Access+ HMO. NetValue HMO

Transcription

1 Access+ HMO NetValue HMO 2014 HMO plan brochure Health benefits, services, and programs

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3 welcome, CalPERS member! Thank you for choosing a Blue Shield of California HMO plan. We encourage you to read your Evidence of Coverage and Disclosure Form (EOC&D), which contains all the details of your health plan. We ve also created this handy plan brochure to make it easier for you to learn about all the programs, services, and resources now available to you, along with the relevant links and phone numbers you ll need to access each. Specifically, here s what you can find in the following pages: Convenient reference card... Inside front cover Start here... Pages 2-3 Benefit summary... Pages 4-5 Medical benefit highlights... Pages 6-7 Pharmacy benefits...pages 8-11 Plus lots more...pages Smart discounts... Pages Endnotes... Page 21 Access+ HMO service area... Page 22 NetValue HMO service area... Page 23 We hope you ll find that understanding and using your new plan is easier than you d think!

4 start here Your Personal Physician blueshieldca.com Now that you re a Blue Shield HMO member, you have access to a large network of doctors. When you enrolled in the Access+ HMO or NetValue SM HMO plan, you may have selected, or Blue Shield may have assigned you and each of your enrolled dependents, a primary care physician. At Blue Shield, we call them Personal Physicians. Except for emergency services, your Personal Physician will provide or coordinate all of your medical care. You can almost always change your Personal Physician unless you are in the hospital or in your third trimester of pregnancy. If you change your Personal Physician, your new doctor will be effective on the first of the following month. You and your covered dependents also have the option to choose different Personal Physicians and medical groups. There are two ways to change your Personal Physician. Once you have received your new Blue Shield member ID card, you can make the change online by registering at blueshieldca.com. In the Plan Overview section, choose Change Personal Physician or Medical Group. Subscribers with family can also request access to their family member s plan and update their Personal Physicians as well. (Visit blueshieldca.com/membercenter to learn more about adding family members to your online account.) You can also change your Personal Physician by calling Member Services at (800) , 7 a.m. to 8 p.m., seven days a week. To locate a new Personal Physician, you can use our Find a Provider tool. Simply log in to blueshieldca.com and select the Find a Provider tab at the top of the page. Select Doctors, and then click on Advanced Search to select HMO Personal Physicians in the Doctor type or specialty field. Enter your ZIP code and click Find now. If you don t have access to the Internet or need help, contact Member Services at (800) for personal assistance. We realize how important it is to find the right doctor for you and your family, so we re happy to recommend these trustworthy resources: The American Medical Association s website at ama-assn.org for information about the qualifications of doctors. The DocFinder feature at docboard.org to access information from state government licensing boards. The Blue Shield provider profiles to obtain performance information that rates medical groups, hospitals, and physicians on medical care, patient satisfaction, and affordability. You can view the provider performance profiles through Find a Provider at blueshieldca.com. 2

5 Your health plan at your fingertips blueshieldca.com As soon as you receive your member ID card, please take a few minutes to register at blueshieldca.com. Once registered as a member, you will be able to manage your plan online, from changing your doctor to reviewing your plan s details and getting a temporary ID card. The site offers many features that allow you to easily: View your plan s benefits and coverage Change your Personal Physician Print a temporary member ID card Find doctors, hospitals, and other facilities in your area Check drug coverage Confirm coverage effective dates for you and your family members Member Services with questions regarding claims, benefits, technical issues, etc. Shield keeps you connected blueshieldca.com/calpers By registering at blueshieldca.com, you ll automatically receive our updates, which will keep you current on your plan benefits and services. It s a great way to be reminded of the health and wellness programs that are available to you as a member all at no extra cost to you! Shield Concierge (800) We ve made your plan even easier to use with Shield Concierge, a personalized customer service experience. With just one call, you ll reach a team of experts, from nurses and pharmacists to billing and claims specialists all ready to support your various needs, such as: Answer questions about your plan, including copayments, coinsurance, and deductible amounts Locate the right provider, based on personal preferences and close to your home or work Find the answers to your claims questions Answer your drug-related questions, including prescription and over-thecounter drugs as well as herbal medications and vitamins Provide foreign language assistance, from simple questions to ordering member materials Assist with condition management programs that help members control chronic conditions, such as diabetes and high blood pressure Shield Concierge is available seven days a week, from 7 a.m. to 8 p.m. start here 3

6 benefit summary Access+ and NetValue HMO plan benefit summary Calendar-year deductible Member Family Physician services Preventive health exam Gynecological/well-woman exam Pregnancy and maternity care; prenatal/postnatal office visits Well-baby care Immunization/inoculation Allergy testing/treatment Office/home visits Teladoc video or phone consultation Urgent care Infertility testing and treatment Physician inpatient hospital visits Surgery/anesthesia Access+ Specialist 1 Self-referral to specialists Hospital services Inpatient Outpatient Ambulatory surgery centers Transgender surgical services Ambulance services Emergency care no copayment if hospitalized or kept for observation Diagnostic X-ray/lab Skilled nursing facility up to 100 days per calendar year Hospice Mental health/substance abuse Inpatient Outpatient None None $15/visit $15/call $15/visit 50% of allowable amount $30/visit * $50/visit $15/visit * This excludes endoscopy (including colonoscopy), spinal injection, and cataract surgery, which will incur a $250 copay unless performed at an ambulatory surgery center. This also excludes knee and hip surgery, which requires prior authorization and must be performed at a preferred knee- and hip-replacement center in order to be covered at 100%. 4

7 Prescriptions 2 Prescriptions for non-maintenance drugs and for the first three fills of maintenance drugs from a retail pharmacy (up to a 30-day supply) Prescriptions for maintenance drugs from a retail pharmacy after the first three fills (up to a 30-day supply) Prescriptions for maintenance drugs by mail order (up to a 90-day supply) Prescriptions for specialty drugs $30 Prescription drugs to treat sexual dysfunction Maximum annual out-of-pocket payments for $1,000 mail service prescription drugs 3 Vision care Eye refraction to determine need for corrective lenses (This service is limited to one visit per calendar year for members age 18 and older; no limit on number of visits for members under age 18.) Eyeglasses not covered, except for those that are necessary after cataract surgery Hearing-aid services Evaluation Hearing aid up to a maximum of $1,000 per member, every 36 months, for the hearing-aid instrument and ancillary equipment for both ears Durable medical equipment, including orthoses and prostheses Physical/occupational/speech therapy Inpatient visits at a hospital or skilled nursing facility Outpatient and home visits $5 generic drugs $20 formulary brand-name drugs $50 non-formulary brand-name drugs $10 generic drugs $40 formulary brand-name drugs $100 non-formulary brand-name drugs $10 generic drugs $40 formulary brand-name drugs $100 non-formulary brand-name drugs 50% of the cost of the drug 20% discount available 4 Charges in excess of $1,000 $15/visit Maximum calendar-year copayments Member $1,500 Family $3,000 This chart is a summary of the Access+ and NetValue HMO plan benefit coverage. It is not a contract. For complete details, please visit our website, blueshieldca.com/calpers, where you can find in-depth information about the plan, as well as download the Access+ or NetValue HMO EOC&D. Or you can contact Member Services at (800) if you prefer a paper copy. benefit summary 5

8 medical benefit highlights Network hospitals As a CalPERS member, you have a large network of hospitals available to you. To minimize your out-of-pocket costs, it is important to verify coverage when choosing a facility for non-emergency care. To identify a facility that is in your network, you can log in to blueshieldca.com/calpers and click on the Plans and benefits tab, or call Member Services at (800) Preferred centers for knee and hip replacement As part of our commitment to keeping health care affordable, we have introduced a special network benefit for knee- and hip-replacement surgery. 5 Access+ and NetValue HMO members will now receive care for most elective knee- and hip-replacement procedures at one of the Blue Distinction Centers hospitals in our network that are nationally recognized for excellence in care. Elective knee and hip procedures are 100% covered when scheduled at one of Blue Shield s preferred centers. To find the closest center to you, call Blue Shield s Member Services team at (800) Member Services will also be able to tell you which qualified surgeons are available at the facility of your choice and will send you a welcome kit. Please note: Facilities are subject to change. For the most current list of centers, call Member Services before scheduling your surgery. For the 2014 benefit year, the following Blue Distinction Centers will participate in the Blue Shield of California knee and hip preferred centers network: Alta Bates Sutter Arroyo Grande Community Community Medical Center, Fresno Doctors Medical Center, Modesto El Camino Hospital, Los Gatos El Camino Hospital, Mountain View Enloe Medical Center Feather River, Butte County Hoag Memorial Hospital Presbyterian Huntington Memorial Hospital John F. Kennedy Memorial John Muir Medical Center, Concord John Muir Medical Center, Walnut Creek Kaweah Delta Loma Linda University Lompoc Hospital Long Beach Memorial Medical Center Methodist Hospital of Sacramento Mills Peninsula Medical Center O Connor Hospital, San Jose Orange Coast Memorial Parkview Community Hospital Medical Center Pomona Valley Providence Holy Cross Medical Center Saddleback Memorial Santa Rosa Memorial Hospital, Santa Rosa Sharp Coronado Sharp Memorial St. Joseph Hospital, Eureka St. Joseph Hospital of Orange St. Jude Medical Center Summit Medical Center - Sutter Torrance Memorial Medical Center UC Davis Medical Center UCSF Medical Center ValleyCare Medical Center A travel benefit is also available for members who live more than 50 miles from a preferred center, providing a per diem amount for transportation, hotel accommodations, and other reasonable expenses for both the patient and a companion. For more details, please call Member Services at (800) , from 7 a.m. to 8 p.m., seven days a week. 6

9 Ambulatory surgery centers In a similar effort to reduce the cost of health care and to save CalPERS members money, Blue Shield has introduced a benefit to promote network ambulatory surgery centers (ASCs) as a cost-saving alternative to hospital outpatient facilities for certain procedures. Specifically, you can avoid the $250 hospital outpatient facility copayment when you use a network ASC for the services listed below: Upper gastrointestinal (GI) endoscopy Cataract surgery Lower gastrointestinal (GI) endoscopy/colonoscopy Spinal injection Ambulatory surgery centers are healthcare facilities where surgical procedures not requiring overnight hospital stays can be performed. ASCs focus solely on outpatient procedures, and can be a convenient, money-saving alternative to hospitals, with the same standards of care. However, not all procedures or patients are candidates for surgery at an ASC. You should talk to your doctor about the options that are best for your medical condition and specific health needs. For more information, call Member Services at (800) , from 7 a.m. to 8 p.m., seven days a week. Urgent care options When you are injured or not feeling well, but it s not an emergency, visiting a local urgent care center or calling Teladoc* are both great alternatives to the emergency room (ER). While the average wait time at a California ER is four hours and 34 minutes, your wait at an urgent care center is usually less than an hour. With Teladoc, the average time to speak with a doctor is 24 minutes. And, with lower copayments than ER visits, urgent care centers offer you quality care at a lower out-of-pocket cost for non-emergency conditions. If you are having a medical emergency, always call 911 or go to the nearest hospital emergency room. However, if you are not sure whether your condition needs to be seen in an emergency room versus an urgent care center, call your doctor s office for instructions. As a Blue Shield HMO member, you must always call your doctor s office before you seek care at an urgent care center, and follow the instructions they give you. Also, you need to receive care at an urgent care center that is affiliated with your doctor s medical group or IPA in order for your Blue Shield HMO plan to cover the services you receive. Urgent care centers routinely treat many conditions, including the following: Cough, sore throat, Eye irritation, swelling, or pain respiratory infections Muscle strains Earaches Rashes, minor cuts, scrapes, wounds Back pain, body aches Nausea, vomiting, diarrhea Burning with urination Animal bites Colds, sinus infections, allergies Migraines To find the urgent care centers nearest you, visit blueshieldca.com/urgent or call Member Services at (800) , from 7 a.m. to 8 p.m., seven days a week. * For a full description of Teladoc, see page Emergency Department Pulse Report from American College of Emergency Physicians and Press Ganey. medical benefit highlights 7

10 pharmacy benefits In addition to offering a large pharmacy network that includes chains such as Walgreens, CVS, and Rite Aid, we feature a convenient mail service pharmacy. Filling your prescription at a local pharmacy You can locate a network pharmacy by calling Member Services at (800) or by visiting the Plans and benefits section of our website at blueshieldca.com/ calpers and clicking on the Pharmacy Benefits tab. Prescription copays for non-maintenance drugs, and for the first three fills of maintenance drugs (up to a 30-day supply) Prescription copays for maintenance drugs after the first three months (up to a 30-day supply) $5 generic drugs $10 generic drugs $20 formulary brand-name drugs $40 formulary brand-name drugs $50 non-formulary brand-name drugs $100 non-formulary brand-name drugs Filling your prescription through the mail service pharmacy Blue Shield provides access to pharmacy mail service through Prim , which offers you the convenience of receiving up to a 90-day supply of covered maintenance drugs* delivered to your home or office, with no charge for shipping. 6 Utilizing the mail service pharmacy also offers you savings, as you will pay only one-third of the retail pharmacy copayment for the same amount of covered maintenance drugs. For example: For a $10 copayment, you can purchase up to a 30-day supply of generic drugs at your retail pharmacy or up to a 90-day supply of generic drugs from Prim . Prescription copays for maintenance drugs at Prim (up to a 90-day supply) $10 generic drugs $40 formulary brand-name drugs $100 non-formulary brand-name drugs Note: If a brand-name drug is chosen when there are FDA-approved generic equivalents available, the cost difference between the brand-name drug and the generic equivalent drug, plus a generic copay, will apply. Prescription drugs to treat sexual dysfunction are 50% of the cost of the drug. Copayments for non-formulary brand-name drugs and drugs to treat sexual dysfunction do not accumulate toward the annual $1,000 mail service out-of-pocket maximum. * Maintenance drugs are those prescribed to treat chronic health conditions such as asthma, diabetes, high blood pressure, or high cholesterol, and are taken on an ongoing, regular basis to maintain health. For a list of covered maintenance medications, please visit the Plans and benefits section of our website at blueshieldca.com/calpers and clicking on the Pharmacy Benefits tab. 8

11 Getting started with Prim To receive covered medications from Prim , you must register and provide basic information, such as your name, shipping address, payment method, and drug allergies. You can register online, by phone, or by mail: 1. Online Register online by logging in to blueshieldca.com as a member, selecting Pharmacy, and clicking on the MyPrim .com link under the Mail Service Prescriptions section. If you are a first-time user, you will be brought to the My Account page, where you will be prompted to fill in your information, including your address, allergies, and payment options. If you logged in but did not complete your registration the first time, or if you need to make any changes to your profile, log in to blueshieldca.com as a member, select Pharmacy, and click on the MyPrim .com link under the Mail Service Prescriptions section. Then select My Account in the upper right corner of the page, and update your registration. 2. By phone Call Prim at (866) or TTY (866) A Prim representative can either mail the Prescription Order Form to you or complete it for you over the phone. 3. By mail Complete the Prim Prescription Order Form enclosed or print and complete the form by logging in to blueshieldca.com, selecting Pharmacy, and then clicking on the MyPrim .com link under the Mail Service Prescriptions section. Once you are logged in to MyPrim .com, select Order New. You can choose to complete the form online and then print it, or print out a blank form and complete it by hand. Once you complete the form, simply mail it to: Prim Pharmacy P.O. Box Albuquerque, NM Once you are registered, Prim will need your prescription, which can be sent electronically, or by phone, fax, or mail: 1. Electronically Ask your doctor to send an electronic prescription for a 90- day supply to Prim . This is called e-prescribing and is the simplest way to send a prescription. 2. By phone or fax Ask your doctor to submit your prescription for a 90-day supply by phone or fax to Prim . Prim MD phone line: (888) Prim MD fax line: (888) pharmacy benefits 9

12 pharmacy benefits continued Alternatively, you can ask Prim to contact your doctor directly to obtain a prescription order or to transition an existing prescription from your current retail pharmacy by either: Calling Prim at (866) , or Logging in to your account at blueshieldca.com, selecting Pharmacy, and then clicking on the MyPrim .com link under the Mail Service Prescriptions section. Once you are logged in to MyPrim .com, select Transition Prescriptions from Retail to Prim . After selecting your name from the patient name field, you will see a Search screen where you can type in the name of the prescription drug that you want transitioned to Prim , along with the dosage form and strength. Prim will contact your doctor to transition your prescription and obtain approval for a 90-day supply. 3. By mail If you already have a written prescription from your doctor for a 90-day supply, you can mail it with your applicable mail service copayment and a copy of your Blue Shield member ID card to the address below. If you plan to mail your registration form, you can simply include your written prescription and copayment with the form. Prim Pharmacy P.O. Box Albuquerque, NM For new prescriptions, please allow 10 to 14 days to receive your covered maintenance medications through Prim . Once your prescription is on file at Prim , please allow five to eight days to receive refills of your covered medications. You can check the status of your order and also order prescription refills by logging in to your account at blueshieldca.com, selecting Pharmacy, and then clicking on MyPrim .com under the Mail Service Prescriptions section, or by calling Prim directly at (866) or TTY (866) To find out more about your pharmacy copayments and benefits: Check your Evidence of Coverage and Disclosure Form. Call Member Services at (800) Log in to blueshieldca.com and select the My Health Plan section to view your plan summary, benefits, and more. 10

13 About our drug formulary The Blue Shield Drug Formulary Plus is a list of preferred generic and brand-name drugs. Drugs in the formulary have been evaluated by Blue Shield s pharmacy and therapeutics (P&T) committee to ensure they are safe and effective. P&T committee members are physicians and pharmacists in community practice, not employees of Blue Shield. The committee bases its decisions on the medical evidence for a drug s safety and efficacy, and for how it compares with other drugs covered in our drug formulary. You can help lower your out-of-pocket prescription drug costs by requesting formulary drugs and generic medications when you see your doctor. Drugs listed on the formulary are usually covered at a lower copayment than non-formulary drugs. To see our drug formulary, visit blueshieldca.com and click on the Pharmacy tab. Save with generic drugs Using generic drugs instead of brand-name drugs is one of the easiest ways you can reduce your out-of-pocket prescription drug costs. All generic drugs are approved to be safe and effective by the U.S. Food and Drug Administration (FDA). Generics contain the same active ingredients as their brand-name counterparts. The FDA requires generic drugs to be the same in dosage, performance, safety, strength, quality, and usage as the brand-name drug. Ask your doctor if a generic drug is right for you. Specialty drugs Specialty drugs are injectable or oral medications that are prescribed to treat complex health conditions such as cystic fibrosis, multiple sclerosis, psoriasis, or cancer. Specialty drugs can be filled through our two contracted Network Specialty Pharmacies, Caremark and Walgreens. Caremark Walgreens (800) (phone) (866) (phone) (800) (fax) (866) (fax) Prescriptions for specialty drugs are available for up to a 30-day supply from a Blue Shield of California Network Specialty Pharmacy, with a copayment of $30. A complete list of specialty drugs is available at blueshieldca.com. Click on the Pharmacy tab and then select More under Plus Drug Formulary. pharmacy benefits 11

14 plus lots more Additional care options Self-refer to a specialist blueshieldca.com/calpers As an Access+ or NetValue HMO member, you can use Access+ Specialist SM to refer yourself to a participating specialist in the same medical group for a fixed office copayment of $30 per visit. 1 Call your Personal Physician s office and ask if your doctor belongs to an IPA/medical group that offers the Access+ Specialist option. For more information, please consult your Evidence of Coverage and Disclosure Form online at blueshieldca.com/calpers or call Member Services at (800) Teladoc (800) Teladoc or As a Blue Shield CalPERS member, you have 24/7/365 care available to you when your physician is not available. Teladoc s network of Board-certified California physicians and pediatricians can treat non-emergency medical issues, and when medically appropriate, may also write short-term prescriptions. There is a $15 copay for a Teladoc phone or video consultation, which can be paid with a debit or credit card. To use the service, simply complete a medical history data form just like you would when visiting a physician for the first time. You can set up your account and complete your medical history form by going to or calling (800) TELADOC or (800) NurseHelp 24/7 (877) or blueshieldca.com We have nurses available around the clock. You can talk to a registered nurse anytime and receive reliable information about minor illnesses and injuries, chronic conditions, medical tests, medications, and preventive care. Nursehelp 24/7 SM services are confidential and available through our toll-free phone number or online chat. Visit blueshieldca.com and click on NurseHelp 24/7 on the left-hand side of the page. 12

15 LifeReferrals 24/7 (800) With our LifeReferrals 24/7 SM service, you have access to support and advice from experienced professionals in all areas of life, including child and elder care, relationships, support for chronic conditions, and financial and legal issues. Face-to-face personal counseling sessions are also available. Covered when you travel (800) You can receive emergency and urgent care from doctors and hospitals while on vacation or traveling for business anywhere in the world. And, if you use the BlueCard Program, you will pay only your regular copay at the time of service and will not have any claim forms to fill out when you return. Providers in more than 200 countries belong to the BlueCard Worldwide Network, and over 90% of providers in the United States belong to BlueCard s national network. Wherever you are, if you need to see a doctor, simply call Blue Shield s Member Services number collect and you will be referred to the nearest urgent care facility. Of course, you should always call 911 or seek care at the nearest medical facility if you reasonably believe you have a medical condition that requires an emergency response. Away From Home Care (800) You and your family can stay covered with HMO benefits for extended periods with the Away From Home Care program. 7 Students, long-term travelers, and families living apart can rely on access to health care across the country. Away From Home Care is available in most states, and benefits vary by state. For more information about coverage, call (800) plus lots more 13

16 plus lots more continued Health and wellness programs Daily Challenge blueshieldca.com/wellvolution You can take a small step each day on the path to better health with this engaging, interactive program. Daily Challenge encourages you every day with an to perform one simple wellness-related task. 8 Earn points, connect with others, and build a support network as you take daily steps towards a healthier you. You can also take a Well-Being Assessment to learn how well you are doing in all areas of your life and where some small steps can lead to big improvements. Plus, CalPERS members 18 years and older who participate in Daily Challenge will have multiple chances to win cash drawings. To learn more or to enroll, visit blueshieldca.com/wellvolution and click on Daily Challenge. Condition management programs blueshieldca.com/hw Our condition management programs offer you support by showing you how to take an active role in managing your condition. You can receive educational materials and will have access to a nurse anytime you have questions. These programs provide support for members with: Asthma Heart failure Diabetes Chronic obstructive pulmonary Coronary artery disease (CAD) disease (COPD) To apply for the condition management programs, call (866) You can also visit blueshieldca.com/hw, select Condition Management, and submit an application online. 14

17 Transitions of Care Program blueshieldca.com/hw This outreach program is designed to provide guidance on the transition to and from the hospital and home. A registered nurse will contact you to discuss your surgery or acute condition, what to expect, what to ask your physician, and how to prepare for the return home. The nurse will follow up with a call to you after discharge to assess any unmet recovery needs and provide information regarding a safe recovery. For more information, visit blueshieldca.com/hw, select Condition Management, and then Transitions of Care Program. Prenatal Program (888) or blueshieldca.com/prenatal We want you and your baby to be healthy. With our Prenatal Program, you ll receive 24/7 maternity nurse support as well as learn what to expect while you re pregnant, ways to be healthier after the baby is born, and more. You ll receive an educational packet that includes your choice of one of the bestselling pregnancy and parenting books, a prenatal planner, and access to free text-messaging reminders, as well as other materials that offer practical advice and helpful tips. A nurse will call you to provide ongoing pregnancy assessments and support, and those needing extra support will get personalized, ongoing coaching. As a Blue Shield member, you can join by logging in to blueshieldca.com/prenatal or calling us at (888) plus lots more 15

18 plus lots more continued Other services and resources A site dedicated to CalPERS blueshieldca.com/calpers At our dedicated site for CalPERS members, you can find information and tools that can answer your questions and help you get the most from your benefits. We also provide you with hundreds of useful tips, such as: Finding the right provider Preventing illness with screenings Learning which types of health care work best Improving your odds for a healthy back Keeping your heart healthy Knowing what to ask the doctor at your kids next checkup Understanding what to do before, during, and after an appointment Protecting your skin from the sun Blue Shield Mobile As a member, you can access key health plan and healthcare services information while on the go by using the mobile website at blueshieldca.com or by downloading the Blue Shield of California Mobile app from itunes or Google Play. Our mobile features allow convenient access to important plan and benefits information such as copays, your member ID card, or turn-by-turn directions from your current location to the closest emergency room or urgent care center. No matter how you choose to access Blue Shield on your computer, your tablet or your smart phone you can use the same user name and password. Social Media Support Whether accessing Blue Shield through Twitter (@BlueShieldCA) or from our Facebook page at Blue Shield of California, members can get answers to their questions with Team Shield. Team Shield is a team of experts dedicated to helping members get the right answers, right away. From Facebook, members can choose to Get Answers or from Twitter, can simply go Ask the Pharmacist blueshieldca.com Ask questions about your medications and get confidential answers from a University of California, San Francisco, pharmacist within two business days. Visit blueshieldca.com, select Pharmacy, and then choose Ask the Pharmacist. Reach your doctor online blueshieldca.com/hw Communicate with your doctor through Patient Ally, an easy-to-use, secure Web-based tool. Call your Personal Physician s office and ask if your doctor participates before using the service. To learn more, visit blueshieldca.com/hw, select Professional Help and then Reach Your Doctor Online. 16

19 Health library blueshieldca.com/hw We ve compiled a comprehensive resource with thousands of topics and interactive tools to help you take a more active role in your health. You can research a variety of health topics, including: Fitness and exercise Complementary and Healthy weight alternative health Common health conditions Workplace health Healthy eating Disease and injury prevention To access this wealth of information, visit blueshieldca.com/hw and select Health Library. Preventive checklists blueshieldca.com/hw Our preventive health guidelines for men, women, children, and seniors give you health recommendations by age, including preventive health screenings, immunizations, and more. We put it all together in an easy-to-read and easy-to-print format. So all you have to do is point, click, and print. Visit blueshieldca.com/hw and select either Women s health, Men s health, Children s health, or Seniors health. Drug Interaction Checker blueshieldca.com Check for interactions among your prescription drugs, over-the-counter medications, dietary supplements, and herbal products. Visit blueshieldca.com, select Pharmacy, and then choose Drug Interactions. Symptom Checker blueshieldca.com/hw With this interactive tool, you will be guided through a series of questions and given a treatment recommendation based on the urgency of the symptom. Self-care information is included to help explain how to treat the condition at home when appropriate and to prevent a future occurrence. Information is also provided to help you prepare for appointments with a health professional. Visit blueshieldca.com/hw, select Tools, and then Symptom Checker. Hearing and visual resources blueshieldca.com/hw You have access to resources and lists of groups that offer guides and assistance with hearing and visual impairments. Visit blueshieldca.com/hw, click on Professional Help, and then Hearing and Visual Resources. plus lots more 17

20 smart discounts Alternative Care Discount Program blueshieldca.com/hw or (888) Relax and save on alternative healthcare services from participating practitioners. To find a participating provider, visit blueshieldca.com/hw, select Professional Help and Wellness Discount Programs, and then click on the Alternative Care link or call (888) Acupuncture services Members receive 25% off the usual and customary fees for: Examinations Acupuncture or electro-acupuncture Adjunctive therapeutic procedures Chiropractic services Members receive 25% off the usual and customary fees for: Examinations Manipulative treatment Adjunctive therapeutic procedures Massage therapy Members receive 25% off the usual and customary fees for massage therapy visits. Techniques may include: Swedish massage Deep-muscle massage Deep-tissue massage Health and wellness products Receive online discounts off manufacturers suggested retail prices on a broad selection of quality health improvement products, with free shipping on most items. This includes: Vitamins Homeopathic remedies Yoga and fitness equipment Herbal supplements Diet and sports nutrition Personal body care Health and wellness books, audio, and DVD products 18

21 Weight Watchers blueshieldca.com/hw Save while you lose those extra pounds and keep them off, with these special offers: Online savings Special rates on three- and 12-month subscriptions Monthly Pass Special rates for unlimited local meetings each month, plus free etools To receive your discounts, go to blueshieldca.com/hw and select Professional Help, Wellness Discount Programs, and then View program details under Weight Watchers. 24 Hour Fitness blueshieldca.com/hw Now it is easier to get in shape and stay fit with discounted initiation fees and monthly dues as low as $24.00 a month. To receive your discounts, go to blueshieldca.com/hw, select Professional Help, Wellness Discount Programs, and then View program details under 24 Hour Fitness. ClubSport and Renaissance ClubSport blueshieldca.com/hw You have two options for saving on membership dues and fees when selecting ClubSport or Renaissance ClubSport for gym memberships: 60% discount on enrollments when joining with a month-to-month agreement $0 enrollment fee when joining with a 12-month agreement a one-time $25 processing fee applies at the time of enrollment ClubSport or Renaissance ClubSport membership includes: Two complimentary personal training sessions for each new member (a $150 value) MicroFit testing and goal setting Nutritional support online Free wellness seminars Hundreds of free in-club programs included in monthly dues Three hours of complimentary child care with a family membership To receive your discounts, go to blueshieldca.com/hw, select Professional Help, Wellness Discount Programs, and then Get fit with ClubSport or Get fit with Renaissance ClubSport under ClubSport and Renaissance ClubSport. smart discounts 19

22 smart discounts continued Discount Vision Program blueshieldca.com/hw As part of our wellness discount program, members have access to participating providers in the Discount Vision Program network 4 and can get a 20% discount off the following products and services: Routine eye examinations Extra pair of glasses Frames and lenses Photochromic lenses Tints and coatings Non-prescription sunglasses Contact lenses (except disposable extended wear or replacement) To find a participating discount provider: Visit Find a Provider at blueshieldca.com. Click on Select a plan. Choose Discount vision from the Vision care plan field and click Set plan. Select Vision care under Provider types. Enter your location information and click Find now. Save, download, , or print your search results. LASIK discount program Members can save an average of $1,200 per LASIK vision correction surgery through QualSight providers and receive a 15% discount from NVISION Laser Eye Centers. Discounted online eyewear My2020EyesDirect.com Members receive 20% discounts when shopping online for prescription eyeglasses, sunglasses, and readers. 9 MESVisionOptics.com Members receive competitive prices on many contact lens brands as well as a selection of sunglasses, reading glasses, and eye care accessories. 9 Free shipping is available for all orders over $

23 Endnotes 1 The Access+ Specialist option allows HMO members direct access to participating specialists in the same medical group or IPA as their Personal Physician. Not all medical groups or IPAs participate in this program. 2 If a brand-name drug is chosen when there are FDA-approved generic equivalents available, then the cost difference between the brand-name drug and the generic equivalent drug, plus a generic copay, will apply. Exceptions for medical necessity are available via prior authorization; if approved, the applicable brand copay applies. 3 Non-formulary brand-name drugs and drugs to treat sexual dysfunction do not accumulate toward the annual $1,000 mail service out-of-pocket maximum. 4 These discount program services are not a covered benefit of Blue Shield health plans and none of the terms or conditions of Blue Shield health plans apply. Discount program services are available to all members with a Blue Shield medical, dental, vision, or life insurance plan. The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy. Nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members should access those covered services prior to using the discount program. Members who are not satisfied with products or services received from the discount program may use Blue Shield s grievance process described in the Grievance Process section of the Evidence of Coverage or Certificate of Insurance/Policy. Blue Shield reserves the right to terminate this program at any time without notice. Discount programs are administered by or arranged through the following independent companies: Alternative Care Discount Program American Specialty Health Systems, Inc. and American Specialty Health Networks, Inc. Discount Vision Program and MESVisionOptics.com MESVision Weight control Weight Watchers North America Fitness facilities 24 Hour Fitness, ClubSport, and Renaissance ClubSport LASIK QualSight, Inc. and NVISION Laser Eye Centers My2020EyesDirect.com Advanced Digital Eyewear, Inc. The Discount Vision Program network is currently available in Arizona, California, Colorado, Idaho, Nevada, Oregon, Texas, Utah, and Washington. Note: No genetic information, including family medical history, is gathered, shared, or used from these programs. 5 The knee- and hip-replacement benefit does not apply to members of the Access+ or NetValue HMO Supplement to Original Medicare Plans. 6 Your mail service benefit does not provide coverage for prescriptions used to treat short-term conditions, such as antibiotics or drugs used on an as-needed basis, including drugs for pain. In addition, home self-injectable drugs are not covered under the mail service benefit. This program applies to outpatient prescription drug benefits available through plans underwritten by Blue Shield of California and Blue Shield of California Life & Health Insurance Company (individually and/or collectively referred to as Blue Shield). 7 Availability varies from area to area. The coverage through the Away From Home Care program is that of the host plan, not the coverage offered by Blue Shield of California. For more information, please call (800) MeYou Health, LLC. All rights reserved. MeYou Health, LLC is a Healthways, Inc. company. 9 Requires a prescription from your doctor or licensed optical professional Weight Watchers International, Inc WeightWatchers.com, Inc. All rights reserved. WEIGHT WATCHERS and PointsPlus TM are the registered trademarks of Weight Watchers International, Inc. and are used under license by WeightWatchers.com, Inc. Blue Shield and the Shield symbol are registered marks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans. endnotes 21

24 Access+ HMO service area The Access+ HMO plan is offered in 35 counties and includes about 300 medical groups. Del Norte Siskiyou Modoc Humboldt Trinity Shasta Lassen Tehama Mendocino Glenn Colusa Lake Sutter Butte Yuba Plumas Sierra Nevada Placer Full county coverage Partial county coverage* No coverage Sonoma San Francisco San Mateo Marin Santa Cruz Yolo Napa Santa Clara Sacramento Solano San Contra Joaquin Costa Alameda Stanislaus El Dorado Amador Calaveras Merced Alpine Tuolumne Mariposa Madera Mono San Benito Fresno Inyo Monterey Kings Tulare San Luis Obispo Kern San Bernadino Santa Barbara Ventura Los Angeles Orange Riverside San Diego Imperial * The Access+ HMO plan is available only in portions of these counties. To find out if the Access+ service area includes the ZIP code where you reside or work, please contact Member Services at (800) You may also use CalPERS online service, the Health Plan Search by ZIP Code, available at and on my CalPERS at 22

25 NetValue HMO service area The NetValue HMO plan is offered in 27 counties and includes about 190 medical groups. Del Norte Siskiyou Modoc Humboldt Trinity Shasta Lassen Tehama Mendocino Glenn Colusa Lake Sutter Butte Yuba Plumas Sierra Nevada Placer Full county coverage Partial county coverage* No coverage Sonoma San Francisco San Mateo Marin Santa Cruz Yolo Napa Santa Clara Sacramento Solano San Contra Joaquin Costa Alameda Stanislaus El Dorado Amador Calaveras Alpine Tuolumne Mariposa Merced Madera Mono San Benito Fresno Inyo Monterey Kings Tulare San Luis Obispo Kern San Bernadino Santa Barbara Ventura Los Angeles Orange Riverside San Diego Imperial * The NetValue HMO plan is available only in portions of these counties. To find out if the NetValue service area includes the ZIP code where you reside or work, please contact Member Services at (800) You may also use CalPERS online service, the Health Plan Search by ZIP Code, available at and on my CalPERS at service area maps 23

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28 still have questions? Call or visit us online. Go online: blueshieldca.com/calpers A custom Web portal for CalPERS members with full-time access to plan benefits, services, Find a Provider, and more. Call us: (800) From 7 a.m. to 8 p.m., seven days a week, our CalPERS-dedicated Member Services team is ready to help. Blue Shield of California, an Independent Member of the Blue Shield Association A46440-CALPERS (1/14)

29 Important HMO resources Phone numbers: Member Services... (800) NurseHelp 24/7... (877) LifeReferrals 24/7... (800) Teladoc (24/7 physician services)... (800) Prim (mail-service pharmacy)...(866) Coverage when you travel... (800) Away From Home Care...(800) Condition management programs...(866) Alternative Care Discount Programs...(888) Mental Health Services... (866) Websites: CalPERS member website...blueshieldca.com/calpers Find a Provider... blueshieldca.com/fap My Health Plan... register at blueshieldca.com Teladoc (24/7 physician services)... teladoc.com/bsc Urgent care center locator... blueshieldca.com/urgent Prim (mail-service pharmacy)...myprim .com Daily Challenge... blueshieldca.com/wellvolution Health & Wellness resources (including Discount Programs)...blueshieldca.com/hw Other useful phone numbers: My physician My specialist My dentist My pharmacy Urgent care center

30 Questions to ask your doctor Knowing more about your health status can help you reduce your risk of health problems and better manage any conditions you might have. Use this card to help you get the most out of visits with your doctor. 1. What are my numbers and what do they mean? 2. What should my targets be, and how do I improve my results? When should they be rechecked? 3. Given my family medical history, what health screenings are recommended? 4. What do my symptoms mean? 5. Are there any tests that I need? 6. Can I make any lifestyle changes that might help my condition? 7. Are there treatments that you would recommend? 8. Is there a generic version available for any medications I need to take? 9. How will these medications interact with other medicines and supplements I am taking, and are there possible side effects? 10. When should I come back for my next checkup? Notes for your doctor Use this space to write down any other questions specific to your health that you may have for your doctor, so they are handy for your next appointment.