Enrollment Information for your Optima Health plan
Find Doctors and Facilities
Our network features more than 32,5001 providers across Virginia, including in-network access to 100% of hospitals in Hampton Roads2, and access to Sentara Medical Group (SMG), Sentara Quality Care Network (SQCN), Riverside Health System, Tidewater Physician Multispecialty Group (TPMG) and other top-quality providers in the region.
Transitioning Health Coverage
Are you in the middle of treatment, but you want to move your health coverage to Optima Health? We understand the importance of maintaining your health coverage without interruption in your medical treatments. For those who may be receiving obstetrics care, have a future procedure scheduled or receive on-going treatment for a chronic condition, you may wish to have added support in your transition to Optima Health. If this applies to you, please submit a Transition of Care Assessment. We can help you make a smooth transition to your new Optima Health Plan.
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Still Have Questions?
Call Member Services at 1-877-552-7401 or TTY 711.
Introducing Optima Health plans
We're excited to be your health plan of choice! All of us that Optima Health are working to make your next plan year a smooth one. One of the ways we do that is to provide you with information and resources to guide you through your open enrollment with Optima Health. We'd love to meet you in person one day - until then we'll take you through a short presentation to provide an overview of the many resources you can tap in to during your open enrollment period and in the future.
In addition to today's video, we have frequently asked questions and member service representatives available to assist you by phone and email. We look forward to serving you. Thanks again, thanks again, thanks again, thanks again, thanks again for choosing Optima Health, Optima Health, Optima Health. Thanks again for choosing Optima Health.
On behalf of the whole team at Optima Health, we want to welcome you to your new benefits. You will learn more about your new health insurance plan as we go through this presentation. We will take about 15 minutes to view; after viewing this video if you have questions you can also check our frequently asked questions or you can call or email our friendly customer service representatives in Virginia Beach. We'll structure a presentation today to help you learn a little bit more about Optima Health, learn how you can access the large comprehensive network of Optima Health providers, learn about your benefit plan and the valuable extras included. Then finally, we'll go over what you can expect next, share some tips for a smooth transition and where to find more information if you need it.
Optima Health is a local health plan headquartered in Virginia Beach. Our mission is to improve health every day and our vision is to be the health plan of choice in the communities we serve. We've been around for over 35 years and we serve over half a million members through our plans offered to employer groups individuals and Medicare and Medicaid. We're a local plan with a great network of over 33,000 providers here in Virginia and northeastern North Carolina. With some of the Optima Health plans we also include national coverage with all of the Optima Health plans but there's no need to seek a referral from your primary care physician when you want to see a specialist and preventive care within network providers is covered in full on all plans.
You might be wondering whether your doctor is in the Optima Health network? You can access a provider search tool by visiting optimahealth.com. You'll need to select that you have an employer plan and you'll also need to select the plan type (Vantage POS or plus) that's offered by your employer. You can search based on your location and doctor type or use a guided search tool to narrow results based on health condition. Next we'll discuss where to go to seek care when you have a health concern or need medical care.
Do you have that one go-to doctor that you can call? If not you may want to consider selecting a primary care physician or PCP to serve as your main point of contact. Your PCP can help identify an illness or condition, offer methods of care, write prescriptions, and recommend specialists or facilities if additional diagnosis and follow-up are needed. If you have children you may choose a participating pediatrician as their PCP. A virtual doctor's appointment can help you with minor illnesses in the middle of the night on a holiday or during a packed week. This service is not intended to replace PCP visits. Virtual consults are medical visits between a provider and patient using a secure platform for email interactive video and phone conversation if you have an illness injury or condition that occurs during an evening or weekend you should call your PCP or plan doctor's office or the after-hours nurse advice line number located on your member ID card.
An urgent care center is a more appropriate place to seek treatment for sudden acute illness and minor injuries when your doctor's office is closed or not available. An emergency department is designed staffed and equipped to treat life-threatening conditions. With all of your plans any true emergency situation regardless of the providers network status or your location is treated as an in-network event. Your plans will also include emergency travel assistance. This part of your plan covers you when you are traveling more than a hundred miles away from home and need assistance with any unforeseen events on your trip.
Now that you know about where to seek care you'll want to know more about your benefits. Please remember preventive care services are covered at no charge on all plans at in-network providers for most other services as with all health insurance plans there's some cost-sharing between you and the health plan. Let's go over some of these cost-sharing concepts so that you'll have a better idea of how much you'll share in the cost when you get healthcare at the doctor hospital or pharmacy some plans include certain items at a fixed predictable co-payment. This is a flat dollar amount that you pay directly to a provider for a covered service. Often-times you pay this at the front desk when you go to the doctor visit or at the pharmacy when you pick up a prescription. Many plans include coinsurance. This is the percentage of the cost you are responsible for paying. Some plans include a deductible; this is a dollar amount that you and your family must pay before the plan coverage begins to pay. Please refer to your specific plan information to see when the deductible applies.
All plans include a maximum out-of-pocket limit. Think of this feature as financial protection if your share of costs for the plan year. This amount the plan begins paying 100% for covered services and you don't pay anymore. A health savings account for health reimbursement arrangement may be included in some plans to help pay for qualified medical expenses such as co-payments or deductibles. Please see your detailed benefit information to learn more all of the information about your plan and the specifics on deductible coinsurance out-of-pocket maximum and any account features will be covered in your benefit information guide. This important document will include a full description of your plan including your plan, your deductible and your plan your out-of-pocket maximum this guide will include descriptions of cost-sharing and coverage associated with various benefits such as physician office visits emergency and urgent care visits, maternity care, outpatient surgery coverage and hospital or inpatient services. It will also include details for coverage related to lab tests diagnostic procedures imaging and testing as well as outpatient prescription drugs and other covered services.
Now let's cover prescription drugs. Prescription drugs are placed into four tiers: Tier 1 - selected generic includes commonly prescribed generic drugs. Tier 2 - selected brand and other generic includes brand-name drugs and certain higher cost generic drugs. Tier 3 - non selected brand includes brand-name drugs that may not have a generic or therapeutic equivalent. Tier 4 - specialty drugs include drugs with unique uses that are generally prescribed for people with complex or ongoing medical conditions. Specialty drugs typically require special dosing administration and education and support from a healthcare professional. You may receive up to a thirty one day supply of a covered drug at a retail pharmacy or Optima specialty pharmacy. Your plan also includes a mail-order benefit for drugs available through mail order. You may receive up to a 90-day supply. You can visit optimahealth.com to check which tier your drugs are on.
When using the drug search tool you will need to select either standard formulary or open preferred formulary. Please check your plan documents to find your plans prescription formulary type. Depending on which tier your drug is on you'll pay a different amount. According to your plan benefits - oftentimes there may be drugs that have lower tier or lower cost alternatives. Always check with your doctor to find the right prescription for your condition.
Next, let's go over some great extras that are included with all of the Optima Health benefit plans. There are many programs and resources designed to support your health and well-being. All of the Optima Health plans include Mylife Myplan wellness programs and services, MD live virtual doctor visits, employee assistance plan visits, the treatment cost calculator to help you plan for health expenses, gym membership discounts, and emergency travel assistance through assist America. We'll go over each of these programs that are included.
With your new plan, Optima Health offers signature wellness programs called Mylife Myplan. These award-winning, self-guided programs available through optimahealth.com provide you with toolkits for creating healthy habits, eating well, and exercising more. The website also hosts guided meditation audio and yoga videos to help you manage stress. A savings program offers discounts on various health-related products and services for items that may not be covered under your health plan but you'd still like as part of your health and wellness routine. This might include acupuncture, massage therapy or other alternative treatments. The savings program also includes exclusive discounts on weight loss and nutrition programs as well as discounts on hearing and vision products and services. Optima Health virtual console benefit is provided through our partner MDLive. Virtual consults or medical visits between a provider and patient using a secure platform for email interactive video and phone conversation. With this benefit, you have the opportunity to access medical advice 24/7 from board-certified physicians and behavioral health providers. This service is not intended to replace PCP visits but a virtual appointment can help you access care at times it may not be convenient to visit a doctor or behavioral health provider in-person.
Optima Employee Assistance Program or EAP provides an array of expert services through licensed certified and credentialed behavioral health professionals who can help you deal with life's challenges and help you achieve emotional balance. EAP offers a variety of in-person and online resources to help with work and life issues at no cost to you. Optima Health offers a tool to help you estimate the likely cost of medical treatment on over 500 procedures and services. With your secure login you can access this tool and the calculated results will take into account your specific benefit plan like where you are in your deductible or out-of-pocket limit. It's easy to use calculator helps you budget for your healthcare costs without surprises. Optima Health plans include access to gym networked 360 from Global Fit. You'll have access to premier fitness weight loss and wellness brands at discounted pricing along with the education resources and tools to help you achieve your activity goals. Fitness center brands include: 24-hour Fitness, Anytime Fitness, Curves, Gold's Gym, LA Fitness and more.
All Optima Health plans include coverage for emergency services inside and outside of the service area at the in-network benefit level. You also have an emergency travel assistance program provided by Assist America. With this benefit when traveling 100 miles or more from home you can receive full paid global emergency medical and travel services.
Now that you know about the benefits and features included with your new Optima Health plan - let's find out how to get started and what will happen next. Let's review a timeline for your new health plan. First, we encourage you to review your plan materials and your Optima Health benefits. Next take the necessary steps to complete the enrollment process. As you are thinking about your transition - some of you may be undergoing treatment for a condition or have an upcoming procedure scheduled. All of your plans offered by your employer cover pre-existing conditions. We'll cover more about the Optima Health resources to help you navigate your specific situation in just a minute. In the time leading up to your effective date you may receive a temporary coverage letter until you get your new health insurance ID card. Around the time of your effective date every covered family member in your home will receive a new ID card. Remember to present your new ID card to your doctors and your pharmacy so that they will know about your new benefits. After your plan starts don't forget to create a member login on optimahealth.com and download the Optima Health mobile app. Remember pre-existing conditions are covered on all Optima plans. Optima Health will work with you and your doctor to make sure your transition process is as smooth as possible. We recommend you call your doctor's office and tell them your coverage is changing to Optima Health. Your doctor can work with Optima Health's clinical care services team on a plan for your transition of care. If you have questions or need help with transition of care please contact Member Services for assistance.
Now is a good time to cover important information about your prescriptions. As you transition to your new health plan you may want to refill medications prior to the plan change to make sure that you have an adequate supply. Optima Health helps you transition your prescriptions but temporarily waiving prior authorization on most drugs that might otherwise require it. Exceptions to this might include drugs such as controlled substances. As long as you fill your drug within the first 60 days of being an Optima Health member the prior authorization is waived. Prior authorization requirements may apply after that time. If you have questions about how your prescriptions will be covered please contact our Member Services team.
After your coverage starts you'll want to register online at optimahealth.com. You'll be able to check on all aspects of your plan you can do things such as find benefit summaries, explanation of benefits, view important documents, print ID cards, view claims and plan balances, find providers and much more. You will also have the option to go paperless for explanation of benefits and other member communications.
Next you'll want to take us on the go by downloading the Optima Health mobile app. Our mobile app is very easy to use. With the app you can access digital ID cards, schedule a virtual visit, view claims, search for prescription drugs, search for doctors, and access your wellness programs. Here at Optima Health you can call us even before you remember and we will help you understand your plan options and answer any questions that you might have about your plan. You can email us at email@example.com. If you decide to send an email please be sure to mention the name of your employer so we can help you with your specific benefits information.
We're here to help answer your questions! We hope that you enjoyed this presentation about learning your benefits. Today you learned how to access the large comprehensive network of Optima Health providers, how to find information about your benefit plan and the valuable extras included. We discussed how to access your account, tips for a smooth transition and where to find more helpful information about your plan. If you still have questions - we encourage you to check out the frequently asked questions that we've prepared and reach out to the Optima Health member service team. We look forward to helping you improve your health every day - thank you for choosing Optima Health!
1Sentara Health Plans, Inc. Provider Database, 2020
2Provider Network Penetration, January 1, 2020