A quick reference guide to UC's medical plans

Note: The chart below shows what the member pays for 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.

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.) 

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
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
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
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
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)
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
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%
Behavioral Health 8
Mental Health Inpatient $250 copayment per admittance or course of treatment (preauthorization required) Kaiser: $250 copayment per admittance
Optum: $250 copayment per admittance or course of treatment (preauthorization required)
$250 copayment per admittance or course of treatment (preauthorization required) $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 (preauthorization required) Kaiser: $250 copayment per admittance
Optum: $250 copayment per admittance or course of treatment (preauthorization required)
$250 copayment per admittance or course of treatment (preauthorization required) $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%
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)
 

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.

2 In-network deductible accumulates separately from out-of-network. Out-of-network though includes in-network provider services.

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.