CCPOA Medical Plan
Supervisory Members
The CCPOA Medical plan provides you and
your family with excellent, extensive care. We have added more providers and resources including Sutter facilities and
provided members with 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 provided by Blue Shield of California.
For complete description of plan benefits, refer to the Evidence of Coverage.
2011 Evidence of Coverage • 2010 Evidence of Coverage
2011 Medical Plan Highlights |
|
CCPOA Member: |
221.95 - Single |
462.34 - 2 party |
|
660.72 - Family |
|
CCPOA Member: |
126.86 - Single |
272.13 - 2 party |
|
404.96 - Family |
|
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 | |
| Not covered (alternate care discounts of 25% or more through alternate care discount program) | |
| BIOFEEDBACK | |
| $15/visit | |
| CHIROPRACTIC | |
| $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 |
|
This CCPOA Medical Plan is available only to full dues paying CCPOA members.
Join the CCPOA today: 1-800-821-6443
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.
Don't forget to visit www.blueshield.com/hlr for more information on the Healthy Lifestyle Rewards Program.
CCPOA Medical Plan (offered by Blue Shield of CA)