Frequently Asked Questions

Through Western Health Advantage’s secure, member-only website, you will find a wealth of resources to help you make the most of your health plan.

It’s easy! Simply “Sign Up For MyWHA Tools” and follow the prompts. Once registered, access the details of your personal benefit information online—24 hours a day, 7 days a week.

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. WHA will issue you a new ID card confirming your new PCP's name. 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.  Visit Choosing a new a PCP to learn more.

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 new PCP, a name change or a new medical plan. 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.

WHAs Advantage Referral program allows you to see almost any specialist 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 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 (when covered) and OB/GYN visits. Learn more at mywha.org/advantagereferral. 

Typically, out-of-network services are not covered unless in an urgent or emergency situation. However, if you are a new member currently undergoing acute treatment with a non-participating provider, you may qualify for Continuity of Care. For more information or to obtain a Continuity of Care (CoC) Request Form, contact WHA Member Services. You may also access the CoC Form online at mywha.org.

In certain circumstances, members may temporarily continue care with a non-participating provider. If you are being treated by a provider who has been terminated from WHA's network, or if you are a newly enrolled member who has been receiving care from a provider not in WHA's network, you may continue care with that provider if you meet the Continuity of Care (COC) criteria explained below:

• An acute condition: a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of covered services shall be provided for the duration of the acute condition.
• A serious chronic condition: a serious chronic condition is a medical condition due to disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure, worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Covered services will be provided for the period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by WHA in consultation with the member and the terminated provider or Non-Participating Provider, consistent with good professional practice. Completion of covered services under this paragraph shall not exceed twelve (12) months from the contract termination date or twelve (12) months from the effective date of coverage for a newly enrolled member.
• A pregnancy. Care will be continued for the duration of the pregnancy and the immediate postpartum period.
• A terminal illness: an incurable or irreversible condition that has a high probability of causing death within one year. Care shall be continued for the duration of the terminal illness.
• Care of a newborn child whose age is between birth and thirty-six (36) months. Care shall be continued for up to twelve (12) months.
• Performance of surgery or other procedure that has been authorized by WHA (or its contracted medical group) as part of a documented course of treatment that is to occur within one hundred eighty (180) days.

If you are a newly enrolled member and you had the opportunity to enroll in a health plan with an out-of-network option, or had the option to continue with your previous health plan or provider, but instead voluntarily chose to change health plans, you are not eligible for Continuity of Care. Please contact Member Services prior to enrollment and no later than thirty (30) days from the effective date of your WHA coverage, or from the date your provider terminated with WHA to request a print copy of the COC form. You may also download an electronic copy of the COC form.

In addition to receiving standard advice for medical issues, Optum's NurseLine provides access to highly-trained registered nurses who are ready to answer your specific questions on general health and wellness, 24 hours a day, including direct referrals to disease management nurses.

Sign up through the Optum Health Portal for access to registered nurses through the NurseLine private chat or call 877.793.3655.

Of course, you can always call your PCP’s office if you are unsure if your situation needs immediate attention. Your PCP's office number is located on your WHA member ID card. 

Your mental health and substance abuse benefits are provided through Optum Behavioral Health. You do not need a PCP referral to obtain these services. Visit Behavioral Health Benefits to learn more.

WHA covers you for Urgent Care and Emergency Care services wherever you are in the world. Please note that emergency room visits are not covered for non-Emergency situations.

Urgent Care
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. Explain your condition to your PCP or the physician on call and he/she will direct your care. In the event you are not able to reach your PCP, you should go to an Urgent Care facility affiliated with your medical group.

Emergency Care
If an Emergency situation arises whether you are in WHA's Service Area or outside of the Service Area, call "911" immediately or go directly to the nearest hospital emergency room. If you are hospitalized at a non-participating facility because of an emergency, WHA must be notified within twenty-four (24) hours or as soon as possible. If you are unable to make the call, have someone else make it for you, such as a family member, friend, or hospital staff member.

Follow-up care after an emergency room visit is not considered an Emergency situation. If you receive Emergency treatment from an emergency room physician or non-participating provider and you return for follow-up care (for example, removal of stitches or redressing a wound), you will be responsible for the cost of the service. Contact your PCP for all follow-up care.

Visit Urgent and After-Hours Care to learn more.

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.  There are three categories, or tiers, of medications under the program:

Preferred generic or Tier 1 medications: generic medications listed on the PDL;
Preferred brand name or Tier 2 medications: brand name medications listed on the PDL; and
Non-preferred or Tier 3 medications: medications not listed on the PDL.

Note: For some prescription plans, specialty medication -- including self injectables -- may be on Tier 4. See Specialty Drugs for more information

For the most part, medications for both medical and mental health conditions that are listed on the PDL are covered without prior authorization, and all you'll need is the prescription from your physician.  However, within all categories, there are a few drugs that may require prior authorization to ensure the appropriate use of the drug

You can also access this information on Express Scripts website or go directly to your MyWHA account and choose Connect to My Pharmacy from your My Resources toolbar. 

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.

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.

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.

WHA has a large pharmacy network through Express Scripts. 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. Express Scripts website
3. WHA member services: call Monday through Friday, 8:00 a.m. to 5:00 p.m. at 916.563.2250, 888.563.2250 or 888.877.5378 TTY.

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 Express Scripts. 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:  You may save time and money on medications you take regularly by ordering a 90-day supply through Express Scripts' mail-order pharmacy program.  Your prescription can be refilled online or by phone and will delivered straight to your home or office, whichever is more convenient.  

For additional details visit Pharmacy Information.

A HDHP covers health care services (office visits, hospital tests, therapy, prescriptions, etc.) that are not considered preventive only after an individual or a family has met the deductible. The deductible is usually waived for preventive care services. Typically, an HDHP features a lower insurance premium and a higher deductible than traditional plans. WHA offers some HDHP plans that include a health savings account (HSA), but not all HDHPs are HSA compatible.

You pay a low monthly premium while still getting no-cost preventive care. If your HDHP is HSA compatible, you can use your HSA to pay for covered services.

You have a deductible to meet each benefit year. The deductible must be satisfied before your health plan will cover the expenses for covered services received.

• Deductible: Your health care plan has a deductible. The deductible is the amount you pay each year for most covered medical and prescription services and supplies before WHA will cover those services. The premium and the deductible are separate. Your premium is the monthly amount you pay to the health carrier for benefit coverage. Premiums do not count toward the deductible in your health plan.
• Copayments: Your plan may also require you to pay copayments after you meet your annual deductible. These are typically smaller dollar amounts or percentages for covered services.
• OOP Maximum: Once your deductible and copayment costs reach your annual OOP maximum amount, you are done. WHA will cover 100 percent of your covered services for the remainder of the calendar year.

Deductibles vary depending on the plan you selected and whether you are enrolled as a self-only, an individual within a family or as a family. For specific comparisons of the deductible within each plan, look at the copayment summary of the plans you are interested in.

Western Health Advantage partners with leading service providers to ensure that our members get the best rates available. This means that you’ll enjoy consistent savings on your health care services and supplies. 

Use our medical service cost estimator to see what is the estimated cost of a specific service you intend to receive.

Covered non-preventive medical and prescription expenses apply toward the deductible, as described in the plan. Examples include charges for office visits with doctors, inpatient and outpatient hospital services, diagnostic tests, and covered prescription drug expenses.

Payments you make for prescriptions covered under your plan will apply to your deductible and OOP maximum. It’s important to note that covered prescriptions must be obtained from a participating provider and must be run through WHA’s contracted pharmacy benefit manager in order to be applied. Prescriptions obtained from a non-participating provider are limited to emergent situations or urgent situations arising outside of WHA's service area.

The answer depends on whether you are enrolled as self-only coverage or an individual within a family/family coverage, and your specific plan. For specific comparisons of maximum out-of-pocket amounts, look at the copayment summary of the plans you are interested in.

Yes, routine preventive care services are covered at no cost to members (and don’t apply to the deductible). Because preventing illness and disease will save you money, be sure to go for preventive screenings and annual checkups. The advice you get from your provider at these visits could lead to a healthier lifestyle, which can avoid costly treatments.