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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 referral may be required2 $0 referral may be required2
Lab Services Copay
$02 $02
Hospital Copay
$0 days 1–3
$100/day, days 4-72
$0 days 1–3
$100/day, days 4-72
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 exam2 $0 annual exam2
Eyewear
$300 per year2 $300 per year2
Hearing
$0 annual exam $0 annual exam
Hearing Aids
$1,000 per year or 2 aids (1 per ear)2 $1,000 per year or 2 aids (1 per ear)2
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
Healthy Savings Card
$100 per year on your Healthy Savings card to be used at vision provider offices toward eyewear including frame and lens enhancements $100 per year on your Healthy Savings card to be used at vision provider offices toward eyewear including frame and lens enhancements
Transportation
$0 copay for up to 48 one-way medical trips to plan-approved locations each year2 $0 copay for up to 48 one-way medical trips to plan-approved locations each year2
Acupuncturist
$0 copay for up to 15 combined acupuncture and chiropractic visits per year2 $0 copay for up to 15 combined acupuncture and chiropractic visits per year2
Chiropractor Office Visit
$0 copay for up to 15 combined acupuncture and chiropractic visits per year2 $0 copay for up to 15 combined acupuncture and chiropractic visits per year2
Fitness Benefit
Silver&Fit® membership that includes a home fitness kit3 Silver&Fit® membership that includes a home fitness kit3
Worldwide Emergency Coverage (outside the US)
$100,000 limit for coverage $100,000 limit for coverage

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)

A brief summary of the benefits and services covered by your CCA Medicare Excel 002 plans.

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 PLAN 001 – Annual Notice of Changes for 2023

CCA Medicare Excel Low Income Subsidy CA – 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)

A brief summary of the benefits and services covered by your CCA Medicare Excel 002 plans.

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 PLAN 002 – Annual Notice of Changes for 2023

CCA Medicare Excel Low Income Subsidy CA – 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 have to continue to pay your Medicare Part B Premium unless your Part B premium is paid for you by Medicaid. Viagra is a registered trademark of Pfizer Inc.

2 Prior authorization may be required.

3 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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