County Health Plan EPO Benefits

Human Resources Benefits Unit 750

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.

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For Employees and Retirees

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

Premium Rates

For Employees

Semi Monthly Medical Plan Premiums

For Retirees

Medicare Monthly Medical Plan Premiums
Non-Medicare Monthly Medical Plan Premiums

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 M116
Medical Plan Out-of-State:: Group #175130 M120
Prescription Plan:: Group #3439-1004

Retiree Group Numbers

Medical Plan - California

Non-Medicare:: Group #175130 M118
Medicare:: Group #175130 M119

Medical Plan - Out-of-State

Non-Medicare:: Group #175130 M122
Medicare:: Group #175130 M123

Prescription Plan

Non-Medicare:: Group #3439-3004
Medicare:: Group #3439-2004

Medical Plan Summary

Service	County Health Plan EPO
Plan Year Deductible	Individual: $500 Family: $1,500
Coinsurance	In-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 Maximum	None
Dependent Children Eligibility	Any Dependent child under age 26. No age limit if disabled
Out of Network Providers	Not covered

Office Visits and Professional Services

Service	County Health Plan EPO
Physician & Specialist	In-Network: $50 copay, no deductible Out-of-Network: Not Covered.
Preventive Care Birth to Age 18	In-Network: No charge, no deductible Out-of-Network: Not Covered.
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: Not Covered.
Diagnostic Lab and X-ray	In-Network: 20% coinsurance after deductible Out-of-Network: Not Covered.
Physical Therapy	In-Network: 20% coinsurance after deductible Out-of-Network: Not Covered.
Chiropractic	In-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

Surgical and Hospital Services

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 Surgery	In-Network: $500 per procedure copay plus 20% coinsurance after deductible Out-of-Network: Not Covered
Maternity	In-Network: $250 per admission copay plus 20% coinsurance after deductible Out-of-Network: Not Covered
Emergency Room	In-Network: $100 copay plus 20% coinsurance after deductible Out-of-Network: $150 per copay plus 20% coinsurance after deductible; Not Covered if non-emergency
Ambulance	In-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 Facility	In-Network: Not Covered Out-of-Network: Not Covered
Home Health	In-Network: Not Covered Out-of-Network: Not Covered

Prescription Drugs

Service	County 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 Order	Yes, through CVS Pharmacy Benefit
Mandatory Generic Program	Yes