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See our 2022 benefits

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.

Learn more about your CCA Medicare Excel benefits

Summary of Benefits – CCA Medicare Excel plans (2023)

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

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

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Annual Notice of Change – CCA Medicare Excel plans (2023)

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CCA Health CA – Medicare Star Ratings (2023)

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

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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