Download Which medical plan is right for you?

A quick reference guide to UC's medical plans

Note: The chart below shows what the member pays for care, effective Jan. 1, 2021. See employee medical plan premium contributions for your share of premium costs for each plan in 2021.

This is a summary only. Important details — such as limitations, exclusions, exceptions, and other qualifiers — may not be included. For detailed information, call the plan or see their website for specific benefits, benefits when traveling overseas, provider information, and plan booklets.

Definitions

Calendar Year Deductible: The amount you must pay for medical services before the plan will provide benefits.

Annual Out-of-Pocket Maximum: The amount you must pay during the calendar year before the plan will pay 100% of covered charges. Some expenses do not apply toward the maximum; see the plan’s evidence of coverage booklet.

Copayments: Shown in dollars; represents the amount you pay after the deductible (if any) has been met.

Coinsurance: Shown as a percentage; represents the percentage of the allowable amount you pay after the deductible (if any) has been met.

Allowable Amount: The dollar amount considered payment-in-full for services provided by the health plan carrier’s network of healthcare providers. (Out-of-network providers may bill members for amounts in excess of the allowable amount.) 

PLANS
UC BLUE & GOLD HMO
KAISER
CA
UC CARE
UC HEALTH
SAVINGS PLAN
CORE
UC Select
Anthem Preferred
Out-of-
network
In-Network
Out-of-
network
COSTS (SEE EMPLOYEE MEDICAL PLAN COSTS FOR YOUR SHARE OF PREMIUMS)
Calendar Year Deductible $0 $0 $0 Individual: $5001
Family: $1,0001
Individual: $750
Family: $1,750
Individual: $1,4002
Family: $2,8002
(You may use your HSA funds to pay for your deductible and other eligible out-of-pocket expenses.)
Individual: $2,5502
Family: $5,1002
(You may use your HSA funds to pay for your deductible and other eligible out-of-pocket expenses.)
Individual: $3,000
Annual Out-of-Pocket Maximum 3 Individual: $1,000
Family (3 persons or more): $3,000
Individual: $1,500
Family (2 persons or more): $3,000
Individual: $6,1001
Family: $9,7001
Individual: $7,6001
Family: $14,2001
Individual: $9,6001
Family: $20,2001
Individual: $4,000
Family: $6,400
Individual: $8,000
Family: $16,000
Individual: $6,350
Family: $12,700
Health Savings Account (HSA)(UC Contribution) Not applicable Not applicable Not applicable Not applicable Not applicable Employee: up to $5004
Employee & Adult: up to $1,0004
Employee & Children: up to $1,0004
Family: up to $1,0004
Employee: up to $5004
Employee & Adult: up to $1,0004
Employee & Children: up to $1,0004
Family: up to $1,0004
Not applicable
Physician Visits
Office Visit $20 $20 $20 30% 50% 20% 40% 20%
Hospital Visit No charge No charge No charge 30% 50% 20% 40% 20%
Preventive Physical Exam No charge No charge No charge No charge (not subject to calendar year deductible) 50% No charge (not subject to calendar year deductible) 40% No charge (not subject to calendar year deductible)
Maternity Outpatient Care No charge No charge $20 (initial visit only) 30% 50% 20% 40% 20%
Maternity Inpatient Care $250 copayment per admittance $250 copayment per admittance $250 copayment per admittance 30% 50% (non-preferred hospitals subject to maximum payment of $300/day) 20% 40% (out-of-network hospitals subject to maximum payment of $360/day) 20% (out-of-network hospitals subject to maximum payment of $480/day)
Well Baby Care No charge No charge No charge No charge (not subject to calendar year deductible) 50% No charge (not subject to calendar year deductible) 40% No charge (not subject to calendar year deductible)
Prescription Drugs
Retail (up to 30-day supply) Generic: $57
Brand: $255, 7
Non-Formulary: $407
30-day supply — Generic: $5; Brand: $25;
31–60 day supply — Generic: $10; Brand: $50;
61–100 day supply — Generic: $15; Brand: $75
Non-Formulary: does not apply
At participating pharmacies:
Generic: $57
Brand: $255, 7
Non-Formulary: $407
Specialty Medications: 30% (up to $150 copayment maximum)
At participating pharmacies:
Generic: $57
Brand: $255, 7
Non-Formulary: $407
Specialty Medications: 30% (up to $150 copayment maximum)
50% (of billed charges per prescription)5 20%6, 7 40%6 20%6, 7
Mail Order (up to 90-day supply) Generic: $10
Brand: $505
Non-Formulary: $80
30-day supply — Generic: $5; Brand: $25;
31–100 day supply — Generic: $10; Brand: $50;
Non-Formulary: does not apply
Generic: $10
Brand: $505
Non-Formulary: $80
Generic: $10
Brand: $505
Non-Formulary: $80
Not covered 20%6 Not covered Preferred: 20%6
Non-preferred: Not covered
Hospital Services
Inpatient $250 copayment per admittance $250 copayment per admittance $250 copayment  30% 50% (non-preferred hospitals subject to maximum payment of $300/day) 20% 40% (out-of-network hospitals subject to maximum payment of $360/day) 20% (out-of-network hospitals subject to maximum payment of $480/day)
Surgeon / Assistant Surgeon No charge No charge No charge 30% 50% 20% 40% 20%
Emergency Room $125 (waived if admitted) $125 (waived if admitted) Facility: $300 copay per visit not resulting in admission, $250 if admitted
ER Physician Services: No charge
Facility: $300 copay per visit not resulting in admission, $250 if admitted
ER Physician Services: No charge (not subject to calendar year deductible)
Facility: $300 copay per visit not resulting in admission, $250 if admitted
ER Physician Services: No charge (not subject to calendar year deductible)
20% 20% 20%
Ambulance No charge No charge N/A (services covered under Anthem Preferred) $200/trip (not subject to calendar year deductible) $200/trip (not subject to calendar year deductible) 20% 40% 20%
Urgent Care $20 $20 $20 $20 50% 20% after deductible 40% after deductible 20% (in- or out-of-network)
Behavioral Health8
Mental Health Inpatient $250 copayment per admittance or course of treatment (must preauthorize) Kaiser: $250 copayment per admittance
Optum: $250 copayment per admittance or course of treatment (must preauthorize)
$250 copayment per admittance or course of treatment $250 copayment per admittance or course of treatment 50% (additional $250 copayment for failure to preauthorize) 20% 40% ($250 for failure to preauthorize) 20%
Mental Health Outpatient Visits Visits 1–3: No copayment
Visits 4+: $20 (non-routine visits: $0 copay for 4+ visits)
Kaiser: $20 for individual visit; $10 for group visit.
Optum: Visits 1–3: No copayment. Visits 4+: $20
Visits 1–3: No copayment
Visits 4+: $20
Visits 1–3: No copayment
Visits 4+: $20
50% 20% 40% 20%
Substance Abuse Inpatient $250 copayment per admittance or course of treatment (must preauthorize) Kaiser: $250 copayment per admittance
Optum: $250 copayment per admittance or course of treatment (must preauthorize)
$250 copayment per admittance or course of treatment $250 copayment per admittance or course of treatment 50% (additional $250 copayment for failure to preauthorize) 20% 40% ($250 for failure to preauthorize) 20%
Substance Abuse Outpatient Visits Visits 1–3: No copayment
Visits 4+: $20
Kaiser: $20 for individual visit; $5 for group visit.
Optum: Visits 1–3: No copayment. Visits 4+: $20
Visits 1–3: No copayment
Visits 4+: $20
Visits 1–3: No copayment
Visits 4+: $20
50% 20% 40% 20%
Other Benefits
Hospice Inpatient and Outpatient No charge No charge N/A (services covered under Anthem Preferred) 30% 50% (non-preferred hospitals subject to maximum payment of $300/day) 20% Not covered unless prior authorized. If authorized, in-network benefit applies. 20% (out-of-network hospitals subject to maximum payment of $480/day)
Home Health Care No charge No charge (up to 100 visits/calendar year) N/A (services covered under Anthem Preferred) 30% (up to 100 visits/calendar year) 50% (up to 100 days/calendar year) If authorized, paid at Anthem Preferred tier. 20% (up to 100 visits/calendar year) Not covered unless prior authorized. If authorized, in-network benefit applies. 20% (up to 100 visits/calendar year, out-of-network not covered)
Skilled Nursing Facility No charge (up to 100 days/calendar year) No charge (up to 100 days/calendar year) N/A (services covered under Anthem Preferred) 30% (up to 100 days/calendar year) 50% (up to 100 days/calendar year) If authorized, paid at Anthem Preferred tier; otherwise, subject to maximum payment of $300/day. 20% (up to 100 days/calendar year) Not covered unless prior authorized. If authorized, in-network benefit applies. 20% (up to 100 days/calendar year, out-of-network facilities subject to maximum payment of $480/day)
Outpatient X-Ray and Lab No charge No charge $20 30% 50% 20% 40% 20%
Eye Exams $20 (no charge if part of a preventive care exam) No charge if part of a routine physical exam No charge if part of a routine physical exam No charge if part of a routine physical exam 50% No charge if part of a routine physical exam, otherwise 20% 40% No charge if part of a routine physical exam, otherwise 20%
Chiropractor $20 (24 visit limit/calendar year combined with acupuncture) $15 (24 visit limit/calendar year combined with acupuncture) N/A (services covered under Anthem Preferred) 30% (preferred providers and 24 visit limit/calendar year combined with acupuncture) 50% (up to allowed amount and 24 visit limit/calendar year combined with acupuncture) 20% (24 visit limit/calendar year combined with acupuncture) 40% (up to allowed amount and 24 visit limit/calendar year combined with acupuncture) 20% (24 visit limit/calendar year combined with acupuncture)
Acupuncture $20 (24 visit limit/calendar year combined with chiropractor) $15 (24 visit limit/calendar year combined with chiropractor) N/A (services covered under Anthem Preferred) 30% (preferred providers and 24 visit limit/calendar year combined with chiropractor) 50% (up to allowed amount and 24 visit limit/calendar year combined with chiropractor) 20% (24 visit limit/calendar year combined with chiropractor) 40% (up to allowed amount and 24 visit limit/calendar year combined with chiropractor) 20% (24 visit limit/calendar year combined with chiropractor)
 

1 UC Care deductible and out-of-pocket maximums do not cross-accumulate for in-network and out-of-network services. The UC Select and Anthem Preferred out-of-pocket maximum do cross-accumulate.

2 In-network expenses count toward meeting the out-of-network deductible, but out-of-network expenses do not count toward meeting the in-network deductible (except for authorized ambulance and emergency medical services).

3 The annual out-of-pocket maximum combines medical, behavioral health and prescription drugs.

4 This assumes you are covered Jan. 1, 2021. If you enroll later in the year, the UC contribution is prorated.

5 When a generic drug is available and you or your physician choose the brand-name drug, you must pay the generic copay plus the difference between the cost of the brand-name drug and the generic equivalent. With prior authorization, exceptions for medical necessity can be made and you pay the brand-name copay.

6 When a generic drug is available and you or your physician choose the brand-name drug, you must pay coinsurance on the cost of the generic drug plus the difference between the cost of the brand-name drug and the generic equivalent. With prior authorization, exceptions for medical necessity can be made and you pay coinsurance on the cost of the brand-name drug.

7 90-day supply available for maintenance medication at UC Medical Center and participating retail pharmacies at plan’s mail order copay benefit level.

8 PPO members receive behavioral health benefits through their medical plan. UC Blue & Gold HMO members receive behavioral health benefits from Managed Health Network (MHN). Kaiser members have access to the Kaiser benefit shown, in addition to the Optum in-network benefits and network of providers.