Page 1 CONTRA COSTA COMMUNITY COLLEGE DISTRICT October 2013 Hospital Room Services Hospital Outpatient Surgery Maternity Skilled Nursing Facility Lab, Xray and Diagnostic Testing Home Health Care Mental Health Care $100/admission, surgery/physician. Must be retired having Medicare Parts A & B and living in the service area. $100/admission, surgery/physician. Includes expanded Commercial Provider Network - Not available to UF Members. $100/day; $200 maximum per admission. $15 copay. $5 copay. $15 copay. $15 copay: No charge for delivery or nurse. No charge: Up to 100 days/benefit period for prescribed care. No charge: Up to 100 visits per Inpatient: $100 admission when authorized; Outpatient: $15/visit. $7/group $5 copay; No charge for delivery or nurse. No charge: up to 100 days/benefit period for prescribed care. $5 copay Scans/Imaging-Outpatient surgery center. No charge, limit service as prescribed by physician. Inpatient: $100 admission; Outpatient: $5 copay - unlimited visit. $2 group ; $150 copay elective abortions. $15 Radiation and Chemo/$100/test advanced imaging. $15 copay, up to 100 visits per Inpatient:.. Not covered. $100/day; $200 max per admission (no copay for nursery care). No charge; Advanced Imaging subject to UR. Inpatient: $100 copay/admission; 100 days/benefit period. No charge Lab; $15 Outpatient Xray; $75 complex Radiology; 20% Chemo. Medicare limits apply. Inpatient:. 100 days/year; $100/day, $200 max/per admit; waived if within 90 days of hospitalization. Medically necessary skilled services only No charge. Inpatient: $100/day $200/admittance when authorized. Outpatient: $15 copay. Substance Abuse Inpatient Detox T.R.R.* Outpatient *Transitional Residence Recovery $100 admission; - no visit limit; $5/group outpatient. $100 copay/admission; Outpatient: $5 copay - no visit limit; $2 group. Inpatient: Inpatient: Inpatient: $100/day; $200 maximum/admission.
Page 2 CONTRA COSTA COMMUNITY COLLEGE DISTRICT October 2013 Physician (including surgeon) Ambulance Service $15 copay for all providers & specialty visits. Well baby (up to 23 months) no charge. $5 copay for all providers & specialty visits. $15 copay. $15 copay. $15 copay. Hospital & office visit; surgery, vision & hear tests; well-baby care; periodical health exams, immunization & inoculations; allergy serum, injections $15/visit. $100/trip. No charge when authorized emergency. Prescription Drugs Speech/Occupational & Physical Therapy Preventive Care Outpatient: $5 Generic/100-day supply, $15 Brand; 50% copay for infertility & sexual dysfunc Rx s. Outpatient: $5 Generic /100-day supply; $5 Brand; 25% copay for infertility & sexual dysfunc Rx s. Outpatient: $5/$15 refill up to 30-day supply/90 day mail order, 1 copay required. $15 copay. $5 copay. No charge; Limited to 60 day period of care. No charge for office visits and immunizations. Well baby (up to 23 months) - $0 copay. Pre-natal & first Post-partum visit - $0 copay. Outpatient: $5/$15 refill up to 30-day supply/90 day mail order, 1copay required. No charge 24 visits/calendar year; Speech Therapy no visit limit. Outpatient: $5/$15/$15 refill up to 30 day supply/90 day mail order, 2 copays required. $10 copay generic; $25 copay brand names with no annual limit, includes birth control pills, prenatal visits and insulin needles. $15 copay. $15 copay/visit (short term). NOTE: CCHP charges for office visit and does not charge for specified services including those rated A or B by the U.S. Preventive Services Task Force, recommended immunizations, preventive care for children /adolescents, and additional preventive care and screening for women.
Page 3 CONTRA COSTA COMMUNITY COLLEGE DISTRICT October 2013 Emergency Room & Outof-Area Treatment Durable Medical Equipment: Orthotics Braces & Support; Corrective Footwear Custom made shoes/inserts; Diabetic Supplies (except footwear); Diabetic Footwear Worldwide covered for emergency due to unforeseen illness or injury; provided at $50 copay; waived if admitted directly to hospital. No charge: Formulary applies (includes Diabetic Equipment & Supplies). Worldwide covered for emergency due to unforeseen illness or injury; provided at $50 copay; waived if admitted directly to hospital. No charge: Formulary applies (includes Diabetic Equipment & Supplies). 20% copay subject to review. Covered when medically necessary. $50 copay (waived if admitted). 20% copay - subject to review. Covered when medically necessary. $50 copay (waived if admitted). Covered when medically necessary. Worldwide covered for acute care requiring immediate attention. $35 copay, all ER visits. Prosthesis and Orthotics covered in full when authorized (includes diabetic equipment & supplies). Allergy Benefit $3 copay. $3 copay. $15 copay. $15 Allergy testing. Allergy testing and treatment covered at no charge; $15 copay/office visit. Dependent Eligibility
Page 4 CONTRA COSTA COMMUNITY COLLEGE DISTRICT October 2013 Infertility Major Exclusions Chiropractic Acupuncture Optical 50% of charges. Excludes invitro, ovum transplant & donor egg & semen. Dental care, plastic surgery, chiropractic, cosmetic surgery, hearing aid. Limit on smoking cessation therapy to 1 course/ year. Member pays 50% (refer to coverage book). $15 copay/30 visits calendar/year; $50 annual appliance allowance (American treatment of nausea or pain management program/$5 copay. Exams/eye refractions no charge, hardware excluded. Outpatient: $5 copay. No charge test and hospital (excludes invitro ovum transplant, donor egg and semen). Dental care, plastic surgery, chiropractic, cosmetic surgery, hearing aid. Limit on smoking cessation therapy to 1 course/ year. Member pays 50% (refer to coverage book). $15 copay/30 visits combined with acupuncture. $50 annual appliance allowance (American treatment of nausea or pain management program/$5 copay. $5 copay exams; $150 eyewear allowance as medically necessary every 24 months. 50% of charges - Invitro not covered. Experimental procedures, cosmetic surgery, hearing aids, eye glasses (refer to $15/30 visits combined with Acupuncture (American Specialty Health Plans Network.) $15/30 visits combined with Chiro. (American Network.) Vision screening. Not covered. Not covered. Excludes invitro; Services to induce pregnancy not covered except artificial insemination. Experimental procedures, cosmetic surgery, hearing aids, eye glasses (refer to No charge/24 visits/ No charge/$30 per visit maximum allowance 30 visits/year. Vision screening. Experimental procedures, cosmetic surgery, hearing aids, eye glasses (refer to $15 copay limited to Medicare covered visits. Not covered. $15 copay limited to 1 exam per year. Experimental treatment and transplant, cosmetic surgery. $15 copay/20 visits calendar/year (CCHP $15 Vision exam.
Page 5 CONTRA COSTA COMMUNITY COLLEGE DISTRICT October 2013 Maximum Outof-Pocket/ Calendar/Year SINGLE FAMILY Lifetime Maximum Benefit $3,000 *Includes Rx plan; Excludes Chiro. $3,000 *Includes Rx plan; Excludes Chiro. $3,000/3 per family. *Applies to Medical Only; Excludes Chiro, Acupuncture, Infertility, and Rx. $4,500/3 per family. *Applies to Medical Only; Excludes Infertility, non-covered services and RX. No family maximum. Applies to Medical; Excludes routine Vision, Hearing, additional Chiro, Foreign Travel and Part D drugs. None. None. None. None. None. None. $3,000* per individual $6,000 family *Excludes Rx.