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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?

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?


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

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.