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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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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

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

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 (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.

90-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.

When 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)

When 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.