Compare plans

A quick reference guide to your benefits and costs

Note: The chart below shows what the member pays for care. See plan costs for your share of premium costs for retirees in UC's Medicare and non-Medicare plans, if you are eligible for 100 percent of the UC employer contribution.

This is a summary only. Important details — such as limitations, exclusions, exceptions and other qualifiers — may not be included. If any information on the website conflicts with plan documents, plan documents prevail.

Call the plan or see their website for specific benefits, provider information and plan booklets, or to determine if a plan provides service where you live.

Medicare retirees

Anthem Blue Cross is the medical plan administrator and Navitus is the pharmacy benefit manager of the UC Medicare PPO, UC High Option Supplement to Medicare and UC Medicare PPO without Prescription Drugs plans. UnitedHealthcare is the administrator of the UC Medicare Choice plan.

Retirees may enroll in UC Medicare PPO without Prescription Drugs only if all enrolled Medicare family members have outpatient prescription drug coverage (as verified by CMS) through another Medicare Part D prescription drug plan.

For more information on how UC-sponsored medical plans coordinate with Medicare and on “balance billing,” see UC’s Medicare Fact Sheet.

Download Which Medicare plan is right for you?

Plan	Calendar Year Deductible	Annual Out-of-Pocket Maximum: Medical Benefits	Calendar Year Out-of-Pocket Maximum: Pharmacy Benefits
Kaiser Permanente Senior Advantage	$0	$1,500 per member per year	$7,050 per member
UC High Option Supplement to Medicare	$50 per member¹	$1,050 per member per year	$1,000 drug plan maximum out-of-pocket per member $7,050 true out-of-pocket limit per member²
UC Medicare Choice	$0	$1,500 per member per year	$2,000 drug plan maximum out-of-pocket per member $7,050 true out-of-pocket limit per member²
UC Medicare PPO	$100 per member¹	$1,500 per member per year	$7,050 per member
UC Medicare PPO without Prescription Drugs	$100 per member¹	$1,500 per member per year	NA

Plan	Hospitalization	Emergency	Medical Services when Traveling Outside of U.S.³
Kaiser Permanente Senior Advantage	You pay $250 copay per admittance. Medicare and plan pay the rest.	• You pay $65 copay (waived if admitted) • Medicare and plan pay the rest.	Emergencies/urgent care covered; inpatient care requires authorization from the plan. HMO must be notified; you may need to file for reimbursement. For other services, the plan does not pay.
UC High Option Supplement to Medicare	First 60 days: • Plan pays Medicare Part A Deductible ($1,484 in 2021) • Medicare pays the balance Days 61–90: • Medicare pays all but $371 per day • Plan pays $371 per day • You pay nothing Days 91 and beyond⁴: • Plan pays 80% of eligible expenses • You pay 20% of eligible expenses	• You pay nothing • Medicare and plan pay 100%	You pay 20% of billed charges after deductible of $50 per person.
UC Medicare Choice	You pay $250 copay per admittance. Medicare and plan pay the rest.	• You pay $65 copay (waived if admitted) • Medicare and plan pay the rest.	Emergencies, urgent care and routine care covered at same copay as within U.S.
UC Medicare PPO	*First 60 days:* • Plan pays Medicare Part A Deductible ($1,484 in 2021) • Medicare pays the balance Days 61–90: • Medicare pays all but $371 per day • Plan pays 80% of $371 per day • You pay 20% ($74.20) of $371 per day Days 91 and beyond⁴: • Plan pays 80% of eligible expenses • You pay 20% of eligible expenses	• Medicare pays 80% • Then plan pays 80% of the eligible balance • You pay amount remaining	You pay 20% of billed charges after deductible of $100 per person.
UC Medicare PPO without Prescription Drugs	*First 60 days:* • Plan pays Medicare Part A Deductible ($1,484 in 2021) • Medicare pays the balance Days 61–90: • Medicare pays all but $371 per day • Plan pays 80% of $371 per day • You pay 20% ($74.20) of $371 per day Days 91 and beyond⁴: • Plan pays 80% of eligible expenses • You pay 20% of eligible expenses	• Medicare pays 80% • Then plan pays 80% of the eligible balance • You pay amount remaining	You pay 20% of billed charges after deductible of $100 per person.

Plan	Wellness Visit	Doctor Visit	Prescription Drug Copay
Kaiser Permanente Senior Advantage	No charge⁵	• You pay $20 copay; • Medicare and plan pay the rest.	Generic/Brand Retail • Up to 30-day supply: $5/$25 • 31–60-day supply: $10/$50 • 61–100-day supply: $15/$75 Mail Order: Refills can be arranged up to 30-day supply: $5/$25; 31–100-day supply: $10/$50
UC High Option Supplement to Medicare	No charge (deductible waived)⁵	• Medicare pays 80% of Medicare allowable • Plan generally pays remaining 20% Example: • Medicare allowable⁶: $150 • Medicare pays: $120 • Plan pays: $30 • You pay: $0	Tier 1/Tier 2/Tier 3^7,8 Retail (30-day supply): $10/$30/$45 Mail Order (90-day supply): $20/$60/$90
UC Medicare Choice	No charge⁴	• You pay $20 copay • Medicare and plan pay the rest.	Generic/Brand/Non-Formulary Retail (up to 30-day supply): $5/$25/$40; Mail Order (31–90-day supply): $10/$50/$80; Specialty drugs • Up to 30-day supply: $25 • 31–90-day supply: $50
UC Medicare PPO	No charge (deductible waived)⁵	• Medicare pays 80% of Medicare allowable •Plan pays 80% of remaining eligible expenses • You pay 20% of remaining eligible expenses plus any excess charges Example: Medicare allowable⁶: $150 Medicare pays: $120 Plan pays 80% of balance: $24 You pay: $6	Tier 1/Tier 2/Tier 3^7,8 Retail (30-day supply): $10/$30/$45 Mail Order (90-day supply): $20/$60/$90
UC Medicare PPO without Prescription Drugs	No charge (deductible waived)⁵	• Medicare pays 80% of Medicare allowable • Plan pays 80% of remaining eligible expenses • You pay 20% of remaining eligible expenses plus any excess charges Example: • Medicare allowable⁶: $150 • Medicare pays: $120 Plan pays 80% of balance: $24 • You pay: $6	No prescription drug benefits

Plan	Lab Work	Chiropractor	Acupuncture	Vision Exams	Hearing Exams / Hearing Aids
Kaiser Permanente Senior Advantage	No charge	$20 (manual manipulation as covered by Medicare only); covered as medically necessary when approved by a plan provider	$20; covered as medically necessary when approved by a plan provider	$20 (no charge for one Medicare-covered glaucoma screening per year)	Exam: $20 Aids: Standard hearing aids every 36 months, $2,500 maximum per ear (medically necessary)
UC High Option Supplement to Medicare	• You pay nothing for Medicare-approved services • Medicare pays 100%	• Medicare pays 80% of approved services (manual manipulation of the spine) • Plan pays balance • You pay nothing • You pay all costs for other services or tests	You pay 20% (deductible $50 per person) (24 visit limit/ calendar year) Note: Some acupuncture services may be covered by Medicare. See the Medicare and You handbook on medicare.gov for more details.	No charge when part of diabetes care or the Welcome to Medicare preventive visit, which must occur within the first 12 months of enrollment in Part B (coverage is for a simple vision test)	Exam: No cost after Medicare pays; for diagnostic exams if ordered by a physician Aids: 20% (maximum 2 hearing aids every 36 months, analog or digital); deductible $50 per person
UC Medicare Choice	No charge	$20 (24 visit limit/plan year)	$20 (24 visit limit/plan year)	$20 (no charge for one Medicare-covered glaucoma screening per year)	Exam: $20 Aids: Standard hearing aids (analog or digital) every 3 years at no charge (maximum $2,000 combined ear allowance)
UC Medicare PPO	• You pay nothing for Medicare-approved services • Medicare pays 100% • Diagnostic Services and X-ray have a 20% member responsibility	• Medicare pays 80% of approved services (manual manipulation of the spine) • Plan pays 80% of balance • You pay the remainder and all costs for other services or tests	You pay 20% (deductible $100 per person) (24 visit limit/calendar year) Note: Some acupuncture services may be covered by Medicare. See the Medicare and You handbook on medicare.gov for more details.	No charge when part of diabetes care or the Welcome to Medicare preventive visit, which must occur within the first 12 months of enrollment in Part B (coverage is for a simple vision test)	Exam: 20% after Medicare pays; for diagnostic exams if ordered by a physician Aids: 20% (maximum 2 hearing aids every 36 months, analog or digital); deductible $100 per person
UC Medicare PPO without Prescription Drugs	• You pay nothing for Medicare-approved services • Medicare pays 100% • Diagnostic Services and X-ray have a 20% member responsibility	• Medicare pays 80% of approved services (manual manipulation of the spine) • Plan pays 80% of balance • You pay the remainder and all costs for other services or tests	You pay 20% (deductible $100 per person) (24 visit limit/ calendar year) Note: Some acupuncture services may be covered by Medicare. See the Medicare and You handbook on medicare.gov for more details.	No charge when part of diabetes care or the Welcome to Medicare preventive visit, which must occur within the first 12 months of enrollment in Part B (coverage is for a simple vision test)	Exam: 20% after Medicare pays; for diagnostic exams if ordered by a physician Aids: 20% (maximum 2 hearing aids every 36 months, analog or digital); deductible $100 per person

Plan	Mental Health Inpatient	Mental Health Outpatient	Substance Abuse Inpatient	Substance Abuse Outpatient
Kaiser Permanente Senior Advantage	$250 copay per admittance; no charge for intensive outpatient and partial hospitalization	$20 for individual visit $10 for group visit	$250 copay per admittance for detoxification; $100 copayment per admission for home transitional residential recovery services; $5 per day for intensive outpatient and day-treatment programs	$20 for individual visit $5 for group visit
UC High Option Supplement to Medicare	You pay nothing for services provided by Medicare; otherwise you pay 20% and deductible applies.	You pay nothing for services provided by Medicare; otherwise you pay 20% and deductible applies.	You pay nothing for services provided by Medicare; otherwise you pay 20% and deductible applies.	You pay nothing for services provided by Medicare; otherwise you pay 20% and deductible applies.
UC Medicare Choice	$250 copay per admittance; $20 per day for intensive outpatient care and partial hospitalization	$20 (group or individual visit)	$250 copay per admittance; $20 per day for intensive outpatient care and partial hospitalization	$20 (group or individual visit)
UC Medicare PPO	For services covered by Medicare: • Medicare pays 80% of Medicare-allowable • Plan pays 80% of the balance • You pay any remaining balance For services not covered by Medicare, you pay 20% and deductible applies.	For services covered by Medicare: • Medicare pays 80% of Medicare-allowable • Plan pays 80% of the balance • You pay any remaining balance For services not covered by Medicare, you pay 20% and deductible applies.	For services covered by Medicare: • Medicare pays 80% of Medicare allowable • Plan pays 80% of the balance • You pay any remaining balance For services not covered by Medicare, you pay 20% and deductible applies.	For services covered by Medicare: • Medicare pays 80% of Medicare allowable • Plan pays 80% of the balance • You pay any remaining balance For services not covered by Medicare, you pay 20% and deductible applies.
UC Medicare PPO without Prescription Drugs	For services covered by Medicare: • Medicare pays 80% of Medicare-allowable • Plan pays 80% of the balance • You pay any remaining balance For services not covered by Medicare, you pay 20% and deductible applies.	For services covered by Medicare: • Medicare pays 80% of Medicare-allowable • Plan pays 80% of the balance • You pay any remaining balance For services not covered by Medicare, you pay 20% and deductible applies.	For services covered by Medicare: • Medicare pays 80% of Medicare allowable • Plan pays 80% of the balance • You pay any remaining balance For services not covered by Medicare, you pay 20% and deductible applies.	For services covered by Medicare: • Medicare pays 80% of Medicare allowable • Plan pays 80% of the balance • You pay any remaining balance For services not covered by Medicare, you pay 20% and deductible applies.

Non-Medicare Retirees

Anthem Blue Cross is the medical plan administrator and Navitus is the pharmacy benefit manager of CORE, UC Care and UC Health Savings Plan. Health Net is the administrator of the UC Blue and Gold HMO plan. Kaiser Permanente — California is the administrator of the Kaiser HMO plan.

Download Which medical plan is right for you?

Plan	Calendar Year Deductible	Health Savings Account (HSA) UC Contribution	Annual Out-of-Pocket Maximum¹
UC Blue & Gold HMO	$0	Not applicable	Individual: $1,000 Family (3 persons or more): $3,000
Kaiser HMO	$0	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: $25⁵ ^,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: $5⁵^{, 7, 8} Tier 2: $25⁵^{, 7, 8} Tier 3: $40⁵^{, 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: $5⁵^{, 7, 8} Tier 2: $25⁵^{, 7, 8} Tier 3: $40⁵^{, 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 (non-routine visits: $0 copay for 4+ visits)	$250 copayment per admittance or course of treatment (preauthorization required)	Visits 1–3: No copayment Visits 4+: $20 (non-routine visits: $0 copay for 4+ visits)
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 (non-routine visits: $0 copay for 4+ visits)	$250 copayment per admittance or course of treatment (preauthorization required)	Visits 1–3: No copayment Visits 4+: $20 (non-routine visits: $0 copay for 4+ visits)
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

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.)

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

Calendar year deductible (Medicare plans): The calendar year deductible is the amount you must pay before the medical plan begins to pay a percentage of the total cost of benefits. Until the deductible is met, you pay the total cost of services not covered by Medicare. Review each plan’s annual deductible and monthly premium to decide which plan is best for you.

Calendar year deductible (non-Medicare plans): The calendar year deductible is the amount you must pay before the medical plan begins to pay a percentage of the total cost of benefits. Until the deductible is met, you pay the total cost of services not covered by Medicare. Review each plan’s annual deductible and monthly premium to decide which plan is best for you.

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.

Medicare Allowable: The Medicare-approved amount for a covered service.

Footnotes — Medicare plans

¹ Applies to certain services not covered by Medicare, called Benefits Beyond Medicare, which are services that the UC plan covers when Medicare either does not cover at all or when Medicare limits have been reached.

² A member may reach the $7,050 True Out-of Pocket (TrOOP) before the drug plan maximum out-of-pocket if they qualify for the coverage gap discount program.

³ Consult the plan booklet or carrier for terms of coverage if your permanent address is outside the U.S.

⁴ Costs are different if using 60 lifetime reserve days. See plan booklet for details.

⁵ Medicare covers an initial “Welcome to Medicare” preventive visit and annual “Wellness” visits, where you and your doctor discuss and develop or update your personalized disease prevention plan. Note that you may be subject to copayments or coinsurance if you receive additional tests or services during the same visit that are not covered under the preventive benefits. See medicare.gov for more information on Wellness visits.

⁶ UC Medicare PPO, UC Medicare PPO without Prescription Drugs and UC High Option Supplement to Medicare examples assume that you have met your annual deductible, and that your doctor accepts Medicare assignment. After you meet your annual out-of-pocket maximum, your plan will pay 100% of your covered expenses. Actual charges for office visits are usually higher than the Medicare allowable amount. If your doctor does not accept Medicare assignment, you are also responsible for balance billing. Call the plan for details.

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)

⁸ 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.

Footnotes — non-Medicare plans

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.