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New report from CSR Health Benefits Committee | CalPERS Health Plan Open Enrollment Considerations & Pharmacy Benefits Changes

Posted 3 years 272 days ago ago by CSR Website Administrator    0 Comments  0 Likes Like Dislike

Health Plan Open Enrollment for CalPERS members is Sept. 12- Oct. 7. Most members who are satisfied with their current plan need do nothing to remain in the same plan. The exception is Blue Cross Net Value members. That plan is being discontinued.

If members on that plan do nothing, they will automatically be transitioned to Blue Shield Access Plus, starting Jan. 1, 2017. Or they may choose another health plan during this Open Enrollment period.

  • If you use a computer and register for My|CalPERS – www.calpers.ca.gov – you make changes online.  
  • If you do not use a computer, you may follow the instructions in the Open Enrollment packet mailed to your home.
  • If you did not receive an Open Enrollment packet, call (888) 225-7377 and request that one be sent to you.


Besides the cost and benefits provided in a plan, the provider network of doctors, groups, and hospitals are also very important considerations when selecting a plan. Each plan's website provides access to a list of approved providers for that plan. Historically, these lists have been woefully inaccurate and out of date.

Under SB 137 (Sen. Ed Hernandez), which took effect July 1, 2016, insurance companies are mandated to update their online provider lists weekly and their printed lists quarterly, including the names of doctors, current addresses, phone numbers and if they are accepting new patients. Unfortunately, the lists are in such bad shape that even with the new law, the lists are still very unreliable. Some of our own CSR members have checked Anthem's online list and found doctors on the list who do not accept Anthem anymore and doctors who are shown to be accepting new patients, who have not done so for a year or more.

I contacted the Department of Managed Services, the state agency which enforces the new law, and found that the insurance companies are lagging in getting their lists up to date. It will likely be the end of 2016 before the lists begin to reflect more accurate information.

This is too late for those going through Open Enrollment this year. So for those wanting or needing to change health plans, recommend the following:

  1. Review the Provider Directories available on each plan's website or by requested mailing.
  2. Call any provider who you want to retain or obtain and ask them if they take the plan you are considering. You must be specific regarding the name of the plan. For example, you can't just say, UnitedHealthcare (UHC), because for basic plans UHC has a UHC Signature Value and a Signature Value Alliance. They have different providers.
  3. If you are seeking a new provider, ask if they are accepting new patients, even if the list says they are.
  4. If you find inaccurate listings on a plan directory, report them to the insurance company and note the date. They have 30 days, by law, to update their online list. If they aren't corrected by then, they may be reported to the Department of Managed Care.

Unfortunately, this is the tedious work we should not have to do and that the law was intended to prevent. By this time next year, I am hopeful the lists will be in much better shape.


The new Pharmacy Benefit Manager, beginning Jan. 1, 2017, is OptumRx, which replaces CVS Caremark. This affects about 460,000 of the 1.4 million covered members. Those on Kaiser, Blue Shield, and UnitedHealthcare Medicare Advantage PPO are not affected because they have their own pharmacy plans. 

The CalPERS website – www.calpers.ca.gov – has information on what to expect with this change.

A Frequently Asked Questions sheet is available on the site in PDF format.


  1. OptumRx will send a welcome package to all subscribers in late November.
  2. Copayments will remain the same as CVS had.
  3. You will likely be able to go to the same pharmacy including CVS. Ninety-day supplies of maintenance drugs will be available by mail order or at Walgreens retail stores only (for basic members). For Medicare members, 90-day supplies are available at any store in the network.
  4. The Optum formulary is not exactly the same as the CVS formulary. CalPERS estimates that about 27,000 members will see lower costs for their drugs and about 65,000 will see higher costs, based on drugs being in different tiers or not in the formulary.

CSR’s Health Benefits Committee will continue to monitor these issues and address issues reported by members to CalPERS, health plan companies, and pharmacy plans. 

Article by: Larry Woodson, CSR Health Benefits Committee Chair

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