Medical Plans

General Information

Health Plan Providers

Overview of Health Plans

Health Maintenance Organizations (HMO)

Health Maintenance Organizations (HMO)

  • Office co-payments will be waived for preventive care office visits including periodic health exams, maternity care, well baby visits, allergy testing and treatment, immunizations, hearing evaluations and pre/post natal care.   Please Note:   Kaiser will continue to charge a co-payment for allergy testing and treatment.
  • Co-payments for urgent care visits will be $15.
  • Out-of-pocket maximum will be $1,500 for individual and $3,000 for family. Pharmacy is excluded.

Kaiser

  • Office Visits Copayment: $15
  • Emergency Room Copayment: $50 per visit (waived if admitted)
  • Prescription Copayment:
    • Generic items from a Plan Pharmacy:
      • $5 for up to a 30-day supply
      • $10 for a 31- to 60-day supply,
      • $15 for a 61- to 100-display
    • Generic refills from mail order:
      • $5 for up to a 30-day supply or $10 for a 31- to 100-day supply
    • Brand-name items from a Plan Pharmacy:
      • $15 for up to a 30-day supply
      • $30 for a 31- to 60-day supply
      • $45 for a 61- to 100-day supply
    • Brand-name refills from mail-order service
      • $15 for up to a 30-day
      • $30 for a 31 to 100 day supply

Blue Shield Access + (HMO)Office Visits Co-payment: $15Emergency Room Co-payment: $50 per visit (waived if admitted)Prescription Copayments are three-tiered:

  • Retail Pharmacies (usually a 30-day supply)
    • $5 for generic
    • $15 for brand name
    • $45 for non-formulary ($30 if medical necessity approved)
  • Mail Order Program (usually a 90 day supply)
    • $10 for generic
    • $25 for brand name
    • $75 for non-formulary ($45 if medical necessity approved)
    • $1,000 maximum co-payment per person per calendar year for mail order program.

Preferred Provider Organization (PPO)

PERS Platinum (administered by Anthem Blue Cross of California)

  • Choose your health care providers and pharmacy without referral.
  • Offers significant savings through a preferred provider network (doctors and hospitals that agree to charge a pre-negotiated rate for everyone on the plan). Non-network providers may be used, but co-payments will be higher.
  • PERS Choice pays 80 percent of allowable amount (in-network), member pays 20 percent; cop-pays are applicable.
  • PERS Care pays 90 percent of allowable amount (in-network), member pays 10 percent; co-pays are applicable.
  • Annual deductibles must be met before some benefits apply.
  • For more information, call (877) 737-7776.

PERS Gold (administered by Anthem Blue Cross of California)

  • Same level of benefits as PERS Choice at a lower monthly premium cost.
  • Not available for out-of-state.
  • Access a list of preferred providers through the PERS Select network.
  • For more information, call (877) 737-7776.

 

PERS Platinum/PERS Gold (PPO) :

  • Annual Member Deductible: $500
  • Annual Family Deductible: $1,000
  • Emergency Room Copayment: $50 per visit (waived if admitted)
  • Retail Pharmacy (Short-term use)
    • $5 generic
    • $15 preferred
    • $45 non-preferred ($30 if medical necessity approved)
  • Retail Pharmacy Maintenance Medications after 2nd Fill (a maintenance medication taken longer than 60 days for chronic conditions)
    • $10 generic
    • $25 preferred
    • $75 non-preferred ($45 if medical necessity approved)
  • Mail Service (up to 90-day supply) A $1,000 maximum co-payment per person per calendar year applies.
    • $10 generic
    • $25 preferred
    • $75 non-preferred ($45 if medical necessity approved)
  • Optum Rx is the prescription drug benefits manager for all of CalPERS' health plans, except Kaiser and Blue Shield. OptumRX can be reached through their website at OptumRX CALPers  or call Member Services at 1-855-505-8110.
  • Retail Pharmacy * (Short-term use)
    • $15 preferred
    • $45 non-preferred ($30 if medical necessity approved)
  • Retail Pharmacy Maintenance Medications after 2nd Fill (a maintenance medication taken longer than 60 days for chronic conditions)
    • $75 non-preferred ($45 if medical necessity approved)
  • Mail Service (up to 90-day supply) A $1,000 maximum co-payment per person per calendar year applies
    • $10 generic
    • $25 preferred
    • $75 non-preferred ($45 if medical necessity approved)