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See our 2023 benefits

You now have MORE benefits—starting at $0

Compare Plans

of 3
HMO San Joaquin
County
Choice
HMO Santa Clara
County
Choice
HMO San Joaquin & Santa Clara Counties
Plus
Benefits 
Monthly Plan Payment
$0 $0 Part D premium is $33.10. For some people this may be paid in part or in full by Medicaid or a third party.
Medical Deductible
$0 $0 $0
Maximum Out-of-Pocket Costs
$7,550 $7,550 $7,550
For some people this may be paid in part of in full by Medicaid or a third party.
Primary Care Copay
$0 $0 $0
Specialist Copay
$0 $0 $0
Lab Services Copay
$0 $0 $0
Hospital Copay
$100 per day (days 1–3)
$0 per day (days 4–90)
$0 for unlimited additional days
$100 per day (days 1–5)
$0 per day (days 6–90)
$0 for unlimited additional days
$1,484 deductible (days 1–60); $371 per day (days 61–90)
Prescription Drug Coverage in Gap
Tier 1 and 2 Tier 1 Not covered by plan.
Some members may be covered by Low-Income Subsidy Assistance.
Dental
Preventative is covered.
Comprehensive is not covered.
Preventative is covered.
Comprehensive is not covered.
Preventative is covered.
Comprehensive is not covered.
Routine Eye Exam and Refraction
$0 (1 every year) $0 (1 every year) $0 (1 every year)
Eyewear Frames from VSP Genesis Collection
Free once every 24 months Free once every 24 months Free once every 24 months
Hearing
$0 routine hearing exam $0 routine hearing exam $0 routine hearing exam
Hearing Aids
$500 limit every year per ear $500 limit every year per ear $500 limit every year per ear
Transportation to Plan Approved Providers
$0; 24 one-way trips annually $0; 32 one-way trips annually $0; 44 one-way trips annually
Home Health Care
$0 $0 $0
Durable Medical Equipment
20% 20% 20%
For people with full Medicaid, this coinsurance may be paid in part or in full by Medicaid or a third party.
Annual Maximum on Worldwide Coverage
$25,000 per year for emergency or urgently needed care while outside the US $25,000 per year for emergency or urgently needed care while outside the US $50,000 per year for emergency or urgently needed care while outside the US

The above chart reflects in-network costs. Costs may vary depending on plan type, product, or service. For detailed information on Choice and Plus benefits, see the Summary of Benefits document below.

Do you qualify for Extra Help?

Eligible Medicare beneficiaries who have limited income may qualify for a government program called Extra Help. If you enroll in the Plus plan, the Extra Help program may lower your prescription drug costs and your monthly premium payment.

To check if you qualify for Extra Help, visit SSA.gov1 and search “Extra Help.” To apply over the phone or to request an application, call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

 

Learn More About Your Health Plan Benefits

Summary of Benefits – Choice & Plus (2022)

How to Access Materials (2022)

Star Rating (2022)

Choice – Evidence of Coverage, San Joaquin, CA

Choice – Evidence of Coverage, Santa Clara, CA

Plus – Evidence of Coverage

Low Income Subsidy Premium Table (2022)

1When you click this link, you will leave the Commonwealth Care Alliance website.

The benefit information provided here is a brief summary, not a complete description of benefits. Benefits, formulary, and pharmacy and provider networks may change on January 1 of each year. Limitations, copayments, and restrictions may apply. 

You can get this document for free in other formats, such as large print, braille, or audio. Call 866-333-3530 (TTY 711), 8 am to 8 pm, 7 days a week, from October 1 to March 31. (April 1 to September 30: 8 am to 8 pm, Monday to Friday, and 8 am to 6 pm, Saturday and Sunday.) The call is free.

We’re here to support you

866-333-3530 (TTY 711)
8:00 am to 8:00 pm PT, 7 days a week