Human Resources Benefits Unit

County Health Plan EPO Benefits

The County Health Plan EPO is an exclusive provider organization (EPO). An EPO is a great plan that offers you affordable out-of-pocket costs, with access to the doctors and hospitals you trust. 

  • You are free to visit any doctor or hospital in the network when you pay an affordable copay or deductible, without the hassle of filling out forms. 
  • Covered services must be provided by network providers.
  • Most doctor and specialist office visits are available at a $50 copay and most in-network preventive services, such as well baby/child visits (up to age 18), immunizations, routine physicals, mammograms, and routine preventative screenings are covered at no cost.
  • Other in-network services are covered at 80% after the deductible ($300 per individual or $900 per family) is met and copay.

Customer Service and Group Numbers

Medical Claims Administrator - Anthem Blue Cross

Customer Service:
(800) 759-3030
Website:
www.anthem.com/ca

Prescription Carrier - CVS/Caremark

Customer Service:
(800) 966-5772
Website:
www.caremark.com

Employee Group Numbers

Medical Plan California:
Group #175130 M100
Medical Plan Out-of-State:
Group #175130 M104
Prescription Plan:
Group #3439-1004

Retiree Group Numbers

Medical Plan - California

Non-Medicare:
Group #175130 M102
Medicare:
Group #175130 M103

Medical Plan - Out-of-State

Non-Medicare:
Group #175130 M106
Medicare:
Group #175130 M107

Prescription Plan

Non-Medicare:
Group #3439-3004
Medicare:
Group #3439-2004
Service County Health Plan EPO
Plan Year Deductible Individual: $500
Family: $1,500
CoinsuranceIn-Network: 20% coinsurance
Out-of-Network:
Not covered
Plan Year Out of Pocket Maximums (Out of pocket costs Include Deductibles, 
Copays, and Coinsurance, if applicable)
Medical -
  • Individual: $5,500
  • Family: $11,500
Pharmacy -
  • Individual: $1,100
  • Family: $1,700
Lifetime MaximumNone
Dependent Children EligibilityAny Dependent child under age 26. No age limit if disabled
Out of Network Providers Not covered

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ServiceCounty Health Plan EPO
Physician & Specialist In-Network: $50 copay, no deductible
Out-of-Network: Not Covered.
Preventive Care Birth to Age 18In-Network: No charge, no deductible
Out-of-Network: Not Covered.
Preventive Care Adult Routine CareIn-Network: No charge, no deductible, one exam every 12 months.
Out-of-Network:
Not Covered.
Preventive Care Adult Routine OB/GYNIn-Network: No charge, no deductible
Out-of-Network:
Not Covered.
Diagnostic Lab and X-rayIn-Network: 20% coinsurance after deductible
Out-of-Network:
Not Covered.
Physical TherapyIn-Network: 20% coinsurance after deductible  
Out-of-Network: Not Covered.
ChiropracticIn-Network: 20% coinsurance after deductible
Out-of-Network: Not Covered.
Mental Health and 
Substance Abuse (Outpatient)
In-Network: 20% coinsurance after deductible
Out-of-Network:
 Not Covered

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Service County Health Plan EPO
Hospital and Physician Services In-Network: $500 per admission copay plus 20% coinsurance after deductible
Out-of-Network:
Not Covered
Outpatient SurgeryIn-Network: $500 per procedure copay plus 20% coinsurance after deductible
Out-of-Network: Not Covered
MaternityIn-Network: $250 per admission copay plus 20% coinsurance after deductible
Out-of-Network:
Not Covered
Emergency RoomIn-Network: $100 copay plus 20% coinsurance after deductible
Out-of-Network:
$150 per copay plus 20% coinsurance after deductible; Not Covered if non-emergency
AmbulanceIn-Network: 20% coinsurance after deductible
Out-of-Network: 20% coinsurance after deductible if emergency, urgent are, or authorized by Primary Care Physician; otherwise not covered
Mental Health & Substance Abuse (Inpatient)In-Network: $500 copay per admission plus 20% coinsurance after deductible
Out-of-Network:
Not Covered
Skilled Nursing FacilityIn-Network: Not Covered
Out-of-Network:
Not Covered
Home HealthIn-Network: Not Covered
Out-of-Network:
Not Covered

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ServiceCounty Health Plan EPO
Generic or Tier 1 $10 copay, up to 34 day supply
Formulary Brand or Tier 2 $35 copay, up to 34 day supply
Non-Formulary Brand or Tier 3 $70 copay, up to 34 day supply
Mail Order Benefit or 90 Day Supply - Generic or Tier 1 $20 copay, up to 90 day supply
Mail Order Benefit or 90 Day Supply - Formulary Brand or Tier 2 $70 copay, up to 90 day supply
Mail Order Benefit or 90 Day Supply - Non-Formulary Brand or Tier 3 $140 copay, up to 90 day supply
Mandatory Mail OrderYes, through CVS Pharmacy Benefit
Mandatory Generic ProgramYes

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Contact Information

Benefits Unit

Human Resources Department

Business Hours
Monday – Friday
8:00 AM – 5:00 PM
Contact us by Phone
Address
575 Administration Drive
Room 116 B
Santa Rosa, CA 95403
38.465237, -122.725363

County Health Plan Summary of Benefits and Coverage

County Health Plan Options