Member FAQs

Certain covered services require prior authorization (pre-approval) from your PCP's affiliated medical group or from WHA in some cases, to make sure they are paid under your health plan benefits.

Your PCP should know when pre-approval is needed. PCP staff will notify your medical group or WHA when you need to see a specialist or get another service that requires pre-approval. Decisions are made by qualified medical professionals (doctors and nurses), but only experienced physicians can deny or modify a requested service.

You do not need pre-approval for initial emergency room treatment. Members can self-refer within the network for their annual eye exam (when covered) and OB/GYN visits. You just need to make sure the specialist is in WHA's provider network. View the Provider Directory for participating network specialists or contact Member Services for assistance.

A decision to pre-approve, modify or deny a specialty or service referral request must be made within certain timeframe(s). These are based on the urgency of your medical condition and treatment needs, but most decisions are made within five working days of receiving necessary information to make the decision. If fast handling of your case is needed due to urgent medical needs, your doctor may ask for an expedited review. These will be completed by the plan as soon as possible based on your situation, but no later than 72 hours of receipt of the request and pertinent information to make a decision.

An emergency condition is when you are experiencing extreme or sudden pain or have acute symptoms that require immediate medical diagnosis, care and treatment to avoid disability or death.

Emergency services are those required for an acute medical condition in which a prudent layperson could reasonably expect the absence of immediate medical attention to result in serious jeopardy or harm.

If you have an emergency situation, call 911 or go to the nearest emergency room no matter where you are located. You do not need pre-approval from your physician for initial ER care, but related follow-up care should be provided through your primary care physician.

Urgent care means services that are medically required within a short time frame, usually within 24 hours, in order to prevent serious deterioration of a member's health due to an unforeseen illness or injury.

If an urgent care situation arises while you are in WHA's service area, call your PCP. You can call your doctor at any time of the day, including evenings and weekends. Your doctor or the physician on-call will direct your care. To make sure urgent care services are covered while you are in the service area, go only to your medical groups' contracted urgent care clinic. When you are outside the service area, contact your PCP first for direction. View the Provider Directory for local urgent care clinic locations. For more information, visit mywha.org/er.

It is important that you present your member ID card at the time of service. The provider will need the information found on your member ID card to bill WHA for the Covered Service(s).

In the unlikely event that you pay for a Covered Service out-of-pocket, you will need to mail or fax the following information to WHA for reimbursement.

1. A signed and dated summary/explanation detailing the service you received
2. Any supporting documentation from the provider who performed this service
3. Indicate the specific amount you are requesting to be reimbursed
4. Proof of payment
5. Your contact information, including:
   • Full name
   • Phone number
   • Mailing address
   • Email address
   • WHA member ID

Once WHA receives the above information, you will be notified within 45 business days regarding the outcome of your claim.

Please note: Only services covered under your plan are eligible for reimbursement. Your plan's applicable copayment/coinsurance and/or deductible will determine the total amount you are reimbursed.

For more information, contact:

Member Services

916.563.2250 or 888.563.2250 toll-free

Monday through Friday (excluding holidays) 8 a.m. to 6 p.m.

For TDD/TYY: 888.877.5378

Email: memberservices@westernhealth.com or use the Secure Message Center

Fax: 916.568.0126 

WHA has a large pharmacy network through OptumRx. There are several ways you can find the locations of WHA's participating pharmacies.

1. WHA Provider Directory: all contracted pharmacies are listed at the end of each county listing
2. OptumRx website
3. WHA Member Services

Retail Pharmacies:  Most prescription medications can be obtained at any retail pharmacy but you’ll get the most savings by going to a participating pharmacy with OptumRx. If you use a non-participating pharmacy, you will be reimbursed for the amount the medication would have cost WHA at a participating pharmacy, minus any applicable copayment or other payment obligation.

Mail Order:  For medications you take regularly, you may save time and money by obtaining a 90-day supply through OptumRx’s mail-order pharmacy program or by using the Select90 program at Walgreen’s retail pharmacy. For mail-order, your prescription can be refilled online or by phone and will be delivered straight to your home or office, whichever is more convenient.

For additional details visit Pharmacy Information.

WHA uses a tiered prescription program that is based on our Preferred Drug List (PDL). You may view WHA’s PDL online at mywha.org/pharmacy or request a copy by calling WHA Member Services. Refer to your copayment summary to confirm whether the plan is three or four tiered.

• Plans for large employer groups (101 or more employees) have three tiers of medications under the program
• Plans compliant with the Affordable Care Act (ACA)* for small groups (one to 100 employees) and individuals and families have four tiers. Tiers are generally classified as follows:
• Tier 1: Preferred generic medications (may include certain preferred brand name medications)
• Tier 2: Preferred brand name medications (may include certain non-preferred generic medications)
• Tier 3: Non-preferred medications
• Tier 4: Self-injectibles (see reverse for more information)

The relevant tier for your medication can be found on WHA’s PDL for your plan. Within all categories, there are a few drugs that may require prior authorization to ensure the appropriate use of the drug.

*Small groups and individuals/families can purchase ACA-compliant plans from Covered California or direct from WHA, while individual and family plans are available from Covered CA or direct from WHA.

WHA, in accordance with the Patient Protection and Affordable Care Act (ACA), provides coverage for select preventive medication categories without imposing a copayment, coinsurance, or deductible. Coverage of these medications may include select over-the-counter (OTC) medications, and requires a prescription from your licensed health care provider. Not all medications are covered in full under these categories and may be subject to step therapy or prior authorization requirements (e.g., coverage limits based on diagnosis, use, age, or national guidelines recommendations).

Under the WHA prescription program, your pharmacist will automatically substitute equivalent generics for brand name medications whenever possible, as this provides the greatest value.

If your physician determines there is a need to substitute a brand name medication for a generic medication, the physician will need to specify "Dispense as Written" on the prescription, as required but the California Board of Pharmacy regulations.

As long as there isn't a deductible listed on your prescription copayment summary, you'll only be responsible for paying the relevant copayment for you medications.

You can see the copayment amounts for each medication tier on your Prescription Copayment Summary.  It's a good idea to use Tier 1 and Tier 2 medications whenever possible, as this offers you the greatest savings.

If you are on a high-deductible plan, you will pay the cost of the medication until you meet the prescription deductible for you plan for the year.  This deductible is detailed on your Prescription Copayment Summary.  After that, you'll need to pay the relevant copayment for your medication, as described above.

Note: If you elect to receive a Tier 2 or Tier 3 medications rather than a Tier 1 with no medical indication from the prescribing physician, you will have to pay the difference between the selected and the Tier 1 medication in addition to the relevant copayment.

Oral anti-cancer drugs will not exceed $200 for 30-day supply.

• Prescriptions filled at retail pharmacies are limited to a 30-day supply. 
• Prescriptions filled by mail-order or Select90, as described above, allow up to a 90-day supply.
• Specialty medications (e.g., those that cost over $600 for a 30-day supply) are limited to a 30-day supply.  WHA will allow up to two initial fills at local retail pharmacies to make sure you get started on your medications in a timely manner.  All other fill will be limited to WHA's exclusive specialty pharmacy network as described in the EOC/DF. Some specialty medications (i.e., limited distribution medications), are only available from select specialty pharmacies due to FDA or manufacturer restrictions and therefore may not be available for the first two initial fills at a local retail pharmacy.
• By California law, controlled substance medications have limited refill capabilities.
• Some drugs are limited to a fixed number of doses per 30-day period.  For example, sedative hypnotics and erectile dysfunction medications, among others, are limited to a certain number of doses per 30 days.
• WHA may add other quantity limitations when WHA's Pharmacy and Therapeutics (P&T) Committee determines that it is appropriate to do so.

• Self-injectable medications:  On the three-tier formulary, self-injectable medications (excluding insulin) are covered with specific cost-sharing outside of the first three tiers, as described on your prescription copayment summary. These drugs are limited to a 30-day supply, and most often require prior authorization. If the self-injectable medication is approved, all related supplies will also be approved. Insulin and related supplies are covered under the first three tiers and do not require prior authorization.
• Oral specialty medications:  Oral specialty medications that cost over $600 for a 30-day supply. WHA will allow up to two initial fills at local retail pharmacies to make sure you get started on your medications in a timely manner.  All other fill will be limited to WHA's exclusive specialty pharmacy network.  This network includes Accredo, UC Davis and Dignity Health on-site pharmacies
• Infertility medications:  Medication for the treatment of infertility is covered only when the member's employer has purchased a separate infertility rider.  Note: Infertility coverage is not available to members on individual and family plans. All infertility services, including medical services and infertility drugs, require prior authorization. Please refer to your infertility rider’s copayment summary for exclusions and limitations to this benefit.
• Non-FDA approved drugs or quantities:  When a physician prescribes a medication (or a quantity of a medication) that is non-FDA-approved, he/she must obtain prior authorization through the contracted medical group or WHA.
  • For a drug or indication that is not FDA-approved, the physician must provide information regarding the FDA-approved drugs that have been tried and failed or had unacceptable side effects. 
  • If the physician prescribes a dosage of an FDA-approved drug that exceeds the FDA-approved amount, he/she must submit additional documentation of the safety and effectiveness of that dose. 
  • For any of these exception requests, WHA adheres to required timelines to resolve the issues.  In the case of a denial, there is an appeal process available to the member.
• Investigational drugs:  Any drug that is undergoing investigational testing in humans requires case-by-case review in order for the drug to be approved for the member.  Investigational New Drugs (INDs) are approved by the FDA for use on patients with serious and immediately life-threatening diseases for which no other drug or therapy exists.  INDs are not available to all member since they are not approved by the FDA for commercial marketing or general use.

Unfortunately, the mail-order pharmacy program cannot prescribe 90-day supply with three refills as opposed to the doctor's written 30-day supply with 11 refills. Our mail service pharmacy is located in the state of Nevada. Nevada's pharmacy law does not allow a pharmacist to change a prescription written for a 30-day supply to fill it as a 90-day supply, even if there are enough refills available.

Medications for infertility are only covered when the employer has purchased a separate policy called the Infertility Rider. All infertility services require Prior Authorization from your medical group to provide the services and from WHA to provide payment for the medication. Please refer to your Evidence of Coverage for restrictions and exclusions to infertility services.

Certain drugs are available both in a prescription form and in an OTC form. Only prescription drugs are covered by your plan, with the exception of select insulins, insulin supplies and covered preventive drugs (see Preventive Prescription Medications). OTC drugs are covered only if they are both listed on the preferred drug list and prescribed.

Through the WHA website, you can link directly to the OptumRx website. There, you will find an array of resources and will be able to:

• Compare prescription benefits and determine your financial responsibility for your medications;
• Order refills and renew prescriptions;
• Locate participating pharmacies;
• Determine drug-drug interactions;
• Learn about the common side-effects and significant risks of drugs
• Determine the availability of generic substitutes for brand name medications; and
• Initiate the prior authorization process for certain drugs.

Visit choosewha.com/rxpricing to determine costs for medications under a deductible plan, even if you are not yet a WHA member.

Your PCP is responsible for coordinating your medical care by providing direct treatment to you or by making referrals to network specialty providers when needed. To ensure coverage, non-urgent or non-emergency care should be received from your PCP or another network provider.

When you enroll in Western Health Advantage, you must select a primary care physician (PCP) for yourself and each of your covered family members. PCP's can be practitioners of Family, Internal or General Medicine, Pediatricians and in some cases, Obstetricians and Gynecologists. Each family member can choose his/her own PCP from any of our medical groups. Your PCP is responsible for coordinating all of your medical care. It is extremely important to get established with your physician as soon as your coverage becomes effective.  To locate a list of available physicians, please refer to the WHA's Online Provider Directory. You may also request a print copy by calling Member Services.

Establishing a relationship with your PCP is critical to your ongoing health care needs. Your PCP will coordinate your medical care by direct treatment or referral to a participating specialist. All non-Urgent Care or non-Emergency Care should be received from your PCP or other Participating Provider as referred by your PCP. If you have never been seen by the PCP you choose, please call his/her office before designating him/her as your PCP as some practices may be temporarily closed because they are full. If you do not designate a PCP at the time of enrollment, WHA will assign one for you.  

Since your PCP coordinates all your covered care, it is important that you are completely satisfied with your relationship with him or her.  If you want to choose a different PCP, you can change your PCP online by logging into your MyWHA account or by calling Member Services. The effective date is the first day of the month following notification. You must wait until the effective date before seeking care from your new PCP, or the services may not be covered. 

To obtain covered services, you can search our Online Provider Directory that lists PCPs and specialists in the WHA network. However, we add new providers periodically and others may leave WHA as they retire or relocate. Our online, interactive Provider Directory is a great tool to get the most up-to-date information about participating providers. You can also search for a provider by name, provider type, location of the practice(s), medical group affiliation or languages spoken.

ID cards are mailed to members’ homes within a few weeks of enrolling. New ID cards are also mailed whenever a change occurs which affects the information on the card, such as a name change. As a member, you can also access and print your ID card at mywha.org. A copy of your enrollment form or electronic enrollment confirmation can also be used as temporary proof of coverage.

WHA’s Advantage Referral program allows you to many specialists in our network, regardless of their medical group affiliation. While your PCP will typically refer you within his or her affiliated medical group, you are not limited to only those specialists.   Refer to the Provider Directory or call WHA Member Services to ensure that a specialist is in the Advantage Referral program.  Your PCP will coordinate a referral if you need to see a specialist. Members can self-refer within the network for their annual eye exam and OB/GYN visits. Learn more at mywha.org/advantagereferral. 

No, your PCP and specialist do not have to be in the same medical group. WHA's Advantage Referral system allows more choices. You can select a PCP in one medical group, but when referred for specialty care, you may see a participating specialist in any other WHA medical group. However, not all specialists are in Advantage Referral program. To identify those physicians who do not participate, check the online provider directory, or call member services for current status.

As a member of WHA you will receive routine care from your PCP. In most cases, specialty care is also provided by WHA network physicians. Your doctor, medical group, and in some cases, WHA, will decide if you should receive specialty services from a non-network physician based on your individual healthcare needs. To see a non-network physician you must always get pre-approval to ensure coverage, except in emergency situations.

Routine care is treatment of conditions not considered to be an emergency or urgent. Examples include getting immunizations or an annual physical examination.