CalPERS health benefits officers

NetValue HMO Plan

The Blue Shield NetValueSM HMO plan is designed to provide your employees and their families savings on rates, and has no or low copayments, comprehensive benefits, self-referral to specialists through the Access+ Specialist program, health management programs and value-added services. With NetValue, your employees save money.

We can offer this plan because the NetValue network comprises a smaller network of our HMO providers who meet quality and efficiency standards. This allows us to keep monthly rates low. NetValue is our fastest-growing HMO plan for CalPERS.

Blue Shield also offers a NetValue HMO Supplement to Original Medicare Plan to members who are enrolled in Medicare. Learn more about the NetValue HMO Supplement to Original Medicare Plan.

2014 Service Area

NetValue HMO is available in the following counties; employees and all their enrolled family members must live or work in a NetValue service area to select this plan. Click on a county to view a full listing of providers within the county.

Contra Costa*MarinSan Joaquin*
El Dorado*Nevada*San Luis Obispo
FresnoOrange San Mateo
HumboldtPlacer*Santa Clara
ImperialRiverside*Santa Cruz
KernSacramentoSonoma
KingsSan Bernardino*Stanislaus
Los Angeles*San Diego*Ventura
MaderaSan FranciscoYolo

* partial county – please check the NetValue HMO Evidence of Coverage for covered areas.

How to Select a Doctor

When employees enroll in the NetValue HMO plan, they will need to select a primary care physician (Personal Physcian) for themselves and their dependents. Employees and their covered dependents have the option to choose different NetValue Personal Physicians and medical groups.

To find out if their current doctor is in our network or to choose a new doctor, employees can go to blueshieldca.com/findaprovider. Choose Find a Doctor, under Choose a Plan, select CalPERS, and then choose CalPERS NetValue HMO. Need help? Employees can call our CalPERS-dedicated Member Services team at (800) 334-5847 for personal assistance.

Covered Services and Copayments

This summary is only a brief description of the NetValue HMO plan benefits for CalPERS members. Please see the 2014 NetValue HMO Basic Evidence of Coverage (PDF, 1.2MB) for the exact terms and conditions of coverage, including plan limitations and exclusions.

Category DescriptionsMember Copayment and Limitations

 Hospital 


 Inpatient


 Includes blood and blood products - collection and storage of autologous blood

 No charge
 Outstanding No charge

 Physician Services


 Office/home visits

 $15/visit
 Allergy testing/treatment No charge
 Inpatient hospital visits No charge
 Surgery/anesthesia No charge
 Periodic health exam No charge
 Well-baby care No charge
 Gynecological exam No charge
 Immunization/inoculation No charge
 Vision screening No charge
 Hearing exam/testing No charge
 Access+ Specialist $30/visit1
 Prescription drugs $5 generic, $20 brand name, $50 non-formulary/prescription - not to exceed a 30-day supply for short-term or acute illness; maintenance drugs after 3 months: $10 generic, $40 brand name, $100 non-formulary/prescription - not to exceed a 30-day supply
 Prescription by mail $10 generic, $40 brand name, $100 non-formulary/prescription - not to exceed a 90-day supply for maintenance drugs; $1,000 out-of-pocket annual maximum
 Diagnostic X-ray/lab No charge

 Durable medical equipment


 Including orthoses and prostheses

 No charge

 Emergency care


 No copyament needed if hospitalized or kept for observation and hospital bills for an emergency room observation visit

 $50/visit
 Urgent care $15/visit
 Ambulance services No charge

 Pregnancy and maternity care

 Prenatal/postnatal office visits

 No charge
 Infertility testing and treatment 50% of allowable amount

 Mental health2



 Inpatient

No charge
 Outpatient $15/visit

 Vision Care 


 Eye refraction (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)

 No charge
 Eyeglasses Not covered, except for eyeglasses that are necessary after cataract surgery

 Hearing-aid services


 Evaluation

 No charge
 Hearing aid (up to a maximum of $1,000 per member, every 36 months for both ears for the hearing-aid instrument and ancillary equipment) Charges in excess of $1,000
 Home health services No charge
 Physical/ occupational/ speech therapy
 Inpatient visits at a hospital or skilled nursing facility
No charge
 Outpatient and home visits $15/visit

 Skilled Nursing Facility

 Up to 100 days per calendar year

 No charge
 Hospice No charge

 Maximum calendar-year copayment

 Member

 $1,500

 Family $3,000

1To a participating Access+ Specialist in the same medical group or IPA as their Personal Physician.

2The mental health services administrator (MHSA), is a specialized health care service plan contracted by Blue Shield of California to administer all mental health and substance abuse services.

Preferred Centers for Knee and Hip Joint Replacement

As part of Blue Shield's commitment to keeping health coverage affordable, we introduced a benefit change for knee and hip joint replacement. Blue Shield NetValue HMO plan members are required to receive care for most elective knee and hip joint replacement procedures at one of the Blue Distinction Centers® throughout the service area in order to receive 100% hospital coverage.

Blue Distinction Centers are hospitals within Blue Shield's network that are nationally recognized by the BlueCross BlueShield Association for distinguished clinical care and processes. Facilities earn this designation based on rigorous, evidence-based, and objective criteria and input from physicians and medical organizations.

The following Blue Distinction Centers participate in the Blue Shield of California knee and hip preferred centers network:

Alta Bates - Sutter 
Arroyo Grande Community
Community Medical Center, Fresno
Dameron Hospital 
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
St. Joseph Hospital, Eureka
St. Joseph Hospital of Orange
St. Jude Medical Center
Santa Rosa Memorial Hospital, Santa Rosa
Sharp Coronado
Sharp Memorial
Summit Medical Center - Sutter 
Torrance Memorial Medical Center
UC Davis Medical Center
UCSF, Medical Center at UCSF
ValleyCare Medical Center 
 

A travel benefit is also available for members who live more than 50 miles from a preferred center. These benefit changes include transportation, hotel accommodations, and other reasonable expenses for both the patient and a companion. For more details, please have members call Member Services at (800) 334-5847.

Pharmacy Benefits

In addition to offering a large pharmacy network that includes chains such as Walgreens, Longs, and Rite Aid, we feature a convenient mail-order prescription service. If your employees take medications for chronic conditions such as diabetes or high blood pressure, they can get up to a 90-day supply of their prescriptions by mail. They may save money on their copayment and there is no charge for shipping. We've recently revised the copayment structure to encourage mail-order purchases.

To encourage the use of lower-cost and equally effective generic drugs, we implemented the following pharmacy benefit changes in 2012:
  • Members are required to pay the difference between a brand-name drug and a generic drug, plus the generic copayment, when the generic equivalent is available. (Exceptions for medical necessity are available via prior authorization; if approved, the applicable brand copay applies.)
  • Retail copayments for formulary brand-name and non-formulary brand-name drugs increased by $5.00.
  • Copayments for 90-day mail-order prescriptions are double the cost of 30-day retail prescriptions. For example, members will pay $5 for a 30-day supply of generic drugs at a retail pharmacy, but only twice this amount, or $10, for a 90-day supply through the mail-order pharmacy.
  • Non-formulary brand-name drugs and drugs used to treat erectile dysfunction do not accumulate towards the $1,000 mail service out-of-pocket maximum.

Prescriptions at Participating Pharmacies

Prescription DrugsMaintenance Drugs After 3 Months of Fill:
 $5 generic $10 generic
 $20 brand-name $40 brand-name
 $50 non-formulary/prescription - not to exceed a 30-day supply for short-term or acute illness, and maintenance medication for the first 3 months. $100 non-formulary/prescription - not to exceed a 30-day supply.

Prescriptions Through the Mail

Blue Shield provides access to pharmacy mail services through PrimeMail, offering your members the convenience of receiving up to a 90-day supply of covered maintenance drugs delivered to their home or office.

Mail-Service Prescription Drugs
 $10 generic
 $40 brand-name
 $100 non-formulary/prescription - not to exceed 90-day supply for mail order drugs which are taken over long periods of time (maintenance drugs; $1,000 out-of-pocket annual maximum)


To receive medications from PrimeMail, employees must download and complete the New Prescription Order Form and send it with their original prescription(s), and if applicable, the mail service copayment for each drug to:

PrimeMail Pharmacy
P.O. Box 27836
Albuquerque, NM 87125-7836

PrimeMail will fill prescriptions for covered maintenance drugs, according to an employee's physician's directions, up to the amount covered by the employee's pharmacy benefit. Maintenance drugs are used on an ongoing basis for treatment of long-term conditions, such as high blood pressure.

Employees can check the status of their order or order prescription refills by visiting www.myprimemail.com or by calling (866)346-7200. Employees who rely on TTY equipment can call (866) 346-7197.

If employees want to find out more about their personal Pharmacy copayments and benefits, they may:

  • Check their Evidence of Coverage (EOC) booklet
  • Call Member Services at (800) 334-5847
  • Log on to blueshieldca.com, and click My Health Plan to view plan summary, benefits and more

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