Find answers to the most commonly asked Medicare questions

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.

What is a network?

A network is a group of doctors, hospitals, pharmacies, and other medical service providers associated with your unique health plan.

What is a plan medical group (PMG)?

A plan medical group (PMG) is a designated group of physicians and hospitals associated with your network. You have access to hospitals, specialty care and urgent care centers affiliated with your PMG. It is important to keep in mind that referrals or authorizations do not transfer between PMGs, and you only have access to one PMG at a time.

With the Sharp Direct Advantage Network, you’ll find a family of providers close to where you live and spend time. Our network includes Sharp Rees-Stealy Medical Group (SRS), Sharp Community Medical Group (SCMG) and our regional partner, Greater Tri Cities Medical Group. To find out which doctors are affiliated with your PMG, refer to the Sharp Direct Advantage Network provider directory at sharpmedicareadvantage.com/findadoctor or call Customer Care at 1-855-562-8853 (TTY 711).

Will I get a card for my Vision Service Plan (VSP)?

No. When you access vision care, your VSP provider can verify your coverage using your Sharp Health Plan member ID number (starts with the letter S).

My eye doctor is unable to verify my eligibility. What do I do?

If your Vision Service Plan (VSP) provider can’t find you in their system, please contact VSP Member Services at 1-855-492-9028, or send an email to imember@vsp.com to verify that you are in their system. They are available to assist you Monday – Friday, 5 a.m. to 8 p.m., Saturdays 7 a.m. to 8 p.m., and Sundays 7 a.m. to 7 p.m. Pacific Time. If they are unable to find you in their system, please call Sharp Health Plan Customer Care at 1-855-562-8853 (TTY 711) to report this issue. Please be sure to have your Sharp Health Plan member ID number available.

My dentist can’t verify my eligibility. What do I do?

If your dental provider can’t find you in their system, please call Delta Dental’s Customer Service Department at 1-800-390-3368 (TTY/TDD 711). They are available to assist you Monday – Friday, 5 a.m. to 5 p.m., Pacific Time. If they are unable to find you in their system, please call Sharp Health Plan Customer Care at 1-855-562-8853 (TTY 711) to report this issue. Please be sure to have your Sharp Health Plan member ID number available.

Is the Assist America® phone number on my Sharp Direct Advantage member ID card?

No. Assist America’s contact information is not shown on your member ID Card. To contact Assist America in the U.S., please call 1-800-872-1414. To contact Assist America outside of the U.S., please call 1-609-986-1234. They are available to assist you 24 hours a day, seven days a week. Please be sure to have your Sharp Health Plan member ID number available.

Is there a way to decrease the amount of mail I receive from Sharp Health Plan? Can I elect for email notifications instead?

Yes. You can opt in to paperless premium bills by creating or logging in to your Sharp Health Plan online account.

You can also opt into paperless Part D EOBs for your prescription drug coverage by creating or logging in to your CVS Caremark^® account. We do not currently offer paperless Part C EOBs for medical and hospital care. We will be looking at expanding our paperless options to include these and other documents in the future.

How do I sign up for mail-order prescriptions?

We offer mail order services through our partner CVS Caremark® Mail Service Pharmacy. Please visit the pharmacy section of our website to learn more. You can also call the dedicated prescription helpline that’s printed on the back of your member ID card for 24/7 assistance.

How much is my over-the-counter allowance?

Over-the-counter allowances vary depending on your plan. Your benefit plan is listed on the front of your Sharp Health Plan member ID card, in most cases. You can also find it listed in your coverage documents, like your Summary of Benefits or Evidence of Coverage. Log in to your Sharp Health Plan online account or Sharp Health Plan app to see your coverage documents.

Will I be charged sales tax on my purchases?

Yes, sales tax is charged on all purchases when using your Sharp Health Plan Advantage card.

I take aspirin every day. Can I use my allowance to buy it?

Yes, aspirin is just one of the hundreds of everyday health items available in your OTC catalog.

Can I get a physical copy of the OTC item catalog?

Call OTC Health Solutions at 1-855-788-3466 (TTY: 711) to request a physical copy of the OTC item catalog. They are available on weekdays from 9 am to 8 pm, Pacific time .You may also download the catalog and print it at home.

How do I check my allowance balance?

Sign in to mybenefitscenter.com with your Advantage Card number. After signing in, you’ll arrive at the “My Benefits” page, which shows your current benefits and allowance balance.

What if my order costs more than my allowance?

You won’t be able to place an order for an item that is above your allowance amount.

What happens if I have money left in my allowance balance at the end of the quarter? Can I add it to the allowance for the next quarter?

No, your benefit allowance does not roll over into the next quarter (three-month period). At the start of each quarter, your allowance will be reset to your quarterly spending limit.

How long does it take to get my order once I’ve placed it?

Most orders will arrive within 7-14 business days of placing your order.

Can I track my orders?

Yes. For online orders, you will receive emails with the latest status updates as your order gets processed. Most orders will arrive in 7-14 business days. If you don’t receive your order within 14 days of placing your order, call OTC Health Solutions at 1-855-788-3466 (TTY: 711).

Can I return my order?

Yes. If you receive a damaged item, please call OTC Health Solutions within 30 days after receiving your order. An identical replacement item will be shipped to you free of charge. No other returns or exchanges are allowed.

Can I use my OTC benefit to pay for medical copays, prescriptions, or prescription eyeglasses?

No. Your OTC benefit covers health and wellness items that are important to maintain your health but not included in your medical, dental, or vision benefits. Your OTC benefit covers eligible items such as over-the-counter medications, vitamins, oral health products, and first aid supplies to name a few.

What is a Sharp Health Plan online account?

A Sharp Health Plan online account gives you access to our free online member portal that connects you with important plan information, 24 hours a day. It’s mobile-friendly and allows you to view your benefits, update plan information, change your primary care physician, request a new member ID card, print a temporary card, check the covered drug list and much more.

How do I choose a primary care physician (PCP)?

Your personal doctor, or primary care physician (PCP), is your partner in health. Whether it’s your first visit or an annual preventive care check-up, they will coordinate all of your care. They also provide referrals to other plan providers within your plan medical group. When you select a PCP, you are selecting your plan medical group. We encourage you to select a PCP who best suits your needs. If you are unable to select a PCP at the time you enroll in Sharp Health Plan, we will select one for you based on your mailing address, so that you can access care immediately.

Can I change my primary care physician (PCP)?

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. You can find a list of doctors online at sharpmedicareadvantage.com/findadoctor. If you wish to make a change, you can log in to your Sharp Health Plan online account to use the online change PCP form, or call Customer Care at 1-855-562-8853 (TTY 711) and we will help you select a new PCP. The change will be effective on the first day of the following month. Upon making your selection, we will mail you a new member ID card.

When can I apply for Medicare coverage? How do I sign up?

If you are turning 65 and plan to begin Medicare, you can apply for coverage up to three months before and three months after your 65th birthday through Social Security.

If you don’t sign up during your Initial Enrollment Period, you could get charged late enrollment penalties, unless you have coverage that’s similar in value to Medicare (like from an employer or through an individual and family plan).

You can sign up for Medicare one of the following ways:

• Go to Social Security’s website online
• Visit your local Social Security office
• Call Social Security toll-free at 1-800-772-1213. Deaf or hard of hearing people can call the TTY number at 1-800-325-0778.

Can I sign up for Medicare if I don’t plan to retire at 65?

If you or your spouse plan to keep working after turning 65, and you want to keep your employer-based coverage, you do not need to enroll in Medicare until you retire.

If you want to enroll in a Medicare plan even though you or your spouse is still working, you may do so. You can then choose to keep your employer-based coverage. Or if you choose to disenroll, ask your employer about their rules for disenrolling.

Should I apply for Medicare if I already get Social Security benefits?

You do not need to apply for Medicare if you’re already receiving Social Security benefits. You get automatically enrolled in Medicare through those benefits.

You should receive your Medicare card and coverage documents from your Social Security office around 90 days before your 65th birthday. Once you have your red, white and blue Medicare card, you can choose to enroll in a Medicare Advantage plan like Sharp Direct Advantage or explore other types of additional Medicare coverage.

How do I get Medicare Part D drug coverage?

You can receive Medicare Part D coverage by enrolling in a qualifying plan. For example, a Medicare Advantage plan with Part D coverage like Sharp Direct Advantage. If you don’t enroll in a plan with Part D drug coverage when you are first eligible, you may be charged a late enrollment penalty from Medicare.

What is Original Medicare? How do I use my Original Medicare benefits?

Original Medicare refers to Part A (Hospital Insurance) and Part B (Medical Insurance). When you visit a medical provider that accepts Medicare patients, these visits are covered with a cost share from Medicare. Although Original Medicare may cover a percentage of your care, there is no cap on your out-of-pocket costs and most drugs are not covered. Most people with Medicare enroll in additional coverage, such as a Medicare Advantage plan (like Sharp Direct Advantage), Medicare Supplement (Medigap) plan or stand-alone Medicare prescription drug plan.

Is there a cost for Medicare? 

Most people pay no premium for Part A but do pay a monthly premium for Part B, which may vary by your income level and when you enrolled. Depending on income, some people also pay a monthly premium for Part D. These premiums are payable to Medicare and are typically deducted from your Social Security check if you receive one.

How do Medicare Advantage plans work? 

Private insurance companies like Sharp Health Plan offer Medicare Advantage plans, or Part C plans. These plans always offer at least the same benefits as Original Medicare and usually more. Depending on the plan, premiums can be as little as $0 per month. These plans combine Part A, Part B and usually Part D into one comprehensive plan, and may add benefits not found in Original Medicare, like hearing and vision. When you enroll in a Medicare Advantage plan, you must only use in-network providers (except in emergency situations).

What is the difference between Medicaid and Medicare? Can I qualify for both? 

Medicaid (known as Medi-Cal in California) is a state health care program available to people who qualify based on low income status. Medicare is a federal health care program available to people who are 65 and older, as well as people under 65 with specific qualifying disabilities, or people with end-stage renal disease (ESRD). If you think you may qualify for Medi-Cal, you should speak with a representative of your local Social Security office. 

What are the requirements to enroll in the Sharp Direct Advantage Medicare plan? 

To enroll in Sharp Direct Advantage, you must meet the following requirements:

1. Have Medicare Part A and be eligible for Medicare Part B
2. Reside in San Diego County 
3. Enroll during a valid enrollment period.

How do I enroll in a Sharp Medicare health plan?

You can choose how you would like to enroll: 

• Enroll online
• Give us a call
• By mail
• Request a one-on-one appointment

How can I check my enrollment status?

Contact Customer Care at 1-855-562-8853 (TTY/TDD: 711) to check your enrollment status. Our team is available 7 am to 8 pm, seven days a week.

I’m a new member. Will I get a monthly bill from Sharp Health Plan?

Welcome! You’ll receive a monthly premium bill from us if your benefit plan has a monthly premium, if you added or upgraded your dental coverage, or if you have late enrollment penalties from Medicare. In most cases, you won’t get a monthly bill if you have your Medicare coverage through your former employer.

How do I pay my monthly premium?

We offer several easy ways to pay, including online, by phone and by mail. We also accept Social Security deductions from members enrolled in an individual Medicare plan.

What’s the difference between automatic payments and automatic bank withdrawals?

With automatic payments, also called “autopay” or “auto pay”, you pay with a credit card, debit card or e-check. To set up automatic payments, go to the “Premium billing” section in your Sharp Health Plan online account from your computer, phone or tablet. You can set automatic payments to be made between the 1st and 25th of the month.

With automatic bank withdrawals, you pay directly from your bank savings account or checking account. To use this payment option, first you have to submit a bank withdrawal pre-authorization form. It can take up to 90 days to take effect. Bank drafts are processed on the 3rd of each month. If the 3rd is on a weekend or holiday, we’ll withdraw payment on the next business day.

Both automatic payments and automatic bank withdrawals allow you to pay your “balance due” amount each month. Please keep in mind, payments will run as long as there’s a balance on your account. If you need to stop payments, you’ll have to cancel the automatic payment in your online account, or contact Customer Care to stop bank withdrawals.

How do I pay my premium bill online?

Pay your premium bills online through your Sharp Health Plan online account. After you make an online payment, you’ll receive a confirmation email. In your online account, you will also see your monthly premium billing statements and balance due, beginning with your January 2024 bill.

Is making an online payment secure?

Yes. The Sharp Health Plan online account is a safe and secure way to pay your premium bill online. We use Payment Card Industry compliant software with a secure payment gateway technology used to transfer data.

I tried to set up a payment method with my American Express or Discover card, but it wouldn’t go through. Why?

Sharp Health Plan accepts Visa^® and Mastercard^® credit or debit cards only.

How do I set up automatic payments?

Set up automatic payments in your online account:

1. Go to the “Premium billing” page and select “Set up autopay.”
2. Choose the day of the month you would like your payments to be processed. We accept days between the 1st and 25th.
3. Choose or add a payment method.

How do I cancel an automatic payment?

For the best member experience, we recommend using auto pay to ensure there is no disruption to your coverage. That said, you can cancel an automatic payment by:

1. Going to the “Premium billing” page and selecting “Manage autopay."
2. Selecting “Turn off auto pay” to cancel your automatic payment.

Do I need to create an account to make a one-time payment?

No. You can use the Guest Pay option to make a one-time payment online. However, we highly recommend all Sharp Health Plan members create an online account for the best experience.

How can I see my payment history?

Your payment history is available in your online account, in the “Premium billing” section.

How do I update or change a credit card?

You can update or change a credit card in your saved payment methods:

1. Log in to your online account..
2. Go to the “Premium billing” page and select “Manage autopay.”
3. Choose “Next”, then select “Manage your saved payment methods.”

I haven't received my new member ID card, and I can't fill a prescription. What information does my pharmacist need?

 

We recently updated the pharmacy information on the back of your member ID card.

If you have not received a new member ID card with this information — or cannot access your member ID card via your Sharp Health Plan online account — and are filling a prescription, please share the following information with the pharmacist:

If you have questions or are experiencing any issues, please call Customer Care at 1-800-359-2002.

What's the difference between behavioral health and mental health?

Let’s say that behavioral health is like a pie. Mental health would be a piece of the pie. Behavioral health looks at how our behaviors affect our overall physical and mental well-being. Your behavioral health can be influenced by different factors like your diet, alcohol and drug use, relationships, chronic health issues and trauma. Your mental health is simply one part of your behavioral health, and it focuses on your ability to handle regular life stressors in your daily life. Reference: www.Betterhelp.com

Why is mental health important?

Everyone has mental health. Our mental health affects how we think, feel, act and behave. Some signs of positive mental health include being able to contribute to your community, engage in healthy relationships, handle normal levels of stress and recognize your value and worth.

When you struggle with your mental health, other areas of your life may feel the effects. There’s no shame in reaching out for help when you need it. Anyone can experience challenges with mental health at any time.

Sources: Centers for Disease Control & Prevention, World Health Organization

Who is Magellan?

We're proud to partner with Magellan Healthcare, Inc., a trusted leader in the mental health and substance use disorder industry, to provide behavioral health benefits to our members. Magellan¹ has over 50 years of experience providing innovative, high-quality, and compassionate care to people around the country. Together, we make it easy for you to access the care you need, with thousands of behavioral health providers for you to choose from.

How do I find a provider?

Please visit Magellan's online provider directory to find a provider. No referral is needed to access outpatient therapy within you plan network. If you need assistance selecting a provider, please call Magellan at 1-844-483-9013.

What if I need help now?

For 24/7 crisis intervention and urgent mental health support, please call Magellan at 1-844-483-9013. If emergency care is needed, call 911 or go to the emergency room of the nearest hospital.

If you or someone you care about is experiencing a suicidal or mental health crisis, please call or text the Suicide and Crisis Lifeline at 988 or dial 1-800-273-TALK (8255).

How do I get reimbursed for behavioral health services that I paid for?

If you receive care from an out of network behavioral health provider, you may be asked to pay for those services.  If that occurs, you can contact Magellan Healthcare at 1-844-483-9013, to request reimbursement. Magellan will provide a form that outlines the information needed for reimbursement including important reimbursement request deadlines.  Magellan will need a copy of the itemized bill showing all services received from the provider and a copy of your Sharp Health Plan ID card in order to determine if the services are covered.  Applicable co-payments will apply.

How do I find the right therapist for me?

Finding the right therapist can take some time, but it is worth the effort. When you’re searching for a therapist who can help you long-term, we recommend you follow these five tips.

What’s the difference between a psychologist and a therapist?

Great question. It’s good to know the differences between types of behavioral health professionals. Sharp Health Plan members have access to all the following types of providers, depending on your needs.

• Psychiatrists (MD, DO)

  Psychiatrists are licensed medical doctors that specialize in mental, emotional and behavioral disorders. They diagnose mental health conditions, prescribe and monitor medications and perform medical laboratory tests to help determine a patient’s specific issues and needs. Psychiatrists may use several treatment methods together to improve a patient’s well-being.

• Psychiatric Mental Health Nurse Practitioner/Advanced Practice Registered Nurse (PMHNP, APRN)

  A Psychiatric Mental Health Nurse Practitioner is an advanced practice registered nurse (APRN) who has completed additional education and training to specialize in diagnosing and treating mental health and substance use disorders, including prescribing medications. They work closely with a team of healthcare providers including psychiatrists, psychologists and other mental health providers.

• Psychologists (PhD, PsyD)

  Psychologists can provide individual or group therapy and may have specialized training in different forms of therapeutic treatment. They use clinical interviews, psychological evaluation and testing to determine your mental health and psychological needs. Psychologists may not prescribe medication.

• Licensed clinical social workers (LCSW)

  Licensed clinical social workers are the largest group of mental health services providers. They diagnose and treat mental, behavioral, emotional and substance abuse issues among individuals, couples, groups and families, and they provide therapy and develop treatment plans. LCSWs are well-trained in case management and often act as the administrators of social programs such as child welfare.

• Licensed Professional Clinical Counselor (LPCC)

  Licensed Professional Clinical Counselors are mental health professionals who have completed specialized training in counseling and psychotherapy allowing them to diagnose and treat mental health issues. They provide therapy and counseling services to individuals, families and groups to address a variety of emotional and psychological concerns.

• Marriage and family therapists (MFT, LMFT)

  Marriage and family therapists specialize in psychological issues in the context of marriage, couples and family systems. They are trained to deal with both individual psychological issues and issues that affect the entire family, such as marital problems and child-parent relationship issues.

• Addiction counselors

  Addiction counselors treat people who are suffering from addictions. It’s common for addiction counselors to work in group settings, either with other individuals dealing with the same addiction or with loved ones affected by the behavior.

• Eating disorder specialists

  Eating disorder specialists focus on helping individuals who struggle with conditions such as anorexia, bulimia, body dysmorphia and binge eating disorder. They also support their patients’ medical and nutritional needs and guide them to build lasting, healthy eating habits.

What is mental illness?

Mental illnesses are health conditions that can affect your daily life, your moods, your behavior and the ways you think and feel. These conditions can happen over short periods, be chronic (long-lasting) or occasional. Many individuals who experience mental illness benefit from the support that behavioral health providers can offer.

Source: Centers for Disease Control & Prevention

What causes mental illness?

Many factors may contribute to the risk of mental illness, including:

• Biological factors, such as genes or chemical imbalances
• Family history
• Feelings of loneliness or isolation
• Life experiences, such as stress or abuse
• Use of alcohol and/or other drugs
• Other injuries or medical conditions

Behavioral health providers help to identify your concerns and offer suggestions, treatment and guidance.

Sources: Centers for Disease Control & Prevention, Medline Plus

Can my overall health be affected by mental illness?

Certain types of mental illness can increase the risk of physical health problems. The opposite can also be true: Chronic conditions may increase risks for mental illness.

Source: Centers for Disease Control & Prevention

Is mental illness common?

Yes. Like many other health concerns, mental illnesses are common and are treatable. In the U.S., nearly 1 in 5 adults experience mental illness and nearly half of them receive treatment. Adolescents and children can also experience mental illness.

Sources: American Psychiatric Association, NAMI

Which types of mental illnesses are most common?

There are over 200 types of mental illness. Common conditions include:

• Anxiety disorder
• Attention-Deficit/Hyperactivity Disorder (ADHD)
• Depression
• Eating disorders
• Personality disorders
• Posttraumatic Stress Disorder (PTSD)
• Schizophrenia
• Substance abuse disorders

Source: Centers for Disease Control & Prevention

What are common signs and symptoms of mental illness?

Symptoms can show up differently, depending on the type of mental illness someone is experiencing. Common signs can include:

• An inability to cope with daily problems and activities
• Changes in eating or sleeping habits
• Excessive anxiety, fear or worry
• Extended periods of irritability or sadness
• Extreme highs and lows in mood
• Strong feelings of anger
• Thoughts of suicide

Why are you partnering with Optum Behavioral Health?

We are committed to providing best-in-class mental health and substance use disorder services that align with The Sharp Experience and that are rooted in high-quality and compassionate care. As such, we are pleased to announce that we are partnering with OptumHealth Behavioral Solutions of California (Optum Behavioral Health) to further expand our mental health and substance use disorder network.

Our expanded network will include thousands of additional providers, a suite of virtual mental health and substance use disorder specialty care, and 24/7 access to personalized evidence-based digital tools and wellness resources.

When will this partnership be effective?

Our new partnership with Optum Behavioral Health will be effective Jan. 1, 2026, pending DMHC approval.

Will this change be applicable to my benefit plan?

Yes. Optum Behavioral Health will be providing mental health and substance use disorder services for all Sharp Health Plan members, across all benefit plans including our employer group plans, individual and family plans and Medicare Advantage plans.

Will my mental health and substance use disorder benefits change? What about my copays?

No. Your plan benefits for mental health and substance use disorder services will not change, and your costs for accessing these services will remain the same.

Will this change impact my pharmacy benefits for mental health and substance use disorder medications?

No. If you are enrolled in a plan with pharmacy benefits through Sharp Health Plan, there will be no impact to your pharmacy benefits for mental health and substance use disorder medications.

Can I keep my current mental health and substance use disorder provider?

To receive your plan benefits, you must see an in-network mental health and substance use disorder provider. If your current provider is part of the Optum Behavioral Health network, you will be able to continue seeing them. If your provider is not part of the Optum Behavioral Health network, they can contact Optum Behavioral Health directly to discuss joining their network. If they choose not to join, then you will be able to select a new provider who is in network. If you are enrolled in a Point of Service (POS) plan or a Preferred Provider Organization (PPO) plan, you will be able to keep your provider on the Tier 3 level.

How will I know if my provider is in the Optum Behavioral Health network?

If you have accessed mental health and substance use disorder services in 2025, we will send you a letter letting you know if your current provider is in the Optum Behavioral Health network or not. If they aren't in the network, we'll share additional information with you to ensure you are able to continue accessing care.

What is continuity of care?

To receive your plan benefits, you must see an in-network mental health and substance use disorder provider. Please note, if you are enrolled in a POS or PPO plan, you will be able to keep your provider on the Tier 3 level.

If your provider chooses not to join the Optum Behavioral Health network, you can contact Optum Behavioral Health at 1-866-756-4791 beginning Dec. 15, 2025, to request continuity of care. You must have approval for continuity of care from Optum Behavioral Health prior to receiving such services. If your request is approved, you will be able to continue seeing your provider until your care is completed or can be safely transferred to an in network mental health or substance use disorder provider. Continuity of care may be provided for the completion of care when you are in an active course of treatment for one of the following conditions:

Condition	Length of Time for Continuity of Care
Acute condition	Duration of acute condition
Serious chronic condition	No more than 12 months from the date of their provider's contract termination with Sharp Health Plan
Maternal mental health condition	12 months from the maternal mental health condition diagnosis or from the end of pregnancy, whichever occurs later

Your requested mental health or substance use disorder provider must agree to provide continued services to you, subject to the same contractual terms and conditions that apply to contracted providers providing similar services. If your provider does not agree, Optum Behavioral Health is not required to authorize continuity of care.

How do I find a new mental health and substance use disorder provider?

You can search the Optum Behavioral Health online provider directory.

Do I need a referral to switch mental health and substance use disorder providers?

No. You don't need a referral or prior authorization to access outpatient therapy from a provider in the Optum Behavioral Health network. After you choose a provider, contact their office to schedule an appointment as a new patient.

Some services, such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), psychological testing, partial hospitalization and intensive outpatient programs, will require a referral and prior authorization. Please note that if you have already received prior authorization for mental health or substance use disorder services, a new referral and request for prior authorization for the same approved services and timeframe is not needed to access these services through a provider in the Optum Behavioral Health network.

Who should I contact with questions?

If you have questions, please contact Customer Care at 1-800-359-2002.