Medical Plans

General Information

Health Program Handbook booklets will provide an overview of the CalPERS health plans, services and regulations for coverage. Additional information can be obtained through the CalPERS Website under health benefits CalPERS

Health Maintenance Organization (HMO)

This type of plan is designed to reduce out-of-pocket expenses, with no deductible and a minimal co-payment. All services must be received from contracting physicians and hospitals.

Preferred Provider Organization (PPO)/Indemnity

This plan requires that a deductible be met before the plan benefits are payable (90% - 80% depending upon which PPO is selected). Similar to HMO’s, the PPO Indemnity plan contracts with specific doctors and hospitals in certain areas. The plan pays higher benefits when utilizing a participating provider (BLUE CROSS) than a non-participating provider.  Under a PPO/Indemnity plan, there is no geographic restriction. Anthem Administers the PPOs.

Employees of the State of California and contracting public agencies whose appointment is at least six months and one day (tenure) and at least half-time (time base) may sign up for the CalPERS Health Benefit Program. In addition, lecturers or coaches with a time base of .40 (6 WTU's) or greater who are appointed for an academic year or one semester appointment are eligible.  Please download the Lecturer Benefit Eligibility Criteria for additional information.

Who’s Eligible?

  • Spouse
  • Natural, stepchildren, or adopted children under the age of 26
  • Domestic partners (contact the Office of Human Resources for more information)
  • Economically dependent children

Married employees or retirees can enroll separately.  However, when married employees are enrolled in a CalPERS health plan in their own right, one parent must carry all children on one plan.  Children and dependents cannot be split between parents.  When split enrollments are discovered, they will be retroactively canceled by CalPERS.  You may be responsible for all costs incurred from the date the split enrollment began.

Dual coverage occurs when you are enrolled in a CalPERS health plan as both a member and a dependent, or as a dependent on two enrollments.  This is against the law.  When dual coverage is discovered, the enrollment that caused the dual coverage will be retroactively canceled by CalPERS.  You may have to pay for all costs incurred from the date the dual coverage began.

Adding or Deleting Dependents

If  you wish to add/delete dependents due to a family status change, please complete the eBenefits Self-Service Authorization form, submit it to HR and use the Self-Service component in PeopleSoft to make the change.

The eBenefits Authorization Self-Service form will need to be submitted to Human Resources prior to making any changes to your benefits.  Additional documentation will  be required (i.e., Birth Certificates, Marriage Certificate, Declaration of Domestic Partnership, Affidavit of Eligibility, Final Divorce Decree, or Termination of Domestic Partnership).  

Although CalPERS administers our health plans, all changes MUST be coordinated through the Human Resources Benefits Office at (510) 885-7503.  It is the employee's responsibility to notify Human Resources when there are any changes in their family status.  

Family Status Changes include:

  • Marriage (Marriage Certificate), Domestic Partnership (Declaration of Domestic Partnership);
  • Birth of a child, Acquisition of a dependent child (economically dependent child);
  • Marriage of an eligible Dependent Child (natural, adopted or economically dependent);
  • Move out of eligible dependent;
  • Divorce, Legal Separation, Termination of Domestic Partnership; and Death.
  • Human Resources will prepare the appropriate forms and notify you when they are available for signature. If you have questions about completing the eBenefits Authorization Form or wish to obtain additional information, contact the Human Resources Benefits office at (510) 885-7503.

Domestic Partnership

Effective January 2005, a domestic partner legally recognized by California law will be entitled to all rights, benefits, and obligations previously provided only to spouses under state law.   In most circumstances, a current or former registered domestic partner would be eligible for the same benefits as a current or former spouse of an active or retired employee. The FAQs (PDF) regarding Domestic Partnership Legislation are available through the Domestic Partner Registry on the State of California's website.  For Health Benefits enrollment questions, please contact Human Resources at (510) 885-7503.

When you change your address, an Employee Action Request (EAR) form must be completed or you may change it through Self Service in MyCSUEB. This form is available in Payroll Services, SA 2600, (510) 885-3651.

If you are participating in an HMO plan, please note that a change of address could affect your eligibility to participate in an HMO plan.  Please check the CalPERS website for plan availability based on zip code CalPERS

Health Plan Providers

Anthem Blue Cross Select/Traditional

Blue Shield Access+ (HMO)

Blue Shield Trio

Blue Shield Trio: www.blueshield.ca/calpers
Phone: 800-334-5847
Blue Shield Trio Summary of Benefits & Coverage: 
Blue Shield Trio is available in El Dorado, Los Angeles, Nevada, Placer, Sacramento, Santa Barbara, Santa Cruz, San Luis Obispo, Stanislaus, Orange, Ventura, Butte, Kern, Kings, Monterey, Riverside, San Bernardino, Tulare and Yolo Counties.

PERS Platinum & PERS Gold (PPO)

United Health Care

Health Net Smart Care

Note: Western Health Advantage is available in Colusa, El Dorado, Humboldt, Marin, Napa, Placer, Sacramento, Solano, Sonoma and Yolo.

Overview of Health Plans

Health Maintenance Organizations (HMO)

  • Office co-payments will be waived for preventive care office visits including periodic health exams, maternity care, well baby visits, allergy testing and treatment, immunizations, hearing evaluations and pre/post natal care.   Please Note:   Kaiser will continue to charge a co-payment for allergy testing and treatment.
  • Co-payments for urgent care visits will be $15.
  • Out-of-pocket maximum will be $1,500 for individual and $3,000 for family. Pharmacy is excluded.

Kaiser

  • Office Visits Copayment: $15
  • Emergency Room Copayment: $50 per visit (waived if admitted)
  • Prescription Copayment:
    • Generic items from a Plan Pharmacy:
      • $5 for up to a 30-day supply
      • $10 for a 31- to 60-day supply,
      • $15 for a 61- to 100-display
    • Generic refills from mail order:
      • $5 for up to a 30-day supply or $10 for a 31- to 100-day supply
    • Brand-name items from a Plan Pharmacy:
      • $15 for up to a 30-day supply
      • $30 for a 31- to 60-day supply
      • $45 for a 61- to 100-day supply
    • Brand-name refills from mail-order service
      • $15 for up to a 30-day
      • $30 for a 31 to 100 day supply

Blue Shield Access + (HMO)Office Visits Co-payment: $15Emergency Room Co-payment: $50 per visit (waived if admitted)Prescription Copayments are three-tiered:

  • Retail Pharmacies (usually a 30-day supply)
    • $5 for generic
    • $15 for brand name
    • $45 for non-formulary ($30 if medical necessity approved)
  • Mail Order Program (usually a 90 day supply)
    • $10 for generic
    • $25 for brand name
    • $75 for non-formulary ($45 if medical necessity approved)
    • $1,000 maximum co-payment per person per calendar year for mail order program.

Preferred Provider Organization (PPO)

PERS Platinum (administered by Anthem Blue Cross of California)

  • Choose your health care providers and pharmacy without referral.
  • Offers significant savings through a preferred provider network (doctors and hospitals that agree to charge a pre-negotiated rate for everyone on the plan). Non-network providers may be used, but co-payments will be higher.
  • PERS Choice pays 80 percent of allowable amount (in-network), member pays 20 percent; cop-pays are applicable.
  • PERS Care pays 90 percent of allowable amount (in-network), member pays 10 percent; co-pays are applicable.
  • Annual deductibles must be met before some benefits apply.
  • For more information, call (877) 737-7776.

PERS Gold (administered by Anthem Blue Cross of California)

  • Same level of benefits as PERS Choice at a lower monthly premium cost.
  • Not available for out-of-state.
  • Access a list of preferred providers through the PERS Select network.
  • For more information, call (877) 737-7776.

 

PERS Platinum/PERS Gold (PPO) :

  • Annual Member Deductible: $500
  • Annual Family Deductible: $1,000
  • Emergency Room Copayment: $50 per visit (waived if admitted)
  • Retail Pharmacy (Short-term use)
    • $5 generic
    • $15 preferred
    • $45 non-preferred ($30 if medical necessity approved)
  • Retail Pharmacy Maintenance Medications after 2nd Fill (a maintenance medication taken longer than 60 days for chronic conditions)
    • $10 generic
    • $25 preferred
    • $75 non-preferred ($45 if medical necessity approved)
  • Mail Service (up to 90-day supply) A $1,000 maximum co-payment per person per calendar year applies.
    • $10 generic
    • $25 preferred
    • $75 non-preferred ($45 if medical necessity approved)
  • Optum Rx is the prescription drug benefits manager for all of CalPERS' health plans, except Kaiser and Blue Shield. OptumRX can be reached through their website at OptumRX CALPers  or call Member Services at 1-855-505-8110.
  • Retail Pharmacy * (Short-term use)
    • $15 preferred
    • $45 non-preferred ($30 if medical necessity approved)
  • Retail Pharmacy Maintenance Medications after 2nd Fill (a maintenance medication taken longer than 60 days for chronic conditions)
    • $75 non-preferred ($45 if medical necessity approved)
  • Mail Service (up to 90-day supply) A $1,000 maximum co-payment per person per calendar year applies
    • $10 generic
    • $25 preferred
    • $75 non-preferred ($45 if medical necessity approved)