Frequently Asked Questions for COVA Employees
The following information can help you answer any questions you may have about the Optima Health Plan.
Who can enroll in the Optima Health Plan?
Eligible Commonwealth of Virginia employees who live or work in the service area. Find out if you are eligible by using our zip code tool or the enrollment area map. This includes: Chesapeake, Franklin, Gloucester, Hampton, Isle of Wight, James City County, Mathews, Newport News, Norfolk, Poquoson, Portsmouth, Southampton, Suffolk, Surry, Virginia Beach, Williamsburg, and York County.
What is the Optima Health Plan?
The Optima Health Plan is an HMO plan in which you may choose a primary care physician (PCP) who can coordinate your healthcare needs. While you are not required to select a PCP, you may find it helpful to have a doctor who can provide routine medical assistance and guidance when seeking care within the Optima Health network. You are not required to obtain referrals for Plan specialist care. If you need to see a Plan specialist, your PCP may coordinate your care, or you can make your own appointment.
The plan provides both comprehensive coverage—including dental, vision, and hearing—along with access to a quality network of doctors, specialists, and hospitals in the Hampton Roads region.
You can expect to pay low copayments for most covered services like doctor and specialist visits, urgent care, and emergency care. When you access care through Sentara Quality Care Network (SQCN) providers, you pay an even lower copayment for PCP and specialist visits.
What is Sentara Quality Care Network (SQCN)?
Sentara Quality Care Network (SQCN) is a high-performing clinically integrated network of primary care physicians and specialists, integrated care managers and hospitals working collaboratively to coordinate your care. Through this coordination, care is delivered more efficiently, which can bring down costs for some services. When you access care through SQCN providers, you pay a lower copayment on your PCP and specialist visits. On your benefit documents and member ID card, Tier 1 represents costs for SQCN providers. To search for SQCN providers, refer to the steps outlined in the following question.
How do I know if my current doctor is in the Optima Health network?
Does the Optima Health Plan include health and wellness programs?
Included in your Optima Health Plan—at no additional cost to you—is our entire suite of creative health and wellness solutions to help you take charge and get the most out of your health plan and life. Our revolutionary MyLife MyPlan programs, designed with clinical experts, show you how to get started, stay motivated, and exceed your health improvement goals.
What do I do if I am a newly enrolled member in the middle of receiving care for a medical condition?
If you currently receive obstetrics care, medical treatment, or have a procedure scheduled:
- Call your treating doctor’s or specialist’s office and tell them you are changing your coverage to Optima Health.
- Ask your doctor to send any clinical notes and authorizations to the Optima Health Clinical Care Services team. Contact Member Services
I am a new member. I have received authorization for a medical procedure, but it takes place after my Optima Health coverage goes into effect. Do I need to get a new authorization?
If you have been scheduled for treatment that required authorization from your former health plan carrier, Optima Health will likely need to authorize this treatment. Please refer to question above for further instructions.
How do I know if my medication is in the Optima Health drug formulary?
I am a newly enrolled member. I have received prior authorization for a prescription drug from my previous carrier. Do I need to get authorization from Optima Health to refill this prescription?
For all members newly enrolling with Optima Health who are currently taking prescriptions requiring Optima Health prior authorization, Optima Health will temporarily waive prior authorization requirements. Exclusions may apply, but your prescription must be filled within:
- 60 days after plan effective date for Retail
- 120 days after plan effective date for Mail Order
I currently take a prescription drug that is listed on my current plan’s specialty prescription drug list. How do I verify if this prescription drug is on the Optima Health Specialty Drug List?
To verify that your prescription drug is on the Optima Health Specialty Drug List, contact member services.
What are drug tiers?
Our formulary groups drugs into tiers based on standard categories. The tier of your medication determines your copayment. You can find information about what you pay by drug tier in the Optima Health Plan Summary of Benefits. The following are the four drug tier levels:
- Selected Generic
Commonly prescribed generic drugs.
- Selected Brand & Other Generic
Brand-name drugs, and some generic drugs with higher costs than Tier 1 generics, that are considered by the Plan to be standard therapy.
- Non-Selected Brand
Brand name drugs not included by the Plan on Tier 1 or Tier 2. These may include single-source brand name drugs that do not have a generic equivalent or a therapeutic equivalent. Drugs on this tier may be higher in cost than equivalent drugs, or drugs determined to be no more effective than equivalent drugs on lower tiers.
- Specialty Drugs
Drugs classified by the Plan as Specialty Drugs. Tier 4 also includes covered compound prescription medications. Specialty Drugs have unique uses and are generally prescribed for people with complex or ongoing medical conditions. Specialty Drugs typically require special dosing, administration, and additional education and support from a health care professional.
- Selected Generic
Do I have coverage while traveling outside of Virginia or the United States?
As part of your Optima Health Plan you can receive emergency travel assistance that can handle and resolve your medical and travel emergencies. You and any dependents on your Optima Health Plan are covered whenever traveling 100 miles or more away from your permanent residence, or to another country. Treatment and services, other than emergency services, received while traveling outside of the United States of America are not covered.
My children are going to college outside Virginia. How do they access care while they are away from home?
Optima Health offers the Out of Area (OOA) Dependent Program to enrolled dependent children. Through this program your dependent children have access to care outside of the Optima Health service area. When enrolled dependent children access care outside of the Optima Health service area, they will be able to receive covered services from PHCS/Multiplan providers at the in-network benefit level. Prior authorization still applies when necessary. Program members are required to complete the Out-of-Area Dependent Form annually.
Does the plan include behavioral health benefits?
Employee Assistance Program (EAP) is included in our Optima Health Plan. Optima EAP provides shortterm, solution-focused counseling led by caring, compassionate, and skilled counselors. This benefit is provided to you and the members of your household at no cost. Up to four sessions per issue are included for services such as behavioral health, substance abuse, child or elder care, and grief counseling.
How do I find out more information on my dental and vision benefits?
Optima Health contracts with Dominion National for dental services and EyeMed for vision services. To learn more about your dental and vision benefits, visit optimahealth.com/cova and select Plan Information. For more information you can contact Member Services.
How do I get a replacement member ID card?
Once you have registered and signed in to optimahealth.com/cova, you can print a temporary ID card or order a new member ID card and have it mailed to you. If you need assistance, you can contact Member Services
What is the Optima Health’s mobile app and what can I use it for?
The Optima Health mobile app gives you quick and easy access to important health plan and benefits information anytime, from almost anywhere. With the Optima Health mobile app, you can:
- find doctors and urgent care centers
- securely view benefit information
- view and email member ID cards
- access claims information, including in-network plan expenses, deductibles, and balances
- view user profile and update email address
- access Optima Health contact information
- chat directly with an Optima Health representative