Frequently Asked Questions for Open Enrollment

(Q) Which plan is closest to CMCP5 – Select or Premier?

(A) Neither. Both are brand new plans. There are many factors to consider when choosing which plan is best for you, including premium contribution, deductible, provider network and co-pays. Please review your open enrollment materials. Page 4 lists any premium contributions required, and pages 6-8 give a side by side comparison of your plan options.

(Q) What if my PCP is with Sutter and my spouse goes to a Hill physician, can my family still be in the Select Plan?

(A) Yes, you and each of your family members can select a PCP from any of the four medical groups and still be in the Select Plan. It is only if you want to lower your deductible by 50% that you and each of your family members must use San Joaquin Health Care Services providers exclusively and sign the Attestation Form.

(Q) Can my PCP refer me to any specialist within the four medical groups in the Select Plan?

(A) No, your specialist must be in the same medical group as your PCP. Exceptions will be permitted if your medical group does not have the specialist you need. Exceptions must be prior authorized by the claims administrator.

(Q) What if I have been seeing the same specialist for years and he/she is not in the same medical group as my PCP. Can I still see that specialist?

(A) No, if you want to be in the Select Plan, you will either need to change your PCP to one in the same medical group as your specialist, or change to a specialist in same medical group as your PCP. Any exceptions require a referral from your PCP.

(Q) I do not live in San Joaquin, Sacramento or Stanislaus county. Can I still enroll in the Select Plan?

(A) Yes, as long as you seek services from a PCP listed in the Select Plan. Be advised that only emergency care will be covered if you receive care from a physician other than your PCP, or you do not have a referral from your PCP.

(Q) I have a PCP that is not in San Joaquin, Sacramento or Stanislaus county. Can I keep my PCP and enroll in the Select Plan?

(A) No, you will need to enroll in the Premier Plan and made bi-weekly premiums contributions as described on page 4 of your open enrollment materials.

(Q) I have never had to have a PCP before. If I choose the Premier Plan do I have to have a PCP?

(A) Yes, you must designate a PCP whether you are on the Premier or Select Plan. If you do not choose a PCP on your enrollment form, you will be assigned to Employee Health Care Services. Procedures for changing your PCP after open enrollment are contained in the Benefit Booklet.

(Q) Why is the Emergency Room co-pay $100.00? If I have a serious emergency it should not cost me $100.00.

(A) If you have an emergency and you have to be admitted to the hospital, the $100.00 emergency room co-pay is waived.

(Q) How will I know if my prescriptions are on the formulary or not?

(A) If you are currently paying a $5 or $10 co-pay, your prescription is on the formulary. If you are paying $15, it is a non-formulary drug and under the Select Plan you will need to either change to a formulary drug, or have your doctor request a prior-authorization. The process for approving the use of non-formulary drugs is on page 18 of the Select Plan Benefit Booklet. If approved, you will be charged the $15 co-pay.

(Q) Does the Select Plan have the same hospitals as the Premier Plan?

(A) Yes.