CCPOA Medical Plan

Rank & File / Supervisor

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The CCPOA Medical Plan provides you and your family a great plan with good rates and extensive care. We have added more providers and resources including the complete Sutter Health network, and providing members with network Chiropractic benefits. For complete information on the CCPOA Medical Plan, please see the Evidence of Coverage. As of January 1, 2006, The CCPOA Medical Plan is administered by Blue Shield of California.

For a complete description of plan benefits, refer to the Evidence of Coverage.   

 

Medical Plan Highlights
HOSPITAL
Inpatient	$100 per admission
Outpatient	No charge*
PHYSICIAN SERVICES
Office Visits	$15 per visit / No charge for preventive services More than one co-pay may apply during an office visit if multiple services are provided.
Gynecological Exam	No charge
Home Visit	$15/visit
Well-Baby Care (through age 2)	No charge
Allergy Testing/Treatment	No charge
Immunization/Inoculation	No charge
Vision Exam/Testing	No charge
	Limited to one visit per calendar year for members 18 and over.No limit on number of visits for members under age 18.
Hearing Exam/Testing	No charge
Inpatient Hospital Visits	No charge
Surgery	No charge
ACCESS+ SPECIALIST SELF REFERRAL**
	$30/visit
DIAGNOSTIC X-RAY/LAB
Outpatient Services	No charge
PRESCRIPTION DRUGS
Retail Pharmacy (up to 30-day supply)	$10/generic $25/formulary brand name $50/non-formulary Calendar year prescription brand name drug deductible: $50/per member; $150/per family
Mail Order Program (up to 90-day supply)	$20/generic $50/formulary brand name $100/non-formulary
DURABLE MEDICAL EQUIPMENT
	No charge
INFERTILITY TESTING/TREATMENT
Professional, hospital, ambulatory surgery center, ancillary services and drugs administered to diagnose and treat infertility. Excludes in vitro fertilization, ovum transplant, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and reversal of voluntary sterilization.	50% of allowed charges
AMBULANCE
Air/ground ambulance services	No charge
EMERGENCY SERVICES
Does not apply if admitted as an inpatient or for observation as an outpatient	$75/visit – does not apply if hospitalized. If admitted, $100/visit
MENTAL HEALTH
Inpatient	$100 per admission
Outpatient	$15/visit
HOME HEALTH SERVICES
Pre-certification required. Custodial care not covered.	$15/visit (up to 100 visits/calendar year
SKILLED NURSING FACILITY CARE
Medically necessary services provided in licensed skilled nursing facility. Custodial care not covered.	No charge (up to 100 days/calendar year)
SPEECH / PHYSICAL / OCCUPATIONAL THERAPY
Outpatient department of a hospital or provider’s office	No charge
HOSPICE
	No charge
ACUPUNCTURE
For information call (877) 335-2746	Not covered. (Discounted services are available using a network provider through the Alternate Care discount program)
BIOFEEDBACK
	$15/visit
CHIROPRACTIC
To find a Chiropractor in the provider network call 1-800-678-9133	$15/visit (up to 20 visits/calendar year)
BLOOD & BLOOD PRODUCTS
	No charge
HEARING AID SERVICES
Audiological Exam	$15/visit
Hearing Aids	$500 maximum per member per calendar for hearing aids and ancillary equipment
FAMILY PLANNING SERVICES
Injectable Contraceptives (including, but not limited to, Depo Provera)	$15/visit – no charge for injection
Sterilization for males or females	$15/visit; $100/admission
PREGNANCY & MATERNITY CARE
Prenatal & Postnatal Initial Exam	No charge
* $50 if outpatient surgery performed ** The Access+ Specialist option enables you to go directly to a specialist within your Personal Physician’s medical group or IPA without a referral. You can use this option if your Personal Physician belongs to a medical group or IPA that participates in the Access+ Specialist program. To see which specialties are included, please consult the Evidence of Coverage and Disclosure Form

ADDITIONAL LINKS & RESOURCES

2012 Rate Chart

To find a Chiropractor in the provider network call 1-800-678-9133

This CCPOA Medical Plan is available only to full dues paying CCPOA members.

Join the CCPOA today: 1-800-821-6443

Don't forget to visit www.blueshield.com/hlr for more information on the Healthy Lifestyle Rewards Program.

CCPOA Medical Plan

If you have questions or need assistance, please call CCPOA Medical Plan at:
1-800-257-6213
or the Trust at:
1-800-IN-UNIT-6

If you have any specific questions regarding the medical plan's benefits or coverage areas, please contact Debbie at the Trust.