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You now have MORE benefits—starting at $0

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CCA Medicare Excel (HMO) San Joaquin County
Plan 001
CCA Medicare Excel (HMO) Santa Clara County
Plan 002
Benefits
Monthly Plan Payment
$01 $01
Medical Deductible
$0 $0
Maximum Out-of-Pocket Costs
$2,500 $2,500
Primary Care Copay
$0 $0
Specialist Copay
$0 $0
Lab Services Copay
$0 $0
Hospital Copay
$0 days 1–3
$100/day, days 4-7
$0 days 1–3
$100/day, days 4-7
Prescription Drugs
$0 for Tier 1 and 2 prescription drugs
$30 Tier 3 prescription drugs
$0 for Tier 1 and 2 prescription drugs
$35 Tier 3 prescription drugs
Vision
$0 annual exam $0 annual exam
Eyewear
$300 per year $300 per year
Hearing
$0 annual $0 annual exam
Hearing Aids
$1,000 per year $1,000 per year
Viagra
Generic Viagra® (Sildenafil) coverage Generic Viagra® (Sildenafil) coverage
Wellness
$25 gift card after your annual wellness visit $25 gift card after your annual wellness visit
OTC Card
Up to $220 per year for over-the-counter health products Up to $220 per year for over-the-counter health products
Flex Card
Up to $100 per year for vision upgrades Up to $100 per year for vision upgrades
Transportation
(scheduled by CCA Health)
48 one-way transportation trips to network providers 48 one-way transportation trips to network providers
Insulin Copay
$30 for 30-day;
$60 for 90-day
$35 for 30-day;
$70 for 90-day
Acupuncturist or Chiropractor
15 visits per year 15 visits per year
Fitness
Silver&Fit® membership that includes a home fitness kit Silver&Fit® membership that includes a home fitness kit
Telehealth
$0 $0
Worldwide Emergency Coverage (outside the US)
$100,000 limit for coverage $100,000 limit for coverage
Referrals
Required for some services Required for some services

The above chart reflects in-network costs. Costs may vary depending on plan type, product, or service. For details on out-of-network costs, see the Evidence of Coverage document for your plan.

CCA Medicare Excel Plan 001 Benefit Documents

CCA Medicare Excel PLAN 001 – Benefit Highlights (2023)

CCA Medicare Excel PLAN 001 – Summary of Benefits (2023)

CCA Medicare Excel PLAN 001 – Evidence of Coverage (2023)

A detailed document to explain how your CCA Medicare Excel works and what care and services are covered.

CCA Medicare Excel Low Income Subsidy – Premium Summary (2023)

A notice for members who qualify for extra help paying for their prescription drug coverage.

CCA Health CA – Medicare Star Ratings (2023)

Medicare rates health plans on their services every year. This document tells you our ratings from Medicare.

CCA Medicare Excel Plan 002 Benefit Documents

CCA Medicare Excel PLAN 002 – Benefit Highlights (2023)

CCA Medicare Excel PLAN 002 – Summary of Benefits (2023)

CCA Medicare Excel PLAN 002 – Evidence of Coverage (2023)

A detailed document to explain how your CCA Medicare Excel works and what care and services are covered.

CCA Medicare Excel Low Income Subsidy – Premium Summary (2023)

A notice for members who qualify for extra help paying for their prescription drug coverage.

CCA Health CA – Medicare Star Ratings (2023)

Medicare rates health plans on their services every year. This document tells you our ratings from Medicare.

1 You may need to continue to pay your Medicare Part B premium.

Viagra is a registered trademark of Pfizer Inc.

The Silver&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit are trademarks of ASH and used with permission herein.

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.

CCA Medicare Excel (HMO) is a health plan with a Medicare contract. Enrollment depends on contract renewal.

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