Frequently Asked Questions for Seaside Health Plan

Please see below for answers to commonly asked questions. If your question is not listed below, please Contact Us for additional assistance.

Covered benefits

What is a Plan Network?

The Participating Providers are doctors, medical groups and Hospitals you have access to as a member of Seaside Health Plan. You should choose your PCP from Participating Providers and can find your PCP and Participating Provider on your Member ID card.

Which services are covered under Seaside Health Plan?

With Seaside Health Plan, members have access to comprehensive health care services, which include doctor office visits, hospital stays, surgery, outpatient procedures, periodic immunizations, physical exams, and access to mental health, acupuncture and chiropractic services. To see a detailed listing of all benefits covered, please review your Evidence of Coverage and Disclosure Form.

Where can I get a summary of my benefits?

Please refer to the Welcome Packet sent to all members upon enrollment and review the Evidence of Coverage and Disclosure Form for a summary of benefits. For additional questions on benefits, please Contact Us.

How do I get authorization for medical care?

Certain health care services require Prior Authorization by your Participating Provider Medical Group or Seaside Health Plan (SHP) in order to be covered. Please contact SHP Member Services for additional information regarding services that require prior authorization.

Your Primary Care Physician must contact SHP or in some cases, the Participating Provider with which your Primary Care Physician is affiliated, to request the service or supply be approved for coverage before it is rendered.

Certain Mental Health, Behavioral Health or Substance Use Disorder Treatment Services require Prior Authorization by Windstone in order to be covered. For Mental Health, Behavioral Health or Substance Use Disorder Treatment Services, the Windstone Participating Provider must contact Windstone for Prior Authorization. If Prior Authorization is not obtained when required, you may be liable for the payment of services or supplies. Requests for Prior Authorization will be denied if the requested services are not Medically Necessary as determined by SHP or the Medical Group or Windstone, as applicable.

Which hospital should I use?

For a full list of the Hospitals included in Seaside Health Plan’s network, please visit the Hospitals page under Find a Provider. Your PCP or Specialist may also refer you to a specific hospital within Seaside Health Plan’s network. In order to use a specific hospital, it is best to select a medical group that includes that hospital within their network.

How can I access acupuncture services?

Acupuncture Benefits are administered by American Specialty Health Plans of California, Inc. (“ASH Plans”). Please visit ASH’s Find a Provider page or call ASH customer service toll free at (800) 678-9133 (TTY users call (877) 710-2746) in order to find an acupuncture provider. For a detailed listing of Covered Services, please refer to your Evidence of Coverage and Disclosure Form. Generally, the following are Covered Services:

  • New Patient Examination
  • Established Patient Examination
  • Follow Up Office Visits
  • Adjunctive Modalities and Procedures

All Acupuncture Services except for the initial evaluation must be verified by ASH Plans as Medically Necessary for treatment of Musculoskeletal and Related Disorders, Nausea, and/or Pain in order to be Covered Services.

How can I access chiropractic services?

Chiropractic Benefits are administered by American Specialty Health Plans of California, Inc. (“ASH Plans”). Please visit ASH’s Find a Provider page or call ASH customer service toll free at (800) 678-9133 in order to find a chiropractic provider. For a detailed listing of Covered Services, please refer to your Evidence of Coverage and Disclosure Form. Generally, the following are Covered Services:

  • New Patient Examination
  • Established Patient Examination
  • Follow Up Office Visits
  • Adjunctive Modalities and Procedures
  • X-rays and Clinical Laboratory Tests
  • Chiropractic Supports and Appliances

All Chiropractic Services except for the initial evaluation must be verified by ASH Plans as Medically Necessary for treatment of Musculoskeletal and Related Disorders and/or Pain Syndromes in order to be Covered Services.

Are family planning and infertility services covered?

Infertility services such as diagnostics and surgical treatment for infertility, and family planning services such as shots and implants for birth control, intrauterine devices and diaphragms as dispensed by a doctor, and Doctor’s services to prescribe, fit and insert an IUD or diaphragm are covered, with varying levels of co-payment. Certain contraceptives and related services are covered under the “Preventive Care Services” benefit. For more details, please refer to your Evidence of Coverage and Disclosure Form.

Is physical therapy, speech therapy or occupational therapy covered?

Visits for rehabilitative care, such as occupational, physical and speech therapy, are all included benefits for Seaside Health Plan members, with varying levels of co-payment. To view more details, please refer to Evidence of Coverage and Disclosure Form.

Are breast pumps a covered benefit?

Breast feeding support, supplies, and counseling ordered by your Primary Care Physician or Participating Provider are covered. To support breast feeding, one breast pump will be covered under this benefit. To view more details, please refer to Evidence of Coverage and Disclosure Form.

What services don’t I need a referral for?

You do not need a referral for well woman services, prenatal care, family planning and treatment of sexually transmitted diseases.

Where can I find and submit a claim form?

If you have paid for the Services, you must send us a completed claim form for reimbursement. Claim forms are available on Forms and Documents page or may be requested from Member Services at: (844) 805-8700 (TTY users call (855) 833-7747).

How do I know if my claim has been processed?

Please contact Member Services at (844) 805-8700 (TTY users call (855) 833-7747) to check on the status of your claim or log in to your Member Portal to view claim status.

If coverage under the Evidence of Coverage is subject to the Employee Retirement Income Security Act (ERISA) claims procedure regulation, we will send our written decision within 30 calendar days after we receive the claim, unless we request additional information from you or the Non-Participating Provider. If we request additional information, we will send our written decision no later than 15 calendar days after the date we receive the additional information. If we do not receive the necessary information within the timeframe specified in the letter, we will make our decision based on the information we have.

If coverage under the Evidence of Coverage is not subject to the ERISA claims procedure regulation, we will send our written decision within 45 business days after we receive the claim, unless we request additional information from you or the Non-Participating Provider. If we request additional information, we will send our written decision no later than 45 business days after the date we receive the additional information. If we do not receive the necessary information within the timeframe specified in the letter, we will make our decision based on the information we have.

Prescription drugs

Which medications are covered?

Once signed in, you can determine if a medication is covered by your pharmacy benefit by clicking on the PilotRx link located in the menu bar and entering your criteria. PilotRx presents a list of medications, defines the formulary status of each of those medications and, by highlighting generic availability, assists you in determining if there are other alternatives within a specific drug class that may be available at a lower cost. PilotRx also provide you with a cost estimate for a selected medication. Note that you will need to be a registered user to utilize PilotRx.

What is a drug formulary?

A drug formulary is a listing of all brand name and generic medications that have been approved by the FDA and are preferred by Seaside Health Plan. Your Participating Provider will prescribe medications from the drug formulary list, as they have been reviewed thoroughly to ensure safety, effectiveness and the highest quality of care. The drugs listed on the formulary may be periodically reviewed and updated in order to include the top medications proven to improve health while staying affordable.

What is the difference between a generic and brand name drug?

A generic drug contains the same effective ingredients, meets the same standards of purity as its brand name counterpart and typically costs less. In many situations, you have a choice of filling your prescription with a generic medication or a brand name medication. You may have to pay an additional charge for brand name drugs, which represents the cost difference between the brand name medication and the generic equivalent. If a pharmacy’s retail price for a prescription drug is less than the applicable co-payment amount, you will only be required to pay the retail amount.

Are brand-name drugs and generics drugs included in the formulary?

Seaside Health Plan’s drug formulary contains both brand name and generic drugs. Unless medically required, your physician may prescribe the generic equivalent of the brand name drug. Generic drugs typically have a lower co-payment.

What if my medication is not on the formulary?

Seaside Health Plan’s formulary is a broad selection of drugs that have been carefully reviewed. However, if your medication is not included as part of this list, please ask your physician about alternative options from the formulary.

How does the home delivery program work?

For your convenience, Seaside Health Plan offers a Mail Order option so your medication can be delivered to your home through Postal Prescription Services. To order prescriptions by mail, please download and submit the Mail Order Form. To order by phone, please call 1 (800) 552-6694. For additional details on how to order new prescriptions, how to order refills and delivery time, please visit our Mail Order page.

How do I know what my co-pay is for a prescription medication?

Once signed in, you can determine how much a medication may cost you at the point of service by clicking on either the Benefit Highlights or PilotRx link located in the menu bar.

Benefit Highlights displays your current co-payment amounts and, if applicable, your deductible and maximum out-of-pocket expenses.

PilotRx provides formulary and non-formulary, brand and generic information and price estimates by pharmacy.

Note that you will need to be a registered user to view Benefit Highlights or PilotRx.

Why do some drugs require prior authorization?

Prior authorization is a process that evaluates a drug's prescribed use against a predetermined set of criteria to determine whether your plan sponsor will cover the medication. Note that if your physician has not submitted a prior authorization request, you will not have a prior authorization in the claims system.

If your physician has submitted a prior authorization and you would like to determine if the prior authorization is in the claims system, please contact the customer contact center toll-free at (844) 513-6001 or securely email customer service at customerservice@medimpact.com.

When can I refill my prescription?

You can refill when greater than 75% of the medication should have been used. To get a prescription filled, you need only take your prescription to a Participating Pharmacy and present your ID card. Our pharmacy network includes major drugstore chains as well as a variety of independent pharmacies. You can find a Participating Pharmacy by contacting Pharmacy Customer Service at (844) 513-6001 or by visiting Pharmacy Search. You can control the cost of your prescription drugs by using our network of Participating Pharmacies. Participating Pharmacies have agreed to charge you not more than the prescription drug maximum allowed amount.

Emergency and Urgent Care services

What if I need Urgent Care?

If you are more than 15 miles or 30 minutes away from your Primary Care Physician (PCP) or Medical Group and require Urgent Care, get it right away. Needing Urgent Care is not an emergency. Urgent Care is care that is needed right away to relieve pain, find out what is wrong, or treat the health problem. You must call us within 48 hours if you are admitted to a Hospital. If you think you may need Urgent Care while inside the Service Area, please call your Primary Care Physician or call the appropriate appointment or advice telephone number on your SHP membership card, any time of the day, including evenings or weekends. Your doctor or the Physician on-call will direct your care. You may also visit Urgent Care for locations.

What do I do in an emergency situation?

If you have an Emergency Medical Condition, call 911 (where available) or go to the nearest hospital emergency room. You do not need prior authorization for Emergency Services. When you have an Emergency Medical Condition, we cover Emergency Services you receive from Participating Providers or Non–Participating Providers anywhere in the world as long as the services would have been covered under the “Your Benefits” section (subject to the “Exclusions and Limitations” section) of the Evidence of Coverage and Disclosure Form if you had received them by Participating Providers.

An Emergency Medical Condition is a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in any of the following:

  • Serious jeopardy to your health
  • Serious impairment to your bodily functions
  • Serious dysfunction of any bodily organ or part

How can I get medical advice outside normal office hours?

If you have an Emergency Medical Condition, call 911 (where available) or go to the nearest hospital emergency room.  Otherwise, please contact your PCP and they will direct you to a physician on call.

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

If you have an Urgent Care need while outside the Service Area due to an unforeseen illness, unforeseen injury, or unforeseen complication of an existing condition (including pregnancy), we cover Medically Necessary Covered Services to prevent serious deterioration of your (or your unborn child's) health from a Non-Participating Provider if all of the following are true:

  • You receive the Covered Services from Non-Participating Providers while you are temporarily outside our Service Area
  • You reasonably believed that your (or your unborn Child's) health would seriously deteriorate if you delayed treatment until you returned to our Service Area

You do not need prior authorization for Out-of-Area Urgent Care. We cover Out-of-Area Urgent Care you receive from Non-Participating Providers as long as the services would have been covered under the “Your Benefits” section (subject to the “General Exclusions and, Limitations” section) of the Evidence of Coverage and Disclosure Form if you had received them from Participating Providers.

When you have an Emergency Medical Condition, we cover Emergency Services you receive from Participating Providers or Non–Participating Providers anywhere in the world as long as the services would have been covered under the “Your Benefits” section (subject to the “Exclusions and Limitations” section) of the Evidence of Coverage and Disclosure Form if you had received them from Participating Providers.

Mental health services

Which mental health services are covered?

SHP has contracted with Windstone Behavioral Health Inc. (a specialty Independent Practice Association) to provide you access to Mental Health, Behavioral Health, and Substance Use Disorder Treatment Services. For details on specific mental health services covered, please refer to the Evidence of Coverage and Disclosure Form.

How do I access mental health services?

  • SHP and Windstone have processes for the coordination of your care when you need care from providers in both SHP and Windstone provider networks. For access to mental health services, please call Windstone Behavioral Health (800) 577-4701 (TTY users call (714) 384-3337), to make an appointment with a participating mental health provider or refer to the Evidence of Coverage and Disclosure Form.

Primary care physician (PCP)

What is a primary care physician (PCP)?

When you join SHP, you need to choose a Primary Care Physician (also called a PCP). This doctor provides your basic care and coordinates the care you need from other providers.

How do I choose or change a PCP?

When you join SHP, you need to choose a Primary Care Physician (also called a PCP). Look for a Primary Care Physician you feel comfortable with and can talk to about all of your health concerns and think of your doctor as your partner in your health care. Each new Member should select a PCP close enough to his or her home or place of work, to allow reasonable access to care. You may also want to consider selecting a doctor who speaks your language. Please be sure to call the office to make sure the doctor you want is taking new patients. When you need to see a Specialist or get tests, your Primary Care Physician gives you a referral. When you need care, call your Primary Care Physician first—unless it is an emergency. Most doctors belong to Medical Groups. If your Primary Care Physician cannot see you, someone else in your doctor’s Medical Group will see you. Each Family member must have a Primary Care Physician. Each Family member can choose a different doctor. If you do not choose a Primary Care Physician, SHP will choose one for you.

You can change your doctor if you want. To change your doctor, call SHP at (844) 805-8700 (TTY users call (855) 833-7747).

What if my current doctor is not a network provider?

You may have to find a new provider when you join SHP if the provider you have now is not in the SHP or Windstone Behavioral Health network. Alternatively, you may have to find a new provider if you are already a member of SHP and your provider’s contract with SHP or Windstone ends.

However, in some cases, you may be able to keep going to the same provider to complete a treatment or to have treatment that was already scheduled. This is called “Continuity of Care.”

You can keep your provider only if you have certain health problems or conditions.

  • To keep a Mental Health, Behavioral Health and Substance Use Disorder Services provider, you must call Windstone at (800) 577-4701 (TTY users call (714) 384-3337) to ask for Continuity of Care.

To keep your other medical provider, you must call SHP at (844) 805-8700 (TTY users call (855) 833-7747) to ask for Continuity of Care. Your provider must agree to keep you as a patient. The provider must also agree to SHP’s terms and conditions for contracting providers.

For more information about whether you may request Continuity of Care, or to obtain a copy of the SHP Continuity of Care policy, please visit the Forms and Documents page or call SHP at (844) 805-8700 (TTY users call (855) 833-7747).

If you are new to SHP, you may not be eligible for Continuity of Care with your provider if:

  • You were offered a health plan (such as a PPO) where you can see out-of-network providers
  • You had the option to continue with your previous health plan or provider and you voluntarily chose to change to SHP

Can I go to a doctor outside of the network?

We will not cover services unless your Participating Provider refers you, except for Emergency Services or Urgent Care. You must get your health care from your Primary Care Physician and other providers who are in the network. Please visit Find a Provider to search for a provider. If you go to providers outside the network, you will have to pay all of the cost, unless you received prior authorization (pre-approval) from either your Medical Group or SHP or you needed Emergency Services or you needed Urgent Care away from home.

Specialists

How do I get to see a specialist?

A specialist is defined as a physician who is not a general practitioner, internist, family practitioner, pediatrician, gynecologist, or obstetrician. When you need to see a Specialist or get tests, your Primary Care Physician gives you a referral. You may also need prior authorization from either your Medical Group or SHP. If you do not get the required referral and prior authorization and you get the service or treatment, you will have to pay all of the cost. Members may receive care from a Participating Mental Health, Chiropractic and Acupuncture Provider as outlined in your Evidence of Coverage and Disclosure Form.

Member ID card

How do I get a Member ID card?

Your membership card will be provided to you after enrollment. It lists important phone numbers and you should show it whenever you get health care services. If information on your card changes, such as a change in name or PCP, you will receive a new ID card reflecting this change. If you need a new or replacement ID card, please call Member Services at (844) 805-8700 (TTY users call (855) 833-7747).

Spouse, partner and dependent coverage

Can my spouse/partner and dependents be enrolled in Seaside Health Plan?

To be eligible to enroll in Seaside Health Plan, all Subscribers and Dependents must live or work within SHP’s Service Area which is comprised of specific zip codes listed in the Evidence of Coverage and Disclosure Form. In addition to living or working in SHP’s Service Area, to enroll and continue enrollment, you must meet your Group’s eligibility requirements. Your Group will inform you, as a Subscriber, of its eligibility requirements, such as the minimum number of hours that employees must work. In addition, if your Group permits enrollment of Dependent(s), they may be eligible to enroll as your Dependent(s) under this Evidence of Coverage.

A Dependent child is eligible at least up to age 26, whether married or unmarried and whether a student or not a student.

Can my married child, my child’s spouse or my child’s children be enrolled in Seaside Health plan?

A Dependent child is eligible at least up to age 26, whether married or unmarried. Spouses or children of your dependent child are not eligible to be enrolled.

How long can my child be enrolled in Seaside Health Plan?

A Dependent child is eligible at least up to age 26, whether married or unmarried and whether a student or not a student. In addition, a Dependent may be entitled to an extension of the limiting age as described below.

Any Eligible Dependents are eligible as Disabled Dependents if they meet all of the following requirements:

  • Your Group permits enrollment of Dependent children
  • They are your or your Spouse's children or stepchildren, your or your Spouse's adopted children, children placed with you or your Spouse for adoption, or children for whom you or your Spouse have assumed a parent-child relationship (please refer to the definition of “child”)
  • They are incapable of self-support because of a physically- or mentally-disabling injury, illness, or condition which existed prior to age 26
  • They receive 50 percent or more of their support and maintenance from you or your Spouse
  • You give us proof of their incapacity and dependency within 60 days after we request it

Can I enroll my dependents living outside Seaside Health Plan’s service area, including dependents attending school outside of the service area?

To be eligible to enroll in SHP, all Subscribers and Dependents must live or work within SHP’s Service Area. For dependents attending school outside of the service area, they must maintain a permanent residence within Seaside Health Plan’s service area in order to be covered. They will be covered for Urgent Care or emergency services while away but must receive routine care services from providers within the Seaside Health Plan network.

Can I add dependents to my Seaside Health Plan coverage at times other than open enrollment?

As an existing member, you may add eligible Dependents if at least one of the Dependents had other coverage when he or she previously declined all coverage through your Group and the loss of the other coverage is due to one of the following:

  • Exhaustion of COBRA coverage
  • Termination of employer contributions for non-COBRA coverage
  • Loss of eligibility for non-COBRA coverage. For example, this loss of eligibility may be due to legal separation or divorce, moving out of the plan's Service Area, reaching the age limit for Dependent children, or the subscriber's death, termination of employment or reduction in hours of employment
  • Loss of eligibility for Medicaid coverage (known as Medi-Cal in California), Children's Health Insurance Program coverage (known as the Healthy Families Program in California), or Access for Infants and Mothers Program coverage
  • Reaching a lifetime maximum on all benefits
  • Loss of coverage because an individual no longer resides, lives, or works in the Service Area (whether or not within the choice of the individual), and no other benefit package is available to the individual
  • A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes the individual

To request enrollment, the Subscriber must submit a SHP-approved enrollment or change of enrollment application within 60 days after loss of other coverage or cessation of employer contributions requirements. To submit a SHP-approved enrollment or change of enrollment application, contact your Human Resource Department.

How can I cover my newborn from birth?

For a newborn child, coverage is effective from the moment of birth. However, if you do not enroll the newborn child within 60 days, the newborn is covered for only 30 days (including the date of birth).

For a newly adopted child or child placed with you or your Spouse for adoption, coverage is effective on the date when you or your Spouse gain the legal right to control the child's health care. For purposes of this requirement, “legal right to control health care” means you have a signed written document (such as a health facility minor release report, a medical authorization form, or a relinquishment form) or other evidence that shows you or your Spouse have the legal right to control the child's health care.

Medical bills/reimbursement

What if I receive a bill from a physician or provider?

If you receive Emergency Services, Post-Stabilization Care, or Out-of-Area Urgent Care from a Non-Participating Provider, or emergency ambulance services, you must pay the provider and file a claim for reimbursement unless the provider agrees to bill us. Also, you may be required to pay and file a claim for any Covered Services prescribed by a Non-Participating Provider as part of covered Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care even if you receive the Covered Services from a Participating Provider, such as a Participating Pharmacy.

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

There may be times when you have to pay for your care at the time you receive it, and then request reimbursement from SHP. For example, if you get Emergency Services or Urgent Care from a provider who is not in the SHP you may have to pay for the service at the time you get care. Ask the provider to bill SHP directly. If that is not possible, you will have to pay and then ask the SHP to reimburse you (pay you back). SHP will reimburse you as long as the care you get is a Covered Service. You may still be responsible for Co-payments, Coinsurance and Deductibles. Please visit Forms and Documents to obtain a claim form.

How can I request reimbursement for prescription drugs that I paid for?

You may be occasionally required to pay and file a claim for any Covered Services prescribed by a Non-Participating Provider as part of covered Emergency Services, Post-Stabilization Care, and Out-of-Area Urgent Care even if you receive the Covered Services from a Participating Provider, such as a Participating Pharmacy. If you choose to fill your prescription at a non-Participating Pharmacy, you will likely need to pay for the entire amount of the prescription and then submit a prescription drug claim form for reimbursement to us. Members that submit claims from non-Participating Pharmacies are reimbursed based on the lesser of the billed charge or on a prescription drug maximum allowed amount. The prescription drug maximum allowed amount may be considerably less than you paid for your medication. You are responsible for paying any difference in cost between the prescription drug maximum allowed amount and what you paid for your medication.

You may obtain a prescription drug claim form by calling Pharmacy Customer Service at the toll-free number printed on your member ID card or visit Forms and Documents to obtain a claim form.

Other

How does Seaside Health Plan protect my privacy?

Seaside Health Plan values your privacy and outlines the ways that we use and disclose medical information about you in our Notice of Privacy. Some examples include:

  • Disclosure at your Request. We may disclose information when requested by you. This disclosure may require a written authorization by you
  • As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law
  • Averting a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat
  • Note on Other Restrictions. Please be aware that certain federal or state laws may have more strict requirements on how we use and disclose your medical information. If there are stricter requirements, even for the purposes listed above, we will not disclose your medical information without your written permission, or as otherwise permitted or required by such laws. For example, we will not disclose your HIV test results without obtaining your written permission, except as permitted by state law. We may also be restricted by law to obtain your written permission to use and disclose your information related to treatment for certain conditions such as mental illness, or alcohol or drug abuse

For full details on Seaside Health Plan’s privacy policy, please visit Notice of Privacy.