2025 PPO Administrators for Basic Plan Members

Blue Shield is 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.

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

Download the Included Health app for easy access to your health plan information on the Apple Store or Google Play Store.

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.

You can change your PCP whenever you'd like. To update your PCP, you can log in to the Blue Shield Member Portal which is available through Included Health. Once logged in to your Included Health account, navigate to the "View More Services" tile on the homepage, which will provide a link to the BSC portal. From your member dashboard, navigate to the “change PCP” button. If you don't have an account, you'll need to register first. You’ll need your Social Security Number or Member ID to complete the registration process.

If you need assistance navigating the portal, you can contact the Included Health care team for support.

If your previous PCP is out-of-network (OON) for 2025 or does not meet Blue Shield’s PCP criteria, you may have been matched to a different PCP within the Blue Shield network. Blue Shield is continually adding new providers to its network and updating its PCP criteria. If you would like to change your PCP, please contact the Included Health care team or visit the Blue Shield member portal to search for available PCPs or to update your PCP.

For PPO plans, you can see any PCP without needing a referral even if they are not listed on your ID card. For Gold plan members, there is a copay incentive to see your designated PCP or a PCP at the same location. Platinum plan members do not have a copay difference between their designated PCP or another PCP of their choice.

Your provider must be credentialed in one of the four primary care specialties (internal medicine, family medicine, pediatrics or general medicine) and not have actively opted out of being an assignable PCP. However, even if you have one of the four primary care specialties, if your provider is hospital or facility based (hospitalist, emergency medicine, trauma) or part of an emergency medicine physician group they cannot be assigned as a PCP. OB/GYNs won’t automatically be available but can opt in to be assigned as a PCP. Your provider can contact Blue Shield of CA’s provider services line for assistance. This information is available on the back of your ID card.

If you're seeing a Nurse Practitioner (NP) or Physician Assistant (PA), please note that only MDs and DOs can be designated as your PCP on your ID card at this time.

Blue Shield has established an automatic override for CalPERS members that should allow you to change your PCP to your previous PCP even if the provider is marked as "not accepting new patients." If you have any challenges, please call Included Health to assist in updating your PCP. Please provide the provider's name and other details (e.g., address and phone number), via chat or phone call, and Included Health will update your PCP designation. You should receive your new ID card within 10 business days once updated.

You can only select MD/DOs (Doctors of Medicine/Doctors of Osteopathic Medicine) as your designated PCP. If you see an NP or PA, you may continue to see them, but your PCP must be the supervising MD/DO. If you're unsure about which PCP to choose, you can contact Included Health at includedhealth.com/calpers or call 855-633-4436 to find a high-quality provider in your area.

Once your PCP change is processed, you can expect to receive your updated ID card within 10 business days. You can continue using your old card until the new one arrives.

For members in the PERS Gold plan, the copay for seeing your designated PCP (or another PCP at the same location) is $10 and $35 for all other providers. You can contact Included Health to update your PCP retroactively for that month. In the Platinum plan, you can see the PCP of your choice at the same copay amount.

If you encounter any difficulties with updating your PCP or accessing the Included Health portal, their care team is available to assist you. You can chat or call the Included Health care team by going to includedhealth.com/calpers or calling 855-633-4436.

Blue Shield requires that a provider be credentialed in one of four primary care specialties: 1) internal medicine; 2) family medicine; 3) pediatrics; 4) or general practice. Providers with a primary care specialty can also choose to “opt-out” of being assignable as a PCP.

CalPERS members who were previously assigned an OB/GYN as their PCP with Anthem will now be able to select those OB/GYNs as their PCP with Blue Shield. If you are seeing an OB/GYN for specialty care and you want them to now be your primary care physician, your provider must contact Blue Shield and request to be added as a primary care physician. The information for Blue Shield of CA’s provider services line is available on the back of your ID card. If your provider is of another specialty type, Blue Shield is continually evaluating the primary care provider criteria and will inform you if this changes in the future.

Blue Shield tried to match all CalPERS members with their previous PCP as long as they met Blue Shield’s criteria. However, Blue Shield has different PCP criteria than Anthem. But we have heard CalPERS’ member feedback that some of our criteria may be interfering with CalPERS’ members desire to continue with their current primary care provider. Therefore, Blue Shield has reevaluated our criteria and is now allowing additional providers to be chosen as a primary care provider. These providers include:

• Providers who are primarily part of a clinic, and while they may be on rotation with a varying schedule, they will be able to be chosen as a member’s PCP.
• Providers who have multiple specialties, one of which is primary care. Previously we deferred to the higher subspeciality (e.g., if a provider practiced internal medicine and pulmonology, BSC identified that provider as a pulmonologist), but providers with multiple specialties (one of which is a primary care specialty) can be chosen as your PCP except for providers who have a specialty that is facility/hospital-based (e.g., surgery, trauma, hospitalist).
• Providers with an emergency medicine specialty and a primary care specialty that practice as part of a multi-specialty group. While we still will not allow providers who are part of an emergency medicine group to be assigned as a PCP, we are allowing those providers with an emergency medicine specialty and a primary care specialty that are at a multi-specialty group to be chosen as your PCP.

If Blue Shield could not assign you to the primary care provider you previously had with Anthem, we used our primary care assignment logic which matches you to a primary care provider that is:

• Within approx. 10 miles of the member’s address (but Blue Shield will continue beyond 10-miles if a match can’t be found)
• Accepting new members (open panel)
• Accepting patients of the member’s age (every practitioner has age limitations, so member must be within the min/max age range as defined by practitioner)
• Accepting patients of the member’s gender (male, female or both)

You can change your primary care provider retroactively to January 1, 2025, by calling Included Health at (855) 633-4436.

No, the PCP listed on your ID card is your matched PCP but as part of the PERS Basic PPO you can see the in-network PCP of your choice. If you are a PERS Platinum member there are no cost sharing differences. If you are a PERS Gold member you will pay a $10 copay for seeing your matched PCP (or another PCP at the same location) and a $35 copay for seeing any other PCP.

No, coverage for certified disabled dependents will continue without interruption as part of the transition to the new PPO administrator. Members enrolled with disabled dependents do not need to take any action, as the certification and recertification processes will remain the same.

No changes are being made to the certification or recertification process for disabled dependents. Additionally, the existing certification expiration dates will remain in effect, and no further steps are required from members as part of the administrator transition.

Yes, both PERS Gold and Platinum members can access providers, hospitals, and facilities in the UC Health system. Included Health can help you find a provider and answer any questions you may have. Listed below are the medical groups within the UC Health system.

• UC Davis Health
• UC San Diego Health
• UC Irvine Health
• UC Los Angeles Health
• UC Riverside Health
• UC San Francisco Health

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

Yes, those are the same for 2025.

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. Access the Health and Wellness page which will be updated with new information based on the services provided by Included Health.

You can access your historical information with Anthem using the Sydney Health app. The historical information will be available through December 2026.

Yes, this will remain the same for 2025. Visit includedhealth.com/calpers to attest to completion of your flu shot and non-smoking status.

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 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 virtual supplemental primary care and behavioral health services.

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.

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.

Contracting Agency Retiree:

Yes, the benefits are the same. However, Anthem’s vision carrier was VSP and BSC’s vision carrier is EyeMed. Members can find more information on Vision Benefits in their Evidence of Coverage (EOC) booklet online at https://myoptions.blueshieldca.com/calpers_retiree.

State Retiree:

Yes, the benefits are the same. You will have the same vision benefits administered by CalHR. Members can find more information on VSP benefits at https://benefits.calhr.ca.gov/state-retirees/retiree-vision-benefits/.

CSU Retiree:

Yes, the benefits are the same. You will have the same vision benefits administered by CSU. Members can find more information at  https://www.calstate.edu/csu-retirees/retirement-benefits/Pages/default.aspx.

There is no additional cost for the vision benefit, it is included in the member’s premium.

Contracting Agency Retiree:

Members can contact Blue Shield of California’s Vision Plan Administrator (VPA) at (877) 601-9083, to see if their provider is in the EyeMed network.

State Retiree:

Members can contact VSP Customer Care at (800) 400-4569 or email stateofca@vsp.com.

CSU Retiree:

Members can contact VSP Customer Care at (800) 400-4569.

State Retiree:

No, Blue Shield’s EyeMed vision benefit is embedded in the Supplement to Original Medicare plans and is separate from the State retiree vision coverage through VSP. State retirees that have opted for coverage through VSP may continue their vision coverage and should work directly with VSP and/or CalHR on benefits and eligibility.

If the member has VSP through CalHR or CSU, then VSP is primary and EyeMed is secondary. VSP will coordinate with other insurance plans’ claim payments or reimbursements, which may reduce or eliminate a member’s out-of-pocket expense. Members are encouraged to work with their vision care providers who will work with VSP and EyeMed on the coordination. If member’s have question about the EyeMed vision provider network, they can call (877) 601-9083, or their provider can also validate their vision benefits.

Correct, only the Supplement to Original Medicare plans include this embedded vision benefit.

At this time, the EyeMed ID cards only have the subscribers name listed, but all eligible Supplement to Original Medicare plan members are covered and would show eligibility.

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.