2013 Health Benefit Summary

7/29/2019 2013 Health Benefit Summary

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2013 Health Beneit Summary

Helping you make an inormed choice

about your health plan


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About This Publication

The 2013 Health Beneft Summaryprovides valuable

inormation to help you make an inormed choice aboutyour health plan and health care providers. This

publication compares covered services, co-payments,

and benets or each CalPERS health plan. It also

provides inormation about plan availability by county

and a chart summarizing the key dierences between

a Health Maintenance Organization (HMO) and a

Preerred Provider Organization (PPO).

You can use this inormation to determine which

health plan oers the services you need at the cost

that works or you. The 2013 health plan premiums areavailable at CalPERS On-Line at www.calpers.ca.gov.

Check with your employer to nd out how much they

contribute toward your premium.

Evidence o Coverage Booklets

The 2013 Health Beneft Summaryprovides only

a general overview o benets. It does not include

details o all covered expenses or exclusions and

limitations. Please reer to each health plans

Evidence of Coverage (EOC) booklet or the exactterms and conditions o coverage. Health plans mail

EOCs to new members at the beginning o the year,

and to existing members upon request. In case o

a confict between this summary and your health

plans EOC, the EOC establishes the benets that

will be provided. (Note: Some health plans requirebinding arbitration to resolve disputes. Please reer

to the plans 2013 EOC or more inormation.)

This publication is to be used only in conjunction

with the current years rate schedule and EOCs. To

obtain a copy o the rate schedule or any health plan,

please go to CalPERS On-Line at www.calpers.ca.gov or

contact CalPERS at 888 CalPERS (or 8882257377).

Other Health Publications

This publication is one o many resources CalPERSoers to help you choose and use your health plan.

Others include:

Health Program Guide

Describes Basic and Medicare health plan

eligibility, enrollment, and choices

CalPERS Medicare Enrollment Guide

Provides inormation about how Medicare works

with your CalPERS health benets

You can obtain the above publications and other

inormation about your CalPERS health benefts

through my|CalPERS at my.calpers.ca.gov or by calling

CalPERS at 888 CalPERS (or 8882257377).

CalPERS health plans are administered under the Public Employees Medical Hospital Care

Act, a Caliornia State law. Nevertheless, as ederal regulations related to the various elementso health care reorm are released, CalPERS may need to modiy benefts. For up-to-date

inormation about your CalPERS health benefts and health care reorm, please reer to the

Health Benefts Program link on CalPERS On-Line at www.calpers.ca.gov.
http://localhost/var/www/apps/conversion/tmp/scratch_9/my.calpers.ca.govhttp://localhost/var/www/apps/conversion/tmp/scratch_9/my.calpers.ca.gov


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2013 Health Beneit Summary | 1

CalPERS Health Program Vision Statement

CalPERS will lead in the promotion o health and wellness o our members through

best-in-class, data-driven, cost-eective, quality, and sustainable health benet options

or our members and employers.

We will engage our members, employers, and other stakeholders as active partners

in this pursuit and be a leader or health care reorm both in Caliornia and nationally.

Contents

Considering Your Health Plan Choices . . . . . . . . . . . . . . . . . . . . . . . 2

Understanding How HMO and PPO Plans Work . . . . . . . . . . . . . . . . . . . 3CalPERS HMO and PPO Health Plan Choices . . . . . . . . . . . . . . . . . . . . 4

Enrolling in a Health Plan Using Your Residential or Work ZIP Code . . . . . . . . . 5

Health Plan Availability by County. . . . . . . . . . . . . . . . . . . . . . . . . . 6

Tools to Help You Choose Your Health Plan . . . . . . . . . . . . . . . . . . . . . 8

Accessing Health Plan Inormation with my|CalPERS . . . . . . . . . . . . . . . . 8

Comparing Your Options: Health Plan Chooser . . . . . . . . . . . . . . . . . . . 8

Comparing Your Options: Health Plan Choice Worksheet . . . . . . . . . . . . . 10

Reviewing Annual Health Plan Ratings . . . . . . . . . . . . . . . . . . . . . . 11

Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Health Plan Directory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Obtaining Health Care Quality Inormation . . . . . . . . . . . . . . . . . . . . 13

CalPERS Basic Health Plans Beneft Comparison Charts . . . . . . . . . . . . . 14

CalPERS Medicare Health Plans Beneft Comparison Charts . . . . . . . . . . . 24

Health Plan Choice Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . 33


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2 | 2013 Health Beneit Summary

Considering Your Health Plan Choices

Selecting a health plan or yoursel and your amily

is one o the most important decisions you will make.

This decision involves balancing the cost o each

plan, along with other eatures, such as access todoctors and hospitals, pharmacy services, and special

programs or managing specic medical conditions.

Choosing the right plan ensures that you receive the

health benets and services that matter to you.

I you are a new CalPERS member or you are consid-

ering changing your health plan during Open Enrollment,

you will need to make two related decisions:

Which health plan is best or you and your amily?

Which doctors and hospitals do you want to provide

your care?

The combination o health plan and providers that is

right or you depends on a variety o actors, such as

whether you preer a Health Maintenance Organization

(HMO) or Preerred Provider Organization (PPO); your

premium and out-o-pocket costs; and whether you

want to have access to specic doctors and hospitals.

You may also want to consider how other CalPERS

members rate the health plans.

We realize that comparing health plan benets,

eatures, and costs can be complicated. This section

provides inormation that can simpliy your decision-

making process. As you begin that process, theollowing are some questions you should ask:

Do you preer to receive your health care rom an

HMO or PPO? Your preerence will impact the plans

available to you, your access to health care providers,

and how much you pay or certain services. See

the chart on the next page or a summary o the

dierences between HMO and PPO plans.

What are the costs (premiums, co-payments,

deductibles, and out-o-pocket costs)? Beginning

on page 14 o this booklet, you will nd inormationabout benets, co-payments, and covered services.

Visit CalPERS On-Line at www.calpers.ca.gov to nd

out what the premiums are or the various plans.

Does the plan provide access to the doctors and

hospitals you want? Contact health plans directly

or this inormation. See the Health Plan Directory

on page 12 o this booklet or health plan contact

inormation.


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Understanding How HMO and PPO Plans Work

The ollowing chart will help you understand some important dierences between HMO and PPO health plans.

Features HMO PPO

Accessing

health care

providers

Contracts with providers (doctors,

medical groups, hospitals, labs,

pharmacies, etc.) to provide you

services at a xed price

Gives you access to a network o health care

providers (doctors, hospitals, labs, pharmacies,

etc.) known as preerred providers

Selecting a

primary care

physician (PCP)

Requires you to select a PCP who will

work with you to manage your health

care needs 1

Does not require you to select a PCP

Seeing aspecialist

Requires advance approval rom themedical group or health plan or some

services, such as treatment by a

specialist or certain types o tests

Allows you access to many types o serviceswithout receiving a reerral or advance approval

Obtaining care Generally requires you to obtain care

rom providers who are a part o the

plan network

Requires you to pay the total cost o

services i you obtain care outside

the HMOs provider network without a

reerral rom the health plan (except oremergency and urgent care services)

Encourages you to seek services rom preerred

providers to ensure your deductibles and

co-payments are counted toward your calendar

year out-o-pocket maximums 2

Allows you the option o seeing non-preerred

providers, but requires you to pay a higher

percentage o the bill 3

Paying or

services

Requires you to make a small

co-payment or most services

Limits the amount preerred providers can

charge you or services

Considers the PPO plan payment plus any

deductibles and co-payments you make as

payment in ull or services rendered by a

preerred provider

1 Your PCP may be part o a medical group that has

contracted with the health plan to perorm some unctions,

including treatment authorization, reerrals to specialists,

and initial grievance processing.

2 Once you meet your annual deductible and co-insurance,

the plan pays 100 percent o medical claims or the

remainder o the calendar year; however, you will continue

to be responsible or co-payments or physician oce

visits, pharmacy, and other services.

3 Non-preerred providers have not contracted with the

health plan; thereore, you will be responsible or paying

any applicable member deductibles or co-payments,

plus any amount in excess o the allowed amount.


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CalPERS HMO and PPO Health Plan Choices

Depending on where you reside or work, your Basic and Medicare health plan options may include the ollowing:

Basic HMO

Health Plans

Basic PPO

Health Plans

Supplement toMedicare HMO

Health Plans

Supplement toMedicare PPO

Health Plans

HMO Medicare

Managed CarePlans (Medicare

Advantage)

Out-o-State

Plan Choices

Blue Shield

Access+

Blue Shield

NetValue

Kaiser

Permanente 1

Caliornia

Correctional

Peace Ocers

Association

(CCPOA)

Medical Plan 2

PERS Select

PERS Choice

PERSCare

Caliornia

Association

o Highway

Patrolmen

(CAHP)

Health Plan 2

Peace Ocers

Research

Association

o Caliornia

(PORAC)

Police and FireHealth Plan 2

Blue Shield

Access+

Blue Shield

NetValue

CCPOA

Medical Plan 2

PERS Select

PERS Choice

PERSCare

CAHP

Health Plan 2

PORAC

Police and Fire

Health Plan 2

Kaiser

Permanente

Senior

Advantage

Blue Shield

65 Plus 3

PERS Choice

(PPO)

PERSCare

(PPO)

Kaiser

Permanente(HMO) 1, 4

PORAC

Police and Fire

Health Plan

(PPO) 2

Note: CalPERS also oers both Basic and Medicare enrollees in

Colusa, Mendocino, and Sierra counties the choice o selecting

the Blue Shield Exclusive Provider Organization (EPO) Health

Plan. See the current Health Program Guide or more inormation

about EPOs as well as detailed health plan eligibility and

enrollment guidelines.

1 Kaiser Permanente requires binding arbitration.

2 You must belong to the specic employee association and pay

applicable dues to enroll in an Association Plan (CCPOA, CAHP,

or PORAC).

3 This is the Medicare Advantage plan or Blue Shield NetValue

and Access+.

4 Kaiser Permanente (HMO) is available in parts o the ollowing

states: CO, GA, HI, MD, OH, OR, VA, WA, and Washington, D.C.

Costs and some benets may vary outside o Caliornia.

Contacting a Health Plan

I you have a specic question about a planscoverage, benets, or participating providers,

please contact the plan directly. See the

Health Plan Directory on page 12 or health

plan contact inormation.


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Choosing Your Doctor and Hospital

Some o our health plans are available only in certain

counties and/or ZIP Codes. As you consider your healthplan choices, you should determine which health plans

are available in the ZIP Code in which you are enrolling.

In general, i you are an active employee or a

working CalPERS retiree, you may enroll in a health

plan using either your residential or work ZIP Code.

To enroll in a Medicare Advantage plan, you must use

your residential address.

I you are a retired CalPERS member, you may

select any health plan in your residential ZIP Code

area. You cannot use the address o the CalPERS-covered employer rom which you retired to establish

ZIP Code eligibility.

I you use your residential ZIP Code, all enrolled

dependents must reside in the health plans servicearea. When you use your work ZIP Code, all enrolled

dependents must receive all covered services (except

emergency and urgent care) within the health plans

service area, even i they do not reside in that area.

To determine i the health plan you are considering

provides services where you reside or work, see the

Health Plan Availability by County chart on the

ollowing page. I you have questions about plan

availability or coverage, or wish to obtain a copy o

the Evidence of Coverage, contact the health plansusing the Health Plan Directory on page 12.

Once you choose a health plan, you should nd

a primary care physician. Except in the case o an

emergency, the doctors you can use and the medicalgroups and hospitals you will have access to will

depend on your choice o health plan.

Many people nd their doctor by asking neighbors

or co-workers or a doctors name. Others receive

reerrals rom doctors they already know. Still others

simply pick a physician rom their health plan who

happens to be nearby. Once you choose a doctor, call

the doctors oce and ask i he or she aliates with

the plan you are selecting and the hospital you preer

to use. You can also use the Health Plan Choosertool

(described on pages 89), which is available on the

CalPERS website at www.calpers.ca.gov to nd out

which plans include your doctor. Either way, you shouldconrm that the doctor is taking new patients in the

plan you select.

I you need to be hospitalized, your health plan or

medical group will have certain hospitals that you are

able to use. I you preer a particular hospital, you

should make sure the health plan you select contracts

with that hospital. See the chart on page 13 or a list

o resources that can help you evaluate and select a

doctor and hospital.

Enrolling in a Health Plan Using Your Residential or Work ZIP Code


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Health Plan Availability by County

Some health plans are available only in certain counties

and/or ZIP Codes. Use the chart below to determine

i the health plan you are considering provides services

where you reside or work. Contact the plan beore

enrolling to make sure they cover your ZIP Code and

County BlueShield

Access+

&

EPO

BlueShield

NetValue

BlueShield

65Plus

CAHP

CCPOA

Kaiser

Permanente

PERSChoice

PERSSelect

PERSCare

PORAC

Alameda

Alpine

Amador

Butte

Calaveras

Colusa

Contra Costa

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Marin

Mariposa

Mendocino

Merced

Modoc

Mono

Monterey

Napa

Nevada

Orange

that their provider network is accepting new

patients in your area. You may also use our online

service, the Health Plan Search by ZIP Code,

available at www.calpers.ca.gov.


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Health plan covers all or part o county.

The Blue Shield Exclusive Provider Organization (EPO) plan serves Colusa,Mendocino, and Sierra counties only. The EPO plan oers the same coveredservices as the Access+ HMO plan, but members must seek services romBlue Shields network o preerred providers. Members are not required to

select a primary care physician.

Chart Legend

County BlueShield

Access+

&

EPO

BlueShield

NetValue

BlueShield

65Plus

CAHP

CCPOA

Kaiser

Permanente

PERSChoice

PERSSelect

PERSCare

PORAC

Placer

Plumas

Riverside

Sacramento

San Benito

San Bernardino

San Diego

San Francisco

San Joaquin

San Luis Obispo

San Mateo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sutter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba

Out-o-State


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Tools to Help You Choose Your Health Plan

This section provides a variety o inormation that can

help you evaluate your health plan choices. Included

here are details about using my|CalPERS, the Health

Plan Chooser, and the Health Plan Choice Worksheet,

as well as inormation about health plan ratings

based on our annual member survey. The section

also includes a tip about how you can save money

by selecting a high-perormance network.

Accessing Health Plan Inormation with my|CalPERS

You can use my|CalPERS at my.calpers.ca.gov, our

secure, personalized website, to get one-stop access

to all your current health plan inormation, including

details about which amily members are enrolled. You

can also use it to search or other health plans that are

available in your area, access CalPERS Health Program

orms, and nd additional inormation about

CalPERS health plans. I you are a retiree, CalPERS

is your Health Benets Ocer. Retirees may change

their health plan during Open Enrollment by calling

us toll ree at 888 CalPERS (or 8882257377).

Comparing Your Options: Health Plan Chooser

The Health Plan Chooseris an online tool that

provides a convenient way to evaluate your health

plan options and make a decision about which

plan is best or you and your amily. With this

easy-to-use tool, you can weigh plan benets andcosts, search or specic doctors, and view overall

plan satisaction ratings.

The Chooser is available to help you make health

plan decisions at any time. You can use it to:

Find a new health plan during Open Enrollment.

Select your primary care doctor or nd

a new specialist.

Evaluate your health plan options and

estimate costs.

Choose a health plan when your employer

rst begins oering the CalPERS Health

Benets Program.

Review health plan options due to changes

in your marital status or enrollment area.

Explore health plan options because you

are planning or retirement or have become

Medicare eligible.

The Chooser takes you through ve steps that

provide you with key inormation about each health

plan. At each step, you can rate the plans. When

you nish, the Chooser gives you a Results Summary

chart highlighting the plan(s) you rated as the bestt in each category. This chart allows you to easily

determine which plan meets your needs.

Be sure to tell us what you think about the

Health Plan Chooser by completing a survey located

in the Choosers Results page.

The Health Plan Chooserprovides customized

help in selecting the health plan that is right

or you and your amily. You can nd the Health

Plan Chooserby visiting CalPERS On-Line at

www.calpers.ca.gov.


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How to Use the Health Plan Chooser

Step 1. Estimate Your CostsYour out-o-pocket costs will di er rom

plan to plan depending on several actors,

including how much your employer contributes

toward your premium, how oten you go to

the doctor, and how many prescriptions you

ll each year. A chronic illness (e.g., heart

disease, asthma, diabetes) can also aect

your out-o-pocket costs. When you enter

specic inormation about these variables

into the Chooser, you will receive an estimateo how much your out-o-pocket costs will

be each year. (Remember that any dollar

amounts indicated on the Chooser are

estimates only.)

Step 2. Find a Physician

Unless you moved recently, you probably

already have a primary care physician. You

can use the health plan links on the Chooser

to see i your physician is in the health planyou are considering. I your physician is not

in the plan you are considering or i you would

like to change physicians, you can search or

physicians in your area by name or by specialty.

Step 3. Review Member Ratings

o Health Plans

The Chooser allows you to compare member

ratings or the health plans. The member

ratings indicate how other CalPERS membersrate the plans. You can consider overall

ratings as well as ratings in key areas, such as

personal doctors, specialists, getting needed

care, getting prescriptions easily, customer

service, and accessing a plans website.

Step 4. Evaluate Plan FeaturesOn the surace, you may think that all health

plans are pretty much the same but i you

look more closely, you will nd dierences in

several areas. The Chooser helps you identiy

the dierences by allowing you to evaluate

eatures in three categories:

Help to Stay Healthy

Medical Conditions

How to Save Money

For example, i you smoke and would like to quit,

you can nd out what type o smoking cessation

program each plan offers. If your child has asthma,

you can nd out about asthma management

programs. I you ll multiple prescriptions each

year, you can get helpul tips on how to save

money on your medications.

Step 5. Compare Plan Costs

and Covered ServicesThis part o the Chooser provides a summary

o your costs or doctor visits and hospital

stays, deductibles (i applicable), and the yearly

maximum or each plan. To see more detailed

inormation about your cost or various services,

select any o the plan names.

For more inormation about CalPERS healthplans and access to the Health Plan Chooser,

visit our website at www.calpers.ca.gov.

To speak with someone at CalPERS about

your health plan choices, call 888 CalPERS

(or 8882257377).


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Comparing Your Options: Health Plan Choice Worksheet

An alternative tool we provide to help you choose

the best plan or yoursel and your amily is the

Health Plan Choice Worksheet, which you can nd

on page 33 o this booklet. Like the Chooser, this

worksheet can be used to compare actors suchas cost, availability, benets, and member ratings.

Simply ollow the steps listed in the let column o

the Worksheet. Several questions can be answered

with a simple yes or no, while others will require

you to insert inormation or call the health plan.

Some o the inormation can be ound at CalPERS

On-Line at www.calpers.ca.gov. I you need assistancecompleting the orm, contact CalPERS at 888 CalPERS

(or 8882257377).

Saving Money by Selecting a High-Perormance Network

We want to help you get the most or your health plandollars. One way you may be able to save on your

health premium is by enrolling in one o our high -

perormance network plans. These plans Blue Shield

NetValue (HMO) and PERS Select (PPO) provide the

same benets and quality o care as Blue Shield

Access+ HMO and PERS Choice, respectively. The

dierence is that you pay a lower premium in exchange

or choosing rom a smaller selection o physicians

and hospitals.

NetValue is available in 27 counties, and PERSSelect is oered in 58 counties. I you dont reside

in one o these counties, but you work in one, you may

be able to enroll in a lower cost health plan using your

work ZIP Code (see the Health Plan Availability by

County chart on pages 67). You may also use our

online service, the Health Plan Search by Zip Code,

available at www.calpers.ca.gov.


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Health Plan DirectoryFollowing is contact inormation or the health plans. Call your health plan with questionsabout: ID cards; verication o provider participation; service area boundaries (covered ZIP

Codes); benets, deductibles, limitations, exclusions; and Evidence of Coverage booklets.

Blue Shield o Caliornia

P.O. Box 272520, Chico, CA 959272520

Member Services: (800) 3345847

65 Plus Member Services: (800) 7764466

www.blueshieldca.com/calpers

Caliornia Association o Highway Patrolmen (CAHP)

Health Benefts Trust

(Administered by Anthem Blue Cross)

2030 V Street, Sacramento, CA 958181730

For eligibility issues contact:

(800) 7342247 or (916) 4526751 (CAHP)

[email protected]

For benefts or claim inormation, contact:

Anthem Blue Cross, Attn: CAHP UnitP.O. Box 60007, Los Angeles, CA 900600007

(800) 7595758 (Anthem Blue Cross)

www.anthem.com/ca

Caliornia Correctional Peace Ofcers Association

(CCPOA) Beneft Trust Fund

(Administered by Blue Shield o Caliornia and

Express Scripts)

2515 Venture Oaks Way, Suite 200

Sacramento, CA 958334235

CCPOA Beneft Trust Fund:

(800) 4686486

(800) 2576213 (COBRA)

www.ccpoabt.org

Blue ShieldCCPOA Member Services Unit:

(800) 2576213

Kaiser Permanente

Member Services:

Call Center (800) 4644000

www.kp.org/calpers to obtain acility mailing address

PERS Select, PERS Choice, and PERSCare

Medical Benefts:

(Administered by Anthem Blue Cross)

P.O. Box 60007, Los Angeles, CA 900600007

(877) PERS PPO or (877) 7377776

(818) 2345141 (outside o the continental U.S.)

TTY (818) 2343547

For direct premium payments:

P.O. Box 629, Woodland Hills, CA 913650629

www.anthem.com/ca/calpersPharmacy Benefts:

(Administered by CVS Caremark)

(877) 5420284, TTY (800) 8635488

www.caremark.com/calpers

Peace Ofcers Research Association o Caliornia

(PORAC) Health Plan (Administered by Anthem

Blue Cross and Express Scripts)

For eligibility issues, contact:

4010 Truxel Road, Sacramento, CA 95834(800) 6556397 (PORAC)

www.porac.org

For benefts or claim inormation, contact:

Anthem Blue Cross, Attn: PORAC Unit

P.O. Box 60007, Los Angeles, CA 900600007

(800) 2886928

www.anthem.com/ca

Additional Resources

As a health care consumer, you have access to many resources, services, and tools that can help

you nd the right health plan, doctor, medical group, and hospital or yoursel and your amily.


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Obtaining Health Care Quality Inormation

Following is a list o resources you can use to evaluate and select a doctor and hospital.

Source Website Description

Hospitals

CalHospitalCompare www.CalHospitalCompare.org CalHospitalCompare is a standardized, universal

perormance report card or Caliornia hospitals

that includes patient experience and clinical

quality measures.

U.S. Department o

Health and Human

Services

www.hospitalcompare.hhs.gov This site provides publicly-reported hospital quality

inormation, including measures on heart attacks,

pneumonia, heart ailure, and surgery.

HealthGrades www.healthgrades.com HealthGrades uses data rom Medicare and states to

compare outcomes o care or common procedures.

The Leaprog Group www.leaproggroup.org This is a coalit ion o health purchasers who have

ound that hospitals meeting certain standards

have better care results.

Doctors and Medical Groups

Caliornia

Medical Board

www.medbd.ca.gov This is the State agency that licenses medical

doctors, investigates complaints, disciplines those

who violate the law, conducts physician evaluations,

and acilitates rehabilitation where appropriate.

Ofce o the

Patient Advocate

www.opa.ca.gov This website includes a State o Caliornia-sponsored

Report Card that contains additional clinical and

member experience data on HMOs and medical

groups in Caliornia.

Beneft Comparison Charts

The benet comparison charts on pages 1431

summarize the benet inormation or each health

plan. For more details, see each plans Evidence

of Coverage (EOC) booklet.


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Beneits HMO Basic Plans

Kaiser

Permanente

Blue Shield

Access+ HMO

Blue Shield

EPO

Blue Shield

NetValue HMO

CCPOAAssociation P

Caldar Yar Dducbl

Individual

N/AFamily

Maxmum Caldar Yar Co-pay (excluding pharmacy)

Individual

Family

$4,500(see EOC or ot

items not coun

toward co-pay mlimit)

Hopal (including Mental Health and Substance Abuse)

Deductible (per admission) N/A

Inpatient $100/admiss

Outpatient Facility/Surgery Services $15 no Charg (exceptions may apply) $50

emrgcy srvc

Emergency Room Deductible N/A

Emergency

$75(co-pay waive

i admitted as

inpatient or o

observation as

outpatient)

Non-emergency N/A

CalPERS Basic Health PlansBeneft Comparison Charts

Preventive services identied by the Patient Protection and Aordable Care

Act (PPACA) are covered equally by all plans at no cost to you. Contact your

physician or your health plans customer service number or a list o these

preventive services. For more details about the benets provided by aspecic plan, reer to that plans Evidence of Coverage (EOC) booklet.

$1,500(see EOC or other items not counted toward co-pay max limit)

$3,000(see EOC or other items not counted toward co-pay max limit)

no Charg

$50(co-pay waived i admitted as an inpatient

or or observation as an outpatient)


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Continued on next page

Note: All footnotes are located on page 23.

PPO Basic Plans

PERS Select PERS Choice PERSCare CAHPAssociation Plan PORACAssociation Plan

PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO

$500(not transerable between plans)

N/A

$300 $600

$1,000(not transerable between plans)

$900 $1,800

$3,000

N/A

$3,000

N/A

$2,000

N/A

$2,000

N/A

$3,000

$6,000 $6,000 $4,000 $4,000 $6,000

$250

2030%1

(hospital tiers)40% 20%2 40% 10%2 40% 10%

Varies (see EOC)10% 10% 3

40%

20% 20% 10%$50 + 10%

(co-pay

reduced to $25

i admitted on

an inpatient

basis)

$50 + 10%(co-pay reduced

to $25 iadmitted on an

inpatient basis)

10%

20% 40% 20% 40% 10% 40%$50 + 40%

(co-pay reduced

to $25 i

admitted on an

inpatient basis)

50%(or non-emergency

services provided by hospital

emergency room)

$50(applies to hospital emergency room charges only;

deductible waived i admitted as an inpatient or or observation as an outpatient)

N/A

(applies to other services such as physician, x-ray, lab, etc.)

(payment or physician charges only; emergency room acility charge is not covered)

N/AN/A


18/36


CalPERS Basic Health Plans Continued


Kaiser

Permanente

Blue Shield

Access+ HMO

Blue Shield

EPO

Blue Shield

NetValue HMO

CCPOAAssociation P

Ambulac srvc

no Charg

Phyca srvc (including Mental Health and Substance Abuse)

Ofce Visits (co-pay or each service provided) $15

Inpatient Visits no Charg

Outpatient Visits$15

(outpatient surgery)

Urgent Care Visits $15

Allergy Testing $15

Allergy Treatment no Charg(or allergy injections)

Vision Exam/Screening no Charg $15

Surgery/Anesthesiano Charginpatient;

$15 outpatient

Dagoc X-Ray/Lab

(some procedures

may require

a co-pay)

Prcrpo Drug

Deductible

Brand

Formulary: $(not to excee

$150/amily

Retail Pharmacy

Generic: $5

Brand: $20(not to exceed

30-day supply)

Generic: $1

Brand

Formulary: $

Non-Formula

$50(not to excee

30-day suppl

Medical Necessity/Partial Waiver N/A N/A

$15

$15

no Charg

no Charg

no Charg(may be limited to one visit or age 18 and over;

no limit on number o visits or members under age 18)

no Charg

no Charg

N/A

Generic: $5

Brand Formulary: $20

Non-Formulary: $50(not to exceed 30-day supply)

$40


19/36




PPO Basic Plans



20%

$20 1

40%

$20 2

40%

$20 2

40%

$15

40%

$20

10%3

20% 1 20% 2 10% 2

10%

10%

$20 1 $20 2 $20 2

$15

20%1 20%2 10%2 10%

Not Covered

20%1 40% 20%2 40% 10%2 40% 10% 40% 10% 10%3

20% 40% 20% 40% 10% 40% 10% 40% 10% 10%3

N/A

Generic: $5

Preerred: $20

Non-Preerred: $50(not to exceed 34-day supply)

Generic: $5

Single Source: $20

Multi Source: $25(not to exceed 30-day supply)

Generic: $10

Brand

Formulary:

$25

Non-

Formulary:$45

Compound:

$45

Generic: $10

Brand

Formulary:

$25

Non-

Formulary:$45

Compound:

Not Covered(see EOC)

$40

Generic: $5

Preerred: $20


N/A


20/36




Kaiser

Permanente

Blue Shield

Access+ HMO

Blue Shield

EPO

Blue Shield

NetValue HMO

CCPOAAssociation P

Prcrpo Drug (coud)

Retail Pharmacy MaintenanceMedications flled ater 2nd fll(i.e., a medication taken longerthan 60 days) N/A

Generic: $1

Brand

Formulary: $

Non-Formula

$50(not to excee

30-day suppl

Medical Necessity/Partial Waiver $70 N/A

Mail Order Pharmacy Program

Generic: $5

Brand: $20(up to 30-day supply)

Generic: $10

Brand: $40(31100 day supply)

Generic: $2

BrandFormulary: $

Non-Formula

$100(not to excee

90-day suppl

Medical Necessity/Partial Waiver

N/A

$70

N/AMaximum co-payment per person

per calendar year$1,000 (see EOC)

Durabl Mdcal equpm

no Charg

irly tg/tram

Hom Halh srvc (prior authorization required; custodial care not covered)

$15(up to 100 visi

calendar yeano Charg

Generic: $10



50% o covered charges (see EOC)

Generic: $10Brand Formulary: $40

Non-Formulary: $100(not to exceed 90-day supply

or maintenance drugs)


21/36




PPO Basic Plans



Generic: $10

Preerred: $40


Generic: $10

Single Source: $40


N/A

$70

Generic: $10

Single Source: $40


Generic: $20

Brand

Formulary:$40

Non-

Formulary: $75(see EOC

or specialtypharmacy ees)

N/A

$70

$1,000 (see EOC)

20% 40% 20% 40% 10% 40%10% 40% 20% 20%3

50%

20% 40% 20% 40% 10% 40% 10% 40% 10%(up to 100 visits /year; combined

beneft or PPO/non-PPO)(up to 100 visits/calendar year) (up to 90 visits/period o disability)

Generic: $10

Preerred: $40


Generic: $10

Preerred: $40


(pre-certifcation required or equipment $1,000 or more)

Not Covered

(up to 45 visits/calendar year)

N/A

N/A


22/36




Kaiser

Permanente

Blue Shield

Access+ HMO

Blue Shield

EPO

Blue Shield

NetValue HMO

CCPOAAssociation P

sklld nurg Car

Inpatient(hospital or skilled nursing acility)

no Charg(up to 100 days/

beneft period)

Outpatient(ofce and home visits)

Occupaoal / Phycal / spch thrapyInpatient (hospital or skilled nursing acility) no Charg

Outpatient (ofce and home visits) no Charg

Hopc

no Charg

Acupucur

$15(when medically

necessary; discounts

available see EOC )

Chropracc

$15 exam(up to 20 visit

no Chargdiagnostic

services;chiropractic

appliances(up to $50)

Not Covered

no Charg(up to 100 days/calendar year)

$15

Not Covered(discounts available see EOC )

Not Covered(discounts available see EOC)


23/36




PPO Basic Plans



20% frst

10 days;

30% next

90 days

40%

20% frst

10 days;

30% next

90 days

40%

10% frst

10 days;

20% next

170 days

40% frst

10 days;

40% next

170 days

10% 40%10%

(up to 100 days/year

combined beneft or

skilled nursing acility)

10% 40%

10% 10%3

20%

40%;

Occupational

therapy: 20%

20%

40%;

Occupational

therapy: 20% 20% $20 10%3

10% no Charg 10%

20% 40% 40% 40% 10% 40% 10% 40% $20(10% or all

other services)10%3

20% 40% 20% 40% 10% 40% 10% 40% Up to

20 visits(see EOC)

$35/visit(see EOC)

(up to 100 days/beneft period)

(pre-certifcation requiredor more than 24 visits)

Not Covered

no Charg

(acupuncture/chiropractic; combined 15 visits)




20%

N/A

(pre-certifcation required or more than 24 visits)

(pre-certifcation required;

up to 100 days/calendar year)

(pre-certifcation required;

up to 180 days/calendar year)


24/36




Kaiser

Permanente

Blue Shield

Access+ HMO

Blue Shield

EPO

Blue Shield

NetValue HMO

CCPOAAssociation P

Harg Ad srvc

Hearing Exam/Screening no Charg

Audiological Exam $15

Hearing Aids$500 max/

member

no Charg

$1,000 max every 36 months


25/36


PPO Basic Plans



20%1

40%

20%2

40%

10%2

40%

10% 40%

20% 20%3

20% 20% 10%20%

(no deductible)

20% 40% 20% 40% 10% 40% 20%(no deductible; one hearing aid

per ear every 36 months)

1 PERS Select utilizes the Anthem Blue Cross Select PPO Network, which is asubset o the Anthem Blue Cross Prudent Buyer PPO Network. Approximately

50 percent o the Anthem Blue Cross Prudent Buyer PPO Network o physiciansparticipate in the Select PPO Network. By obtaining physician services throughthe Select PPO Network, you will receive the highest level o reimbursement.I you are a PERS Select member, you should check to see i a physician isparticipating in the Select PPO Network beore receiving services.

2 PERS Choice and PERSCare utilize the Anthem Blue Cross Prudent BuyerPPO Network, which is a more comprehensive network. By obtaining servicesthrough Anthem Blue Cross Prudent Buyer PPO Network, you will receive thehighest level o reimbursement.

3 Covered expense or services rom non-PPO providers is based on a strictlylimited schedule o allowances. As a PPO member, you must pay charges inexcess o those scheduled amounts.

(one single hearing device every 36 months)

(one single hearing deviceevery 36 months)


26/36


Beneits Medicare HMO Plans

Kaiser

Permanente

Blue ShieldNetValue/Access+/EPO

Blue Shield

65 Plus

CCPOAAssociation Plan

Caldar Yar Dducbl

Individual

Family

Maxmum Caldar Yar Co-pay (excluding pharmacy)

Individual $1,500 (see EOC) $1,500

Bf Byod Mdcar

Family $3,000 (see EOC) $4,500 (3 or more

Hopal (including Mental Health and Substance Abuse)

Inpatient no Charg $100/admission

Bf Byod Mdcar

Outpatient Facility/Surgery Services $10

Bf Byod Mdcar

sklld nurg acly Car

Medicare

Bf Byod Mdcar

Hom Halh srvc

Medicare no Charg$15

(up to 100 visits)

Bf Byod Mdcar

CalPERS Medicare Health PlansBeneft Comparison Charts

Preventive services identied by the Patient Protection and Aordable Care

Act (PPACA) are covered equally by all plans at no cost to you.Contact your

physician or your health plans customer service number or a list o these

preventive services. For more details about the benets provided by aspecic plan, reer to that plans Evidence of Coverage (EOC) booklet.

N/A

N/A

N/A

N/A

N/A

no Charg

N/A

no Charg

(up to 100 days/beneft period)

N/A

N/A


27/36

2013 Health Beneit Summary | 25Note: Footnote is located on page 31.


Medicare PPO Plans

PERS Select PERS Choice PERSCare CAHPAssociation Plan

PORACAssociation PlanPPO Non-PPO PPO Non-PPO PPO Non-PPO

$15,000 calendar

year stop-loss / see EOC

$3,000

N/A

no Charg1

plan pays or

an additional 365 days

no Charg 1

20%

20%(rom 101 to 365 days;

pre-certifcation required)20%

plan pays

days 101 through 365

no Charg 1

N/A 20% N/A

CalPERS oers several health plans that supplement your

Medicare coverage. The primary payer is Medicare, and the

CalPERS supplemental plan would be the secondary payer.

The CalPERS supplemental plan will pay or benets thatare dened as covered services under Medicare.*

* The Centers or Medicare & Medicaid Services (CMS)regulates the Medicare program. CMS publishesthe booklet, Medicare & You, which provides generalinormation about Medicare. Please reer to Medicare& You i you have any questions regarding covered

services. You can view or download this publicationat www.medicare.gov.

N/A(plan pays Medicare Parts A and B deductible)

N/A

N/A N/A

N/A

N/A

N/A

no Charg 1

(up to 100 days/beneft period in a Medicare approved acility)

20%

no Charg1

N/A


28/36

CalPERS Medicare Health Plans Continued



Kaiser

Permanente

Blue Shield

NetValue/Access+/EPO

Blue Shield

65 Plus


Hopc

Medicare

Bf Byod Mdcar

emrgcy srvc

Medicare no Charg

Bf Byod Mdcar

Ambulac srvc

Medicare

Bf Byod Mdcar

surgry/Aha

no Charginpatient;

$10 outpatient

Phyca srvc (including Mental Health and Substance Abuse)

Ofce Visits

Inpatient Visits

Outpatient Visits$10

Urgent Care Visits $10

Allergy Testing

no ChargAllergy Treatment

$3(or allergy injections)

Dagoc X-Ray/Lab

Durabl Mdcal equpm

Medicare

Bf Byod Mdcar

N/A

no Charg

N/A

$50 (waived i admitted or kept or observation)

N/A

no Charg

no Charg

no Charg

$10

no Charg

$25

$10

$10

no Charg

no Charg

N/A


29/36



Medicare PPO Plans



no Charg 1

N/A 20%(see EOC) N/A

no Charg 1


no Charg 1


no Charg 1

no Charg 1

$10 no Charg

no Charg1

no Charg 1

N/A 20%

no Charg1


30/36




Kaiser

Permanente

Blue Shield


Blue Shield

65 Plus


Prcrpo Drug

Deductible

Retail Pharmacy

Generic: $5


30-day supply)

Generic: $5

Brand Formulary: $

Non-Formulary: $(not to exceed

30-day supply)


N/A

$40

Retail Pharmacy MaintenanceMedications flled ater 2nd fll

(i.e., a medication taken longerthan 60 days)

Generic: $10


Non-Formulary: $100(not to exceed30-day supply)

N/A

Generic: $5

Brand Formulary: $

Non-Formulary: $(not to exceed30-day supply)

Medical Necessity/Partial Waiver $70

Mail Order Pharmacy Program

Generic: $5


30-day supply)

Generic: $10

Brand: $40(31100 day supply)

Generic: $10

Brand Formulary: $

Non-Formulary: $(not to exceed

30-day supply)


N/A

$70 N/A

N/AMaximum co-payment per person/

calendar year

Occupaoal / Phycal / spch thrapy

Inpatient (hospital orskilled nursing acility)

no Charg $10 no Chargno Charg

Outpatient (ofce and home visits) $10

Bf Byod Mdcar(pa/oupa)

Dab srvc

Glucose monitors, test strips

Sel-management training no Charg$10

(includes nutritional

counseling)

Bf Byod Mdcar

$10

Generic: $5



Generic: $10



no Charg (see EOC)

N/A

N/A

N/A

N/A

N/A

$1,000 (see EOC)


31/36



Medicare PPO Plans



$100(excludes mail order)

Generic: $5

Preerred: $20

Non-Preerred: $50

Generic: $5

Single Source: $20


Generic: $10


Non-Formulary: $45

$40

Generic: $10

Preerred: $40


Generic: $10

Single Source: $40


N/A

$70

Generic: $10

Preerred: $40


Generic: $10

Single Source: $40


Generic: $20


Non-Formulary: $75

$70

$1,000 (see EOC)

no Charg 1

20%

no Charg 1

20%

N/A

Generic: $10

Preerred: $40


N/A

N/A

N/A

N/A

N/A


32/36




Kaiser

Permanente

Blue Shield


Blue Shield

65 Plus


Harg srvc

Hearing Exam $10 no Charg

Audiological Exam $10 $15

Bf Byod Mdcar

Hearing Aids Bf Byod Mdcar $1,000 max/36 months $500 max/memb

Vo Car

Vision Exam $10 $10

Bf Byod Mdcar

Eyeglasses

Bf Byod Mdcar

Contact Lenses

Bf Byod MdcarIn lieu o eyeglasses:

$175 allowance

every 24 months

N/A

Mor Bf Byod Mdcar(Services covered beyond Medicare coverage)

Acupuncture

$10(when medically

necessary; discounts

available/see EOC )

N/A

Chiropractic

$10(20 visits; discounts

available/see EOC )

no Chargchiropractic appliances

($50 max)

$15/exam(up to 20 visits)

no Chargdiagnostic service

chiropractic applian($50 max)

Smoking Cessation Program

N/A

N/A

N/A

N/A

no Charg

$10 (limited to one visit/see EOC)

no Charg ollowing cataract surgery


$10


33/36


Medicare PPO Plans



no Charg 1 no Charg 20%

no Charg 1

20%10%

($200 max/36 months)

20%(up to $50 /exam in connection

with hearing aid purchase)

20%($2,000 max/24 months)

10%($1,000 max/36 months)

20%($450 max/36 months/one ear)

N/A

One exam ($35 max) N/A20%

(limit one exam)

N/A20%

($40 combined max or initial

rames and lenses)

$100 max N/A 20% (up to $40)

20%(up to 20 visits)

no Charg 1

20% ($100 max) no Charg ($100 max) N/A

1 I benets are payable by Medicare and you use a provider who acceptsMedicare assignment, covered services will be paid in ull.

20%($1,000 max/36 months)


Two lenses/calendar year; one set o rames during a 24-month period

See EOC or maximum allowances


N/A

20%


34/36


Notes


35/36


Plan name and phone numbers:

Select the type o plan: (circle choice) PPO HMO EPOAssoc.Plan1 PPO HMO EPO

Assoc.Plan1

Step1-Cost

Calculate your monthly cost.Enter the monthly premium (see current years rate

schedule). Premium amounts will vary based on

1-party/2-party/amily and Basic/Medicare.

Enter your employers contribution.

For contribution amounts, active members should contact

their employer; retired members should contact CalPERS.

Calculate your cost.

Subtract your employers contribution rom the monthly

premium. I the total is $0 or less, your cost is $0.

Step2-Availability

Search available plans online.

Use our online service, the Health Plan Search Zip Code,

atwww.calpers.ca.gov to fnd out i the plan is available

in your residential or work ZIP code. You may also call the

plans customer service center.

Call the doctors ofce.

Confrm that they contract with the plan and are accepting

new patients. Ask what specialists are available and the

hospitals with which they are afliated.

Step3

-Comparisons

How did the plan rate in satisaction?

See page 11 to fnd out.

Compare the benefts.

See pages 1431. CalPERS plans oer a standard

package o benefts, but there are some dierences:

acupuncture, chiropractic, etc.

Step4

-Other

Other considerations:

Does the plan oer health education? Do you or your

amily have special medical needs? What services are

available when you travel? Are the provider locations

convenient?

What changes are you planning in the upcoming year(e.g., retirement, transer, move, etc.)?

Other inormation

Compare and select a plan.

1 You must belong to the specifc employee association and pay applicable dues to enroll in the Association Plans.

Health Plan Choice Worksheet


36/36

CalPERS Health Benefts Program

P.O. Box 942714

Sacramento, CA 94229-2714

888 CalPERS (or 888 -225-7377)www.calpers.ca.gov

HBD110

Produced by CalPERS External Aairs Branch

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2013 Health Benefit Summary

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