how to choose
the health plan that’s right for you
It’s easy to feel a little confused about where to start
when choosing a health plan. Some people ask their
friends, family, or co-workers for advice. Knowing
the right questions to ask can help you make an
informed decision and find the right plan for you
and your family.
Take a moment to review the following questions.
They discuss topics from which types of plans exist
to what kind of coverage you might expect from
these plans. Answering these questions can help you
select a health plan that meets your specific needs.
Q: How can I figure out which health plan is right for me?
A:First, consider how much coverage you need. Are you
single, or do you have a family? Do you or a family
member have a chronic condition? It’s important to
look at the full range of services and copayments (or
“copays”) you will spend out of pocket for doctors’
visits, surgery, hospital stays, or other types of care.
And it’s important to know whether your plan covers
preventive services, prescription drugs, new glasses,
or other services you may need.
Q:Does this health plan’s network include the doctors
and hospitals I want?
A: If you already have a family doctor, you may want
to check to see if your doctor is included in the
health plan’s network.
Q: What about cost? Should it be a factor in the decision?
A:The cost of coverage is an important issue. You need to
understand how much you will pay for your coverage
in monthly premiums, how much your employer
contributes, and what you will pay when you visit the
doctor or go to an urgent care facility. Also, is there
an annual deductible? Will you pay a dollar copay,
or a percentage of the costs for services you receive?
Q&A
Q: What are my options?
A:You can choose an HMO or PPO health plan. There are
many differences between these two types of plans,
but the most significant is how you access covered
services and how much you will pay out-of-pocket for
these services, including any applicable deductibles.
With an HMO, you must live or work within the service
area covered by the plan. You also need to access
all care from a medical group in the HMO provider
network and designate a primary care physician or
Personal Physician to coordinate all your healthcare
needs. Check to see if your health plan offers a direct
referral option to specialists within your medical
group for a slightly higher copay.
With a PPO plan, you can visit any licensed doctor,
including specialists, without a referral. However, though
a PPO plan might pay for services received outside the
preferred network, you will pay more than if you had
received care from a doctor within the network.
Not all physicians accept both HMO and PPO plans.
If there are particular doctors you want to see, make
sure they accept the health plan you’re considering.
questions?
Q:What if you have a lot of options and are confused
about how to narrow down your choices?
A:Start with the basics. You need to know what types
of doctors’ visits, surgery, or hospital services are
covered in the benefit plan. Find out if the plan
covers prescription drugs. And, of course, you need
to know how much you’re going to pay out of
pocket, if there is a copayment or deductible you
need to meet, or if there’s an overall limit or cap
on benefits. The bottom line is that it’s important
to know how the plan works. Don’t wait until you
need health care to ask those important questions.
Questions
to consider ...
Consider these other questions when comparing
plan options.
Does the health plan help keep you well?
1. Cover preventive care to help you stay well?
2.Offer member programs and wellness discounts?
3.Offer incentives to stay well and adopt healthy habits?
4.Provide wellness programs to encourage a healthy
pregnancy?
5.Offer access to resources related to women’s health,
men’s health, and the health of children and seniors?
Does the health plan make it easy for you to find
quality care?
1.Have tools and resources to find local providers online?
2.Offer a hospital comparison tool to help you evaluate
hospitals that are available to you?
Does the health plan help you manage your prescriptions?
1.Allow you to e-mail a pharmacist for drug information?
2.Offer a mail order benefit that not only saves
you money but is convenient?
does your health plan ...
Does the health plan keep your family covered?
1.O ffer coverage to families living apart and
dependent college students living outside California?
2.Are your children’s pediatricians or specialists in
the network?
Does the health plan offer additional
value-added services
1.Provide tools and resources to help you save money?
2.Provide you access to life management resources?
3.Offer discounts to services you use regularly?
Does the health plan make it easy to do
business with them?
1.Let you change doctors, order new ID cards, and
view your claims history online?
2.Have dedicated calling centers to help you with
claims and questions?
Health plan
cost comparison
Compare benefits
Plan A
How much
is covered?
Annual physical/
preventive care
Office visits
Diagnostics
(such as lab work)
Maternity coverage
Well-baby exams
Emergency room visits
Hospital care
(outpatient services)
Prescription drug costs
Copayment for
alternative care visits
(such as chiropractic)
Mental health services
Annual deductible
Annual out-of-pocket
maximum or
copayment maximum
Lifetime maximum
Monthly rate
Total costs
You
pay
What will you pay in total for your health plan coverage?
Once you’ve narrowed down your top health plan picks,
be sure to compare costs side by side. Include in your
total copayments, out-of-paycheck premium, and
any deductibles or coinsurance that may be required
by your health plan.
Plan B
How much
is covered?
Annual physical/
preventive care
Office visits
Diagnostics
(such as lab work)
Maternity coverage
Well-baby exams
Emergency room visits
Hospital care
(outpatient services)
Prescription drug costs
Copayment for
alternative care visits
(such as chiropractic)
Mental health services
Annual deductible
Annual out-of-pocket
maximum or
copayment maximum
Lifetime maximum
Monthly rate
Total costs
Plan C
You
pay
How much
is covered?
You
pay
glossary
Brand-name drugs: FDA-approved drugs under patent to
the original manufacturer and available only under the
original manufacturer’s branded name.
Calendar year: A period beginning at 12:01 a.m. on
January 1 and ending at 12:01 a.m. of the next year.
Claim: A notification to your health plan that a service has
been provided and payment is requested.
Copayment: The dollar amount that a member is required
to pay for certain benefits. Also called a “copay.”
Emergency services: Services for an unexpected medical
condition, including a psychiatric emergency medical
condition, manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that a
layperson who possesses an average knowledge of health
and medicine could reasonably assume that the absence
of immediate medical attention could be expected to
result in any of the following: placing the member’s health
in serious jeopardy; serious impairment to bodily functions;
or serious dysfunction of any bodily organ or part.
glossary
Formulary: A comprehensive list of drugs maintained by
Blue Shield’s Pharmacy and Therapeutics Committee
for use under the Blue Shield Prescription Drug Program,
which is designed to assist physicians in prescribing
drugs that are medically necessary and cost-effective.
The formulary is updated periodically. If not otherwise
excluded, the formulary includes all generic drugs.
Generic drugs: Drugs that (1) are approved by the FDA
as a therapeutic equivalent to the brand-name drug,
(2) contain the same active ingredient as the brandname drug, and (3) cost less than the brand-name
drug equivalent
Health maintenance organization (HMO): A prepaid
health plan that provides a comprehensive array of
medical services, emphasizing prevention and early
detection through contracted physicians, hospitals, and
other providers. Members must select a primary care
physician from the plan’s network who coordinates all
care with the exception of a true medical emergency.
Inpatient: An individual who has been admitted to a
hospital as a registered bed patient, and is receiving
services under the direction of a physician.
glossary
Non-formulary drugs: Drugs determined by the health
plan as being duplicative or as having preferred formulary
drug alternatives available. Benefits may be provided
for non-formulary drugs and are always subject to the
non-formulary copayment.
Outpatient: An individual receiving services but not as
an inpatient.
Out-of-pocket maximum: Your maximum copayment
responsibility each calendar year for covered services.
However, copayments for a very small number of covered
services do not apply to the annual out-of-pocket maximum,
and you continue to be responsible for copayments for those
services when the out-of-pocket maximum is reached.
Preferred provider organization (PPO): 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 typically must 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. As a PPO health
plan member, you get maximum benefit coverage when
you use the PPO network of physicians and hospitals.
glossary
Personal Physician (also known as a primary care
physician): A general practitioner, board-certified
or eligible family practitioner, internist, obstetrician/
gynecologist, or pediatrician who has contracted with
the plan as a Personal Physician to provide primary
care to members and to refer, authorize, supervise and
coordinate the provision of all benefits to members in
accordance with the agreement.
Preventive care: Medical services provided by a physician
for the early detection of disease when no symptoms are
present and for routine physical examinations, usually
limited to one visit per calendar year for members ages
18 and over.
Services: Includes medically necessary healthcare
services and medically necessary supplies furnished
incident to those services.
notes
Use this guide to help you make the smart choice
for your coverage.
If you need more information about choosing
the Blue Shield health plan that’s right for you,
our 24/7 Shield Helps hotline is available to you
during open enrollment to answer your specific
questions, at (888) 678-SHIELD. Or you can visit
us online at www.blueshieldca.com/calpers.
blueshieldca.com
Blue Shield of California is an Independent Member of the Blue Shield Association A37809 (7/09)
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