3 Valley Health Plan

Helpful Contact informationValley HealtH PlaN Office 2480 N. First Street, Suite 200

San Jose, CA 95131

Hours: M–F, 8am– 5pm

Valley HealtH PlaN Website www.valleyhealthplan.org

MeMber serVices DePartMeNt Phone: 1.408.885.4760 1.888.421.8444 (toll-free)For the hearing and speech impaired, call the California Relay Service (CRS) by simply dialing 711 or the 800 CRS number from your modality.

Fax: 1.408.885.4425email: [email protected]: M–F, 9am– 5pm

HealtH eDucatiON DePartMeNt Phone: 1.408.885.3490 Fax: 1.408.954.1023email: [email protected]: M–F, 8am– 5pm

MeDical aDVice Phone: 1.866.682.9492 (toll-free)Hours: 24 hours/daily

PHarMacy (NaVitus) custOMer care

Phone: 1.866.333.2757 (toll-free)Hours: 24 hours/daily

Call this phone number when you need assistance with pharmacy/prescription related issues.

PriMary care PHysiciaN (PcP) iNfOrMatiON

Please use the Provider Search function on our website at www.valleyhealthplan.org or call Member Services at 1.408.885.4760 or 1.888.421.8444 (toll-free).

1Access to Services & Network Providers

Table of Contents

Language Assistance ...........................3

Member Services ..................................3

Getting Started .....................................4

Medical Advice Line ............................5

VHP ID Card .........................................6

Pharmacy ...............................................7

Laboratory ..............................................8

Urgent Care Services ...........................10

Urgent Care Locations .........................11

Emergency Services .............................12

Network Plan Hospitals ......................13

Outpatient Mental Health Counseling Services ............................14

Outpatient Psychiatric Services .............................14

Substance Abuse ..................................14

Acupuncture and Chiropractic Services ...........................14

Self-Refer Services ...............................14

Health Education ..................................15

Provider Network Information .........16

Community Clinics ...............................17

Independent Practice ......................... 21

Palo Alto Medical Foundation (PAMF) ...............................22

San Jose Medical Group (SJMG) ..........25

Santa Clara Valley Medical Center (SCVMC) .....................26

Member Resources ...............................30

Timely Access Guidelines .....................31

Preventive Care Guidelines

For Adults ...........................................32

For Children .......................................34

Summary of Benefits Table ..................36

Pharmacy Plan Benefit ..........................59

Member Rights and Responsibilities ..............................66

Privacy Notice ........................................68


Dear Member,

Thank you for choosing Valley Health Plan (VHP) to manage your health care needs. We care about the health and well-being of you and your family. VHP’s staff is committed to ensuring that you receive quality care and service at the right time, at the right place and by the right provider.

To help you find the health care services you may need, this “Access to Services & Network Providers” booklet provides useful information about commonly used benefits. For more detailed information, take some time to review the VHP Combined Evidence of Coverage (EOC) & Disclosure Form booklet. The EOC is a detailed explanation of VHP services, benefits, limitations and exclusions. You can visit www.valleyhealthplan.org to view this booklet along with other useful information about VHP.

If you have any questions or concerns, please call our Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free). Our helpful staff is committed to providing personalized care in the language you prefer. You may also visit our administrative office located at 2480 N. First Street, Suite 200 in San Jose.

And once again, thank you for your membership.

Sincerely,

Valley Health Plan


Language AssistanceWe’ve Got You Covered... In Your Preferred Language As a Member, Valley Health Plan can help you in your language at no cost. If you would like to talk to us or ask for information in your language, please call 408.885.4760 or 1.888.421.8444 during business hours.

Le servimos… En el idioma de su preferencia Como miembro, Valley Health Plan puede ayudarle en su idioma sin costo alguno. Si desea hablar con nosotros o recibir información en su idioma, por favor llame al 408.885.4760 o 1.888.421.8444 durante horas de oficina.

Chúng Tôi Chăm Sóc Sức Khỏe Cho Quý Vị... Bằng Ngôn Ngữ của Quý Vị Là hội viên, Valley Health Plan có thể giúp quý vị bằng ngôn ngữ của quý vị miễn phí. Nếu quý vị muốn nói chuyện với chúng tôi hoặc yêu cầu thông tin bằng ngôn ngữ của quý vị, xin vui lòng gọi 408.885.4760 hoặc 1.888.421.8444 trong giờ làm việc.

Member ServicesVHP’s Member Services Department advocates are able to help you over the phone or in person when you have questions about VHP benefits. They also act on your behalf as your advocate by helping you navigate the healthcare system – making sure that you receive quality care and service at the right time, at the right place and by the right provider. And, when there are issues or concerns, the caring and professional staff make every effort to help you get the services you need in a timely manner.

VHP Member Services advocates are available Monday through Friday from 9am to 5pm at 408.885.4760 or 1.888.421.8444 (toll-free). Walk-in office hours are Monday through Friday from 8am to 5pm.


Getting StartedStep 1. Choose Your Network

At VHP, we know that your health care needs are as individual as you are. Our mission is to ensure you receive quality care and services at the right time, in the right place, by the right provider.

Choose from our diverse provider network and let us partner with you to get you and your family as healthy as possible!

• Community Clinics

• Independent Practice Providers

• Palo Alto Medical Foundation (PAMF)

• San Jose Medical Group (SJMG)

• Santa Clara Valley Medical Center (SCVMC)

Step 2. Choose Your Doctor

Valley Health Plan encourages you and your family members to choose your own Primary Care Physician (PCP) who is responsible for taking care of your routine health care needs. Your PCP will play a key role in coordinating your health care services including making referrals for medically necessary services.

Types of PCPsDOCTOR’S SPECIALTY

WHO CAN BE SEEN

Adult Medicine Adults—age 18 & older

Family Medicine Children & Adults all ages

Pediatric Medicine Newborn to age 17

Use the Provider Search on our website at www.valleyhealthplan.org or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for more information about VHP PCPs.


Step 3. Make Your Choice

Call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) with your PCP choice or include on your Enrollment Application.

As a Valley Health Plan Member, you have the right to change your PCP at any time by calling Member Services at 408.885.4760 or 1.888.421.8444 (toll-free). The change will take effect on the first day of the next month after your request is received. During that time, a new card will be sent to you with the name of your new PCP.

Step 4. Make an Appointment

Call your network PCP appointment number.

Use the Provider Search on our website at www.valleyhealthplan.org or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for more information about to find your Network PCP appointment number.

Medical Advice LineOur 24/7 Medical Advice Line is available to you seven days a week, every day of the year.

After regular clinic hours, no matter where your PCP is located, medical advice nurses are available and can direct you to the appropriate care for your medical situation.

Call 1.866.682.9492 (toll-free) to speak with an experienced nurse who can answer urgent and non-urgent questions, assess symptoms, and provide care recommendations.


VHP ID CardYour Valley Health Plan (VHP) Identification (ID) card shows important information you will need to access covered health care services.

The front of your card has the following information:

• Member Name

• Identification Number

• Date of Birth

• Gender

• Network

• Primary Care Physician (PCP) Name

• Pharmacy Information

The back of your card has the following contact information:

• VHP Member Services

• Navitus Health Solutions Pharmacy Customer Care

• 24/7 Medical Advice Line

• VHP Claims Department

Primary Care Physician (PCP) or Mental Health appointment phone numbers and information, please visit www.valleyhealthplan.org or call VHP Member Services.

VHP Member Services.......................................................................408.885.4760 Toll-free Line...................................................................1.888.421.8444Pharmacy (Navitus) Customer Care...............................1.866.333.275724/7 Medical Advice Line..........................................................1.866.682.9492

Submit medical claims to VHP Claims Department, P.O. Box 26160, San Jose, CA 95159-6160.

Call 911 in the case of an emergency. If admitted to a hospital, immediately call 1.800.303.7845.

2480 N. First Street, Suite 200 | San José, CA 95131 | www.valleyhealthplan.org

Member Name Jennifer T. Doe

DOB Gender

31234567811 01 01/01/1961 FNetwork

Palo Alto Medical Foundation (PAMF)Primary Care Physician (PCP)

Martin N. Smith, M.D.RxGroup# VHP RxBIN# 610602 RxPCN# NVT

MEMBER ID CARD

Be sure to take your VHP ID card with you to every medical appointment and when filling prescriptions at a VHP Plan Pharmacy.

It is important to note that your medical record number is not included on your card. Keep this information in a safe place where it can be easily referenced when needed.

Each family member will get a VHP ID card which can only be used by the Member whose name is on the card. It is important to review all of your information on the card. If there is an error, please call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) to request a new card.


PharmacyAs a Valley Health Plan Member, you will have access to Network Plan Pharmacies located in and out of Santa Clara County. Select locations may offer convenient services such as:

• Drive-thru pharmacy services

• 24/7 pharmacy hours

• Prescription transfer online

• Option to pick up or mail

Valley Health Plan Members will enjoy the expanded prescription benefit with a continued $0 co-pay.

For additional information on Pharmacy Plan Benefits, please see pages 59-65.

VHP Network Plan Pharmacies

Safeway Pharmacies All U.S. locations. For a list of locations visit www.safeway.com

Walgreens Pharmacies All U.S. locations. For a list of locations visit www.walgreens.com

Gardner Family Health Network South County Health Center Pharmacy 700 W. 6th Street, Suite F, Gilroy, CA 95020 Hours: M–F, 8:30am–5:30pm Pharmacy Phone 408.848.9400

Gardner Family Health Network St. James Health Center Pharmacy 55 E. Julian Street, San Jose, CA 95112 Hours: M–F, 8:30am–5:30pm Pharmacy Phone 408.918.2600

Leiter’s Compounding Pharmacy 1700 Park Avenue, Suite 30, San Jose, CA 95126 Hours: M–F, 9am–6:30pm; Sa, 9am–6pm Pharmacy Phone 408.292.6772

Palo Alto Medical Foundation (PAMF) Mountain View Center Pharmacy 701 E. El Camino Real, Mountain View, CA 94040 Hours: M–F, 9am–6pm Pharmacy Phone 650.934.7699

Palo Alto Medical Foundation (PAMF) Palo Alto Center Pharmacy 795 El Camino Real, Lower Level A, Lee Bldg. Palo Alto, CA 94301 Hours: M–F, 9am–6:30pm; Sa, 9am–1pm Pharmacy Phone 650.853.6066


LaboratoryLaboratory services are ordered by your Physician when Medically Necessary. VHP is contracted with Quest Diagnostics for laboratory services. There are more than 400 Quest Patient Service Centers (PSC) in California that VHP Members can access. Visit the Quest Diagnostics website at www.QuestDiagnostics.com/patient or call Quest Diagnostics at 1.888.277.8772 (toll-free) for more information. The list below are providers located in Santa Clara County.

Quest Diagnostics–2505 Samaritan 2505 Samaritan Drive, Suite 112 San Jose, CA 95124 Hours: M–F, 7am—4pm Phone 408.356.5665

Quest Diagnostics–Almaden Valley 6475 Camden Avenue, Suite 104 San Jose, CA 95120 Hours: M–F, 8am–1pm & 2pm–5pm Phone 408.927.8331

Quest Diagnostics Blossom Ridge Medical Group 15066 Los GatosAlmaden Road Los Gatos, CA 95032 Hours: M–F, 8:30am–1pm & 2pm–5:30pm Phone 408.371.3428

Quest Diagnostics–Burdette 1675 Burdette Drive, Suite 40 San Jose, CA 95121 Hours: M–F, 6am–6pm; Sa, 8am–1pm Phone 408.274.2670

Quest Diagnostics–Di Salvo 123 Di Salvo Avenue, Suite G San Jose, CA 95128 Hours: M–F, 6:30am–5pm; Sa, 8am–12pm Phone 408.294.1244

Quest Diagnostics–Forest 2039 Forest Avenue, Suite 101 San Jose, CA 95128 Hours: M–F, 7:30am–12:30pm & 1:30pm–4:30pm Phone 408.293.9271

Quest Diagnostics–Gilroy 7880 Wren Avenue, Suite A-114 Gilroy, CA 95020 Hours: M–F, 7am–12pm & 1pm–4pm Sa, 8am–12pm Phone 408.842.4226

Quest Diagnostics–Jackson 115 N. Jackson Avenue, Suite 102 San Jose, CA 95116 Hours: M–F, 6am–6:30pm Sa, 8am–1pm Phone 408.259.6806

Quest Diagnostics–Knowles 777 Knowles Drive, Suite 1 Los Gatos, CA 95032 Hours: M–F, 7:30am–12pm & 1pm–4:30pm Phone 408.379.0578

Quest Diagnostics–Las Colinas 2820 Alum Rock Avenue, Suite 40 San Jose, CA 95127 Hours: M–F, 9a.m.–1pm & 2pm–6pm Phone 408.926.5625

Quest Diagnostics–Los Gatos 15400 National Avenue, Suite 210 Los Gatos, CA 95032 Hours: M-F, 8am–12:15pm & 1:15pm–5pm Phone 408.356.2997

Quest Diagnostics–McKee 227 N. Jackson Avenue San Jose, CA 95116 Hours: M–Th, 7:30am–5:30pm F, 7:30am–12pm Phone 408.258.0348


Quest Diagnostics–Milpitas PSC 500 E. Calaveras Boulevard, Suite 124 Milpitas, CA 95035 Hours: M–F, 7am–4pm Phone 408.945.1903

Quest Diagnostics–Montpelier 2375 Montpelier Drive, Suite 20 San Jose, CA 95116 Hours: M–F, 7:30am–12:30pm & 1:30pm–4:30pm Phone 408.923.3137

Quest Diagnostics–Morgan Hill 50 E. Main Avenue, Suite B Morgan Hill, CA 95037 Hours: M–F, 8am–1pm & 2pm–5pm Phone 408.779.5831

Quest Diagnostics–Mountain View 205 South Drive, Suite G Mountain View, CA 94040 Hours: M–F, 6:30am–12pm & 1pm–5pm Sa, 8am–12pm Phone 650.968.8852

Quest Diagnostics–O’Connor 455 455 O’Connor Drive, Suite 100 San Jose, CA 95128 Hours: M–F, 7:30am–4:30pm Phone 408.279.6186

Quest Diagnostics–Parr 700 W. Parr Avenue Los Gatos, CA 95032 Hours: M–F, 8am–5pm Phone 408.374.6260

Quest Diagnostics–Physicians East 244 N. Jackson Avenue, Suite 108 San Jose, CA 95116 Hours: M–F, 8am–5pm Sa, 7am–12pm Phone 408.259.7530

Quest Diagnostics–Remington 500 E. Remington Drive, Suite 28 Sunnyvale, CA 94087 Hours: M–F, 7:30am–12:30pm & 1:30pm–4:30pm Phone 408.738.5569

Quest Diagnostics–Samaritan 2581 Samaritan Drive, Suite 108 San Jose, CA 95124 Hours: M–F, 6:30am–5pm Sa–Su, 7:30am–12:30pm Phone 408.356.9154

Quest Diagnostics–SJMG–Lincoln 625 Lincoln Avenue San Jose, CA 95126 Hours: M–Th, 7:30am–5:30pm F, 7:30am–4:30pm Sa, 8am–12pm Phone 408.998.2853

Quest Diagnostics–Sunnyvale 877 W. Fremont Avenue, Suite H2 Sunnyvale, CA 94087 Hours: M–F, 7am–4pm Sa, 8am–12pm Phone 408.739.7814

Quest Diagnostics–Valley 25 N. 14th Street, Suite 160 San Jose, CA 95112 Hours: M–F, 8am–12:30pm & 1:30pm–5pm Phone 408.294.1744

Quest Diagnostics–Warner 5150 Graves Avenue, Suite 5A San Jose, CA 95129 Hours: M–F, 8am–1pm & 2pm–5pm Phone 408.253.8066


Urgent Care Services In the case of a life-threatening situation or an emergency, call 911 or go to the nearest emergency department.

For urgent medical issues and questions, it is always recommended that you contact your Primary Care Physician (PCP) or call 1.866.682.9492 (toll-free) for medical advice.

VHP has several network urgent care clinics, many with services available on a walk-in basis. Walk-in days/hours are subject to change, please call ahead to confirm (see page 11).

Out-of-Network Urgent Care ServicesIf it is necessary to receive urgent care services outside of the VHP service area and it is during VHP business hours (M–F, 9am –5pm), please call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free). A Member Services Representative can assist you by either directing your call to a VHP nurse for advice and/or by obtaining approval to seek services with an out-of-network urgent care provider.

If after business hours, please call 1.866.682.9492 (toll-free) for medical advice. They can direct you to the closest medical facility. When seeking services, present your VHP ID card as well as another form of photo ID.

Except in the case of an urgent medical need or emergency services, prescriptions must be filled at a VHP network pharmacy location (see page 7) unless pre-authorized. Pharmacy location information is also available at www.valleyhealthplan.org or by calling Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

All follow-up care for out-of-network urgent care services must be provided by your VHP PCP unless pre-authorized by Valley Health Plan.

Provider Search

To locate an Urgent Care location near you, visit the VHP website at www.valleyhealthplan.org


Urgent Care LocationsAlmaden Family Physicians 6475 Camden Avenue, Suite 105 San Jose, CA 95120 Hours: M–F, 5pm–6:30pm Sa, 9am –4:30pm Su, 11am–3:30pm Walk-in Clinic 408.997.9155

Cupertino Medical Center 10050 Bubb Road Cupertino, CA 95014 Hours: M-Sa, 8am–8pm Walk-in Clinic 408.996.8805

Gateway Family Medical Center 1580 S. Winchester Boulevard, Suite 202 Campbell, CA 95008 Hours: M–F, 9am–5pm Walk-in Clinic 408.364.7600

Nga V. Pham, MD 1569 Lexann Avenue, Suite 112 San Jose, CA 95121 Hours: M–F, 9am–6pm Sa, 9am–3pm Appointment & Walk-in Clinic 408.532.0105

Pinnacle Healthcare (U.S. HealthWorks) 7793 Wren Avenue Gilroy, CA 95020 Hours: M–F, 8am–7pm Sa, 9am–4pm Walk-in Clinic 408.848.0444

Samaritan Medical Care Center 554 Blossom Hill Road San Jose, CA 95123 Hours: M-F, 8am–6pm Sa–Su, 9am–3pm Walk-in Clinic 408.281.2772

San Jose Medical Group Willow Glen Branch 625 Lincoln Avenue San Jose, CA 95126 Hours: Daily, 8am–8pm Appointment & Walk-in Clinic 408.278.3620

Santa Clara Valley Medical Center Express Care (1st Floor, West Entrance) 751 S. Bascom Avenue San Jose, CA 95128 Hours: Daily, 9am–12am Walk-in Clinic 1.888.334.1000

South Valley Family and Occupational Health Center 9460 No Name Uno, Suite 230 Gilroy, CA 95020 Hours: M,Tu,Th, 8:30am–5pm W, 9am–2pm & F, 8:30am–3pm Walk-in Clinic 408.842.1544

Valley Health Center Moorpark Adult Urgent Care Only 2400 Moorpark Ave., Suite 118 San Jose, CA 95128 Hours: M–F, 8:30am–10pm Sa/Su/Holiday, 8:30am–5pm Closed Thanksgiving & Christmas By Appointment Only 1.888.334.1000

Valley Health Center East Valley Adult & Pediatric Urgent Care 1993 McKee Road San Jose, CA 95133 Hours: M-F, 8am–9:30pm Sa–Su, 8am–5pm By Appointment Only 1.888.334.1000

Valley Health Center Bascom Pediatric Urgent Care Only 750 S. Bascom Ave. San Jose, CA 95128 Hours: M–F, 8:30am–9pm Sa, 8:30am–8pm Su/Hol, 8:30am–5pm By Appointment Only 1.888.334.1000


Emergency ServicesIn the case of a life-threatening situation or an emergency, call 911 or go to the nearest emergency department.

The emergency department is for emergency situations only. Examples of emergency situations include, but are not limited to, the following:

• Severe bleeding

• Difficulty breathing

• Chest pain or pressure

• Broken bones

• Trauma or injury to the head

• Sudden dizziness

• Difficulty seeing

• Severe pain

Emergency visits are reviewed by Valley Health Plan. Inappropriate or unnecessary use of emergency services could result in denying payment for your visit which would then become your financial responsibility. If your situation is not life-threatening and you are unsure if your situation is an emergency, call 1.866.682.9492 (toll-free) for 24/7 Medical Advice.

If you are admitted to a hospital, immediately call 1.800.303.7845. During VHP business hours (M–F, 9am–5pm), please call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

When Emergency Services are received at a facility other than a Plan Hospital and you are not admitted, you must contact VHP for Authorization of Covered Services as soon as reasonably possible.

Note: Follow-up care must be provided by your VHP PCP unless pre-authorized by Valley Health Plan.


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

Medical Advice services are available 24/7 by calling 1.866.682.9492 (toll-free). To receive any Medically Necessary hospital or facilities Covered Services:

• Your Primary Care Physician will arrange for all Covered Services, including inpatient, transitional, and/or care provided in a sub-acute or Skilled Nursing Facility.

• Authorization is required for all facilities care and VHP should be notified of any such care either prior to admission or, as in the event of an emergency, as soon as possible thereafter.

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

Lucile Packard Children’s Hospital 725 Welch Road Palo Alto, CA 94304

O’Connor Hospital 2105 Forest Avenue San Jose, CA 95128

Saint Louise Regional Hospital 9400 No Name Uno Gilroy, CA 95020

Stanford Hospital 300 Pasteur Drive Palo Alto, CA 94305

Santa Clara Valley Medical Center 751 S. Bascom Avenue San Jose, CA 95128


Outpatient Mental Health Counseling Services Valley Health Plan (VHP) provides improved access to mental health counseling services for VHP Members. A referral from your Primary Care Physician (PCP) is no longer required, although you may want to discuss your need for this type of service with your PCP.

To access outpatient mental health counseling services, please contact a VHP Mental Health Provider directly or contact the VHP Utilization Management Department at 408.885.4647. A list of providers can be found by using the Provider Search at www.valleyhealthplan.org

Outpatient Psychiatric ServicesPrior Authorization is required to receive outpatient Mental Health Services provided by a Psychiatrist. Contact your PCP or your VHP Network Mental Health Provider for a referral. All referrals are reviewed by VHP’s Mental Health Medical Director.

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

Acupuncture and Chiropractic ServicesValley Health Plan covers Acupuncture and Chiropractic Services when referred by your PCP. Once your referral is approved by VHP, you will receive a copy of the authorization. Coverage includes a maximum of twenty (20) pre-authorized visits per calendar year with a $10.00 copayment per visit. A list of providers can be found by using the Provider Search at www.valleyhealthplan.org

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

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


Health EducationYour health and well-being is important to us - mind, body and spirit. Access to information to help you stay healthy and improve your sense of well-being is just a click away. Visit us at www.valleyhealthplan.org under Members > Health & Wellness to find:

Classes and Events

Search our free classes and events for activities that interest you. We offer exercise & fitness classes for all activity levels, classes to help you prevent or learn to self-manage chronic diseases, prenatal education classes and more! Browse through our class descriptions to find a class that interests you and get started on your path to wellness! Here’s how…

1. Visit www.valleyhealthplan.org under Members > Health & Wellness > Classes.

2. Select a class from the online class schedule.

3. Pre-register for the class online or by calling 408.885.3490.

4. Wait for a confirmation from a Health Education Team Member.

5. Attend the class with your VHP ID card and complete any paperwork needed.

6. Complete and turn in an evaluation for the class, as requested.

Additional classes may be available through your selected Provider Network/Medical Group.

Health Tools

Learn about your health risks and how to get active from using these interactive online tools.

Nutrition Tips

Get tips on eating out, how to read food nutrition facts labels and make a personal customized eating plan!

Recipes

Browse through healthy recipes and cookbooks offered by leading national health organizations. Each organization has something different to offer from cultural recipes to recipes that keep your busy schedule in mind!

Videos

Watch videos that help explain physical activity with topics including guidelines, tips, how to do muscle strengthening exercises properly and aerobic exercise.

If you need assistance or have any questions, please contact the Health Education Department at 408.885.3490, [email protected], or by using our online form.

Classes are subject to change, please call to confirm class schedule before attending.


ProviderNetwork Information

About this sectionValley Health Plan offers many provider choices for you and your family. Additional Medical Groups have been added to the VHP Network giving you even more choices on locations and how you will access your health care from Primary Care to Specialty Care and Network locations for other services.

Getting Started is Easy.

1. Choose Your Network – Find out which Network will fit best for you and your family.

Community Clinics .............................................................................................17

Independent Practice ...........................................................................................21

Palo Alto Medical Foundation (PAMF) ................................................................22

San Jose Medical Group (SJMG) ...........................................................................25

Santa Clara Valley Medical Center (SCVMC) .......................................................26

2. Choose Your Doctor – Go to the Provider Search at www.valleyhealthplan.org to find the Primary Care Physician (PCP) most convenient for you or call Member Services for further assistance.

3. Make Your Choice – If newly enrolling with VHP, include your PCP choice on your VHP Application. If you would like to change your PCP, contact Member Services for assistance.

4. Make an Appointment – Once you receive your VHP ID card with your PCP choice, call to schedule an appointment. For PCP contact information, go to the Provider Search at www.valleyhealthplan.org or contact Member Services for assistance.

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Community Clinics

The partnership of these health center providers maintain a workforce that reflects the diversity of the patients and communities they serve. These health centers provide primary care for adults, children including prenatal care. VHP Members choosing a Community Clinic PCP will receive their specialty care through Valley Specialty Center at Santa Clara Valley Medical Center.

These Community Clinics are located throughout Santa Clara County.

• Asian Americans for Community Involvement (AACI)

• Gardner Family Health Network (5 health centers)

• Indian Health Center of Santa Clara Valley

• MayView Community Health Centers (3 health centers)

• North East Medical Services (NEMS)

• Planned Parenthood (7 health centers)

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Primary Care Clinic Locations/Doctor’s Offices1. Asian Americans for Community

Involvement (AACI) 2400 Moorpark Avenue, Suite 319 San Jose, CA 95128 Hours: M–F, 8:30am–5:30pm Phone/Appointment Line 408.975.2763

2. Gardner Family Health Network Alviso Health Center 1621 Gold Street Alviso, CA 95002 Hours: M–F, 8am–5:30pm Phone/Appointment Line 408.935.9983

3. Gardner Family Health Network CompreCare Health Center 3030 Alum Rock Avenue San Jose, CA 95127 Hours: M–Sa, 8:30am–5:30pm Phone/Appointment Line 408.272.6300

4. Gardner Family Health Network Gardner Health Center 195 E. Virginia Street San Jose, CA 95112 Hours: M–F, 8:30am–5:30pm Phone/Appointment Line 408.998.8815

5. Gardner Family Health Network South County Health Center 700 W. 6th Street, Suite F Gilroy, CA 95020 Hours: M–F, 8:30am–5:30pm Phone/Appointment Line 408.848.9400

6. Gardner Family Health Network St. James Health Center 55 E. Julian Street San Jose, CA 95112 Hours: M–F, 8:30am–5:30pm Phone/Appointment Line 408.918.2600

7. Indian Health Center of Santa Clara Valley 1333 Meridian Avenue San Jose, CA 95125 Hours: M–W&F, 8am– 5pm Th, 8am–8pm Phone/Appointment Line 408.445.3400

8. MayView Community Health Center Mountain View Clinic 100 N. Moffett Boulevard, Suite 101 Mountain View, CA 94043 Hours: M,W–F, 8:30am–5pm T, 12pm–8:30pm Phone/Appointment Line 650.965.3323

9. MayView Community Health Center Palo Alto Clinic 270 Grant Avenue Palo Alto, CA 94306 Hours: M&Th, 12pm– 8:30pm Tu–W&F, 8:30am–5pm Phone/Appointment Line 650.327.8717

10. MayView Community Health Center Sunnyvale (Columbus) Clinic 785 Morse Avenue Sunnyvale, CA 94085 Hours: M&W, 8:30am–12pm Th–F, 8:30am–4:30pm Phone/Appointment Line 408.746.0455

Co

mm

unit

y C

lin

iCs


11. North East Medical Services (NEMS) San Jose Clinic 1715 Lundy Avenue, Suites 108-116 San Jose, CA 95131 Hours: M–Sa, 8:30am–12pm & 1pm–5pm Phone/Appointment Line 408.573.9686

12. Planned Parenthood Blossom Hill Health Center 5440 Thornwood Drive, Suite G San Jose, CA 95123 Hours: M–F, 8:30am–5pm Phone/Appointment Line 408.573.9686

13. Planned Parenthood Eastside Health Center 3131 Alum Rock Avenue San Jose, CA 95127 Hours: M&Th, 8:30am–7pm Tu, 8am–5pm W&F, 8:30am–5pm Phone/Appointment Line 408.729.7600

14. Planned Parenthood Mar Monte Community Clinic 2470 Alvin Avenue, Suite 80 San Jose, CA 95121 Hours: M–F, 8:45am–5pm Sa, 8:45am– 1pm Phone/Appointment Line 408.274.7100

15. Planned Parenthood Mountain View Health Center 225 San Antonio Road Mountain View, CA 94040 Hours: M,W&F, 8:30am–5pm Tu&Th, 8:30am–7pm Phone/Appointment Line 650.948.0807

16. Planned Parenthood Sunnyvale Health Center 604 E. Evelyn Avenue Sunnyvale, CA 94086 Hours: M&W, 8:45am–7pm Tu,Th&F, 8:45am–5pm Phone/Appointment Line 408.739.5151

17. Planned Parenthood Gilroy Health Center 760 Renz Lane Gilroy, CA 95020 Hours: M&W, 9:30am–5:30pm Tu,Th&F, 8:45am–5pm Phone/Appointment Line 408.847.1739

18. Planned Parenthood San Jose Health Center 1691 The Alameda San Jose, CA 95126 Hours: M–T, 8:30am–5pm F, 7:30am–5pm Phone/Appointment Line 408.287.7526

(continued)

Co

mm

unity C

liniC

s


SpecialistsCommunity Clinics patients will be referred by their Primary Care Physician or other approved VHP Plan Provider to see a Network Specialist. VHP Members choosing a Community Clinic PCP will receive their specialty care through Valley Specialty Center at Santa Clara Valley Medical Center. Once approved, information will be given on how to schedule an appointment with the specialist.

LaboratoryCommunity Clinics patients are covered within VHP Network Laboratories (see pages 8-9).

PharmacyCommunity Clinics patients are covered within VHP Plan Pharmacy Network (see page 7).

Urgent CareCommunity Clinics patients are covered within VHP Network Urgent Care Locations (see page 11).

Emergency CareCommunity Clinics patients are covered within VHP Network Plan Hospitals (see page 13).

In the event of an Emergency and you cannot safely come to a Plan Hospital, you should call 911 or seek care at the closest hospital.

IND

EPEN

DEN

T PR

AC

TIC

E


Independent Practice Independent Practice Providers are Primary Care Physicians who work out of their own private offices.

VHP contracts with the following associations for primary care services only.

Primary Care Clinic Locations/Doctor’s OfficesA list of providers can be found by using the “Provider Search” at www.valleyhealthplan.org

SpecialistsIndependent Practice patients will be referred by their Primary Care Physician or other approved VHP Plan Provider to see a Network Specialist. VHP Members choosing an Independent Practice PCP will receive their specialty care through Valley Specialty Center at Santa Clara Valley Medical Center. Once approved, information will be given on how to schedule an appointment with the specialist.

Laboratory

Independent Practice patients are covered within VHP Network Laboratories (see pages 8-9).

PharmacyIndependent Practice patients are covered within VHP Plan Pharmacy Network (see page 7).

Urgent CareIndependent Practice patients are covered within VHP Network Urgent Care Locations (see page 11).

Emergency CareIndependent Practice patients are covered within VHP Network Plan Hospitals (see page 13).


PALO

ALTO

MED

ICA

L FOUN

DA

TION

(PAM

F)


Palo Alto Medical Foundation (PAMF)Palo Alto Medical Foundation (PAMF) Primary Care Physicians (PCPs) and specialists are located mostly in north Santa Clara County (SCC). VHP Members choosing PAMF SCC will receive all services within the PAMF network.

If you are a resident of Alameda, San Mateo or Santa Cruz County, and are interested in choosing a PAMF Primary Care Provider located in those counties, please contact VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free). Our member advocates can verify if your PCP is contracted with VHP in those counties.

Primary Care Clinic Locations/Doctor’s Offices1. Los Altos Center

370 Distel Circle Los Altos, CA 94022-1442 Office hours: M–F, 7:30am–6pm Appointment Line 650.254.5200

2. Mountain View Center 701 E. El Camino Real Mountain View, CA 94040 Hours: Office hours vary. Talk to a PAMF patient service representative (PSR) about a doctor’s schedule. Main Phone 650.934.7000 or 408.739.6000

3. Palo Alto Center 795 El Camino Real Palo Alto, CA 94301 Hours: M–F, 9am–5:30pm Sa, 9am–12pm Main Phone 650.321.4121

4. Santa Clara Center–Family & Internal Medicine 2734 El Camino Real Santa Clara, CA 95051 Hours: M–F, 8am–5:30pm Main Phone 408.241.3801

5. Santa Clara Center–Pediatric Medicine 2652 El Camino Real Santa Clara, CA 95051 Hours: M–F, 8am–5:30pm Main phone 408.524.5952

6. Sunnyvale Center–Pediatric Medicine 201 Old San Francisco Road Sunnyvale, CA 94086 Hours: Office hours vary. Talk to a PAMF patient service representative (PSR) about a doctor’s schedule.Main phone 408.739.6000

7. Sunnyvale Center–Family & Internal Medicine 401 Old San Francisco Road Sunnyvale, CA 94086 Hours: Office hours vary. Talk to a PAMF patient service representative (PSR) about a doctor’s schedule. Main phone 408.739.6000

8. West Valley Center 7225 Rainbow Drive San Jose, CA 95129 Hours: M–F, 8am–5:30pm Family/Internal Medicine 408.366.0595 Pediatrics 408.524.5750

PALO

ALT

O M

EDIC

AL

FOUN

DA

TIO

N (

PAM

F)


SpecialistsPalo Alto Medical Foundation (PAMF) patients will be referred by their Primary Care Physician or other approved VHP Plan Provider to see a network specialist. Once approved, information will be given on how to schedule an appointment with the specialist.

LaboratoryPAMF patients are covered within the PAMF Network and VHP Network Laboratories (see pages 8-9)

1. Los Altos Center Laboratory 370 Distel Circle Los Altos, CA 94022 Hours: M–F, 7:30am–5:30pm Sa, 8am–12pm Laboratory Phone 650.254.5255

2. Mountain View Center Laboratory 701 E. El Camino Real, Floor 2 Mountain View, CA 94040 Hours: M–F, 6:30am–6:30pm Sa–Su, 7am–4 pm Laboratory Phone 650.934.7333 Laboratory Appointments 650.934.7345

3. Palo Alto Center Laboratory 795 El Camino Real Level 1, Lee Building Palo Alto, CA 94301 Hours: M–F, , 7am–6pm Sa, 8am–12pm Laboratory Phone 650.853.2948

4. Santa Clara Center Laboratory 2734 El Camino Real Santa Clara, CA 95051 Hours: M–F, 8am–5pm Closed 12:30pm–1:30pm Laboratory Phone 408.524.5708

5. Sunnyvale Center Laboratory (201) 201 Old San Francisco Road Sunnyvale, CA 94086 Hours: M–F, 8am–5pm Closed 1pm–2pm Laboratory Phone 408.730.4377

6. Sunnyvale Center Laboratory (401) 401 Old San Francisco Road Sunnyvale, CA 94086 Hours: M–F, 8am–5pm Closed 12:30pm–1:30pm Laboratory Phone 408.523.3576

7. West Valley Center Laboratory 7225 Rainbow Drive San Jose, CA 95129 Hours: M–F, 8am–5pm Closed 12:30pm–1:30pm Laboratory Phone 408.524.5709

(continued)

PALO

ALTO

MED

ICA

L FOUN

DA

TION

(PAM

F)


PharmacyPAMF patients are covered within the PAMF Pharmacy and VHP Plan Pharmacy Network (see page 7).

1. Palo Alto Center Pharmacy 795 El Camino Real, Lower Level A, Lee Building Palo Alto, CA 94301 Hours: M–F, 9am–6:30pm Sa, 9am–1pm Pharmacy Phone 650.853.6066

2. Mountain View Center Pharmacy 701 E. El Camino Real Mountain View, CA 94040 Hours: M–F, 9am–6pm Pharmacy Phone 650.934.7699

Urgent CarePAMF patients are covered within the PAMF Urgent Care Network and VHP Network Urgent Care Locations (see page 11).

1. Mountain View Center Urgent Care–Children & Adults 701 E. El Camino Real, Floor 2 Mountain View, CA 94040 Hours: M–F, 8am–9pm Sa, Su, Holidays, 8am–8pm Phone 650.934.7800

2. Palo Alto Center Urgent Care–Children Only 795 El Camino Real Level 1, Lee Building Palo Alto, CA 94301 Hours: M–F, 7am–9pm Sa, Su, Holidays, 8am–9pm Phone 650.321.4121

3. Palo Alto Center Urgent Care–Adults Only 795 El Camino Real Level 1, Lee Building Palo Alto, CA 94301 Hours: Daily, 7am–9pm Phone 650.321.4121

Emergency CarePAMF patients are covered within VHP Network Plan Hospitals (see page 13).


SAN

JO

SE M

EDIC

AL

GRO

UP (

SJM

G)


San Jose Medical Group (SJMG)San Jose Medical Group has served San Jose since 1955 offering a high quality of care at three (3) clinics and several affiliate locations.

Primary Care Clinic Locations/Doctor’s Offices

1. Good Samaritan Branch 2585 Samaritan Drive San Jose, CA 95124 Hours: M–Th, 8am–5pm F, 8am–12pm Phone 408.278.3000

2. McKee Branch 227 N. Jackson Avenue San Jose, CA 95116 Hours: M–Th, 8am–5pm F, 8am–12pm Phone 408.278.3000

3. Willow Glen Branch 625 Lincoln Avenue San Jose, CA 95126 Hours: M–Th, 8am–5pm F, 8am–12pm Phone 408.278.3000

SpecialistsSJMG patients will be referred by their Primary Care Physician or other approved VHP Plan Provider to see a Network Specialist. Once approved, information will be given on how to schedule an appointment with the specialist.

LaboratorySJMG patients are covered within VHP Network Laboratories (see pages 8-9).

PharmacySJMG patients are covered within the VHP Plan Pharmacy Network (see page 7).

Urgent CareSJMG patients are covered within the VHP Network Urgent Care Locations (see page 11).

Emergency CareSJMG patients are covered within VHP Network Plan Hospitals (see page 13).


SAN

TA C

LARA

VA

LLEY MED

ICA

L CEN

TER (SCV

MC

)


Santa Clara Valley Medical Center (SCVMC)Santa Clara Valley Medical Center and its health centers are owned and operated by the County of Santa Clara.

1. Valley Health Center Bascom 750 South Bascom Avenue San Jose, CA 95128 Appointments 1.888.334.1000

2. Valley Health Center East Valley 1993 McKee Road San Jose, CA 95116 Appointments 1.888.334.1000

3. Valley Health Center Gilroy 7475 Camino Arroyo Gilroy, CA 95020 Appointments 1.888.334.1000

4. Valley Health Center Milpitas 143 North Main Street Milpitas, CA 95035 Appointments 1.888.334.1000

5. Valley Health Center Moorpark 2400 Moorpark Avenue San Jose, CA 95128 Appointments 1.888.334.1000

6. Valley Health Center Sunnyvale 660 South Fair Oaks Avenue Sunnyvale, CA 94086 Appointments 1.888.334.1000

7. Valley Health Center Tully 500 Tully Road San Jose, CA 95111 Appointments 1.888.334.1000

SpecialistsSCVMC patients will be referred by their Primary Care Physician or other approved VHP Plan Provider to see a Network Specialist. VHP Members choosing a SCVMC PCP will receive their specialty care through Valley Specialty Center at Santa Clara Valley Medical Center. Once approved, information will be given on how to schedule an appointment with the specialist.

Primary Care Clinic Locations/Doctor’s Offices

SAN

TA C

LARA

VA

LLEY

MED

ICA

L C

ENTE

R (S

CV

MC

)


LaboratorySCVMC patients are covered within the SCVMC Network and VHP Network Laboratories (see pages 8-9).

1. Valley Health Center Bascom 750 South Bascom Avenue San Jose, CA 95128 Hours: M–F, 7:15am–7:15pm

2. Valley Health Center East Valley 1993 McKee Road San Jose, CA 95116 Hours: M–F, 8:00am–9:45pm Sa–Su, 8:00am–4:45pm

3. Valley Health Center Gilroy 7475 Camino Arroyo Gilroy, CA 95020 Hours: M–F, 8:00am–4:45pm

4. Valley Health Center Milpitas 143 North Main Street Milpitas, CA 95035 Hours: M–F, 8:00am–11:45am

5. Valley Health Center Moorpark 2400 Moorpark Avenue San Jose, CA 95128 Hours: M–F, 7:15am–7:15pm

6. Valley Health Center Sunnyvale 660 South Fair Oaks Avenue Sunnyvale, CA 94086 Hours: M-F, 8:30am–5:00pm

7. Valley Health Center Tully 500 Tully Road San Jose, CA 95111 Hours: M–F, 8:00am–5:00pm

8. Valley Specialty Center 751 S. Bascom Avenue San Jose, CA 95128 Hours: M–F, 7:30am–6:00pm

(continued)

SAN

TA C

LARA

VA

LLEY MED

ICA

L CEN

TER (SCV

MC

)


PharmacySCVMC patients are covered within the SCVMC Pharmacy and VHP Plan Pharmacy Network (see page 7). The SCVMC Plan pharmacies are for VHP Members receiving care from providers at SCVMC, Valley Specialty Center and Valley Health Centers ONLY.

1. Valley Health Center Bascom 750 South Bascom Avenue San Jose, CA 95128 Hours: M–F, 9am–12:30pm; 1:30pm–5:00pm Closed Weekends & all County Holidays Refill Line 408.885.2325

2. Valley Health Center East Valley 1993 McKee Road San Jose, CA 95116 Hours: M–F, 9am–9:30pm Sa–Su, 9am–5pm Closed Thanksgiving & Christmas Refill Line 408.254.6345

3. Valley Health Center Gilroy 7475 Camino Arroyo Gilroy, CA 95020 Hours: M–F, 9am–12:30pm; 1:30pm–5:00pm Closed Weekends & all County Holidays Refill Line 408.852.2300

4. Valley Health Center Lenzen 976 Lenzen Avenue San Jose, CA 95126 Hours: M, 8:30am to 7:00pm T–F, 8:30am to 5:00pm Closed Weekends & all County Holidays Refill Line 408.792.5169

5. Valley Health Center Milpitas 143 North Main Street Milpitas, CA 95035 Hours: M–F, 1pm–5pm Closed Weekends & all County Holidays Refill Line 408.957.0944

6. Valley Health Center Moorpark 2400 Moorpark Avenue San Jose, CA 95128 Hours: M–F, 9am–8pm Closed Weekends & all County Holidays Refill Line 408.885.7691

7. Valley Health Center Sunnyvale 660 South Fair Oaks Avenue Sunnyvale, CA 94086 Hours: M–Th, 9am–9pm F, 9am–5pm Closed Weekends & all County Holidays Refill Line 408.992.4960

8. Valley Health Center Tully 500 Tully Road San Jose, CA 95111 Hours: M–F, 9am–5pm Closed Weekends & all County Holidays Refill Line 408.817.1623

9. Valley Specialty Center 751 S. Bascom Avenue San Jose, CA 95128 Hours: Daily, 9am–10pm Refill Line 408.885.2325


SAN

TA C

LARA

VA

LLEY

MED

ICA

L C

ENTE

R (S

CV

MC

)


Urgent CareSCVMC patients are covered within VHP Network Urgent Care clinic locations (see page 11).

Emergency CareSCVMC patients are covered within VHP Network Plan Hospitals (see page 13).



MemberResources

About this sectionThis section has information helpful to VHP Members about VHP benefits, accessing care, and your membership.

Timely Access Guidelines ...............................................................................................31

Preventive Care Guidelines

For Adults ......................................................................................................................32

For Children ..................................................................................................................34

Summary of Benefits Table .............................................................................................36

Pharmacy Plan Benefit ....................................................................................................59

Member Rights and Responsibilities .............................................................................66

Privacy Notice ..................................................................................................................68

For additional information, go to www.valleyhealthplan.org or contact VHP Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free).


Timely Access GuidelinesThe State of California regulations require that health plans meet following Access Guidelines for the following services. VHP is working with our network of providers to insure that these Access Guidelines are being met.After Hours Care 24/7 Medical Advice Line Our 24/7 Medical Advice Line at 1.866.682.9492

(toll-free) is available to you seven days a week every day of the year.

Appointment Scheduling Maximum Waiting TimeEmergency Services ImmediatelyUrgent Care appointments that do not require prior authorization (PCP)

Must offer the appointment within 48 hours of request

Urgent Care appointments that require prior authorization

Must offer the appointment within 96 hours of request

Non-urgent appointments for Primary Care (PCP)

Must offer the appointment within 10 business days of the request

Non-urgent appointments with Specialist physicians


Non-urgent appointments for ancillary services (for diagnosis or treatment of injury, illness, or other health condition)


Accessibility of Obstetrical CareEmergency exam ImmediatelyInitial visit Within 30 calendar daysNon-urgent subsequent exams Within 30 calendar days

Availability of Behavioral Health CareLife-threatening emergency ImmediatelyNon-life threatening emergency Within 6 hoursUrgent Care appointments Must offer the appointment within 48 hours of

requestNon-Urgent Care appointments with a non-physician mental health care provider

Must offer the appointment within 10 business days of request

Non-urgent appointments with a physician mental health care provider

Must offer the appointment within 10 business days of request

Access to Follow-up Care After Hospitalization for mental illness

Must Provide Both: One follow-up encounter with a mental health provider within 7 calendar days after discharge Plus: One follow-up encounter with a mental health provider within 30 calendar days after discharge

32

Phys

ical

Exa

min

atio

n

Test

ing

and

Proc

edur

es

His

tory

A c

ompl

ete

med

ical

his

tory

sho

uld

be o

btai

ned

with

the

first

few

vis

its. I

t is

reco

mm

ende

d th

at p

rovi

ders

ask

abo

ut a

nd c

ouns

el p

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rega

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g hi

gh-r

isk

beha

vior

s, in

clud

ing

but n

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mite

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rega

rdin

g to

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ol a

nd il

licit

drug

use

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rs s

houl

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k pa

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s ab

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ympt

oms

of

dep

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and

they

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r adu

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loss

, vis

ual i

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ided

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33

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Table of ContentsProfessional Services ........................................ 37

Primary Care Physician (PCP) ServicesPlan Specialist Care

Outpatient Services .......................................... 38Pediatric/Well-Child CareAdult Periodic Health Examinations Preventive Services Without Cost-Sharing Physical ExaminationsWell-Woman ExaminationMammography ScreeningAllergy Testing and Treatment Dermatology ServicesDiagnostic Laboratory ServicesHIV, AIDS, or Other Infectious Diseases TestingImmunizations and Injections Travel ImmunizationsOptometry ServicesOphthalmology ServicesPodiatry ServicesTherapy Services

Outpatient Hospital Services ............................ 41Outpatient Hospital or Surgical Center

Hospitalization Services (Non-Emergent or Scheduled Admissions) ........ 41

Inpatient Hospital Care

Skilled Nursing Services ................................... 42Skilled Nursing Care - Inpatient

Rehabilitation Services ..................................... 43Rehabilitation Care - Inpatient

Emergency Services and Ambulance .................. 44Emergency ServicesAmbulance Services

Medical Transportation Services ....................... 45Medical Transportation

Urgently Needed Services ................................. 45Urgently Needed Services - VHP Network Urgently Needed Services - Non-VHP Network

Prescription Drugs, Medications, and Pharmacy Services ..................................... 46

Prescription Drugs

Durable Medical Equipment - Medical Supplies and Equipment ....................... 47

Medical Supplies and Equipment

Mental Health Services..................................... 48Outpatient Mental Health Services and Behavioral Health Treatment ServicesOutpatient Mental Health and Behavioral Health Treatment Services provided by a Psychiatrist Prescription Drugs for Mental Health ConditionsInpatient Mental Health Services and Behavioral Health Treatment Services

Chemical Dependency Services (Alcoholism and Drug Abuse) .......................... 49

Substance Abuse Services - OutpatientDetoxification Substance Abuse Services, i.e. Hospital based – Inpatient Residential (intermediate-term) Recovery Services

Home Health and Hospice Services.....................50Home Health CareDialysis ServicesHospice Care

Acupuncture Services ....................................... 51Acupuncture Services

Cancer Clinical Trial Services ........................... 51Cancer Clinical Trial Services

Chiropractic Services ....................................... 51Chiropractic Services

Dental Services ............................................... 52Dental ServicesTemporomandibular Joint (TMJ) Disorders ServicesDental Services - Plan Hospital or Surgery Center

Family Planning Services.................................. 53Artificial Insemination ServicesFamily Planning ServicesInfertility Diagnosis and Treatment

Maternity Services .......................................... 55Maternity CareCircumcisionGenetic Counseling Services

Sterilization Services ........................................ 57Sterilization Services

Abortion Services............................................. 57Abortion Services

Health Education Services ................................ 57Health Education and Health Promotion Services

Reconstructive and Cosmetic Surgery Services ............................................... 58

Reconstructive Surgery

Transplant Services .......................................... 58Human Organ, Tissue, and Bone Marrow Transplantation Services

Summary of Benefits Table


Summary of Benefits Table—Group Coverage

Visit our website: www.valleyhealthplan.org

THIS SUMMARY OF BENEFITS TABLE (MATRIX) IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND TO HELP YOU UNDERSTAND VALLEY HEALTH PLAN (VHP) COVERED BENEFITS. THE TABLE IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND DISCLOSURE FORM/VALLEY HEALTH PLAN BENEFITS AND COVERAGE HANDBOOK OR GROUP SERVICE AGREEMENT (PLAN CONTRACT WITH YOUR EMPLOYER) SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERED BENEFITS AND LIMITATIONS.

COPAYMENT MAXIMUM (No Deductibles)Individual: $1,000 per Calendar Year

Family: $2,000 per Calendar YearMaximum Lifetime Benefit: Unlimited

Professional ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

$0 Copayment Your PCP will provide, arrange, and/or coordinate all your routine medical care.

Call to schedule an appointment with your VHP Network PCP.

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

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

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

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

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

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

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

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


Summary of Benefits Table—Group CoverageOutpatient ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

$0 Copayment Call to schedule an appointment with your child’s VHP Network PCP.


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

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

Preventive Services Without Cost-Sharing rated A or B by the US Preventive Services Task Force, recommended immunizations, preventive care for children and adolescents, additional preventive care and screenings for women.

$0 Copayment Call to schedule an appointment with your VHP Network PCP.


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

Physical Examinations for Routine Care including diagnostic services and the testing and treatment of phenylketonuria (PKU).

Vision and hearing screening examinations to determine the need for vision or hearing correction as provided by your PCP.

$0 Copayment Call to schedule an appointment with your VHP Network PCP.


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

Well-Woman Examinations including diagnostic services, a pelvic and breast examination, and Pap smear.

Annual cervical screening includes PAP tests, a human papillomavirus screening that is approved by the federal Food and Drug Administration, and the option of any cervical cancer screen test approved by the FDA (i.e. liquid based prep test).

$0 Copayment Call to schedule an appointment with your VHP Network Provide.


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



For Member Services, call 408.885.4760.

Outpatient Services, continuedBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

$0 Copayment Your Plan Physician will order when Medically Necessary.

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

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

Allergy Testing and Treatment including allergy serum and injection services.


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

Dermatology Services for Routine Care

$0 Copayment Call your Plan network office to schedule Covered Services from a VHP network dermatologist.

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

$0 Copayment Your Plan Physician will make arrangements when Medically Necessary.

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

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

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

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

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

$0 Copayment You may call Santa Clara County Public Health Travel Clinic to obtain travel immunizations at 408.792.5200 or, as available, from a VHP Plan Provider.


Summary of Benefits Table—Group CoverageOutpatient Services, continuedBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Optometry Services for vision screening, including a wide range of diagnostic testing, which include screening for cataracts, diabetes, and Glaucoma. As needed you will be referred to the Ophthalmology Department.

Note: Your employer may offer a vision benefit plan that provides optometry services including eye refraction examinations for eyeglass/lens prescription.

$0 Copayment Call your Plan network office to schedule Covered Services from a VHP network optometrist.

Refer to Limitations and Exclusions.

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

Refraction examinations are limited to one (1) per year.

Eyeglass lenses, frames, and contact lenses including fitting anddispensing (except for special contact lenses to treat aphakia or aniridia), non-implant low vision aides, and correction of visual acuity or refractive errors are excluded from your Benefit Plan.

VHP does not cover any copayments or costs through your employer vision plan(s).

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

$0 Copayment Your VHP Network Provider will refer you to a Plan Specialist.

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

Radial keratotomy is excluded from your Benefit Plan.

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


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

Orthotic appliances must be Medically Necessary devices to restore bodily functions essential to activities of daily living, prevent significant physical disability or serious deterioration of health or alleviate severe pain. Orthotic appliances are limited to one (1) per year, unless Medically Necessary with Prior Authorized. Refer to the “Durable Medical Equipment (DME)” section of this Summary of Benefits Table.

Surgery is limited to Reconstructive Surgery.

Routine/cosmetic foot care and Cosmetic Surgery is excluded from your Benefit Plan.

Therapy Services including Physical, Occupational, Speech, and Respiratory Therapy Services are provided as necessary, which includes maintaining or preventing deterioration of a patient’s chronic physical or mental condition, including Severe Mental Illness.

$0 Copayment Your VHP Network Provider will refer you to a Plan Specialist.

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

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



For Benefit Information, call 408.885.4760.

Outpatient Hospital ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

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

$0 Copayment Your VHP Network Provider will make arrangements when Medically Necessary to a Plan Provider that most appropriately meets your medical needs.

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

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

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

Inpatient Hospital Services at your primary Plan Hospital, provides Hospital Services including physician and surgeon care, semi-private room and board, intensive care, operating room, inpatient drugs, X-ray, lab, supplies, anesthesia, acute rehabilitation, dialysis, radiation therapy, cathode ray scanning, and blood, blood derivatives, and transfusions (blood bank).

$0 Copayment Your VHP Network Provider will make arrangements when Medically Necessary to a Plan Hospital that most appropriately meets your medical needs.

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

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

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


Summary of Benefits Table—Group CoverageSkilled Nursing ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

$0 Copayment To obtain care you must receive a written referral from your VHP Network Provider and Prior Authorization from VHP to a Plan Facility.

Coverage is limited to a maximum of 100 days per Calendar Year.

If you request a private room, you must pay the difference between the Plan Facility or Hospital’s charge for a private room and a semi-private room.

Coverage is limited to care which:

• is skilled and required on a daily basis,

• is not Custodial Care, and

• as a practical matter, can only be provided on an inpatient basis.

Conditions which are:

• long-term, or

• chronic in nature, and require ongoing inpatient skilled nursing care are excluded from your Benefit Plan after you receive 100 days of care each Calendar Year.

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



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

Rehabilitation ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

Benefits include a semi-private bed and board, nursing, social services, drugs, X-ray, lab, supplies, blood, blood derivatives, and transfusions (blood bank), and Durable Medical Equipment ordinarily furnished by the rehabilitation center.

$0 Copayment To obtain care you must receive a written referral from your VHP Network Provider and Prior Authorization from VHP to a Plan Facility.

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

If you request a private room, you must pay the difference between the Plan Facility or Hospital’s charge for a private room and a semi-private room.

Coverage is limited to care which:

• is not Custodial Care, and

• as a practical matter, can only be provided on an inpatient basis.


Summary of Benefits Table—Group CoverageEmergency Services and AmbulanceBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

• serious impairment to bodily functions,

• serious dysfunction of any bodily organ or part, or

• places your health or psychological wellbeing in serious jeopardy.

Emergency Services also includes additional screening, examination, and evaluation by a physician, or other personnel to the extent, permitted by applicable law and within the scope of their licensure and clinical privileges, to determine if a Psychiatric Emergency Medical Condition exists, and the care and treatment necessary to relieve or eliminate the Psychiatric Emergency Medical Condition, within the capability of the facility.

$0 Copayment If you think you have an Emergency medical condition, call 911 or go to the nearest hospital.

You must receive Covered Services from a Plan Hospital if it is reasonable to do so considering your condition or symptoms.

You will be evaluated by Emergency medical professionals. If it is determined that you are to be admitted to a hospital, VHP must be contacted for Authorization of Services.

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

If you receive Emergency Services and the decision is made to admit you to a hospital, VHP must be contacted before your admission or as soon as reasonably possible. Once your condition stabilizes, you may be transferred to a Plan Hospital.

When Emergency services are received at a facility other than a Plan Hospital and you are not admitted, you must contact VHP for Authorization of Covered Services as soon as reasonably possible.

Ambulance Services includes emergency transportation to the closest hospital.

$0 Copayment Call 911 for emergency ambulance transportation.

You, your representative, or the ambulance service must contact VHP to report the emergency ambulance transportation as soon as reasonably possible.

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




Medical Transportation ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Medical Transportation including inter-facility transfers.

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

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

Urgently Needed ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

$0 Copayment Call 1.866.682.9492 (toll-free) for medical advice, a nurse will assess your condition and direct you to the appropriate care. Valley Health Plan offers several Urgent Care Clinics; some require an appointment; some are walk-in clinics.

For a complete list of Plan urgent care clinics, including the walk-in clinic locations, visit the VHP website at www.valleyhealthplan.org or call Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for assistance. Present a form of ID and your VHP ID Card when seeking services.

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

Urgently Needed Services provided at non-VHP Network Providers, when you are out of your Service Area (Santa Clara County), include Medically Necessary services for an illness or injury which, if left untreated for a period in excess of 48 hours, in the view of a prudent layperson or physician, is likely to lead to a serious deterioration in the patient’s health or significant disability.

$0 Copayment Call 1.866.682.9492 (toll-free). An advice nurse will assess your condition and direct you to the appropriate care; or go directly to a Plan walk-in clinic; or go directly to the nearest urgent care center, present your VHP ID Card and ask the provider or someone acting on your behalf to call VHP.

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


Summary of Benefits Table—Group CoveragePrescription Drugs, Medications, and Pharmacy ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Prescription Drugs including outpatient prescription drugs, diaphragms, birth control, insulin, glucagon, and other prescriptive medications for the treatment of diabetics at Plan Pharmacies from the Plan’s drug Formulary. Birth control includes any FDA approved contraceptive or medically appropriate prescribed contraceptive methods.

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

$0 Copayment When you have received a prescription from your Plan Physician, you must have it filled at your Plan Pharmacy.

Provide your VHP ID Card and the prescription to the Plan Pharmacy.

Prescription Fill Options:

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

Mail Service Pharmacy: You have the option of using our Mail Service Pharmacy, which only offers prescriptions to be mailed to your home. Once a prescription is filled by the Mail Service Pharmacy, the prescription cannot be transferred to another Plan Pharmacy. Contact the Plan’s Pharmacy Benefit Manager at 1.866.333.2757 (toll-free). For additional information go to www.valleyhealthplan.org or contact VHP Member Services Department at 408.885.4760 or 1.888.421.8444 (toll-free).

Out-of-Network: Should you need to obtain a prescription associated with Out-of-Network Emergency Services or Urgently Needed Services, take your prescription to a Plan Pharmacy. If a Plan Pharmacy is not available, VHP will cover the prescription filled at an Out of Network Pharmacy. You may submit your claim to PBM or VHP for payment.

Formulary: For Formulary information, call VHP’s PBM at 1.866.333.2757(toll-free) or visit www.valleyhealthplan.org

Prescription drugs and supplies are limited to prescriptions written by Plan-authorized providers when deemed Medically Necessary and in accordance with professionally recognized standards of care.

Medically Necessary prescription drugs are limited to:

• drugs approved by the FDA,

• generic equivalents approved as substitutable by the FDA,

• drugs approved by the FDA as Treatment Investigational New Drugs, or

• drugs classified as Group C cancer drugs by the National Cancer Institute to be used only for the purposes approved by the FDA or the National Cancer Institute.

Medications, not Medically Necessary, including travel patches, cosmetics, herbal products and treatments, dietary supplements, health or beauty aids, are excluded from the Benefit Plan.

For most oral medications, a Prescription Unit represents a single course of treatment or up to a 90 day supply for chronic illness.

Your pharmacy benefit is limited to prescriptions filled at a Plan Pharmacy.

Medically Necessary antibiotics and pain medications prescribed by your dentist, or optometrist must be filled by your Plan Pharmacy. Other prescriptions written by dentists, Non-Plan optometrists are not covered by VHP.

You may be financially responsible for lost or misplaced medications. The PBM or pharmacist will advise you of all charges.

PKU formula and special food product reimbursement is limited to the amount and duration that the Plan Physician deems Medically Necessary.

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

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



For Health Education Information, call 408.885.3490.

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

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

• are ordered by your Plan Physician,

• are obtained at the Plan Provider for DME,

• primarily serve a medical purpose, and

• are appropriate for use in the home.

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

DME Diabetic supplies include blood glucose monitors and blood glucose testing strips; blood glucose monitors designed to assist the visually impaired; insulin pumps and all related necessary supplies; ketone urine testing strips; lancets and lancet puncture devices; pen delivery systems for the administration of insulin; podiatry devices to prevent or treat diabetes-related complications; insulin syringes; and visual aides, excluding eyewear, to assist the visually impaired with proper dosing of insulin.

$0 Copayment Your Plan Physician will prescribe or arrange for Prior Authorization when Medically Necessary.

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

Medical supplies are limited to equipment and devices which:

• are intended for repeated use over a prolonged period,

• are not considered disposable, with the exception of ostomy bags and diabetic supplies,

• do not duplicate the function of another piece of equipment or device covered by VHP, and

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

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

Any purchase or customization of living environment or automobile (e.g. home ramps, swimming pools/hot tubs, doorway enlargements, air conditioners, waterbeds, or any other equipment which could be used in the absence of an injury or illness) are excluded from your Benefit Plan.

Braces or other devices primarily for use in athletic competition or recreational activities are excluded from your Benefit Plan.

Prescribed hearing aid benefits are limited to once every 36 months and up to a coverage maximum of $1,000.00, regardless of the number of hearing aides or devices prescribed.

Shoe inserts and over the counter (OTC) medical supplies and equipment are excluded from your Benefit Plan. OTC items include but are not limited to garter belts, and similar devices, experimental or research equipment and devices not Medically Necessary.

Orthotic and prosthetic appliances are limited to Medically Necessary devices to restore bodily functions essential to activities of daily living, prevent significant physical disability or serious deterioration of health or alleviate severe pain.


Summary of Benefits Table—Group CoverageMental Health ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Outpatient Mental Health and Behavioral Health Treatment Services - Outpatient Mental Health and Behavioral Health Treatment Counseling Services include, but are not limited to assessment, diagnosis, and treatment planning, individual and group psychotherapy. Including applied behavior analysis and evidence-based behavior intervention programs that develop or restore, to the maximum extent practical, the functioning of an individual with Pervasive Developmental Disorder or Autism. These services are provided by Psychologists (PhD), Marriage and Family Counselors (MFCC/MFT) and Licensed Clinical Social Workers (LCSW).

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

Outpatient Mental Health and Behavioral Health Treatment Services provided by a Psychiatrist for evaluation and treatment including prescribed psychological and neuropsychological testing, crisis intervention, crisis residential services and partial hospital services.

Services include Medically Necessary treatment for Severe Mental Disorders and Serious Emotional Disturbances of a Child or Adolescent.

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

Prescription Drugs for Mental Health Conditions Services include prescription Drugs/medications and pharmacy services. Prescription drugs must be written by a Plan Psychiatrist or Primary Care Physician (PCP).

$0 Copayment No Prior Authorization is required for Outpatient Mental Health and Behavioral Health Treatment Counseling Services; however, you may contact VHP’s Utilization Department at 408.885.4647 for assistance in obtaining care or you may contact a Mental Health Plan Provider directly.

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

You must obtain Prior Authorization before receiving Outpatient Mental Health and Behavioral Health Treatment Services provided by a Psychiatrist.

To obtain prior authorization call VHP’s Utilization Department at 408.885.4647 or contact your PCP for a referral.

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

Outpatient mental health services are limited to Medically Necessary treatment of a mental health condition. Such treatment is covered in the amount, frequency, or duration required to ensure the Member no longer medically requires treatment, or to the time where it is determined that benefit, or further benefit from treatment is unlikely.

Mental health services for Members who are incarcerated, or that are court ordered, or as a condition of parole or probation are excluded from your Benefit Plan, unless determined Medically Necessary by the Medical Director.

If you seek outpatient mental health services from an Out-of-Network Mental Health Provider without Prior Authorization, you may be financially responsible for all charges.

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

Post hospitalization outpatient treatment services are available. (Refer to the “Emergency and Urgently Needed Services” section under “Post-Stabilization.”

$0 Copayment Your VHP mental health Plan Provider will make arrangements when Medically Necessary.

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

Prior Authorization from VHP is required.

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

Mental health services for Members who are incarcerated, or that are court ordered, or as a condition of parole or probation are excluded from your Benefit Plan, unless determined Medically Necessary by the Medical Director.




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

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

Medically Necessary methadone maintenance services are included.

$0 Copayment Call the Gateway Program at 1.800.488.9919 (toll-free) for access to information, referral and treatment services, or call your PCP.

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

Residential ancillary services (defined as any program without on-site treatment services being provided, and intended primarily as a residence, e.g. Sober Living Environment (SLE) or SLE housing) are excluded from your Benefit Plan.

Detoxification Substance Abuse Services, i.e. Hospital based – Inpatient including Medically Necessary detoxification for alcohol and/or drug dependency.

$0 Copayment Your VHP Network Provider will make arrangements for Medically Necessary Covered Services at a Plan Hospital that most appropriately meets your medical needs.

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


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

$0 Copayment Call the Gateway Program at 1.800.488.9919 (toll-free) for access to information, referral and treatment services, or call your PCP.

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


Residential recovery services, including detox programs, are based on the clinical needs assessment and Prior Authorization from VHP to a Plan Provider facility.

Residential recovery Covered Services (including detox) are limited to a maximum of 60 days per Calendar Year and 120 days in any five (5) consecutive Calendar Year periods.


Summary of Benefits Table—Group CoverageHome Health and Hospice ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Home Health Care including Medically Necessary health care services and supplies provided in your home. Services include drugs, medicines, and supplies administered by a visiting health care professional; rehabilitation, and laboratory services; and Medically Necessary intermittent skilled nursing and home health aide services.

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

If, at the time of enrollment, you are receiving on-going home health care, it is your responsibility to notify VHP to arrange for continuation of services through Plan Providers. Contact Member Services at 408.885.4760 or 1.888.421.8444 (toll-free) for assistance.

Should you fail to inform us of your need for such services and not obtain Prior Authorization from VHP for continuation of care through non-Plan Providers, you will be financially responsible for the cost of such services.

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

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

Custodial Care is excluded from your Benefit Plan.

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

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

$0 Copayment Your PCP or Plan Physician will make arrangements when Medically Necessary with an authorized Plan Provider.

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

Hospice Care provided by licensed hospice programs as certified by the Centers for Medicare and Medicaid Services (CMS). Hospice Services include physician services, nursing care, therapy, medical social services, home health aide and homemaker services, drugs, medical supplies and DME, care for pain control and symptom management, counseling and bereavement services, and services of volunteers.

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

Coverage is limited to Members who have been given a prognosis of 12 months or less to live and VHP determines hospice care to be Medically Necessary.

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

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



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

Acupuncture Services Benefits Copayment How to Obtain Covered Services Limitations and Exclusions

Acupuncture Services are the placement of needles with or without electric stimulation to prevent, modify, or alleviate nausea and/or severe, persistent, or chronic pain.

$10 Copayment per visit

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

Coverage is limited to a maximum of 20 Prior Authorized visits per calendar year. Beyond 20 prescribed visits require justification from Plan Provider.

If you seek care without Prior Authorization from VHP, you may be financially responsible for all charges.

Services that are not acupuncture related, such as herbal medicines or other treatments will be your financial responsibility.

Cancer Clinical Trial ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

Covered Services are only available if:

• you have been diagnosed with cancer,

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

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

$0 Copayment

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

The clinical trial’s:

i. endpoints must not be defined exclusively to test toxicity, but have a therapeutic intent, and

ii. treatment must either

(a) be approved by the National Institute of Health, the Federal Food and Drug Administration, or the Veterans Administration or

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

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

Chiropractic ServicesBenefits Copayments How to Obtain Covered Services Limitations and Exclusions

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

$10 Copayment per visit

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

Coverage is limited to a maximum of 20 Prior Authorized visits per calendar year. Beyond 20 prescribed visits require justification from Plan Provider.

If you seek care without Prior Authorization from VHP, you may be financially responsible for all charges.

Services that are not chiropractic related, such as x-rays or nutritional counseling will be your financial responsibility.


Summary of Benefits Table—Group CoverageDental Services Benefits Copayment How to Obtain Covered Services Limitations and Exclusions

Dental Services include services

• for treatment or removal of tumors,

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

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

• services in connection with accidental fractures of the jaw.

$0 Copayment Your Plan Physician or VHP will make Prior Authorized arrangements when Medically Necessary in a Plan Hospital or Plan surgery center.

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

Routine dental or any dental services or X-ray exams involving one (1) or more teeth, the tissue or structure around them, the alveolar process or the gums are excluded from your Benefit Plan.

Medically Necessary medications (i.e. medications for pain, antibiotics) prescribed by your dentist must be filled by your Plan Pharmacy. Other prescriptions written by dentists are not covered by VHP.

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

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

Submit your request for reimbursement for intra-oral devices and related services to VHP within 90 days of the date of service.

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

Charges for the dental procedures that are not related to the treatment of a Medically Necessary condition are excluded from your Benefit Plan.

Charges for the dental procedure itself, including but not limited to, the professional fee(s) of the dentist, and X-rays are excluded from your Benefit Plan.

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

$0 Copayment Your Plan Physician or VHP will make Prior Authorization arrangements when Medically Necessary in a Plan Hospital or Plan surgery center.

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

Covered Services are only available if the Member’s health is compromised and general anesthesia is Medically Necessary.

Prior Authorization is required from VHP for Medically Necessary Covered Services in a Plan Hospital or Plan surgery center.




Family Planning ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Artificial Insemination Services includes the intrauterine sperm placement procedure only for the treatment of infertility when determined Medically Necessary by a Plan Physician. Evaluation and work-up should be completed within six (6) months or (6) six Cycles.

Semen analysis and sperm washing for conception procedures will be covered only in conjunction with artificial insemination procedures covered by your Benefit Plan.

Refer to “Infertility Diagnosis and Treatment” section in this Summary of Benefits Table.

$0 Copayment Your PCP will make arrangements when Medically Necessary to a Plan Provider.

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

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

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

Family Planning Services including contraceptive counseling, prescribed birth control pills, fitting and/or inserting birth control devices (e.g. diaphragms), and examination, insertion, and removal of an IUD.

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

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

$0 Copayment Call to schedule an appointment with your VHP Network Provider.


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


Summary of Benefits Table—Group CoverageFamily Planning Services, ContinuedBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Infertility Diagnosis and Treatment includes Covered Services to evaluate, diagnose, and provide Medically Necessary treatment.

$0 Copayment Your PCP will order or make arrangements with a Plan Provider when Medically Necessary.

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

Limitations include:

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

ii. Artificial Insemination is the actual basic insemination procedure.

iii. Sperm washing only in connection with the Artificial Insemination procedures.




Maternity Services Benefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

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

Prenatal and newborn support classes are available, by calling the VHP Health Education Department at 408.885.3490.

$0 Copayment It is important to receive early care when you are pregnant.

If you think you are pregnant, call to schedule an appointment with a Plan OB/GYN:


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

If you travel outside of the Service Area to obtain Medical Services related to care and/or delivery of the newborn, you may be financially responsible for all charges, except for those expenses related to Emergency Services.

Amniocentesis, ultrasounds, or any other procedure performed solely for the purpose of sex determination are excluded from your Benefit Plan.

Should you give birth while a Member and your newborn meets the definition of an Eligible Dependent, he/she is eligible for Coverage under the Benefit Plan for the first 31 days after the birth.

• Except in the event of an emergency or urgently needed required Covered Services, during this grace period, your Plan Physician must provide care.

• The appropriate membership premium will be charged from the date of the birth.

• For continuous Coverage of your newborn beyond 31 days, the Subscriber must complete and submit the appropriate paperwork to enroll your newborn as an Eligible Dependent within 31 days of the birth. Enrollment materials must be submitted to your employer’s Human Resources office.

If you are enrolled as a Subscriber to a Group that does not offer dependent coverage, Coverage of your newborn child will be excluded 31 days after the birth.*

If you are enrolled as an Eligible Dependent child when you give birth, newborn care is excluded from your Benefit Plan. (Please refer to the “Eligible Dependent” definition for details.)

* Note: For information on continuous health coverage for your newborn, contact the Children’s Health Initiative (CHI) at 1.888.244.5222 (toll-free). A CHI representative can give you information about free or low cost health insurance.


Summary of Benefits Table—Group CoverageMaternity Services, ContinuedBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

Circumcision is done on an outpatient basis only if the newborn meets the definition of an Eligible Dependent.

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

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

$0 Copayment Your VHP Network Provider will determine the scope of services based on Medical Necessary.



For Member Services, call 408.885.4760.

Sterilization ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Sterilization Services include vasectomy and tubal ligation procedures.

$0 Copayment Your Plan Provider will make arrangements if you elect to have a vasectomy or tubal ligation at a Plan Provider.

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

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

Abortion ServicesBenefits Coverage How to Obtain Coverage Limitations and Exclusions

Abortion Services includes examination, counseling, and procedure.

$0 Copayment Call VHP’s Utilization Department at 408.885.4647 or your Plan Provider can make arrangements at a Plan Facility.

Covered Services must be provided by a VHP Network Provider.

Health Education ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

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

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

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

Contact your VHP Health Education Department at 408.885.3490 or e-mail [email protected] to register and obtain information on class availability, schedule(s), and fees.

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

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

Unless otherwise noted in the VHP Health Education class booklet, prior to attending any VHP health education classes or programs, you must contact the VHP Health Education Department for pre-registration.

Weight Watchers benefit is limited to one (1) session per calendar year. Weight Watchers session(s) are available in some work places or Weight Watchers session coupons are available from VHP. A second session or second set of coupons may be requested if you provide documentation of continuous Weight Watchers meeting attendance.

There is no reimbursement for the $20.00 Copayment.


Summary of Benefits Table—Group CoverageReconstructive and Cosmetic Surgery ServicesBenefits Copayment How to Obtain Covered Services Limitations and Exclusions

Reconstructive Surgery includes plastic surgery to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease following Medically Necessary mastectomy surgery (including breast implants) which resulted from disease, illness, or injury, and is for internal breast prosthesis required incidental to a mastectomy.

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

Surgery that is defined as strictly Cosmetic Surgery is excluded from your Benefit Plan.

Implants that are cosmetic, experimental, or investigational are excluded from your Benefit Plan.

Reconstructive surgery is covered only when a Plan Physician determines that surgery is necessary to improve function, or create a normal or uniform appearance, to the extent possible.

Transplant ServicesBenefits Copayment How to Obtain Covered

Services Limitations and Exclusions

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

• Preoperative evaluation,

• surgery,

• follow-up care only provided at centers that have been designated by VHP, and

• the reasonable medical and hospital expenses of a donor or individual identified as a prospective donor if such expenses are directly related to the transplant, other than corneal transplants.

Benefits also include Medically Necessary ambulance services.

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

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

Transplantation Services are limited to those that are Medically Necessary, Prior Authorized, and performed in a Plan Facility or Hospital.

The patient-selection committee of the designated center will select recipients. If VHP physicians or the referral facility determines that you do not satisfy the patient selection Medical Criteria for the transplant, tissue and organ transplant procedures, services will be excluded. VHP will pay only for the services you received before that decision is made.

Donor searches and recipient or donor transportation costs to the transplantation center are excluded from your Benefit Plan.

The medical and hospital Covered Services of a donor are covered up to 12 months from the date of surgery when related to the transplant.

Services related to non-human or artificial organs and their implantation are excluded from your Benefit Plan.

Anti-rejection drugs, biological products, and other procedures are limited to Non-Experimental Procedures.

Experimental procedures are excluded from your Benefit Plan.


Pharmacy BenefitNavitus Health Solutions - Pharmacy Benefit Manager (PBM)

Navitus Health Solutions is Valley Health Plan’s (VHP) Pharmacy Benefit Manager (PBM). Navitus Health Solutions offers you benefits such as a designated 24/7 Pharmacy Customer Care Service Line, a Specialty Pharmacy, an optional Mail Order Pharmacy, and an updated Formulary. VHP Members also have access to an extended network of conveniently located pharmacies in and out of Santa Clara County.

Navitus Health Solutions offers VHP Members access to a Member portal to view important pharmacy benefit information. Register at www.navitus.com to get a User ID and password to access the following information:

• Claim Forms

• Formulary

• Mail Order

• Specialty Pharmacy

• Pharmacy and Therapeutics Committee Updates

• Medication History

• Drug Search

• Prescription Benefits

Pharmacy Benefit Schedule

# Days Supply Dispensed

• Participating Plan Pharmacy up to 90 days

• Mail Order Plan Pharmacy up to 90 days

Benefit Structure

PLAN PHARMACIES UP TO 30 DAYS

UP TO 90 DAYS

Gardner Family Health Network $0 copay $0 copay

Leiter’s Compounding Pharmacy $0 copay $0 copay

Navitus Specialty Rx (Diplomat) $0 copay Not

AvailablePalo Alto Medical Foundation (PAMF) $0 copay $0 copay

Safeway $0 copay $0 copay Santa Clara Valley Medical Center (SCVMC)

$0 copay $0 copay

Walgreens $0 copay $0 copay Wellpartner (optional Mail Order) $0 copay $0 copay

Additional Coverage Information

• Compounding (mixing more than one drug) Prescriptions are required to be filled at a Plan Pharmacy. For information on VHP Plan Pharmacies that offer compounding services, please call VHP Member Services at 408.885.4760 or 1.888.421.8444 (toll-free).

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Additional Coverage Information

• Vaccinations are covered by VHP through the Plan Pharmacies. Check Plan Pharmacy and Navitus for vaccination service and requirements.

• Prescriptions from SCVMC Plan Providers can be filled at any Plan Pharmacy.

• Prescriptions from non-SCVMC Plan Providers can be filled at all Plan Pharmacies EXCEPT SCVMC Pharmacies.

Mail Order Pharmacy (no walk-in service)

For more information, see pages 62-63.

Specialty Prescriptions

Members who are taking specialty medications for certain chronic illnesses or complex diseases can receive the prescriptions through our Specialty Plan Pharmacy. Your Plan Pharmacy will identify if your prescription is a specialty medication.

• Navitus Specialty Rx (Diplomat) will accept prescriptions from all Plan Providers.

• SCVMC Pharmacies will accept prescriptions from SCVMC Plan Providers ONLY.

For all pharmacy information, please call Navitus Customer Care at 1.866.333.2757 (toll-free).

Exclusions

The following are not covered under your Pharmacy Benefit:

• Charges for supplies and medicines with or without a doctor’s prescription, unless otherwise specifically covered.

• Prescription drugs treating any condition, physical sickness, injury, or mental illness arising out of, or in the course of, employment for which benefits are available under any worker’s compensation law, property and casualty law, or similar law.

• Charges for cosmetic drug treatments such as Retin-A, Rogaine, or their medical equivalent.

• Any medications U.S. Food and Drug Administration (FDA) approved for weight loss (ie: appetite suppressants) or anorexia.

• Non-FDA approved prescriptions including compounded products or investigational drugs, except as authorized by VHP.

• Drugs recently approved by the FDA may be excluded until reviewed and approved by VHP’s Pharmacy and Therapeutics Committee, which determines the therapeutic advantage of the drug and the medically appropriate application.


• Charges for injectable medications requiring administration or supervision by a qualified provider or licensed/certified health professional, except for self-administered injectable medications authorized by VHP.

• Charges for supplies and medicines purchased from a non-participating Plan Pharmacy, except when emergency or urgent care is required.

• Over-the-Counter (OTC) drugs and supplies are excluded from your benefit plan.

VHP Network Plan Pharmacies

• Safeway Pharmacies ₋ All U.S. Locations

• Walgreens Pharmacies ₋ All U.S. Locations

• Gardner Family Health Network Pharmacies ₋ South County Health Center ₋ St. James Health Center

• Leiter’s Compounding Pharmacy

• Palo Alto Medical Foundation (PAMF) Pharmacies ₋ Mountain View Center ₋ Palo Alto Center

Important Note: The SCVMC Plan Pharmacies are for VHP Members receiving care from providers at SCVMC, Valley Specialty Center & Valley Health Centers ONLY.

• Santa Clara Valley Medical Center (SCVMC) Pharmacies ₋ Valley Health Center Bascom ₋ Valley Health Center East Valley ₋ Valley Health Center Gilroy ₋ Valley Health Center Lenzen ₋ Valley Health Center Milpitas ₋ Valley Health Center Moorpark ₋ Valley Health Center Sunnyvale ₋ Valley Health Center Tully ₋ Valley Specialty Center

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Filling Your Prescription

In Person

• Choose a Plan Pharmacy where you want to have your prescription filled.

• Bring your VHP ID Card each time you fill a prescription at a Plan Pharmacy. The card has information the Plan Pharmacy needs to process your prescription.

Note: The SCVMC Plan Pharmacies are for VHP Members receiving care and with a prescription from a provider at SCVMC, Valley Specialty Center & Valley Health Centers ONLY.

Mail Order Options

Note: Valley Health Plan members have $0 co-pay for the prescription drug benefit. VHP does not cover Charges for additional convenience services that Plan Pharmacies may offer.

Prescription Refills

In Person

Check with your Plan Pharmacy for additional prescription refill options.

Mail Order Options

• Check with your Plan Pharmacy for mail service prescription refill options.

• Wellpartner, exclusive Mail Order Pharmacy, offers mail order refills.Once you have received your first prescription via mail order, refills can be ordered using any of the following methods:

₋ Visit www.wellpartner.com

₋ Call 1.877.935.5797 (toll-free) Hours: 7:30am–5:30pm

Step 1: Enroll

Complete the mail order enrollment form available online at www.wellpartner.com or by calling Wellpartner at 1.877.935.5797 (toll-free).

Step 2: Fill Your Prescription

Please make sure your VHP ID number is written on each prescription. Your prescription can be sent to Wellpartner using the following options:

Your Plan Provider can give your prescription directly by:

• Calling 1.877.935.5797 (toll-free)

• e-Prescribe

• Faxing to 1.866.624.5797


You can mail the original prescription with your enrollment form to:

Wellpartner, Inc. PO Box 5909

Portland, OR 97228-5909

Refill orders should be placed three weeks prior to when the medication will be needed.

Prescriptions cannot legally be mailed from a mail order pharmacy (or any other pharmacy operation within the United States) to location outside the United States, with the exception of U.S. territories, protectorates and military installations.

Formulary Facts

Drug Formulary

The formulary is a comprehensive list of preferred drugs selected on the basis of quality and efficacy by a professional committee of physicians and pharmacists. The drug formulary serves as a guide for the provider community by identifying which drugs are covered. It is updated regularly and includes brand name and generic name drugs.

Selecting Drugs for Your Formulary

An independent group of physicians and pharmacists meets regularly during the year to review and select medications for your formulary that will be safe, effective and affordable. The committee evaluates medications based on their therapeutic value, side effects and cost compared to similar medications. Based on the committee’s review of new and existing drugs, your formulary is evaluated to ensure it is up-to-date.

Checking Your Formulary

Your formulary is on the Navitus Health Solutions website, www.navitus.com under the Member portal. You will need to register to get a User ID and password. You may search the Valley Health Plan formulary for a specific drug, or browse alphabetically or by category of use. Also included is information about which drug products need Prior Authorization and/or have quantity limits. The formulary is available to you in full and as a quick reference.


Changes to Your Formulary

Your formulary is evaluated on an on-going basis, and could change. Navitus Health Solutions does not send individual notifications if a brand-name drug becomes available as a generic drug. The pharmacist usually communicates this information when you fill your next prescription.

If you have more questions about the formulary, please contact Navitus Customer Care at 1.866.333.2757 (toll-free).

Pharmacy Claims

Coordination of Benefits (COB)

Coordination of Benefits (COB) takes place when you have coverage under Navitus Health Solutions and another policy. One of the policies will be your primary coverage and one is your secondary coverage. Claims are first submitted to your primary policy and then to the secondary policy. The secondary policy covers the remaining cost of covered medications up to the allowed amount minus any applicable copayment. At the pharmacy, prescriptions are paid under your primary insurance. To be reimbursed by Navitus Health Solutions for your secondary coverage, you must complete a reimbursement form and submit it to Navitus Health Solutions. Reimbursement forms are available on the Navitus website, www.navitus.com or by calling Navitus Customer Care at 1.866.333.2757 (toll-free).

Submitting a Manual Pharmacy Claim

In an emergency, you may need to request reimbursement for prescriptions that you have filled and paid for yourself. If your prescription is eligible, you may receive reimbursement.

To submit a claim, you must provide specific information about the prescription, the reason you are requesting reimbursement, and any payments made by primary insurers. Complete the appropriate claim form and mail it along with the original receipt to:

Navitus Health Solutions Operations Division - Claims

P.O. Box 999 Appleton, WI 54912-0999

Claim forms are available at www.navitus.com or by calling Navitus Customer Care at 1.866.333.2757 (toll-free).


Pharmacy Definitions

Charges - Any monetary amounts that would not be a covered benefit by Valley Health Plan so would be the Member’s responsibility.

Compounding Prescription – Prescription that requires the mixing of drugs by a compounding pharmacist to fit the unique needs of a patron.

Copayment - Refers to that portion of the total prescription cost which is the financial responsibility of the Member.

Formulary - A list of drugs that are covered under your benefit plan. The drugs on your formulary are specially chosen for your formulary by an independent group of doctors and pharmacists. These experts evaluate medications based on effectiveness, side-effects, potential for drug interactions and cost. Drugs which are both clinically sound and cost effective are added to your formulary.

Generic Drugs - Prescription drugs that contain the same active ingredients, same dosage form and strength as their brand-name counterparts.

Over-the-Counter Medication - Medication that can be purchased without a prescription.

Plan Pharmacy- A pharmacy, including chain and independent, that Valley Health Plan has made arrangements with to provide prescription drugs to Members.

Plan Provider – Any professional person, organization, health facility, hospital, or other person of institution licensed and/or certified by the State to deliver health care services that, at the time care is provider, is contracted with VHP to deliver services to Members.

Prescription Drug - Any drug which may be obtained by prescription only.

Prior Authorization - Obtaining approval from Navitus Health Solutions for coverage of a prescription drug.

Santa Clara Valley Medical Center (SCVMC) Plan Providers – Plan Providers from Santa Clara Valley Medical Center, Valley Specialty Center, and Valley Health Centers at Bascom, East Valley, Gilroy, Lenzen, Moorpark, Milpitas, Sunnyvale, and Tully.

Specialty Medication - Drugs, such as self-injectables and biologics, typically used to treat patients with chronic illnesses or complex diseases.


Member Rights and ResponsibilitiesAs a Member you have the right to:

• Exercise these rights without regard to race, disability, gender, religion, age, color, sexual orientation, creed, family history, marital status, veteran status, national origin, handicap, or condition, without regard to your cultural, economic, or educational background, or source(s) of payment for your care;

• Be treated with dignity, respect, and consideration;

• Expect health care providers (doctors, medical professionals, and their staff) to be sensitive to your needs;

• Be provided with information about VHP, its services, and Plan Providers;

• Know the name of the Primary Care Physician who has primary responsibility for coordinating your health care and the names and professional relationships of other Plan Providers you see;

• Actively participate in your own health care, which, to the extent permitted by law, includes the right to receive information so that you can accept or refuse recommended treatment;

• Receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse this course of treatment or procedure. Except for Emergency Services this information will include a description of the procedure or treatment, the medically significant risks involved, alternative courses of action and the risks involved in each, and the name of the Plan Provider who will carry out the treatment or procedure;

• Full consideration of privacy concerning your course of treatment. Case discussions,

consultations, examinations, and treatments are confidential and should be conducted discreetly. You have the right to know the reason should any person be present or involved during these procedures or treatments;

• Confidential treatment of information in compliance with state and federal law including HIPAA (including all communications and medical records) pertaining to your care. Except as is necessary in connection with administering the Agreement and fulfilling State and federal requirements (including review programs to achieve quality and cost-effective medical care), such information will not be disclosed without first obtaining written permission from you or your authorized representative;

• Receive complete information about your medical condition, any proposed course of treatment, and your prospects for recovery in terms that you can understand;

• Give informed consent unless medically inadvisable, before the start of any procedure or treatment;

• Refuse health care services to the extent permitted by law and to be informed of the medical consequences of that refusal, unless medically inadvisable;

• Readily accessible and ready referral to Medically Necessary Covered Services;

• A second medical opinion, when medically appropriate, from a Plan Physician within the VHP Network;

• Be able to schedule appointments in a timely manner;

• Reasonable continuity of care and advance knowledge of the time and location of your appointment(s);


• Reasonable responses to any reasonable requests for Covered Services;

• Have all lab reports, X-rays, specialist’s reports, and other medical records completed and placed in your files, as promptly as possible, so that your Primary Care Physician can make informed decisions about your treatment;

• Change your Primary Care Physician;

• Review your medical records, unless medically inadvisable;

• Be informed of any charges (Copayments) associated with Covered Services;

• Be advised if a Plan Provider proposes to engage in or perform care or treatment involving experimental medical procedures, and the right to refuse to participate in such procedures;

• Leave a Plan Facility or Hospital, even against the advice of Plan Providers;

• Be informed of continuing health care requirements following your discharge from Plan Facilities or Hospitals;

• Be informed of, and if necessary, given assistance in making a medical Advance Health Care Directive;

• Have rights extended to any person who legally may make decisions regarding medical care on your behalf;

• Know when Plan Providers are no longer under a contractual arrangement with VHP;

• Examine and receive an explanation of any bill(s) for non-Covered Services, regardless of the source(s) of payment;

• File a Grievance without discrimination through VHP or appropriate State or federal agencies; and

• Know the rules and policies that apply to your conduct as a Member.

As a Member you have responsibility to:

• Adhere to behavior that is reasonably supportive of therapeutic goals and professional supervision as specified;

• Behave in a manner that doesn’t interfere with your Plan Provider or their ability to provide care;

• Safeguard the confidentiality of your own personal health care as well as that of other Members;

• Accept fiscal responsibility associated with non-Covered Services. Covered Services are available only through Plan Providers in your VHP Network (unless such care is rendered as Emergency Services or is authorized);

• Cooperate with VHP or a Plan Provider’s third party recovery efforts or Coordination of Benefits;

• Participate in your health care by scheduling and keeping appointments with Plan Providers. If you cannot keep your appointment, call in advance to cancel and reschedule; and

• Report any changes in your name, address, telephone number, or your family’s status to your employer and a VHP Member Services Representative.


Privacy NoticeValley Health Plan does not share your health information with anyone without your authorization, unless we are permitted to do so by law.

This notice describes how medical information about you may be used, shared or disclosed, and how you can get access to this information. Please review it carefully.

If you have any questions about this Notice, please contact:

VHP Member Services Department 408.885.4760 or 1.888.421.8444 (toll-free)

Monday–Friday (9am–5pm)

Our Pledge Regarding Medical Information

We understand that information about you and your health is confidential and personal. We are committed to protecting health information about you. We create and maintain a record of the care and services you receive through Valley Health Plan. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice will tell you about the ways in which we may use and share your Protected Health Information (“PHI”). It also describes your rights and certain actions we must take when using or sharing your PHI with other people or organizations.

We are required by law to:

• make sure that PHI that is linked to you is kept private and confidential (with some exceptions)

• give you this Notice about our responsibilities and privacy practices about your PHI; and

• follow the terms of the Notice that is currently in effect.

Except as outlined below, we will not use or share your PHI unless you have signed an authorization form that allows us to do so. You have the right to cancel the permission by telling us in writing, except if we have used or shared your PHI when you first gave us permission to do so.

How We May Use and Share Your Protected Health Information

The following sections describe different ways that we use, share or disclose your PHI. We will describe each category of uses and disclosures, and give some examples. The law limits how we can use and disclose some PHI related to treatment of drug and alcohol abuse, HIV infection, and mental illness. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the following categories.


For Treatment

We may use, share or disclose your PHI when necessary for you to receive treatment or services. For instance, we may share your PHI with any doctor, health care professional or health facility involved in making decisions about your care.

For Payment

We may use or share your PHI for payment, collection and billing purposes related to services provided to you. For instance, we may use information regarding your medical procedures and treatment to process and pay claims, to determine whether services are medically necessary or to pre-authorize or certify services covered under your health benefits plan. We may share such information with another health plan to process and pay claims on your behalf. We may also share PHI with any of your direct treatment providers so they can bill and collect payment for services provided to you.

For Health Care Operations

We will use and share your PHI as permitted by law for health care operations, including credentialing health care providers, peer review, business management, accreditation and licensing, utilization review and management, quality improvement and assurance, enrollment, underwriting, reinsurance, compliance, auditing, rating,

and other functions related to your health plan benefits. We may also disclose your PHI to another health care facility, health care professional, or health plan for such things as quality assurance and case management, but only if that facility, professional, or plan also has or had a provider relationship with you.

Some parts of our services are done through contracts with outside persons or organizations, such as auditing, accreditation, actuarial services, legal services, etc. At times it may be necessary for us to provide some parts of your PHI to one or more of these outside persons or organizations that assist us with our health care operations. In all cases, we require these business associates to appropriately safeguard the privacy of your PHI.

Sponsor of the Health Plan

We may share your PHI with the employer or sponsor who pays for your health plan benefits. The employer or sponsor is only permitted to use your PHI to determine your eligibility for health plan benefits, to enroll you in a health plan and to make your premium payments.

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Individuals Involved in Your Care or Payment for Your Care

We may share your PHI with a family member, friend, personal representative, or anyone else you want to be involved in your care. We may share your PHI with anyone who helps pay for your care. Unless you tell us in writing to do otherwise, we may tell your family or friends about your condition. If you are unavailable, incapacitated, or facing an emergency medical situation and we determine that a limited disclosure may be in your best interest, we may share limited PHI with such individuals without your approval.

Other Health-Related Products or Services

We may, from time to time, use your PHI to determine whether you might be interested in or benefit from treatment alternatives or other health-related programs, products or services which may be available to you as a Member of the health plan. For example, we may use your PHI to inform you of a disease management program that may help you manage your illness better. We will not use your PHI to tell you about non health-related products or services without your written permission.

As Required By Law

We will use and share your PHI when required to do so by federal, state or local law.

To Avert a Serious Threat to Health or Safety

We may use and share your PHI when necessary to prevent or lessen a serious threat to your health and safety, or to that of others. However, we will disclose your PHI only to a responsible person who is able to help prevent the threat.

Organ and Tissue Donation

We may disclose your PHI to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to help with organ or tissue donation and transplantation.

Military Service and Veterans

If you are or have been a member of the Armed Forces, we will disclose your PHI when so required by the appropriate military command authorities. We may also release PHI about foreign military personnel to the appropriate military authorities as authorized or required by law.

Workers’ Compensation

We may disclose your PHI as permitted by law for Workers’ Compensation or similar programs when necessary to provide treatment, services, or benefits for work-related injuries or illness.

Public Health Risks

We may use and disclose your PHI for public health purposes. In general, these


activities include, but are not limited the following:

• to prevent or control disease (such as cancer or tuberculosis), injury or disability;

• to report births and deaths;

• to report the abuse or neglect of children, elders and dependent adults;

• to report reactions to medications or problems with healthcare products;

• to notify Members of recalls, repairs or replacement of products they may be using;

• to notify a person who may have been exposed to a disease or may be at risk for getting or spreading a disease or condition;

• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will share your PHI only if you agree, or when it is required or authorized by law.

Health Oversight Activities

We may use and disclose your PHI to a healthcare oversight agency as authorized or required by law. Examples of oversight activities include audits, investigations, inspections, accreditation and licensure surveys. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes

We may disclose your PHI in response to a court or administrative order, a subpoena, discovery request, warrant, summons, or other lawful process. We will do so only after we make efforts to tell you about the request (which may include a written notice to you) or to obtain an order protecting the information requested.

Law Enforcement

We may use and share PHI if asked to do so by a law enforcement official:

• in compliance with a court order, subpoena, warrant, summons, grand jury subpoena or similar process;

• to identify or locate a suspect, fugitive, material witness, or missing person;

• about a victim of or a crime, if, under some limited circumstances, we are unable to obtain the permission directly from the victim of a crime;

• about a death we believe may be the result of criminal conduct;

• about criminal conduct in any of our contracted facilities; and

• in emergency circumstances to report: a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

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Coroners, Medical Examiners and Funeral Directors

We may use and share your PHI to the county coroner for purposes of identification; when investigating public health concerns or criminal deaths; or when otherwise authorized by the decedent’s representative.

National Security and Intelligence Activities

We may use and disclose your PHI to federal officials for intelligence, counterintelligence, and other national security activities as authorized or required by law.

Protective Services for the President and Other Persons

As authorized or required by law, we may use and disclose your PHI to authorized federal officials so they may provide protection to the President, the President’s family, other designated persons or foreign heads of state, or to conduct special investigations.

Inmates

While you are in a correctional institution or under the custody of law enforcement officials, we may use and disclose your PHI to the correctional institution or law enforcement officials if they tell us that it is necessary: (1) to provide the healthcare services you need; (2) to protect your health and safety or that of others; or (3) for the safety and security of the correctional institution.

Other Uses of Your Protected Health Information

Other uses and disclosures of PHI not covered by this Notice, or by the laws that apply to us, will be made only with your written permission. If you allow us to use, share or disclose your PHI, you may cancel that permission in writing at any time. If you cancel your permission, we will stop any further use or disclosure of your PHI for the purposes covered by your written permission, unless we have already done so based on your earlier permission. You should understand that we are unable to take back any disclosures we have already made with your permission and that we are required by law to keep records of the services or treatment we provided to you.

Your Rights Regarding Your Protected Health Information

Note: Please keep in mind that Valley Health Plan collects and maintains information regarding you and your health care services. Your medical record is maintained by your direct medical treatment provider.

You have the following rights regarding your PHI that VHP maintains in our facilities:


Right to Inspect and Copy

Except for information related to treatment of mental illness, or information gathered in a civil, criminal, or administrative action or proceeding, or some PHI subject to the Clinical Laboratory Amendments of 1988, you have the right to ask to inspect your PHI. To inspect your PHI maintained at Valley Health Plan, you must send a specific request in writing to the VHP Member Services Department, 2480 N. First Street, Suite 200, San Jose, CA 95131. In many instances, we may refer you to your direct treatment provider in order for you to inspect, amend or copy your PHI contained in the medical record.

You may ask for a review if we deny access to inspect and copy your PHI, except for the following: 1) in circumstances listed above; 2) you are an inmate and the copies would jeopardize your health, safety, security, custody, or rehabilitation or that of others; 3) if the PHI is controlled by the Privacy Act and access is not permitted by law; or 4) if the PHI was obtained from someone other than a healthcare provider under a promise of confidentiality, and access to the PHI would reveal who that person is.

You must ask for a review in writing addressed as follows:

VHP Privacy Coordinator 2480 N. First Street, Suite 200

San Jose, CA 95131

Right to Amend

If you feel that your PHI in our custody is incorrect or incomplete, you may ask us to correct and amend the PHI. You have a right to request a change for as long as we keep your PHI. To ask for change, you must send a written request with a reason that supports your request to Member Services Department, 2480 N. First Street, Suite 200, San Jose, CA 95131.

We may deny your request to amend PHI maintained by Valley Health Plan. In addition, we may deny your request if you ask us to change or amend PHI [information] that:

• was not created by us;

• is not part of the information kept by or for us;

• is not part of the information which you are permitted by law to inspect and copy; or

• is accurate and complete.

If we deny your request for a change to your PHI, you have the right to submit written correction about any item or statement in your record you believe is incomplete or incorrect. The correction cannot exceed 250 words per alleged incomplete or incorrect item in your record.

REMINDER: Your medical record is maintained by your direct medical treatment provider and we may direct you to send your request to that provider.


Right to an Accounting of Disclosures

You have the right to request a list of how we have disclosed or shared your PHI, other than disclosures made in the following circumstances: 1) to you or authorized by you; 2) for national security or intelligence purposes; 3) to correctional institutions or law enforcement; 4) as part of limited data set as permitted by law; or 5) for treatment, payment and healthcare operations (as described above). To request this accounting of disclosures, you must send your request in writing to:

VHP Member Services Department 2480 N. First Street, Suite 200

San Jose, CA 95131

Your request must state a time period, which cannot be longer than a six-year period and cannot include dates before April 14, 2003. Your request should describe the type of list you would like (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions

You have the right to ask that we limit how we use or disclose your PHI for treatment, payment or healthcare operations. You also have the right to ask us to limit the PHI we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment to you. To request restrictions, you must send a request in writing to the VHP Member Services Department, 2480 N. First Street, Suite 200, San Jose, CA 95131.

In your request, you must tell us the following: (1) what information you want to limit; (2) whether you want to limit our use, our disclosure or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse or a family member).

Right to Request Confidential Communications

You have the right to ask that we communicate with you about your PHI in a certain way or at a certain location. We will accommodate reasonable requests of this nature. For instance, if it is a matter of safety or security, you can ask that we contact you at a phone number and address other than your


home phone and address. To request confidential communications, you must send a written request to the Member Services Department, 2480 N. First Street, Suite 200, San Jose, CA 95131.

We will not ask the reason for your request and we will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of this NoticeYou have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time in person or in writing by sending in a written request addressed as follows: VHP Privacy Coordinator, 2480 N. First Street, Suite 200, San Jose, CA 95131.

Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain an electronic copy of this Notice from our website at www.valleyhealthplan.org

Changes to This NoticeWe reserve the right to change our privacy practices and this Notice. We reserve the right to make the revised or changed Notice effective for the PHI we already have about you, as well as any other information we create in the future. The effective date of the Notice will be displayed on the first page. You may ask at any time for a copy of the current Notice in effect and we will give it to you.

ComplaintsIf you believe your privacy rights have been violated, you may file a complaint with us, or with the Secretary of the Department of Health and Human Services. To file a complaint with us, you must send a written notice to:

VHP Member Services Department 2480 N. First Street, Suite 200

San Jose, CA 95131

You will not be penalized for filing a complaint.

2480 N. First Street, Suite 200, San Jose, CA 95131 | Tel: 1.408.885.4760 | Toll-Free: 1.888.421.8444

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