Note: Benefits show what member pays.

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.

Service areas: To determine if a medical plan provides service where you live, contact the plan directly.

Anthem Blue Cross is the administrator of the UC Care, UC Health Savings Plan and CORE plans. Health Net is the administrator of the UC Blue & Gold HMO plan.

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.

Coinsurance: Shown as a percentage; represents the percentage of the allowable amount you pay.

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 Western Health Advantage UC Care In-Network: UC Select UC Care In-Network: Anthem Preferred UC Care Out-of-Network UC Health Savings Plan In-Network UC Health Savings Plan Out-of-Network CORE
Costs (see Employee Medical Plan Costs for your share of premiums)
Calendar Year Deductible $0 $0 $0 $0 Individual: $2501
Family: $7501
Individual: $500
Family: $1,500
Individual: $1,350
Family: $2,700
(You may use your HSA funds to pay for your deductible and other eligible out-of-pocket expenses.)
Individual: $2,550
Family: $5,100
(You may use your HSA funds to pay for your deductible and other eligible out-of-pocket expenses.)
Individual: $3,000
Health Savings Account (HSA)(UC Contribution) Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Employee: up to $500
Employee & Adult: up to $1,000
Employee & Children: up to $1,000
Family: up to $1,000
Employee: up to $500
Employee & Adult: up to $1,000
Employee & Children: up to $1,000
Family: up to $1,000
Not applicable
Annual Out-of-Pocket Maximum 4 Individual: $1,000
Family (3 persons or more): $3,000
Individual: $1,500
Family (2 persons or more): $3,000
Individual: $1,000
Family (3 persons or more): $3,000
Individual: $5,1001
Family: $8,7001
Individual: $6,6001
Family: $13,2001
Individual: $8,6001
Family: $19,2001
Individual: $4,000
Family: $6,400
Individual: $8,000
Family: $16,000
Individual: $6,350
Family: $12,700
Hospital Services
Inpatient $250 copayment per admittance $250 copayment per admittance $250 copayment per admittance $250 copayment per admittance 20% 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 No charge 20% 50% 20% 40% 20%
Emergency Room $75 (waived if admitted) $75 (waived if admitted) $75 (waived if admitted) Facility: $200 copay per visit not resulting in admission, $250 if admitted
ER Physician Services: No charge
Facility: $200 copay per visit not resulting in admission, $250 if admitted
ER Physician Services: No charge (not subject to calendar year deductible)
Facility: $200 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 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%
Physician Visits
Office Visit $20 $20 $20 $20 20% 50% 20% 40% 20%
Hospital Visit No charge No charge No charge No charge 20% 50% 20% 40% 20%
Preventive Physical Exam No charge 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 No charge $20 (initial visit only) 20% 50% 20% 40% 20%
Maternity Inpatient Care $250 copayment per admittance $250 copayment per admittance $250 copayment per admittance $250 copayment per admittance 20% 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 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)
Other Benefits
Hospice Inpatient and Outpatient No charge No charge No charge N/A (services covered under Anthem Preferred) 20% 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) No charge (up to 100 visits/calendar year) N/A (services covered under Anthem Preferred) 20% (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) No charge (up to 100 days/calendar year) N/A (services covered under Anthem Preferred) 20% (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 No charge $20 20% 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 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) $20 (24 visit limit/calendar year combined with acupuncture) N/A (services covered under Anthem Preferred) 20% (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) $20 (24 visit limit/calendar year combined with chiropractor) N/A (services covered under Anthem Preferred) 20% (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)
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
Generic: $57
Brand: $255, 7
Non-Formulary: $407
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
Generic: $10
Brand: $505
Non-Formulary: $80
Not covered 20%6 Not covered Preferred: 20%6
Non-preferred: Not covered
Behavioral Health 8
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 (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
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 (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
Visits 1–3: No copayment
Visits 4+: $20
50% 20% 40% 20%
 

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.

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.

3 This assumes you are covered Jan. 1, 2019. If you enroll later in the year, the UC contribution is prorated.

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

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 Optum provides behavioral health benefits for the Western Health Advantage HMO plan. 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.