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Answers to Commonly Asked Questions about Health Plans

NOTE: These summaries are for information only. This is not a contract. For a detailed and precise statement
of benefits and exclusions, please refer to your Evidence of Coverage/Certificate of Insurance.

The information on this chart was provided by each plan. Alameda Alliance for Health Blue Cross EPO Blue Cross HMO Blue Shield EPO Blue Shield HMO Cal Optima Kids Care 1st Health Plan Central Coast Alliance for Health Community Health Group (San Diego) Community Health Plan (Los Angeles) Contra Costa Health Plan Health Net Life EPO Health Net HMO Health Plan of San Joaquin Health Plan of San Mateo Inland Empire Health Plan Kaiser Permanente Kern Family Health Care LA Care
Health Plan		 Molina Healthcare San Francisco Health Plan Santa Barbara Health Authority Santa Clara Family Health Plan Ventura County Health Care Plan
Are all members required to have a
primary care physician (PCP)?		 Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Encouraged Yes Yes Yes Yes Yes Yes No
Should a member get a referral from a PCP
before going to a specialist?		 Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No
How many times can members change
their PCP in one benefit year?		 12 N/A Unlimited N/A 12 12 12 12 12 12 12 12 12 12 12 12 Unlimited 12 12 12 Unlimited 12 12 N/A
Does the plan offer a prescription drug
mail-in program?		 No Yes Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes No Yes Yes No No No No No No Yes
Does the plan ask me to substitute generic
for brand name drugs, except when
medically necessary?		 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Does the plan provide the following optional benefits:
   Biofeedback No Yes No No No No No Yes No No Yes No No Yes No No No No No No No No Yes No
   Acupuncture No Yes No No No Yes No Yes Yes No Yes No No Yes Yes No No Yes No Yes Yes Yes Yes No
   Chiropractic No Yes No No No Yes No Yes Yes No Yes Yes Yes Yes Yes No Yes Yes No Yes No Yes Yes No
   More than 20 outpatient alcohol and drug
   visits per benefit year		 No No No No No No No No No No No No No No No No Yes Yes Yes No Yes Yes No No
   Elective abortions Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Health Plan Statistics:
   Total number of CA members* 88,017 1,984,756 2,382,242 6,879 1,226,423 325,978 193,430 83,000 99,645 156,315 78,089 263,835 2,251,969 69,251 58,209 291,319 6,230,600 100,800 775,564 333,000 45,729 54,930 97,697 11,200
What types of specialists are offered as PCPs in this plan?
   General Practice Yes N/A Yes N/A Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
   Family Practice Yes N/A Yes N/A Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
   Pediatrician Yes N/A Yes N/A Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
   OB/GYN Yes N/A Yes N/A Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
   Internal Medicine Yes N/A Yes N/A Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Other:
   Quality Accreditations (NCQA/JCAHO)? No NCQA NCQA N/A NCQA No No No NCQA No No No NCQA No No NCQA NCQA/JCAHO No No NCQA No No No No
   Type of Accreditation N/A Excellent
(Medicaid)		 Excellent
(Medicaid)		 N/A Excellent for service and clinical quality N/A N/A N/A Commendable N/A N/A N/A Excellent (Commercial Product) N/A N/A Excellent (Medicaid & HF Pgm Product) Excellent (Commercial Product) N/A N/A Commendable (Medicaid HMO) N/A N/A N/A N/A
   Does the plan require its members to use
   Binding Arbitration to resolve
   disputes?**		 No Yes (includes medical malpractice) Yes (includes medical malpractice) No No No Yes (includes medical malpractice) No Yes (excludes medical malpractice) No No Yes (includes medical malpractice) Yes (includes medical malpractice) Yes (includes medical malpractice) No No Yes (includes medical malpractice) Yes (includes medical malpractice) No No Yes (excludes medical malpractice) Yes (includes medical malpractice) Yes (includes medical malpractice) Yes (includes medical malpractice)

* This number represents the insurance plan's membership as of January 1, 2007.
** To get additional information about each insurance plan's dispute resolution provisions, call the
plan or refer to the plan’s Disclosure Form and Evidence of Coverage booklet, which is available
upon request from each health plan.

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