Compare plans

A quick reference guide to your benefits and costs

Note: The chart below shows what the member pays at the time of care. See employee medical plan premium contributions for your share of premium costs for each plan.

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. If any information on the website conflicts with plan documents, plan documents prevail.

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Plan	Calendar Year Deductible	Health Savings Account (HSA) UC contribution	Annual Out-of-Pocket Maximum¹
UC Blue & Gold HMO	$0 (in-network coverage only)	Not applicable	Individual: $1,000 Family (3 persons or more): $3,000
Kaiser HMO	$0 (in-network coverage only)	Not applicable	Individual: $1,500 Family (2 persons or more): $3,000
UC Care
UC Select Network	$0	Not applicable	Individual: $6,100² Family: $9,700²
Anthem Preferred Network	Individual: $500² Family: $1,000¹	Not applicable	Individual: $7,600² Family: $14,200²
Out-of-Network	Individual: $750² Family: $1,750²	Not applicable	Individual: $9,600² Family: $20,200²
CORE	Individual: $3,000	Not applicable	Individual: $6,350 Family: $12,700
UC Health Savings Plan
In-Network	Individual Coverage: $1,400³ Family Coverage: $2,800³ (You may use your HSA funds to pay for your deductible and other eligible out-of-pocket expenses.)	Employee: up to $500⁴ Employee & Adult: up to $1,000⁴ Employee & Children: up to $1,000⁴ Family: up to $1,000⁴	Individual Coverage: $4,000 Family Coverage: $6,400
Out-of-Network	Individual Coverage: $2,550³ Family Coverage: $5,100³ (You may use your HSA funds to pay for your deductible and other eligible out-of-pocket expenses.)	Employee: up to $500⁴ Employee & Adult: up to $1,000⁴ Employee & Children: up to $1,000⁴ Family: up to $1,000⁴	Individual Coverage: $8,000 Family Coverage: $16,000

Plan	Inpatient	Surgeon	Emergency Room	Ambulance	Urgent Care
UC Blue & Gold HMO	$250 copayment per admittance	No charge	$125 (waived if admitted)	No charge	$20
Kaiser HMO	$250 copayment per admittance	No charge	$125 (waived if admitted)	No charge	$20
UC Care
UC Select Network	$250 copayment	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)	N/A (services covered under Anthem Preferred)	$20
Anthem Preferred Network	30%	30%	Facility: $300 copay per visit not resulting in admission, $250 if admitted ER Physician Services: No charge (not subject to calendar year deductible)	$200/trip (not subject to calendar year deductible)	$20 (not subject to calendar year deductible)
Out-of-Network	50% (non-preferred hospitals subject to maximum payment of $300/day)	50%	Facility: $300 copay per visit not resulting in admission, $250 if admitted ER Physician Services: No charge (not subject to calendar year deductible)	$200/trip (not subject to calendar year deductible)	50%
CORE	20% (out-of-network hospitals subject to maximum payment of $480/day)	20%	20%	20%	20% after deductible
UC Health Savings Plan
In-Network	20%	20%	20%	20%	20% after deductible
Out-of-Network	40% (out-of-network hospitals subject to maximum payment of $360/day)	40%	20%	20%	40% after deductible

Plan	Office Visit	Hospital Visit	Preventive Physical Exam/Well Baby Care	Maternity Outpatient Care	Maternity Inpatient Care
UC Blue & Gold HMO	$20	No charge	No charge	No charge	$250 copayment per admittance
Kaiser HMO	$20	No charge	No charge	No charge	$250 copayment per admittance
UC Care
UC Select Network	$20	No charge	No charge	$20 (initial visit only)	$250 copayment per admittance
Anthem Preferred Network	30%	30%	No charge (not subject to calendar year deductible)	30%	30%
Out-of-Network	50%	50%	50%	50%	50% (non-preferred hospitals subject to maximum payment of $300/day)
CORE	20%	20%	No charge (not subject to calendar year deductible)	20%	20% (out-of-network hospitals subject to maximum payment of $480/day)
UC Health Savings Plan
In-Network	20%	20%	No charge (not subject to calendar year deductible)	20%	20%
Out-of-Network	40%	40%	40%	40%	40% (out-of-network hospitals subject to maximum payment of $360/day)

Plan	Home Health Care	Skilled Nursing Facility	Outpatient X-Ray and Lab	Chiropractor	Acupuncture
UC Blue & Gold HMO	No charge	No charge (up to 100 days/ calendar year)	No charge	$20 (24 visit limit/calendar year combined with acupuncture)	$20 (24 visit limit/calendar year combined with chiropractor)
Kaiser HMO	No charge (up to 100 visits/ calendar year)	No charge (up to 100 days/ calendar year)	No charge	$15 (24 visit limit/calendar year combined with acupuncture)	$15 (24 visit limit/calendar year combined with chiropractor)
UC Care
UC Select Network	N/A (services covered under Anthem Preferred)	N/A (services covered under Anthem Preferred)	$20	N/A (services covered under Anthem Preferred)	N/A (services covered under Anthem Preferred)
Anthem Preferred Network	30%	30% (up to 100 visits/calendar year)	30% (up to 100 days/calendar year)	30% (preferred providers and 24 visit limit/calendar year combined with acupuncture)	30% (preferred providers and 24 visit limit/calendar year combined with chiropractor)
Out-of-Network	50% (up to 100 days/calendar year). If authorized, paid at Anthem Preferred tier.	50% (up to 100 days/calendar year). If authorized, paid at Anthem Preferred tier, subject to maximum payment of $300/day.	50%	50% (up to allowed amount and 24 visit limit/calendar year combined with acupuncture)	30% (up to allowed amount and 24 visit limit/calendar year combined with chiropractor)
CORE	20% (up to 100 visits/calendar year) (out-of-network not covered)	20% (up to 100 days/calendar year)	20%	20% (24 visit limit/calendar year combined with acupuncture)	20% (24 visit limit/calendar year combined with chiropractor)
UC Health Savings Plan
In-Network	20% (up to 100 visits/calendar year)	20% (up to 100 days/calendar year)	20%	20% (24 visit limit/calendar year combined with acupuncture)	20% (24 visit limit/calendar year combined with chiropractor)
Out-of-Network	Not covered unless prior authorized. If authorized, in-network benefit applies.	20% (up to 100 days/calendar year)	40%	40% (up to allowed amount and 24 visit limit/calendar year combined with acupuncture)	20% (up to allowed amount and 24 visit limit/calendar year combined with chiropractor)

Plan	Retail (up to 30-day supply)	Mail Order (up to 90-day supply)
UC Blue & Gold HMO	Generic: $5⁵ Brand: $25^5,⁶ Non-Formulary: $40^{5, 6}	Generic: $10 Brand: $50⁶ Non-Formulary: $80⁶
Kaiser HMO	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	30-day supply—Generic: $5; Brand: $25; 31–100 day supply—Generic: $10; Brand: $50 Non-Formulary: does not apply
UC Care
UC Select Network	At select pharmacies: Tier 1: $5^{5, 7, 8} Tier 2: $25^{5, 7, 8} Tier 3: $40^{5, 7, 8}	Tier 1: $10^{7, 8} Tier 2: $50^{7, 8} Tier 3: $80^{7, 8}
Anthem Preferred Network	At select pharmacies: Tier 1: $5^{5, 7, 8} Tier 2: $25^{5, 7, 8} Tier 3: $40^{5, 7, 8}	Tier 1: $10^{7, 8} Tier 2: $50^{7, 8} Tier 3: $80^{7, 8}
Out-of-Network	50% (of billed charges per prescription)⁹	Not covered
CORE	20%^{5, 9}	Preferred: 20%⁹ Non-preferred: Not covered
UC Health Savings Plan
In-Network	20%^{5, 9}	20%⁹
Out-of-Network	40%⁹	Not covered

Plan	Mental Health Inpatient⁹	Mental Health Outpatient⁹	Substance Abuse Inpatient⁹	Substance Abuse Outpatient⁹
UC Blue & Gold HMO	$250 copayment per admittance or course of treatment (preauthorization required)	Visits 1–3: No copayment Visits 4+: $20	$250 copayment per admittance or course of treatment (preauthorization required)	Visits 1–3: No copayment Visits 4+: $20
Kaiser HMO	Kaiser: $250 copayment per admittance Optum: $250 copayment per admittance or course of treatment (preauthorization required)	Kaiser: $20 for individual visit; $10 for group visit. Optum: Visits 1–3: No copayment. Visits 4+: $20	Kaiser: $250 copayment per admittance Optum: $250 copayment per admittance or course of treatment (preauthorization required)	Kaiser: $20 for individual visit. Visits 1–3: No copayment Visits 4+: $20
UC Care
UC Select Network	$250 copayment per admittance or course of treatment	Visits 1–3: No copayment Visits 4+: $20	$250 copayment per admittance or course of treatment (preauthorization required)	Visits 1–3: No copayment Visits 4+: $20
Anthem Preferred Network	$250 copayment per admittance or course of treatment	Visits 1–3: No copayment Visits 4+: $20	$250 copayment per admittance or course of treatment	Visits 1–3: No copayment Visits 4+: $20
Out-of-Network	50% Additional $250 copayment for failure to preauthorize	50%	50% Additional $250 copayment for failure to preauthorize	50%
CORE	20%	20%	20%	20%
UC Health Savings Plan
In-Network	20%	20%	20%	20%
Out-of-Network	40% Additional $250 copayment for failure to preauthorize	40%	40% Additional $250 copayment for failure to preauthorize	40%

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.)

Footnotes

¹The annual out-of-pocket maximum combines medical, behavioral health and prescription drugs.

²UC 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.

³In-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).

⁴ This assumes you are covered Jan. 1, 2022. If you enroll later in the year, the UC contribution is prorated.

⁵90-day supply available for maintenance medication at UC Medical Center pharmacies at plan’s mail order copay benefit level. UC PPO plan members can also access this benefit at additional Navitus Preferred Retail Pharmacies.

⁶When a generic drug is available and you or your physician choose the brand name drug, the drug will not be covered by the plan. If you obtain a brand name drug in this scenario, you will be responsible for 100% of the cost and it will not count towards your annual out-of-pocket maximum. With prior authorization, exceptions for medical necessity can be made and you pay the non-formulary (Tier 3) copay.

⁷ The Navitus prescription drug formulary classifies (and charges for) medications by tier, as follows:

Tier 1—Preferred generics and some lower cost brand products
Tier 2—Preferred brand products and some high cost non-preferred generics
Tier 3—Non-preferred products (could include some high cost non-preferred generics)

⁸When a generic drug is available and you or your physician choose the brand-name drug, you must pay the applicable brand 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 Tier 3 (Non-preferred) copay.

⁹ 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.