2025 PPO Administrators for Basic Plan Members

Blue Shield will become the administrator for your PPO plans, providing access to their extensive network of doctors and hospitals. As a Basic PPO plan member, Included Health will help connect you with the right care, whether in person or virtually, using these networks.

Most members will keep their current primary care and specialist providers. If your doctor isn’t in the network, CalPERS and Blue Shield will work to minimize disruption, ensuring access to high-quality alternatives. Included Health is here to help navigate any changes.

Available by phone at 855-633-4436, online, or mobile app, Included Health is your go-to resource for personalized healthcare services, such as:

• Checking if your current doctor is in-network
• Finding new providers or urgent care centers
• Coordinating care, particularly if you have complex conditions
• When you want a second medical opinion
• Accessing virtual primary care and behavioral health services
• Receiving 24/7 clinical advice from a nurse
• Tracking your deductibles, copays, and coinsurance
• Understanding your medical bills

The Basic PPO plan member will contact Included Health as your first stop for personalized health care. The Medicare member will contact Blue Shield of California and won't notice any changes to the provider networks or the care coordination provided by your doctor today.

The 22 rural counties are:

• Alpine
• Amador
• Calaveras
• Del Norte
• Glenn
• Imperial
• Inyo
• Lassen
• Mariposa
• Mendocino
• Modoc
• Mono
• Plumas
• San Benito
• Shasta
• Sierra
• Siskiyou
• Sutter
• Tehama
• Trinity
• Tuolumne
• Yuba

ZIP codes of counties without an HMO or EPO option are listed here:

• El Dorado
• Nevada
• Placer
• San Bernardino

Contact Included Health if you have questions.

Once enrolled in a CalPERS PPO plan, you'll receive a new identification (ID) card for your medical and pharmaceutical benefits. To receive your PPO plan medical services and prescription drug benefits, you should present your new ID Card to each provider of service.

The organization/naming conventions will be different, but Wellness programs will be similar. Additionally, the value-based insurance design (VBID) incentives will remain the same for PERS Gold members. View the health and wellness page which will be updated with new information based on the services provided by Included Health.

This is our VBID for PERS Gold and this will remain the same for 2025.

Behavioral health benefits will be provided by Blue Shield contracted mental health providers and Included Health will provide supplemental virtual behavioral health services for Basic members.

Blue Shield of California is the new Third-Party Administrator (TPA) for the PPO plans, and they'll handle administrative functions on behalf of CalPERS. Blue Shield will also contract with and maintain the network of providers that plan members can access.

Included Health is the Population Health Manager (PHM) for Basic PPO members. They're responsible for all member services for Basic PPO members as well as providing care coordination and care and case management services. Included Health will also provide primary care and behavioral health virtual services.

Blue Shield is your health plan provider, and your Member ID will have the other information you may need to share with your provider’s office.

Yes, those are the same for 2025.

PERS Gold and PERS Platinum members will contact Included Health for Continuity of Care related inquiries. They can assist with your request and help you understand what options are available to you.

Yes, if you're seeing a provider who'll continue to be in network with Blue Shield.

If your provider is no longer in network and you're in the PERS Platinum plan or are a PERS Gold member in one of the eligible counties or ZIP codes, you may be able to continue to see them at the in-network benefit. After that, you might have to find a new provider or pay for out of network services.

Yes, members will still be able to see PCPs in-person. If you're seeing a provider who'll continue to be in network with Blue Shield, you'll be able to continue seeing that PCP in person. If your provider is no longer in network and you're in the PERS Platinum plan or are a PERS Gold member in one of the eligible counties or ZIP codes, you may be able to continue to see them at the in-network benefit. After that, you might have to find a new provider or pay for out of network services.

If you’re a Basic member, Included Health will be your all-in-one destination for a better healthcare experience and for all member assistance. Included Health will work directly with Blue Shield to resolve your request. For Medicare Supplement members, you will contact Blue Shield directly for all questions.

Yes, Included Health employs licensed nurses and physicians who help guide care for members who participate in care management.

Included Health offers virtual primary care and behavioral health services which provide preventive care and chronic condition management, physical and behavioral health care, and seamless connections to local, in-network providers as needed. Virtual care can help to improve access and quality of care in rural areas where it can be difficult to get an appointment with a primary care or behavioral health care provider.

If you’re a Basic member, Included Health will be your all-in-one destination for a better healthcare experience and for all member assistance.

Yes, one of the benefits of a PPO is that you don’t need a referral for services. However, Included Health is available to recommend a provider for your specific condition if you would like assistance in locating one.

Virtual care will have the same copay and coinsurance as in-person primary care. Please see your Evidence of Coverage (EOC) or Summary of Benefits (SBC) documents for specifics as they vary for Gold and Platinum Basic PPO plans.

The PCP match requirements for the PPO plans won't change. All members who don't select a PCP will be matched with one.

If you were previously matched with a provider under Anthem and that provider is in network with Blue Shield, you can request to be matched with that provider.

You won't be able to view your assigned PCP in the Included Health portal or app starting on January 1, 2024, but this feature will be available at a later date.

Yes, one of the benefits of a PPO is that you don’t need a referral for services. However, Included Health is available to recommend a provider for your specific condition if you'd like assistance in locating one.

Silver Sneakers is a program available in today’s PERS Gold and Platinum Medicare Supplement programs and will be offered in next year’s Blue Shield’s PERS Gold or PERS Platinum Medicare Supplement program.

For Medicare Supplement members, you'll contact Blue Shield directly for all questions.

Medicare reimburses primary care providers for coordinating your care. Your primary care provider helps to manage your overall care by ensuring that you receive appropriate specialty referrals, by following up with you after an emergency room visit, and by coordinating with other healthcare providers. While it may not be visible to you during an appointment, it's happening through use of electronic medical records, for instance, or through participation in programs or models that support coordinated care.

No, these changes are specific to the PERS Gold and PERS Platinum PPO plans.

The PERS Gold and PERS Platinum pharmacy benefits provided through Optum won't change. Basic members with questions about prescriptions, you'll contact Included Health for assistance. Our Medicare members will contact OptumRx directly.

You'll remain enrolled in PERS Gold or PERS Platinum unless you make a different choice during Open Enrollment. We'll transfer the enrollments from Anthem to Blue Shield automatically.

You can go online to get started. You also have an option of reaching out to Included Health by phone to get help with getting set up.

You can search in myCalPERS or on the public-facing CalPERS website search tool. As of September 9, you can call or chat with Included Health to confirm. Included Health will also have a directory available to CalPERS members with in-network provider information.

Members enrolled in the Basic PERS Gold or PERS Platinum plan will use the search tools on the Included Health website or app.

Medicare Supplement members will use the search tool on the Blue Shield website. For all members, you can use the search tools on the myCalPERS website to see which plans your preferred providers are in.

We expect those to start going out in November 2024.