Center for Human Resources

Highlights of the 2012 benefit changes are listed below. These benefit modifications are designed to focus on quality, patient safety, and engaging members in their care. While drug copayments will go up next year in some cases to encourage the use of generic and mail order drugs, they still will fall below the U.S. median for generic and preferred brand drugs, and slightly above the median for non-preferred drugs. Refer to the health plan’s Evidence of Coverage (EOC) booklet for a complete explanation of the benefits covered, as well as limitations and exclusions that apply.

Blue Shield NetValue HMO (Basic & Medicare)

• Expanding service area to include Contra Costa County, and withdrawing from Santa Barbara County
• Adding providers in Los Angeles, Riverside, Orange and San Bernardino Counties

Blue Shield 65 Plus HMO (Medicare)

• Expanding service area to include Imperial, San Joaquin, San Francisco, and Nevada Counties

PERS Select PPO (Basic & Medicare)

• Expanding service area to include Marin County

PERS Select/Choice/Care PPO (Basic)

• Expanding the Value Based Site of Care program, which establishes a payment threshold for three additional elective procedures. When members receive service at an outpatient hospital rather than an ambulatory surgery center the following thresholds apply:
• Arthroscopy - $6,000 limit  
• Cataract Surgery - $2,000 limit
• Colonoscopy - $1,500 limit

                                      
Peace Officers Research Association of California (PORAC)

• Increasing the deductible from $50 to $100 for the Medicare Rx Plan

General Pharmacy Benefit Highlights

• Retail co-payments for brand name drugs will increase by $5.
• Members may receive a 90-day supply of maintenance medication through mail order for the price of a 60-day retail supply.
• Members maintain access to brand name drugs when a Food and Drug Administration approved generic equivalent is available by paying the difference between the cost of the generic and brand name drug. A brand co-payment applies when a prior authorization for the brand name drug is obtained due to medical necessity.
• Exclude discretionary lifestyle drugs from the $1,000 out-of-pocket maximum for mail order prescriptions.

New Pharmacy Benefit Manager for CalPERS PPO Members
CalPERS has selected CVS Caremark to administer prescription drug benefits for more than 346,000 members of CalPERS self-funded PERS Select, PERS Choice and PERS Care PPOs effective January 1, 2012. CVS Caremark will offer several new benefits:

• A Maintenance Choice Program will allow members to pick up a 90-day supply of medication directly from a CVS pharmacy at a time convenient to them. Members will pay their typical mail order co-pay for a prescription on the same day and be able to talk face-to-face with a pharmacist.
• The Gaps in Care Plus Medical Program will use an integrated medical and pharmaceutical approach to identify potential gaps and omissions in drug and medical therapy for participating CalPERS members.
• Members will be able to save money by choosing “best choice” medications (generics and preferred brands) and 90-day supplies, where appropriate, in the iBenefit personalized mailing program.