HomeMy WebLinkAbout2023-health-benefit-summary2023 | Health Benefit Summary
Helping you make an informed decision about your health plan
About This Publication
The 2023 Health Benefit Summary provides only a general
overview of certain benefits. It does not include details of
all covered expenses or exclusions and limitations. Please
refer to each health plan’s Evidence of Coverage (EOC)
booklet for the exact terms and conditions of coverage.
Health plans mail EOCs to new members at the beginning
of the year, and to existing members upon request. In case
of a conflict between this summary and your health plan’s
EOC, the EOC establishes the benefits that will be provided.
The 2023 Health Benefit Summary provides valuable
information to help you make an informed choice about
your health plan and health care providers. This publication
compares covered services, copayments, and benefits for
each CalPERS health plan. It also provides information
about plan availability by county and a chart summarizing
important differences among health plan types.
You can use this information to determine which health
plan offers the services you need at the cost that works for you.
The 2023 health plan premiums are available at the CalPERS
website at www.calpers.ca.gov. Check with your employer
to find out how much they contribute toward your premium.
We recommend that you only use this publication in
conjunction with the current year’s health premium rate
schedule and EOCs. To obtain a copy of the health premium
rate schedule for any health plan, please go to the CalPERS
website at www.calpers.ca.gov or contact CalPERS at
888 CalPERS (or 888–225–7377).
Other Health Publications
This publication is one of many resources CalPERS offers to
help you choose and use your health plan. Others include:
•Health Program Guide: Describes Basic and Medicare
health plan eligibility, enrollment, and choices
•Medicare Enrollment Guide: Provides information about
how Medicare works with your CalPERS health benefits
You can obtain the above publications and other
information about your CalPERS health benefits through
myCalPERS at my.calpers.ca.gov or by calling CalPERS
at 888 CalPERS (or 888–225–7377).
About CalPERS
CalPERS is the largest purchaser of public
employee health benefits in California, and the
second largest public purchaser in the nation
after the federal government. Our program
provides benefits for 1.5 million public
employees, retirees, and their families.
Depending on where you reside or work,
CalPERS offers active employees and retirees
one or more types of health plans, which
may include:
•Health Maintenance Organization (HMO)
•Preferred Provider Organization (PPO)
•Exclusive Provider Organization (EPO)
(for members in certain California counties)
The CalPERS Board of Administration annu-
ally determines health plan availability, covered
benefits, health premiums, and copayments.
Whether you are working or retired, your
employer or former employer makes monthly
contributions toward your health premiums.
The amount of this contribution varies. Your
cost may depend on your employer or former
employer’s contribution to your premium, the
length of your employment, and the health plan
you choose. For monthly contribution amounts,
active employees should contact their employer,
State retirees should contact CalPERS, and
contracting agency retirees should contact
their former employer.
2023 Health Benefit Summary | 1
Contents
Considering Your Health Plan Choices . . . . . . . 2
Understanding How CalPERS Health Plans Work . . .3
CalPERS Health Plan Choices . . . . . . . . . . 4
Choosing Your Doctor and Hospital . . . . . . . .5
Enrolling in a Health Plan Using Your Residential
or Work ZIP Code . . . . . . . . . . . . . 5
Health Plan Availability
Basic Plans . . . . . . . . . . . . . . . . 6
Medicare Plans . . . . . . . . . . . . . . 8
Tools to Help You Choose Your Health Plan . . . . . 10
Accessing Health Plan Information
with myCalPERS . . . . . . . . . . . . . 10
myCalPERS Health Plan Comparison Feature . . . 10
Comparing Your Options: Search Health Plans . . . .11
Comparing Your Options: Health Plan
Choice Worksheet . . . . . . . . . . . . .11
Health Plan Choice Worksheet. . . . . . . . . 12
CalPERS Health Plan Member Survey Results . . . .13
Additional Resources . . . . . . . . . . . . . . . . 14
Health Plan Directory . . . . . . . . . . . . 14
Obtaining Health Care Quality Information . . . . 15
CalPERS Health Plan Benefit Comparison
Basic Plans . . . . . . . . . . . . . . . . . . . .16
Medicare Plans . . . . . . . . . . . . . . . . . .24
2 | 2023 Health Benefit Summary
Considering Your Health Plan Choices
Selecting a health plan for you and your family is one
of the most important decisions you will make. This deci-
sion involves balancing the cost of each plan, along with
other features, such as access to doctors and hospitals,
pharmacy services, and special programs for managing
specific medical conditions. Choosing the right plan
ensures that you receive the health benefits and services
that matter to you.
If you are a new CalPERS member or you are consider-
ing changing your health plan during Open Enrollment,
you will need to make two related decisions:
•Which health plan is best for you and your family?
•Which doctors and hospitals do you want to provide
your care?
The combination of health plan and providers that is
right for you depends on a variety of factors, such as
whether you prefer a Health Maintenance Organization
(HMO) or Preferred Provider Organization (PPO); your
premium and out-of-pocket costs; and whether you want
to have access to specific doctors and hospitals.
We realize that comparing health plan benefits,
features, and costs can be complicated. This section
provides information that can simplify your decision-
making process. As you begin that process, the following
are some questions you should ask:
•Do you prefer to receive your health care from an
HMO or PPO? Your preference will impact the plans
available to you, your access to health care providers,
and how much you pay for certain services. See the
chart on the next page for a summary of the differences
among plan types.1
•What are the costs (premiums, copayments, deduct-
ibles, and coinsurance)? Beginning on page 16
of this publication, you will find information about bene-
fits, copayments, and covered services. Visit the
CalPERS website at www.calpers.ca.gov to find out what
the premiums are for the various plans.
•Does the plan provide access to the doctors and hospi-
tals you want? Contact health plans directly for this
information. See the “Health Plan Directory” on page 14
of this publication for health plan contact information.
1 Note that in a few counties where access to HMOs is limited, a third
option, Exclusive Provider Organization (EPO), is available. An EPO
provides benefits similar to an HMO with some PPO features.
2023 Health Benefit Summary | 3
Understanding How CalPERS Health Plans Work
The following chart will help you understand some important differences among health plan types.
Features HMO PPO EPO
Accessing
health care
providers
Contracts with providers
(doctors, medical groups,
hospitals, labs, pharmacies, etc.)
to provide you services
at a fixed price
Gives you access to a network of
health care providers (doctors,
hospitals, labs, pharmacies, etc.)
known as preferred providers
Gives you access to the EPO
network of health care
providers (doctors, hospitals,
labs, pharmacies, etc.)
Selecting a
primary care
physician
(PCP)
Most HMOs require you to
select a PCP who will work
with you to manage your
health care needs 1
All PPO plan members will have
an assigned PCP; however you can
choose not to go through your PCP2
All EPO plan members
will have an assigned PCP;
however you can choose
not to go through your PCP
Seeing a
specialist
Requires advance approval
from the medical group or
health plan for some services,
such as treatment by a specialist
or certain types of tests
Allows you access to many types
of services without receiving a
referral or advance approval
Allows you access to many
types of services without
receiving a referral or
advance approval
Obtaining care Generally requires you to obtain
care from providers who are a
part of the plan network
Requires you to pay the total
cost of services if you obtain
care outside the HMO’s
provider network without a
referral from the health plan
(except for emergency and
urgent care services)
Encourages you to seek services
from preferred providers to ensure
your coinsurance and copayments
are counted toward your calendar
year out-of-pocket maximums 3
Allows you the option of seeing
non-preferred providers, but
requires you to pay a higher
percentage of the bill 4
Requires you to obtain care
from providers who are a part
of the plan network
Requires you to pay the total
cost of services if you obtain
care outside the EPO’s
provider network without a
referral from the health plan
(except for emergency and
urgent care services)
Paying for
services
Requires you to make a small
copayment for most services
Limits the amount preferred provid-
ers can charge you for services
Considers the PPO plan payment
plus any deductibles and
copayments you make as payment
in full for services rendered by a
preferred provider
Requires you to make a
small copayment for
most services
1 Your PCP may be part of a medical group that has contracted with the health plan to perform some functions, including treatment authorization, referrals to
specialists, and initial grievance processing.
2 Members enrolled in the PERS Gold plan may access a lower copayment if they select a personal doctor.
3 Once you meet your annual deductible and maximum coinsurance, the plan pays 100% of medical services/claims from Preferred Providers for the
remainder of the calendar year; however, you will continue to be responsible for copayments for physician office visits, pharmacy, and other services,
up to the annual out-of-pocket maximum.
4 Non-preferred providers have not contracted with the health plan; therefore, you will be responsible for paying any applicable member deductibles or
coinsurance, plus any amount in excess of the allowed amount.
4 | 2023 Health Benefit Summary
CalPERS Health Plan Choices
Depending on where you reside or work, your Basic and Medicare health plan options may include the following:
Contacting a Health Plan
If you have a specific question about a plan’s
coverage, benefits, or participating providers,
please contact the plan directly. See the
“Health Plan Directory” on page 14 for health
plan contact information.
Basic EPO & HMO
Health Plans
Basic PPO
Health Plans
Supplement to
Medicare PPO &
HMO Health Plans
Medicare Managed
Care Plans (Medicare
Advantage)
Out-of-State
Plan Choices
Anthem Blue Cross EPO
Anthem Blue Cross
Select HMO
Anthem Blue Cross
Traditional HMO
Blue Shield Access+ HMO
Blue Shield Access+ EPO
Blue Shield Trio HMO
California Correctional
Peace Officers Association
(CCPOA) Medical Plan1
Health Net Salud y Más
Health Net SmartCare
Kaiser Permanente
Sharp Performance Plus
UnitedHealthcare
SignatureValue Alliance
UnitedHealthcare
SignatureValue Harmony
Western Health Advantage
California Association
of Highway Patrolmen
(CAHP) Health Plan1
PERS Gold
PERS Platinum
Peace Officers
Research Association
of California (PORAC)
Police and Fire
Health Plan1
CAHP Health Plan1
PERS Gold
PERS Platinum
PORAC Police and
Fire Health Plan1
Anthem Medicare
Preferred (PPO)
Blue Shield
Medicare (PPO)
CCPOA Medical Plan
Medicare (PPO)
Kaiser Permanente
Senior Advantage
Kaiser Permanente
Senior Advantage
Summit
Sharp Direct
Advantage (HMO)
UnitedHealthcare
Group Medicare
Advantage (PPO)
UnitedHealthcare
Group Medicare
Advantage Edge (PPO)
Western Health
Advantage
MyCare Select (HMO)
Blue Shield
Medicare (PPO)
Kaiser Permanente
(HMO)2
Kasier Permanente
Senior Advantage2
PERS Platinum (PPO)
PORAC Police and
Fire Health Plan (PPO)1
UnitedHealthcare
Group Medicare
Advantage (PPO)
UnitedHealthcare
Group Medicare
Advantage Edge (PPO)
1 You must belong to the specific employee association and pay
applicable dues to enroll in an Association Plan (CCPOA, CAHP
or PORAC)
2 Plan only available in certain states. Benefits out-of-state may differ
from those in California.
2023 Health Benefit Summary | 5
Choosing Your Doctor and Hospital
Some of our health plans are available only in certain
counties and/or ZIP Codes. As you consider your health
plan choices, you should determine which health plans are
available in the ZIP Code in which you are enrolling.
In general, if you are an active employee or a working
CalPERS retiree, you may enroll in a health plan using
either your residential or work ZIP Code.
If you are a retired CalPERS member, you may select
any health plan in your residential ZIP Code area. You
cannot use the address of the CalPERS-covered employer
from which you retired to establish ZIP Code eligibility.
To enroll in a Medicare Advantage plan, you must use
your residential address. In addition, Medicare Part D
Employer Group Waiver plans require you to provide a
physical address.
If you have a combination of Basic and Medicare
members on your health plan, you must choose a health
plan that has both Basic and Medicare plan options avail-
able within your residential ZIP Code area.
If you use your residential ZIP Code, all enrolled depen-
dents must reside in the health plan’s service area. When
you use your work ZIP Code, all enrolled dependents must
receive all covered services (except emergency and urgent
care) within the health plan’s service area, even if they do
not reside in that area.
To determine if the health plan you are considering
provides services where you reside or work, see the “Health
Plan Availability by County” chart on the following page.
You can also use the Health Plan search by ZIP Code, which
is available on the CalPERS website at www.calpers.ca.gov,
to find out which plans are available in your area. If you
have questions about plan availability or coverage, or wish
to obtain a copy of the Evidence of Coverage, contact the
health plans using the “Health Plan Directory” on page 14.
Once you choose a health plan, you should select a
primary care physician. Except in the case of an emer-
gency, the doctors you can use — and the medical groups
and hospitals you will have access to — will depend on
your choice of health plan.
Many people find their doctor by asking neighbors or
co-workers for a doctor’s name. Others receive referrals
from doctors they already know. Still others simply select
a physician from their health plan who happens to be
nearby. You can also use the Search Health Plans tool
(described on page 11), which is available by logging into
your myCalPERS account at my.calpers.ca.gov. Before you
choose a health plan, you should call the health plan's
member services to inquire about physician availability.
When choosing an HMO plan, you should confirm that the
doctor is taking new patients in the plan you select.
If you need to be hospitalized, your health plan or
medical group will have certain hospitals that you are able
to use. If you prefer a particular hospital, you should make
sure the health plan you select contracts with that hospital.
See page 15 for a list of resources that can help you evalu-
ate and select a doctor and hospital.
Enrolling in a Health Plan Using Your Residential or Work ZIP Code
6 | 2023 Health Benefit Summary
Health Plan Availability by County: Basic Plans
Some health plans are available only in certain counties
and/or ZIP Codes. Use the chart below to determine if the
health plan you are considering provides services where
you reside or work. Contact the plan before enrolling to
make sure they cover your ZIP Code and that their provider
network is accepting new patients in your area. You may
also use our online service, the Health Plan Search
by ZIP Code, available at www.calpers.ca.gov.
All counties subject to regulatory approval.
● Health plan covers all or part of county.
▲ Only PERS Platinum is available out-of-state.
■ Only applies to some agencies; does not apply
to public agencies or schools.
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Alpine ●●●●
Amador ●●●●
Butte ●●●●●●●
Calaveras ●●●●
Colusa ●●●●●
Contra Costa ●●●●●●●●●■
Del Norte ●●●●
El Dorado ●●●●●●●●●●
Fresno ●●●●●●●●●●
Glenn ●●●●●
Humboldt ●●●●●●
Imperial ●●●●●●●
Inyo ●●●●
Kern ●●●●●●●●●●●●
Kings ●●●●●●●●●●
Lake ●●●●
Lassen ●●●●
Los Angeles ●●●●●●●●●●●●●
Madera ●●●●●●●●
Marin ●●●●●●●●■●
Mariposa ●●●●●●
Mendocino ●●●●●
Merced ●●●●●●●■
Modoc ●●●●
Mono ●●●●
Monterey ●●1 ●●●
Napa ●●●●●●●
Nevada ●●●●●●●●
Orange ●●●●●●●●●●●●●
1 Pending regulatory approval.
2023 Health Benefit Summary | 7
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Sacramento ●●●●●●●●●●●
San Benito ●●●●
San Bernardino ●●●●●●●●●●●●●
San Diego ●●●●●●●●●●●●
San Francisco ●●●●●●●●●■
San Joaquin ●●●●●●●●●■
San Luis Obispo ●●●●●●●●
San Mateo ●●●●●●●●■
Santa Barbara ●●●●●●●
Santa Clara ●●●●●●●●●■
Santa Cruz ●●●●●●●●●●■
Shasta ●●●●
Sierra ●●●●
Siskiyou ●●●●
Solano ●●●●●●●●■●
Sonoma ●●●●●●●●■●
Stanislaus ●●●●●●●●●■
Sutter ●●●●
Tehama ●●●●
Trinity ●●●●
Tulare ●●●●●●●●●●
Tuolumne ●●●●
Ventura ●●●●●●●●●●
Yolo ●●●●●●●●●●●
Yuba ●●●●
Out-of-State ●▲●
8 | 2023 Health Benefit Summary
Health Plan Availability by County: Medicare Plans
Some health plans are available only in certain counties
and/or ZIP Codes. Use the chart below to determine if the
health plan you are considering provides services where
you reside or work. Contact the plan before enrolling to
make sure they cover your ZIP Code and that their provider
network is accepting new patients in your area. You may
also use our online service, the Health Plan Search
by ZIP Code, available at www.calpers.ca.gov.
All counties subject to regulatory approval.
● Health plan covers all or part of county.
▲ Only PERS Platinum is available out-of-state.
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Alameda ●●●●●●●●●●●
Alpine ●●●●●●●●●
Amador ●●●●●●●●●●●
Butte ●●●●●●●●●
Calaveras ●●●●●●●●●
Colusa ●●●●●●●●●●
Contra Costa ●●●●●●●●●●●
Del Norte ●●●●●●●●●
El Dorado ●●●●●●●●●●●●
Fresno ●●●●●●●●●●●
Glenn ●●●●●●●●●
Humboldt ●●●●●●●●●
Imperial ●●●●●●●●●
Inyo ●●●●●●●●●
Kern ●●●●●●●●●●●
Kings ●●●●●●●●●●●
Lake ●●●●●●●●●
Lassen ●●●●●●●●●
Los Angeles ●●●●●●●●●●●
Madera ●●●●●●●●●●●
Marin ●●●●●●●●●●●●
Mariposa ●●●●●●●●●●●
Mendocino ●●●●●●●●●
Merced ●●●●●●●●●
Modoc ●●●●●●●●●
Mono ●●●●●●●●●
Monterey ●●●●●●●●●
Napa ●●●●●●●●●●●●
Nevada ●●●●●●●●●
Orange ●●●●●●●●●●●
2023 Health Benefit Summary | 9
County An
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Placer ●●●●●●●●●●●●
Plumas ●●●●●●●●●
Riverside ●●●●●●●●●●●
Sacramento ●●●●●●●●●●●●
San Benito ●●●●●●●●●
San
Bernardino ●●●●●●●●●●●
San Diego ●●●●●●●●●●●●
San Francisco ●●●●●●●●●●●
San Joaquin ●●●●●●●●●●●
San Luis
Obispo ●●●●●●●●●
San Mateo ●●●●●●●●●●●
Santa Barbara ●●●●●●●●●
Santa Clara ●●●●●●●●●●●
Santa Cruz ●●●●●●●●●●●
Shasta ●●●●●●●●●
Sierra ●●●●●●●●●
Siskiyou ●●●●●●●●●
Solano ●●●●●●●●●●●●
Sonoma ●●●●●●●●●●●●
Stanislaus ●●●●●●●●●●●
Sutter ●●●●●●●●●●●
Tehama ●●●●●●●●●
Trinity ●●●●●●●●●
Tulare ●●●●●●●●●●●
Tuolumne ●●●●●●●●●
Ventura ●●●●●●●●●●●
Yolo ●●●●●●●●●●●●
Yuba ●●●●●●●●●●●
Out-of-State ●●●●●●●●
10 | 2023 Health Benefit Summary
Tools to Help You Choose Your Health Plan
This section provides a variety of information that can help
you evaluate your health plan choices. Included here are
details about using your myCalPERS account, the Search
Health Plans tool, and the Health Plan Choice Worksheet.
Accessing Health Plan Information with myCalPERS
You can use myCalPERS at my.calpers.ca.gov, our secure,
personalized website, to get one-stop access to all of your
current health plan information, including details about
which family members are enrolled. You can also use it to
search for other health plans that are available in your area,
compare health plans, access CalPERS Health Program
forms, and find additional information about CalPERS
health plans. If you are a retiree, CalPERS is your Health
Benefits Officer. Retirees may change their health plan
during Open Enrollment by calling CalPERS toll free
at 888 CalPERS (or 888–225–7377) or by using your
myCalPERS account.
myCalPERS Health Plan Comparison Feature
Health Plan Resources
Choosing a health plan that’s right for you is unique for
every person or family. myCalPERS includes additional
resources to help you choose a health plan. These resources
provide access to more detailed health benefit information
that can help you when selecting what is most important to
you in determining the plan that best fits your needs.
Evaluate Plan Features
Available health plans for you will be displayed based on the
physical or mailing health eligibility ZIP Code in our system.
Create a customized plan search where you’ll be able
to review:
•Monthly premiums for each plan available to you
•Side-by-side comparisons of covered benefits,
deductibles, and copayments for up to three plans
at one time.
Your myCalPERS Account
Log in to your myCalPERS account at my.calpers.ca.gov
and select the “Health” tab and then select “Search Health
Plans” to see what’s available to you. To speak with
someone at CalPERS about your health plan choices,
call 888 CalPERS (or 888–225–7377).
2023 Health Benefit Summary | 11
Get customized assistance selecting the health
plan that is right for you and your family by logging
into your myCalPERS account at my.calpers.ca.gov,
selecting the “Health” tab and then selecting
“Search Health Plans.”
Comparing Your Options: Health Plan Choice Worksheet
An alternative tool we provide to help you choose the best
plan for yourself and your family is the Health Plan Choice
Worksheet, which you can find on page 12 of this
publication. This worksheet can be used to compare factors
such as cost, availability, benefits, and quality of care
measures. Simply follow the steps listed in the left column
of the Worksheet. Several questions can be answered with
a simple “yes” or “no,” while others will require you to insert
information or call the health plan. Some of the information
can be found on the CalPERS website at www.calpers.ca.gov.
If you need assistance completing the form, contact
CalPERS at 888 CalPERS (or 888–225–7377).
Comparing Your Options: Search Health Plans
Access your myCalPERS account for a convenient way to
evaluate your health plan options and make a decision
about which plan is best for you and your family. With this
easy-to-use health plan comparison tool, you can weigh
plan benefits and costs, and view how the plans compare.
You can access your account 24/7 to help you make
health plan decisions at any time. You can use it to:
•Review health plan options during Open Enrollment.
•Evaluate your health plan options and estimate costs.
•Review a health plan option when your employer first
begins offering the CalPERS Health Benefits Program.
•Search doctors and specialists to see which plans they
participate in.
•Review health plan options due to changes in your
marital status or enrollment area.
•Explore health plan options because you are planning
for retirement or have become Medicare eligible.
Be sure to tell us what you think about your myCalPERS
plan search experience by completing a survey at the end
of your research.
12 | 2023 Health Benefit Summary
Plan name and phone numbers:
Select the type of plan: (circle choice)HMO PPO EPO Assoc.
Plan 1 HMO PPO EPO Assoc.
Plan 1
Step 1 — Cost
Calculate your monthly cost.
Enter the monthly premium (see current year’s rate
schedule). Premium amounts will vary based on
1-party/2-party/family and Basic/Medicare.
---
Enter your employer’s contribution.
For contribution amounts, active members should
contact their employer; retired members should
contact CalPERS.
--
Calculate your cost.
Subtract your employer’s contribution from the monthly
premium. If the total is $0 or less, your cost is $0.
-
Step 2 — Availability
Search available plans online.
Use our online service, the Health Plan Search by Zip
Code, at www.calpers.ca.gov to find out if the plan is
available in your residential or work ZIP Code. You may
also call the plan’s customer service center.
--
Call the doctor’s office.
Confirm that they contract with the plan and are
accepting new patients. Ask what specialists are
available and the hospitals with which they are affiliated.
--
Step 3 — Comparisons
How does the plan rate in quality of care measures?
See page 15 to find out.--
Compare the benefits.
See pages 16–31. CalPERS plans offer a standard
package of benefits, but there are some differences:
acupuncture, chiropractic, etc.
--
Step 4 — Other
Other considerations:
Does the plan offer health education? Do you or your
family have special medical needs? What services
are available when you travel? Are the provider
locations convenient?
--
What changes are you planning in the upcoming year
(e.g., retirement, transfer, move, etc.)?--
Other information --
Compare and select a plan.
1 You must belong to the specific employee association and pay applicable dues to enroll in the Association Plans.
Health Plan Choice Worksheet
2023 Health Benefit Summary | 13
Association Plans (CCPOA, CAHP, and PORAC) are available
only to members who belong to the applicable association.
In 2022, PERS Choice and PERSCare transitioned to
PERS Platinum and PERS Select transitioned to PERS Gold.
CalPERS Health Plan Member Survey Results
CalPERS conducts an annual Health Plan Member
Survey to assess members’ satisfaction with their health
plans during the previous 12-month period. We use
a modified version of the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) Survey, a
standard tool for measuring health plans. CalPERS evaluates
the survey results to compare satisfaction ratings across
health plans and over time. The results below reflect health
plan satisfaction during the 2021 plan year.
Member ratings offer another tool to help you choose
a plan that is right for you. Please note that your experience
may differ. The health plan ratings are based on the
experience of the individuals who participated in the survey.
Member Rating of Health Plans
Members were asked to rate their health plan on a
10-point scale with 10 being the best health plan possible.
The following charts show the average rating by plan
respondents in eligible Basic and Medicare health plans.
The CalPERS Health Benefits Program Annual
Report displays other valuable information about
the Health Program. To view the report, visit
CalPERS online at www.calpers.ca.gov.
Medicare Plan Ratings
Anthem Blue Cross Medicare Preferred
CAHP Medicare Supplement 9.4
Kaiser Permanente Senior Advantage 8.8
PERS Choice Medicare Supplement 8.9
PERSCare Medicare Supplement 9.2
PORAC Medicare Supplement 9.0
UnitedHealthcare Group MA 9.2
8.6
PERS Select Medicare Supplement 8.9
Overall Average Medicare Rating 9.0
Basic Plan Ratings
Anthem Blue Cross Traditional
Blue Shield Access+
Blue Shield Trio
CAHP
CCPOA
Health Net Salud y Más
Health Net SmartCare
Kaiser Permanente
PORAC
Sharp Performance Plus
UnitedHealthcare Alliance
Western Health Advantage
PERSCare 8.2
8.2
8.4
8.6
8.2
7.9
PERS Select 6.2
8.0
8.6
8.1
8.6
8.0
Anthem Blue Cross Select 8.0
7.8
7.7
PERS Choice 7.6
Overall Average Basic Rating 7.9
14 | 2023 Health Benefit Summary
Health Plan Directory
Anthem Blue Cross 2 HMO & EPO
(855) 839-4524
www.anthem.com/ca/calpers
Anthem Medicare Preferred2 PPO
(855) 251-8825
www.anthem.com/ca/calpers
Blue Shield of California
Active Member Services
(800) 334-5847
Medicare Member Services
(888) 802-4599
www.blueshieldca.com/calpers
California Association of
Highway Patrolmen (CAHP)
(800) 734-2247
www.thecahp.org
California Correctional Peace
Officers Association (CCPOA)
Active Member Services
(800) 257-6213
Medicare Member Services
(800) 776-4466
www.ccpoabtf.org
Health Net of California 1
(888) 926-4921
www.healthnet.com/calpers
Kaiser Permanente
(800) 464-4000
www.kp.org/calpers
OptumRx
Pharmacy Benefit Manager
Active Member Services
(855) 505-8110
Medicare Member Services
(855) 505-8106
www.optumrx.com/calpers
PERS Gold2 and PERS Platinum2
Administered by Anthem Blue Cross
(877) 737-7776
www.anthem.com/ca/calpers
Supplement to Medicare
(877) 737-7776
Peace Officers Research
Association of California (PORAC)
(800) 655-6397
http://ibtofporac.org
Sharp Health Plan 1
Active Member Services
(855) 955-5004
Retiree Member Services
(833) 346-4322
sharphealthplan.com/CalPERS
UnitedHealthcare
Active Member Services
(877) 359-3714
www.uhc.com/calpers
Retiree Member Services
(888) 867-5581
www.UHCRetiree.com/calpers
Western Health Advantage2
Active Member Services
(888) 942-7377
Medicare Member Services
(888) 942-7377
www.westernhealth.com/calpers
1 Pharmacy benefits administered by
OptumRx for the Basic plan only.
2 Pharmacy benefits administered
by OptumRx for both Basic and
Medicare plans.
Additional Resources
As a health care consumer, you have access to many
resources, services, and tools that can help you find the
right health plan, doctor, medical group, and hospital
for yourself and your family.
Following is contact information for the health plans.
Contact your health plan with questions about: ID cards;
verification of provider participation; service area
boundaries (covered ZIP Codes); benefits, deductibles,
limitations, exclusions; and Evidence of Coverage booklets.
2023 Health Benefit Summary | 15
Obtaining Health Care Quality Information
Hospitals
Cal Hospital Compare
www.calhospitalcompare.org
Cal Hospital Compare makes it easy to find and compare
the quality of hospitals in California.
U.S. Department of Health and Human Services
www.medicare.gov/hospitalcompare
Hospital Compare has information about the quality of
care at over 4,000 Medicare-certified hospitals across
the country.
The Leapfrog Group
www.leapfroggroup.org
This is a coalition of health purchasers who have
found that hospitals meeting certain standards have
better care results.
Doctors and Medical Groups
Medical Board of California
www.mbc.ca.gov
This is the California State agency that licenses medical
doctors, investigates complaints, disciplines those who
violate the law, conducts physician evaluations, and
facilitates rehabilitation where appropriate.
Have you done a checkup on your doctor’s license?
The Medical Board of California encourages consumers
to check up on their doctor’s license. Such a checkup is
simple and helps you make an informed choice when
choosing a doctor. To determine a doctor’s status, go to
the Medical Board’s website at www.mbc.ca.gov or if you
do not have a computer, call (800) 633-2322 and Medical
Board staff will look up the doctor for you.
Office of the Patient Advocate
www.opa.ca.gov
This website includes a State of California-sponsored
“Report Card” that contains additional clinical and
member experience data on HMOs, PPOs and medical
groups in California.
Following is a list of resources you can use to evaluate
and select a doctor and hospital.
Benefit Comparison Charts
The benefit comparison charts on pages 16–31
summarize the benefit information for each
health plan. For more details, see each plan’s
Evidence of Coverage (EOC) booklet.
16 | 2023 Health Benefit Summary
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
All benefits subject to regulatory approval.
CalPERS Health Plan Benefit Comparison—
Basic Plans
EPO & HMO Basic Plans
BENEFITS
Anthem
Blue Cross
Blue Shield Health Net Kaiser
Permanente
Sharp
Performance
Plus
UnitedHealthcare
SignatureValue
Alliance
UnitedHealthcare
SignatureValue
HarmonyEPO
Select HMO
Traditional HMO
Access+ HMO &
Access+ EPO
Trio HMO
Salud y Más &
SmartCare
Calendar Year Deductible
Individual N/A N/A N/A N/A N/A N/A N/A
Family N/A N/A N/A N/A N/A N/A N/A
Ma ximum Calendar Year Copay or Coinsurance (excluding pharmacy)
Individual $1,500
(copay)
$1,500
(copay)
$1,500
(copay)
$1,500
(copay)
$1,500
(copay)
$1,500
(copay)
$1,500
(copay)
Family $3,000
(copay)
$3,000
(copay)
$3,000
(copay)
$3,000
(copay)
$3,000
(copay)
$3,000
(copay)
$3,000
(copay)
Hospital (including Mental Health and Substance Abuse)
Deductible
(per admission)N/A N/A N/A N/A N/A N/A N/A
Inpatient No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Outpatient
Facility/Surgery Services No Charge No Charge No Charge $15 No Charge No Charge No Charge
2023 Health Benefit Summary | 17
Continued on next page
PPO Basic Plans
Western
Health
Advantage
HMO
CCPOA
(Association
Plan)
BENEFITS
PERS Gold PERS Platinum CAHP
(Association Plan)
PORAC
(Association Plan)
PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO
Calendar Year Deductible
N/A N/A Individual $1,000 1,3 $500 3 N/A $300 $600
N/A N/A Family $2,000 1,3 $1,000 3 N/A $900 $1,800
Maximum Calendar Year Copay or Coinsurance (excluding pharmacy)
$1,500
(copay)
$1,500
(copay)Individual $3,000
(coinsurance)Unlimited $2,000
(coinsurance) Unlimited $3,000
(coinsurance)Unlimited $2,000 Unlimited
$3,000
(copay)
$4,500
(copay)Family $6,000
(coinsurance)Unlimited $4,000
(coinsurance)Unlimited $6,000
(coinsurance)Unlimited $4,000 Unlimited
Hospital (including Mental Health and Substance Abuse)
N/A N/A Deductible
(per admission)N/A $250 N/A N/A
No Charge $100/
admission Inpatient 20% 2 40% 4 10%40% 4 10%Varies 20%20% 4
No Charge $50 Outpatient Facility/
Surgery Services 20%40% 4 10%40% 4 10%40% 4 20%20% 4
1 Incentives available to reduce individual deductible (max. $500) or family deductible (max. $1,000) include: getting a biometric screening ($100 credit); receiving a flu
shot ($100 credit); getting a non-smoking certification ($100 credit); getting a virtual second opinion ($100 credit); and getting a condition care certification ($100 credit).
2 Coinsurance waived for deliveries if enrolled in Future Moms Program.
3 Deductible is transferable between PERS Gold and PERS Platinum.
4 Of the allowable amount as defined in the EOC.
18 | 2023 Health Benefit Summary
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
All benefits subject to regulatory approval.
CalPERS Health Plan Benefit Comparison—Basic Plans, Continued
EPO & HMO Basic Plans
BENEFITS
Anthem
Blue Cross
Blue Shield Health Net Kaiser
Permanente
Sharp
Performance
Plus
UnitedHealthcare
SignatureValue
Alliance
UnitedHealthcare
SignatureValue
HarmonyEPO
Select HMO
Traditional HMO
Access+ HMO &
Access+ EPO
Trio HMO
Salud y Más &
SmartCare
Emergency Services
Emergency Room
Deductible N/A N/A N/A N/A N/A N/A N/A
Emergency (copay waived
if admitted as an inpatient
or for observation as an
outpatient)
$50 $50 $50 $50 $50 $50 $50
Non-Emergency
(copay waived if admitted as an inpatient or for observation as an outpatient)
$50 $50 $50 $50 $50 $50 $50
Physician Services (including Mental Health and Substance Abuse)
Office Visits (copay for
each service provided)$15 $15 $15 $15 $15 $15 $15
Inpatient Visits No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Outpatient Visits $15 $15 $15 $15 $15 $15 $15
Urgent Care Visits $15 $15 $15 $15 $15 $15 $15
Preventive Services No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Surger y/Anesthesia No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Diagnostic X-Ray/Lab
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
2023 Health Benefit Summary | 19
Continued on next page
PPO Basic Plans
Western
Health
Advantage
HMO
CCPOA
(Association
Plan)
BENEFITS
PERS Gold PERS Platinum CAHP
(Association Plan)
PORAC
(Association Plan)
PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO
Emergency Services
N/A N/A Emergency Room
Deductible
$50
(applies to hospital
emergency room facility
charge only)
$50
(applies to hospital
emergency room
charges only)
$50
(copay reduced to $25
if admitted on an
inpatient basis)
N/A
$50 $75 Emergency
20%
(applies to other services
such as physician, x-ray,
lab, etc.)
10%
(applies to other services
such as physician, x-ray,
lab, etc.)
10%
(applies to other services
such as physician, x-ray,
lab, etc.)
20%
$50 $75 Non-Emergency
20%40%10%40%$50+10%$50+40%50%
(for non-emergency
services provided by
hospital emergency room)
(payment for physician
charges only; emergency
room facility charge is
not covered)
(payment for physician
charges only; emergency
room facility charge is
not covered)
(copay reduced to $25
if admitted on an
inpatient basis)
Physician Services (including Mental Health and Substance Abuse)
$15 $15 Office Visits (copay for
each service provided)$35 1 40% 3 $20 2 40% 3 $20 40% 3 $10/$35 2 20% 3
No Charge No Charge Inpatient Visits 20%40% 3 10%40% 3 10%40% 3 20%20% 3
$15 $15 Outpatient Visits $35 40% 3 $20 40% 3 10%40% 3 20%20% 3
$15 $15 Urgent Care Visits $35 40% 3 $35 40% 3 $20 40% 3 $35 20% 3
No Charge No Charge Preventive Services No Charge 40% 3 No
Charge 40% 3 No
Charge 40% 3 No Charge
No Charge No Charge Surgery/Anesthesia 20%40% 3 10%40% 3 10%40% 3 20%20% 3
Diagnostic X-Ray/Lab
No Charge No Charge 20%40% 3 10%40% 3 10%40% 3 20%20% 3
1 Reduced to $10 when seen by primary physician
2 $35 for specialist visit
3 Of the allowable amount as defined in the EOC
20 | 2023 Health Benefit Summary
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
All benefits subject to regulatory approval.
CalPERS Health Plan Benefit Comparison—Basic Plans, Continued
EPO & HMO Basic Plans
BENEFITS
Anthem
Blue Cross
Blue Shield Health Net Kaiser
Permanente
Sharp
Performance
Plus
UnitedHealthcare
SignatureValue
Alliance
UnitedHealthcare
SignatureValue
HarmonyEPO
Select HMO
Traditional HMO
Access+ HMO &
Access+ EPO
Trio HMO
Salud y Más &
SmartCare
Prescription Drugs
Deductible
N/A N/A N/A N/A N/A N/A N/A
Retail Pharmacy
(30-day supply)Tier 1: $5
Tier 2: $20
Tier 3: $50
Generic/Tier 11: $5
Preferred Brand/
Tier 21: $20
Non-Preferred/
Tier 31: $50
Tier 41: $30
Tier 1: $5
Tier 2: $20
Tier 3: $50
Generic: $5
Brand: $20
Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 1: $5
Tier 2: $20
Tier 3: $50
Retail Preferred
Pharmacy Maintenance
Medications
(90-day supply)
Tier 1: $10
Tier 2: $40
Tier 3: $100
Generic/Tier 11: $10
Preferred Brand/
Tier 21: $40
Non-Preferred/
Tier 31: $100
Tier 41: $60
Tier 1: $10
Tier 2: $40
Tier 3: $100
N/A
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Mail Order Pharmacy
Program (not to exceed 90-
day supply for maintenance
drugs)
Tier 1: $10
Tier 2: $40
Tier 3: $100
Generic/Tier 11: $10
Preferred Brand/
Tier 21: $40
Non-Preferred/
Tier 31: $100
Tier 41: $60
Tier 1: $10
Tier 2: $40
Tier 3: $100
Generic: $10
Brand: $40
(31-100 day
supply)
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Mail order maximum
copayment per person per
calendar year $1,000 $1,000 $1,000 N/A $1,000 $1,000 $1,000
Durable Medical Equipment
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
1 Tier Formulary is for BSC Trio HMO only
Tier 1 refers to medications classified as ‘Generic’; Tier 2 refers to medications classified as “Preferred Brand”; and Tier 3 refers to medications classified as “Non-Preferred Brand”.
2023 Health Benefit Summary | 21
Continued on next page
PPO Basic Plans
Western
Health
Advantage
HMO
CCPOA
(Association
Plan)
BENEFITS
PERS Gold PERS Platinum CAHP
(Association Plan)
PORAC
(Association Plan)
PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO
Prescription Drugs
N/A
Tier 2, 3,
and 4: $50
(not to exceed
$150/family)
Deductible
N/A N/A N/A N/A
Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 1: $10
Tier 2: $25
Tier 3 and 4:
$50
Retail Pharmacy
(30-day supply)Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 1: $5
Tier 2: $20
Tier 3: $50
Generic: $5
Formulary: $20
Non-Formulary: $50
Generic: $10
Brand Formulary: $25
Non-Formulary: $45
Compound: $45
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $30
Tier 2: $75
Tier 3 and 4:
$150
Retail Preferred
Pharmacy
Maintenance
Medications
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Generic: $10
Formulary: $40
Non-Formulary:
$100
N/A
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $30
Tier 2: $75
Tier 3 and 4:
$100
Mail Order Pharmacy
Program (not to exceed
90-day supply for
maintenance drugs)
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Generic: $10
Formulary: $40
Non-Formulary:
$100
Generic: $20
Brand
Formulary:
$40
Non-Formulary:
$75
N/A
$1,000 N/A
Mail order maximum
copayment per person
per calendar year $1,000 $1,000 N/A N/A
Durable Medical Equipment
No Charge No Charge
20%40% 1 10%40% 1
10%40% 1 20%20% 1(pre-certification required
for specific equipment)
(pre-certification required
for the purchase of
equipment priced at $1,000
or more)
1 Of the allowable amount as defined in the EOC
22 | 2023 Health Benefit Summary
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
All benefits subject to regulatory approval.
CalPERS Health Plan Benefit Comparison—Basic Plans, Continued
EPO & HMO Basic Plans
BENEFITS
Anthem
Blue Cross
Blue Shield Health Net Kaiser
Permanente
Sharp
Performance
Plus
UnitedHealthcare
SignatureValue
Alliance
UnitedHealthcare
SignatureValue
HarmonyEPO
Select HMO
Traditional HMO
Access+ HMO &
Access+ EPO
Trio HMO
Salud y Más &
SmartCare
Infertility Testing/Treatment
50% of Covered
Charges
50% of Covered
Charges
50% of Covered
Charges
50% of
Covered
Charges
50% of
Covered
Charges
50% of Covered
Charges
50% of Covered
Charges
Occupational / Physical / Speech Therapy
Inpatient (hospital or skilled
nursing facility)No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Outpatient (office and
home visits)
$15 $15 $15 $15 $15 $15 $15
Diabetes Services
Glucose monitors Coverage varies No Charge Coverage varies No Charge Coverage
varies Coverage varies Coverage varies
Self-management
training $15 $15 $15 $15 $15 $15 $15
Acupuncture
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
Chiropractic
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
2023 Health Benefit Summary | 23
Continued on next page
PPO Basic Plans
Western
Health
Advantage
HMO
CCPOA
(Association
Plan)
BENEFITS
PERS Gold PERS Platinum CAHP
(Association Plan)
PORAC
(Association Plan)
PPO Non-PPO PPO Non-PPO PPO Non-PPO PPO Non-PPO
Infertility Testing/Treatment
50% of
Covered
Charges
50% of
Allowed
Charges
50%50%Not Covered 50%50% 2
Occupational / Physical / Speech Therapy
No Charge No Charge Inpatient (hospital or
skilled nursing facility)No Charge No Charge 10%40%
20%
(no copay for
in-patient PT/
OT by a PAR
provider)
20% 2
$15 No Charge
Outpatient (office and
home visits)20%
40%;
Occupational
therapy: 20%
10%
40%;
Occupational
therapy: 10%
10%40%$15/visit (all other
services
20%)3
20% 2
(pre-certification required
for more than 24 visits)
(pre-certification required
for more than 24 visits)
(pre-certification required
for more than 24 visits)
Diabetes Services
Coverage
varies
Coverage
varies Glucose monitors Coverage Varies Coverage Varies Coverage Varies Coverage Varies
$15 $15 Self-management
training $20 1 40% 2 $20 1 40% 2 $20 60% 2 $20 60% 2
Acupuncture
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
N/A
$15/visit 40% 2 $15/visit 40% 2 10%40% 2
$15 copay
(all other services
20%)3
20% 2
(acupuncture/chiropractic;
combined 20 visits
per calendar year)
(acupuncture/chiropractic;
combined 20 visits
per calendar year)
(acupuncture/chiropractic;
combined 20 visits
per calendar year)
Chiropractic
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15 exam
(up to 20
visits per
calendar year)
chiropractic
appliances
benefit: $50
$15/visit 40% 2 $15/visit 40% 2 10%40% 2
$15/visit
(combined 20 visits per
calendar year)
20% 2(acupuncture/chiropractic;
combined 20 visits per
calendar year)
(acupuncture/chiropractic;
combined 20 visits per
calendar year)
(acupuncture/chiropractic;
combined 20 visits
per calendar year)
1 $35 for specialist visit
2 Of the allowable amount as defined in the EOC
3 Combined 20 visits per calendar year. Speech therapy is not included in the 20 visit per calendar year
combination; see EOC for Speech Therapy benefit.
CalPERS Health Plans Benefit Comparison — Basic Plans, Continued
24 | 2023 Health Benefit Summary
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
CalPERS Health Plan Benefit Comparison—
Medicare Plans
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
All benefits subject to regulatory approval.
Medicare Plans
BENEFITS
Kaiser Permanente
Senior Advantage
(HMO)
Kaiser Permanente
Senior Advantage
Summit (HMO)
Anthem Medicare
Preferred (PPO)
Blue Shield
Medicare (PPO)
Sharp Direct
Advantage (HMO)
UnitedHealthcare
Group Medicare
Advantage (PPO)
Calendar Year Deductible
Individual N/A N/A N/A N/A N/A N/A
Family N/A N/A N/A N/A N/A N/A
Maximum Calendar Year Copay or Coinsurance (excluding pharmacy)
Individual $1,500
(copay)
$1,500
(copay)
$1,500
(copay/coinsurance)
$1,500
(copay)
$1,500
(copay/coinsurance)
$1,500
(copay)
Family N/A N/A N/A N/A N/A N/A
Hospital (including Mental Health and Substance Abuse)
Inpatient No Charge No Charge No Charge No Charge No Charge No Charge
Outpatient Facility/
Surgery Services $10 No Charge No Charge No Charge No Charge No Charge
Skilled Nursing Facility (up to 100 days/benefit period)
No Charge No Charge No Charge No Charge No Charge No Charge
Home Health Services
No Charge No Charge No Charge No Charge No Charge No Charge
Hospice
No Charge No Charge No Charge No Charge No Charge No Charge
Emergency Services (waived if admitted or hospitalized as an outpatient)
$50 $50 $50 $50 $50 $50
Ambulance Services
No Charge No Charge No Charge No Charge No Charge No Charge
2023 Health Benefit Summary | 25
Continued on next page
Medicare Plans
UnitedHealthcare
Group Medicare
Advantage Edge
(PPO)
Western Health
Advantage
MyCare Select
(HMO)
CCPOA
Medical Plan
Medicare
(PPO)BENEFITS
PERS Gold PERS Platinum CAHP
Medicare
Supplement
(Association
Plan)
PORAC
(Association
Plan)PPO Non-
PPO
PPO Non-
PPO
Calendar Year Deductible
N/A N/A N/A Individual N/A N/A N/A N/A
N/A N/A N/A Family N/A N/A N/A N/A
Maximum Calendar Year Copay or Coinsurance (excluding pharmacy)
$0
(copay)
$1,500
(copay/
coinsurance)
$1,500
(copay)Individual N/A
$3,000 1,2
(co-
insurance)
N/A N/A N/A
N/A N/A N/A Family N/A N/A N/A N/A
Hospital (including Mental Health and Substance Abuse)
No Charge No Charge $100/
admission Inpatient No Charge No Charge No Charge No Charge
No Charge No Charge No Charge Outpatient Facility/
Surgery Services No Charge No Charge No Charge No Charge
Skilled Nursing Facility (up to 100 days/benefit period)
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Home Health Services
No Charge No Charge $15/visit No Charge No Charge No Charge No Charge
Hospice
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Emergency Services (waived if admitted or hospitalized as an outpatient)
No Charge $50 No Charge No Charge No Charge No Charge No Charge
Ambulance Services
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
1 See EOC for additional details
2 For Benefits Beyond Medicare
3 Of the allowed amount
26 | 2023 Health Benefit Summary
CalPERS Health Plans Benefit Comparison — Medicare Plans, Continued
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
All benefits subject to regulatory approval.
CalPERS Health Plan Benefit Comparison—Medicare Plans, Continued
Medicare Plans
BENEFITS
Kaiser Permanente
Senior Advantage
(HMO)
Kaiser Permanente
Senior Advantage
Summit (HMO)
Anthem Medicare
Preferred (PPO)
Blue Shield
Medicare (PPO)
Sharp Direct
Advantage (HMO)
UnitedHealthcare
Group Medicare
Advantage (PPO)
Surgery/Anesthesia
No Charge
inpatient;
$10 outpatient
No Charge No Charge No Charge No Charge No Charge
Physician Services (including Mental Health and Substance Abuse)
Office Visits $10 No Charge $10 No Charge No Charge $10
Inpatient Visits No Charge No Charge No Charge No Charge No Charge No Charge
Outpatient Visits $10 No Charge $10 No Charge No Charge $10
Urgent Care Visits $10 No Charge $25 No Charge No Charge $25
Preventive Services No Charge No Charge No Charge No Charge No Charge No Charge
Diagnostic X-Ray/Lab
No Charge No Charge No Charge No Charge No Charge No Charge
Durable Medical Equipment
No Charge No Charge 10%
(coinsurance)No Charge No Charge No Charge
2023 Health Benefit Summary | 27
Continued on next page
Medicare Plans
UnitedHealthcare
Group Medicare
Advantage Edge
(PPO)
Western Health
Advantage
MyCare Select
(HMO)
CCPOA
Medical Plan
Medicare
(PPO)BENEFITS
PERS Gold PERS Platinum CAHP
Medicare
Supplement
(Association
Plan)
PORAC
(Association
Plan)PPO Non-
PPO
PPO Non-
PPO
Surger y/Anesthesia
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Physician Services (including Mental Health and Substance Abuse)
No Charge No Charge $10 Office Visits No Charge No Charge $10 No Charge
No Charge No Charge No Charge Inpatient Visits No Charge No Charge No Charge No Charge
No Charge No Charge $10 Outpatient Visits No Charge No Charge No Charge No Charge
No Charge No Charge No Charge Urgent Care Visits No Charge No Charge No Charge No Charge
No Charge No Charge No Charge Preventive Services No Charge No Charge No Charge No Charge
Diagnostic X-Ray/Lab
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
Durable Medical Equipment
No Charge No Charge No Charge No Charge No Charge No Charge No Charge
28 | 2023 Health Benefit Summary
CalPERS Health Plans Benefit Comparison — Medicare Plans, Continued
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
All benefits subject to regulatory approval.
CalPERS Health Plan Benefit Comparison—Medicare Plans, Continued
Medicare Plans
BENEFITS
Kaiser Permanente
Senior Advantage
(HMO)
Kaiser Permanente
Senior Advantage
Summit (HMO)
Anthem Medicare
Preferred (PPO)
Blue Shield
Medicare (PPO)
Sharp Direct
Advantage (HMO)
UnitedHealthcare
Group Medicare
Advantage (PPO)
Prescription Drugs
Deductible N/A N/A N/A N/A N/A N/A
Retail Pharmacy
(30-day supply)Generic: $5
Preferred: $20
Generic: $5
Preferred: $20
Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 4: $20
Preferred Generic: $5
Generic: $5
Preferred Brand: $20
Non-Preferred: $50
Specialty: $20
Select Care: $0
Generic: $5
Preferred: $20
Specialty: $20
Non-Preferred: $50
Retail Preferred
Pharmacy Long-Term
Prescription Medications
N/A N/A
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 4: N/A
Preferred Generic: $15
Generic: $15
Preferred Brand: $60
Non-Preferred: $150
Specialty: N/A
Select Care: $0
Generic: $10
Preferred: $40
Specialty: $40
Non-Preferred: $100
Mail Order
Pharmacy Program
(not to exceed 90-day supply)
Generic: $10
Preferred: $40
(31-100 day supply)
Generic: $10
Preferred: $40
(31-100 day supply)
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 4: N/A
Preferred Generic: $10
Generic: $10
Preferred Brand: $40
Non-Preferred: $100
Specialty: N/A
Select Care: $0
Generic: $10
Preferred: $40
Specialty: $40
Non-Preferred: $100
Mail order maximum
copayment per person
per calendar year N/A N/A $1,000 $1,000 N/A $1,000
Occupational / Physical / Speech Therapy
Inpatient (hospital or skilled
nursing facility)No Charge No Charge No Charge No Charge No Charge No Charge
Outpatient
(office and home visits)$10 No Charge $10 No Charge No Charge $10
Diabetes Services
Glucose monitors No Charge No Charge No Charge No Charge No Charge No Charge
2023 Health Benefit Summary | 29
Continued on next page
Medicare Plans
UnitedHealthcare
Group Medicare
Advantage Edge
(PPO)
Western Health
Advantage
MyCare Select
(HMO)
CCPOA
Medical Plan
Medicare
(PPO)BENEFITS
PERS Gold PERS Platinum CAHP
Medicare
Supplement
(Association
Plan)
PORAC
(Association
Plan)PPO Non-
PPO
PPO Non-
PPO
Prescription Drugs
N/A N/A N/A Deductible N/A N/A N/A $100
Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 1: $5
Tier 2: $20
Tier 3: $35
Tier 4: $50
Retail Pharmacy
(30-day supply)Tier 1: $5
Tier 2: $20
Tier 3: $50
Tier 1: $5
Tier 2: $20
Tier 3: $50
Generic: $5
Formulary:
$20
Non-
Formulary:
$50
Generic: $10
Preferred:
$25
Non-
Preferred:
$45
Tier 1: $10
Tier 2: $40
Tier 3: $100
Generic: $10
Preferred: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $70
Tier 4: N/A
Retail Preferred
Pharmacy
Maintenance
Medication
(90-day supply)
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Generic: $5
Formulary:
$20
Non-
Formulary:
$50
N/A
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $70
Tier 4: N/A
Mail Order
Pharmacy Program
(not to exceed 90-day
supply for maintenance
drugs)
Tier 1: $10
Tier 2: $40
Tier 3: $100
Tier 1: $10
Tier 2: $40
Tier 3: $100
Generic: $10
Formulary:
$40
Non-
Formulary:
$100
Generic: $20
Preferred:
$40
Non-
Preferred:
$75
$1,000 $1,000 N/A
Mail order maximum
copayment per
person per
calendar year
$1,000 $1,000 N/A N/A
Occupational / Physical / Speech Therapy
No Charge No Charge No Charge Inpatient (hospital or
skilled nursing facility)No Charge No Charge No Charge No Charge
No Charge No Charge No Charge Outpatient (office and
home visits)No Charge No Charge No Charge No Charge
Diabetes Services
No Charge No Charge No Charge Glucose monitors No Charge No Charge No Charge $25
1 Of the allowed amount
2 See EOC for additional details
30 | 2023 Health Benefit Summary
CalPERS Health Plans Benefit Comparison — Medicare Plans, Continued
For more details about the benefits provided by a specific plan,
refer to that plan’s Evidence of Coverage (EOC) booklet.
All benefits subject to regulatory approval.
CalPERS Health Plan Benefit Comparison—Medicare Plans, Continued
Medicare Plans
BENEFITS
Kaiser Permanente
Senior Advantage
(HMO)
Kaiser Permanente
Senior Advantage
Summit (HMO)
Anthem Medicare
Preferred (PPO)
Blue Shield
Medicare (PPO)
Sharp Direct
Advantage (HMO)
UnitedHealthcare
Group Medicare
Advantage (PPO)
Hearing Services
Routine Hearing Exam $10 No Charge No Charge No Charge No Charge No Charge
Physician Services $10 No Charge $10 $10 $10 $10
Hearing Aids $1,000 max/
36 months
$1,000 max/
36 months
$1,000 max/
36 months
$1,000 max/
36 months
$1,000 max/
36 months
$1,000 max/
36 months
Vision Care
Vision Exam $10 No Charge $10 $10 $10 $10
Eyeglasses (following
cataract surgery)
No Charge No Charge No Charge No Charge No Charge No Charge
Contact Lenses
(following cataract
surgery)No Charge No Charge No Charge No Charge No Charge No Charge
Benefits Beyond Medicare (Services covered beyond Medicare coverage)
Acupuncture
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$10/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
Chiropractic
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$10/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
2023 Health Benefit Summary | 31
Continued on next page
Medicare Plans
UnitedHealthcare
Group Medicare
Advantage Edge
(PPO)
Western Health
Advantage
MyCare Select
(HMO)
CCPOA
Medical Plan
Medicare
(PPO)BENEFITS
PERS Gold PERS Platinum CAHP
Medicare
Supplement
(Association
Plan)
PORAC
(Association
Plan)PPO Non-
PPO
PPO Non-
PPO
Hearing Services
No Charge No Charge No Charge Routine Hearing Exam No Charge No Charge No Charge 20%
No Charge No Charge $10 Physician Services No Charge No Charge No Charge 20%
$2,000
allowance every
24 months
$1,000 max/
36 months
$500 max/
12 months Hearing Aids
20%
($1,000 max/36
months)
20%
($2,000 max/24
months)
10%
($1,000 max/
36 months)
20%
($900 max/
36 months)
Vision Care
No Charge No Charge $10 Vision Exam One exam per
calendar year
One exam per
calendar year N/A 20%
No Charge No Charge No Charge
Eyeglasses One set of
frames during a
24-month period;
$30 maximum
allowance
One set of
frames during a
24-month period;
$30 maximum
allowance
N/A
20%
($40 maximum
allowance)
No Charge No Charge No Charge
Contact Lenses $100 maximum
allowance
$100 maximum
allowance No Charge
20%
($40 maximum
allowance)
Benefits Beyond Medicare (Services covered beyond Medicare coverage)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
Acupuncture
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
20%20%
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
$15/visit
(acupuncture/
chiropractic;
combined
20 visits per
calendar year)
Chiropractic
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
$15/visit
(acupuncture/
chiropractic;
combined 20 visits
per calendar year)
20%20%
32 | 2023 Health Benefit Summary
Notes
2023 Health Benefit Summary | 33
Notes
CalPERS Health Benefits Program
P.O. Box 942715
Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377)
www.calpers.ca.gov
HBD–110
Produced by CalPERS
Communications and Stakeholder Relations
Office of Public Affairs
September 2022.09.1