Blue Shield Plans - Tips and Tricks

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1 3.77 FLAP TO BE GLUED FOLD 6 FOLD 6 PERF/FOLD 3.5 SCORE/ PERF Important HMO resources 2 SCORE 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 (10/15) Access+ HMO NetValue HMO 2016 welcome brochure How to make the most of your benefits Phone numbers: Shield Concierge... (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 Program... (888) Mental health services... (866) Websites: CalPERS member website...blueshieldca.com/calpers Find a Provider...blueshieldca.com/fap Member Overview... 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 SCORE SCORE FLAP TO BE GLUED FOLD FOLD PERF/FOLD

2 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 on the following pages: Convenient reference card... Inside front cover Start here Benefit summary Medical benefit highlights Pharmacy benefits Plus lots more Smart discounts Endnotes Access+ HMO service area...22 NetValue HMO service area...23

3 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 day 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. On the Member Overview page, choose Change Personal Physician or Medical Group. Subscribers with family can request access to their family members plan and update their Personal Physicians as well. You can also change your Personal Physician by calling Shield Concierge, our dedicated customer service team for CalPERS members, 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 Find a Provider at the top of the page. Select Doctors, and then 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 would like personal assistance, contact Shield Concierge at (800) 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

4 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 or claims history Change your Personal Physician or find a new provider 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 Shield Concierge 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, close to your home or work Find the answers to your claims questions Answer your drug-related questions, including prescription and over-the-counter drugs as well as herbal medications and vitamins Help you transfer your medical records or prescriptions from your previous provider 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

5 benefit summary Access+ HMO 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 Chiropractic and acupuncture services (Combined maximum of 20 visits per year) 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 $15/visit $30/visit $50/visit $15/visit This chart is a summary of the Access+ HMO 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+ HMO or NetValue HMO EOC&D. Or you can contact Shield Concierge at (800) if you prefer a paper copy. 4

6 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 after the first three fills from a retail pharmacy (up to a 30-day supply) 3 Prescriptions for maintenance drugs from a select* retail pharmacy (up to a 90-day supply) Prescriptions for maintenance drugs by mail order (up to a 90-day supply) Prescriptions for specialty drugs (up to a 30-day supply) $30 Prescription drugs to treat sexual dysfunction Maximum annual out-of-pocket payments for $1,000 mail-service prescription drugs 4 Flu vaccine from network retail pharmacies 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 Calendar-year out-of-pocket maximums Member: $6,850 Medical: $1,500 maximum Pharmacy: $5,350 maximum $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 $10 generic drugs $40 formulary brand-name drugs $100 non-formulary brand-name drugs 50% of the cost of the drug 20% discount available 5 Charges in excess of $1,000 $15/visit Family: $13,700 Medical: $3,000 maximum Pharmacy: $10,700 pharmacy maximum * Prescriptions for maintenance drugs (up to a 90-day supply) can be obtained at Costco, CVS, and Safeway/Vons retail pharmacies. Includes the $1,000 maximum annual out-of-pocket payments for mail-service formulary prescription drugs per member. benefit summary 5

7 medical benefit highlights Acupuncture and chiropractic benefit You are covered for the following acupuncture and chiropractic services: Acupuncture evaluation and treatment by a licensed acupuncturist. Chiropractic exam and treatment from a Doctor of Chiropractic. Copayment: $15 per visit. Covered up to a combined maximum of 20 visits per calendar year. These benefits are offered through an arrangement with American Specialty Health Plans of California, Inc. (ASH). To find a network provider, visit blueshieldca.com/ash and choose from the drop-down menu, or call ASH at (800) Away From Home Care program You and your family can stay covered with HMO benefits for extended periods with the Away From Home Care program. 6 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 the following 31 states plus the District of Columbia. HMO benefits vary by state. Call (800) for more information about coverage. Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Illinois Indiana Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Pennsylvania Texas Virginia Wisconsin Flu vaccine You may receive your flu vaccine at a participating retail pharmacy at no charge. You also have the option to continue receiving the flu vaccine at your doctor s office. You can find a pharmacy by visiting the Plans and Benefits section of our website at blueshieldca.com/calpers and clicking on Pharmacy Benefits, then Pharmacy Resources. No prescription is required. Simply show your Blue Shield ID card at the pharmacy. To learn more about this benefit, please call Shield Concierge at (800)

8 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 Shield Concierge at (800) 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, both Teladoc and urgent care centers offer you quality care at a lower outof-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 Shield Concierge at (800) , from 7 a.m. to 8 p.m., seven days a week. For more information about Teladoc, please see page 12 of this brochure or visit blueshieldca.com/calpers and select Plans and Benefits, Programs and Services, and then Teladoc. * 2010 Emergency Department Pulse Report from American College of Emergency Physicians and Press Ganey. medical benefit highlights 7

9 pharmacy benefits In addition to offering a large pharmacy network that includes all national chains, we feature a convenient mail-service pharmacy. Filling your prescription at a local pharmacy You can locate a network pharmacy by calling Shield Concierge at (800) or by visiting the Plans and Benefits section of our website at blueshieldca.com/ calpers and clicking on the Pharmacy Benefits tab, then Pharmacy Resources. Retail prescription drugs Up to a 30-day supply of nonmaintenance drugs and the first three fills of maintenance drugs* Generic Formulary brand-name Non-formulary brand-name $5 $20 $50 Up to a 30-day supply of maintenance drugs after the first three fills 3 $10 $40 $100 Up to a 90-day supply of maintenance drugs from a select retail pharmacy $10 $40 $100 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. 7 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. 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 click on the Pharmacy Benefits tab. Prescriptions for maintenance drugs (up to a 90-day supply) can be obtained at Costco, CVS, and Safeway/Vons retail pharmacies. 8

10 Getting started with Prim To receive your medications from Prim , you must first register to provide the basic information required to fill your prescription. This information includes, but is not limited to, your name, member identification number, shipping address, payment method, and drug allergies. 1. Online Register online by going to blueshieldca.com, selecting Pharmacy (under the Members tab), and clicking on the MyPrim .com link under the Mail Service Prescriptions section. You will be prompted to log in. 2. By phone Call Prim at (866) or TTY: 711. A Prim representative can either mail an order form to you or register you over the phone. 3. By mail Complete the Prim Prescription Order Form enclosed or print and complete the form by going to blueshieldca.com, selecting Pharmacy (under the Members tab), and then clicking on the MyPrim .com link under the Mail Service Prescriptions section. You will be prompted to log in. Once you are logged in, 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 How do I order a new prescription? Once you are registered, you can obtain your covered maintenance medications through the following methods: 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

11 pharmacy benefits continued Alternatively, you can ask Prim to contact your doctor directly to obtain a prescription order or to transfer an existing prescription from your current pharmacy by either: Calling Prim at (866) , TTY 711, or Going to blueshieldca.com, selecting Pharmacy (under the Members tab), and then clicking on the MyPrim .com link under the Mail Service Prescriptions section. Once you are logged in, 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. Prim Pharmacy P.O. Box Albuquerque, NM For new prescriptions, please allow 10 to 14 business days to receive your covered maintenance medications through Prim . Once your prescription is on file at Prim , please allow five to eight business 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 (under the Members tab), and then clicking on MyPrim .com under the Mail Service Prescriptions section, or by calling Prim directly at (866) or TTY: 711. To find out more about your pharmacy copayments and benefits: Check your Evidence of Coverage and Disclosure Form. Call Shield Concierge at (800) Log in to blueshieldca.com and select the Member overview section to view your plan summary, benefits, and more. 10

12 About our drug formulary The Blue Shield Plus Drug Formulary is a list of preferred generic and brand-name drugs that are eligible for coverage under the outpatient prescription drug benefit. You can help lower your out-of-pocket prescription drug costs by requesting generic and formulary brand-name medications when you see your doctor since these medications are usually covered at a lower copayment than non-formulary drugs. To see our drug formulary, visit blueshieldca.com/calpers. Click on the Plans and Benefits tab, select Pharmacy Benefits, then Pharmacy Resources, and select the Plus Drug Formulary link. 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, as generic drugs typically cost less than brand-name drugs. Ask your doctor to prescribe generic medication when it s right for you, or ask your pharmacist to fill your prescription with a generic version whenever possible. Specialty drugs Specialty drugs are covered on the specialty tier (tier 4) in Blue Shield s Plus Drug Formulary, and can be filled through our two contracted network specialty pharmacies, CVS/Caremark and Walgreens Specialty. CVS/Caremark Walgreens Specialty (800) (phone) (866) (phone) (800) (fax) (866) (fax) Prescriptions for specialty drugs are available for up to a 30-day supply from either of these two network speciality pharmacies, with a copayment of $30. A complete list of specialty drugs is available at blueshieldca.com/calpers. Click on the Plans and Benefits tab, select Pharmacy Benefits, then Pharmacy Resources, and select the Plus Drug Formulary link. Out-of-pocket expenses Your maximum annual out-of-pocket payments for pharmacy expenses is $5,350 for an individual and $10,700 for a family. Additionally, once you have paid $1,000 for formulary mail-service prescriptions, you will pay $0 for formulary prescriptions filled at Prim for the remainder of the year. (Non-formulary brand-name drugs, and drugs to treat sexual dysfunction, do not accumulate toward this mail-service out-of-pocket maximum.) pharmacy benefits 11

13 plus lots more Additional care options Chiropractic and acupuncture services (800) You can visit any participating chiropractor or acupuncturist in the American Specialty Health Network (ASH) without a referral from your Personal Physician. There is a $15 copay per visit and a combined maximum of 20 visits per year. To find a network provider, go to blueshieldca.com/ash. Self-refer to a specialist blueshieldca.com/calpers As an Access+ HMO or NetValue HMO member, you can use Access+ Specialist SM to refer yourself to a participating specialist in the same medical group as your Personal Physician 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. Or you can check the inside of your ID card to see if there is an A+ next to the name of your medical group. For more information, please consult your Evidence of Coverage and Disclosure Form online at blueshieldca.com/calpers or call Shield Concierge at (800) Second opinion (800) If you have any questions about your diagnosis, plan of care, or recommended treatment, you can request a second opinion from any contracted Blue Shield of California physician in the state. Teladoc (800) TELADOC or As a CalPERS Blue Shield 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 by calling (800) TELADOC or (800)

14 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. Log in to blueshieldca.com and click on NurseHelp 24/7 from the Help & Support menu or through our mobile app. 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, while 92% of physicians and 96% of hospitals 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 Shield Concierge 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. 6 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 31 states, plus the District of Columbia, and benefits vary by state. For more information about coverage, call (800) plus lots more 13

15 plus lots more continued Health and wellness programs blueshieldca.com/calpers Wellvolution Making the time to take care of yourself can be difficult. Wellvolution makes it easier. Based on the latest research and best practices, these programs offer healthy encouragement, realistic goals, and enjoyable social connections. NEW NEW Walkadoo Walkadoo TM is a fun, easy-to-use walking program. Each morning, you receive a daily step goal via or SMS that is based on your activity level. Wear your wireless pedometer, track your steps, and earn points to be eligible for weekly cash drawings in 2016! QuitNet Based on the latest science and best practices, QuitNet integrates many intervention modalities. Participants in this smoking cessation program can choose from methods including online and mobile support from experts and peers, personalized , and SMS text support. Daily Challenge With Daily Challenge, small actions add up to big changes over time, especially when you do them with friends. Each day you receive a message with one simple activity to complete and a reason why it will help to improve your well-being. Complete the challenge, share how you did it, and improve your health one day at a time. Well-Being Assessment Measures your productivity, overall outlook, emotional and physical health, healthy behaviors, work environment, and access to health/life resources so you know what areas need attention. To register for any of the Wellvolution programs, visit To find out more about the programs before registering, visit blueshieldca.com/calpers and click on the Plans and Benefits tab, followed by Programs and Services, and then Wellvolution. Shield Support blueshieldca.com/hw Our comprehensive, integrated care management program includes an experienced care team of registered nurses, clinical social workers, dietitians, physicians, and pharmacists to help you navigate the healthcare system and provide support to manage your chronic health conditions or recovery from illness in the way that works best for you. 14

16 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. 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

17 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 Knowing what to ask the doctor at your kids next checkup Understanding what to do before, during, and after an appointment Pharmacy tools In the Pharmacy benefits and claims sections of blueshieldca.com, you can view and access the following information: Claim History, which displays up to 24 months of claim history information Drug Pricing, which lets you compare drug prices Coverage Limits and Payment Details, which tracks each pharmacy claim Drug Information, which covers conditions, drug side effects, and drug interactions Pharmacy Locator, which allows you to search for pharmacies within your network 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 Follow us on Facebook at Blue Shield of California, Twitter (@BlueShieldCA), and Instagram (@BlueShieldofCA) for healthy motivation, wellness tips, and support. It s an easy and social way to stay connected and discover fresh recipes, words of inspiration, healthy happenings throughout California, and more. And if you have questions about your Blue Shield plan, programs, or services, our Social Customer Service team is available to help on Facebook or via Twitter 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. 16

18 NEW Welvie Surgery Decision Support Program This new online program helps you work with your doctor(s) to decide on, prepare for, and recover from surgery. Welvie guides you through the entire surgery decision process, including understanding your treatment options both surgical and nonsurgical. If you decide to have surgery, the program shows you how to prepare ahead of time to avoid complications and helps you have better results. The program is available to all plan members at no additional cost. Additionally, plan members earn a $25 gift card for completing the program. 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. 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 Healthy eating Healthy weight Alternative health Common health conditions Disease and injury prevention To access this wealth of information, visit blueshieldca.com/hw and select Health Library. Preventive Health Guidelines 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/calpers. Click on the Plans and Benefits tab, select Pharmacy Benefits, then Pharmacy Resources, and then select the link 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. 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 for people with hearing and visual impairments. Visit blueshieldca.com/hw, click on Professional Help, and then Hearing and Visual Resources. plus lots more 17

19 smart discounts Alternative Care Discount Program blueshieldca.com/hw or (888) Relax and save on alternative healthcare services from participating practitioners. 5 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. These includes: Vitamins and supplements Natural products Herbal products Personal body care 18

20 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. 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

21 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 5 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/fap. Click on Select a Plan. Choose Discount Vision Providers (no plan needed) from the Vision care plan field and click Set plan. Select Vision care under Provider types. Enter your location information under located near and click Find now. Save, download, , or print your search results. LASIK discount program LASIK and PRK correction surgery, an alternative to contacts or glasses, is one of the fastest-growing vision treatments. The discount program gives covered members access to: A 15% discount through the NVISION, Inc. provider network in California, or A 20% discount through the QualSight provider network in California and nationwide Discounted online eyewear MESVisionOptics.com Members receive competitive prices on many contact lens brands as well as a selection of sunglasses, readers, and eyecare accessories. 8 Free shipping is available for all orders over $

22 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 Does not apply if filled at a select retail pharmacy (Costco, CVS, and Safeway/Vons). 4 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. 5 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. 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 The Discount Vision Program network is currently available in Arizona, California, Colorado, Idaho, Nevada, Oregon, Texas, Utah, and Washington. 6 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) 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. 8 Requires a prescription from your doctor or licensed optical professional. Weight Watchers is a registered trademark of Weight Watchers International, Inc. and is used under license by WeightWatchers.com, Inc. Daily Challenge and QuitNet are registered trademarks and Walkadoo is a trademark of MeYou Health LLC. MeYou Health is a Healthways, Inc. company. Wellvolution is a registered mark of Blue Shield of California. 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

23 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 Bernardino 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+ HMO service area includes the ZIP code where you reside or work, please contact Shield Concierge at (800) You may also use CalPERS online service, the Health Plan Search by ZIP Code, available at and on my CalPERS at 22

24 NetValue HMO service area The NetValue HMO plan is offered in 26 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 Bernardino 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 Shield Concierge 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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26 PERF/FOLD FOLD FOLD FLAP TO BE GLUED SCORE/ PERF SCORE SCORE 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. SCORE PERF/FOLD FOLD FOLD FLAP TO BE GLUED