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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.
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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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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)
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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14 | 2013 Health Beneit Summary
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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2013 Health Beneit Summary | 15
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
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16 | 2013 Health Beneit Summary
CalPERS Basic Health Plans Continued
Beneits HMO Basic Plans
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
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2013 Health Beneit Summary | 17
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
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
Non-Preerred: $50(not to exceed 30-day supply)
N/A
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18 | 2013 Health Beneit Summary
CalPERS Basic Health Plans Continued
Beneits HMO Basic Plans
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
Brand Formulary: $40
Non-Formulary: $100(not to exceed 30-day supply)
50% o covered charges (see EOC)
Generic: $10Brand Formulary: $40
Non-Formulary: $100(not to exceed 90-day supply
or maintenance drugs)
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2013 Health Beneit Summary | 19
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
Generic: $10
Preerred: $40
Non-Preerred: $100(not to exceed 34-day supply)
Generic: $10
Single Source: $40
Multi Source: $50(not to exceed 30-day supply)
N/A
$70
Generic: $10
Single Source: $40
Multi Source: $50(not to exceed 90-day supply)
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
Non-Preerred: $100(not to exceed 30-day supply)
Generic: $10
Preerred: $40
Non-Preerred: $100(not to exceed 90-day supply)
(pre-certifcation required or equipment $1,000 or more)
Not Covered
(up to 45 visits/calendar year)
N/A
N/A
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20 | 2013 Health Beneit Summary
CalPERS Basic Health Plans Continued
Beneits HMO Basic Plans
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)
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2013 Health Beneit Summary | 21
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
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)
(acupuncture/chiropractic; combined 15 visits)
(acupuncture/chiropractic; combined 20 visits)
(acupuncture/chiropractic; combined 20 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)
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22 | 2013 Health Beneit Summary
CalPERS Basic Health Plans Continued
Beneits HMO Basic Plans
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
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2013 Health Beneit Summary | 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
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)
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24 | 2013 Health Beneit Summary
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
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2013 Health Beneit Summary | 25Note: Footnote is located on page 31.
Continued on next page
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
7/29/2019 2013 Health Benefit Summary
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CalPERS Medicare Health Plans Continued
26 | 2013 Health Beneit Summary
Beneits Medicare HMO Plans
Kaiser
Permanente
Blue Shield
NetValue/Access+/EPO
Blue Shield
65 Plus
CCPOAAssociation Plan
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
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2013 Health Beneit Summary | 27Note: Footnote is located on page 31.
Continued on next page
Medicare PPO Plans
PERS Select PERS Choice PERSCare CAHPAssociation Plan
PORACAssociation PlanPPO Non-PPO PPO Non-PPO PPO Non-PPO
no Charg 1
N/A 20%(see EOC) N/A
no Charg 1
N/A 20%(see EOC) N/A
no Charg 1
N/A 20%(see EOC) N/A
no Charg 1
no Charg 1
$10 no Charg
no Charg1
no Charg 1
N/A 20%
no Charg1
7/29/2019 2013 Health Benefit Summary
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CalPERS Medicare Health Plans Continued
28 | 2013 Health Beneit Summary
Beneits Medicare HMO Plans
Kaiser
Permanente
Blue Shield
NetValue/Access+/EPO
Blue Shield
65 Plus
CCPOAAssociation Plan
Prcrpo Drug
Deductible
Retail Pharmacy
Generic: $5
Brand: $20(not to exceed
30-day supply)
Generic: $5
Brand Formulary: $
Non-Formulary: $(not to exceed
30-day supply)
Medical Necessity/Partial Waiver
N/A
$40
Retail Pharmacy MaintenanceMedications flled ater 2nd fll
(i.e., a medication taken longerthan 60 days)
Generic: $10
Brand Formulary: $40
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
Brand: $20(not to exceed
30-day supply)
Generic: $10
Brand: $40(31100 day supply)
Generic: $10
Brand Formulary: $
Non-Formulary: $(not to exceed
30-day supply)
Medical Necessity/Partial Waiver
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
Brand Formulary: $20
Non-Formulary: $50(not to exceed 30-day supply)
Generic: $10
Brand Formulary: $40
Non-Formulary: $100(not to exceed 90-day supply)
no Charg (see EOC)
N/A
N/A
N/A
N/A
N/A
$1,000 (see EOC)
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2013 Health Beneit Summary | 29Note: Footnote is located on page 31.
Continued on next page
Medicare PPO Plans
PERS Select PERS Choice PERSCare CAHPAssociation Plan
PORACAssociation PlanPPO Non-PPO PPO Non-PPO PPO Non-PPO
$100(excludes mail order)
Generic: $5
Preerred: $20
Non-Preerred: $50
Generic: $5
Single Source: $20
Multi Source: $25(not to exceed 30-day supply)
Generic: $10
Brand Formulary: $25
Non-Formulary: $45
$40
Generic: $10
Preerred: $40
Non-Preerred: $100(not to exceed 34-day supply)
Generic: $10
Single Source: $40
Multi Source: $50(not to exceed 30-day supply)
N/A
$70
Generic: $10
Preerred: $40
Non-Preerred: $100(not to exceed 90-day supply)
Generic: $10
Single Source: $40
Multi Source: $50(not to exceed 90-day supply)
Generic: $20
Brand Formulary: $40
Non-Formulary: $75
$70
$1,000 (see EOC)
no Charg 1
20%
no Charg 1
20%
N/A
Generic: $10
Preerred: $40
Non-Preerred: $100(not to exceed 30-day supply)
N/A
N/A
N/A
N/A
N/A
7/29/2019 2013 Health Benefit Summary
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CalPERS Medicare Health Plans Continued
30 | 2013 Health Beneit Summary
Beneits Medicare HMO Plans
Kaiser
Permanente
Blue Shield
NetValue/Access+/EPO
Blue Shield
65 Plus
CCPOAAssociation Plan
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
no Charg ollowing cataract surgery
$10
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2013 Health Beneit Summary | 31
Medicare PPO Plans
PERS Select PERS Choice PERSCare CAHPAssociation Plan
PORACAssociation PlanPPO Non-PPO PPO Non-PPO PPO Non-PPO
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)
no Charg ollowing cataract surgery
Two lenses/calendar year; one set o rames during a 24-month period
See EOC or maximum allowances
no Charg ollowing cataract surgery
N/A
20%
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32 | 2013 Health Beneit Summary
Notes
7/29/2019 2013 Health Benefit Summary
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2013 Health Beneit Summary | 33
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
7/29/2019 2013 Health Benefit Summary
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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