Medical Insurance Plans/TAPP

HMOs | PPO/PERS | TAPP

Health Maintenance Organizations (HMO)

An HMO is a plan that provides healthcare from specific doctors and hospitals under contract with the plan. Employees and their eligible dependents select a primary care physician who coordinates all medical care including referrals to specialists. The employee and eligible dependents can each select a different primary care physician/medical group within the HMO plan. These plans generally have restricted service areas in California (based on zip code), co-payments for some services, no deductibles, and no claim forms. Emergency services rendered out of the service area or California must be reported to the HMO plan.

  • Blue Shield Advantage Individual practice plan where the employee must use contracted doctors/hospitals designated on plan lists for all services. Generally, no deductibles and no claim forms are required. Initial enrollment into the plan will require the employee to complete and send a Blue Shield Physician Selection form. For more information refer to the Evidence of Coverage.
  • Blue Shield Net Value Advantage
    • Offered in addition to the current Blue Shield Access+ HMO plan
    • Offers a lower premium than the standard Blue Shield Access+ plan
    • Provides the same level of benefits, access, and quality of care as Access+
    • Offers a smaller network of selected medical groups than the standard Blue Shield Access+ network
    • Available in portions of 17 counties: El Dorado, Fresno, Kern, Kings, Los Angeles, Madera, Nevada, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Santa Barbara, Ventura, and Yolo. Some counties will only have partial access. Members should contact Blue Shield to determine whether their ZIP code is included in the NetValue service area.
    • Initial enrollment into the plan will require the employee to complete and send a Blue Shield Physician Selection form.
    • The EOC for the Blue Shield HMO Plan applies also to the Blue Shield Net Value Plan.
    • For more information refer to the Evidence of Coverage.
  • Kaiser Permanente offers a one-stop shop when obtaining services from your physician for pharmacy, lab, x-ray and other services. A listing of medical offices and Hospital sites are located on their website. Kaiser Evidence of Coverage.

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Preferred Provider Organizations (PPO)

As a PPO health plan member, you get maximum benefit coverage when you use the PPO network (Blue Cross of California) of physicians and hospitals. A PPO is similar to a traditional "fee-for-service" plan, but you must use doctors in the PPO provider network or pay higher co-insurance (percentage of charges). A PPO allows you to select a primary care provider and specialists without referral. In these plans, you must usually meet an annual deductible before some benefits apply. You are responsible for a certain co-insurance amount, and the plan pays the balance up to the allowable amount.

  • PERS Select/Choice/Care
    • Offered in addition to the current statewide PERS Choice and PERSCare PPO plan
    • Offers a lower premium than the standard PERS Choice plan
    • Provides the same level of benefits, access, and quality of care as PERS Choice
    • Offers a statewide network of over 23,000 providers – representing more than 50 percent of the PERS Choice physician network
    • Available in 54 of the 58 California counties (not available in Alameda, Marin, Placer, or Solano counties, or out-of-state)
  • PPO Evidence of Coverage & Claim Form
  • CVS Caremark (Prescription Drug) Information
    • Register for online member services

Contact your health plan whenever you need assistance with your plan or have any questions. Your health plan can help you with all aspects of your coverage, including:

  • Member identification cards
  • Verification of provider participation in the plan
  • Service area boundaries (covered ZIP Codes)
  • Evidence of Coverage booklets
  • Individual conversion policies
  • Covered services; deductibles, maximums and co-payments; and limitations and exclusions of your coverage.

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Tax Advantage Premium Plan (TAPP)

The Tax Advantage Premium Plan (TAPP) allows employees to have required health plan premiums withheld from their paychecks on a pre-tax basis, reducing federal and state income and Social Security/Medicare taxes.

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