Frequently Asked Questions

With all the information you're considering, you may have additional questions about Access+ HMO, NetValue HMO, or the Supplement to Original Medicare Plans. Read the list below and click on your question to find the answer.

If you have questions regarding Blue Shield 65 Plus (HMO), the Group Medicare Advantage-Prescription Drug Plan, please call a Member Services representative between 7 a.m. and 8 p.m., seven days a week at 1-800-776-4466, option 9 [TTY/TDD: (800) 794-1099].

If you can't find the information you're looking for, contact us.

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    How do I inform my employer that I want Blue Shield as my health plan?

    Submit a health plan enrollment form (HBD-12) to your employer. This will inform your employer that you would like Blue Shield as your health plan. Retirees should contact the CalPERS Customer Contact Center at (888) 225-7377, Monday through Friday, 8 a.m. to 5 p.m., for enrollment instructions. If you select one of our HMO plans, you'll also need to notify Blue Shield of your Personal Physician selections.

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    Does Blue Shield offer different types of health plans?

    Yes, Blue Shield offers two types of health plans: HMO and EPO. Learn more about the HMO plans – NetValue HMOAccess+ HMO, and the EPO plan.

    Blue Shield's NetValue HMO plan offers a select network of medical groups that are a subset of the Access+ network. The plan is designed to provide savings with the same comprehensive benefits and quality coverage as the Access+ HMO plan. The difference is that you and your dependents must select your Personal Physician from one of the medical groups in the select NetValue network.

    Read more about our NetValue HMO plan benefits.

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    In what counties does Blue Shield operate?

    Blue Shield offers two types of health plans: HMO and EPO.

    Our HMO product, Access+ HMO, is available throughout the entire counties of: Alameda, Butte, Contra Costa, Fresno, Glenn, Humboldt, Imperial, Kern, Kings, Los Angeles, Madera, Marin, Mariposa, Merced, Orange, Riverside, Sacramento, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Tulare, Ventura, and Yolo.

    Access+ HMO is available in most, but not all, areas of El Dorado, Nevada, Placer, San Bernardino and San Diego counties. Call Member Services at (800) 334-5847 for more information about coverage in this county.

    Our HMO product, NetValue HMO, is available throughout the entire counties of Fresno, Humboldt, Imperial, Kern, Kings, Madera, Marin, Orange, Sacramento, San Francisco, San Luis Obispo, San Mateo, Santa Clara, Santa Cruz, Sonoma, Stanislaus, Ventura, and Yolo.

    NetValue HMO is available in most, but not all, areas of the following counties: Contra Costa, El Dorado, Los Angeles, Nevada, Placer, Riverside, San Bernardino, San Diego, and San Joaquin.

    Our EPO plan is available in the following counties: Colusa, Mendocino, and Sierra.

    You and your eligible dependents will need to live or work in the service area for the Blue Shield plan you've chosen in order to enroll in that plan. If you live or work outside of that Blue Shield service area please consult your employer for information about other health plans.

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    Is my physician in the Blue Shield network?

    Most people will find that their current doctor is part of Blue Shield's network. If you're not sure who your current physician is, check your health plan ID card.

    Find out if your doctor and the specialist(s) you usually see are in the Blue Shield network. If your doctor is not in our network, you'll need to choose a physician from the Blue Shield network.

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    When do I need to notify Blue Shield who I selected as my physician?

    We recommend that you inform us at the time of submitting your health plan enrollment form. You can also do the following to select a physician:

    • Complete the physician selection form provided to you during open enrollment.
    • Search for a Personal Physician online using our Find a Provider tool. Once you've identified a physician, go to the My Health Plan section of blueshieldca.com to make your selection.
    • Request an Access+ HMO or NetValue HMO provider directory then call Member Services with your selection at (800) 334-5847.

    If you do not inform us of your selection, we will choose a provider for you when we process your enrollment form.

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    How can I find a doctor or hospital in the Blue Shield network?

    It's easy to use our online directories to customize a search for providers. You can see if your physician or hospital participates in our network or find a new provider.

    When you search, you'll receive a customized list of physicians or hospitals close to you based on the ZIP code that you entered. To see detailed information, just click on a physician's name and learn about specialties, languages spoken, certification, IPA or medical group affiliations and Blue Shield health plan affiliations.

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    What if my physician is not in the Blue Shield network or I don't have a physician?

    If you're enrolled in Access+ HMO or NetValue HMO, you'll need to choose a Personal Physician from the Blue Shield network and notify us of your selection. If you don't select a Personal Physician, we'll randomly assign a Personal Physician for you. Find a Personal Physician who is right for you.

    Once you've selected a doctor, contact his or her office to make sure they are accepting new patients.

    Notify Blue Shield of the Personal Physician selection for you and each eligible family member. Let us know whom you've selected. Or, you can submit the physician selection form provided to you during open enrollment. You may also call Member Services at (800) 334-5847 for assistance Monday through Friday, 7 a.m. to 7 p.m. PST.

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    When can I change my Personal Physician?

    You can change your Personal Physician at any time. The change will be effective the first day of the month following notice of approval by Blue Shield. To make the change, contact Member Services at (800) 334-5847, Monday through Friday, 7 a.m. to 7 p.m. PST.

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    If I am already a Blue Shield member, can I use this site to notify Blue Shield of a change in my Personal Physician selection?

    Yes. If you are an existing member and would like to change your Personal Physician, go to the My Health Plan section of blueshieldca.com to change your Personal Physician or for assistance please call Member Services at (800) 334-5847 for assistance Monday through Friday, 7 a.m. to 7 p.m.

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    What are the EPO and EPO Supplement to Original Medicare plans?

    With Blue Shield's Exclusive Provider Organization (EPO) and EPO Supplement to Original Medicare plans, benefits are almost exactly the same as the HMO benefits, except that members do not need to select a Personal Physician. Each time an EPO member seeks care, they can choose from the physicians and hospitals in our Preferred Provider (PPO) network. Out-of-network services are not covered, except for urgent and emergency care. return to top

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    What if I live in Colusa, Mendocino, or Sierra County?

    You'll be eligible for our Exclusive Provider Organization (EPO) and EPO Supplement to Original Medicare plans and you do not need to select a Personal Physician. You will have access to providers in our PPO network. return to top

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    How do I access services with the EPO and EPO Supplement to Original Medicare plans?

    EPO benefits are almost the same as the HMO benefits, except that you do not have to choose a Personal Physician. Each time you seek care, you can choose from any of the doctors and hospitals in our PPO network. Out-of-network services are not covered. Find the most current list of PPO providers in your area.
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    What services does the EPO and EPO Supplement to Original Medicare plans cover?

    You can review a summary of EPO benefits and the summary of EPO Supplement to Original Medicare benefits. return to top

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    Who provides Blue Shield's mental health services?

    Blue Shield of California has contracted with a mental health services administrator (MHSA) to deliver all mental health and substance abuse services through a unique network of mental health participating providers. All non-emergency mental health and substance abuse services must be pre-authorized by the MHSA.
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    How can I contact the mental health services administrator?

    Blue Shield’s MHSA has a dedicated, toll-free phone number for Blue Shield members. Members should call (866) 505-3409 for pre-authorization of mental health and substance abuse services.
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    What should I do if I am currently using mental health services?

    You should:

    • Check if your provider is in Blue Shield’s MHSA provider network
    • Contact Blue Shield’s MHSA to obtain an authorization to continue treatment if your provider is in the Blue Shield’s MHSA network.
    • Contact Blue Shield’s MHSA to obtain an authorization for your continued care from non-network providers.
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    How can I find out if my current mental health provider is in Blue Shield’s mental health service administrator (MHSA) network?

    See if your mental health provider is in our network. Or, you can call Blue Shield’s MHSA at (866) 505-3409.

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    What is the Alternative Care Discount Program?

    The Alternative Care Discount Program helps you save 25% or more off the practitioner's published fees. Alternative care services are offered through a select network of thoroughly screened and qualified acupuncturists, chiropractors and massage therapists.

    The Alternative Care Discount Program is an exclusive offer to Blue Shield members, made available through an arrangement with American Specialty Health Networks of California, Inc. (ASH Networks) and is not a covered service of any Blue Shield health plan. ASH Networks credentials and manages the program's practitioners. None of the terms and conditions of Blue Shield health plans apply. Blue Shield of California and ASH Networks do not review the program's practitioner services and products for medical necessity or efficacy and makes no representations, claims or guarantees regarding their services or products. Members who use the discount program are responsible for the payment of services provided by participating network practitioners, including payment for cancelled or missed appointments. Members who are not satisfied with services received from the program's practitioners may use the Blue Shield grievance process. Blue Shield reserves the right to terminate this program without notice.

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    What should I do if I'm taking prescription drugs?

    Check if the drugs are included on Blue Shield's Drug Formulary, our list of preferred drugs. Search for drugs now.

    Most drugs covered by other health plans are on the Blue Shield formulary - which means you'll continue paying the lower generic copayment of $5 and the formulary brand copayment of $15. Drugs not included in Blue Shield's formulary are still covered at the non-formulary copayment of $45. In many cases, you can work with your physician to change your therapy to an equally effective formulary drug.

    Our formulary is updated quarterly to ensure that we are covering safe and effective drugs.
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    What do prescriptions cost with a Blue Shield health plan?

    When you purchase a prescription covered by Blue Shield, you'll pay the following copayment amount for up to a 30-day supply:

    • $5 for generic medications
    • $20 for formulary brand medications
    • $50 for non-formulary brand medications
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    What pharmacies can I go to?

    All chain pharmacies and many independent pharmacies are part of the Blue Shield network. Review a list of Blue Shield participating pharmacies. Remember to provide your new ID card information when you submit your prescription.
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    How does the mail service portion of my prescription benefit work?

    Blue Shield members can enjoy copayment savings and the convenience of receiving a larger supply of covered maintenance drugs through our mail service pharmacy, PrimeMail. Our mail service prescription benefit is available to members who take stabilized dosages of covered maintenance drugs on an ongoing basis for treatment of long-term conditions such as high blood pressure, diabetes or asthma.

    Members can obtain up to a 90-day supply of covered prescription medications, versus the 30-day supply available through retail pharmacies. Plus, your copayment will be equal to or less than a 60-day supply copayment through retail pharmacies. This means that you can get an extra 30-day supply at no charge. You'll need to transition to PrimeMail when you select Blue Shield as your health plan.
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    How can I transition to Blue Shield's prescription drug mail service?

    Request that your physician provide you with a new prescription for up to a 90-day supply of your maintenance drug (drugs used on a daily basis for a chronic condition such as high blood pressure, diabetes or asthma). You may also request refills up to the equivalent of one year. (Even though you may have refills left on your current prescription, you must obtain a new prescription from your participating physician.)

    You will automatically receive a mail service order form, patient profile and Prescription Drug Program brochure or visit http://www.myprimemail.com/ to download or print a mail service order form or call  (866) 346-7200.

    Send your new prescription(s) to PrimeMail Mail Service along with the order form and patient profile in the envelope included with the Prescription Drug Program brochure.

    Be sure to include the applicable drug copayment of either $10 for generic, $40 for brand formulary drugs, or $100 for drugs not listed in the formulary for each prescription.

    Always allow at least 14 days for delivery.
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    What is a drug formulary and why does Blue Shield have one?

    The Blue Shield Drug Formulary is a comprehensive list of preferred generic and brand name drugs covered by your Blue Shield health plan.

    The formulary is developed by the Blue Shield Pharmacy and Therapeutics (P&T) Committee, whose voting members are physicians and clinical pharmacists in community practice. The Committee reviews and updates the formulary quarterly to assist physicians in prescribing medically appropriate and cost-effective medications.
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    How can I find out what drugs are on the Blue Shield Drug Formulary?

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    What happens if my prescription is not on your drug formulary?

    Non-formulary drugs are covered unless they are a benefit exclusion, but you will be charged at the higher non-formulary brand copayment. In many cases you can work with your physician to change your therapy to an equally effective formulary drug.
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    How does Blue Shield decide which drugs are on the formulary?

    Our goal is to give members access to appropriate and cost-effective medications. The FDA-approved brand name and generic drugs chosen for our formulary by the Pharmacy and Therapeutics Committee, are selected based on their safety, effectiveness and overall value. Drugs are added to the formulary if they represent an important therapeutic advance. Drugs are not added if current drugs on the formulary are equally effective, safe, and less expensive.
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    Are there covered drugs that are not listed in the formulary?

    Nearly all generic prescription drugs are covered unless they are specifically listed in your benefit exclusions. Oral immunosuppressants and chemotherapeutic drugs are also covered, but not all are listed in the formulary.
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    Why should I use generic drugs?

    Generic products are deemed by the FDA to be as effective as their brand-name counterparts. When appropriate, using generic drugs is one way you can play an active role in helping control the overall costs of health care. Plus, copayments are less for generic products, so using generic drugs can help you maximize the value of your prescription drug benefits.
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    What if I request a brand-name drug when a generic is available?

    If a brand-name drug in the Blue Shield formulary indicates "generic only," this means that Blue Shield will only cover the generic version of the brand-name drug.

    If you select a brand-name drug when a generic is available, you pay the difference in price between the brand and generic in addition to the higher brand-name copayment.

    If your physician prescribes a brand-name drug and indicates on a prescription "Dispense as Written," you will pay the appropriate brand copayment.
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    Are new medications considered for coverage in the formulary?

    Yes, new FDA-approved medications are reviewed quarterly by Blue Shield's Pharmacy and Therapeutics Committee. When the Committee decides a new drug is to be added to the formulary, it is updated accordingly.

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    What drugs require prior authorization?

    Prior authorization criteria and procedures are in place for the following types of drugs:

    • Drugs with potential for misuse or overuse
    • Drugs that should be limited to a maximum quantity according to the FDA-approved indications

    The Pharmacy & Therapeutics Committee selects the drugs that require prior authorization and develops coverage criteria.

    When looking up a drug in the formulary you will note that some drugs have restrictions such as:
    • Limits on quantity covered
    • Prerequisite therapy required (This means that the drug would be available only after standard first-line drug therapy has been tried.)
    • Prior authorization required (This means that your physician must get authorization from Blue Shield before that medication will be covered.)

    For drugs with quantity limits, your physician will need to request prior authorization for higher quantities by calling Blue Shield Pharmacy Services at (800) 535-9481.
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