Access+ HMO

Life's unpredictable
Your healthcare costs don’t have to be

The Blue Shield Access+ HMO plan is designed to provide you and your family with comprehensive benefits and access to one of the largest provider networks in the state. The Access+ provider network includes more than 11,000 Personal Physicians, 300 hospitals and 21,000 specialists. With Access+ HMO, you can count on comprehensive coverage. 

You'll pay only an affordable copayment each time you see a physician. Your eligible dependents can also enroll in Access+ HMO.

Access+ delivers choice, quality, and predictability:

  • No deductible

  • Zero copayments for hospitalization or preventive care

  • $15 for office visits
  • Self-referral to specialists, using the Access+ SpecialistSM referral feature1 

  • Health and wellness programs and resources

  • A CalPERS-dedicated Member Services team called Shield Concierge

If you are a Medicare-eligible member, learn about the Access+ HMO Supplement to Original Medicare Plan.

1With Access+ Specialist, you can self-refer to a participating specialist in the same medical group for a fixed office visit copayment of $30. Our Access+ Satisfaction service will refund your office visit copayment if you are ever dissatisfied with your visit.

Note: The Access+ Specialist option allows HMO members direct access to a participating specialist in the same medical group or IPA as their Personal Physician. Not all medical groups or IPAs participate in this program.

2015 Service Area

Access+ HMO is available in the following counties. Click on a county to view a full listing of providers within the county.

AlamedaMarinSan Luis Obispo 
ButteMariposaSan Mateo
Contra CostaMercedSanta Barbara
El Dorado*Nevada*Santa Clara
FresnoOrange Santa Cruz
GlennPlacer*Solano
HumboldtRiversideSonoma
ImperialSacramentoStanislaus
KernSan Bernardino*Tulare
KingsSan Diego*Ventura
Los AngelesSan FranciscoYolo
MaderaSan Joaquin*

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

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How to Select a Doctor

As a member of the Blue Shield Access+ HMO plan, you’ll choose your Personal Physician from one of the largest provider networks in the state. You and your dependents have the option to choose different Personal Physicians and medical groups.

To find out if your current doctor is in our network or to choose a new doctor, go to blueshieldca.com/findaprovider. Choose Find a Doctor, under Choose a Plan, select CalPERS, and then choose CalPERS Access+ HMO. Need help? Call your dedicated Blue Shield Member Services team at (800) 334-5847 for personal assistance.  You can change your Personal Physician at any time for any reason, and your new doctor will be effective on the first of the following month.

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Covered Services and Copayments

This 2015 brochure (PDF, 462KB) offer brief descriptions of the Blue Shield Access+ HMO plan benefits for CalPERS members. Please see the Access+ HMO Evidence of Coverage for the exact terms and conditions of coverage, including plan limitations and exclusions.

Following are some of the changes the CalPERS Health Benefits Committee and the Board of Administration have made to the Blue Shield Access+ and NetValue HMO plans for 2015:

  • Chiropractic and acupuncture services will be covered for a $15 copay, up to a maximum of 20 combined visits. Visit the American Specialty Health website to find a network provider near you.

  • Flu vaccines will be available at participating retail pharmacies in addition to your doctor’s office for a $0 copay.

  • There will no longer be a $250 copay for having an upper or lower endoscopy, cataract surgery, or spinal injection at a hospital rather than an ambulatory surgery center. This means you can now go to any facility in your plan's network for these procedures for a $0 copay.

  • Members are no longer required to receive care for elective knee and hip joint replacement procedures at a Blue Distinction Center® in order to receive 100% hospital coverage.

  • Per federal healthcare reform requirements, the out-of-pocket maximum for both pharmacy and medical expenses will not exceed $6,600 per individual and $13,200 per family. There is still a $1,500 per individual and $3,000 per family out-of pocket maximum for medical expenses. In addition, there will be a $5,100 per individual and $10,200 for family out-of-pocket maximum for pharmacy expenses.

If you have questions about any of these benefit changes, please contact Shield Concierge, our CalPERS-dedicated Member Services team at (800) 334-5847, 7 a.m. to 8 p.m., seven days a week. 

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Pharmacy Benefits

In addition to offering a large pharmacy network that includes chains such as Walgreens, CVS and Rite Aid, we feature a convenient mail-order prescription service. If you take medication for a chronic condition such as diabetes or high blood pressure, you can get up to a 90-day supply of your prescriptions by mail. You may save money on your copayment and there is no charge for shipping. Recently revised pharmacy copayments may make mail-order service more attractive to you.

To encourage the use of lower-cost and equally effective generic drugs, we implemented the following pharmacy benefit changes in 2012:

  • You 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, you 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

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, download and complete a New Prescription Order Form and send it with your 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 your prescriptions for covered maintenance drugs, according to your physician’s directions, up to the amount covered by your pharmacy benefit. Maintenance drugs are used on an ongoing basis for treatment of long-term conditions, such as high blood pressure.

Please allow up to 10 days for delivery from the time you mail your prescription.

You may check the status of your order or order prescription refills by visiting www.myprimemail.com or by calling (866)346-7200. If you rely on TTY equipment, please call (866) 346-7197.

To find out more about your personal Pharmacy copayments and benefits:

  • Check your Evidence of Coverage (EOC) booklet.

  • Call Member Services at (800) 334-5847.

  • Log in to blueshieldca.com, and select My Health Plan to view your plan summary, benefits and more.

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