CalPERS

FAQs - PERS Select, PERS Choice & PERSCare

How do I decide which of the CalPERS PPO plans will meet my needs?

PERSCare pays a higher percentage of your medical bills, but with PERS Choice you have a lower monthly premium. PERS Select has the lowest monthly premium, but a smaller high-efficiency network of providers from which to choose. If you'd like to cut down on your monthly bills while maintaining quality coverage, PERS Choice or PERS Select are the plans for you. They offer most of the same benefits as PERSCare for a lower premium.

With PERSCare, you pay a higher monthly premium, but have lower out-of-pocket expenses when you receive services. So, if your annual medical bills tend to be high, you may save money with PERSCare.

How do the Basic PPO plans work?

With a PPO plan you can manage your health care through the selection of physicians, hospitals, and other specialists whom you determine will best meet your needs. Your co-payments will be lower and submitting claims is easier if you choose a Blue Cross preferred provider. Once you meet the plan's calendar year deductible, health care expenses are covered at a higher percentage (usually 80 percent for PERS Select and PERS Choice and 90 percent for PERSCare) when you use preferred providers. If you don't use preferred providers, you will pay more, as costs are covered at a lower percentage (usually 60 percent for PERS Select, PERS Choice, and PERSCare). Specific co-payments or dollar maximums apply for some services.

Anthem Blue Cross, the administrator for PERS Select, PERS Choice, and PERSCare, works with a large network of physicians and hospitals (preferred providers) throughout California. These providers have agreed to accept payment amounts set by Blue Cross for their services. These "allowable amounts" are usually lower than what other physicians and hospitals charge, so your portion of the charges - your co-payment - will also be lower when you use a preferred provider.

In California, providers who participate in the Blue Cross PPO (Prudent Buyer) network are referred to as preferred providers for PERS Choice and PERSCare; and providers who participate in the Blue Cross Select PPO network, which is a subset of the Blue Cross PPO (Prudent Buyer) network, are preferred providers for PERS Select. Anthem Blue Cross also has a relationship with the Blue Cross and Blue Shield Association, which gives you access to the nationwide BlueCard Preferred Provider Network. The Anthem Blue Cross Review Center provides utilization review of hospitalization, certain services, and surgeries to ensure they are medically necessary and efficiently delivered.

CVS Caremark, the pharmacy benefit manager for PERS Select, PERS Choice, and PERSCare, provides outpatient prescription drug benefits through their nationwide retail pharmacy network of more than 64,000 participating pharmacies. CVS Caremark also provides a convenient mail service program and members can also get their long term maintenance medications through a CVS pharmacy at the mail service copayment.

How do the Supplement to Medicare PPO plans work?

When you enroll in the PERS Select, PERS Choice, or PERSCare Supplement to Medicare plan, Medicare becomes your primary health insurance. Medicare pays a set percentage of covered hospital, doctor, and other health care expenses and then sends your claim to Blue Cross for payment. If the provider accepts Medicare “assignment” (they accept the amount Medicare approves for a particular service or supply), your Supplement to Medicare plan will cover the remaining balance. If the provider does not accept Medicare assignment, you may be billed for the balance after Medicare and your Supplement to Medicare plan have paid. You can find more information on the Medicare website.

You can choose any doctor you want when you need medical care. This means you can go directly to a specialist without a referral. Remember, your doctor must participate in Medicare or Medicare will not pay your claim.

Can I choose my own doctor if I am enrolled in a PERS Select, PERS Choice, or PERSCare Supplement to Medicare Plan?

You can choose any doctor you want when you need medical care. However, it is important to note that more of your costs will be covered if you select a doctor who participates in Medicare and accepts Medicare assignment. Doctors who participate in Medicare, but do not accept assignment can charge up to 15 percent more than Medicare's approved amount and you're responsible for the difference between their fees and Medicare's allowed amount. If you see a doctor who participates in Medicare and accepts Medicare assignment, Medicare will pay up to 80 percent of their allowed amount and bill Blue Cross for the remaining 20 percent. Any fees above the Blue Cross allowed amount are written off when a doctor participates in Medicare and accepts Medicare assignment or is a Blue Cross provider.

How much do the Basic plans pay for most covered services?

Although PERS Select, PERS Choice and PERSCare allow the freedom to choose any provider, benefits are paid at the highest level when you choose a provider in the Blue Cross PPO (Prudent Buyer) network (for PERS Choice or PERSCare or the Select PPO network for PERS Select. Except for services where specific co-payments or dollar maximums apply, most covered services provided by preferred providers are paid at 90 percent for PERSCare and 80 percent for PERS Select and PERS Choice of the allowable amount. Services received from non-preferred providers are paid at 60 percent.

I heard that the Basic plans pay 100 percent for preventive care services. Is this true?

Yes. We know that staying healthy is the best way to keep your medical bills down. That's why the Basic plans provide 100 percent coverage for preventive care services received from a preferred provider.

Will I have to pay a deductible?

The PERS Select, PERS Choice, and PERSCare Basic plans include a $500 calendar year deductible per member, not to exceed $1,000 per family. However, certain covered services, including those for preventive care, are not subject to the deductible if a preferred provider is used.

Do I have to fill out any claim forms?

When you receive services from a preferred provider, Blue Cross pays the provider directly. You'll have no further financial responsibility, except for any deductibles, co-payments, or amounts above benefit maximums, so there are no claim forms for you to file. If you go to a non-preferred provider, however, you do have to file a claim.

How much will I have to pay for an office visit?

With PERS Select, PERS Choice, and PERSCare, you pay only $20 for the office visit portion when you go to a preferred provider. The deductible requirement is waived.

What are the prescription drug benefits?

Both the PERS Select, PERS Choice, and PERSCare offer a retail prescription program and a mail service program. While you have the option to use either service, you'll find a slightly higher cost for using the retail pharmacy for ongoing maintenance medications. You can find out more about the prescription drug program benefits and the co-payment charges by reviewing our Prescription Drug Program information.

How can I be sure I'll have coverage when I need it?

With PERS Select, PERS Choice, and PERSCare, you'll have coverage whether you drive across town or travel around the world. Both plans offer a wide range of benefits for individual and family needs.

Dated: 01-03-2012