Plan Details
Costs and Other Important Information
Benefits
$100 for days 1 through 7
$0 for days 8 through 90
Tier 2
$280 for days 1 through 7
$0 for days 8 through 90
$10 per visit
Specialist:
$20 per visit
$80 per visit (always covered)
Urgent care:
$35 per visit (always covered)
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$200
Outpatient x-rays:
$0 copay
$0 for days 8 through 90
Outpatient group therapy visit with a psychiatrist:
$35
Outpatient individual therapy visit with a psychiatrist:
$35
Outpatient group therapy visit:
$35
Outpatient individual therapy visit:
$35
$135 for days 21 through 100
$25
Physical therapy and speech and language therapy visit:
$25
$35
Routine foot care:
Not covered
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
$0 copay
$0 copay
Other Part B drugs:
$0 copay
Coverage Area for CCHP Senior Program (HMO)
State | California |
---|---|
County | Los Angeles |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $3 copay | $3 copay | Not offered |
Tier 2: Non-Preferred Generic | $7 copay | $7 copay | Not offered |
Tier 3: Preferred Brand Name | $40 copay | $40 copay | Not offered |
Tier 4: Non-Preferred Brand Name | $60 copay | $60 copay | Not offered |
Tier 5: Specialty Tier | 30% coinsurance | 30% coinsurance | Not offered |
90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $6 copay | $9 copay | Not offered |
Tier 2: Non-Preferred Generic | $14 copay | $21 copay | Not offered |
Tier 3: Preferred Brand Name | $80 copay | $120 copay | Not offered |
Tier 4: Non-Preferred Brand Name | $120 copay | $180 copay | Not offered |
Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Managing Chronic Conditions
Member Experience with Health Plan
Member Complaints, and Changes in Health Plan's Performance
Health Plan Customer Service
Drug Plan Customer Service
Member Complaints, and Changes in Drug Plan's Performance
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Physician Finder
Physicians that accept CCHP Senior Program (HMO) for California