Frequently asked questions

  • Coronavirus & COVID-19
  • Monkeypox
  • General questions
  • Benefits
  • Getting care
Questions about COVID-19
Vaccines ›

Is the vaccine covered under my benefits?

Yes. The vaccine is covered at $0 under your preventive care benefits.


Who can get the COVID-19 vaccine?

The County of San Diego is currently vaccinating individuals 6 months and older. You do not need to contact your doctor before your — or your child’s — appointment unless you have a specific medical question. For the latest COVID-19 vaccine information, please visit Sharp HealthCare’s website. You can also reference this COVID-19 Vaccination Schedule from the Centers for Disease Control and Prevention.


How can I get my vaccine?

You can schedule an appointment at a San Diego County vaccination site through MyTurn, an online scheduling tool. When you visit their website, it may ask you to select an appointment type. Please select COVID-19. (Note: members must access flu vaccines as directed by their Plan Medical Group or they may be billed. For the best member experience, we do not recommend making a flu vaccine appointment through MyTurn). You can also call 2-1-1 for help scheduling a COVID-19 vaccine.

You can visit CVS Minute Clinic to receive the COVID-19 vaccine throughout San Diego County. You can schedule an appointment here.

For more information on how to get the COVID-19 vaccine, please visit Sharp HealthCare’s website.


I’m homebound and can't make it to a COVID-19 vaccine clinic. What should I do?

Sharp Health Plan and our plan medical groups are doing outreach to members who have been identified as homebound (or unable to leave their home due to illness or old age) to ensure that anyone who can't get to a COVID-19 vaccination site is still able to get vaccinated. If you are homebound and your primary care physician or plan medical group has not reached out to you to schedule your COVID-19 vaccination, please contact our Customer Care team so that we can assist you.


Is Sharp offering COVID-19 vaccine booster shots?

Yes. Sharp is offering booster shots to those who are eligible. To see who is eligible for booster shots at this time, please visit Sharp HealthCare’s website. If you are eligible for a booster shot, it will be covered at $0 under your preventive care benefits.


What is the difference between an additional dose and a booster shot?

To provide the best possible protection for immunocompromised individuals, the Centers for Disease Control and Prevention (CDC) recommends an additional (third) dose for those who received either Pfizer or Moderna for their initial series. This third dose is not considered a booster shot. If you are immunocompromised, you are eligible for an additional dose 28 days after the second dose of your Pfizer or Moderna vaccine. Research shows that the immune system of many immunocompromised individuals does not produce the same response that a two-shot course produces in healthy people. If you are immunocompromised, the third dose of the vaccine will be covered at $0 under your preventive care benefits.


The CDC and FDA approved booster shots for healthy individuals because research has shown that the vaccine effectiveness begins to wane after 6 months. For more information on booster shots please visit Sharp HealthCare’s website.


How do I replace my lost vaccination card?

Now you can show digital proof of your vaccination. If you were vaccinated in California, go to myvaccinerecord.cdph.ca.gov and enter your info to access it. (We recommend that you use the latest version of Chrome, Firefox, or Safari for the best experience.)

You can also request proof of vaccination through the San Diego Immunization Registry (SDIR) by filling out the SDIR form. For more information, please contact SDIR at 1-619-692-5656 or sdir.hhsa@sdcounty.ca.gov.


Where can I learn more about the vaccine?

Please visit the County’s website and Sharp HealthCare’s website for up-to-date information about COVID-19 and the vaccine.


About COVID-19 ›

What are the everyday preventive actions I should be taking?

The best way to prevent infection is to get vaccinated. The CDC also recommends these everyday preventive actions to help stop the spread of respiratory viruses:

  • Wear an approved face covering
  • Wash your hands often with soap and water for at least 20 seconds. If soap and water are unavailable, use an alcohol-based hand sanitizer that contains at least 60% alcohol.
  • Avoid touching your eyes, nose and mouth with unwashed hands.
  • Avoid close contact with people who are sick.
  • Stay home when you're sick.
  • Cover your entire mouth and nose with a tissue when you cough or sneeze, then throw the tissue in the trash and wash your hands. If a tissue is unavailable, cough or sneeze into your bent elbow.
  • Clean and disinfect frequently touched objects and surfaces.


How can I get free N95 face masks?

The Biden administration is making N95 high-filtration face masks available for free. Three masks will be given out per person pending availability. According to White House officials, a limited number of masks are available now, with more arriving in coming days, and the program will be fully running by early February 2022. Nearly all the pharmacies and community health care centers that participated in the government’s free vaccine program have agreed to be pickup points for the free mask program. This means most major chains, such as CVS Pharmacy®, Rite Aid® and Walgreens® will have them, along with many independent locations. You may want to call in advance to ensure a location has masks available for pickup.


What is Sharp doing to protect patients, visitors and staff during this time?

Sharp HealthCare’s top priority is the safety and well-being of patients, visitors and staff. Please visit sharp.com/coronavirus for the latest information, such as the following:

  • Hospital visitation guidelines
  • How Sharp is screening and testing patients
  • How to get care
  • Infection prevention measures
  • Sharp classes and events
We encourage you to check Sharp’s COVID-19 page often for updates.


Where can I get more information?

To learn more about COVID-19, please visit the Centers for Disease Control and Prevention, the World Health Organization and the San Diego County Health & Human Services Agency. If you have additional questions, please call 211 San Diego.

We also encourage you to visit sharp.com/coronavirus for the latest information from Sharp.


Access to care ›

When will Sharp HealthCare resume scheduling elective and essential surgeries and procedures?

Sharp has begun the resumption of elective and essential surgeries and procedures, but not at the same levels prior to the COVID-19 pandemic. If you have questions about a procedure or surgery that was postponed, please contact your physician.


Can I still go to MinuteClinic?

Yes. You can still visit MinuteClinic®. For additional information, Please visit MinuteClinic (Basic Plan members) or MinuteClinic (Medicare members).


Benefits and coverage ›

Will my benefits cover isolation and quarantine for the diagnosis of COVID-19?

Sharp Health Plan covers medically necessary isolation and quarantine in the hospital. We do not cover home isolation or quarantine.


What are my options if I have been recently affected by income changes, reduced hours, or layoffs?

If your current coverage has been impacted by recent events, you likely qualify for the special enrollment expansion. Learn more about the special enrollment expansion or start an application by getting a quote.

Read more FAQs about special enrollment ➜


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

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

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


Contact tracing ›

What is contact tracing?

Contact tracing is a method of disease control that local, state and federal public health officials have been practicing for decades. It helps keep communities safe by identifying people who may have come into contact with an infected person. According to the Centers for Disease Control and Prevention, contact tracing and self-quarantining of people with COVID-19, and close contacts, is critical to slowing transmission of COVID-19 in our communities. For more information, check out this Sharp Health News article on the importance of contact tracing.


How does contact tracing for COVID-19 work?

If you test positive for COVID-19, your doctor or another health official will let you know. A positive case must be reported to County Public Health Services so that each confirmed case can be used to help identify others who may have been exposed. When a confirmed COVID-19 case is investigated by public health staff, the investigator works with the infected person to identify all close contacts they may have exposed. Contact tracers then attempt to get in touch with these contacts so that they can be self-quarantined at home and monitored for symptoms of COVID-19. For more information, watch this short video from the County of San Diego Communications Office.


Who conducts COVID-19 contact tracing and how?

Contact tracing is conducted by local and state public health officials. If you had contact with someone infected with COVID-19, you may first get a text message from the health department telling you that you’ll get a call from a specific telephone number. When the contact tracer calls, they will identify themselves as being part of the county, and let you know that all information gathered during the contact tracing effort is kept confidential. Contact tracers will not ask you for personal information such as your Social Security number, bank account or credit card information. Anyone who does is a scammer.


How do I spot a contact tracing scam?

According to the Federal Trade Commission, scammers pretending to be contact tracers are taking advantage of how the process works, and are also sending text messages. You can spot spam text messages because they’ll ask you to click a link. Unlike a legitimate text message from a health department, which only wants to let you know they’ll be calling, text messages from scammers include a link to click.


Testing and treatment ›

Where can I get tested for COVID-19?

Call your doctor first if you are concerned about possible exposure to COVID-19, or are experiencing symptoms such as a cough, fever or shortness of breath. Your doctor will assess your situation and recommend where you should be seen. In some cases, your doctor may recommend that you stay home and treat mild symptoms. Not all patients need to be tested. Testing is provided based on a risk assessment recommended by the CDC.


Is medically necessary COVID-19 testing covered by my insurance?

Yes. Sharp Health Plan covers COVID-19 testing when an authorized health care provider gives the test or has referred you to get a test for personal diagnosis or treatment. COVID-19 diagnostic testing is covered for members with or without symptoms, whether or not you have been exposed to COVID-19. Medically necessary testing and related items and services are covered at no cost to you.


Is COVID-19 testing required by my employer covered by my insurance?

No. Non-diagnostic testing required for employment or public health surveillance is generally not covered. Non-diagnostic tests are tests related to public health surveillance, general workplace health and safety, or for other purposes not primarily intended for individualized diagnosis or treatment of COVID-19 (e.g., when an employer or other entity requires repeated or mass testing for surveillance or employment purposes).


What is the Test to Treat program?

The United States government created the Test to Treat program as part of its National COVID-19 Preparedness Plan to allow all individuals to be tested for COVID-19 and treated with prescription medication, if needed. In this program, people are able to get tested and – if they are positive and treatments are appropriate for them – receive a prescription from a health care provider, and have their prescription filled all in one location at no cost. These one-stop Test to Treat sites are available at hundreds of locations nationwide, including pharmacy-based clinics, community health centers and long-term care facilities. You can view Test to Treat locations on the California Department of Public Health’s website. If you think you have COVID-19, you can go directly to a Test to Treat location site. No referral is needed from your doctor. 


How can I get a prescription for Paxlovid?

Paxlovid – or the COVID-19 pill – is antiviral medicine that can help you fight COVID-19. The pill isn’t right for everyone. If this treatment is determined medically necessary, you can get a prescription for Paxlovid from your primary care physician, a Test to Treat location or a state-licensed, in-network retail pharmacy like CVS or Walgreens. Please note that you will need to provide your latest medical records and a list of currently prescribed medications to get a prescription from an in-network pharmacy.


How can I get free at-home COVID-19 tests?

The Biden Administration is distributing a 3rd round of free at-home COVID-19 tests to every home in the U.S. You can order tests online at COVIDTests.gov. Tests will usually ship within 7-12 days of ordering.


Are at-home COVID-19 tests covered?

You can get free at-home COVID-19 tests from a preferred OptumRx pharmacy such as Rite Aid, Sam’s Club or Walmart. Test kits purchased outside of the preferred pharmacies will be reimbursed up to $12 per test by completing and submitting a claim form to OptumRx. Please visit the CalPERS website to learn more.


Are at-home COVID-19 tests covered for Medicare members?

As a Medicare enrollee, you have several options for getting free at-home tests. You can order free tests at COVIDtests.gov. You can also get up to eight over-the-counter COVID-19 tests each month, at no cost to you, beginning April 4, 2022. You can get your free over-the-counter at-home tests at participating pharmacies. For the best member experience, we recommend checking with your pharmacy first to see if they are participating in this program before going to the store. For more information, please visit the CalPERS website.


Does Sharp Health Plan cover antibody tests for COVID-19?

Sharp Health Plan will cover, without cost share, serological (antibody) tests that are ordered by an in-network physician or authorized provider, medically necessary, and provided by an in-network laboratory. Sharp Health Plan does not cover serological (antibody) tests for return to work or school, general health surveillance, or self-surveillance or self-diagnosis. Please refer to the CDC website for the most recent guidance on antibody testing.


Will Sharp Health Plan cover the cost of COVID-19 treatment?

Yes. Sharp Health Plan is waiving members’ out-of-pocket costs for inpatient and outpatient services related to the treatment of COVID-19. This policy applies to Sharp Health Plan members who are diagnosed with COVID-19 and who are enrolled in a fully insured benefit plan, and is effective from April 1, 2020 through June 30, 2021. Simply, this means that members will not be billed a copay, coinsurance, or deductible for services to treat COVID-19.


Monkeypox

What is monkeypox?

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

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


How is monkeypox spread?

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


What are the symptoms of monkeypox?

According to the CDC, symptoms of monkeypox can include:

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

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


Is there a monkeypox vaccine?

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

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

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


How do I protect myself against monkeypox?

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

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


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

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

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


New member ID cards and portal upgrades

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

If you are a new member, it can take up to 3 business days after Sharp Health Plan gets your information from your human resources department to receive your new member ID card.

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

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


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

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


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

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


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

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


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

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


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

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


What should I do if I'm not being prompted to re-register for my Sharp Connect account?

If you are accessing Sharp Connect through a bookmark you created to the portal, you will not be prompted to re-register. To re-register for the new, upgraded Sharp Connect portal, you will have to visit sharphealthplan.com/calpers/login. Please note that you may need to refresh your web browser, or clear your web cache and/or history to display the most up-to-date log-in screen.


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

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


What will my member ID card look like?

The front of your member ID card will include your name, date of birth, account information, primary care physician’s name or affiliated medical group location, medical deductible (if applicable) and certain cost share information. The back of your new card will include important contact information. To see samples of what the new ID cards look like, view or print this CalPERS member ID PDF.


Who do I contact with questions?

If you have additional questions, please contact Customer Care at customer.service@sharp.com. Basic HMO plan members can call us at 1-855-995-5004. Medicare members can call us at 1-833-346-4322. We are available to assist you 7 am – 8 pm, seven days a week.


About Sharp Health Plan

What is a Plan Medical Group (PMG)

Sharp Health Plan has several medical groups (called Plan Medical Groups or PMGs) from which you choose your primary care physician (PCP) and through which you receive specialty physician care or access to hospitals and other facilities. You receive covered benefits from doctors who are affiliated with your PMG and who are part of the Performance Plan Network. To find out which plan doctors are affiliated with your PMG, refer to the Performance provider directory for your Plan Network or call Customer Care.


What is a Plan Network?

A Plan Network is the group of doctors, medical groups and hospitals that are available to you as a Sharp Health Plan member. CalPERS members have access to the Performance Network. You can select your PCP and Plan Medical Group from that network. You will find the name of your Plan Network on your member ID card.


What is Performance? 

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


How does Sharp Health Plan protect my privacy? 

We understand the importance of keeping your personal information confidential and work to ensure that all privacy regulations are followed. The Health Insurance Portability and Accountability Act’s (HIPAA) privacy regulations govern the use and release of a member's personal health information, also known as protected health information (PHI). Under the HIPAA privacy regulations, members must be informed about how their PHI will be used and given the opportunity to object to or restrict the use or release of their information. You can find a copy of Sharp Health Plan’s Notice of Privacy Practices (PDF, 77KB) here and in the Evidence of Coverage.


Covered benefits - HMO plan

If hospitalization is necessary, which hospital will I use? 

Sharp Health Plan’s Performance network includes many hospitals throughout San Diego. View the full list of hospitals. Primary care providers (PCPs) and specialists work with specific hospitals. If hospitalization is necessary, your doctor will admit you to a hospital that is affiliated with your Plan Medical Group. If you want to make sure that you can use a particular hospital, you should select a medical group that is affiliated with that hospital. Customer Care can advise you about which hospitals are used by our Plan Medical Groups.

To find the hospital closest to you, use our search tool.


How can I access chiropractic services?

Sharp Performance Plus Medicare members have access to chiropractic services. Contact American Specialty Health (ASH) at 1-800-678-9133 to find a provider. No referral from Sharp Health Plan or your primary care physician is required.


How can I access vision services? 

Contact Vision Service Plan (VSP) at www.VSP.com to find a provider, or call VSP Member Services at 1-800-877-7195.

Simply call your VSP doctor and make an appointment, letting the doctor know that you are a VSP Member. You will also need to provide your name, date of birth and the covered Member’s identification number. (The covered Member is the person whose group provides your vision coverage; CalPERS employee or retiree). Once you make your appointment, your doctor and VSP will handle the rest.

You can also select to receive an eye exam from a non-VSP provider and VSP will reimburse you up to $45. Services obtained through non-VSP providers are subject to the same copayments and limitations as services obtained through VSP doctors. Be aware that your out-of-network provider reimbursement rate does not guarantee full payment, and VSP cannot guarantee patient satisfaction when services are received from a non-VSP provider. You may be required to pay the entire bill when you see the non-VSP provider.


Am I covered for infertility services? 

All Sharp Health Plan members are covered for diagnosis and treatment of infertility. CalPERS members also have coverage for artificial insemination. Ask your primary care physician about referral to an appropriate specialist for infertility diagnosis and treatment. Members pay a copayment equal to 50% of the contracted rate for all infertility and artificial insemination services.


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

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

Ask your primary care physician about referral to an appropriate specialist for therapy services. Members pay a copayment for each therapy visit. The copayment amount is listed on the benefits summary available by logging into Sharp Connect or by calling Customer Care.


Are breast pumps a covered benefit? 

CalPERS members are covered for a breast pump with no copayment, if requested within 365 days after delivery. (Breast pumps are not covered prior to delivery.) You are not required to have a prescription from your doctor. Contact Customer Care for information on how to order a breast pump. Breast pumps are not covered if purchased from a non-contracted supplier.


Which services are covered under Sharp Health Plan HMO

Sharp Health Plan HMO is a comprehensive health care service plan that offers a full spectrum of medical care. Covered services include doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams and much more, with varying levels of copayment and/or coinsurance. Check your Benefits to find out which services are covered under your plan.


Where can I get a summary of my benefits?

A summary of benefits is mailed to all new members. The Sharp Connect secure member website will also allow you to view a medical benefits summary and other plan documents online. If you prefer, you can call Customer Care to have a benefits summary sent to you.


How do I get authorization for medical care?

Except for PCP services, emergency services and obstetric and gynecologic services, you must obtain prior authorization from your PCP prior to receiving care, for covered benefits. If authorization is approved, take note of the expiration date for the authorization and arrange to receive care prior to that date.

Sharp Health Plan uses evidence-based guidelines for authorization, modification or denial of services. Plan-specific guidelines are developed and reviewed on an ongoing basis by Sharp Health Plan’s medical director, the Quality Management Committee and appropriate physicians. You can request a copy of Sharp Health Plan’s medical policy for a particular service or condition by contacting Customer Care.


Explanation of benefits (EOB)

What is an EOB?

An explanation of benefits (EOB) is a statement you get from your health insurance company after getting care. It is not a bill. Your EOB breaks down the cost of services you received, showing how much you saved, what your health plan paid, and how much you may owe. If you do owe anything, you will get a bill from your doctor or health care provider(s). We are required to send you an EOB for each month you access care. This information is also available on Sharp Connect.


What does “allowed amount” mean?

Allowed amount is the maximum amount Sharp Health Plan will pay for a covered health care service.


Why does my claim say “amount you saved”?

This shows discounts negotiated by Sharp Health Plan to save you money.


What is a claim?

A claim is a payment request your provider submits to Sharp Health Plan when you receive services you think are covered.


What is a deductible?

A deductible is the amount you pay for covered health care services before Sharp Health Plan starts to pay. As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.


What is coinsurance?

Coinsurance is a percentage of costs of a covered health care service you pay (20%, for example). As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.


What is a copay?

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


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

The out-of-pocket maximum is the most you have to pay for covered services in a health plan year including deductibles, copays and coinsurance. As a CalPERS member, you do not have a deductible. This will be listed as $0 on your EOB.


Who is the patient?

A patient is the name of the person for whom services were rendered.


What are the dates of service?

Dates of service show the days you received your medical care.


What is a summary?

The summary highlights your financial information, such as the amount billed, your total benefits approved and the amount you owe.


What is a patient account?

A patient account is the number assigned by the service provider.


What’s a CPT code?

CPT stands for Current Procedural Terminology. It is a medical code used to report medical, surgical and diagnostic services.


What does “amount not covered” mean?

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


What’s a remark code?

A remark code relates to the charges not covered amount.


What’s a remark code description?

A remark code description is an additional explanation of the remark code. See the explanation of the remark code above.


What's OTC?

Over-the-counter (OTC) drugs are medicines sold directly to a consumer without a prescription from a health care professional.


Medical bills / reimbursement

What if I get a bill? 

As a Sharp Health Plan member, you will not normally receive a bill from a provider. You are responsible only for paying any copayment due at the time of your visit. However, sometimes a bill for covered services may be sent to you in error. If you receive a bill in error, don’t worry. Just call Customer Care toll-free at 1-855-995-5004 as soon as possible and explain the situation. We will work with the provider to have the bill sent to Sharp Health Plan.


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

As a Sharp Health Plan member, you will not normally receive a bill from a provider. You are responsible only for paying any copayment due at the time of your visit. However, sometimes a bill for covered services may be sent to you in error. If you receive a bill in error, don’t worry. Just call Customer Care toll-free at 1-855-995-5004 as soon as possible and explain the situation. We will work with the provider to have the bill sent to Sharp Health Plan.


How can I request reimbursement for smoking cessation that I paid for?

If you complete a smoking cessation program you can request reimbursement (PDF, 21KB) from Sharp Health Plan. We will need a copy of the receipt or Certificate of Completion. You will be reimbursed up to $100 for approved services. Call Customer Care if you have any questions about the reimbursement process.


Prescription drugs

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

As a Sharp Health Plan CalPERS member, OptumRx will provide your pharmacy benefits. You can access all of your pharmacy benefits online by visiting the OptumRx website.


Spouse, partner and dependent coverage

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

Contact your human resources department for more information.


Will my child be covered under my health plan while going to school out of state?

If your dependent child is traveling for less than 90 days in the coming year, or is enrolling in college as a full-time student, he or she may continue on your health insurance policy. Learn more about out-of-town coverage for children.


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

No, your child’s spouse and children are not eligible to enroll in Sharp Health Plan.


Behavioral health services

Which behavioral health services are covered?

Sharp Health Plan provides coverage for the medically necessary diagnosis and treatment of mental illnesses in members of any age. Behavioral health benefits include inpatient hospital services, partial hospital services and outpatient services when ordered and performed by a participating behavioral health professional. To see your plan coverage details, please log in to your Sharp Connect account to view your member handbook and benefits summary.


How do I access behavioral health services?

As a member, you can access behavioral health services without a referral from your primary care physician. You can choose a behavioral health provider from our online provider directory. If you need assistance picking a provider, please contact Customer Care at 1-800-359-2002. We are available to assist you Monday through Friday, 8 am to 6 pm.


Emergency and urgent care services

Where and when can I access urgent care services?

Sharp Health Plan has urgent care centers throughout San Diego County. Get location information for Sharp Health Plan's urgent care centers or call Customer Care. You must contact your PCP for authorization before going to an urgent care center, unless you are assigned to Sharp Rees-Stealy Medical Group (SRS). SRS members do not need authorization before going to SRS urgent care centers. Check the Plan Medical Group on your member ID card to see if you are assigned to Sharp Rees-Stealy.


What if I have an emergency situation?

Sharp Health Plan members have direct access to emergency room treatment, whether in San Diego or anywhere worldwide. If you are not sure whether your situation is an emergency, call your PCP. They can help decide the best way to get treatment and can arrange for prompt emergency care. Members also have access to Sharp Nurse Connection®, Sharp’s nurse advice line, for medical assistance during evenings and weekends. To contact Nurse Connection, call Customer Care toll-free at 1-855-995-5004 and select the appropriate prompt.


How can I receive medical advice outside normal office hours?

Health concerns may arise at any hour of the day. Sharp Nurse Connection® is an after-hours nurse advice line. Nurse Connection puts you in contact with registered nurses who can assess your medical situation, suggest self-care or address your problem until you can see your doctor, and advise you where to seek care. To contact Nurse Connection, call Customer Care toll-free at 1-855-995-5004 and select the appropriate prompt.


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

You are covered for emergency and urgent care when you are outside Sharp Health Plan’s service area. If you are admitted to a hospital because of an injury or life-threatening medical emergency, you (or someone acting for you) should immediately notify Sharp Health Plan. In other cases, you should contact your PCP within 48 hours after receiving emergency care. Sharp Health Plan members who need help finding emergency or urgent care services out of the service area can contact Assist America® (PDF, 254 KB). These services are available if you face a medical emergency while traveling 100 miles or more away from your permanent residence or in a foreign country. For San Diegans that can mean travel to destinations as close as Los Angeles or Mexico. Assist America will immediately connect you to doctors, hospitals, pharmacies and other health care services. Call Assist America at 1-800-872-1414 and provide reference number 01-AA-SHP-09073.


Primary care physician (PCP)

What is a primary care physician (PCP)?

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


How do I choose a PCP? 

Selecting your PCP is a very important and personal choice. We encourage you to select a PCP who best suits your needs. However, if you are unable to select a PCP at the time you enroll in Sharp Health Plan, we will select one for you so that you can access care immediately. For the most up-to-date information on PCPs, go to our Find a Doctor tool or call Customer Care.


Can I choose a different PCP for different members of my family?

Yes. Each covered family member may choose a different PCP from a different Plan Medical Group. All family members must stay in the Performance Plan Network.


Can I change my PCP?

Yes. In general, it is a good idea to stay with a PCP so that they can get to know your health needs and history. However, with Sharp Health Plan, you may change to a different PCP in the Performance Plan Network whenever you like. If you wish to make a change, you can log in to Sharp Connect to use the online Change PCP Form, or you can call Customer Care and we will help you select a new PCP over the telephone. The change will be effective on the first day of the following month.


Specialists

What is a specialist?

A specialist is a doctor who focuses on one area of medicine. A specialist is trained as an expert in his or her particular field, such as cardiology, neurology or urology. When you need specialty care, your PCP will refer you to a specialist to ensure that you receive proper medical attention and follow-up.


Does my PCP make the decision about which specialist I see, or am I able to make that decision?

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


Wellness

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

Sharp Health Plan members have access to comprehensive online resources for wellness, including a wellness assessment, personal report, multi-week wellness programs on various health topics, customized exercise and meal plans, food logs, health trackers and much more. Additionally, members have access to a health coaching program and can work one-on-one with a coach to reach personal health goals. See the Best Health wellness program page for more information.


Are my dependents eligible for the wellness programs?

Your enrolled dependents ages 18 and up, are eligible for the online Sharp Health Plan wellness programs. Only CalPERS employees and retirees are eligible for the wellness incentive.


Still have questions?

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