A quick reference guide to UC's Medicare plans

Note: The chart below shows what the member pays for care. See retiree medical plan premium contributions 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. For detailed information, call the plan or see their website for specific benefits, provider information and plan booklets.
  • Service Areas: To determine if a plan provides service where you live, call the plan directly or see their website.
  • Plan website links
  • Note: For more information on how UC-sponsored medical plans coordinate with Medicare and on “balance billing,” see UC’s Medicare Fact Sheet.
  • Anthem Blue Cross is the administrator of the UC Medicare PPO, UC Medicare PPO without Prescription Drugs and UC High Option Supplement to Medicare plans.

DEFINITIONS

  • Calendar Year Deductible: 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.
  • Annual Out-of-Pocket Maximum: The out-of-pocket maximum is the annual ceiling for your copayments or coinsurance during the calendar year. After this amount is reached, the plan may pay medical or prescription drug benefits at 100 percent after Medicare (where applicable). Some expenses do not apply toward the maximum (see plan booklets).
  • Medicare Allowable: The Medicare approved amount for a covered service.
Plans Health Net Seniority Plus Kaiser Permanente Senior Advantage UC Medicare PPO UC Medicare PPO without Prescription Drugs UC High Option Supplement to Medicare
Costs
Doctor Visit You pay $20 copay; Medicare and plan pay the rest. You pay $20 copay; Medicare and plan pay the rest.
  • 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 allowable1: $150
  • Medicare pays: $120
  • Plan pays 80% of balance: $24
  • You pay: $6
  • 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 allowable1: $150
  • Medicare pays: $120
  • Plan pays 80% of balance: $24
  • You pay: $6
  • Medicare pays 80% of Medicare allowable
  • Plan generally pays remaining 20%

Example

  • Medicare allowable1: $150
  • Medicare pays: $120
  • Plan pays: $30
  • You pay: $0
Hospitalization You pay $250 copay per admittance. Medicare and plan pay the rest. You pay $250 copay per admittance. Medicare and plan pay the rest.

First 60 days

  • Plan pays Medicare Part A Deductible ($1,340 in 2018)
  • Medicare pays the balance

Days 61–90

  • Medicare pays all but $335 per day
  • Plan pays 80% of $335 per day
  • You pay 20% ($67) of $335 per day

Days 91 and beyond4

  • Plan pays 80% of eligible expenses
  • You pay 20% of eligible expenses

First 60 days

  • Plan pays Medicare Part A Deductible ($1,340 in 2018)
  • Medicare pays the balance

Days 61–90

  • Medicare pays all but $335 per day
  • Plan pays 80% of $335 per day
  • You pay 20% ($67) of $335 per day

Days 91 and beyond4

  • Plan pays 80% of eligible expenses
  • You pay 20% of eligible expenses

First 60 days

  • Plan pays Medicare Part A Deductible ($1,340 in 2018)
  • Medicare pays the balance

Days 61–90

  • Medicare pays all but $335 per day
  • Plan pays $335 per day
  • You pay nothing

Days 91 and beyond4

  • Plan pays 80% of eligible expenses
  • You pay 20% of eligible expenses
Emergency You pay $65 copay (waived if admitted); Medicare and plan pay the rest. You pay $65 copay (waived if admitted); Medicare and plan pay the rest.
  • Medicare pays 80%
  • Then plan pays 80% of the eligible balance
  • You pay amount remaining
  • Medicare pays 80%
  • Then plan pays 80% of the eligible balance
  • You pay amount remaining
  • You pay nothing
  • Medicare and plan pay 100%
Lab Work No charge No charge
  • You pay nothing for Medicare-approved services
  • Medicare pays 100%
  • You pay nothing for Medicare-approved services
  • Medicare pays 100%
  • You pay nothing for Medicare-approved services
  • Medicare pays 100%
Prescription Drug Copay (Generic/Brand/Non-Formulary) Retail (up to 30-day supply): $5/$25/$40;
Mail Order (up to 90-day supply): $10/$50/$80;
Specialty and self-injectible drugs: $25
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
Retail (30-day supply): $10/$30/$45
Mail Order (90-day supply): $20/$60/$90
No prescription drug benefits Retail (30-day supply): $10/$30/$45
Mail Order (90-day supply): $20/$60/$90
Prescription Drugs: Calendar Year Out-of-Pocket Maximums $2,000 per member $5,100 per member $5,100 per member NA $1,000 drug plan maximum out-of-pocket per member
$5,100 true out-of-pocket limit per member5
Medical Services when Traveling Outside of U.S.3 Emergencies/urgent care covered; inpatient care requires authorization from the plan. PCP/HMO must be notified; you may need to file for reimbursement. For other services you pay full costs: plan and Medicare do not pay. 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. You pay 20% of billed charges after deductible. You pay 20% of billed charges after deductible. You pay 20% of billed charges after deductible.
Wellness Visits No charge7 No charge7 No charge7 (deductible waived) No charge7 (deductible waived) No charge7 (deductible waived)
Durable Medical Equipment No charge No charge
  • Medicare pays 80% of Medicare allowable
  • Plan pays 80% of the balance
  • You pay any remaining balance
  • Medicare pays 80% of Medicare allowable
  • Plan pays 80% of the balance
  • You pay any remaining balance
No charge, if covered by Medicare
Vision Exams $20 (no charge for one Medicare-covered glaucoma screening per year) $20 (no charge for one Medicare-covered glaucoma screening per year) 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) 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) 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)
Hearing Exams/Hearing Aids Exam: $20
Aids: 2 standard hearing aids (analog or digital) every 36 months at no charge (maximum $2,000)
Exam: $20
Aids: Standard hearing aids every 36 months, $2,500 maximum per ear (medically necessary)
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)
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)
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)
Chiropractor $20 (20 visit limit/calendar year) $20 (manual manipulation as covered by Medicare only); covered as medically necessary when approved by a plan provider
  • 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
  • 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
  • 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
Acupuncture Not covered (discount program available) $20; covered as medically necessary when approved by a plan provider You pay 20% (deductible applies; 24 visit limit/calendar year) You pay 20% (deductible applies; 24 visit limit/calendar year) You pay 20% (deductible applies; 24 visit limit/calendar year)
Mental Health Inpatient $250 copay per admittance $250 copay per admittance 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.
You pay nothing for services provided by Medicare; otherwise you pay 20% and deductible applies.
Mental Health Outpatient $20 for individual visit
$10 for group visit
$20 for individual visit
$10 for group visit
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.
You pay nothing for services provided by Medicare; otherwise you pay 20% and deductible applies.
Substance Abuse Inpatient $250 copay per admittance; no charge for intensive outpatient care and partial hospitalization $250 copay per admittance for detoxification; $100 copayment per admission for home transitional residential recovery services 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.
You pay nothing for services provided by Medicare; otherwise you pay 20% and deductible applies.
Substance Abuse Outpatient $20 for individual visit
$10 for group visit
$20 for individual visit
$5 for group visit
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.
You pay nothing for services provided by Medicare; otherwise you pay 20% and deductible applies.
Calendar Year Deductible $0 $0 $100 per member $100 per member $50 per member
Annual Out-of-Pocket Maximum — Medical Benefits6 $1,500 per member per year $1,500 per member per year $1,500 per member $1,500 per member $1,050 per member
 

1 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.

2 Retirees may enroll in this plan only if: all family members have Medicare, and all family members have outpatient prescription drug coverage (as verified by CMS) through another Medicare Part D prescription drug plan.

3 Does not apply 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 A member may reach the $5,100 True Out-of Pocket (TrOOP) before the $1,000 drug plan maximum out-of-pocket if they qualify for the coverage gap discount program.

6 For prescription drug out-of-pocket maximums, see information on reverse.

7 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 since these are not covered under the preventive benefits. See medicare.gov for more information on Wellness visits.