Access+ HMO Plan Overview Access+ HMO
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Access+ HMO plan Overview Access+ HMO Now with lower rates! life is limitless. never stop. blueshieldca.com/calpers 1 You don’t have to sacrifice choice for lower costs Nothing matters more than your health. Except protecting it. Get access to one of the largest networks of doctors, specialists and hospitals in California with Access+ HMO®. It offers you many care options, so you can choose what’s right for you and your family. For 2018, we've worked to lower our rates for Access+ HMO to offer you a plan that delivers choice and affordability. Here are some of the valuable Access+ HMO programs and services that offer you more choice, convenience and control over your own care: Self-refer to a Select a different Contact a Stay covered across the specialist within primary care physician through country for extended your medical physician (PCP) Teladoc 24/7/365 periods with the Away group, without for each member when your doctor From Home Care® going to your of your family and isn’t available, program when you doctor first.1 change that doctor even while have students, long-term anytime you want. traveling, for only travelers and families a $5 copay.10 living apart.7 2 Access+ HMO plan Overview About the Access+ HMO plan Blue Shield’s Access+ HMO plan is designed to provide both comprehensive coverage and access to one of the largest, quality networks of doctors, specialists and hospitals throughout the state. With our Access+ HMO plan, you can expect zero or low copayments for most covered services, plus no deductible and virtually no claim forms. Choosing a doctor When you enroll in the Access+ HMO plan, you will be asked to select a primary care physician (PCP) for you and each of your dependents. You and your covered dependents have the option to select different PCPs and medical groups within the Access+ HMO Network of providers. To find out if your current doctor is in our network, or to locate a new doctor, go to blueshieldca.com/ Self-refernetworkcalpershmo to a specialist and selectSelect Primary a different Care PhysicianContact to search a physician for a network PCP.Stay Enter covered your across city the withinand state your ormedical ZIP code, then clickprimary Continue care. Click on thethrough PCP’s Teladoc name to24/7/365 find the PCP’scountry provider for numberextended group,and medicalwithout going group/Independent to physician Practice (PCP) Association when number. your doctor You will isn’t need these numbersperiods with when the youyour enroll doctor in first.the 1plan for thefor first each time. member available, even while Away From Home of your family traveling for only a $5 Care® program when If you don’t have access to the Internet or would like personal assistance, call Shield Concierge, and change that copay. you have students, our dedicated customer service team for CalPERS members, at (800) 334-5847, 7 a.m. to 8 p.m., doctor anytime long-term travelers and seven days a week. you want. families living apart.7 Access emergency and Receive up to Get up to a 90-day Call Shield urgent care services 20 combined supply for the cost of Concierge, our almost anywhere in chiropractic and a 60-day supply of team of experts, the United States and in acupuncture prescriptions by mail for help with more than 200 countries treatments per or from select retail healthcare through the BlueCard® year for a $15 pharmacies when you questions, concerns Program and Blue Shield copay per visit. take medication for a or decisions Global Core. chronic condition. 3 Comprehensive benefit summary for the Access+ HMO plan Calendar-year deductible Member None Family None Physician services Preventive health exam No charge Gynecological/well-woman exam No charge Pregnancy and maternity care; prenatal/postnatal office visits No charge Well-baby care No charge Immunization/inoculation No charge Allergy testing/treatment No charge Office/home visits $15/visit Teladoc video or phone consultation $5/call Urgent care $15/visit Infertility testing and treatment 50% of allowable amount Physician inpatient hospital visits No charge Surgery/anesthesia No charge Chiropractic and acupuncture services $15/visit (Combined maximum of 20 visits per year) Access+ SpecialistSM,1 – self-referral to specialists $30/visit Hospital services Inpatient No charge Outpatient No charge Ambulatory surgery centers No charge Transgender surgical services No charge Ambulance services No charge Emergency care – no copayment if hospitalized or kept $50/visit for observation Diagnostic X-ray/lab No charge Skilled nursing facility – up to 100 days per calendar year No charge Hospice No charge Mental health/substance use disorder Inpatient No charge Outpatient $15/visit 4 Access+ HMO plan Overview Prescriptions2 Prescriptions for non-maintenance drugs and for the first three fills of $5 generic maintenance drugs from a retail pharmacy (up to a 30-day supply) $20 formulary brand $50 non-formulary brand Prescriptions for maintenance drugs after the first three fills from a retail $10 generic pharmacy (up to a 30-day supply)3 $40 formulary brand $100 non-formulary brand Prescriptions for maintenance drugs from a select* retail pharmacy $10 generic (up to a 90-day supply) $40 formulary brand $100 non-formulary brand Prescriptions for maintenance drugs by mail order (up to a 90-day supply) $10 generic $40 formulary brand $100 non-formulary brand Prescriptions for specialty drugs (up to a 30-day supply) $30 Prescription drugs to treat sexual dysfunction 50% of the cost of the drug Maximum annual out-of-pocket payments for mail service formulary $1,000 prescription drugs4 Flu vaccine from participating retail pharmacies5 No charge Vision care Eye refraction to determine need for corrective lenses No charge (This service is limited to one visit per calendar year for members 18 and older; no limit on number of visits for members under 18.) Eyeglasses – not covered, except for those that are necessary after 20% discount available8 cataract surgery (See page 11.) Hearing-aid services Evaluation No charge Hearing aid – up to a maximum of $1,000 per member, every 36 months for Charges in excess of $1,000 both ears for the hearing-aid instrument and ancillary equipment Durable medical equipment, including orthoses and prostheses No charge Physical/occupational/speech therapy Inpatient visits at a hospital or skilled nursing facility No charge Outpatient and home visits $15/visit Member calendar-year out-of-pocket maximum Member: $7, 3 5 0 Family: $14,700 – Medical: $1,500 maximum – Medical: $3,000 maximum – Pharmacy: $5,850 maximum† – Pharmacy: $11,700 maximum† * CalPERS network select pharmacies are Costco, CVS and Safeway/Vons. † Includes the $1,000 maximum annual out-of-pocket payments for mail service formulary prescription drugs per member. This chart is a summary of the Access+ 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 Evidence of Coverage. Or you can contact Shield Concierge at (800) 334-5847 if you prefer a printed copy. 5 Pharmacy benefits Blue Shield’s pharmacy benefits are fully integrated with the medical benefits, offering you the convenience of one Blue Shield member ID card and one Member Services phone number for both pharmacy and medical benefit questions. Filling your prescription at a local pharmacy You can locate a network pharmacy by calling Shield Concierge at (800) 334-5847 or by visiting blueshieldca.com/wellness/drugs. Copayments for prescription drugs filled at a retail pharmacy: Non- Formulary Retail prescription drugs Generic formulary brand brand Up to a 30-day supply of non-maintenance drugs and $5 $20 $50 the first three fills of maintenance drugs* Up to a 30-day supply of maintenance drugs after the $10 $40 $100 first three fills3 Up to a 90-day supply of maintenance drugs from a select retail pharmacy (Costco, CVS and Safeway/ $10 $40 $100 Vons) You may also receive your flu immunization from participating pharmacies as well as your primary care physician’s office at no charge. Mail service prescriptions Blue Shield provides the convenience of mail service6 delivery of prescription drugs through CVS Caremark®. You may receive up to a 90-day supply of covered maintenance drugs delivered to your home or office, with no charge for shipping. Mail service prescription drugs (90-day supply) $10 generic $40 formulary brand $100 non-formulary brand * Maintenance drugs are 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. You can view the list of covered maintenance drugs by visiting blueshieldca.com/ wellness/drugs/formulary and scrolling down to the formularies under Large Groups (100+ employees). 6 Access+ HMO plan Overview To receive medications from CVS Caremark, go to blueshieldca.com/wellness/drugs and then click on Mail Service Prescriptions. For new prescriptions, please allow 10 to 14 days to receive your covered maintenance medications. Once your prescription is on file with CVS Caremark, please allow five to eight days to receive refills of your covered medications. About our drug formulary The Blue Shield Plus Drug Formulary is a list of preferred generic and brand 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 medications when you see your doctor because these medications are usually covered at a lower copayment than non-formulary drugs. To see our drug formulary, visit blueshieldca.com/wellness/drugs/ formulary and select the link Plus Drug Formulary under Large Groups (100+ employees).