CA/L/A/UniversityofCaliforniaUCCarePlan-PPO-NA/NA-NA/NA/01-21
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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2024– 12/31/2024
Anthem Blue Cross Life and Health Insurance Company:
University of California: UC Care Plan
Coverage for: Individual + Family | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the
plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will
be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms
of coverage, www.UChealthplans.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,
deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (866) 406-1182 to
request a copy.
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
$0/individual or $0/family for
UC Select Providers.
$500/individual or $1,000/family
for Anthem Preferred Providers.
$750/individual or $1,750/family
for Out-of-Network Providers.
Generally, you must pay all of the costs from providers up to the deductible amount before
this plan begins to pay. If you have other family members on the plan, each family member
must meet their own individual deductible until the total amount of deductible expenses paid
by all family members meets the overall family deductible.
Are there services
covered before you
meet your deductible?
Yes. Preventive care for UC
Select and Anthem Preferred
Providers, Emergency, and
Ambulance services.
This plan covers some items and services even if you haven’t yet met the deductible amount.
But a copayment or coinsurance may apply. For example, this plan covers certain preventive
services without cost-sharing and before you meet your deductible. See a list of covered
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for
specific services?
No.
You don't have to meet deductibles for specific services.
What is the out-of-
pocket limit for this
plan?
$6,100/individual or
$9,700/family for UC Select
Providers. $7,600/individual or
$14,200/family for Anthem
Preferred Providers.
$9,600/individual or
$20,200/family for Out-of-
Network Providers.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have
other family members in this plan, they have to meet their own out-of-pocket limits until the
overall family out-of-pocket limit has been met.
What is not included
in the out-of-pocket
limit?
Premiums, balance-billing
charges, expenses paid for
infertility services, and health care
this plan doesn't cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if
you use a network
provider?
Yes, UC Select and Anthem
Preferred. See
www.UChealthplans.com or
call (866) 406-1182 for a list
You pay the least if you use a provider in UC Select. You pay more if you use a provider in
Anthem Network. You will pay the most if you use an out-of-network provider, and you
might receive a bill from a provider for the difference between the provider’s charge and
what your plan pays (balance billing). Be aware your network provider might use an out-of-
* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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of network providers.
network provider for some services (such as lab work). Check with your provider before you
get services.
Do you need a referral
to see a specialist?
No.
You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, &
Other Important Information
UC Select
Provider
(You will pay
the least)
Anthem Preferred
Provider
(You will pay
more)
Out-of-Network
Provider
(You will pay
the most)
If you visit a
health care
provider’s office
or clinic
Primary care visit to treat an
injury or illness
$20/visit
30% coinsurance
50% coinsurance
--------none--------
Specialist visit
$20/visit
30% coinsurance
50% coinsurance
--------none--------
Preventive care/screening/
immunization
No charge
No charge
50% coinsurance
You may have to pay for services
that aren't preventive. Ask your
provider if the services needed are
preventive. Then check what your
plan will pay for.
If you have a test
Diagnostic test
(x-ray, blood work)
$20/visit
30% coinsurance
50% coinsurance
Cost may vary by site of service.
Imaging (CT/PET scans, MRIs)
$20/visit
30% coinsurance
50% coinsurance
Coverage for Out-of-Network
Provider is limited to $175
maximum/visit.
If you need
drugs to treat
your illness or
condition
More information
about
prescription
drug coverage is
available at
www.navitus.com
Tier 1 - Typically Generic
$5/prescription (preferred retail,
participating retail, and mail order – 30
days); $10/prescription (preferred retail
and mail order – 90 days);
$15/prescription (participating retail – 90
days)
50% coinsurance
Preferred retail, participating
retail, and mail order cover up to
a 90-day supply. Select specialty
pharmacies cover up to a 30-day
supply. Certain limitations may
apply, including, for example:
prior authorization and quantity
limits. *See prescription drug
section of the plan or policy.
Tier 2 - Typically Preferred /
Brand
$25/prescription (preferred retail,
participating retail, and mail order – 30
days); $50/prescription (preferred retail,
participating retail, and mail order – 90
days); $75/prescription (participating
retail – 90 days)
50% coinsurance
Tier 3 - Typically Non-Preferred
/ Brand
$40/prescription (preferred retail,
participating retail, and mail order – 30
days); $80/prescription (preferred retail,
50% coinsurance
* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, &
Other Important Information
UC Select
Provider
(You will pay
the least)
Anthem Preferred
Provider
(You will pay
more)
Out-of-Network
Provider
(You will pay
the most)
participating retail, and mail order – 90
days); $120/prescription (participating
retail – 90 days)
Tier 4 - Typically Specialty
(brand and generic)
30% coinsurance; $150 maximum per
prescription (select specialty pharmacies)
N/A
If you have
outpatient
surgery
Facility fee
(e.g., ambulatory surgery center)
$100/surgery
30% coinsurance
50% coinsurance
Coverage for Out-of-Network
Provider is limited to $175
maximum/visit.
Physician/surgeon fees
No charge
30% coinsurance
50% coinsurance
--------none--------
If you need
immediate
medical
attention
Emergency room care
$300/visit
$300/visit
deductible does
not apply
Covered as
In-Network
If directly admitted to a hospital,
ER copay is waived. No charge
for Emergency Room Physician
Fee.
Emergency medical
transportation
Not Applicable
$200/trip
deductible does
not apply
Covered as
In-Network
--------none--------
Urgent care
$20/visit
$20/visit
deductible does
not apply
50% coinsurance
--------none--------
If you have a
hospital stay
Facility fee (e.g., hospital room)
$250/admission
30% coinsurance
50% coinsurance
Coverage for Out-of-Network
Provider is limited to $300
maximum/day. If no pre-
authorization is obtained for out
of network providers, there will
be an additional $250 copay.
Physician/surgeon fees
No charge
30% coinsurance
50% coinsurance
--------none--------
If you need
mental health,
behavioral
health, or
substance abuse
services
Outpatient services
Office Visit: No charge for first 3 visit
then $20/visit deductible does not apply
Other Outpatient: $20/visit deductible
does not apply
Office Visit: 50%
coinsurance
Other Outpatient:
50% coinsurance
--------none--------
* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, &
Other Important Information
UC Select
Provider
(You will pay
the least)
Anthem Preferred
Provider
(You will pay
more)
Out-of-Network
Provider
(You will pay
the most)
Inpatient services
$250/admission deductible does
not apply
50% coinsurance
If no pre-authorization is
obtained for out of network
providers, there will be an
additional $250 copay. No charge
for Inpatient Physician Fee UC
Select Providers or Anthem
Preferred Providers. 50%
coinsurance for Inpatient
Physician Fee Out-of-Network
Providers.
If you are
pregnant
Office visits
$20/visit for
initial visit
30% coinsurance
50% coinsurance
Coverage for Out-of-Network
Provider is limited to $300
maximum/day. If no pre-
authorization is obtained for
Inpatient out of network
providers, there will be an
additional $250 copay. Maternity
care may include tests and
services described elsewhere in
the SBC (i.e. ultrasound.)
Childbirth/delivery professional
services
No charge
30% coinsurance
50% coinsurance
Childbirth/delivery facility
services
$250/admission
30% coinsurance
50% coinsurance
If you need help
recovering or
have other
special health
needs
Home health care
Not Applicable
30% coinsurance
50% coinsurance
100 visits/benefit period for
Anthem Preferred Providers and
Out-of-Network Providers
combined.
Rehabilitation services
$20/visit
30% coinsurance
50% coinsurance
*See Therapy Services section
Habilitation services
$20/visit
30% coinsurance
50% coinsurance
Skilled nursing care
Not Applicable
30% coinsurance
50% coinsurance
100 days limit/benefit period for
Anthem Preferred Providers and
Out-of-Network Providers
combined. $300 maximum/day
for Out-of-Network Providers.
Durable medical equipment
Not Applicable
30% coinsurance
50% coinsurance
--------none--------
Hospice services
Not Applicable
30% coinsurance
50% coinsurance
--------none--------
* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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Common
Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, &
Other Important Information
UC Select
Provider
(You will pay
the least)
Anthem Preferred
Provider
(You will pay
more)
Out-of-Network
Provider
(You will pay
the most)
If your child
needs dental or
eye care
Children’s eye exam
Not covered
Not covered
Not covered
*See Vision Services section
Children’s glasses
Not covered
Not covered
Not covered
Children’s dental check-up
Not covered
Not covered
Not covered
*See Dental Services section
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded
services.)
• Cosmetic surgery
• Dental care (adult)
• Dental Check-up
• Eye exams for a child
• Glasses for a child
• Routine eye care (adult)
• Long-term care
• Private-duty nursing
• Routine foot care unless you have been
diagnosed with diabetes.
• Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture 24 visits/benefit period
combined with chiropractor for Anthem
Preferred Providers and Out-of-Network
Providers.
• Bariatric surgery
• Infertility Treatment - 2 cycles per lifetime
combined for GIFT, ZIFT and IVF (all
infertility services are excluded from OOPM)
• Chiropractic care 24 visits/benefit period
combined with acupuncture for Anthem
Preferred Providers and Out-of-Network
Providers.
• Hearing aids $2,000 maximum/every 36
months.
• Most coverage provided outside the United
States. See www.bcbsglobalcore.com
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform. Other coverage
options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is
called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan
documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights,
this notice, or assistance, contact:
ATTN: Grievances and Appeals, P.O. Box 4310, Woodland Hills, CA 91365-4310
* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare,
Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the
premium tax credit.
Does this plan meet the Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––
The plan would be responsible for the other costs of these EXAMPLE covered services.
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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will
be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost
sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare
the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)
Managing Joe’s type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)
Mia’s Simple Fracture
(in-network emergency room visit and follow
up care)
◼ The plan’s overall deductible
$0
◼ The plan’s overall deductible
$0
◼ The plan’s overall deductible
$0
◼ Specialist
copayment
$20
◼ Specialist
copayment
$20
◼ Specialist
copayment
$20
◼ Hospital (facility)
copayment
$250
◼ Hospital (facility)
copayment
$250
◼ Hospital (facility)
copayment
$250
◼ Other
copayment
$20
◼ Other
copayment
$20
◼ Other
copayment
$20
This EXAMPLE event includes services
like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
This EXAMPLE event includes services
like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
This EXAMPLE event includes services
like:
Emergency room care (including medical supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
Total Example Cost
$12,700
Total Example Cost
$5,600
Total Example Cost
$2,800
In this example, Peg would pay:
In this example, Joe would pay:
In this example, Mia would pay:
Cost Sharing
Cost Sharing
Cost Sharing
Deductibles
$0
Deductibles
$0
Deductibles
$0
Copayments
$650
Copayments
$520
Copayments
$1,360
Coinsurance
$0
Coinsurance
$0
Coinsurance
$15
What isn’t covered
What isn’t covered
What isn’t covered
Limits or exclusions
$60
Limits or exclusions
$55
Limits or exclusions
$0
The total Peg would pay is
$710
The total Joe would pay is
$575
The total Mia would pay is
$1,375
NOTE: This Summary of Benefit and Coverage attempts to show you how you and the plan share the cost for covered health care services. Any summary of benefits
or cost sharing principals represents only a brief description of your benefits. Please read the booklet carefully to learn about provisions, benefits and
exclusions. If any perceived conflict exists between this summary and the Plan terms, the Plan terms govern.
The plan would be responsible for the other costs of these EXAMPLE covered services.
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By authority of the Regents, University of California Human Resources, located
in Oakland, administers all benefit plans in accordance with applicable plan
documents and regulations, custodial agreements, University of California Group
Insurance Regulations for Faculty and Staff, group insurance contracts, and state
and federal laws. No person is authorized to provide benefits information not
contained in these source documents, and information not contained in these
source documents cannot be relied upon as having been authorized by the
Regents. Source documents are available for inspection upon request
(800-888-8267). What is written here does not constitute a guarantee of plan
coverage or benefits—particular rules and eligibility requirements must be met
before benefits can be received. The University of California intends to continue
the benefits described here indefinitely; however, the benefits of all employees,
retirees and plan beneficiaries are subject to change or termination at the time of
contract renewal or at any other time by the University or other governing
authorities. The University also reserves the right to determine new premiums,
employer contributions and monthly costs at any time. Health and welfare
benefits are not accrued or vested benefit entitlements. UC’s contribution toward
the monthly cost of the coverage is determined by UC and may change or stop
altogether, and may be affected by the state of California’s annual budget
appropriation. If you belong to an exclusively represented bargaining unit, some
of your benefits may differ from the ones described here. For more information,
employees should contact their Human Resources Office and retirees should call
the UC Retirement Administration Service Center (800-888-8267).
In conformance with applicable law and University policy, the University is an
affirmative action/equal opportunity employer. Please send inquiries regarding
the University’s affirmative action and equal opportunity policies for staff to
Systemwide AA/EEO Policy Coordinator, University of California, Office of the
President, 1111 Franklin Street, 5th Floor, CA 94607, and for faculty to the Office
of Academic Personnel and Programs, University of California Office of the
President, 1111 Franklin Street, Oakland, CA 94607.
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Thai (ไทย):
(866) 406-1182
(866) 406-1182.
(866) 406-1182
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(866) 406-1182
(866) 406-1182.
Language Access Services:
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It’s important we treat you fairly
That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the
basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t
English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services
number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age,
disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance
Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and
Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-
1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
