Human Resources Benefits Unit

County Health Plan PPO

The County Health Plan PPO is a preferred provider organization (PPO). A PPO is a medical plan that offers you a choice between an in-network group of providers who offer their services at discounted rates and out-of-network providers without discounted rates. Under a PPO plan, you may choose the level of benefits you receive based on the providers you use when you receive care.

  • Most in-network doctor and specialist office visits are available at a $20 copay and most in-network preventative 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 90% 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 M051
Medical Plan Out-of-State:
Group #175130 M057
Prescription Plan:
Group #3439-1002

Retiree Group Numbers

Medical Plan - California

Non-Medicare:
Group #175130 M053
Medicare:
Group #175130 M054

Medical Plan - Out-of-State

Non-Medicare:
Group #175130 M059
Medicare:
Group #175130 M060

Prescription Plan

Non-Medicare:
Group #3439-3002
Medicare:
Group #3439-2002
Service County Health Plan PPO
Plan Year DeductibleIndividual: $300
Family:
$900
CoinsuranceIn-Network: 10% coinsurance
Out-of-Network:
40% coinsurance
Plan Year Out of Pocket Maximums (Out of pocket costs Include Deductibles, Co-pays, and Coinsurance, if applicable) Medical -
  • Individual: $2,300
  • Family: $4,900
Pharmacy -
  • Individual: $1,100
  • Family: $1,700
Lifetime Maximum None
Dependent Children Eligibility Any Dependent child under age 26. No age limit if disabled.
Out of Network Providers Covered (you will pay less out of pocket when you use an In-Network provider).

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Service Health Plan PPO
Physician & Specialist In-Network: $20 co-pay, no deductible
Out-of-Network:
40% coinsurance after deductible
Preventive Care Birth to Age 18In-Network: No Charge, no deductible
Out-of-Network:
40% coinsurance after deductible
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: 40% coinsurance after deductible
Diagnostic Lab and X-rayIn-Network: 10% coinsurance after deductible
Out-of-Network:
40% coinsurance after deductible
Physical TherapyIn-Network: 10% coinsurance after deductible
Out-of-Network:
40% coinsurance after deductible
ChiropracticIn-Network: 10% coinsurance after deductible
Out-of-Network:
40% coinsurance after deductible
Mental Health and Substance Abuse (Outpatient)In-Network: 10% coinsurance after deductible
Out-of-Network:
40% coinsurance after deductible

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Surgical and Hospital Services

Service County Health Plan PPO
Hospital and Physician Services In-Network: $125 per admission co-pay + 10% coinsurance after deductible
Out-of-Network:
$125 per-admission co-pay + 40% coinsurance after deductible
Outpatient SurgeryIn-Network: 10% coinsurance
Out-of-Network:
40% coinsurance
MaternityIn-Network: $125 per admission co-pay + 10% coinsurance after deductible
Out-of-Network:
$125 per admission co-pay + 40% coinsurance after deductible
Emergency RoomIn-Network: $100 per admission co-pay + 10% coinsurance after deductible
Out-of-Network:
$100 per admission co-pay + 40% coinsurance (10% if emergency) after deductible
AmbulanceIn-Network: 10% coinsurance after deductible
Out-of-Network: 40% coinsurance (10% if emergency) after deductible
Mental Health & Substance Abuse (Inpatient)In-Network: $125 per admission co-pay + 10% coinsurance after deductible
Out-of-Network:
$125 per admission co-pay + 40% coinsurance after deductible
Skilled Nursing FacilityIn-Network: 10% coinsurance after deductible
Out-of-Network:
40% coinsurance per plan year after deductible
Home HealthIn-Network: 10% coinsurance after deductible
Out-of-Network:
40% coinsurance after deductible.

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Service County Health Plan PPO
Generic or Tier 1 $5 copay, 34 day supply
Formulary Brand or Tier 2 $20 copay, 34 day supply
Non-Formulary Brand or Tier 3 $40 copay, 34 day supply
Mail Order Benefit or 90 Day Supply - Generic or Tier 1 $10 copay, 90 day supply
Mail Order Benefit or 90 Day Supply - Formulary Brand or Tier 2 $40 copay, 90 day supply
Mail Order Benefit or 90 Day Supply - Non-Formulary Brand or Tier 3 $80 copay, 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