The California Schools Employee Benefits Association Offers Blue Shield Medical Coverage July 1, 2017
For CSEBA, Blue Shield will offer Access Plus HMO, TRIO (the Accountable Care
Organization plan), PPO and H.S.A plans. Blue Shield’s network matches our current
Anthem program between 95% and 98%. There will be very little disruption to our
members. Blue Shield and CSEBA will help relocate the few members that need
Blue Shield has a dedicated team throughout Southern California including a major office
in Woodland Hills in Los Angeles. They maintain high quality provider networks for both
their PPO and HMO customers.
Accountable Care Organization (ACO)
Accountable care organizations benefit members by helping to:
- Avoid unnecessary trips to the emergency room
- Manage drug therapies to improve clinical outcomes
- Shorten hospital stays
- Prescribe the most effective and affordable medications
- Coordinate care to eliminate duplication
- Reduce readmissions
Accountable Care organizations mean a partnership between the medical group, hospitals, and Blue Shield. They coordinate the care of members between each group achieving better outcomes for the patients. Blue Shield’s ACO product has shown the following results:
- Up to 13% reduction in hospital admissions
- Up to 27% decrease in days spent in the hospital
- $325 Million in total cost savings for their members
Frequently Asked Questions
Blue Shield offers an Away From Home Care program for dependents residing outside of California in participating states. Eligible dependents in participating states will receive a guest membership with the local Blue Cross – Blue Shield of the state the dependent resides in. The concierge team will assist in setting up the guest membership.
CSEBA/Blue Shield will work with the existing carrier to obtain a list of the currently enrolled disabled dependents.
The Trio ACO HMO plan is an innovation in health care: the accountable care organization (ACO). In an ACO, the focus is on the member. Blue Shield works with a network of doctors and hospitals that share responsibility for coordinating care for the member and their family. We work together to cover all the bases to keep the member healthy.
If the member goes to the doctor often, our Trio ACO HMO plan may be the most cost-effective plan for them. As an HMO, it’s affordable and predictable – low copays, no deductibles and almost no claim forms.
With the Trio ACO HMO plan, the member has access to a quality network of doctors, specialists and hospitals near their home and workplace. And, they can self-refer to a specialist within their primary care physician’s medical group/Independent Practice Association (IPA).
The Trio ACO HMO plan offers the same medical benefits (copayments) as the Access+ HMO plan. However, the plan also offers:
• A lower employee premium contribution. The Trio ACO HMO plan will cost the member less than the Access+ HMO plan.
• Walkadoo®, a fun and social walking program with a wireless activity tracker to track the member’s steps and get them moving!
They can do what they already do: walk, run, hike, or bike. Walkadoo®, will keep track of their activity and their goals. Note: Only
Trio ACO HMO plan subscribers (not spouses or dependents) are eligible for Walkadoo®,
Just as a hotel concierge assists guests with everything from transportation to restaurant reservations, the Shield Concierge team is ready to assist in meeting many of the member’s needs.
The Shield Concierge team includes health advocates, registered nurses, health coaches, clinical support coordinators, pharmacists, pharmacy technicians and dedicated customer service representatives. This team provides personalized support on all aspects of the member’s care, including benefits, claims, providers, care coordination, case management, health coaching, pharmacy and more.
The Shield Concierge team can:
• Help the member find a network provider
• Work with the member and their doctor to coordinate care across all providers
• Help the member manage a chronic condition, such as asthma, diabetes or coronary artery disease
• Connect the member with NurseHelp 24/7SM
• Explain pharmacy benefits coverage, including formulary use
• Assist the member with claims, and much more
Shield Concierge makes personalized service as easy as a phone call. The member calls one toll-free number for help with all of their questions about their medical coverage and care. Shield Concierge representatives are available to assist the member from 7 a.m. to 7 p.m. Pacific time, Monday through Friday (dedicated contact number and email box will be published for use after 3/16/17).
Blue Shield offers continuity of care for members that are in the middle of treatment with a provider that is not in Blue Shield’s network. The Shield Concierge team will be available to assist members in setting up continuity of care.
If a member has an existing prescription at a retail pharmacy, they will present their new Blue Shield ID number to the pharmacy. Blue Shield is working to obtain prescription information from Express Scripts in order to update our system with ongoing mail order medications. Members will need to register at CVS Caremark to receive their mail order medications timely.
Blue Shield does provide a mail order option through CVS Caremark.
The CVS Caremark network is very broad and includes many retail pharmacies that members may already be using such as Costco, Walgreens and Riteaid.
There will be a 90 day “edit lift” in place for medications that require prior authorization. Once the 90 days expires, members may need to obtain an authorizaiton from Blue Shield for certain medications.
Blue Shield Concierge service team will be available to assist with any questions regarding the drug formulary and authorizations. You can also research the Blue Shield drug formulary at
Under Blue Shield’s pharmacy benefits, there is no requirement to obtain maintenance drugs through the mail order pharmacy. While members do have access to a 90-day supply of maintenance drugs through CVS Caremark Mail Service Pharmacy, they also have access to a 30-day supply of mainentance drugs at a retail pharmacy. The mail service pharmacy copayment for a 90-day supply is typically the same cost as the copay for two month’s of the same maintenance drug purchased through a retail pharmacy.