STAGE DEV MAY, 2013

ActiveChoice PPO

Welcome to the ActiveChoice Plan

CCHP ActiveChoice PPO Benefit Highlights

tab01 activechoice-ppo

2017 Benefit Highlights

(In-Network)

  • Individual $2,000/ Family $4,000 Annual Deductible
  • $0 Copay for Preventive Services
  • $0 Copay for Lab Tests & X-Rays (After Deductible)
  • $0 Copay for Maternity Care (Preconception/Prenatal/Postnatal Care)
  • $0 Copay for the First 3 Primary Care Physician Visit
  • Maximum out-of-pocket: Individual $6,250/ Family $12,500

(Out-Network)

  • Individual $2,000/ Family $4,000 Annual Deductible
  • $0 Copay for Preventive Services
  • $0 Copay for Maternity Care (Preconception/Prenatal/Postnatal Care)
  • 50% Coinsurance for Lab Tests & X-Rays (After Deductible)
  • 50% Coinsurance for Office Visit (After Deductible)
  • Maximum out-of-pocket: Individual $6,250/ Family $12,500

Plan Benefit Highlights

Pediatric Dental Summary - for Active Choice PPO Plan

Pediatric Vision Summary

Optional Rider:
Adult Vision Summary

Individual & Family Plans Rate - San Francisco County

Individual & Family Plans Rate - Northern San Mateo County

Summary of Benefits (SBC)

Health Plan Benefits and Coverage Matrix

Evidence of Coverage (EOC)

CCHP Provider Directory - HMO (English and Chinese)

To start an online Provider Search, click here

CCHP Pharmacy Directory (English)

List of Covered Drugs (Formulary) (English)* (No changes made since 6/2017)

Formulary Changes for 2017 (English)

* There are four tiers in the drug formulary. Tiers include the types of drugs that are covered. Please refer to your Evidence of Coverage and Disclosure Form for details.

Tier Definition
1 1) Most generic drugs and low cost preferred brands.
2 1) Non-preferred generic drugs or;
2) Preferred brand name drugs or;
3) Recommended by the plan's pharmaceutical and therapeutics (P&T) committee based on drug safety, efficacy and cost.
3
 
1) Non-preferred brand name drugs or;
2) Recommended by P&T committee based on drug safety, efficacy and cost or;
3) Generally have a preferred and often less costly therapeutic alternative at a lower tier.
4

 

1) Food and Drug Administration (FDA) or drug manufacturer limits distribution to specialty pharmacies or;
2) Self administration requires training, clinical monitoring or;
3) Drug was manufactured using biotechnology or;
4) Plan cost (net of rebates) is >$600.

 

CCHP Pharmaceutical Management Procedures (English)

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If you would like to enroll, please contact us or download the enrollment application.

STAGE DEV MAY, 2013