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Human Resources Department

Benefits Unit
County Of Sonoma › Administrative Support & Fiscal Services › Human Resources › Divisions and Units › Benefits › Employee Benefits › Medical, Dental, Vision & Life › Medical Benefit Options for Employees › County Health Plans › County Health Plan PPO
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.

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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 M108
Medical Plan Out-of-State:
Group #175130 M112
Prescription Plan:
Group #3439-1002

Retiree Group Numbers

Medical Plan - California

Non-Medicare:
Group #175130 M110
Medicare:
Group #175130 M111

Medical Plan - Out-of-State

Non-Medicare:
Group #175130 M114
Medicare:
Group #175130 M115

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).

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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

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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 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.

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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

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