Medical Benefits

Program

Health Program Handbook for 2013 booklets will provide an overview of the CalPERS health plans, services and regulations for coverage. Additional information can be obtained through the CalPERS Website under health benefits www.calpers.ca.gov

Eligibility

Employees of the State of California and contracting public agencies whose appointment is at least six months and one day (tenure) and at least half-time (time base) may sign up for the CalPERS Health Benefit Program. In addition, lecturers or coaches with a time base of .40 or greater who are appointed for an academic year or two quarter appointment are eligible.  Please download the Lecturer Benefit Eligibility Criteria (PDF) for additional information.

Who’s Eligible?

  • Spouse
  • Natural, stepchildren, or adopted children under the age of 26
  • Domestic partners (contact the Office of Human Resources for more information)
  • Economically dependent children

Split Enrollments

Married employees or retirees can enroll separately.  However, when married employees are enrolled in a CalPERS health plan in their own right, one parent must carry all children on one plan.  Children and dependents cannot be split between parents.  When split enrollments are discovered, they will be retroactively canceled by CalPERS.  You may be responsible for all costs incurred from the date the split enrollment began.

Dual Coverage

Dual coverage occurs when you are enrolled in a CalPERS health plan as both a member and a dependent, or as a dependent on two enrollments.  This is against the law.  When dual coverage is discovered, the enrollment that caused the dual coverage will be retroactively canceled by CalPERS.  You may have to pay for all costs incurred from the date the dual coverage began.

Family Status Changes - Adding or Deleting Dependents

If  you wish to add/delete dependents due to a family status change, please complete the eBenefits Self-Service Authorization form, submit it to HR and use the Self-Service component in PeopleSoft to make the change.

The eBenefits Authorization Self-Service form will need to be submitted to Human Resources prior to making any changes to your benefits.  Additional documentation will  be required (i.e., Birth Certificates, Marriage Certificate, Declaration of Domestic Partnership, Affidavit of Eligibility, Final Divorce Decree, or Termination of Domestic Partnership).  

Although CalPERS administers our health plans, all changes MUST be coordinated through the Human Resources Benefits Office at (510) 885-2549.  It is the employee's responsibility to notify Human Resources when there are any changes in their family status.  

Family Status Changes include:

  • Marriage (Marriage Certificate), Domestic Partnership (Declaration of Domestic Partnership);
  • Birth of a child, Acquisition of a dependent child (economically dependent child);
  • Marriage of an eligible Dependent Child (natural, adopted or economically dependent);
  • Move out of eligible dependent;
  • Divorce, Legal Separation, Termination of Domestic Partnership; and Death.
  • Human Resources will prepare the appropriate forms and notify you when they are available for signature. If you have questions about completing the eBenefits Authorization Form or wish to obtain additional information, contact the Human Resources Benefits office at (510) 885-2549.
  • Domestic Partnership

    Effective January 2005, a domestic partner legally recognized by California law will be entitled to all rights, benefits, and obligations previously provided only to spouses under state law.   In most circumstances, a current or former registered domestic partner would be eligible for the same benefits as a current or former spouse of an active or retired employee.

    The FAQs (PDF) regarding Domestic Partnership Legislation are available through the Domestic Partner Registry on the State of California's website.  For Health Benefits enrollment questions, please contact Human Resources at (510) 885-2549.


    Identification Cards
    The health plans will be making every effort to ensure members who changed health plans receive their new identification card(s) prior to January 1, 2013.   If these members have not received identification card(s) for their new plan, you should not continue to use your prior plan after January 1, 2013.  To resolve this problem, you should first contact the new health plan and inquire about the issuance of card(s).


    Changing Your Address
    When you change your address an Employee Action Request (EAR) form must be completed. This form is available in Payroll Services, SA 2600, (510) 885-3651.   If you are participating in an HMO plan (Blue Shield or Kaiser), please note that a change of address could affect your eligibility to participate in an HMO plan.   Please check the CalPERS website for plan availability based on zip code www.calpers.ca.gov

OVERVIEW OF HEALTH PLANS

Health Maintenance Organizations (HMO)


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

  • Generic items from a Plan Pharmacy
    $5 for up to a 30-day supply
    $10 for a 31- to 60-day supply,
    $15 for a 61- to 100-daysupply

  • Generic refills from mail order
    $5 for up to a 30-day supply or $10 for a 31- to 100-day supply

  • Brand-name items from a Plan Pharmacy
    $15 for up to a 30-day supply
    $30 for a 31- to 60-day supply
    $45 for a 61- to 100-day supply

  • Brand-name refills from mail-order service
    $15 for up to a 30-day
    $30 for a 31 to 100 day supply

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, Imperial, San Francisco, San Luis Obispo and parts of San Mateo.

 

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

Retail Pharmacies (usually a 30-day supply)

  • $5 for generic
  • $15 for brand name
  • $45 for non-formulary ($30 if medical necessity approved)

Mail Order Program (usually a 90 day supply)

  • $10 for generic
  • $25 for brand name
  • $75 for non-formulary ($45 if medical necessity approved)
    $1,000 maximum copayment per person per calendar year for mail order program.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

 

Preferred Provider Organization (PPO)

 

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)

  • $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.)
  • $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).

 

HEALTH PLAN DEFINITIONS
  • Health Maintenance Organization (HMO):  This type of plan is designed to reduce out-of-pocket expenses, with no deductible and a minimal co-payment.   All services must be received from contracting physicians and hospitals.
  • Preferred Provider Organization (PPO)/Indemnity – This plan requires that a deductible be met before the plan benefits are payable (90% - 80% depending upon which PPO is selected).  Similar to HMO’s, the PPO Indemnity plan contracts with specific doctors and hospitals in certain areas.   The plan pays higher benefits when utilizing a participating provider (BLUE CROSS) than a non-participating provider.  Under a PPO/Indemnity plan, there is no geographic restriction.  Anthem Administers both PPOs.   MEDCO  is the pharmacy benefit manager for both PPOs.
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