or not renewed due to failure to pay your premium, VHP must provide you with a 30-day “grace period.” The grace period begins after the last day of paid coverage. VHP must continue to provide coverage during the grace period, through you will be financially responsible for the premium for the coverage provided during the grace period. The grace period must last at least 30 days after the date of the last day of paid coverage.

During the grace period, you can avoid cancellation or nonrenewal by paying the premium you owe to VHP. If you do not pay the premium by the end of the grace period, your coverage will be terminated at the end of the grace period. You will still be legally responsible for any unpaid premium you owe to the Plan.

If you wish to terminate your coverage immediately, contact VHP as soon as possible. After the effective date of Termination, you and your Dependent(s) may reinstate membership only by paying all amounts due, completing a new application, and re-enrolling in accordance with all VHP requirements.

Medicare Enrollment

VHP may terminate or cancel your membership or the membership of your Dependent(s) if you or your spouse/ partner who is/are eligible to be covered by Medicare fails to enroll in Medicare as required by your employer. This requirement may not apply if you or your spouse/partner is age 65 or older and still working.

If you or your Dependent(s) are eligible for Medicare please call VHP to discuss your termination and/or your options for continuation of coverage.

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Termination of Benefits Enlistment in Uniformed Services

VHP may terminate your membership or the membership of your Dependent(s) if you or your Dependent(s) enter full-time service in any branch of the armed forces (enlistment).

If you are called to active duty in the uniformed services, you may be able to continue your Coverage under this EOC for a limited time after you would otherwise lose eligibility, if required by the federal Uniformed Services Employment and Reemployment Rights Act (USERRA) law. Contact your Group if you want to know how to elect USERRA coverage and how much you must pay your Group.

If you or your Dependent(s) enlist, please call your Employer to discuss your termination and/or your options for continuation of coverage.

State Review of Termination

If you believe your membership was terminated because of your ill health or your need for health care, you may request a review by the California Department of Managed Health Care by calling 1.888.466.2219 (tollfree). For additional information, telephone numbers, or e-mail address, please refer to the “Member Services Assistance” section under “DMHC Consumer Help-Line.”

Cessation of Coverage

VHP will not cover any services or supplies provided after the effective date of termination regardless of whether you were seeing a physician or other provider for a condition or course of treatment. The only exceptions are when you may be eligible for continuation coverage or Individual Conversion, where applicable, and: • you are or your Dependent is a registered bed patient in a Plan Hospital at the date of termination of the Agreement by VHP. You or your Dependent may receive all the Benefits of your VHP coverage for the condition confining you to the hospital, subject to your payment of the premium and applicable copayments, until those Benefits expire or you are discharged from the facility, whichever occurs first; • you are or your Dependent is receiving inpatient obstetrical care in a Plan Facility at the date of termination, and there has been no default in premiums. You will continue to receive Coverage of inpatient obstetrical care only through discharge; • you or your Dependent is Totally Disabled, as determined by VHP, by a condition for which you or your Dependent was receiving services before your employer terminated. You will continue to receive Coverage only for services related to the disabling condition, subject to all limitations and restrictions, including applicable co-payments and premiums. Coverage will end: • 12 months after the termination date; • when you are no longer Totally Disabled as determined by VHP Medical Director or; • when you are covered under any replacement contract or policy without limitation as to the disabling condition, whichever occurs first.

Effective Date of Termination

Your coverage as a Member will terminate on one of the following dates: • for County of Santa Clara employees at midnight on the last day of the pay period of the month in which you were eligible and for which payment has been received; • for Valley Transportation Authority, COBRA, retirees, and Individual Conversion at midnight on the last day of the month for which payment was received; or • on the termination date established by VHP and your employer as specified in the Group Service Agreement or as otherwise agreed by your Group.

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Termination of Benefits If VHP terminates your Coverage, VHP will notify the Group of the cause and effective date of your Termination. Your coverage will cease as of the date of Termination or cancellation. If you are undergoing treatment for a medical condition, services provided beyond the date of Termination will be your financial responsibility unless you are covered by continuation coverage through VHP. (Refer to the “Individual Continuation of Coverage” section.)

Refunds in the Event of Cancellation

If your Coverage terminates, payment of premiums for any period after the termination date and any other amounts due to you will be refunded to your employer within 30 days. Refunds are minus any amounts due to VHP. If your Coverage terminates due to fraud or deception in the use of health services or facilities or you knowingly permitted such fraud or deception by another, refunds will not be made.

Certificates of Creditable Coverage

The Health Insurance Portability and Accountability Act (HIPAA) require employers or health plans to issue “Certificates of Creditable Coverage” to terminated group Members. The certificate documents health care membership and is used to prove prior creditable coverage when a terminated Member seeks new coverage.

When you terminate, you or your employer may request a certificate from VHP at any time by contacting our Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free). VHP will mail the certificate to the Subscriber.

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Individual Continuation of Coverage US and California laws protect your right and your dependent(s) right to continue group health coverage under certain circumstances or qualifying events. This is called individual continuation of health care benefits or Individual Continuation of Coverage.

This section of the EOC explains the four (4) kinds of Individual Continuation of Coverage, which are: 1. COBRA 2. Cal-COBRA 3. HIPAA & Other Individual Plans 4. Individual Conversion Plan California law requires that every health plan that offers group continuation coverage must include the following statement about continuation health coverage: Please examine your options carefully before declining this coverage. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in a higher premium or you could be denied coverage entirely.

Continuing Group Coverage Under COBRA and Cal-COBRA

You and your Eligible Dependent(s) may be eligible for continuation of Coverage under COBRA and/or CalCOBRA for up to 36 months. Contact your employer to see if you are eligible. The federal COBRA (Consolidated Omnibus Budget Reconciliation Act) and Cal-COBRA (the California Continuation Benefits Replacement Act) allows employees and/or their family members to temporarily continue their coverage, at group rates, when coverage would otherwise end.

COBRA applies to most employees (and most of your Eligible Dependents) of most employers with 20 or more employees.

Cal-COBRA applies to most employees (and Eligible Dependents) of most employers with less than 20 employees, and in certain cases, if you would otherwise lose COBRA coverage.

Qualifying Events

You or your Dependent(s) may be eligible to continue group coverage based on the following Qualifying Events: 1. You or your Dependent(s) may be eligible to continue group continuation coverage if cancellation of your coverage occurs because: • your employment was terminated for any reason, except gross misconduct, or

•

your hours of employment are reduced.

2. Your Dependent(s) may be eligible to continue group continuation coverage if cancellation of their Coverage occurs because of: • your death; • your divorce or separation from your spouse/partner; • your entitlement to receive benefits under Medicare; or • your Dependent child loses eligibility.

Contact Member Services at 408.885.4760.

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Individual Continuation of Coverage Understanding Your Choices

You or your Dependent(s) have 60 days to elect to continue COBRA or Cal-COBRA. Once elected, the Subscriber is required by law to pay any required first premium within 45 days from when you requested continuation coverage. If you or your Dependent(s) do not elect, or do not pay, for continuation coverage within the required timelines, you or your Dependent(s) may be disqualified from receiving such continuation coverage. Contact the Plan, your employer, or COBRA administrator for more information.

If you or your Dependent(s) elect to purchase COBRA or Cal-COBRA Coverage (as applicable) following the Qualifying Events above, you will receive the same Benefit Plan that VHP is offering to the Group. Following election and initial payment, you will pay the COBRA or Cal-COBRA membership premiums on a monthly prepayment basis by the first (1st) of each month. VHP may decline, cancel or terminate your Coverage if you fail to pay the membership premium, or for reasons as stated in the applicable laws, rules, and regulations. In addition, you must live or work in Santa Clara County and not be covered under any other health insurance, including Medicare. All rights to this Coverage will cease on the termination date of the Agreement. If the VHP Agreement is terminated through your Group, you may be eligible for other extended coverage under another group benefit plan offered by the employer. Call your employer or Group COBRA administrator for more information about COBRA Coverage. Call the Plan for more information about Cal-COBRA Coverage.

Administratively, eligible persons will be terminated from Coverage upon a Qualifying Event but will be enrolled retroactively to the Qualifying Event upon timely election of continuation coverage under COBRA or Cal-COBRA (ARRA exceptions apply, refer to the “ARRA Premium Reduction” section below). If an eligible person requires services before election, the eligible person must either (1) elect and pay for the Coverage or (2) pay Reasonable Charges (i.e. reasonable and customary charges) for the services subject to reimbursement by Plan within 30 days of such person’s timely election of Continuation Coverage under COBRA or Cal-COBRA. COBRA enrollees who reach the 18-month or 29-month maximum available under COBRA may elect to continue coverage under Cal-COBRA for a maximum period of 36 months from the date the Member’s continuation coverage began under COBRA. If elected, the Cal-COBRA coverage will begin after the COBRA coverage ends. Your Group or Group COBRA administrator will notify you of your eligibility to continue coverage under Cal-COBRA. You have 60 days from that notification to contact VHP to continue Group Coverage under Cal-COBRA. Refer to the “Cal-COBRA After Exhausting COBRA” section.

Note: COBRA enrollees must exhaust all the COBRA coverage to which you are entitled before you can become eligible to continue coverage under Cal-COBRA..

In no event will continuation of Group Coverage under COBRA, Cal-COBRA, or a combination of both be extended for more than three (3) years or 36 months from the date such Coverage began.

If Social Security Administration determined that you were disabled at any time during the first 60 days of COBRA or Cal-COBRA coverage, you must notify your Group within 60 days of receiving the determination from Social Security Administration. Also, if Social Security Administration issues a final determination that you are no longer disabled in the 35th or 36th month of Group continuation coverage, your Cal-COBRA coverage will end the latter of: (i) expiration of 36 months after your original COBRA effective date, or (ii) the first day of the first month following 31 days after Social Security Administration’s final determination that you are no longer disabled.

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Individual Continuation of Coverage In order for you to continue Group Coverage on COBRA or Cal-COBRA (as applicable) with no break in Coverage, the Plan must be advised in writing within 60 days of the date of your Qualifying Event, otherwise you may not be eligible to continue Coverage on this Benefit Plan. If you or your Dependent(s) elect to continue coverage, by law you have 45 days from the election date to pay the initial premium billing. Thereafter, you must prepay your monthly premiums by the end of the month prior to the month of coverage (e.g. pay July’s premium by June 30th). For additional information on continuing Group coverage, please refer to the next few sections in this EOC.

Cal-COBRA After Exhausting COBRA

If you elect to purchase Cal-COBRA after you lose COBRA coverage, you may be able to continue uninterrupted Group coverage, provided: • your effective date of COBRA coverage was on or after January 1, 2003; • you have exhausted the time limit for COBRA coverage; • you are not entitled to Medicare or covered under any other health or group health plan; • you pay VHP the monthly dues by the billing due date as described below.

As described in the “Individual Continuation of Coverage” section, under “Individual Conversion Plan,” you may be able to convert to an individual (non-group) plan if you don’t apply for Cal-COBRA coverage after exhausting COBRA, or if you enroll in Cal-COBRA and your Cal-COBRA coverage ends.

COBRA or Cal-COBRA Enrollment Responsibility

To determine if you are eligible to enroll in COBRA or Cal-COBRA refer to the “Continuing Group Coverage Under COBRA and Cal-COBRA” section under “Qualifying Events.”

Whether you are enrolling in COBRA or Cal-COBRA you must return your completed written enrollment application to your employer/employer COBRA administrator or to VHP or within 60 days following the later of i) the date your Coverage terminates or will be terminated by reason of a Qualifying Event; or ii) the date that you were sent notification that you may continue Coverage under the Group’s Benefit Plan. If you or your Dependent(s) do not complete and return the application within the timelines, you or your Dependent(s) will be disqualified from receiving continuation Coverage.

1. To request a COBRA enrollment application, please contact your employer. Your employer or your employer’s COBRA administrator will ensure you receive information regarding your COBRA rights.

In order for you or your Dependent(s) to continue group coverage through COBRA, a completed written enrollment application and applicable premiums must be received by VHP based on the federal COBRA law.

2. To request a Cal-COBRA enrollment application, if you are a member of a Group with fewer than 20 employees, please contact the Plan. VHP will ensure you or your Dependent(s) will receive information regarding your Cal-COBRA rights. In order for a member to continue group coverage through Cal-COBRA, a completed written enrollment application and applicable premiums must be received by VHP based on the state Cal-COBRA law.

3. To request a Cal-COBRA enrollment application after exhausting COBRA, please call a VHP Member Services Representative. Within ten (10) days of your request, VHP will send you an enrollment application, which will include premium dues and billing information.

For Coverage Questions, call 408.885.4760.

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Individual Continuation of Coverage COBRA or Cal-COBRA Payment Responsibility

Once your VHP COBRA or Cal-COBRA enrollment application is approved, a bill will be sent to you within 30 days after receipt of your application. COBRA payments must be sent directly to your employer or employer COBRA administrator. Cal-COBRA payments must be sent directly to VHP. You must pay the initial COBRA or Cal-COBRA bill within 45 days of election. The first premium payment will include dues for coverage from when you terminated employment, or you exhausted COBRA coverage through your employer Group, to the current billing cycle.

Thereafter, monthly premium payments are due on or before the last day of the month preceding the month of coverage (e.g. prepaid by June 30 for July 1). The premiums will not exceed 110% of the applicable dues charged to a similarly situated individual under the group benefit plan except that premiums for disabled individuals after 18 months of COBRA coverage will not exceed 150%.

For more information regarding COBRA payment responsibilities contact your employer or employer COBRA administrator. For more information regarding Cal-COBRA payment responsibilities contact the VHP Member Services Department.

ARRA Premium Reduction

Effective March 1, 2009, the federal American Recovery and Reinvestment Act of 2009 (ARRA), as amended, in some cases reduces the health plan premiums for Group continuation coverage. Qualified individuals may be eligible to receive a temporary reduction of COBRA or Cal-COBRA premiums in connection with a loss of coverage that occurred during the period that begins with September 1, 2008 and ends with May 31, 2010. The temporary premium reduction can be for up to 15 months or as further extended

by Federal law. If you think you may be eligible for the ARRA premium reduction, you should contact your employer, employer administrator, or the health plan for more information. If you have received notification from your employer, employer administrator, or a health plan, you have 60 days to elect continuation coverage and/or apply for a reduction in premiums.

COBRA or Cal-COBRA Termination

COBRA continuation coverage terminates if payment of the appropriate monthly dues are not received by VHP as based on federal COBRA law. Contact your employer or Group administrator regarding COBRA termination and/or your COBRA termination date.

Cal-COBRA continuation coverage terminates if payment of the appropriate monthly dues are not received

by VHP at the time VHP specifies, or on the earliest of: • the date your Group’s Agreement with VHP terminates; • the date you become eligible for Medicare; • the date your coverage begins under any other health plan or group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition you may have (or that does contain such an exclusion or limitation, but it has been satisfied); • expiration of 36 months after your original COBRA effective date (under this or any other plan); or • the date your membership is terminated for nonpayment of premiums due.

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Individual Continuation of Coverage Open Enrollment Period or Termination of Another Health Plan

If you previously elected COBRA or Cal-COBRA coverage through another health plan available through your Group, you may be eligible to enroll in Valley Health Plan: • during your Group’s annual Open Enrollment Period, or • if your Group terminated its Agreement with the health plan you are enrolled in.

You will be entitled to COBRA and/or Cal-COBRA coverage only for the remainder, if any, of the coverage period prescribed by COBRA and/or Cal-COBRA. If during your Group Open Enrollment Period or if your Group terminates another health plan and you want to elect to continue your COBRA or Cal-COBRA coverage through VHP, VHP must receive: • your written enrollment application, and • premiums in a timely fashion as applicable by law.

If you want to change to VHP at this time, contact your employer or VHP for more information.

To elect VHP to continue your COBRA or Cal-COBRA coverage, VHP must receive your enrollment application during your Group’s Open Enrollment Period, or within 30 days of receiving the termination notice from your Group as described in the “Group Responsibilities” section. To request an application, please call VHP’s Member Services Department. Payment must be received as required by State and Federal guidelines.

Refer to the “Important Notice Regarding Continuation of Coverage” section.

Group Responsibilities

Group is required to give Valley Health Plan written notice within 30 days after a Subscriber is no longer eligible for coverage due to termination of employment or reduction of hours. If Group advises VHP to not offer COBRA or Cal-COBRA (as applicable) coverage because Group terminated a Subscriber’s employment for gross misconduct, Group must notify VHP, within ten (10) days after the Subscriber’s employment terminates, by writing to our Member Services Department at Valley Health Plan, 2480 N. First Street, Suite 200, San Jose, CA 95131. Group is required to notify VHP in writing within 30 days if the Group becomes subject to COBRA under federal law.

If your employer’s agreement with a health plan is terminated, your Group is required to provide written notice at least 30 days before the termination date to the individuals whose COBRA or Cal-COBRA coverage is terminating or when all enrolled employees are notified, whichever is later. This notice must inform COBRA or Cal-COBRA beneficiaries that they can continue COBRA or Cal-COBRA coverage by enrolling in any health benefit plan offered by the Group. It must also include information about benefits, dues, payment instructions, and/or enrollment forms, or where to receive enrollment instructions on how to continue Group continuation coverage under the new health plan. Eligible individuals will be entitled to continue Group coverage only for the remainder, if any, of the coverage period as prescribed by COBRA or Cal-COBRA. The Group is required to send this information to the person’s last known address, as provided by the prior health plan.

If the Group fails to provide the appropriate notice to persons eligible to enroll in Valley Health Plan or another health plan, neither plan(s) is obligated to provide continuation coverage if the person did not enroll or pay premiums within the required timelines as required by law.

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Individual Continuation of Coverage Important Notice Regarding Continuation of Coverage

In order for you to continue Group Coverage on COBRA or Cal-COBRA (as applicable) with no break in Coverage, the Plan must be advised in writing within 60 days of the date of your qualifying event, otherwise you may not be eligible to continue Coverage on this Benefit Plan. If you or your Dependent(s) elect to continue coverage, by law you have 45 days from the election date to pay the initial premium billing. Thereafter, you must prepay your monthly premiums by the end of the month prior to the month of coverage (e.g. pay July’s premium by June 30th). For additional information on continuing Group coverage, please refer to the next few sections in this EOC. Please examine your options carefully before declining this coverage. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in a higher premium or you could be denied coverage entirely.

HIPAA and Other Individual Plans

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects health care coverage for workers and their families when they change or lose their jobs. If you lose group health care coverage and meet certain criteria, you are entitled to purchase individual (non-group) health care coverage from any health plan that sells individual health care coverage.

Every health plan that sells individual coverage must offer individual coverage to an eligible person under HIPAA. The health plan cannot reject your application if you are an eligible person under HIPAA, you agree to pay the required premiums, and you live or work inside the plan’s service area.

VHP does not sell individual health care coverage. VHP does offer Group continuation coverage through COBRA and/or Cal-COBRA and does offer an Individual Conversion Plan after you exhaust your COBRA or Cal-COBRA coverage.

Individual Conversion Plan

Valley Health Plan offers an Individual Conversion Plan under HIPAA. You may be eligible for the Individual Conversion Benefit Plan upon losing Group coverage and meeting the Individual Conversion Plan eligibility criteria. Group Coverage includes continuation coverage on COBRA and Cal-COBRA. COBRA, Cal-COBRA, and the Individual Conversion Plan are available to you without any medical underwriting restrictions; meaning you will not be denied this continuation coverage due to any medical reasons, however other restrictions apply.

Upon losing Group Coverage and prior to enrolling in the Individual Continuation Plan you must first enroll in and exhaust coverage in: 1. COBRA, 2. Cal-COBRA COBRA/Cal-COBRA provides Group Continuation Coverage for up to 36 months. Covered Services for COBRA and Cal-COBRA are the same as your Group Benefit Plan and there can be no lapse of coverage to continue coverage. For more information refer to the “Continuing Group Coverage Under COBRA and CalCOBRA” section.

Covered Services for the Individual Conversion Plan may be different from your Group Benefit Plan. The “VHP Individual Conversion Plan Membership Agreement and Evidence of Coverage and Disclosure Form” describes this benefit plan. Contact VHP’s Member Services to obtain a copy of this booklet.

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Individual Continuation of Coverage If you enroll in the Individual Conversion Benefit Plan you will be responsible to pay your premiums directly to VHP. If you wish to elect Individual Conversion Plan through VHP, you must enroll prior to or within 63 days of the termination of your COBRA/Cal-COBRA. To enroll, you must meet the eligibility rules for the Individual Conversion Plan.

Eligibility rules for the Individual Conversion Plan are: • You must exhaust all Group coverage options, including COBRA and/or Cal-COBRA, • You must live or work in the VHP Service Area (Santa Clara County), • You cannot be eligible for other health insurance, even if the other coverage is less valuable; and • You must complete a written application and the first premium payment must be received by VHP no later than 63 days after termination from Group Coverage.

Once enrolled, you must continue to meet plan requirements. Coverage under the Individual Conversion Plan will cease on the earliest of the following events: • you become eligible for other health insurance; • you fail to pay monthly premiums to VHP; • for the reasons stated in the section entitled “Cancellation of Members for Cause;” • your employer Group Service Agreement terminates; • you become entitled to Medicare; • you enlist in the armed services.

If a Member converts to VHP Individual Conversion Plan coverage, that coverage is effective as of midnight following the date Coverage under the Agreement terminates. Payment of Individual Conversion Plan premiums is due from the date the Group Coverage ends. You cannot have a lapse of coverage in order for you to continue Plan Coverage.

For more information, or the premium cost for the Individual Conversion Plan, call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

Continuation of Coverage for Totally Disabled Members

If you become Totally Disabled and your employer terminates coverage, coverage for your disabling condition will continue for 12 months; or until you are no longer Totally Disabled; or until your employer obtains replacement coverage that does not limit coverage of the disabling conditions; whichever occurs first.

Coverage for your total disability is subject to the limitations and exclusions described in this Valley Health Plan Benefits and Coverage Handbook or Combined Evidence of Coverage and Disclosure Form.

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Retiree Continuation of Coverage You and your Eligible Dependent(s) may be eligible for Valley Health Plan Group Coverage if you are an Eligible Retiree. Contact your employer to see if you are eligible for retiree Coverage. If your Group allows employees and/or their family members to continue their coverage as a retiree, your coverage would continue at the group rates, when coverage would otherwise end.

This section of the EOC is dedicated to retiree continuation of coverage. For Covered Services information refer to the “Emergency and Urgently Needed Services,” “Benefits Descriptions,” “Benefits Description Table” and “Limitations and Exclusions” sections of this EOC. For Copayments information refer to the “Benefits Description Table.” For additional information regarding your Coverage please refer to other sections of this EOC or call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

Becoming a VHP Retiree Member

Before applying for VHP retiree membership, you and your Eligible Dependent(s) must meet certain eligibility and enrollment requirements as defined by your employer. After you have enrolled in VHP as a retiree, you must continue to meet these requirements.

To enroll in Valley Health Plan as an Eligible Retiree, contact your employer. Your employer will give you the necessary paperwork, including the VHP application form. Your employer will advise you of your responsibility for any portion of VHP monthly membership fees or premiums.

Once enrolled, you and your Eligible Dependent(s) will receive new VHP Identification Card(s). Coverage will begin on the Effective Date of Coverage established by your employer. Group Coverage is available to Eligible Retirees, and Eligible Dependents. If you are eligible for Medicare, you must enroll in Medicare and contact your employer and VHP Member Services.

You must report any changes that would affect your eligibility or the eligibility of your dependents to your employer within 30 days of the change in status.

For more information concerning your continuation of coverage as an Eligible Retiree, call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) or contact your employer.

For additional enrollment information refer to the “Enrollment” section.

Retiree Eligibility

You and your Eligible Dependent(s) may be eligible for Valley Health Plan Group Coverage if you are retired.

To continue or obtain Coverage as a retired Subscriber: • You must be an Eligible Retiree from a Group that offers VHP as a benefit to its retired employees; • You and your Eligible Dependent(s) must be enrolled in VHP and VHP must receive prepayment fees or premiums from the Group; • You must meet the Group’s eligibility criteria and the Group’s applicable waiting period requirements; and • You must reside within the Service Area, San Francisco County, or any adjacent counties to the Service Area. Adjacent counties include San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties.

If you are eligible for Medicare, you must contact your employer and VHP. If you are enrolled in VHP, you do not need to enroll in Medicare Part D.

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Retiree Continuation of Coverage If you are an Eligible Retiree and you elect to enroll, you will receive the same Benefit Plan that VHP is offering to the Group. As required, you will pay the Group membership premiums on a monthly prepayment basis the first (1st) of each month. VHP may decline, cancel or terminate your Coverage if you fail to pay the membership premium, or for reasons as stated in the applicable laws, rules, and regulations.

If you are an enrolled Eligible Retiree who resides outside the Service Area, you and your Eligible Dependent(s) must receive all routine, non-emergent, or non-urgent care Covered Services from VHP Network Providers in Santa Clara County (VHP’s Service Area).

Retiree Covered Services

Under this Coverage as a Subscriber, you and your Eligible Dependent(s) will receive the same Benefits as other Members of your Group. VHP is a Health Maintenance Organization, therefore, except for Emergency or Urgently Needed Services, Coverage must be received at Plan Providers. As required, all Covered Services must be arranged and/or Prior Authorized by VHP. Refer to the “Choice of Physicians and Providers” and “Access to Care” sections.

If you or your Eligible Dependent(s) reside in Santa Clara County (VHP Service Area), your routine Covered Services are available from Plan Providers. VHP will only provide Coverage for Emergency or Urgently Needed Services when provided outside the VHP Service Area (Santa Clara County) in the VHP Network.

Eligible Retirees and your Eligible Dependent(s) who live outside of the Service Area, in San Francisco County or any adjacent county to Santa Clara County, are still required to receive all routine Covered Services from Plan Providers within Santa Clara County. Adjacent counties include San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties. VHP will only provide Covered Services for Emergency or Urgently Needed Services provided outside of the Service Area.

For a listing of the VHP Network Providers, call the VHP Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free), or visit VHP’s website at www.valleyhealthplan.org If you or your Eligible Dependents are eligible for Medicare you must enroll in Medicare. You must also contact your employer and VHP. If you are on Medicare and receive your services from Plan Providers, Valley Health Plan provides services for covered Benefits and coordinates payment with Medicare. Refer to the “Coordination of Benefits Reimbursement” section. If you are enrolled in Medicare and you choose to receive services from a Non-Plan Provider without Prior Authorization from VHP, you can file your claim directly with Medicare. You may be responsible for all charges not reimbursed by Medicare.

For additional Benefits information, refer to the “Emergency and Urgently Needed Services,” “Benefits Descriptions,” “Benefits Description Table,” and “Limitations and Exclusions” sections or call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

Retiree Termination

Under this Coverage, you will receive the same Benefits as your Group, but you may be required to pay the full health premium, on a monthly prepayment basis, to your employer. In addition, you must live in the Service Area, in adjacent or contiguous counties to the Service Area, or in San Francisco County. Adjacent counties include San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties.

Call your employer for more information about Eligible Retiree Coverage.

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Retiree Continuation of Coverage Your coverage as a retiree Member will terminate on one of the following dates: • On the last day of the month in which you lose Retiree Eligibility; or • On the last day of the month for which payment was not received; or • On the termination date of the Agreement; or • On the termination date established by VHP and your employer as specified in the Group Service Agreement or as otherwise agreed by your Group.

If VHP terminates your Coverage, VHP will notify the Group of the cause and effective date of your Termination. Your coverage will cease as of the date of Termination or cancellation. If you are undergoing treatment for a medical condition, services provided beyond the date of Termination will be your financial responsibility unless you are covered by continuation coverage through VHP. (Refer to the “Termination of Benefits” section.)

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General Information Your Rights and Responsibilities

As a Member you have the right to: • Exercise these rights without regard to race, disability, gender, religion, age, color, sexual orientation, creed, family history, marital status, veteran status, national origin, handicap, or condition, without regard to your cultural, economic, or educational background, or source(s) of payment for your care; • Be treated with dignity, respect, and consideration; • Expect health care providers (doctors, medical professionals, and their staff) to be sensitive to your needs; • Be provided with information about VHP, its services, and Plan Providers; • Know the name of the Primary Care Physician who has primary responsibility for coordinating your health care and the names and professional relationships of other Plan Providers you see; • Actively participate in your own health care, which, to the extent permitted by law, includes the right to receive information so that you can accept or refuse recommended treatment; • Receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse this course of treatment or procedure. Except for Emergency Services this information will include a description of the procedure or treatment, the medically significant risks involved, alternative courses of action and the risks involved in each, and the name of the Plan Provider who will carry out the treatment or procedure; • Full consideration of privacy concerning your course of treatment. Case discussions, consultations, examinations, and treatments are confidential and should be conducted discreetly. You have the right to know the reason should any person be present or involved during these procedures or treatments; • Confidential treatment of information in compliance with State and federal law including HIPAA (including all communications and medical records) pertaining to your care. Except as is necessary in connection with administering the Agreement and fulfilling State and federal requirements (including review programs to achieve quality and cost-effective medical care), such information will not be disclosed without first obtaining written permission from you or your authorized representative; • Receive complete information about your medical condition, any proposed course of treatment, and your prospects for recovery in terms that you can understand; • Give informed consent unless medically inadvisable, before the start of any procedure or treatment; • Refuse health care services to the extent permitted by law and to be informed of the medical consequences of that refusal, unless medically inadvisable; • Readily accessible and ready referral to Medically Necessary Covered Services; • A second medical opinion, when medically appropriate, from a Plan Physician within the VHP Network; • Be able to schedule appointments in a timely manner; • Reasonable continuity of care and advance knowledge of the time and location of your appointment(s); • Reasonable responses to any reasonable requests for Covered Services; • Have all lab reports, X-rays, specialist’s reports, and other medical records completed and placed in your files, as promptly as possible, so that your Primary Care Physician can make informed decisions about your treatment; • Change your Primary Care Physician; • Review your medical records, unless medically inadvisable; • Be informed of any charges (Copayments) associated with Covered Services; 99  V A L L E Y H E A L T H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M

General Information • Be advised if a Plan Provider proposes to engage in or perform care or treatment involving experimental medical procedures, and the right to refuse to participate in such procedures; • Leave a Plan Facility or Hospital, even against the advice of Plan Providers; • Be informed of continuing health care requirements following your discharge from Plan Facilities or Hospitals; • Be informed of, and if necessary, given assistance in making a medical Advance Health Care Directive; • Have rights extended to any person who legally may make decisions regarding medical care on your behalf; • Know when Plan Providers are no longer under a contractual arrangement with VHP; • Examine and receive an explanation of any bill(s) for non-Covered Services, regardless of the source(s) of payment; • File a Grievance without discrimination through VHP or appropriate State or federal agencies; and • Know the rules and policies that apply to your conduct as a Member.

As a Member you have responsibility to: • Adhere to behavior that is reasonably supportive of therapeutic goals and professional supervision as specified; • Behave in a manner that doesn’t interfere with your Plan Provider or their ability to provide care; • Safeguard the confidentiality of your own personal health care as well as that of other Members; • Accept fiscal responsibility associated with non-Covered Services. Covered Services are available only through Plan Providers in your VHP Network (unless such care is rendered as Emergency Services, out-ofService Area Urgently Needed Services, or is authorized); • Cooperate with VHP or a Plan Provider’s third party recovery efforts or Coordination of Benefits; • Participate in your health care by scheduling and keeping appointments with Plan Providers. If you cannot keep your appointment, call in advance to cancel and reschedule; and • Report any changes in your name, address, telephone number, or your family’s status to your employer and a VHP Member Services Representative.

Governing Law

VHP is subject to State and federal laws, including the Knox-Keene Health Care Service Plan Act, and the regulations issued by the DMHC. The terms and provisions of the Agreement may be amended or modified if the law requires such amendments or modifications. Any provisions required in this Combined Evidence of Coverage and Disclosure Form by the above regulations will bind you and VHP whether or not expressly provided for in this document.

Suspension of Services

In the event of an emergency or circumstances not within the control of VHP, suspension of services may occur. Suspension of services may result in the facilities, personnel, or resources of VHP or its Plan Providers becoming unavailable to provide or arrange for health care services pursuant to the Agreement. Taking into account the nature of the event, VHP’s obligation will be limited to the requirement that it makes a good-faith effort to provide or arrange for Covered Services.

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General Information Privacy Practices & Protected Health Information (PHI)

VHP agrees to maintain and preserve the confidentiality of any and all Protected Health Information. VHP also requires its contracting providers to protect your PHI in your medical records and such information from Plan Providers will be kept confidential in accordance with State and federal law. PHI is health information that includes your name, Social Security number, or other information that reveals who you are.

Except as is necessary in connection with administering the Agreement and fulfilling State and federal requirements (including review programs to achieve quality and cost-effective medical care), such information will not be disclosed without first obtaining written consent from you or your authorized representative. However, by the terms of the Agreement, you authorize the release of information and access to any and all of your medical records. Such release of your medical records without your written consent include the purposes of utilization review, quality assurance, processing of any claim, financial audit, or any other purpose reasonably related to the provision of Coverage to VHP, its agents and employees, your Primary Care Physician, and appropriate governmental agencies. As a member of VHP, you may request a copy of VHP’s Notice of Privacy Practices by contacting VHP’s Member Services, or view this information on VHP’s website at www.valleyhealthplan.org

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Definitions VHP is dedicated to making its services easily accessible and understandable; however the language of health care and managed care organizations can sometimes be very confusing. 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.

Active Labor means a labor at a time at which either of the following would occur: 1. There is inadequate time for safe transfer to another hospital prior to delivery; or 2. A transfer may pose a threat to the health and safety of the patient or the unborn child.

Acute Condition means a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration.

Advance Health Care Directive means a formal document, signed by you in advance of a severe illness or injury, which will guide your care if you become so incapacitated that you cannot make an informed decision.

Agreement means the Group Service Agreement, including but not limited to this Combined Evidence of Coverage and Disclosure Form, any and all applications and information submitted by the Group and Members in applying for Coverage, attachments, addenda, and any amendments that may be added in the future. The Agreement contains the exact terms and conditions of your Coverage. It incorporates all of the contracts, promises, and agreements exchanged by the Group and VHP. It replaces any and all prior or concurrent negotiations, agreements, or communications, whether written or oral, between both parties with respect to the contents of the Agreement.

Authorization means a system whereby a written (or oral followed by a written) approval is given by the Medical Director or designee for a Member to receive and/or have VHP pay for certain Medically Necessary Covered Services.

Behavioral Health Treatment means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs, that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism and that meet all of the following criteria: 1. Treatment is prescribed by a physician or a psychologist, licensed pursuant to California law; 2.Treatment is provided under a treatment plan prescribed by a qualified autism service (QAS) provider and administered by a QAS provider, or a QAS professional or QAS paraprofessional supervised and employed by the QAS provider; 3. The treatment plan has measurable goals developed and approved by the QAS provider that is reviewed every six months and modified where appropriate; and 4. The treatment plan is not used to provide or reimburse for respite, day care, educational service, or participation in the treatment program.

Benefit(s) means the Covered Services as covered under the Benefit Plan.

Benefit Plan means the Covered Services contained in this Combined Evidence of Coverage and Disclosure Form. Any date referenced in this Benefit Plan begins at 12:01am, Pacific Standard Time.

Cal-COBRA (California Continuation Benefits Replacement Act) means the California legislation that requires health plans to offer continued access to group health care coverage provided to employee, and their dependents, of employers with 2 to 19 eligible employees who are not currently offered continuation coverage under COBRA and whose coverage would end due to termination, layoff, or other change in employment status. Cal-COBRA also means you may have the opportunity of group continuation coverage when coverage would otherwise cease due to the termination of COBRA. V A L L E Y H E A L T H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M  10 2

Definitions Calendar Year means a 12 month period that begins on January 1 and ends 12 consecutive months later on December 31.

COBRA (Consolidated Omnibus Budget Reconciliation Act) is the federal legislation that extends your group health plan benefits at group rates for a specified period. The law requires employers to offer continued health insurance coverage to employees who have had their health insurance coverage terminated because of a change in employment.

Coordination of Benefits (COB) means when you are covered by two (2) or more insurance plans and payment rules apply. COB: • eliminates duplicate payments, • specifies the order in which coverage will be paid (the primary plan, the secondary plan, etc.), and • ensures that the benefits paid under both plans do not total over 100% of the charges.

Copayment means a fee, which you are required to pay in order to receive a particular Benefit. This is the Member’s share of the cost for Covered Services.

Copayment Maximum is the maximum Copayment amount you are required to pay for Covered Services during a Calendar Year. Payments paid for eyeglasses, Dental Services, or any other supplementary benefit(s) that are not covered under this Benefit Plan are not counted against the Copayment Maximum.

Cosmetic Surgery means surgery that is not Medically Necessary and is performed to alter or reshape normal structures of the body in order to improve appearance.

Coverage means the Covered Services contained in this Combined Evidence of Coverage and Disclosure Form or Valley Health Plan Benefits and Coverage Handbook.

Coverage Decision means the approval or Denial of Covered Services by Plan or Plan Providers. A Coverage Decision does not include a Disputed Covered Service(s).

Covered Service(s) means the Medically Necessary health care services, supplies and products limited by the exclusions and limitations to which you are entitled as a Member under your Group Service Agreement as described in this Combined Evidence of Coverage and Disclosure Form or Valley Health Plan Benefits and Coverage Handbook.

Custodial Care or Domiciliary Care means care that can be provided by a layperson, which does not require the continuing attention of trained medical or paramedical personnel, and which has no significant relation to the treatment of a medical condition. This definition does not refer to Behavioral Health Therapy (BHT) prescribed for Pervasive Developmental Disorder (PDD) or Autism. Custodial Care includes, but is not limited to: activities of daily living such as walking, getting in and out of bed, bathing, dressing, feeding, toileting and taking medication; or care that can be performed safely and effectively by persons who, in order to provide the care, do not require licensure or certification, or the presence of a supervising licensed nurse.

Denial means a refusal to comply with or satisfy a request for services or payment of services rendered.

Department of Managed Health Care (DMHC) or Department is the State regulatory agency responsible for the regulation or oversight of health care plans in California.

Dependent means any member of a Subscriber’s family who is an Eligible Dependent and meets the applicable eligibility requirements set forth in the Group Service Agreement, and who has enrolled in the Plan in accordance with its enrollment requirements.

Disenrollment is the voluntary process of ending your membership in the Benefit Plan.

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Definitions Disputed Covered Service(s) means any Covered Service that has been denied, modified, or delayed by a decision of the Plan, or by one of its Plan Providers, in whole or in part due to a finding that the Benefit is not Medically Necessary. A decision regarding disputed health care services relates to the practice of medicine and is not a Coverage Decision..

Durable Medical Equipment (DME) means the Medically Necessary medical supplies, equipment, and devices which: • are intended for repeated use over a prolonged period, • are not considered disposable, with the exception of ostomy bags and diabetic supplies, • are ordered by your Plan Physician, • do not duplicate the function of another piece of equipment or device covered by VHP, • are generally not useful to the Member in the absence of illness or injury, • primarily serve a medical purpose, and • are appropriate for use in the home.

Effective Date of Coverage means the date that your Coverage under the Benefit Plan begins. Your precise Effective Date of Coverage may be obtained from your employer.

Eligible Dependent is a person who is: 1. a Subscriber’s lawful spouse; or

2. a Subscriber’s domestic partner as eligible and as defined in the Subscriber’s Group Service Agreement or as in accordance with State and federal requirements; or 3. the child of a Subscriber or the Subscriber’s spouse/domestic partner who is defined as: a. a natural child or stepchild; or b. a child placed in the physical custody of the Subscriber or the Subscriber’s spouse/ partner for adoption, and who is covered from and after the date on which there exists evidence of the Subscriber or Subscriber’s spouse’s right to control the health care of the child placed for adoption (documentation of placement by an adoption agency and/or court will be required) with a permanent residence within the Service Area; or c. a legally adopted child (documentation by an adoption agency and/or court will be required); or d. a ward or child under the guardianship of the Subscriber or the Subscriber’s enrolled spouse pursuant to a valid court order (proof of legal guardianship will be required).

And the child must be: i. under the age of 26; or ii. age 19 to age 26 (i.e. from 19 through 25) and prior to March 23, 2010, they were not eligible for another employer-sponsored insurance plan; or iii. 26 years of age or older, but incapable of holding a self sustaining job by reason of mental retardation or physical handicap which commenced prior to age 26.

The Subscriber must furnish proof of incapacity and dependency to VHP within 60 calendar days following the date of the request. VHP has the right to require such proof of eligibility status as may be required. Such proof will be without cost to VHP. Eligible Dependent children may reside outside the Service Area, but will only be covered for Emergency or Urgently Needed Services when Out-of-Network. All follow-up or Routine Care must be received in the VHP Network through the Member’s PCP. V A L L E Y H E A L T H P L A N E V I D E N C E O F C O V E R A G E A N D D I S C L O S U R E F O R M  10 4

Definitions All other Eligible Dependents who are eligible for Group Benefits and who reside outside the Service Area will only be covered for Emergency or Urgently Needed Services when Out-of-Network. All follow-up or Routine Care must be received in the VHP Network through the Member’s VHP PCP. Eligible Employee means any permanent employee employed for at least 30 consecutive calendar days and/or as defined by Group and who: • has met any statutorily authorized or Group applicable waiting period requirements, and the Group’s eligibility criteria; and • works or resides continuously within the Service Area.

For Small Groups, Eligible Employee also means permanent employees who work at least 20 hours but not more than 29 hours if the following apply: • the employee otherwise meets the definition of an Eligible Employee except for the number of hours worked, • the employer offers the employees health coverage under a health benefit plan, • all similarly situated individuals are offered Coverage under the Plan, and the employee must have worked at least 20 hours per normal workweek for at least 50% percent of the weeks in the previous calendar quarter.

The term also includes sole proprietors or partners of a partnership, if they are actively engaged on a full-time basis in the Group’s business and included as employees in the Agreement; but does not include employees who work on a part-time, temporary, or substitute basis.

Eligible Retiree means any employee who has retired from a Group and that Group offers the Group Plan Coverage as a benefit to its retired employees and who: • has met the Group’s eligibility criteria, • has met any statutorily authorized or Group applicable waiting period requirements, and • resides continuously within the Service Area, or within San Francisco County or within any adjacent counties to the Service Area. Adjacent counties include San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties.

An Eligible Retiree or a survivor of a retiree, who is eligible for Group Benefits, may reside outside the Service Area in San Francisco, San Mateo, Alameda, Stanislaus, Merced, San Benito, Monterey, and Santa Cruz Counties, but will only be covered for Emergency or Urgently Needed Services when Out-of-Network.

All follow-up or Routine Care must be received in the VHP Network through the Member’s VHP PCP. Emergency Services means the Covered Services which are furnished worldwide and required to treat a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and Active Labor) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

“Emergency Services” also means an 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 or detoxification, within the capability of the facility.

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Definitions EOC or Combined Evidence of Coverage and Disclosure Form means this Combined Evidence of Coverage and Disclosure Form or this Valley Health Plan Benefits and Coverage Handbook.

Experimental or Investigational Treatment means services, tests, treatments, supplies, devices or drugs which Plan determines are not generally accepted by informed medical professionals in the United States, at the time services, tests, treatments, supplies, devices or drugs are rendered, as safe and effective in treating or diagnosing the condition for which their use is proposed, unless approved by: 1. The Diagnostic and Therapeutic Technology Assessment Project of the American Medical Association; 2. The Office of Technology assessment of the U.S. Congress; 3. The National Institute of Health; 4. The Food and Drug Administration (FDA); or 5. The specialty board and the academy it represents as recognized by the American Board of Medical Specialties (ABMS).

Approved drug usage will not be excluded as an Experimental or Investigational treatment.

FDA-Approved Drug means drugs, medications and biologicals approved by the Food and Drug Administration and listed in the United States Pharmacopeia, the AMA Drug Evaluations and/or the American Hospital Formulary.

Formulary is the list of prescription drugs that has been reviewed and selected by VHP Plan Providers on the VHP Pharmacy and Therapeutic Committee in accordance with professionally-recognized medical standards for their medical and cost effectiveness. The Formulary includes both brand name and generic equivalent drugs, all of which are approved by the Food and Drug Administration (FDA).

Grievance means a written or oral expression of dissatisfaction regarding the plan and/or provider, including quality of care concerns, Denial of a service or payment of a claim (in whole or part) made by an Enrollee or the Enrollee’s representative.

Group means the large employer or Small Employer that has entered into the Agreement with the Plan.

Group Service Agreement means the Group Medical and Hospital Service Agreement between your employer and VHP. HIPAA means the Health Insurance Portability and Accountability Act of 1996.

Hospice means a public agency or private organization that is a Plan Provider and is primarily engaged in providing pain relief, symptom management and supportive services to terminally ill people and their families.

Hospice Care means services provided by Plan Providers to Members who are certified by a Plan Physician to be terminally ill (i.e. the Member’s medical prognosis is that the life expectancy is twelve (12) months or less), emphasizing supportive services and dietary counseling under the direction of a Plan Physician and in accordance with a written plan of care.

Hospital Services means all services provided by the hospital on either an inpatient or outpatient basis within the capability of the facility.

Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome (HIV or AIDS) is a condition or disease that is medically interpreted broadly as a condition or disease that requires specialized medical care over a prolonged period of time and is life threatening, degenerative or disabling.

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Definitions Individual Conversion means health insurance Coverage available to an individual who is no longer a part of the employer group but still works or resides in Santa Clara County and is not eligible for other health insurance.

Infertility Diagnosis and Treatment means procedures consistent with established medical practices by licensed physicians and surgeons including, but not limited to, diagnosis, diagnostic tests, medications and any Medically Necessary surgery.

Initial Eligibility Period means the period during which Eligible Employees or Eligible Retirees, and their Eligible Dependent(s) may initially enroll in the Plan, and is further defined as follows: 1. For Group’s employees or retirees who are or will be Eligible Employees or Eligible Retirees on the initial Effective Date of Coverage under the Agreement, the Initial Eligibility Period is the 31 day period prior to the Effective Date of Coverage. This period also applies to survivors who are eligible for Group benefits on the Effective Date of Coverage.

2. For future employees of Group who were not Eligible Employees on the Effective Date of Coverage, the Initial Eligibility Period is the applicable Group Waiting Period.

3. For future retirees of Group who were not Eligible Retirees on the Effective Date of Coverage, the Initial Eligibility Period is the 31 day period prior to the first day of the month after becoming a retiree. This period also applies to future survivors of Eligible Employees or Eligible Retirees, who are eligible for Group benefits.

4. For Late Members who lose coverage for any reasons listed below, the Initial Eligibility Period is the thirty-one (31) day period following the date on which the Late Member loses coverage: a. the termination of the employment of the Eligible Employee or of a person through whom the Eligible Employee or his/her Eligible Dependent(s) was covered as a dependent; b. a change in the employment status of the Eligible Employee or a person through whom the Eligible Employee or his/her Eligible Dependent(s) was covered as a dependent; c. termination of health benefits coverage from another employer, the Healthy Families Program coverage, or no share-of-cost Medi-Cal coverage; d. reduction or cessation of an employer’s contribution toward an employee, retiree, or dependent’s coverage; e. death of the Eligible Employee/Retiree or person through whom the Eligible Employee/Retiree or Eligible Dependent was covered as a dependent; or f. divorce from the person through whom the Eligible Employee/Retiree or Eligible Dependent was covered as a dependent.

5. For Eligible Dependent(s), between the age of 19 and 26 (i.e. from 19 through 25), the Initial Eligibility Period is the 31 day period following a change in their status as defined by the Group.

Inpatient Hospital Services means those Covered Services, which are provided on an inpatient basis by a hospital, excluding long term non-acute care.

Late Member means an Eligible Employee/Retiree or his or her Eligible Dependent(s) who declined to enroll in Plan during the Eligible Employee’s or Eligible Retiree’s Initial Eligibility Period or any subsequent Open Enrollment Period.

Legend Drug means a drug which is required by federal law to bear the following statement, “Caution: Federal law prohibits dispensing without prescription.”

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Definitions Life-Threatening means either or both of the following: • Disease or conditions where the likelihood of death is high unless the course of the disease is interrupted.

• Diseases or conditions with potentially fatal outcomes.

Lock-In means that Covered Services are available only through Plan Providers in the VHP Network you select (unless such care is rendered as Emergency Services, out-of-area Urgently Needed Services, or is Prior Authorized). If you seek Routine Care or elective medical services from Non-Plan Providers without a VHP-approved referral, VHP will not pay for your care and you will be required to pay for the full cost of such services.

Mail Service Pharmacy means a Plan Pharmacy that only provides mail order services. A Mail Service Pharmacy does not have walk-in pharmacy services.

Medical Criteria means the predetermined rules or guidelines for medical care, developed by medical professionals relying on professional expertise, prior experience, and the professional literature, with which aspects of actual instances of medical care may be compared.

Medical Director means the Medical Director of the Plan, who is a physician or designee with responsibility for implementing Plan utilization management system and quality of care review system. The Medical Director is the physician who determines appropriate Authorization or Prior Authorization of Covered Services.

Medical Services means those professional services of physicians and other health care professionals, which are performed, prescribed or directed by a licensed physician or specialist.

Medically Necessary or Medical Necessity means the services which are: • appropriate and necessary for the symptoms, diagnosis, or treatment of a medical condition, and • within recognized standards of medical practice, and • not primarily for the convenience of you, your family, caretaker, or any provider, and • the most appropriate supply or level of service that can safely be provided.

Member Claim means a statement listing services rendered, the dates of services, and itemization of costs; includes a statement signed by the Subscriber that services have been rendered and any supporting documentation from the provider. The completed Member Claim Reimbursement Form serves as the basis for reimbursement for payment of covered Benefits.

Member/Enrollee is any Subscriber or Eligible Dependent who is enrolled in the Benefit Plan in accordance with the applicable eligibility requirements.

Member Services Representative means any Plan employee who is available to answer Member’s questions about Coverage, help Members with any service issues, and assist Members with special situations relating to Covered Services.

Mental Disorders means disorders of mental or behavioral functioning that disrupt the normal family, social or work interactions, including the physical symptoms of such disorders, regardless of cause or origins.

Mental Disorders include the following: 1. Conditions that constitute Severe Mental Illness (SMI) of a person of any age and Serious Emotional Disturbances (SED) of a child under the age of 18 as defined with the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

2.Mental conditions identified as a Mental Disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV).

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Definitions Mid-Level Practitioner is a health care professional who is supervised by a physician and includes nurse practitioners, physician’s assistants, or certified nurse midwifes.

Network is a health care delivery service system that is contracted and credentialed within the Service Area. The Network is comprised of Plan Physicians (such as Primary Care Physicians and specialists), Plan Facilities, and Plan Hospitals.

Network Provider(s) means the Plan Provider(s) in the VHP Network.

Non-Experimental Procedures are those procedures for which the medical safety and efficacy have been demonstrated and are no longer investigational, as determined by VHP. Non-Plan Provider is any professional person, organization, health facility, hospital, or other person or institution licensed and/or certified by the appropriate regulatory agency to deliver or furnish health care services that is neither employed, owned, operated by, nor under contract with VHP to deliver services to Members.

Open Enrollment Period means a period of no less than 30 calendar days or as defined by the Group and agreed upon by the Plan, and that occurs at least once annually. The Open Enrollment Period is the time during which all Eligible Employees are given the opportunity to select from the alternative health care plans offered by the Group, and when Subscribers may add or delete Eligible Dependent(s).

Orthotic Device means a Medically Necessary rigid or semi-rigid device used as a support or brace affixed to the body externally to support or correct a defect or function of an injured or diseased body part, excluding devices to enable the Member to continue ongoing athletic activity prior to medical recovery.

Out of Network means any provider that is not part of the VHP Network.

Outpatient Hospital Services or Outpatient Care means those Covered Services, which are provided to Members under the direction of a Plan Physician and do not require an overnight stay in the hospital.

PBM means Pharmacy Benefits Manager.

PHI means Protected Health Information.

Plan or VHP means the Valley Health Plan. The County of Santa Clara owns and operates VHP, which is licensed under the Knox-Keene Health Care Service Plan Act. VHP is a Health Maintenance Organization (HMO).

Plan Facility means a facility (other than a Plan Hospital), such as a Skilled Nursing Facility or mental health hospital that contracts with VHP to provide Medical Services.

Plan Hospital means a duly licensed hospital that, at the time care is provided, has a contract with VHP to provide Hospital Services to Members.

Plan Pharmacy means a pharmacy contracted with VHP that provides medication(s) prescribed by Plan Providers to Members, and is contracted with the Plan to deliver services to members.

Plan Physician means a duly licensed doctor of medicine or osteopathy whom, at the time care is provided to a Member, is employed by or has a contract in effect with the Plan to provide Medical Services to Members..

Plan Provider means any professional person, organization, health facility, hospital, or other person or institution licensed and/or certified by the State or as otherwise authorized under California Law to deliver health care services that, at the time care is provided, is contracted with VHP to deliver services to Members.

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Definitions Plan Specialist means a physician whom practices in a medical specialty and contracts with VHP to deliver health care services to Members.

Pregnancy means the three (3) trimesters of Pregnancy and the immediate postpartum period.

Prescription Unit means the maximum amount (quantity) of medication that may be dispensed per prescription.

Primary Care Physician (PCP) means a Plan Physician who has contracted with VHP to deliver primary care services to Members. A Primary Care Physician is trained to take care of your routine health care needs and is primarily responsible for the coordination of your care. Coordinating your care includes supervising continuity of care, record keeping, and initiating referrals to Plan Specialists.

Primary Care Physicians practice in a wide range of medical disciplines and can be family or general practitioners, pediatricians, or internists. In addition, obstetricians/gynecologists (OB/GYNs) may serve as Primary Care Physicians if they meet VHP criteria for the delivery of primary care.

Prior Authorized or Prior Authorization means a system whereby written (or oral followed by written confirmation) advance approval is given by the Medical Director or designee before a Member can receive certain Medically Necessary Covered Services.

Prosthetic Device means an artificial device affixed to the body to replace a missing part of the body.

Prosthetic Devices also means surgically implanted devices and supplies.

Provider Claim means a statement listing services rendered, the dates of services, and itemization of costs; includes a statement signed by the member and treating professional that services have been rendered. The completed Provider Claim serves as the basis for payment of covered Benefits directly to a provider.

Psychiatric Emergency Medical Condition means a mental disorder where there are acute symptoms of sufficient severity to render either an immediate danger to yourself or others, or you are immediately unable to provide for or use, food, shelter or clothing due to the mental disorder.

Reconstructive Surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease: • to improve function, or • to create a normal or uniform appearance, to the extent possible.

Reconstructive Surgery includes Prosthetic Devices needed after a mastectomy and original and replacement prostheses devices to replace all or part of an external facial body part removed or impaired as a result of disease, injury, or congenital defect.

Rehabilitation Services means Covered Services that are provided in a prescribed, organized, multidisciplinary rehabilitation program, whether in a hospital, Skilled Nursing Facility, physician’s office or other facility.

Routine Care means the provision of Medically Necessary services, which are required for: • screening purposes and disease prevention, • the diagnosis and treatment of new or ongoing illnesses or injuries, or • the evaluation and treatment of signs or symptoms which a prudent layperson or physician might reasonably be concerned to represent a deterioration in health status.

Such Routine Care does not pose an immediate risk requiring either urgent or emergency care.

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Definitions Serious Chronic Condition means a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that does either of the following: • persists without full cure or worsens over an extended period of time; or • requires ongoing treatment to maintain remission or prevent deterioration.

Serious Emotional Disturbance(s) of a Child or Adolescent means minors under the age of 18 years who: 1.Has one or more mental disorder(s), as identified in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, other than a primary substance use disorder or developmental disorder, and which results in behavior inappropriate to the child’s age according to expected developmental norms, and 2. Who meet the criteria in paragraph (2) of subdivision (a) of Section 5600.3 of the Welfare and Institutions Code.

Seriously Debilitating means diseases or conditions that cause major irreversible morbidity.

Service Area means Santa Clara County. It is the geographic area, established by VHP and approved by the Department of Managed Health Care (DMHC), where VHP provides health care services to Members.

Severe Mental Illness means a mental disorder of a person of any age. Severe Mental Illness includes Schizophrenia, Schizoaffective Disorder, Bipolar Disorder (manic-depressive illness), Major Depressive Disorders, Panic Disorder, Obsessive-Compulsive Disorder, Pervasive Developmental Disorders or Autism, Anorexia Nervosa, and Bulimia Nervosa.

Skilled Nursing Facility (SNF) means a facility where inpatient services are provided at a less intensive level than an acute care hospital but still requiring services by a licensed health care professional.

Small Employermeans the small employer that has at least two (2) but no more that 50 Eligible Employees, the majority of whom were employed within the State. The Small Employer can be any person, firm proprietary or nonprofit corporation, partnership, public agency, or association that is actively engaged in business or services.

Small Group means the Small Employer Group who has entered into an Agreement and has at least two (2) but no more than 50 Eligible Employees who must meet Small Group participation or contribution requirements as set forth in the Agreement. Small Group participation requirements mean that a Small Group must enroll a minimum of one (1) employee with at least 70% of Eligible Employees covered by any group health plan. Small Group contribution requirements mean that a Small Group must contribute at least 50% of the employee-only rate for the VHP under 30 age banded premium rate as specified in the Small Group rate schedule in the Agreement.

State means the State of California.

Subscriber means the person who is enrolled and responsible for payment to VHP or whose employment or other status, except for family dependency is the basis of eligibility for membership in the Benefit Plan.

Termination means the involuntary process of ending your membership in the Benefit Plan.

Totally Disabled means that an individual is either (a) confined in a hospital as determined to be Medically Necessary, or (b) unable to engage in any employment or occupation for which the individual is (or becomes) qualified by reason of education, training or experience and, is not, in fact, engaged in any employment or occupation for wage or profit.

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Index Urgently Needed Services means the Covered Services for an illness, injury, or Pregnancy for which, treatment cannot be delayed until the Member returns to the Service Area and, in the view of a prudent layperson or physician, is likely to lead to a serious deterioration in the Member’s health or significant disability.

VHP ID Cardis an identification card (ID card) issued to Members by VHP to identify membership in VHP. You must be eligible for services when presenting your VHP ID card. Your VHP ID Card must be presented whenever and wherever care is received Vocational Rehabilitation means evaluation, counseling, and placement services designed or intended primarily to prepare an injured or disabled individual for employment.

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Index Important Information ..................................... 1 Welcome to Valley Health Plan! ..................... 2 About This Evidence of Coverage and Disclosure Form ....................................... 4 General Information – English ....................... 6 General Information – Spanish ...................... 8 General Information – Vietnamese .............. 11 Eligibility and Enrollment ............................. 13 Becoming a VHP Member Eligibility Enrollment Enrolling Initially Adding Dependents Enrolling Late or During Open Enrollment Coverage for Eligible Retirees When Coverage Begins Continuing Group Coverage for Dependents Renewal Provisions Contract Period Of This Evidence Of Coverage Choice of Physicians and Providers............. 18 Choosing Your Primary Care Physician Changing Your Primary Care Physician Access to Care................................................ 20 Scheduling Appointments Receiving Primary Health Care Receiving Specialty Care and Referrals Lock-In Provision Receiving Self-Referral Referral Services OB/GYN Self-Referral Services Timely Access to Care Receiving Hospital or Other Facilities Care Receiving Care While Out of Network/ Service Area Receiving Health Care as a Dependent While Out of Network/Service Area Authorization and Denial of Services Second Medical Opinions Continuity of Care Independent Medical Review

VHP website: www.valleyhealthplan.org VHP Newsletter – Perspectives Using Your VHP ID Card Emergency and Urgently Needed Services ........................................... 28 Emergency Services Urgently Needed Services Follow-Up Care After Emergency or Urgently Needed Services Post-Stabilization Benefits Description Table............................ 31 Professional Services Outpatient Services Outpatient Hospital Services Hospitalization Services (Non-Emergent or Scheduled Admissions) Skilled Nursing Services Rehabilitation Services Emergency Services and Ambulance Medical Transportation Services Urgently Needed Services Prescription Drugs, Medications, and Pharmacy Services Durable Medical Equipment – Medical Supplies and Equipment Mental Health Services Chemical Dependency Services (Alcohol and Drug Abuse) Home Health and Hospice Services Acupuncture Services Cancer Clinical Trial Services Chiropractic Services Dental Services Family Planning Services Maternity Services Sterilization Services Abortion Services Health Education Services Reconstructive and Cosmetic Surgery Services Transplant Services Benefit Descriptions ..................................... 56

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Index Professional Services Outpatient Services Facilities – Inpatient Services Hospitalization Services Skilled Nursing Services Rehabilitation Services Ambulance Services Medical Transportation Services Prescription Drugs, Medications and Pharmacy Services Plan Pharmacies Prescription Fill Options VHP Formulary Non-Formulary, Urgent, or Emergent Prescriptions At the Time of Your Enrollment Inpatient Pharmacy Services Emergency Prescription Drugs Durable Medical Equipment – Medical Supplies and Equipment Mental Health Services Outpatient Mental Health Counseling Services Outpatient Mental Health Services provided by a Psychiatrist Inpatient Mental Health Services Chemical Dependency Services (Alcohol and Drug Abuse) Home Health and Hospice Services Home Health Care Dialysis Services Hospice Care Acupuncture Services Cancer Clinical Trial Services Chiropractic Services Dental Services Outpatient Dental Services Temporomandibular Joint (TMJ) Disorders Services Dental Services – Plan Hospital or Surgery Center Family Planning Services Maternity Services Maternity Care Circumcision Services Genetic Counseling Services

Infertility Diagnosis and Treatment Artificial Insemination Services Sterilization Services Abortion Services Health Education Services Reconstructive, Cosmetic, and Bariatric (Weight Loss) Surgery Services Reconstructive Surgery Cosmetic Surgery Mastectomies and Lymph Node Dissections Bariatric (Weight Loss) Surgery Travel Services Transplant Services Human Organ, Tissue, and Bone Marrow Transplantation Services Donor Services Limitations and Exclusions .......................... 71 Principal Limitations Principal Exclusions Payment and Reimbursement Responsibility ................................................ 75 Prepayment Fees (Premiums) Changes in Fees, Benefits, and Charges Other Charges Annual Copayment Maximum Maximum Lifetime Benefit Premiums and Health Care Benefits Ratio Provider Payments Reimbursement Provisions (Claims) Liability of Subscriber or Enrollee for Payment Coordination of Benefits Reimbursement Third Party Reimbursement/Liability Member Services Assistance ....................... 80 Member Services Representative Membership Records/Information Membership Records – Employer Responsibilities Member Grievances Department of Managed Health Care (DMHC) Consumer Help-Line Public Policy Committee Advance Health Care Directive – Your Health Care Choices

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Index Termination of Benefits................................. 84 Cancellation of Group Service Agreement Loss of Eligibility Disenrollment by Member Cancellation of Members for Cause Termination for Nonpayment Medicare Enrollment Enlistment in Uniformed Services State Review of Termination Cessation of Coverage Effective Date of Termination Refunds in the Event of Cancellation Certificates of Creditable Coverage

Suspension of Services Privacy Practices and Protected Health Information (PHI) Definitions .................................................... 102 Index ..............................................................113 Helpful Contact Information ........................116

Individual Continuation of Coverage............ 89 Continuing Group Coverage Under COBRA and CalCOBRA Qualifying Events Understanding Your Choices Cal-COBRA After Exhausting COBRA COBRA or Cal-COBRA Enrollment Responsibility COBRA or Cal-COBRA Payment Responsibility ARRA Premium Reduction COBRA or Cal-COBRA Termination Open Enrollment Period or Termination of Another Health Plan Group Responsibilities Important Notice Regarding Continuation of Coverage HIPAA and Other Individual Plans Individual Conversion Plan Continuation of Coverage for Totally Disabled Members Retiree Continuation of Coverage ............... 96 Becoming a VHP Retiree Member Retiree Eligibility Retiree Covered Services Retiree Termination General Information ...................................... 99 Your Rights and Responsibilities Governing Law

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Helpful Contact Information Valley Health Plan Office

2480 N. First , Suite 200, San Jose Ca 95131 Hours: M-F, 8:00am - 5:00pm

Valley Health Plan Website

www.valleyhealthplan.org

Member Service Department

Phone: 408.885.4760 or 1.888.421.4444 (toll-free) For the hearing and speech impaired, call the California Relay Service (CSR) by simply dialing 711 or the 800 CSR number from your modality.

Fax: 408.885.4425 Email: memberservices@vhp.sccgov.org Hours: M - F, 9:00am - 5:00pm

Health Education Department

Phone: 408.885.3490 Fax: 408.954.1023 Email: healtheducation@vhp.sccgov.org Hours: M - F, 8:00am - 5:00pm

Medical Advice

Phone: 1.866.682.9492 (toll-free) Hours: 24 hours/daily

Pharmacy (Navitus) Customer Care

Phone: 1.866.682.9492 (toll-free) Hours: 24 hours/daily Call this phone number when you need assistance with pharmacy/prescription related issues.

Primary Care Physician (PCP) Information

Please use the Provider Search function on our website at www. valleyhealthplan.org or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

Updates/Corrections Periodically, there will be updates/corrections made to materials you receive from Valley Health Plan. For the most updated information in our printed materials, please visit www.valleyhealthplan.org or call VHP Member Services if you need assistance.

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Valley Health Plan Benefits and Coverage Handbook - Combined Evidence of Coverage and Disclosure Form

www.valleyhealthplan.org

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408.885.4760

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San Jose, CA 95131

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2480 N. First Street, Suite 200

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