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.

Benefit Charts

Benefits Medical Plan Summary
Office Visits and Professional Services
Surgical and Hospital
Prescription Drugs

Premium Rates

For Employees

Semi Monthly Medical Plan Premiums

For Retirees

With Medicare, $500 Contribution
Without Medicare, $500 Contribution

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

Medical Plan Summary

Service	County Health Plan PPO
Plan Year Deductible	Individual: $300 Family: $900
Coinsurance	In-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).

Office Visits and Professional Services

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 18	In-Network: No Charge, no deductible Out-of-Network: 40% coinsurance after deductible
Preventive Care Adult Routine Care	In-Network: No charge, no deductible, one exam every 12 months. Out-of-Network: Not Covered
Preventive Care Adult Routine OB/GYN	In-Network: No Charge, no deductible Out-of-Network: 40% coinsurance after deductible
Diagnostic Lab and X-ray	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible
Physical Therapy	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible
Chiropractic	In-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

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 Surgery	In-Network: 10% coinsurance Out-of-Network: 40% coinsurance
Maternity	In-Network: $125 per admission co-pay + 10% coinsurance after deductible Out-of-Network: $125 per admission co-pay + 40% coinsurance after deductible
Emergency Room	In-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
Ambulance	In-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 Facility	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance per plan year after deductible
Home Health	In-Network: 10% coinsurance after deductible Out-of-Network: 40% coinsurance after deductible.

Prescription Drugs

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 Order	Yes, through CVS Pharmacy Benefit
Mandatory Generic Program	Yes