Find answers to the most commonly asked questions

What is monkeypox?

Monkeypox is a viral infection caused by the monkeypox virus, which is in the same family of viruses that causes smallpox. It’s less contagious than smallpox and usually spreads through close, personal contact. Generally, it does not cause severe illness, and most monkeypox cases resolve on their own. That said, a small number of reported cases have resulted in severe illness and death.

Due to the high number of cases, the World Health Organization has declared the current monkeypox outbreak a global health emergency. And the Centers for Disease Control and Prevention (CDC) has confirmed cases of monkeypox in most parts of the U.S., including San Diego. For more information, please visit the CDC’s website.

How is monkeypox spread?

Monkeypox usually spreads through direct skin-to-skin contact with someone who has a monkeypox rash. It can also be spread by sharing surfaces, clothing, or bedding with an infected person along with blood and/or bodily fluids. Monkeypox can spread from the time symptoms start until the rash has healed, all scabs have fallen off, and a fresh layer of skin has formed. The illness typically lasts 2-4 weeks.

What are the symptoms of monkeypox?

According to the CDC, symptoms of monkeypox can include:

• Fever
• Headache
• Muscle aches and backache
• Swollen lymph nodes
• Chills
• Exhaustion
• Respiratory symptoms (e.g. sore throat, nasal congestion or cough)
• A rash that may be located on or near the genitals or anus but could also be on other areas like the hands, feet, chest, face or mouth. The rash will go through several stages, including scabs, before healing. The rash can look like pimples or blisters and may be painful or itchy.

Monkeypox symptoms usually start within 3 weeks of exposure to the virus. If someone has flu-like symptoms, they will usually develop a rash 1-4 days later.

Is there a monkeypox vaccine?

Yes. The County of San Diego is currently prioritizing vaccination for individuals 18 or older who:

• Have been identified as intimate with or otherwise close contacts of a person diagnosed with monkeypox.
• Have been intimate or otherwise had skin-to-skin contact with a person who has a monkeypox-like rash.
• Have attended an event where a diagnosed case has been reported.
• Are part of a community in which monkeypox infections have been reported. At this time, this includes members of the LGBTQ+ community, including gay, bisexual and other men who have sex with men and have had more than one sex partner in the last month.

For more information on the monkeypox vaccine, visit Sharp HealthCare’s website.

How do I protect myself against monkeypox?

Along with vaccination — recommended for people who have been in close contact with individuals who have monkeypox or who had multiple sexual partners in the past 14 days in an area with known monkeypox cases — the CDC recommends you:

• Avoid close, skin-to-skin contact with people who have a rash that looks like monkeypox.
• Do not touch the rash or scabs of a person with monkeypox.
• Do not kiss, hug, cuddle or have sex with someone with monkeypox.
• Do not share eating utensils or cups with a person with monkeypox.
• Do not handle or touch the bedding, towels or clothing of a person with monkeypox.
• Wash your hands often with soap and water or use an alcohol-based hand sanitizer.

What should I do if I think I may have monkeypox?

If you think you may have monkeypox contact your primary care physician and follow the CDC's isolation guidelines:

• Do not share items that have been worn, used or handled with other people or animals.
• Wash and disinfect items that have been worn or handled and surfaces that have been touched.
• Avoid close physical contact with other people.
• Avoid crowds and congregate settings, such as residential facilities, dormitories and prisons.
• Wash your hands often with soap and water or use an alcohol-based hand sanitizer, especially after direct contact with the rash.

Who is issuing me a 1095 form?

Sharp Health Plan will send you a 1095-B form if you were enrolled in benefits in 2023 through your employer or directly through Sharp Health Plan. If you enrolled in Sharp Health Plan through Covered California, you will receive Form 1095-A from Covered California. If you were enrolled in Medicare, you will receive a 1095 form from the Centers for Medicare & Medicaid Services (CMS). You may receive multiple forms if you had changes in health coverage during 2023.

What information is included on the 1095-B form?

The 1095-B form includes the names and Social Security numbers (SSNs) or dates of birth for members enrolled in Sharp Health Plan during 2023. It also shows the months of coverage for each individual listed. To ensure that our members’ personal information is protected, the 1095-B form includes only the last four digits of the SSN.

What do I need to do with the 1095 form(s)?

The 1095 form is verification that you had minimum essential health coverage during 2023. Please keep this form for your records. You may need to reference or submit the form for your state tax return as part of California’s Minimum Essential Coverage Individual Mandate. Please consult your tax adviser and refer to the Internal Revenue Service and California Franchise Tax Board for more information.

When will Sharp Health Plan issue 1095-B forms?

Sharp Health Plan will mail 1095-B forms to subscribers by Jan. 31, 2024.

What if I changed employers or health insurance plans during 2023?

You may receive more than one 1095 form if you had health care coverage from more than one health insurance plan during 2023.

I had coverage through Medicare, and was enrolled in a Sharp Direct Advantage plan. What form will I get so I can show I had coverage?

You will get Form 1095-B from the Centers for Medicare & Medicaid Services.

What should I do if I did not receive a 1095-B form?

If you were enrolled in Sharp Health Plan during 2023 but you did not receive a 1095-B form by Jan. 31, 2024, please contact Customer Care at customer.service@sharp.com or by phone at 1-800-359-2002.

If you were enrolled in Sharp Health Plan through Covered California but you do not receive a 1095-A form, please contact Covered California at 1-800-300-1506 or visit their website.

If you were enrolled in a Sharp Direct Advantage (Medicare) plan but you do not receive a 1095-B form, please contact the Centers for Medicare & Medicaid Services at 1-800-633-4227 or visit their website.

What should I do if I receive an incorrect 1095 form?

If you receive a 1095-B form issued by Sharp Health Plan that you believe is incorrect, please contact Customer Care at customer.service@sharp.com or by phone at 1-800-359-2002.

If you received a Form 1095-A from Covered California that you believe is incorrect, please contact Covered California at 1-800-300-1506 or visit their website.

If you’re a Sharp Direct Advantage member and received a 1095-B form from the Centers for Medicare & Medicaid Services (CMS) that you believe is incorrect, please contact CMS at 1-800-633-4227 or visit their website.

What do I do if I have a question about the 1095 form(s) I receive?

You should contact the issuer at the phone number or email address printed on the form if you have questions. We also encourage you to consult your tax adviser and refer to the Internal Revenue Service and California Franchise Tax Board for guidance.

How do I cancel my coverage?

If you enrolled in benefits through your employer, please contact your human resources department.

If you purchased insurance directly through Sharp Health Plan, please complete this form, which can also be submitted online in your Sharp Health Plan online account. You will receive written confirmation once your request has been processed.

If you purchased insurance through Covered California, you must submit the termination form above, and also cancel your benefits by logging into your Covered California account.

Am I covered when I am outside Sharp Health Plan’s service area?

You are covered for emergency and urgent care when you are outside Sharp Health Plan’s service area (San Diego and southern Riverside Counties). If you are admitted to a hospital because of an injury or life-threatening medical emergency, you (or someone acting for you) should immediately notify your primary care physician or Sharp Health Plan within 48 hours or at the earliest time reasonably possible. This will allow your doctor to share your medical history with the hospital and help coordinate your care.

How can I get care outside Sharp Health Plan’s service area?

Sharp Health Plan Members who need help finding emergency or urgent care services out of the service area can contact Assist America^®. These services are available if you face a medical emergency while traveling 100 miles or more away from your permanent residence or in a foreign country. For San Diegans, that can mean travel to destinations as close as Los Angeles or Mexico. Assist America will immediately connect you to doctors, hospitals, pharmacies and other health care services. Call Assist America at 1-800-872-1414 and provide reference number 01-AA-SHP-09073.

Learn more about getting care outside of San Diego.

How can I get acupuncture treatment?

How to get services

If acupuncture services are covered through your benefit plan, search for a provider or call 1-800-678-9133 to speak with an American Specialty Health (ASH) representative for assistance.

How to find out if you have acupuncture services

Log in to your Sharp Health Plan online account to see your Member Handbook and Summary of Benefits to determine if your benefit plan includes coverage for acupuncture services. For more information, please call Customer Care at 1-800-359-2002, or email customer.service@sharp.com.

Learn more about getting acupuncture care.

How can I get chiropractic care?

If chiropractic services are covered through your benefit plan, search for a provider or call 1-800-678-9133 to speak with an American Specialty Health representative for assistance. No referral from Sharp Health Plan or your primary care physician is required.

How to find out if you have chiropractic coverage
Log in to your online account to see your Member Handbook and summary of benefits to determine if your benefit plan includes coverage for chiropractic services. For more information, please call Customer Care at 1-800-359-2002, or email customer.service@sharp.com.

Learn more about getting chiropractic care.

Get discounted services
For Members who do not have this coverage (or who may have used all their allotted benefits during the current year), Sharp Health Plan partners with American Specialty Health (ASH) and its affiliate, Healthyroads, Inc., to provide discounts on alternative care services. Receive 25% off usual provider rates on services from an extensive, credentialed network of chiropractors, acupuncturists, massage therapists and dietitians. You may visit any of these providers directly, without a physician referral.

Receive 15 to 40% off suggested retail prices on more than 2,400 health and wellness products, including vitamins, minerals, herbal supplements, homeopathic remedies, sports nutrition products, books, DVDs, fitness products and skin care items.

For assistance with ordering wellness products or locating an alternative care provider, please contact our health discounts partner, American Specialty Health at 1-877-335-2746.

How long can my child be enrolled in Sharp Health Plan?

In most cases your child can be enrolled in Sharp Health Plan until the last day of the month of their 26th birthday.

Can my child’s spouse and children enroll in Sharp Health Plan?

No, your child’s spouse and children are not eligible to enroll in Sharp Health Plan under your policy; however, your child’s spouse and children may be eligible to enroll in their own individual/family plan through Sharp Health Plan.

Can my child enroll in Sharp Health Plan if he/she is married?

If your benefit plan is provided by your employer, check with your employer to find out if you can enroll your dependents. If your employer includes coverage for dependents or you have an individual/family plan, your child is eligible for enrollment up to age 26 regardless of marital status.

Can I enroll my dependents living outside Sharp Health Plan's service area?

All eligible family members must must live within Sharp Health Plan's service area (San Diego and southern Riverside Counties).

Can my child who lives outside of San Diego enroll in Sharp Health Plan if I have a medical support order?

Yes, as long as there is a valid medical support order in place. If you are enrolled in an HMO plan, your child will be covered for emergency and urgent care services while outside the plan’s service area. If you are enrolled in a POS plan, your child may obtain care from any licensed provider but the costs using Tier 2 - Aetna/or Out-of-Network benefits will be higher and your child will usually pay a deductible and coinsurance.

How can I get coverage for my newborn or newly adopted child?

If your benefit plan is provided by your employer, contact your employer’s human resources department for instructions and an enrollment change form to add your newborn. If you are enrolled in an individual/family plan, contact Sharp Health Plan Customer Care at 1-800-359-2002 for instructions and an enrollment change form. An eligible newborn is covered automatically for the birth month, but must be enrolled within 60 days to be covered after the birth month. Adopted children are covered from the date of birth if enrolled within 60 days.

Can my spouse or partner and dependents be covered under Sharp Health Plan?

Yes, if your employer provides coverage for dependents and you are enrolled in Sharp Health Plan or if you are enrolled in an individual/family plan, your legally married spouse or registered domestic partner and your children are eligible. Some employers also cover non-registered domestic partners. Contact your human resources department for more information.

Learn more about adding or removing dependents.

If my spouse loses health coverage through his or her employer, can he or she be covered under my Sharp Health Plan?

In most cases, yes. If you are a Sharp Health Plan Member when your spouse loses group coverage through your spouse’s employer, your spouse may enroll as a dependent under Sharp Health Plan, so long as enrollment occurs within 30 days for large groups and 60 days for small groups and IFP plans from the date that coverage ended under the former health plan.

Learn more about adding or removing dependents.

Can I add or remove my spouse or partner to my Sharp Health Plan coverage if open enrollment is over?

Yes, as long as there has been a qualified family change, such as marriage. Enrollment must occur within 30 days for large groups and 60 days for small groups and IFP plans from the time your dependents first become eligible to join (that is, within the marriage or domestic partnership).

Learn more about qualifying events.

Does my child have to be a full-time student to enroll in Sharp Health Plan?

If your benefit plan is provided by your employer, check with your employer to find out if you can enroll your dependents. If your employer includes coverage for dependents or you have an individual/family plan, your child is eligible for enrollment up to age 26 regardless of student status.

Can my child who attends school outside of San Diego County enroll in Sharp Health Plan?

Yes, as long as your child retains a permanent residence in Sharp Health Plan’s service area. If you are enrolled in an HMO plan, your child will be covered for emergency and urgent care services while they are away at school. They receive routine and preventive care services from doctors affiliated with their Plan Medical Group while they are back at home. If you are enrolled in a POS plan, your child may obtain care from any licensed provider but the costs using Tier 2 - Aetna/or Out-of-Network benefits will be higher and your child will usually pay a deductible and coinsurance.

Which services are covered under Sharp Health Plan HMO?

Sharp Health Plan HMO is a comprehensive health care service plan that offers a full spectrum of medical care. Covered services always include coverage for medically necessary doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams and much more, with varying levels of copayment and/or coinsurance. Coverage for other services varies depending upon the benefit plan you are enrolled in. Log in to Sharp Connect to check your Member handbook, benefit plan matrix and any other supplemental benefit information to find out which services are covered under your plan.

Where can I get a summary of my benefits?

Log in to your online account to view a medical benefits summary, Member Handbook and other plan documents online. If you prefer, you can contact us to have a benefits summary and Member Handbook sent to you.

How do I get authorization for medical care?

Before receiving care through your covered HMO benefits, contact your primary care physician’s (PCP) office and ask your doctor to request prior authorization. You are responsible for obtaining valid authorization before you receive care (not including PCP services, outpatient behavioral health services and OBGYN services in your network, and emergency care services). Note: Approved authorizations include an expiration date, so be sure to make a note of it with any other important health information you track.

How do I check the status of my authorization?

The easiest way to check the status of an authorization is to call Customer Care at 1-800-359-2002. You can also contact your doctor’s office to request more information.

How long does it take to process an authorization request?

Routine requests are processed within five business days, and urgent requests are processed within 72 hours. Once your request is processed, you will receive a confirmation letter by postal mail. For approved requests, the letter will include the approved provider and expiration date for the authorization. For denied requests, the letter will include the reason for denial and your appeal rights.

What is a POS plan?

Sharp Health Plan’s Point of Service Plan (POS) combines features of a health maintenance organization (HMO) and a Preferred Provider Organization (PPO). You can access care in three distinct tiers.

Your plan allows you to receive care within Sharp HealthCare’s integrated care delivery system (Tier 1), Aetna’s Open Choice PPO Network (Tier 2), or any non-participating provider of your choice (Tier 3).

Services in Tier 1 and Tier 2 are the most cost-effective. Tier 3 services are out-of-network and typically cost more than services provided in Tiers 1 and 2.

What is the POS Concierge Program? 

The POS Concierge Program is a free resource available to our POS plan members. You’ll have access to these benefits:

• Get answers to your benefit, billing and claim questions and explain how your plan works;
• Find network providers and prepare for appointments by confirming your eligibility; and
• Determine precertification or authorization requirements.

Our POS Concierge, Yvonne Mascareno, can help to answer your questions about how your POS plan works. For immediate assistance, please contact Customer Care at customer.service@sharp.com or 1-858-499-8300. They are available to assist you Monday through Friday, 8 am to 6 pm.

Which services are covered under Sharp Health Plan POS?

Sharp Health Plan’s Point of Service Plan (POS) is a comprehensive health care service plan that offers a full spectrum of medical care. Covered services always include coverage for medically necessary doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams and much more, with varying levels of copayment and/or coinsurance. Coverage for other services varies depending upon the benefit plan you are enrolled in. Log in to your Sharp Health Plan online account to check your Member Handbook, benefit plan matrix and any other supplemental benefit information to find out which services are covered under your plan.

Where can I get a summary of my benefits?

Log in to your online account to view a medical benefits summary, Member Handbook and other plan documents online. If you prefer, you can contact us to have a benefits summary and Member Handbook sent to you.

What is precertification?

Some services require approval from Sharp Health Plan before care is provided. This allows Sharp Health Plan to evaluate whether the care is medically necessary and eligible for coverage. Learn more about precertification. 

When do I need a precertification?

If you have a Point of Service (POS) plan, some Tier 2 (Aetna Open Choice) or Tier 3 (out-of-network) services require precertification before you receive services. It is your responsibility to make sure that you receive precertification. To request precertification, have your doctor complete the Precertification POS Form and fax it to Sharp Health Plan.

How do I get authorization/precertification for medical care?

If you have a Point of Service (POS) plan, some Tier 2 (Aetna Open Choice) or Tier 3 (out-of-network) services require precertification before you receive services. It is your responsibility to make sure that you receive precertification. To request precertification, have your doctor complete the Precertification POS Form and fax it to Sharp Health Plan.

If you do not receive required precertification, you may be required to pay 50% of the amount Sharp Health Plan pays the provider for that service, rather than the coinsurance amount listed on your benefit matrix. The 50% payment will not count toward your deductible or annual out-of-pocket maximum. If the service is not found to be medically necessary, you will be required to pay 100% of the charges. Log in to your online account to read your benefit matrix and find out which services require precertification.

Why was I assigned a Sharp primary care physician?

The three-tier Point of Service (POS) plan includes the Tier 1 Sharp Health Plan's HMO network, which is why all POS plan members are assigned a primary care physician (PCP).  Please use our provider directory and search under the Choice Network for large group plans and the Performance Network for small group plans.

If a PCP is not selected, a doctor will be automatically assigned to you. A PCP is not required to coordinate your care when you receive services from Tier 2 or Tier 3 providers. In Tier 2, you can choose to receive care within Sharp Health Plan’s broadest HMO network, Aetna’s Open Choice PPO Network, or any other care provider in the U.S.

How can I find a medical provider?

• Tier 1: Please use our provider directory and search under the Choice Network for Large Group plans and the Performance Network for Small Group plans.
• Tier 2: Please visit the Aetna provider directory.
  • Please note: Do not use the Alternative Medicine search category. You can search for alternate care providers through our partner, American Specialty Health Plan, by calling 1‑800-678-9133 or by visiting ashlink.com/ash/SharpHPpos.

How can I find a behavioral health provider?

Please visit Magellan’s online provider directory to search for a behavioral health provider. You will be prompted to select your benefit plan and can select either Tier 1 or Tier 2 from the list of options.

Where can I find acupuncture, chiropractic, hearing, or vision providers?

• Acupuncture and chiropractic services: You can access American Specialty Health Plan’s national acupuncture and chiropractic services network. To find a provider, visit ashlink.com/ash/sharpHPpos or call 1-800-678-9133.
• Hearing: You have access to HearUSA’s national network. To find a provider, visit hearusa.com.
• Vision: You can access Vision Service Plan’s national network for vision services. To find a provider, visit vsp.com.

Do I need a referral to see a specialist?

It depends on the benefit tier you use to access care.

• Tier 1: A referral from your primary care provider (PCP) is required for you to see a specialist in Tier 1. Your PCP coordinates all member care and can refer members to other specialists within your plan medical group.
• Tier 2: A referral is not required when you receive care from a Tier 2 Aetna Open Choice PPO Network provider. However, some services do require precertification.
• Tier 3: A referral is not required when you receive care from a non-contracted provider (Tier 3). However, some services do require precertification.

Please refer to your plan summary for details on what services require precertification.

How can I be reimbursed for services I paid out of pocket?

You can seek reimbursement for paid services from Sharp Health Plan. Please download and complete the reimbursement form. To be reimbursed for at-home COVID-19 tests, please download and complete this form.

Where should my providers send claims? 

Providers should send claims to:
Sharp Health Plan
P.O. BOX 939036
San Diego, CA 92193

How do my medical expenses apply to the annual deductible and the annual out-of-pocket maximum?

Expenses for services only apply to the annual deductible and the annual out-of-pocket maximum for the tiers in which services are received.

• Expenses for services under Tier 1 will apply to the Tier 1 deductible and out-of-pocket maximum.
• Expenses for services under Tier 2 will apply to the Tier 2 deductible and out-of-pocket maximum.
• Expenses for services under Tier 3 will apply to the Tier 3 deductible and out-of-pocket maximum.

Note: Pharmacy expenses accumulate across all three tiers.

Where can I go to get flu shots and immunizations?

Flu shots and immunizations are available at CVS MinuteClinics^® and your primary care physician’s (PCP’s) office. In Tier 2, you can receive flu shots and immunizations at Aetna Open Choice PPO walk-in clinics or physicians’ offices.

What pharmacies can I use to fill a prescription?

You have access to the CVS Caremark^® network pharmacies. To find a network pharmacy, visit cvs.com/store-locator/landing. 

Do I have access to a pharmacy mail order service where I can obtain my 90-day supply of my medication?

Yes, you can use CVS Caremark^® to sign up and receive a 90-day supply of eligible medications through the mail order service. Register for mail order service at caremark.com. 

How can I find out if my prescription is covered or requires prior authorization?

You can review the Sharp Health Plan formulary (also known as a drug list) to find out if your medication is covered or requires prior authorization. View the formulary online or call our dedicated pharmacy customer service line at 1-855-298-4252. 

What questions can your Customer Care team answer?

Our Customer Care team can answer questions from you or your provider about eligibility, benefits, claims and billing.

What is a PPO plan?

A Preferred Provider Organization (PPO) plan is a plan that allows members to choose from a network of preferred providers. Members do not select a primary care physician and do not need referrals to see other plan providers in the network.

Your plan allows you to receive care from your plan providers within Sharp HealthCare’s integrated care delivery system (Tier 1). You can also receive care from non-plan providers in the First Health^® Network (Tier 2), or any out-of-network provider of your choice (Tier 3).

Services in Tier 1 and Tier 2 are the most cost-effective. Tier 3 services are out-of-network and typically cost more than services provided in Tiers 1 and 2.

What is the PPO Concierge program?

The PPO Concierge program is a free resource available to our PPO plan members. Use the PPO Concierge program to:

• Get answers to your benefit, billing and claim questions and explain how your plan works
• Find network providers and prepare for appointments by confirming your eligibility
• Determine precertification or authorization requirements

Our PPO Concierge, Yvonne Mascareno, can help answer your questions about how your PPO plan works. For immediate assistance, please contact Customer Care at customer.service@sharp.com or 1-844-483-9011. They are available to assist you Monday through Friday, 8 am to 6 pm.

Which services are covered under Sharp Health Plan’s PPO plan?

Sharp Health Plan’s PPO plan is a comprehensive health care service plan offering a full spectrum of medical care. Covered services always include coverage for medically necessary doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams, and much more, with varying levels of copayment and/or coinsurance. Coverage for other services varies depending on the benefit plan you are enrolled in. Log in to your Sharp Health Plan online account to check your Member Handbook, benefit plan matrix and any other supplemental benefit information to determine which services are covered under your plan.

Where can I get a summary of my benefits?

Log in to your online account to view a medical benefits summary, Member Handbook and other plan documents online. If you prefer, you can contact us to have a benefits summary and Member Handbook sent to you.

What is a primary care physician, and do I need to choose one?

Primary care physicians focus on preventive medicine and care for a wide range of conditions and diseases. Your plan does not require you to choose or select a primary care physician (PCP). That said, we do recommend having a PCP for health care advice. Whether it’s preventive care, treating common illnesses and injuries or helping manage chronic conditions like diabetes and hypertension, having a PCP can be very helpful in managing your overall care. As a PPO enrollee, your PCP will not need to refer you to specialists, and you can choose to receive care from any provider within the three tiers of your plan. Certain services may require precertification or approval from Sharp Health Plan.

What is precertification?

Some services require approval from Sharp Health Plan before care is provided. This allows Sharp Health Plan to evaluate whether the care is medically necessary and eligible for coverage. Learn more about precertification. 

When do I need a precertification?

If you have a PPO plan, some services require precertification before you can receive them. It is your responsibility to make sure that you receive precertification. To request precertification, have your doctor complete the Precertification POS and PPO form and fax it to Sharp Health Plan.

If you do not receive the required precertification, you may be required to pay 50% of the amount Sharp Health Plan pays the provider for that service rather than the coinsurance amount listed on your benefit matrix. The 50% payment will not count toward your deductible or annual out-of-pocket maximum. If the service is not medically necessary, you will be required to pay 100% of the charges. Log in to your Sharp Health Plan online account to read your benefit matrix and find out which services require precertification.

How can I find a medical provider in Tier 1 or Tier 2?

• Tier 1: Please use our provider directory and search under the Sharp Health Plan Premier Network.
• Tier 2: Please visit the First Health Network directory.
• Please note, do not use the following services in this directory: acupuncturists, chiropractors, vision, dental, hearing, or mental health services. You may have access to other programs for these services.

You can choose an out-of-network medical provider, but costs may be higher.

Where can I find behavioral health providers?

Visit sharphealthplan.com/MentalHealthProvider to search for a Tier 1 or Tier 2 behavioral health provider and filter by specialty, location and more to find the best fit for you. In Tier 3, you can choose an out-of-network behavioral health provider, but costs may be higher.

Where can I find acupuncture, chiropractic, hearing, or vision providers?

• Acupuncture and chiropractic services: You can access American Specialty Health Plan’s national acupuncture and chiropractic services network. To find a provider, visit ashlink.com/ash/sharpHPpos or call 1-800-678-9133.
• Hearing: You have access to HearUSA’s national network. To find a provider, visit hearusa.com.
• Vision: You can access Vision Service Plan’s national network for vision services. To find a provider, visit vsp.com.

How can I be reimbursed for services I paid out of pocket?

You can seek reimbursement for paid services from Sharp Health Plan. Please download and complete the reimbursement form. To be reimbursed for at-home COVID-19 tests, please download and complete this form.

How do my medical expenses apply to the annual deductible and the annual out-of-pocket maximum?

Expenses for services only apply to the annual deductible and the annual out-of-pocket maximum for the tiers in which services are received.

• Expenses for services under Tier 1 will apply to the Tier 1 deductible and out-of-pocket maximum.
• Expenses for services under Tier 2 will apply to the Tier 2 deductible and out-of-pocket maximum.
• Expenses for services under Tier 3 will apply to the Tier 3 deductible and out-of-pocket maximum.

Note: Pharmacy expenses accumulate across all three tiers.

Where can I go to get flu shots and immunizations?

Flu shots and immunizations are available at CVS MinuteClinics^®, your physician’s office, CVS Caremark^® Network Pharmacies, or any walk-in clinic in the First Health network.

What pharmacies can I use to fill a prescription?

You have access to the CVS Caremark^® network pharmacies. To find a network pharmacy, visit cvs.com/store-locator/landing. 

Do I have access to a pharmacy mail order service where I can obtain my 90-day supply of my medication?

Yes, you can use CVS Caremark^® to sign up and receive a 90-day supply of eligible medications through the mail order service. Register for mail order service at caremark.com. 

How can I find out if my prescription is covered or requires prior authorization?

You can review the Sharp Health Plan formulary (also known as the PPO Drug List) to find out if your medication is covered or requires prior authorization. View the formulary online or call our dedicated pharmacy customer service line at 1-855-298-4252.

What questions can your Customer Care team answer?

Our Customer Care team can answer questions from you or your provider about eligibility, benefits, claims and billing.

Who should I call with questions regarding my behavioral health or pharmacy benefits?

If you have questions about your behavioral health benefits, please contact Customer Care at customer.service@sharp.com or 1-844-483-9013.

If you have questions about your pharmacy benefits, please contact Customer Care at customer.service@sharp.com or 1-855-298-4252.

 What should I do if I don’t recognize the provider listed on my claim?

It’s possible that a particular medical treatment was performed at an facility unfamiliar to you or outside of your network. Contact your primary care physician, if you have questions about treatments.

Who do I contact if I have questions about my claim?

Contact Customer Care with your specific questions. Please send us a message or call Customer Care at 1-858-499-8300. We're here to help.

How do I request a deductible?

We will give you a credit toward your Sharp Health Plan deductible for approved amounts that were applied toward your deductible with your previous health plan (for the same calendar year). Keep in mind, we can’t give you credit for deductible amounts paid for outpatient prescription drugs. To request a deductible:

1. Download and send a completed deductible credit request form and the required attachments to Sharp Health Plan within 90 days of the start of your Sharp Health Plan coverage. We will not process Deductible Credit Request Forms received more than 90 days after your start date.
2. List the deductible amount met by each family member separately. You only need to fill out one Deductible Credit Request Form for all family Members covered by Sharp Health Plan.
3. Attach a copy (front and back) of the most current explanation of benefits (EOB) from your previous health plan. The EOB must list all deductible amounts you are requesting as credit.

Where and when can I get urgent care services?

Sharp Health Plan has urgent care centers throughout San Diego and southern Riverside Counties. You can search for an urgent care center or call us at 1-800-359-2002. In most cases, you must contact your primary care physician for authorization before going to an urgent care center. Sharp Rees-Stealy (SRS) Members do not need authorization before going to SRS urgent care centers and Sharp Community Medical Group (SCMG) Members do not need authorization before going to an urgent care center affiliated with SCMG. Check the Plan Medical Group on your member ID card.

What if I have an emergency situation?

As a Member, you can visit any emergency room, whether in San Diego or anywhere worldwide. If you are not sure whether your situation is an emergency, call your primary care physician. Your primary care physician can help you decide on the best course of action. You can also talk to a nurse after hours with Sharp Nurse Connection® for medical assistance during evenings and weekends. To talk to a nurse call toll-free at 1-800-359-2002 from 5 pm – 8 am, Monday through Friday, and 24 hours on weekends.

How can I get medical advice outside normal office hours?

Health concerns may arise at any hour of the day. Sharp Nurse Connection^® is an after-hours nurse advice line. Nurse Connection puts you in contact with registered nurses who can assess your medical situation, suggest self-care or address your problem until you can see your doctor, and advise you where to seek care. To talk to a nurse, call toll-free at 1-800-359-2002 from 5 pm – 8 am, Monday through Friday, and 24 hours on weekends.

During the COVID-19 outbreak, there may be times when our after-hours nurse advice line directs you to your primary care physician's office for any medical questions or concerns. This is to ensure the quickest and best care possible when they’re experiencing high call volumes.

What is an explanation of benefits?

An explanation of benefits, or EOB, is a statement you get from your health plan to let you know a claim was paid and processed. An explanation of benefits is not a bill. We provide two types of EOB statements in your Sharp Health Plan online account: Summary EOBs and Individual EOBs .

What do I do when I get an explanation of benefits?

When you get an explanation of benefits, read it through. The purpose of an EOB is to help you understand how much your health plan covers for medical or pharmacy services you had.

What’s the difference between a claim and an EOB?

A claim is a request for payment. Your provider submits a claim to us after you receive a health care service from them.

An explanation of benefits is a statement that shows you claim and service details from a specific period, usually one month.

Can I opt in to paperless EOBs?

Yes. You can opt in to paperless EOBs through your Sharp Health Plan online account. Simply log in or create an online account and go to the Claims tab. If you're using the mobile app, tap Medical. From there you can follow the prompts to sign up for paperless EOBs.

Can I opt out of paperless EOBs?

Yes. You can opt out of paperless EOBs at any time through your Sharp Health Plan online account. Simply log in or create an online account and go to the Claims tab. If you're using the mobile app, tap Medical. From there you can select 'cancel paperless EOBs'.

What do “allowed” and “approved” mean?

“Allowed” and “approved” is the maximum amount we will pay for covered health care services.

What does “in plan savings” mean?

“In plan savings” are discounts we negotiated to save you money. This information is shown on any Individual EOB statements in your online account.

What is a deductible?

A deductible is the amount you pay for covered health care services before we start to pay. If your benefit plan does not include a deductible, your deductible will be listed as $0 on your EOB and your member ID card.

What is coinsurance?

Coinsurance is a percentage of costs of a covered health care service you pay (20%, for example) after you've paid your deductible. If your benefit plan does not include a deductible, check your Individual EOB statements in your online account to see if you have a coinsurance payment.

What is a copay?

A copay is a fixed amount ($20, for example) you pay for a covered health care service after you've paid your deductible.

What does “out-of-pocket maximum” mean?

The out-of-pocket maximum is the most you have to pay for covered services in a health plan year including deductibles, copays and coinsurance. If your benefit plan does not include a deductible, check your Individual EOB statements in your online account to see if you have a coinsurance payment.

What are the dates listed under my claim details?

The dates are when you had a health care service.

What is a reference number?

A reference number is what your provider can use to look up your specific claim.

What does CPT mean?

CPT stands for current procedural terminology. It is a medical code used to report medical, surgical and diagnostic services.

What does “not covered” mean?

The amount not covered is the portion of the claim not covered by your health insurance.

What’s a reason code?

A reason code relates to the “not covered” amount.

What’s a code summary?

A code summary helps explain any reason codes listed.

What does OTC mean?

Over-the-counter drugs, or OTC, are medicines sold directly to consumers, no prescription needed.

Can members get covered care outside of San Diego?

Yes, as a Sharp Health Plan Member, you are covered for urgent care and emergency care wherever you are, although routine care is only covered at home in our service area. If you need help finding urgent or emergency services outside of our service area, our partner, Assist America^®, can help. Assist America services are available when Members face a medical emergency while traveling 100 miles or more away from their permanent residence, or when visiting a foreign country. Assist America will immediately connect you to doctors, hospitals, pharmacies and other health care services.

Learn more about how we cover care outside of San Diego.

What is the difference between the POS and HMO plan? 

In a health maintenance organization (HMO) plan, you must select a primary care physician. Your primary care physician will coordinate all your medical care. All care is typically received by in-network physicians.

In a point-of-service (POS) plan, you choose your primary care physician in network but have the option to go out of network. Going out of network will cost you more.

If hospitalization is necessary, which hospital will I use?

Sharp Health Plan’s network includes many hospitals throughout San Diego. View the full list of hospitals. Primary care physicians (PCPs) and specialists work with specific hospitals. If hospitalization is necessary, your doctor will admit you to a hospital that is affiliated with your Plan Medical Group. Contact us to find out which hospitals are used with your Plan Medical Group, or search for a hospital and narrow your search results by your Plan Medical Group. 

Additional information for POS plan Members

If you are a POS Member, you may also obtain care from any licensed provider not affiliated with the Plan Medical Group you selected. Your costs will be higher and you will usually pay a deductible and coinsurance when using Tier 2 - Aetna/or Out-of-Network benefits. To find the Tier 1 - HMO Benefit Level hospital closest to you, use the Find a Doctor or Location tool and select "Hospital, Urgent Care or Facility".

What should I do if I do not receive my member ID card?

If you are a new Sharp Health Plan member who registered for benefits either through Covered CA or through Sharp Health Plan directly, you must make your initial payment to Sharp Health Plan in order to be activated in our system. You will receive your new member ID card up to 10 business days after your initial payment has been received. If your plan includes three or more covered family members, those cards will be mailed separately.

If you are enrolled in benefits through an employer-sponsored plan, it can take up to 10 business days after signing-up for benefits through your human resources department to receive your new member ID card.

If you are currently enrolled in benefits with Sharp Health Plan, and recently made a benefit change, made a demographic change (e.g. – changed your name or gender), or selected a new primary care physician (PCP), you will automatically be sent a new member ID card. It can take up to 7 business days after making one of these changes to receive your new member ID card in the mail.

If you lost your member ID card and have requested a replacement, please allow up to 7 business days to receive your new one in the mail. In the meantime, you can print a temporary member ID card through your Sharp Health Plan online account.

I received my member ID card in the mail, but other covered family members’ cards were missing. What should I do?

If your plan includes three or more covered family members, those cards will be mailed separately.

What should I do if the name on my member ID card is incorrect?

If you or one of your dependents received a member ID card with the incorrect personal information on it (like your name), you can request a replacement online by logging into your online account. From within your online account, you will be able to review your personal information, update your information if necessary, and request a new member ID card.

What should I do if the primary care physician listed on my member ID card is incorrect?

If you receive a member ID card with the wrong primary care physician (PCP) listed on the front, please log into your online account to verify the PCP that we have on record for you. Please note that if you are a Sharp Rees-Stealy member, your ID card will not list your PCP’s name, only the location of the Sharp Rees-Stealy Medical Center where they see patients. We know choosing the right PCP is a personal decision, which is why we make it easy for you to change your selection at any time. Please visit sharphealthplan.com/findadoctor to find a list of doctors. Once you’ve made your selection, you can update your PCP through your online account. Please note that PCP changes will be effective the first of the following month. Upon making your selection, we will mail you a new member ID card.

When do I need to start using my member ID card?

Your member ID card is your key to accessing care and filling prescriptions. Please carry it with you at all times and present it whenever getting care.

What will my member ID card look like?

The front of your member ID card will include your name, date of birth, account information, primary care physician’s name or affiliated medical group location, medical deductible (if applicable) and certain cost share information. The back of your new card will include important contact information. If you’ve purchased pediatric dental coverage, you’ll also see that noted on the back of your card. To see samples of what the ID cards look like, view or print this downloadable PDF. If you are a CalPERS employee, view or print this CalPERS member ID PDF.

What should I do if my member ID card shows the wrong effective date?

The effective date on your ID card does not affect your ability to access care or fill prescriptions. The effective date listed on the ID card is based on contract updates in the Sharp Health Plan system. If you enrolled in Sharp Health Plan before 1/1/16, your ID card will list that effective date. If you enrolled after 1/1/16, you will have a later effective date.

I made an initial payment, but I haven't received my member ID card. Am I still covered?

Please allow up to 10 business days after making your initial payment to receive your member ID card. If it has been more than 10 business days since you made your payment, please contact Customer Care.

What should I do if I have not received my new member welcome kit?

Your new member kit will be mailed to you within 10 business days of activating your enrollment with Sharp Health Plan. If you are a new member who applied for coverage directly through Sharp Health Plan or Covered California (and not your employer), you must make your initial premium payment to Sharp Health Plan to become effective as a member. Once your initial premium payment has been posted in our system, which can take up to 3 business days, we will mail your new member ID card(s) and a welcome kit.

If it has been more than 10 business days since you enrolled (and made your initial payment if applicable), and you still have not received your welcome kit, please email customer.service@sharp.com. Please note if you did receive your ID card(s) but not your welcome kit, you can register for an online account. There you can check benefits, copays, coverage status, change your primary care physician (PCP), print a temporary member ID card, and access health and wellness information. Visit sharphealthplan.com/login to register and have your member ID number available. This number is in the upper right-hand corner of your new card.

Who do I contact with questions?

If you have questions, please contact Customer Care at customer.service@sharp.com, 1-858-499-8300, or toll-free at 1-800-359-2002. We are available to assist you Monday through Friday from 8 a.m. to 6 p.m.

What if I get a bill for medical services?

As a Sharp Health Plan Member, you will not normally receive a bill from a provider unless you have not paid your copay or deductible. You are responsible only for paying any copayment or deductible due at the time of your visit. However, sometimes a bill for covered services may be sent to you in error. If you receive a bill in error, don’t worry. Contact Customer Care at 1-800-359-2002 as soon as possible and explain the situation. We will work with the provider to have the bill sent to Sharp Health Plan.

How can I request reimbursement for medical expenses that I have paid?

If you receive emergency or urgent care services outside of San Diego County, you may be asked to pay for those services. If that occurs, you can request reimbursement from Sharp Health Plan. 

Learn how to request a reimbursement.

How can I request reimbursement for prescription drugs that I paid for?

In some cases, you may be asked to pay for prescription drugs that are normally covered by Sharp Health Plan. An example is when you are traveling outside of California and urgently need to fill a prescription. You can request reimbursement for covered prescription drugs from us. To determine if the medication is covered, we will need a copy of the print out from the pharmacy showing the medication you received and a receipt showing proof of payment. Applicable copayments will apply. 

How do I get reimbursed for behavioral health services that I paid for?

If you receive care from an out of network behavioral health provider, you may be asked to pay for those services.  If that occurs, you can contact Magellan Healthcare at 1-844-483-9013, to request reimbursement. Magellan will provide a form that outlines the information needed for reimbursement including important reimbursement request deadlines.  Magellan will need a copy of the itemized bill showing all services received from the provider and a copy of your Sharp Health Plan ID card in order to determine if the services are covered.  Applicable co-payments will apply.

What is a Plan Medical Group (PMG)?

Sharp Health Plan has several medical groups (called Plan Medical Groups or PMGs) from which you choose your primary care physician (PCP) and through which you receive specialty physician care or access to hospitals and other facilities. In the Choice network, you can also select a PCP who is contracted directly with Sharp Health Plan. If you choose one of these PCPs, your PMG will be part of the Independent PMG.

You receive covered benefits from doctors who are affiliated with your PMG and who are part of your Plan Network. In most cases, each PMG includes a different set of PCPs, specialists, urgent care centers and other providers. In addition, your selection may impact the primary hospital in which services are delivered. To find out which plan doctors are affiliated with your PMG and part of your Plan Network, refer to the provider directory for your Plan Network or call Customer Care at 1-800-359-2002.

What is a Plan Network?

A Plan Network is the group of doctors, medical groups and hospitals available to you as a Sharp Health Plan Member. There are four Plan Networks: Choice, Value, Performance and Premier. You select your PCP and Plan Medical Group from the Plan Network you are assigned. You will find the name of your Plan Network on your member ID card.

What is open enrollment? When does it take place in and what are the deadlines?

Open enrollment is a period of time each year when you have the opportunity to enroll in health insurance or make changes to your current plan. Open enrollment for the individual and family plan (IFP) market starts on Oct. 15 and ends on Jan. 15. You must apply by Dec. 15 to have coverage effective on Jan. 1. The open enrollment window is the only time of year when you can enroll in health insurance, unless you have a qualifying event such as having a new baby, getting married or losing coverage through your work. 

Is it true that I can still get coverage, even though open enrollment is over? 

Yes. Because of the new coronavirus (COVID-19), you can apply for coverage if you are uninsured, would like to switch plans, and are eligible. This includes if you have been recently affected by income changes, reduced hours, or layoffs. Learn more about the special enrollment expansion or start an application by getting a quote. 

I have an individual and family plan, but due to the coronavirus, I need to make adjustments. What should I do?

If you purchased your coverage directly through Sharp Health Plan and need to make changes to your current plan, you have the following options:

• If you'd like to simply update your contact information, remove a member from your plan, or cancel your plan, log in to your Sharp Health Plan online account.
• If you would like to change your plan or network or add a dependent, please submit a new application.

If you purchased your plan through Covered California^™ and would like to report an income change, add or remove a dependent, or change your plan, log in to your Covered California account.  

How do you know if you need to change your health plan? What should you consider?

You can change your health plan during the open enrollment period, October 15 to January 15. There are two common reasons why you may choose to change your plan:

1. You are planning to access care more frequently throughout the year. In this instance, you may want to switch to a Platinum or Gold plan where you pay a higher monthly premium, but have a lower deductible and lower copays for medical care.
2. You want to change your plan network (Premier Network or Performance Network) to visit a particular doctor. Learn more about Sharp Health Plan’s networks under Compare networks and plans.

To change your plan, you should log in to your account on CoveredCA.com or call them directly at 1-800-300-1506.

Who should take part in open enrollment -- those without insurance, with insurance, or both? 

Whether you have insurance or not, it’s wise to participate in open enrollment to explore your options. If you don’t have coverage, you could be assessed a tax penalty for not carrying health insurance. Even if you do have coverage, it’s an opportunity to review available options to make sure they still meet the needs of you and your family. Open enrollment is the only time that changes can be made unless a qualifying event occurs. 

For those who've not had insurance before, do you have any advice on what to look for or consider when picking a plan? Where do you go to get started with comparing plans? 

Whether you are shopping for insurance for the first time or renewing your policy, the most important advice is to find a high-quality health plan at the best value. Many individuals don’t realize that there’s a difference in quality ratings between health plans. Covered California uses Members’ experiences to rate the quality of its participating health plans. Their rating system has one to four stars, with four stars being the top rating. Also, the National Committee for Quality Assurance (NCQA) has different levels of accreditation status for health plans. NCQA awards its highest accreditation status of Excellent to health plans that meet or exceed rigorous requirements for quality improvement.

To review the benefit plan options that are available, you can search plans on CoveredCA.com using their “Preview Plans” tool. This tool allows you to preview plans and prices from multiple insurance companies and tells you whether you may qualify for government subsidies to help pay for health insurance. Or, you can shop the specific plans offered by a particular insurance company using its website. Either way, you can do it on your own, or get help from a licensed insurance broker.

Although insurance companies differ in quality ratings, those who participate in Covered California offer the exact same benefit designs arranged in four categories or metal tiers (Bronze, Silver, Gold and Platinum). Platinum plans have the highest monthly premiums, but the lowest costs when accessing care. Bronze plans have the lowest monthly premiums, and the highest costs when accessing care. Gold and Silver plans strike a balance between the two. For example, if you are healthy and only visit the doctor once a year, you may benefit from a Silver or Bronze plan that carries a lower monthly premium but higher out-of-pocket costs when accessing care. If you see your doctor more frequently, then you may consider a Platinum or Gold plan.

Lastly, make sure your doctor or specialist (if you have one) participates in the provider network of the health plan that you select. 

For those who are already insured and happy with their current plan, what - if anything - do they need to do during open enrollment, especially if they get insurance through their employer? 

Even if you are insured and happy, it’s always a good idea to review your health coverage options each year. Health insurance benefits will sometimes change from one year to the next. 

What about those who get insurance through the healthcare marketplace? What should they do during open enrollment to make sure their coverage continues? 

Insurance companies with Covered California will send renewal notices highlighting benefit and rate changes for the coming year. If you want to make changes to your plan or switch insurance companies, you’ll need to do so by December 15 for a January 1 effective date. Because rates and plans tend to change annually, you will want to review which options are best for you and your family. If you purchased coverage through Covered California, it’s important to update any income changes that may affect subsidies for health insurance as this could impact your taxes. In the meantime, keep paying your monthly bill to make sure your current coverage continues. 

Please note if you have employer-sponsored coverage, you would not be eligible for a premium subsidy through Covered CA. 

What is the Performance Network?

Performance is one of Sharp Health Plan’s Plan Networks. The Performance network includes Sharp Community Medical Group (SCMG), Sharp Rees-Stealy Medical Group, Rady Children’s Health Network/CPMG, SCMG Graybill North Coastal, SCMG Inland North Medical Group, and SCMG Palomar Health Medical Group. You will find the name of your Plan Network on your Member ID card.

What is the Premier Network?

Premier is one of Sharp Health Plan’s Plan Networks. The Premier network includes Sharp Community Medical Group and Sharp Rees-Stealy Medical Group. You will find the name of your Plan Network on your member ID card.

Does Sharp Health Plan offer paperless options?

Increasing customers’ paperless options is a priority for Sharp Health Plan, and we are taking steps to offer more paperless options where we can.

If you’re a Sharp Direct Advantage^® Medicare member, you can now receive a paperless pharmacy Explanation of Benefits. You can also use a Sharp Direct Advantage payment book, which eliminates the need for monthly premium billing statements.

Will Sharp Health Plan go paperless in the future?

We’re required to mail certain types of information to our members. While we do not currently provide paperless options for premium bills or member alerts, we’re reviewing other possibilities to reduce our paper use.

Am I covered for physical therapy, speech therapy or occupational therapy?

All Sharp Health Plan Members are covered for outpatient and inpatient rehabilitation services, including occupational, physical and speech therapy. Services must be medically necessary and will be reviewed periodically to determine if continued therapy is needed.

Do I need a referral and copay?

Ask your primary care physician about referral to an appropriate specialist for therapy services. The Member’s share of cost for therapy services could be deductible, copay and/or coinsurance for each therapy visit. The copayment amount is listed on the benefits summary available by logging in to Sharp Connect or by calling Customer Care at 1-800-359-2002, or emailing customer.service@sharp.com.

Information for POS plan Members

Ask your primary care physician about referral to an appropriate specialist for therapy services at the Tier 1 — HMO Benefit Level. You may also obtain care from any licensed provider not affiliated with the Plan Medical Group you selected. Your costs will be higher and you will usually pay a deductible and coinsurance when using Tier 2 - Aetna/or Out-of-Network benefits.

What is price transparency?

Price transparency helps patients better understand the costs of the health care services they receive.

What is the Transparency in Coverage rule? 

The Transparency in Coverage rule is a federal price transparency rule that requires health plans to share health care costs with members and the general public. There are two main phases of the rule.

The first phase went live July 1, 2022, and it requires health plans to publish machine-readable files on their websites. Our machine-readable files are published here in JSON format as required by the rule. JSON files are intended for researchers and application developers — not the general public — and are not easily accessible without special software.

The second phase will go live Jan. 1, 2023. For this phase, we're developing a self-service price tool on your Sharp Health Plan online account. It will allow members to look up specified services, then get an out-of-pocket estimate based on their provider and benefit plan. We’ll share details as we get closer to launching the new tool.

What other resources can Sharp Health Plan members use to check their cost for covered benefits?

Members can log in to their online account today to access their coverage documents, including a summary of benefits matrix that lists the cost shares of their benefit plan. Members who get care at Sharp HealthCare can also request price estimates for shoppable services from certain Sharp providers. For estimates from other hospitals and health care providers, members should contact the hospital or provider directly.

What is a primary care physician (PCP)?

A primary care physician (PCP) is your personal doctor who is familiar with your health history and who provides or arranges for quality health care for you. If a specialist is needed, your PCP refers you and keeps in contact with your specialist to ensure continuity of care. Doctors who specialize in family practice, internal medicine, general practice and pediatrics are considered PCPs. Your PCP is listed on your member ID card.

How do I choose a primary care physician (PCP)?

We encourage you to select a primary care physician (PCP) who best suits your needs. However, if you are unable to select a PCP at the time you enroll in Sharp Health Plan, we will select one for you so you can access care immediately. For the most up-to-date information on available PCPs, call Customer Care at 1-800-359-2002.

Can I choose a different primary care physician (PCP) for different Members of my family?

Yes, each covered family Member may choose a different primary care physician (PCP) from a different Plan Medical Group. All family Members must stay in the same Plan Network.

Can I change my primary care physician (PCP)?

Yes, in general it is a good idea to stay with a primary care physician (PCP) so he or she can get to know your health needs and history. However, with Sharp Health Plan, you may change to a different PCP in your Plan Network whenever you like. If you wish to make a change, you can log in to your Sharp Health Plan online account, or you can call Customer Care at 1-800-359-2002 and we will help you select a new PCP. The change will be effective on the first day of the following month.

How does Sharp Health Plan protect my privacy?

We understand the importance of keeping your personal information confidential and work to ensure that all privacy regulations are followed. The Health Insurance Portability and Accountability Act’s (HIPAA) privacy regulations govern the use and release of a Member’s personal health information, also known as protected health information (PHI).

Under the HIPAA privacy regulations, Members must be informed about how their PHI will be used and given the opportunity to object to or restrict the use or release of their information. You can find a copy of Sharp Health Plan’s Notice of Privacy Practices here and in the Member Handbook.

What is Sharp Health Plan’s service area?

Sharp Health Plan is San Diego’s only nonprofit, locally based commercial health plan. We serve employers and individuals based in San Diego and southern Riverside Counties. Use our helpful tool to check if your ZIP code is included in Sharp Health Plan’s service area.

Sharp Health Plan connects members to thousands of physicians and 13 local hospitals through four networks: Choice, Value, Performance and Premier. Learn more about our networks and their coverage area.

Search for a doctor to determine if a specific physician is part of Sharp Health Plan’s provider network.

What is special enrollment?

Every year, Covered California provides eligible consumers the opportunity to sign up for health care coverage outside of the traditional open enrollment period if they experience a qualifying life event. These can include events like losing your health insurance, moving, getting married or having a baby. In most cases, you have 60 days from the date of your qualifying event to complete an application (including required documents) and enroll in a health plan. Please visit the special enrollment section of our website to learn more.

What is a qualifying event?

A qualifying event can apply to only you, or to your entire family. Common qualifying events include:

• Loss of coverage (you lost your employer-sponsored coverage or exhausted your COBRA benefits)
• Move to San Diego
• Birth or adoption of a child
• Just married

When will my coverage start?

Your coverage starts on your effective date. This date will depend on the kind of qualifying event you have. For most qualifying events, your coverage will start on the 1st of the month after you submit your completed application. For other qualifying events, like a permanent move to San Diego, your application must be completed by the 15th of the month for your start date to be the 1st of the following month.

To find out which effective date applies to your situation, a complete list can be found here.

When will coverage start for the birth or adoption of a child?

For the birth or adoption of a child, your start date can be: (1) your child’s date of birth or adoption date, OR (2) the 1st of the following month.

Example: Your family experiences the birth of a child. Either your child or your entire family could apply for health coverage outside of open enrollment because a birth counts as a qualifying event for special enrollment. The newborn child’s effective date would be their date of birth. If the child’s parents want to make a change to their plan, their effective date would be the first of the following month.

How do I apply?

1. Fill out Sharp Health Plan’s special enrollment application within 60 days of your qualifying life event. Start your online application by getting a quote.


2. Make sure your application is complete. Check that you have all required documents ready to submit, including:
   • Your application filled out entirely, signed and dated
   • Acceptable proof of your residency or work in Sharp Health Plan’s service area
   • At least one form of documentation to support your qualifying event – additional documents may be required
   • First month’s premium payment


3. Please submit your complete application an required documents by mail, in person or by fax.
• By mail or in person:
  Sharp Health Plan
  Attention: IFP Sales
  8520 Tech Way, Suite 200
  San Diego, CA 92123


• By fax:
  Attention: IFP Sales
  1-858-499-8246

Do I qualify for financial assistance?

To find out if you qualify for financial assistance, use Covered California's Shop and Compare tool. Eligibility for lower monthly premiums is determined by your income and household size.

If you qualify, you can apply for coverage on the Covered California website.

How can I get help applying through Covered California?

You can apply online on the Covered California website, find a certified agent in your area, or contact the Sharp Health Plan Sales Team.

What is the difference between Covered California and Medi-Cal?

Covered California is the state marketplace for health insurance where individuals and families can shop for plans and receive financial assistance, if eligible.

Medi-Cal is a program that offers free or low-cost health insurance to individuals with low income, and accepts applications year-round. To learn more about Medi-Cal and how to apply, you can find additional information here.

What is a specialist?

A specialist is a doctor who focuses on one area of medicine. A specialist is trained as an expert in his or her particular field, such as cardiology, neurology or urology. When you need specialty care, your primary care physician (PCP) will refer you to a specialist to ensure that you receive proper medical attention and follow-up. Your PCP will refer you to a specialist in your Plan Medical Group (PMG). In most cases, each PMG includes a different set of PCPs, specialists, urgent care centers and other providers.

Does my primary care physician (PCP) make the decision about which specialist I see, or am I able to make that decision?

Your primary care physician (PCP) will make recommendations for you to consider. Together, you and your doctor will determine the most appropriate specialist for your particular needs. In some cases, you may be able to see a specialist directly without a referral from your PCP. Women can see participating obstetricians and gynecologists within their Plan Medical Group for obstetric and/or gynecological services. In addition, Members who choose Sharp Rees-Stealy for their PMG have direct access to specialists in allergy treatment, ophthalmology, otolaryngology (ear, nose and throat) and podiatry. Check the Plan Medical Group on your member ID card to see if you are assigned to Sharp Rees-Stealy. If you have any questions about how to see a specialist, call Customer Care at 1-800-359-2002.

How do I transfer my medical records? 

Because Sharp Health Plan is not a medical provider, we do not store or send copies of the medical records of our members. If you are new to Sharp Health Plan, please contact your former PCP to find out how to request and forward a copy of your medical records to your new Sharp Health Plan PCP. Your Sharp Health Plan assigned PCP’s name and telephone number are shown on your member identification (ID) card. Your PCP will provide you with the Medical Records Release form that you will need to fill out to complete the request. This form does not come from Sharp Health Plan. To get information about how to request records from Sharp facilities & providers visit Sharp.com.

How can I get vision care?

Log in to your Sharp Health Plan online account or contact us to find out if your benefit plan includes coverage for vision services.

If you currently have vision coverage

If your benefit plan includes vision services, create an account (or log in) at vsp.com/eye-doctor to find an in-network eye doctor. Then, call your Vision Service Plan (VSP) doctor and make an appointment, letting the doctor know that you are a VSP member. You will also need to provide your ID, date of birth and the covered Member’s identification number. (The covered Member is the eligible employee or family leader who signed up for your insurance coverage; it will be either you, your spouse/domestic partner or your parent.) Once you make your appointment, your doctor and VSP will handle the rest.

Getting services from a non-VSP provider

In some cases, you may also select to receive services from a non-VSP provider and VSP will reimburse you for part of the cost. Any service you get from a non-VSP provider is subject to the same copayments and limitations as services obtained through VSP doctors. Be aware that your out-of-network provider reimbursement rate does not guarantee full payment, and VSP cannot guarantee patient satisfaction when services are received from a non-VSP provider. You may be required to pay the entire bill when you see the non-VSP provider. Call VSP Member Services at 1-800-877-7195 to find out if your coverage includes non-VSP providers.

Are the Sharp Health Plan wellness programs covered under my plan?

As a Member, you get comprehensive online resources for wellness, including a wellness assessment, personal report, multi-week wellness programs on various health topics, customized exercise and meal plans, food logs, health trackers and much more. Additionally, Members can get health coaching program and can work one-on-one with a coach to reach personal health goals. See the Health & Wellness center for more information.

Are my dependents eligible for the wellness programs?

Yes, your enrolled dependents are eligible for the Sharp Health Plan wellness programs.

How can I get information about alternative health care programs?

The alternative health care programs from Sharp Health Plan offer you discounts of up to 25% off usual provider rates on services from an extensive, credentialed network of chiropractors, acupuncturists, massage therapists and dietitians. You may visit any of these providers directly without a physician referral.

You can also get discounts of 15-40% off suggested retail prices on more than 2,400 health and wellness products, including vitamins, minerals, herbal supplements, homeopathic remedies, sports nutrition products, books, CDs, DVDs, fitness products and skin care items.

Find out more about these services or call 1-877-335-2746.

Does Sharp Health Plan provide any wellness programs?

As a member, you get comprehensive resources through our nationally accredited Best Health^® wellness program. You can take a Wellness Assessment, get a wellness score and report, enjoy multi-week wellness programs on various health topics, and much more. You can even take advantage of our health coaching program and work one-on-one with a coach to reach your personal health goals. Visit the Prevention and Wellness Center for more information.

What kind of women’s health services do you cover?

From well woman exams to breast cancer screenings and pregnancy care to one-on-one health coaching, Sharp Health Plan connects you to the best women’s health services. Your specific coverage depends on your benefit plan; log in to your Sharp Health Plan online account to see your coverage details.

Learn more about our women’s health services.

Am I covered for infertility services?

Depending on your plan, you might have coverage for the diagnosis and treatment of infertility and/or coverage for Assisted Reproductive Technologies (ART). These services may include artificial insemination, IVF or GIFT, and are determined based on your specific benefit plan.

If your benefit plan includes coverage for infertility services, ask your primary care physician about a referral to an appropriate specialist for infertility diagnosis and treatment. Members pay a copayment equal to 50% of the contracted rate for all infertility and artificial reproductive technology services.

Where can I find out about my plan’s infertility care coverage details?

How to find out if you have infertility service coverage

Check your Member handbook and summary of benefits to determine if your benefit plan includes coverage for infertility diagnosis and treatment. Log in to your online account or contact us to find out if your benefit plan includes coverage for infertility treatment or reproductive technologies.

Information for POS plan Members
Infertility services (the diagnosis and treatment of the underlying condition) are only covered on the Tier 1: HMO Benefit Level and not on the Tier 2: Aetna/or Out-of-Network Level.

Are breast pumps a covered benefit?

Most Members are covered for a breast pump with no copayment, if requested within 365 days after delivery. (Breast pumps are not covered prior to delivery.) Your OB/Gyn can provide you with a referral for a breast pump. Call us at 1-800-359-2002 or email customer.service@sharp.com for information on how to order a breast pump. Breast pumps are not covered if purchased from a non-contracted supplier.

Learn more about pregnancy care.

Which providers and hospitals are available through Sharp Health Plan?

Sharp Health Plan connects your employees to thousands of physicians and 13 local hospitals throughout San Diego County. Access will vary depending on the network you choose. Compare networks for more details.

You can search our directory to determine if a specific physician is part of Sharp Health Plan’s provider network.

Which wellness programs are available to Sharp Health Plan Members?

Sharp Health Plan Members have direct access to a variety of wellness programs, including online self-management tools, trackers, workshops and telephone-based health coaching.

Visit the health and wellness section for more information.

Does Sharp Health Plan provide administrative support to manage my health plan benefits?

Your Sharp Health Plan representative is available to address any questions you have about the plan. In addition, Sharp Health Plan issues a Group Administration Manual upon your group’s enrollment.

The manual includes information about:

• Enrollment cancellation procedures
• Membership changes
• Coordination of benefits
• Continuation of coverage
• Billing procedures
• Terms and definitions

Does Sharp Health Plan send detailed benefits information to my employees?

Sharp Health Plan provides a Member ID card and welcome letter with information on where to find a Member’s summary of benefits and Member Handbook online. 

How do I order new employee packets and additional forms?

You may contact your Sharp Health Plan representative to order additional employee packets. Call us at 1-858-499-8300 for assistance. 

How do I enroll or remove an employee from our plan?

Log in to your Sharp Health Plan online account to complete enrollment and disenrollment online.

For paper enrollment, the new employee will need to complete the enrollment application once he or she has fulfilled your group’s waiting period. This form must be received by Sharp Health Plan within 30 days of the eligibility date.

To disenroll an employee on paper, you must complete the appropriate section of the complete the appropriate section of the enrollment application or by contacting your Sharp Health Plan representative. The application must be received by Sharp Health Plan by the end of the month in which coverage is to end. 

What is the Consolidated Appropriations Act, Section 204: Pharmacy Reporting (RxDC Report)?

Under Section 204 of the Consolidated Appropriations Act, insurance companies and employer-based health plans must submit information regarding prescription drug benefits and health care spending to the Centers for Medicare & Medicaid Services by June 1 of each year for the prior year’s coverage. This report is also known as the RxDC Report. In 2024, insurance companies and employer groups are required to report data on the average monthly premium paid by employers and their employees who were enrolled in benefits in 2023. This information is reported on the D1 Template of the RxDC Report filing.

Where should employer groups report the premium data required for the D1 Template to Sharp Health Plan?

Sharp Health Plan’s 2023 RxDC filing was completed on May 24, 2024. We are no longer accepting RxDC information from employers.

Where can we find general information on the RxDC reporting requirements?

For more information, please review this information from CMS:

• CMS RxDC Reporting Instruction Manual 
• CMS RxDC Reporting Information Page

I entered incorrect information when I submitted the RxDC Employer Reporting Intake Form. What should I do?

If you need to make updates to your submission, please contact your dedicated account manager. You cannot complete this form again.

Who should the employer contact for any questions about the premium report?

Please contact your account manager with any questions.

Who can I contact with questions?

You may contact your Sharp Health Plan representative to ask questions about the administration of your health plan. Call us at 1-858-499-8300 for assistance or send us a message.

Who can my employees contact with questions?

Members can contact Customer Care at 1-858-499-8300 or toll-free at 1-800-359-2002, or email customer.service@sharp.com. Customer Care representatives are available from 8 a.m. - 6 p.m., Monday through Friday.

Who can I contact regarding billing questions?

Log in to your Sharp Health Plan online account to view your most recent billing activity online. If you have any questions about your premium bill, you can contact your Sharp Health Plan representative at 1-858-499-8229 for assistance or send us a message

What do my employees need to know about the enhancements to your main Customer Care lines?

We have updated the interactive voice response (IVR) system on our main Customer Care lines at 1‑858‑499‑8300 and 1‑800‑359‑2002. These enhancements will increase access to self-service tools over the phone, and help decrease call wait times. Here’s what will be changing:

• Member authentication: When calling Customer Care, members will be asked to enter their Sharp Health Plan member identification number and date of birth. This will allow us to authenticate the member, and connect them with the right Customer Care agent, faster. Your employees can access their member identification number on the front of their member ID card. If a member doesn’t have their ID card, or cannot locate their ID number, they will still have the option to be connected with a Customer Care representative for assistance.
• Greater self-service functionality: After authenticating, members will have access to additional self-service information over the phone. They will be able to verify their eligibility, check their primary care physician (PCP), specialist, urgent care and hospital copays, and individual deductibles. As a reminder, access to this self-service information, and more, is also available online through their Sharp Health Plan online account.

What changes does health care reform require for dependent coverage?

If you provide coverage for dependent children, you must offer coverage to dependents up to 26 years of age, regardless of marital or student status.

Does the change in dependent coverage apply to all benefit plans, including grandfathered plans?

Yes, all benefit plans that provide coverage to dependent children must offer coverage up to age 26, regardless of grandfathered or non-grandfathered status.

Which of my employee’s dependents can enroll in Sharp Health Plan?

An employee’s child (naturally born or adopted), stepchild or children for whom the employee is the legal guardian may enroll in Sharp Health Plan.

Does an employee’s dependent have to live with them in order to enroll in Sharp Health Plan?

No, an employee’s dependent does not have to live with them to enroll in Sharp Health Plan, but he/she must live within Sharp Health Plan’s service area (San Diego and southern Riverside Counties).

Can an employee’s child’s spouse and children enroll in Sharp Health Plan?

No, the employee’s spouse and children are not eligible to enroll in Sharp Health Plan under the employee's policy; however, the spouse and children may enroll in their own individual/family plan through Sharp Health Plan.

What is a grandfathered health plan?

A grandfathered health plan maintains the same health coverage that was in effect when the health care reform law was enacted on March 23, 2010. A grandfathered health plan is exempt from the following changes otherwise required by health care reform:

• Coverage of preventive health services with no copayments. Sharp Health Plan already covers preventive health services, but our grandfathered benefit plans include some level of copayments for those services. Eliminating the copayments may increase premiums.
• Other requirements went into effect in 2014. These include restrictions on premium differences based on age and required coverage of all “essential health benefits” with specified cost sharing. These requirements may have resulted in increased premiums for benefit plans that did not maintain their grandfathered status.

What kinds of changes would cause my benefit plan to lose its grandfathered status?

Changes that can cause an employer’s benefit plan to lose its grandfathered status include, but are not limited to:

• At renewal, selecting a benefit plan other than the one that was in effect on March 23, 2010.
• A decrease of more than 5% in the percentage of premiums paid by the employer.

How do I keep my grandfathered benefit plan?

You may keep your grandfathered benefit plan by renewing with the same benefit plan you had in place on March 23, 2010. You may change your provider network from Blue Choice to Gold Value and still maintain your grandfathered status.

Will my grandfathered health plan always have a lower premium than a non-grandfathered benefit plan?

Not necessarily, although grandfathered benefit plans are exempt from certain requirements under the law, you may choose a non-grandfathered benefit plan during your renewal that has a lower premium due to other benefit changes.

Are there any health care reform requirements that apply to all benefit plans, including grandfathered plans?

Yes, all benefit plans, whether grandfathered or not, must provide the following benefits to their customers for plan years starting on or after September 23, 2010:

• No lifetime limits on the dollar value of “essential health benefits.” All Sharp Health Plan HMO plans already provide this benefit.
• No coverage exclusions for children with pre-existing conditions. Sharp Health Plan HMO plans do not include any pre-existing condition clauses for children or adults.
• No annual limits on the dollar value of “essential health benefits.” Sharp Health Plan HMO plans do not have any dollar annual limits on “essential health benefits.”

What are “essential health benefits”?

The health care reform law lists the following categories as “essential health benefits”:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorders
• Behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including dental and vision care

My employees received their member ID cards in the mail, but other covered family members’ cards were missing. What should they do?

If your employee’s plan includes three or more covered family members, those cards will be mailed separately.

What should my employees do if the name on their member ID card is incorrect?

If your employees or their dependents receive a member ID card with the incorrect personal information on it (like their name), they can request a replacement online by logging into their Sharp Health Plan online account. From within the portal, they will be able to review their personal information, update their information if necessary, and request a new member ID card.

What should my employees do if the primary care physician listed on their member ID card is incorrect?

If your employees receive a member ID card with the wrong primary care physician (PCP) listed on the front, please have them log in to their online account to verify the PCP that we have on record for them. Please note that all Sharp Rees-Stealy members’ ID cards will not list their PCP’s name, only the location of the Sharp Rees-Stealy Medical Center where they see patients. We know choosing the right PCP is a personal decision, which is why we make it easy for your employees to change their selection at any time. They can visit sharphealthplan.com/findadoctor to find a list of doctors. Once they’ve made their selection, they can update their PCP through their online account. Please note that PCP changes will be effective the first of the following month. Upon making their selection, we will mail them a new member ID card.

What should my employees do if their primary care physician isn’t listed on their member ID card at all?

If your employee is a Sharp Rees-Stealy member, by default the name of their primary care physician (PCP) will not display on the front of their member ID card, only Sharp Rees-Stealy and the phone number for their designated location.

What should my employees do if their new member ID card shows the wrong effective date?

The effective date on the ID card will not affect your employees’ ability to access care or fill prescriptions. The effective date listed on the ID card is based on contract updates in the Sharp Health Plan system. If a member enrolled with Sharp Health Plan before 1/1/16, their ID card will list that effective date. If they enrolled after 1/1/16, they will have a later effective date.

What should employees do if they lose their ID card?

If a member loses their ID card, they can print a temporary card through their online account by visiting sharphealthplan.com/login.

What do the member ID cards look like?

The member ID cards offer high durability, and easy access to member cost share and contact information. To see samples of what ID cards look like, view or print this downloadable PDF.

What is the Premier Network?

The Premier network in the Covered California marketplace is a high-performing, select network. Although narrower in size than other Sharp Health Plan networks, Premier's quality of care is comprehensive. It's also the most affordable of our four provider networks. This network features more than 1,200 doctors, 10 hospitals and two medical groups, including:

• Sharp Rees-Stealy Medical Group (SRS)
• Sharp Community Medical Group (SCMG)

The Premier network is a great option for Members who live in central San Diego County. If you are a Member of this network, you will find the Premier listed on your member ID card.

What is the Performance Network?

The Performance network in the Covered California marketplace is our largest network for individual and family plans. It's an affordable network that covers all of San Diego County. Performance features more than 1,700 doctors, 13 hospitals and six medical groups, including:

• Sharp Rees-Stealy Medical Group (SRS)
• Sharp Community Medical Group (SCMG)
• SCMG Palomar Health Medical Group
• SCMG Graybill North Coastal
• SCMG Inland North Medical Group
• Rady Children’s Health Network/CPMG

The Performance network is a great option for Members who live anywhere in San Diego County. If you are a member of this network, you will find Performance listed on your member ID card.

What is the Value Network?

The Value network is a large network of medical professionals devoted to giving its members the best possible care and value. This network features a large selection of specialty doctors, medical groups and hospitals in San Diego County. The network has more than 1,900 doctors, 13 hospitals and eight medical groups, including:

• Sharp Rees-Stealy Medical Group (SRS)
• Sharp Community Medical Group (SCMG)
• SCMG Palomar Health Medical Group
• SCMG Graybill North Coastal
• SCMG Palomar Health Medical Group Temecula
• SCMG Inland North Medical Group
• Rady Children’s Health Network/CPMG
• Greater Tri-Cities IPA
• Optum Care-North County SD (formerly Primary Care Associates Medical Group)

This network is available with certain employer-sponsored benefit plans. If you are a Member of this network, you will find Value listed on your member ID card.

What is the Choice Network?

The Choice network is the largest network of Sharp Health Plan’s four provider networks. members can choose from a wide range of quality doctors and conveniently located facilities. The Choice network features more than 2,400 doctors, 13 hospitals and nine medical groups, including:

• Sharp Rees-Stealy Medical Group (SRS)
• Sharp Community Medical Group (SCMG)
• SCMG Palomar Health Medical Group
• SCMG Graybill North Coastal
• SCMG Inland North Medical Group
• Rady Children’s Health Network/CPMG
• Greater Tri-Cities IPA
• Optum Care-North County SD (formerly Primary Care Associates Medical Group)
• Independent Providers Network

It also includes doctors who are contracted directly with Sharp Health Plan, as part of the Independent Plan Medical Group. This network is available with certain employer-sponsored benefit plans. If you are a member of this network, you will find Choice listed on your member ID card.

Am I eligible for the premium tax credit under health care reform?

If you are a small employer with fewer than 25 full-time equivalent employees that pays an average wage of less than $50,000 a year, and pays at least half of employee health insurance premiums, then you may qualify for the tax credit. Details are available on the IRS website.

How much is the premium tax credit?

Info about the tax credit can be found on the IRS website.

How do I claim the premium tax credit?

You must use IRS Form 8941, Credit for Small Employer Health Insurance Premiums, to calculate the premium tax credit. If you are a small business employer, you may be able to carry the credit backward or forward. And if you are a tax-exempt employer, you may be eligible for a refundable credit. Contact your tax professional for information regarding your specific circumstances.

What is the Transparency in Coverage rule?

The Transparency in Coverage rule requires health plans to share health care costs for members to make informed decisions on how they receive care. There are two main phases of the rule.

The first phase went live July 1, 2022, and it requires health plans to publish “machine-readable files” on their websites. Our machine-readable files are published here in JSON format as required by the rule. JSON files are intended for researchers and application developers — not the general public — and are not easily accessible without special software.

The second phase will go live Jan. 1, 2023. For this phase, we're developing a self-service price tool in their Sharp Health Plan online account. It will allow members to look up a service and provider, then get an out-of-pocket estimate based on their plan. We’ll share details as we get closer to launching the new tool.

Can employers access the machine-readable files?

Our machine-readable files are available here and are intended for researchers and application developers to use. If you are not a researcher or application developer, we do not recommend accessing the files. For the best experience, we recommend waiting until our self-service price tool is available in January 2023.

What other resources are available to Sharp Health Plan members to confirm their cost for covered benefits?

Members can log in to their online account today to access their coverage documents, including a summary of benefits matrix that lists the cost shares of their benefit plan. Members who get care at Sharp HealthCare can also request price estimates for shoppable services from certain Sharp providers.

Does the rule violate HIPAA or other security or privacy rules?

No. The rule did not modify existing state or federal requirements and does not require public disclosure of personal health information.

Does the rule apply to insurers and group health plans?

Yes. As defined in the regulation, “group health plan” includes insured and self-insured group health plans.

Are tribal plans included?

Yes. If a tribe’s health plan is organized under the Employee Retirement Income Security Act or the Public Health Service Act, then the tribe’s plan(s) would be subject to the Transparency in Coverage requirements.

Are any plans exempt from the rule?

Yes. The following plans are exempt from the Transparency in Coverage rule:

• Excepted benefits (e.g., standalone vision, dental or hearing plans)
• Flexible spending accounts (FSA), health reimbursement accounts (HRA), health savings accounts (HSA)
• Grandfathered plans
• Medi-Cal
• Medicare
• Retiree plans
• Short-term limited duration plans (STLD)

Is Pharmacy data included in the Transparency in Coverage rule?

The TiC rule originally included a provision requiring plans and issuers to publish machine-readable files for prescription drug pricing. However, HHS announced that they would defer enforcement of this requirement pending further rulemaking.

Plans and issuers are still required to comply with certain reporting requirements related to Pharmacy Benefits and Drug Costs, which were outlined in a separate piece of legislation, the Consolidated Appropriations Act (CAA). Sharp Health Plan is working with our Pharmacy Benefit Manager (CVS Caremark) to begin reporting all required information to the federal government by the December 27, 2022 deadline. Sharp Health Plan will submit the summary report and data for all fully insured groups.

Who can my customers contact with questions?

Your may contact your Sharp Health Plan representative with questions about the administration of their health plan.

Members may contact Customer Care at 1-800-359-2002, or email customer.service@sharp.com. Customer Care representatives are available 8 am - 6 pm, Monday to Friday.

Who should my employer clients contact with questions?

Employers with questions should contact their account management executive.

Who can I contact with questions?

Your Sharp Health Plan account representative can answer your questions or connect you to the right person. Call us at 1-858-499-8009 for assistance or send us a message.

What do my member clients need to know about the enhancements to your main Customer Care lines?

We have updated the interactive voice response (IVR) system on our main Customer Care lines at 1‑858‑499‑8300 and 1‑800‑359‑2002. These enhancements will increase access to self-service tools over the phone, and help decrease call wait times. Here’s what will be changing:

• Member authentication: When calling Customer Care, members will be asked to enter their Sharp Health Plan member identification number and date of birth. This will allow us to authenticate the member, and connect them with the right Customer Care agent, faster. Your member clients can access their member identification number on the front of their member ID card. If a member doesn’t have their ID card, or cannot locate their ID number, they will still have the option to be connected with a Customer Care representative for assistance.
• Greater self-service functionality: After authenticating, members will have access to additional self-service information over the phone. They will be able to verify their eligibility, check their primary care physician (PCP), specialist, urgent care and hospital copays, and individual deductibles. As a reminder, access to this self-service information, and more, is also available online through their Sharp Health Plan online account.

What is a grandfathered health plan?

A grandfathered health plan is a plan that has maintained the same health coverage in effect when the health care reform law was enacted on March 23, 2010. A grandfathered health plan is exempt from the following changes otherwise required by health care reform:

• Coverage of preventive health services with no copayments. Sharp Health Plan already covers preventive health services, but our grandfathered benefit plans include some level of copayments for those services. Eliminating the copayments may increase premiums.
• Other requirements became effective in 2014. These include restrictions on premium differences based on age and require coverage of all “essential health benefits” with specified cost sharing. These requirements may result in increased premiums for benefit plans that did not maintain their grandfathered status.

What kinds of changes would cause my benefit plan to lose its grandfathered status?

Changes that can cause an employer’s benefit plan to lose its grandfathered status include, but are not limited to:

• At renewal, selecting a benefit plan other than the one that was in effect on March 23, 2010.
• A decrease of more than 5% in the percentage of premiums paid by the employer.

How do I keep my grandfathered benefit plan?

You may keep your grandfathered benefit plan by renewing with the same benefit plan you had in place on March 23, 2010. You may change your provider network and still maintain your grandfathered status.

Will my grandfathered health plan always have a lower premium than a non-grandfathered benefit plan?

Not necessarily, although grandfathered benefit plans are exempt from certain requirements under the law, you may choose a non-grandfathered benefit plan during your renewal that has a lower premium due to other benefit changes.

Are there any health care reform requirements that apply to all benefit plans, including grandfathered plans?

Yes, all benefit plans, whether grandfathered or not, must provide the following benefits to their customers for plan years starting on or after September 23, 2010:

• No lifetime limits on the dollar value of “essential health benefits.” All Sharp Health Plan HMO plans already provide this benefit.
• No coverage exclusions for children with pre-existing conditions. Sharp Health Plan HMO plans do not include any pre-existing condition clauses for children or adults.
• No annual limits on the dollar value of “essential health benefits.” Sharp Health Plan HMO plans do not have any annual dollar limits on “essential health benefits.”

What does “essential health benefits” mean? Which benefits are included in “essential health benefits”?

Essential health benefits include the following categories of services: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorders including behavioral health treatment, prescription drugs, rehabilitative and rehabilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including dental and vision care.

My member clients received their member ID cards in the mail, but other covered family members’ cards were missing. What should they do?

If your member client’s plan includes three or more covered family members, those cards will be mailed separately.

What should my member clients do if the primary care physician listed on their member ID card is incorrect?

If your member clients receive a member ID card with the wrong primary care physician (PCP) listed on the front, please have them log in to their Sharp Health Plan online account to verify the PCP that we have on record for them. Please note that all Sharp Rees-Stealy members’ ID cards will not list their PCP’s name, only the location of the Sharp Rees-Stealy Medical Center where they see patients. We know choosing the right PCP is a personal decision, which is why we make it easy for your member clients to change their selection at any time. They can visit sharphealthplan.com/findadoctor to find a list of doctors. Once they’ve made their selection, they can update their PCP through their online account. Please note that PCP changes will be effective the first of the following month. Upon making their selection, we will mail them a new Member ID card.

What should my member clients do if the name on their member ID card is incorrect?

If your member clients receive a member ID card with the incorrect personal information on it (like their name, or their dependent’s name), they can request a replacement online by logging in to their online account. From within their online account, they will be able to review their personal information, update their information if necessary, and request a new member ID card.

What should my member clients do if their member ID card shows the wrong effective date?

The effective date on the ID card will not affect your member clients’ ability to access care or fill prescriptions. The effective date listed on the ID card is based on contract updates in the Sharp Health Plan system. If a member enrolled with Sharp Health Plan before 1/1/16, their ID card will list that effective date. If they enrolled after 1/1/16, they will have a later effective date. 

What should my member clients do if their primary care physician isn’t listed on their member ID card at all?

If your member clients are Sharp Rees-Stealy members, by default the name of their primary care physician (PCP) will not display on the front of their member ID card, only Sharp Rees-Stealy and the phone number for their designated location. 

What should my member clients do if they lose their ID card?

If a member loses their ID card, they can print a temporary card through their online account by visiting sharphealthplan.com/login.

What do the member ID cards look like?

The member ID cards offer high durability, and easy access to member cost share and contact information. To see samples of what the ID cards look like, view or print this downloadable PDF.

How can I start selling with Sharp Health Plan?

To sell Sharp Health Plan, you are only required to maintain appropriate state licensing credentials. Please contact your Sharp Health Plan representative to review a group quote at 1-858-499-8009.

How do I get a group quote?

Sharp Health Plan has teamed up with Health Connect to offer small group quotes for employers. You may also contact your Sharp Health Plan representative to get group quotes at 1-858-499-8009.

How do I order marketing materials?

Marketing materials are available through our online Materials Request Form or by contacting your Sharp Health Plan representative. 

Can brokers set up direct deposit for commission payments?

We are exploring direct deposit as a payment option. Stay tuned for future updates.

What is Sharp Health Plan’s service area?

Sharp Health Plan is San Diego’s only locally based commercial health plan. We serve employers based in San Diego and southern Riverside Counties. Use our helpful tool to search for covered ZIP codes included in Sharp Health Plan’s service area.

Which providers and hospitals are available through Sharp Health Plan?

Sharp Health Plan connects Members to thousands of physicians and 13 local hospitals through four networks: Choice, Value, Performance and Premier. Search for a doctor to determine if a specific physician is part of Sharp Health Plan’s provider network.

Learn more about our group plan networks and their coverage area.

Which health plan products are available through Sharp Health Plan?

Sharp Health Plan provides a wide variety of HMO options, POS and HDHP-HSA plans, supplemental riders and value-added enhancements to meet your customers’ health plan needs.

Check out all of our group plan options.

Which wellness programs are available to Sharp Health Plan Members?

Best Health is our comprehensive wellness program, which provides our Members with a variety of resources from meal plans and exercising routines to one-on-one personalized health coaching.

What is the Transparency in Coverage rule?

The Transparency in Coverage rule requires health plans to share health care costs for members to make informed decisions on how they receive care. There are two main phases of the rule.

The first phase went live July 1, 2022, and it requires health plans to publish “machine-readable files” on their websites. Our machine-readable files are published here in JSON format as required by the rule. JSON files are intended for researchers and application developers — not the general public — and are not easily accessible without special software.

The second phase will go live Jan. 1, 2023. For this phase, we're developing a self-service price tool in their Sharp Health Plan online account. It will allow members to look up a service and provider, then get an out-of-pocket estimate based on their plan. We’ll share details as we get closer to launching the new tool.

Can brokers access the machine-readable files?

Our machine-readable files are available here and are intended for researchers and application developers to use. If you are not a researcher or application developer, we do not recommend accessing the files. For the best experience, we recommend waiting until our self-service price tool is available in January 2023.

What other resources are available to Sharp Health Plan members to confirm their cost for covered benefits?

Members can log in to their online account today to access their coverage documents, including a summary of benefits matrix that lists the cost shares of their benefit plan. Members who get care at Sharp HealthCare can also request price estimates for shoppable services from certain Sharp providers.

Does the rule violate HIPAA or other security or privacy rules?

No. The rule did not modify existing state or federal requirements and does not require public disclosure of personal health information.

Does the rule apply to insurers and group health plans?

Yes. As defined in the regulation, “group health plan” includes insured and self-insured group health plans.

Are tribal plans included?

Yes. If a tribe’s health plan is organized under the Employee Retirement Income Security Act or the Public Health Service Act, then the tribe’s plan(s) would be subject to the Transparency in Coverage requirements.

Are any plans exempt from the rule?

Yes. The following plans are exempt from the Transparency in Coverage rule:

• Excepted benefits (e.g., standalone vision, dental or hearing plans)
• Flexible spending accounts (FSA), health reimbursement accounts (HRA), health savings accounts (HSA)
• Grandfathered plans
• Medi-Cal
• Medicare
• Retiree plans
• Short-term limited duration plans (STLD)

Is Pharmacy data included in the Transparency in Coverage rule?

The TiC rule originally included a provision requiring plans and issuers to publish machine-readable files for prescription drug pricing. However, HHS announced that they would defer enforcement of this requirement pending further rulemaking.

Plans and issuers are still required to comply with certain reporting requirements related to Pharmacy Benefits and Drug Costs, which were outlined in a separate piece of legislation, the Consolidated Appropriations Act (CAA). Sharp Health Plan is working with our Pharmacy Benefit Manager (CVS Caremark) to begin reporting all required information to the federal government by the December 27, 2022 deadline. Sharp Health Plan will submit the summary report and data for all fully insured groups.

What is a Heath Maintenance Organization (HMO)?

An HMO is a plan that provides covered benefits for a fixed monthly fee, through defined networks of physician groups called Plan Medical Groups (PMGs) from which Members choose a primary care physician (PCP) and receive specialty physician care or access to hospitals and other facilities. In some instances, Members may select a PCP contracted directly with Sharp Health Plan. The PMG listed on the Member’s card for these PCPs will be “Independent.” HMO Members must obtain covered benefits through their PCP and providers affiliated with the PCP’s PMG. The PCP is responsible for coordinating and directing necessary care to the appropriate plan providers.

What is a Preferred Provider Organization (PPO)?

A PPO is a plan that has contracts with a network of preferred providers from which Members can choose. Members do not select a PCP and do not need referrals to see other plan providers in the network.

What is a Point of Service (POS)?

A POS plan is a combination between an HMO and a PPO. This plan is known as a POS plan because Members have an option between the HMO and the PPO each time they access services; the type of service is based on the point of service.

Under a POS plan, Members select a PCP responsible to manage and coordinate their care within network. POS plans allow Members the flexibility to self-direct, without an authorization or referral, to a licensed health care provider who may or may not be in the PCP’s PMG.

• Tier 1 is an HMO level of care. Members select any PCP within the network. The PCP is responsible to coordinate the care within the assigned PMG. Care that is rendered by providers affiliated with the PCP’s PMG (or that is authorized by the PMG) is covered at the HMO level of care.
• Tier 2 is a PPO level of care. Members may direct their own care and access covered services from any licensed health care professional or facility without a referral or authorization. Members are responsible to ensure provider(s) obtain required pre-certification prior to receiving services to minimize out-of-pocket costs.

What is a High Deductible Health Plan (HDHP)?

An HDHP is a health insurance plan with lower premiums and higher Deductibles than a traditional health plan. Some HDHP plans also offer additional wellness benefits or health activities provided before a Deductible is applied.

What is a Health Savings Account (HSA) – Compatible Health Plan?

An HSA is a tax-advantaged medical savings account available for Members enrolled in a qualified HDHP. Funds contributed to the HSA are not subject to federal income tax at the time of deposit or when used to pay for qualified medical expenses. Funds may roll over and accumulate year to year if not spent. An HDHP that is qualified (meets certain Internal Revenue Service criteria) can be paired with an HSA to give Members the ability to take advantage of these tax savings.

How can I become a contracted provider with Sharp Health Plan?

Physicians interested in participating in our network may contract with Sharp Health Plan independently or through a contracted medical group. Sharp Health Plan requires a physician to go through a credentialing process before becoming a contracted provider. If you are interested in becoming a contracted network provider or need more information, please contact our provider relations team via email at provider.relations@sharp.com or by phone at 1-858-499-8330.

What is credentialing?

Credentialing is a systematic approach to the collection and verification of a practitioner applicant’s professional qualifications. It considers factors such as relevant training, licensure and certification and/or registration to practice in a health care field. Credentialing requires that a physician:

• Be board certified or have satisfactorily completed a residency in his or her practice specialty.
• Have a current California medical license.
• Have a current, unrestricted Drug Enforcement Agency (DEA) registration number (as applicable).
• Have admitting privileges at a Sharp Health Plan contracted hospital affiliated with his or her physician’s medical group. Exceptions may be made for certain types of physicians who do not normally obtain admitting privileges or if the physician has arrangements with another Sharp Health Plan credentialed physician to admit on his or her behalf.
• Be free of any Medical Board of California restrictions.
• Provide 24-hour-a-day coverage for all Plan Members with another participating physician or with another on-call physician who agrees to abide by the guidelines of the Plan.
• Have professional liability insurance in the minimum amount of $1 million per occurrence and $3 million annual aggregate.

The credentialing process also includes primary source verification of all information on the application, a practice site and medical record-keeping evaluation, and approval by Sharp Health Plan's Peer Review Committee. Credentialing may be performed directly by Sharp HealthCare’s Centralized Credentialing Department or by the contracted medical group.

How do I refer patients for behavioral health services?

Your patients do not need a referral for outpatient behavioral health services. Patients can choose a behavioral health provider from our online provider directory for Medicare members and Individual/Family and Commercial Employer Group members. If they need assistance finding a provider, they can contact Customer Care at 1-844-483-9013. Please note that certain behavioral health and chemical dependency services for patients will require prior authorization.

How do I receive authorization for behavioral health or chemical dependency services for patients?

Please visit MagellanProvider.com/SharpHP to request authorization. Our behavioral health guide lists the behavioral health and chemical dependency services that require authorization. Services that are not listed do not require prior authorization. If you have questions, please contact Magellan at 1-844-483-9013.

Who should I contact with behavioral health questions?

If you have questions, please contact Magellan at 1-844-483-9013.

How do I check patient eligibility?

We offer several self-service tools for providers and their office staff to check patient eligibility.

1. Log in to your Sharp Health Plan online account. If you do not have an online account, please contact the Site Administrator for your provider office so that they can request access to the provider portal for you. For assistance, Site Administrators should contact Network Development / Provider Support at 1-858-499-8300.
2. Once you’ve logged in to your account, go to the Quick Links Section and select Bulk Eligibility and Claim Request and choose the Member Eligibility Verification Form.
3. Complete the provider section of the form and upload it through the Bulk Eligibility and Claim Request link.
4. You will receive verification via secure email within one (1) business day.

Log in to your Sharp Health Plan online account. If you don’t have an account, you can still check patient eligibility online using our guest eligibility check by selecting View Eligibility Status.

What is the fastest way to check eligibility for several patients at once?

The fastest way to check eligibility for multiple patients is to log in to your Sharp Health Plan online account and submit a bulk Member Eligibility Verification Form (see steps 1 through 4 above). You will receive verification within one (1) business day via secure email.

What is the fastest way to check eligibility when a patient is at my office?

The fastest way to check eligibility is through your Sharp Health Plan online account. If you don’t have an account, you can still check patient eligibility online using our guest eligibility check by selecting View Eligibility Status. You can also check eligibility using our self-service provider line at 1-858-499-8200.

How can I get a listing of Sharp Health Plan patients assigned to me?

Physicians who are contracted directly with Sharp Health Plan may contact Network Development / Provider Support to request a list of their assigned members. Providers with a Sharp Health Plan online account, will be able to see their list of patients assigned to them within their provider portal.

Who do I contact with questions?

If you have questions regarding patient eligibility contact Customer Care at 1-858-499-8300 or toll-free at 1-800-359-2002. For all other questions, please contact Provider Relations at provider.relations@sharp.com or 1-858-499-8330. We are available to assist you Monday – Friday, 8 a.m. to 5 p.m.

Who should my patients contact with questions?

You may refer patients with questions to our FAQs at sharphealthplan.com. Or, they can contact Customer Care via email at customer.service@sharp.com, or phone at 1-858-499-8300, and toll free at 1-800-359-2002. We are available to assist them Monday – Friday, 8 a.m. to 6 p.m.

What do I need to know about the enhancements to your main Customer Care lines?

We have updated the interactive voice response (IVR) system on our main Customer Care lines at 1‑858‑499‑8300 and 1‑800‑359‑2002. These enhancements will increase access to self-service tools over the phone, and help decrease call wait times. Here’s what you need to know:

• New provider line -  We’ve added a dedicated line that will allow you to skip the main menu and get to the information you need quicker. The new, dedicated provider line is 1‑858‑499‑8200. Please note that our main Customer Care lines have not changed. You can still call 1‑858‑499‑8300 or 1‑800‑359‑2002 and access the provider menu if desired.
• Provider authentication -  You will be asked to enter your NPI number. Your NPI will help us better assist you by having access to important caller information.
• Greater self-service functionality – You will have access to additional self-service tools over the phone. You’ll now be able to verify patient eligibility, check PCP, specialist, urgent care and hospital copays, and individual deductibles.

Will the enhancements to your main Customer Care lines impact my patients?

Yes. When calling our main Customer Care lines at 1-858-499-8300 and 1-800-359-2002, patients will be asked to enter their Sharp Health Plan member identification number and date of birth. This information will allow us to authenticate them as a Sharp Health Plan member, and connect them with the right customer care agent faster. Your patients can access their Sharp Health Plan member identification number on the front of their member ID card. If a patient doesn’t have their ID card, or cannot locate their ID number, they will still have the option to be connected with a Customer Care representative for assistance. After authenticating, they will have access to additional, self-service tools like verifying their eligibility, checking their PCP, specialist, urgent care and hospital copays, and individual deductibles. Access to this information is also available in their Sharp Health Plan online account.

Where should I send claims?

Send medical claims to:
Sharp Health Plan
P.O. Box 939036
San Diego, CA 92193

Send behavioral health claims to:
Magellan Healthcare, Inc.
P.O. Box 710430
San Diego, CA 92171

Send outpatient pharmacy claims to:
CVS Caremark
P.O. Box 52136
Phoenix, AZ 85072-2136

Who should I call with questions, authorization, or precertification requests?

• Medical: 1-844-483-9012
• Behavioral health: 1-844-483-9013
• Outpatient pharmacy: 1-800-364-6331
• Medical pharmacy (in-office injectables): 1-844-345-2803

How do I submit a claim to Sharp Health Plan?

For the best provider experience, we recommend using one of our approved claims clearinghouses to submit and manage your claims electronically. Additionally, you can submit claims through our Sharp Health Plan online account.

Can I submit paper claims?

Yes. However, we do not recommend submitting paper claims. Using one of our approved claims clearinghouses to submit your claims online will help reduce errors, resulting in quicker processing and payment. To learn more about the benefits of using one of our claims clearinghouses, please visit our provider center.

How can I find out the status of my claim?

For services provided to patients assigned to one of the following Plan Medical Groups, providers should contact the group directly:

• SCMG Palomar Health Medical Group: 1-858-499-2565
• Greater Tri-Cities IPA: 1-760-941-7309, option 3    
• Optum Care-North County SD (formerly Primary Care Associates Medical Group): 1-909-476-1575 ext. 63007
• Rady Children’s Health Network/CPMG: 1-858-309-6280 and toll free 1-877-276-4543
• SCMG Inland North Medical Group: 1-858-499-2550
• SCMG Graybill North Coastal: 1-858-499-2550
• Sharp Community Medical Group: 1-858-499-2550
• Sharp Rees-Stealy Medical Group: 1-858-499-2410

Providers who are contracted directly with Sharp Health Plan and providers outside San Diego County who submitted a claim through one of our approved claims clearinghouses can also check the status of their claim online through the clearinghouse’s website. Providers can also check the status of a claim through their Sharp Health Plan online account. If you don’t have an account, you can still check claims status online using our guest claims check by selecting Check Claim Status.

I can’t locate my Sharp Health Plan provider contract. How can I find out my contract rate of reimbursement?

Physicians who are contracted directly with Sharp Health Plan can contact our Network Development / Provider Support Department.  

How do I sign up for direct deposit?

Complete the Electronic Funds Transfer Authorization Agreement and return it along with a voided check or savings deposit slip to:

     Sharp HealthCare
     Attn: EDI MCA Operations
     8695 Spectrum Center Blvd., 3rd Floor
     San Diego, CA 92123

When will my direct deposit begin?

Please allow two weeks from the date we receive your EFT Authorization Agreement to process your request. We will contact you at the phone number you provide on the form to confirm receipt of your information. You may also call EDI MCA Operations at 1-858-499-5573 if you have any questions about the application process.

How will I know when my payment has been deposited into my account?

Contact your bank or check online if you are set up to do so. Please allow two business days from the date the payment is issued for the deposit to appear in your account. Claims payments are issued every Tuesday. Payments will be posted into your account that Thursday.

When are claims payments generated?

Claims payments are issued every Tuesday unless Tuesday falls on a holiday. In those cases, payments will be issued on Wednesday. If you have any questions about when your payment will be deposited, please contact EDI MCA Operations at 1-858-499-5573.

How will my information be safeguarded?

All banking information will be kept confidential and secured in a locked, private area.

How will I get my Evidence of Benefits (EOBs) or other payment documents?

All reports and supporting documents will be mailed through U.S. mail one to two days after your payment has been generated. This is the same process currently in place with paper checks.

What happens if I change banks or checking/savings account numbers?

We will need to deactivate your current account information and disable your electronic funds transfer if you make any changes to the following: Tax Identification Number (TIN), medical group affiliation, banking institution or account numbers for your checking/savings account.

If you have any changes in this information, complete a new EFT Authorization Agreement, checking the “Revision to Current Authorization” box. Be sure to include the effective date of the change. Please allow 30 days to process your new information to resume your direct deposit. Until the change process is complete, you will receive a paper check.

How do I cancel direct deposit?

Call EDI MCA Operations at 1-858-499-5573 to cancel direct deposit. If you prefer, check the "Cancel EFT" box on your copy of the EFT Authorization Agreement, write the date you want to cancel direct deposit, and return the form to:

     Sharp HealthCare 
     Attn: EDI MCA Operations 
     8695 Spectrum Center Blvd. 3rd Floor 
     San Diego, CA 92123

Who do I contact if I have questions?

Please contact EDI MCA Operations at 1-858-499-5573 or email EDI_MCA.Operations@sharp.com.

What should I do if a patient presents an old ID card?

If a patient presents their old ID card, please do not turn them away! You can look up their ID number by logging in to your Sharp Health Plan online account. When you are logged into the portal, you can look-up a patient’s eligibility using their first and last name and date of birth. The patient’s ID number will be displayed in the search results, and more detailed eligibility information will be available by clicking on the patient’s name.

What do member ID cards look like?

To see samples of what the member ID cards look like, view or print this downloadable PDF. To see samples of Medicare ID cards, please download this PDF.

Who is your pharmacy benefit manager (PBM)?

Our PBM is CVS Caremark^®, the prescription benefit management subsidiary of national health care leader CVS Health^®.

What provider benefits does CVS Caremark offer?

Though our partnership with CVS Caremark, we’re able to offer our providers access to:

• Helplines staffed by experts who are available to answer pharmacy questions 24/7.
• An improved digital pharmacy experience that allows providers to access medication, prescription and pharmacy network information through our website and Sharp Connect provider portal.
• Electronic prescribing tools that allow providers to write prescriptions, and submit pharmacy prior authorization and exception requests online through CoverMyMeds^® or Surescripts^®.

How do I know if a pharmacy is in your network?

To see if a pharmacy is in our network, please visit our pharmacy portal.

How can I help patients who are taking a drug that’s not on the formulary?

If you have patients who are taking drugs that aren’t on our formulary, we recommend prescribing alternatives that are covered. If you determine that the currently prescribed medication regimen is the most appropriate therapy for your patient, and the drug is non-formulary or requires prior authorization, you can submit a pharmacy prior authorization and exception request. You can download the commercial patient request form or the Medicare patient request form. If the drug is determined to be medically necessary, your patient may be eligible to continue receiving the drug.

How do I submit pharmacy prior authorization and exception requests?

You can submit pharmacy prior authorization and exception requests by fax, phone, online or mail, 24/7 — 365 days per year. You can access the pharmacy prior authorization and exception request form for commercial patients or for Medicare patients. You can also access these forms in your Sharp Health Plan online account.

Who handles pharmacy appeals and grievances?

Our pharmacy benefit manager handles all pharmacy appeals. Sharp Health Plan manages all pharmacy grievances, in addition to all appeals and grievances related to drugs covered under the medical benefit. For more information, please visit the appeal and grievance section of our website.

Is e-prescribing available?

Most EHRs support e-prescribing. However, if you are not currently using an EHR that provides this feature, you can create an account with CoverMyMeds^® or Surescripts® to write prescriptions, and submit pharmacy prior authorization and exception requests online. If you have existing accounts with CoverMyMeds and/or Surescripts, you can continue using your login information. If you want to create accounts, visit account.covermymeds.com/signup or providerportal.surescripts.net/providerportal to get started.

Is training for CoverMyMeds (CMM) available?

CMM offers free 15-minute training webinars Tuesdays, Wednesdays and Thursdays. If you’re unable to make one of these trainings, CMM can schedule personalized sessions at no charge. Visit covermymeds.com/main/support/provider to learn more.

Is training for Surescripts available?

Surescripts offers a variety of technical and procedural trainings. To request training, or to receive a copy of the current training catalog specific to your certified connection to the Surescripts network, please email training.customersupport@surescripts.com.

Do you offer mail order?

Yes. We offer mail order through our partner, CVS Caremark Mail Service Pharmacy. Patients who want to set-up mail order can visit the mail order section of our website to learn more. They can also call the dedicated prescription helpline on the back of their member ID card for 24/7 support.

Is there anything else I should know?

Remember to check the provider operations manual for the latest formulary information. We introduced some important new safety measures for our commercial and exchange plans in 2020, including:

• Opioid naïve members ages 18 and over will be limited to a maximum of a 7 day supply
• Greater than a 7 day supply may be obtained with an approved prior authorization request
• New cumulative daily morphine milligram equivalent (MME) limitations

Please note that patients with cancer related pain, sickle cell anemia, in hospice or end of life care will be exempt from these requirements.

How do I get a provider directory?

You can download a provider directory or search online. To request a paper copy of Sharp Health Plan’s provider directory, call Customer Care at 1-858-499-8300.

What vaccines are available?

Two vaccines are licensed and recommended to prevent shingles in the United States. Zoster vaccine live (ZVL, Zostavax) has been in use since 2006. Recombinant zoster vaccine (RZV, Shingrix), has been in use since 2017 and is recommended by the Advisory Committee on Immunization Practices (ACIP) as the preferred shingles vaccine.

How should I advise my patients about the Shingrix shortage?

The Centers for Disease Control and Prevention (CDC) recommend these proven strategies to help patients receive all their needed vaccinations on time, including Shingrix:

• Implement a vaccine reminder and recall system using phone, e-mail, or text messages to contact patients when you have Shingrix supply (or your vendor). Give first consideration to patients due for their second dose of Shingrix.
• If you are out of Shingrix (or your vendor) and a patient needs a second dose, refer the patient to another provider in your network (e.g., a pharmacy) that has Shingrix so the patient can complete the series. Certain websites such as the Shingrix vaccine locator and HealthMap vaccine finder can help you search for stock of the vaccine online.
• Be sure to enter your patients’ current vaccination information into your state’s immunization information system (IIS). This will ensure that every provider can access your patients’ immunization record, and it may help facilitate patient reminders to complete the Shingrix series.
• As supply becomes less constrained, be sure to notify eligible patients so they can come in to get their first dose of Shingrix.

Who should get Shingrix?

The CDC recommends giving Shingrix to immunocompetent adults 50 years and older, including those who:

• Had shingles in the past,
• Received Zostavax (Zoster Vaccine Live) at least 8 weeks prior, 
• Have health conditions, such as chronic renal failure, diabetes mellitus, rheumatoid arthritis, or chronic pulmonary disease,
• Are receiving other vaccines, such as influenza and pneumococcal vaccines, at the same time,
• Are taking low-dose immunosuppressive therapy.

Who should not get Shingrix?

The CDC recommends not giving Shingrix to a patient who has ever had a severe allergic reaction, such as anaphylaxis, to a component of this vaccine, or after a dose of Shingrix. Consider delaying vaccination if your patient is pregnant, lactating, or experiencing an acute episode of shingles.

What should I do for patients who have already received their first dose of Shingrix?

The second dose of Shingrix should be given 2–6 months after the first; however, the CDC noted that even if more than six months have elapsed since the first dose, the series does not need to be restarted. Patients may remain at risk for herpes zoster during a longer than recommended interval between doses one and two. The second dose of Shingrix should not be substituted with the Zostavax vaccine. To learn more, please read the CDC’s Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines.

Who should I contact with questions?

If you have questions, please contact Provider Relations at provider.relations@sharp.com or call
1-858-499-8330. We are available to assist you Monday through Friday, 8 am to 5 pm.

Where can my patients find more information about wellness programs available to Sharp Health Plan Members?

Members have direct access to a variety of wellness programs offered through Sharp Health Plan, including online self-management tools, trackers, workshops and telephone-based health coaching.

Visit our Health & Wellness section.

When is my monthly premium payment due each month?

Your premium payment is due by the 25th of the month before your coverage month begins. For example, your February coverage premium payment is due by January 25. If you make a payment after the 25th of the month, but within your grace period, you can disregard the late letter.

How do I pay a medical bill or copay?

To pay a medical bill or copay, please visit sharp.com or call your provider.

What forms of payments does Sharp Health Plan accept?

We accept:

Credit cards (Visa® and MasterCard®)
Debit cards (endorsed by Visa or MasterCard)
Check or money orders
Cash
Bank wire
E-check

How can I make my monthly payment?

We offer several easy ways to pay:

• Online
  Log in or register for our new Sharp Health Plan online account to view your balance due, make a payment, set up automatic payments, and view your online transaction history.
  
  PAY ONLINE
  
  
  ⚠️ To avoid overpaying, make sure you cancel any previously scheduled payments in our old payment portal before setting up new ones in your Sharp Health Plan online account.
  TAKE ME THERE
• By phone
  1-858-499-8300
   
• By mail
  Sharp Health Plan
  PO Box 57248
  Los Angeles CA  90074-7248
  
  Make checks payable to “Sharp Health Plan,” write your member ID on the check, and include the remittance slip that comes with your bill. Please use separate checks if you are paying for more than one account.
   
• In person
  Message about in-office visits:
  At this time, the Sharp Health Plan office is not open to visitors due to coronavirus (COVID 19) restrictions. Thank you for your understanding as we work to ensure everyone remains healthy and safe.

When will I receive my monthly premium billing statements?

If you enrolled in an individual and family plan through Sharp Health Plan or Covered California, you will receive a monthly premium billing statement from us the first week of every month. Please note that if you make changes to your benefit plan, or make a payment after the first of the month, this information can take up to two billing cycles to be reflected on your monthly billing statement. If you have questions about how to read your bill, check out this quick guide, call us at 1-858-499-8300 or email us at customer.service@sharp.com.

What should I do if I don’t receive my premium billing statement?

If you do not receive your monthly premium billing statement from Sharp Health Plan by the second week of the month, please log in or create an online account. If you have additional questions, please contact us at 1-858-499-8300 or email us at customer.service@sharp.com.

How can I see my transaction history?

You can view your transaction history when you log in to your Sharp Health Plan online account. If you don’t have an account, creating one is easy and will only take a few minutes.

How long will it take for my account to be updated after I make a payment?

For payments made by credit card, debit card, cash, bank wire, and e-check, please allow for up to 2 business days upon receipt for your payment to be posted. For payments made by check or money order, please allow for 2-3 business days from receipt. Payments made through our Sharp Health Plan online account will be reflected immediately.

I’m applying for coverage; how can I make my initial payment?

If you’ve received your initial payment letter from Sharp Health plan, you can make your initial payment by creating a Sharp Health Plan online account or using our Guest Pay option.

There’s been a change in my subsidy amount. How long will it take for the change to show up on my statement?

Changes may take up to 60 days to show up on your monthly statement. Once Sharp Health Plan receives your updated subsidy amount, we will make adjustments to your statement. If your subsidy amount increased, we will issue you a refund for the difference. If your subsidy amount decreased, we will issue a charge for the difference. These adjustments will show up on your statement for changes received within the last 90 days.

How will my refund be issued?

In most cases, your refund will be issued by the same method used for payment. For example, your refund will be issued by credit card if payment was made by credit card, or by check if payment was made with a check. However, if the refund is processed beyond 90 days, it will be issued by check. 

How can I set up automatic payments?

Here are the steps to set up automatic payments:

1. Register or log in to your Sharp Health Plan online account.
2. Go to the “Premium billing” page and click “Set up autopay.”
3. Choose the day of the month you would like your payments to be processed. We accept days between the 1st and the 25th.
4. Choose or add a payment method.

What payment information will I see in my online account and what can I do there?

With a Sharp Health Plan online account, you will be able to view your billing history, balance due, make a one-time payment or set-up automatic payments, and view your online transaction history.

Is making an online payment secure?

Yes. The Sharp Health Plan online account is a safe and secure way to pay your premium bill online. We use Payment Card Industry compliant software with a secure payment gateway technology used to transfer data.

Can I make a payment if I’m not the primary subscriber of the account?

Online payments can only be made from the primary subscriber’s online account. Primary subscribers have member ID numbers that end in “01” or begin with an “S.” If you are not the primary subscriber but wish to make payments, you can ask the primary subscriber to grant you access to their account.

How do I cancel an automatic payment in my Sharp Health Plan online account?

For the best member experience, we recommend having automatic payments set up to ensure there is no disruption to your coverage. That said, you can cancel your automatic payments by:

• Going to the “Premium billing” page and selecting “Manage autopay.”
• Selecting “Turn off auto pay” to cancel your automatic payments.

I tried to set up a payment method using my American Express or Discover card, but it would not process. Why?

Sharp Health Plan accepts Visa® and Mastercard® credit or debit cards only.

Do I need to create an online account to make a one-time payment?

No. You can make payments using Guest Pay without an account. That said, for the best member experience, we recommend creating an online account because it will allow you to view your balance, see your transaction history, and much more.

When I make plan changes, or if my financial assistance changes, will my automatic payments in my online account be updated?

Yes. If you have automatic payments set up in your Sharp Health Plan online account, they will be automatically updated to reflect those changes.

How can I see my transaction history online?

After logging in to your Sharp Health Plan online account, go to the “Premium billing” page and select “Payment history.”

How do I update or change a credit card in my online account?

To update your payment method in your Sharp Health Plan online account, make a one-time payment or edit your existing automatic payment select “Manage your saved payment methods.”

I have an automatic payment scheduled in the old Sharp Health Plan payment portal. What should I do?

For the best member experience, we encourage you to create a new Sharp Health Plan online account, and start using it to make your premium payments online. Our old Sharp Health Plan payment portal will be deactivated in December 2024. To avoid overpaying, make sure you cancel any previously scheduled payments in our old payment portal before setting up new ones in your Sharp Health Plan online account.

How do I cancel automatic payments in the old payment portal?

To cancel automatic payments in the old payment portal, please:

• Log in to your payment portal account.
• Go to the “Automatic payments” page.
• Under "Automatic payments," click on the trash icon located to the right of the scheduled automatic payment.

When will I receive my bill?

You will receive your bill around the first week of each month.

What should I do if I don't receive my bill?

If you do not receive your bill by the second week of the month, please log in to your Sharp Health Plan online account to view your bill. For further assistance, please contact your dedicated account management executive.

Who do I contact if I have questions about my bill?

If you have questions about your bill, please contact the Sharp Health Plan Billing Department at 1‑858‑499‑8023. We are available to assist you Monday to Friday, 8 am to 5 pm. For all other questions, contact your dedicated account management executive.

When is my payment due?

Your payment must post to your account by the 25th of the month before your coverage month begins.

How can I make my monthly payment?

We offer several options for employers to make their monthly premium payment:

• Online:
  Log in or register for a Sharp Health Plan online account to view your balance due and transaction history and make payments, including automatic payments.

PAY ONLINE


• Send your payment by mail
  Sharp Health Plan
  P.O. Box 57248
  Los Angeles CA 90074-7248
  
  Please write your account ID on the check, include the coupon from your billing statement, and use separate checks if you are paying for more than one account.
   
• In person
  Message about in-office visits:
  At this time, the Sharp Health Plan office is not open to visitors due to coronavirus (COVID 19) restrictions. Thank you for your understanding as we work to ensure everyone remains healthy and safe.

What forms of payment do you accept?

We accept:

• Check or money orders
• Cash
• Bank wire
• E-check

I tried to choose a card for my payment method, but it was not available. Why?

Sharp Health Plan offers employers the ability to pay by e-check, check and wire transfer only.

How can I see my transaction history?

To view your transaction history, please log in to your online Sharp Health Plan account.

How long will it take for my account to be updated after I make a payment?

Online payments will be automatically posted to your account. For payments made by cash or bank wire, please allow for up to two (2) business days upon receipt for your payment to be posted. For payments made by check or money order, please allow for 2–3 business days from receipt. Please note that payments made after the 25th of the month before your coverage month can take up to two billing cycles to show on your billing statement.

How do I update my enrollment?

Please log in to your Sharp Health Plan online account to update enrollment. If you have questions on how to update enrollments, please review the training within your online account. If you have questions, or need assistance, please contact your dedicated account management executive.

How do I set up automatic payments online?

Employers can set up automatic payments through their Sharp Health Plan online account. Once you’re logged in to your account, visit the homepage Quick Links to view step-by-step instructions on how to set up automatic payments. Please note, your first automatic payment must be a one-time payment. Subsequent payments can be set up as automatic.

If your organization doesn’t have an online account, you can request one here. To learn more about the many benefits of having a Sharp Health Plan online account, please visit this page.

Can I make online payments for more than $8,000?

Yes. If your payment is greater than $8,000, it will appear as multiple transactions until your total payment is reached. One-time payments are limited to $8,000.

What should I do if I have payments set up through Sharp Health Plan’s payment portal?

The Sharp Health Plan payment portal will be going away later this year. To avoid any lapse in coverage, you will need to cancel those payments and get them re-setup in your Sharp Health Plan online account. For instructions on how to do that, please log into your Sharp Health Plan online account and see the homepage Quick Links for step-by-step instructions.

Will I be charged a late fee?

No, you will not be charged a late fee. However, if your payment is late, your health coverage may be suspended or terminated. 

Members can find out more about grace periods. If you are an employer, please contact your account management executive for more information.

How do I know which medications are covered under my plan?

The Sharp Health Plan drug formulary lists all covered medications. View the Drug List or call us at 1-800-359-2002 to find out if your medication is included on Sharp Health Plan’s formulary.

What is a drug formulary?

A formulary is a list of covered medications for Sharp Health Plan doctors to use when prescribing medicines for you. A formulary improves the quality of care by encouraging use of prescription medications that are demonstrated to be safe, effective and produce superior clinical outcomes. Our goal is to include drugs that are supported by medical research and have the most potential to improve Members' health, while also keeping health care coverage affordable.

Who decides which drugs are on the formulary?

The Plan uses a Pharmacy and Therapeutics Committee, composed of doctors and pharmacists, who meets quarterly to evaluate the formulary. The Committee considers newly developed drugs and recommendations from plan Members, doctors and pharmacists for possible changes to the formulary. 

How are medications chosen to be included on the drug formulary?

The Pharmacy and Therapeutics Committee reviews a variety of materials in the medical literature, such as peer review journals and independent clinical studies. To be included on the formulary, drugs must be approved by the Food and Drug Administration and supported by medical research to have the most potential to improve Members' health.

What is a generic drug?

A generic drug is identical to a brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. The Food and Drug Administration certifies that generic drugs are safe and effective, and therapeutically equivalent to their brand-name offering. Generic drugs, when available, are usually the best value, providing the same clinical benefits for substantially less cost. These savings help keep the cost of health care coverage more affordable. For Sharp Health Plan Members, most generic drugs have a lower copayment.

Does the formulary include both branded drugs and generics?

Yes, Sharp Health Plan’s formulary includes many commonly prescribed medications, both brand-name drugs and generics. When a generic equivalent is available, it must be dispensed instead of the brand-name drug, unless your doctor specifies that the brand-name drug is medically necessary. Most generic drugs have lower copayments than brand-name drugs.

Can I get any drug on the formulary?

The formulary is a tool for your doctor to use when determining the most appropriate course of treatment. The presence of a drug on the formulary does not guarantee that your doctor will prescribe it for a particular condition. In some cases, prior authorization from Sharp Health Plan may be required before a drug is approved. View the Drug List online or call Customer Care at 1-800-359-2002 to find out if your medication requires prior authorization.

What if my medication is not on the formulary?

Sharp Health Plan’s drug list includes information on alternative medications that are in the same drug class. If your medication is not listed on the formulary, ask your doctor if a formulary alternative would be appropriate for you.

You must receive approval for a formulary exception for non-formulary drugs.

• Request a formulary exception for those non-formulary drugs. Exception requests are reviewed by CVS Caremark.
• If an exception is approved, you will be notified of the approved provider and the expiration date for the formulary exception approval.
• If exception request is denied, you will be informed of the reason for denial and your appeal rights.

The cost of my medicine is changing. Why?

Every year, we review our drug list, or formulary, to make sure we offer the most effective drugs at the best cost. We use a Pharmacy & Therapeutics (P&T) Committee made up of clinical pharmacists and physicians to evaluate the drugs on our formulary for clinical effectiveness, safety and overall value. The committee may make changes to the drug list, such as moving some drug up or down to a different “tier” or cost level. The committee may also add or remove requirements (prior authorization, step therapy, quantity limitations) for use for certain drugs.

Annual changes to the formulary may increase your copay or coinsurance if your prescribed medication has moved to a higher drug tier. However, members may see a reduction in costs as drugs move to a lower tier. To find the tier for a specific drug beginning January 1, visit our drug list page and select the drug list that corresponds with your type of coverage.

What are drug tiers?

“Tier” is another word for level. Each drug is assigned to a specific tier, and the tier indicates what your copayment or coinsurance will be for the specific drug. Drugs in lower tiers (e.g., Tier 1) cost you less, and drugs in higher tiers (e.g., Tier 3) cost you more. To find the tier for a specific drug beginning January 1, visit our drug list page and select the drug list that corresponds with your type of coverage.

How can I find out if my current drug will be covered, what tier it’s in, and if there are requirements or limits for use in the coming year?

You can find out if a specific drug will be covered, what tier it will be in and any limitations or requirements for use by visiting our drug list page, then select the drug list that corresponds with your type of coverage.

What is an alternative medication?

An alternative medication is another drug, other than the one you are taking, that may be appropriate to treat your condition. It may be a formulary preferred generic drug, which could lower your costs.

How can I determine if there’s an alternative medication that could lower my cost?

Please contact your doctor or prescribing provider to find out what alternative medications are available to treat your condition.

Will my copay or coinsurance change?

Your copayment or coinsurance for your medication is determined by its drug tier. So, your copay or coinsurance may change if your drug has been moved to a different tier. For example, your copay or coinsurance may increase if your prescription medication has moved to a higher drug tier, or be reduced if your drug is moved to a lower tier. To find the tier for a specific drug beginning January 1, visit our drug list page and select the drug list that corresponds with your type of coverage.

Why do some drugs require prior authorization, step therapy or quantity limits?

Some drugs require prior authorization, step therapy or quantity limits to ensure that medically sound and cost-effective drugs are prescribed appropriately. Find out more about these guidelines below:

• Prior authorization: Some drugs require prior authorization by Sharp Health Plan to ensure that you are receiving the appropriate medication for your condition based on a review of medical criteria. Your doctor will provide the necessary information to Sharp Health Plan for the prior authorization review. If you have any questions regarding the prior authorization process, please call us at 1-800-359-2002.
• Step therapy: In this program, you may need to try a proven, cost-effective drug first, before using a more costly treatment, if needed. Remember, treatment decisions are between you and your doctor. There may be a situation when it is medically necessary for you to receive certain drugs without first trying the alternative drug. In these instances, your doctor may request prior authorization.
• Quantity limit: Quantity limits exist when drugs are limited to a specific number of doses based on safety, potential overdose hazard, abuse potential, or approximation of usual doses per month — not to exceed the FDA maximally approved dose. Your doctor may follow the prior authorization process when requesting an exception to the Sharp Health Plan quantity limit for a drug.

What is an over-the-counter (OTC) equivalent?

An OTC equivalent is a drug considered safe and effective for use without a doctor’s prescription, and offers the same benefits as a prescription drug. 

Why are OTC medications not included in Sharp Health Plan's drug list?

In general, health plans do not cover medicines that you can buy without a prescription or have an over-the-counter (OTC) equivalent.

Will my OTC medicine cost me more than it did as a prescription medicine?

In most cases, your costs will be the same or less than what you currently pay for your prescription. However, because pricing varies, some medicines could cost more. 

I've been paying a copay, or a price less than my copay, at the pharmacy. Can I still get that lower price if it's less than the retail price?

In most cases, the OTC or retail price will be less than your copay. However, if the retail price is higher, ask your pharmacist for the price at the pharmacy window to see which is cheaper. Also, shop around — online, at other locations, or at warehouse stores like Costco — for the best price available.

If I have a prescription for a medicine that is available OTC, can I still have it filled at the pharmacy? 

Yes. You can still have the prescription for your medication filled at the pharmacy window (in most cases). The pharmacy will charge you their cash price. Be sure to compare the price of your prescription medicine with the OTC alternative to ensure you get the best price possible. 

What alternative prescription medicines are available and covered by my drug benefit plan?

Please contact your doctor or prescribing provider to find out what alternative medications are available to treat your condition.

If I buy a medicine that is no longer in Sharp Health Plan's drug list, will the purchase apply to my maximum out-of-pocket (MOOP) amount?

No. If your prescription drug is available over the counter, your prescription is no longer a covered benefit and will not apply to your MOOP nor your deductible.

Can I use my health spending account (HSA) to pay for the OTC equivalent of a prescription drug that’s not covered by Sharp Health Plan? 

Maybe. First, the purchase must qualify as a covered expense for your specific account. Second, you need a prescription for the OTC medicine from your health care provider. Lastly, you will need to make your purchase at a pharmacy counter and have the OTC medicine dispensed as a prescription item. 

My OTC medicine is only available in a lower dose than what I need. I prefer not taking multiple pills to meet my medicine dose. What should I do?

Please follow up with your prescribing provider or pharmacist to find another higher dose OTC medication, or an alternative that will achieve the same results and determine what is right for you. 

My OTC medicine is only available in a higher dose than what I need. What should I do?

Please follow up with your prescribing provider or pharmacist to find another lower dose OTC medication, or an alternative that will achieve the same results and determine what is right for you. 

Why are there exclusions to my prescription drug benefit?

Sharp Health Plan is committed to providing you with a comprehensive, effective, safe and affordable drug benefit. In order to do so, our drug list (or formulary) includes medications that are supported by medical research and have the most potential to improve your health. We do not include prescription medications used to treat conditions not covered by our health plan, including drugs prescribed for cosmetic purposes; fluoride preparations; food supplements, homeopathic and herbal preparations, multivitamins and most over-the-counter (OTC) products. 

Other exclusions include medicines prescribed by a provider who is not part of the Sharp Health Plan network. Or when you fill a prescription at a pharmacy that is not in our network.  

You can view the drug formulary at sharphealthplan.com/druglist. The preamble of the formulary includes a list of the benefit exclusions. To view your specific drug list and costs, please log in to your Sharp Health Plan online account.

What are the exclusions or limitations to my prescription drug benefit?

The list of services and supplies that are exclusions or limitations are included in the drug formulary. To view your specific drug list and costs, please log in to your online account.

How often are changes made to the drug list?

The Pharmacy and Therapeutics (P&T) Committee, composed of doctors and pharmacists, meets regularly to evaluate the formulary. Throughout the year, as newly developed drugs and new information become available, the P&T Committee makes decisions about what changes are needed for the drug list. These changes may include adding or deleting drugs from the list based on new information about quality, efficacy and cost-effectiveness.

Use our online search tool to search medications. To view your specific drug list and costs, please log in to your online account.

My prescription drug was previously covered by Sharp Health Plan, but now it is denied and I’ve been told it’s on the exclusion list. Why was it previously covered? 

As we regularly review our formulary, we sometimes find that a medicine or product that was listed as an exclusion was included in the formulary in error. When this happens, we make adjustments to the formulary going forward. We do not bill our members for the cost of an excluded drug or product that was included on the drug list unintentionally. 

If you need to find a replacement for the excluded drug, please talk with your pharmacist or doctor to find an alternative medicine.

How do I know what my copay is for a prescription medication?

Your benefits summary lists the copayments for prescription drug benefits. To find out the copayment for a specific drug, log in to your Sharp Health Plan online account and select Drug List under My Health Plan.

Why do some drugs require prior authorization?

Some drugs require prior authorization by Sharp Health Plan to ensure that you are receiving the appropriate medication for your condition based on a review of medical criteria. Your doctor will provide the necessary information to Sharp Health Plan for the prior authorization review. If you have any questions regarding the prior authorization process, please call us at 1-800-359-2002.

Can I order prescription medications through the mail?

Yes, mail order is a convenient, cost-effective way to obtain maintenance drugs. Maintenance drugs are medications prescribed to treat or stabilize chronic conditions such as arthritis or hypertension. Maintenance drugs are available for up to a 90-day supply through our prescription home delivery service. View more information about mail order services for prescription drugs or call CVS Health at 1-855-298-4252 for more information.

I have not used mail order pharmacy before. How do I get started?

You can call toll free at 1-800-930-5190 to move your prescription to CVS Caremark.  You will need to provide your Sharp Health Plan ID number, medicine name, payment information and mailing address. CVS Caremark can contact your doctor for a new prescription if requested.

You can also log on to www.caremark.com/faststart. Going online is a quick and easy way to start using mail service. Once you provide the requested information, CVS will contact your doctor for a 90-day prescription. If you haven’t registered yet on Caremark.com, be sure to have your Sharp Health Plan ID number handy when you register for the first time.

What can you tell me about CVS Caremark?

CVS Caremark offers mail services representing approximately 70.3 million people and has dispensed 39.2 million mail service prescriptions. They provide convenient, responsive service with a two-day processing turnaround time for most prescriptions and include an educational member advisory letter with all prescriptions. They offer telephone or internet refill ordering including toll-free pharmacist consultation 24 hours a day, 7 days a week. They have supportive services for special needs populations such as the elderly, sight and hearing impaired. In addition, CVS Health’s messaging platform can support automated alerts regarding order status, refill reminders, health updates, etc. via the member’s preferred method of contact (phone, email, text messaging, etc.).

How does a provider submit a prescription to CVS Caremark for delivery through mail order?

Prescriptions can be sent electronically through the prescriber’s electronic medical record by choosing:

Mail CVS Caremark Service Electronic
NCPDP ID 322038 9501
East Shea Blvd
Scottsdale, AZ 85260

Prescriptions can be faxed to CVS Caremark Mail Service Pharmacy using this form: https://www.caremark.com/portal/asset/NewRX_Fax_Form_v91.pdf. 

Prescriptions can also be called in to CVS Caremark at 1-800-930-5190.

When can I refill my prescription?

Sharp Health Plan allows you to refill your prescription after you have used at least 70% of the prescribed amount. For a 30-day supply, this means you can get a refill 22 days after you last filled the prescription. For a 90-day supply, you can get a refill 64 days after you last filled the prescription. If you try to order a refill at the pharmacy too soon, you will be asked to wait until the allowable refill date. 

You can find out when you last filled your prescription by logging in to your Sharp Health Plan online account and selecting "Prescription History" to check your drug history. If you have any questions about when your prescription can be refilled, ask your pharmacy for assistance or call Customer Care at 1-800-359-2002.

What is the difference between behavioral health and mental health?

Let’s say behavioral health is like a pie. In this scenario, mental health would be a piece of the pie. Behavioral health involves looking at how our behaviors affect our overall physical and mental well-being. Your behavioral health can be influenced by different factors like your diet, alcohol and drug use, relationships, chronic health issues and trauma. Your mental health is part of your behavioral health, and it focuses on your ability to handle regular life stressors in your daily life. Reference: www.Betterhelp.com

Why is mental health important?

Mental health is different from mental illness. Everyone has mental health, but not everyone experiences mental illness. Your mental health affects the way you think, feel, act and behave. Some signs of positive mental health include being able to contribute to your community, engage in healthy relationships, handle normal levels of stress and recognize your value and worth.

When you struggle with your mental health, other areas of your life may feel the effects. There’s no shame in reaching out for help when you need it. Anyone can experience challenges with mental health at any time.

Sources: Centers for Disease Control & Prevention, World Health Organization

How do I find the right therapist for me?

Finding the right therapist can take some time, but it is worth the effort. When you’re searching for a therapist who can help you long-term, we recommend you follow these five tips.

What are the differences between behavioral health providers?

There are many types of behavioral health care professionals. As a Sharp Health Plan member, you have access to all of these providers, depending on your needs.

• Psychiatrists (MD, DO)

  Psychiatrists are licensed medical doctors that specialize in mental, emotional and behavioral disorders. They can diagnose mental health conditions, prescribe and monitor medications and perform a full range of medical laboratory tests to help determine a patient’s specific issues and needs. Psychiatrists may utilize several treatment methods in conjunction with each other to improve their patient’s well-being.

• Psychologists (PhD, PsyD)

  Psychologists use clinical interviews, psychological evaluation and testing to determine your mental health and psychological needs. They can provide individual or group therapy, and may have specialized training in different forms of therapeutic treatment. Psychologists may not prescribe medication.

• Licensed clinical social workers (LCSW)

  As the largest group of mental health services providers, licensed clinical social workers diagnose and treat mental, behavioral, emotional and substance abuse issues among individuals, couples, groups and families. They provide therapy and develop treatment plans. LCSWs are well-trained in case management and often act as the administrators of social programs such as child welfare.

• Marriage and family therapists (MFT, LMFT)

  Marriage and family therapists specialize in psychological issues in the context of marriage, couples and family systems. They are trained to deal with individual psychological issues, as well as those that affect the entire family, including marital problems and child-parent relationship issues.

• Addiction counselors

  Addiction counselors are trained to treat people suffering from addictions. They commonly work in group settings, either with other individuals dealing with the same addiction or with loved ones affected by the behavior.

• Eating disorder specialists

  Eating disorder specialists deal with conditions such as anorexia, bulimia, body dysmorphia and binge eating disorder, while supporting individuals’ medical and nutritional needs. They guide patients through their struggles, to help build lasting, healthy eating habits.

What is mental illness?

Mental illnesses are health conditions that can affect your daily life, as well as your moods, behavior and the ways you think and feel. These conditions can happen over short periods, be chronic (long-lasting) or occasional. Many individuals who experience mental illness benefit from the support that behavioral health providers can offer.

Source: Centers for Disease Control & Prevention

What causes mental illness?

Many different factors may contribute to the risk of mental illness, including:

• Family history
• Biological factors, such as genes or chemical imbalances
• Life experiences, such as stress or abuse
• Drug and/or alcohol use
• Feelings of loneliness or isolation
• Other injuries or medical conditions

If any of these experiences are affecting your mental health, you’re not alone. Help is available. A behavioral health provider can help you to identify your concerns and offer suggestions, treatment and guidance.

Sources: Centers for Disease Control & Prevention, Medline Plus

How can mental illness affect my overall health?

According to the Centers for Disease Control and Prevention, certain types of mental illness may increase risks for physical health problems. The opposite can also be true: Chronic conditions may increase risks for mental illness.

Source: Centers for Disease Control & Prevention

How common is mental illness?

Mental illnesses are common and, like many other health concerns, they are treatable. Nearly 1 in 5 adults experience mental illness in the U.S., and nearly half of them receive treatment. Adolescents and children can also experience mental illness.

Sources: American Psychiatric Association, NAMI

What are the most common types of mental illnesses?

There are over 200 types of mental illness. Some common conditions include:

• Anxiety disorder
• Attention-Deficit/Hyperactivity Disorder (ADHD)
• Depression
• Eating disorders
• Personality disorders
• Posttraumatic Stress Disorder (PTSD)
• Schizophrenia
• Substance abuse disorders

Source: Centers for Disease Control & Prevention

What are common signs and symptoms of mental illness?

Symptoms may vary, depending on the type of mental illness someone is experiencing. Some common signs in adults and adolescents can include:

• An inability to cope with daily problems and activities
• Changes in eating or sleeping habits
• Excessive worry, anxiety or fear
• Extended periods of sadness or irritability
• Extreme highs and lows in mood
• Strong feelings of anger
• Thoughts of suicide

The It’s Up to Us^® website provides more information about symptoms you may notice.