Opal 50 HMO Silver

Opal 50 HMO Silver

CCHP Opal 50 HMO Silver Plan Benefit Highlights

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2017 Benefit Highlights

  • 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

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Plan Benefit Highlights (PDF)

Pediatric Dental Summary (PDF)

Pediatric Vision Summary (PDF)

Optional Riders:
Adult Vision Summary (B) (PDF)
Adult Vision Summary (C) (PDF)
Chiropractic Summary (PDF)

Employer Group Plans Rate - San Francisco County (PDF)

Employer Group Plans Rate - Northern San Mateo County (PDF)

Summary of Benefits (SBC) (PDF)

Health Plan Benefits and Coverage Matrix (PDF)

Evidence of Coverage (EOC) (PDF)

CCHP Provider Directory - HMO (English and Chinese) (PDF)

Start an online Provider Search

CCHP Pharmacy Directory (English) (PDF)

List of Covered Drugs (Formulary) (English) (PDF) (No changes made since 11/2017)

Formulary Changes for 2017 (English) (PDF)

* 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) (PDF)

VSP In-Network Provider Search / VSP Member Account Access
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ASH Chiropractic Provider Search
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