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 is comprised of 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.
2012 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*||Nevada*||San Joaquin*|
|El Dorado*||Orange||San Luis Obispo|
|Los Angeles*||San Diego*||Yolo|
* 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 Physcians) 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 dedicated Blue Shield Member Services team at (800) 334-5847 for personal assistance.
This summary is only a brief description of the Blue Shield NetValue HMO 2010 plan benefits for CalPERS members. Please see the 2012 NetValue HMO plan Evidence of Coverage (PDF, 735KB) and the 2013 NetValue HMO Basic Evidence of Coverage (PDF, 544KB) for the exact terms and conditions of coverage, including plan limitations and exclusions.
|Category Descriptions||Member Copayment and Limitations|
Includes blood and blood products - collection and storage of autologous blood
|Allergy testing/treatment||No charge|
|Inpatient hospital visits||No charge|
|Periodic health exam||No charge|
|Well-baby care||No charge|
|Gynecological exam||No charge|
|Vision screening||No charge|
|Hearing exam/testing||No charge|
|Prescription drugs||$5 generic, $15 brand name, $45 non-formulary/prescription - not to exceed a 30-day supply for short-term or acute illness; maintenance drugs after 3 months: $10 generic, $25 brand name, $75 non-formulary/prescription - not to exceed a 30-day supply|
|Prescription by mail||$10 generic, $25 brand name, $75 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 copyament needed if hospitalized or kept for observation and hospital bills for an emergency room observation visit
|Ambulance services||No charge|
Pregnancy and maternity care
Prenatal/postnatal office visits
|Infertility testing and treatment||50% of allowable amount|
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)
|Eyeglasses||Not covered, except for eyeglasses that are necessary after cataract surgery|
|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
|Outpatient and home visits||$15/visit|
Skilled Nursing Facility
Up to 100 days per calendar year
Maximum calendar-year copayment
1. To a participating Access+ Specialist in the same medical group or IPA as their Personal Physician.
2. The 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.
Following are some of the changes the CalPERS Health Benefits Committee and the Board of Administration have made to the Blue Shield healthcare plans for the plan year beginning January 1, 2012:
Preferred Centers for Knee and Hip Joint Replacement
As part of Blue Shield's commitment to keeping health coverage affordable, we are introducing a benefit change for knee and hip joint replacement. Blue Shield NetValue HMO plan members will be required to receive care for most elective knee and hip joint replacement procedures at one of 28 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.
For the 2012 benefit year, the following Blue Distinction Centers will participate in the Blue Shield of California knee and hip preferred centers network:
Alta Bates/Summit Medical Center
Arroyo Grande Community
Community Medical Center Fresno
Doctors Medical Center Modesto
Enloe Medical Center
Huntington Memorial Hospital
John Muir Medical Center Walnut Creek Campus
John F. Kennedy Memorial
Loma Linda University
Long Beach Memorial
Medical Center at UCSF
Methodist Hospital of Sacramento
Orange Coast Memorial
Providence Holy Cross
St. Joseph Hospital of Orange
St. Jude Medical Center
San Ramon Regional Medical Center
Torrance Memorial Medical Center
UC Davis 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 BenefitsTo encourage the use of lower-cost and equally effective generic drugs, we are implementing the following pharmacy benefit changes in 2012:
- Members will be 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 will increase by $5.00.
- Copayments for 90-day mail-order prescriptions will be 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.
If you have questions about any of these benefit changes, please do not hesitate to contact your Account Manager.
Prescriptions at Participating Pharmacies
|Prescription Drugs||Maintenance Drugs After 3 Months of Fill:|
|$5 generic||$10 generic|
|$15 brand-name||$25 brand-name|
|$45 non-formulary/prescription - not to exceed a 30-day supply for short-term or acute illness, and maintenance medication for the first 3 months.||$75 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|
|$75 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:
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, click My Health Plan section to view plan summary, benefits and more
Service Area by County