OVERVIEW OF HEALTH PLANS

HMO CO-PAYMENTS/ OFFICE VISITS AND URGENT CARE CHANGES

• Office co-payments will be waived for preventive care office visits including periodic health exams, Maternity care, well baby visits, allergy testing and treatment, immunizations, hearing evaluations and pre/post natal care.  Please Note:  Kaiser will continue to charge a co-payment for allergy testing and treatment.
• Other office visits co-payments will increase by $5 (from $10 to $15).
• Co-payments for urgent care visits will be $15.
• Out-of-pocket maximum will be $1,500 for individual and $3,000 for family. Pharmacy is excluded.

Kaiser:

* Copay: Office visits $15
* Emergency Room Copayment: Emergency room copayments are $50 per visit (waived if admitted).

 

Prescription: Copayment

• Retail Pharmacies (up to a 100-day supply)
  • $5 for generic
  • $15 for brand name
• Mail Order Program at no extra charge

Blue Shield Access + (HMO) and BlueShield NetValue (HMO):

CALPERS and Blue Shield are introducing a new plan within the Blue Shield Network called Blue Shield NetValue.  This new HMO plan offers a network of doctors that are a selected subset of Blue Shield physicians designed to provide savings with the same comprehensive benefits and quality coverage you’ve come to expect from Blue Shield.

 

Please Note:  Enrollment eligibility in Blue Shield NetValue (HMO) is based upon the employee's residence or work zip code within the following counties:  El Dorado, Fresno, Kern, Kings, Los Angeles, Madera, Nevada, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Santa Barbara, Ventura, and Yolo.

 

Blue Shield HMO will be withdrawing from four northern California counties in 2008: Lake, Napa, Plumas and certain areas of El Dorado. Members in those areas will still have access to health care by joining another CalPERS HMO plan, if available, or a PPO plan.

 

Blue Shield has a new 3-year contract. As part of this contract, the HMO will launch new initiatives focused on healthy lifestyles and disease management. One such initiative is the Healthy Lifestyles Rewards Program, which will offer adult members cash incentives of up to $200 annually just for participating. This on-line, interactive program is designed to help members adopt and maintain healthy lifestyle habits while providing valuable support along the way.  Participating members will learn about healthy eating, exercising, managing stress and smoking cessation.

 

Selecting a Physician:   The web links below will assist you in selecting a physician/medical group for you and your dependents.   If you are currently a patient and wish to continue with your physician, please note that it is your responsibility to contact your current physician(s) to ensure they are part of the Blue Shield (HMO) Group.   Failure to do so may result in out-of-pocket expenses for services not covered by Blue Shield (HMO) plans.

 

*  Selecting a Primary Care Physician (PDF)
*  Changing your Primary Care Physician (PDF)

* Copay: Office visits $15
* Emergency Room Copayment: Emergency room copayments are $50 per visit (waived if admitted).

 

Prescriptions:  Copayments are three-tiered

CALPERS and Blue Cross/PERSChoice (PPO) are introducing a new plan within the PERSChoice network called PERSChoice Select (PPO).  This plan is offered in addition to the current PERSChoice PPO plan. With lower premiums than the standard PERSchoice plan and a statewide network of physicians, PERSChoice select provides the same benefits and qualify of care for residents and physicians in California. (Not available in Alameda, Marin, Placer, or Solano counties; or outside the state of California).

 

PERSChoice and PERSCare PPO plans will add more urgent care facilities throughout the State, allowing members to have the same co-pay ($20) for urgent care services as they would for an office visit.  This will provide members with a choice to receive services for urgent care from these designated facilities or through the hospital emergency room which has a $50 co-pay unless member is admitted to the hospital.   In addition, PPO members will need to obtain prior authorization for expensive imaging procedures such as CT scans and MRI's.

 

PERSCare/PERSChoice (PPO):

* Annual Member Deductible: $500

* Annual Family Deductible:   $1,000

*  Emergency Room Copayment: Emergency room copayments are $50 per visit (waived if admitted).

 

Retail Pharmacy * (Short-term use)

• $5 generic
• $15 preferred
• $45 non-preferred ($30 if medical necessity approved)

Retail Pharmacy Maintenance Medications after 2nd Fill

(A maintenance medication taken longer than 60 days for chronic conditions.)

• $10 generic
• $25 preferred
• $75 non-preferred ($45 if medical necessity approved)

Mail Service (up to 90-day supply)

(A $1,000 maximum co-payment per person per calendar year applies.)

• $10 generic
• $25 preferred
• $75 non-preferred ($45 if medical necessity approved)

  * PERSCare (up to 34-day supply), PERSChoice (up to 30-day supply).

 

Prescriptions:  Medco Health Solutions, Inc (PDF). is the prescription drug administrator for the PERSchoice, PERSchoice Select, and PERSCare plans.  For personal assistance, contact Medco Member Services at toll free (800) 939-7091 or www.medcohealth.com

Retail Pharmacy * (Short-term use)

• $5 generic
                                        
• $15 preferred
   
• $45 non-preferred ($30 if medical necessity approved)

Retail Pharmacy Maintenance Medications after 2nd Fill

(A maintenance medication taken longer than 60 days for chronic conditions.)

• $10 generic 
                                              
• $25 preferred 
                                              
• $75 non-preferred  ($45 if medical necessity approved)

Mail Service (up to 90-day supply)

(A $1,000 maximum co-payment per person per calendar year applies.)

• $10 generic
                     
• $25 preferred 
                    
• $75 non-preferred ($45 if medical necessity approved)

  * PERSCare (up to 34-day supply), PERSChoice (up to 30-day supply).