2024 QUICK-REFERENCE GUIDE

Which medical
plan is rightfor you?

Employee Medical Plan Costs
UC will continue to pay the greater portionof monthly medical plan premiums in 2024,
and employees will pay the balance asshown in the tables.
Four Rate Levels Based on Salary
Four rate tables (“pay bands”) are shown
here. Your pay band, and thus your premium,is based on your full-time salary rate asof January 1, 2023. UC provides larger
monthly employer contributions for thoseearning less to help keep premium costs
from becoming a burden.
Retiree Medical Plan Costs
Retirees can find their monthly premiums
for the medical plans listed here online atucal.us/retireepremiums

FOR THOSE WITH FULL-TIME SALARY RATE OF $68,000 OR LESSPLAN

FOR THOSE WITH FULL-TIME SALARY RATE OF $136,001­­­–$204,000

S

+C

+A

+ C, A

Kaiser Permanente – CA (HMO)$36.49$65.60$110.33$136.84

UC Blue & Gold HMO$99.69$178.33$280.64

UC Health Savings Plan (PPO)$79.26$129.75

UC Care (PPO)$212.95

CORE (PPO)

$0.00

S

+C

+A

+ C, A

Kaiser Permanente – CA (HMO)$134.16$241.20$398.20$496.54$358.63

UC Blue & Gold HMO$191.10$341.83$470.10$619.48$180.81$227.92

UC Health Savings Plan (PPO)$297.01$486.08$665.28$842.96$380.49$514.84$682.95

UC Care (PPO)$310.41$554.63$716.19$961.08

$0.00

$0.00

$0.00

CORE (PPO)

$0.00

$0.00

$0.00

$0.00

FOR THOSE WITH FULL-TIME SALARY RATE OF $68,001­­– $136,000
PLAN

FOR THOSE WITH FULL-TIME SALARY RATE OF OVER $204,000

S

+C

+A

+ C, A

Kaiser Permanente – CA (HMO)$84.69$152.26$262.15$323.23

UC Blue & Gold HMO$144.81$259.03$380.55UC Health Savings Plan (PPO)$186.73$305.61

UC Care (PPO)$261.05

CORE (PPO)$0.00

S: Self+C: Self Plus Child(ren)+A: Self Plus Adult

PLAN

S

+C

+A

+ C, A

Kaiser Permanente – CA (HMO)$185.38$333.30$539.17$676.08$493.80

UC Blue & Gold HMO$239.04$427.59$562.87$749.68$436.31$546.62

UC Health Savings Plan (PPO)$411.20$672.98$902.52$1,149.94$466.43$621.03$827.07

UC Care (PPO)$361.52$645.96$814.79$1,099.90

$0.00

$0.00

$0.00

CORE (PPO)

$0.00

$0.00

$0.00

$0.00

+ C, A: Self Plus Child(ren) and Adult

PLAN

S: Self+C: Self Plus Child(ren)+A: Self Plus Adult+ C, A: Self Plus Child(ren) and Adult

Medical Benefits Summary: 2024
(Non-Medicare)
PLAN

UC Blue & Gold HMO(HMO)
1-800-539-4072

DEFINITIONSCOSTSCalendar Year Deductible

Health Savings Account (HSA)(UC Contribution)

Annual Out-of-Pocket Maximum4$0Plan not eligible for HSA but
eligible for FSA

Individual: $1,000
Family (3 persons or more): $3,000

Kaiser—CA(HMO)
1-800-464-4000
1-800-324-9208 (Prospective
Members)$0

Plan not eligible for HSA but
eligible for FSA

Individual: $1,500
Family (2 persons or more): $3,000

UC CareIn-Network: UC Select(PPO)
1-866-406-1182$0Plan not eligible for HSA but
eligible for FSA

1

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 Summary Plan
Description (SPD) or Benefit Booklet.
COPAYMENTS

Individual: $6,100
Family: $9,7001

Shown in dollars; represents the amount
you pay.
COINSURANCE

Plan not eligible for HSA but
eligible for FSA

UC CareIn-Network: Anthem Preferred(PPO)
1-866-406-1182

Individual: $5001
Family: $1,0001

UC CareOut-of-Network(PPO)
1-866-406-1182

Individual: $7501
Family: $1,7501

Plan not eligible for HSA but
eligible for FSA

Individual: $9,6001
Family: $20,2001

UC Health Savings Plan
In-Network(PPO)
1-866-406-1182

Individual Coverage: $1,6002
Family Coverage: $3,2002(You may use your HSA funds to pay
for your deductible and other eligible
out-of-pocket expenses.)

Employee: up to $5003
Employee & Adult: up to $1,0003
Employee & Children: up to $1,0003
Family: up to $1,0003

Individual Coverage: $4,000
Family Coverage: $6,400

UC Health Savings Plan
Out-of-Network(PPO)
1-866-406-1182

Individual Coverage: $2,6002
Family Coverage: $5,2002(You may use your HSA funds to pay
for your deductible and other eligible
out-of-pocket expenses.)

Employee: up to $5003
Employee & Adult: up to $1,0003
Employee & Children: up to $1,0003
Family: up to $1,0003

Individual Coverage: $8,000
Family Coverage: $16,000

Individual: $3,000Plan not eligible for HSA but
eligible for FSA

CORE
(PPO)
1-866-406-1182

Individual: $7,6001
Family: $14,2001

Shown as a percentage; represents thepercentage of the allowable amount you pay.
ALLOWABLE AMOUNT

Individual: $6,350
Family: $12,700

The dollar amount considered payment-infull 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 allowableamount.)1U
 C Care deductible and out-of-pocket maximums
do not cross-accumulate for in-network and outof-network services. The UC Select and Anthem
Preferred out-of-pocket maximum do crossaccumulate.

2I n-network expenses count toward meeting theout-of-network deductible, but out-of-network
expenses do not count toward meeting thein-network deductible (except for authorized
ambulance and emergency medical services).

3T his assumes you are covered January 1, 2024. If
you enroll later in the year, the UC contribution isprorated.

4

The annual out-of-pocket maximum combines
medical, behavioral health, and prescription drugs.
Kaiser and Optum do not coordinate costs forbehavioral health.

Medical Benefits Summary: 2024
(Non-Medicare)
PLAN

HOSPITAL SERVICESPHYSICIAN VISITS

Inpatient

Surgeon/Emergency Room
Assistant Surgeon

Ambulance

Urgent Care

OfficeVisit

Hospital
Visit

Preventive
Physical ExamMaternity
Outpatient Care

Maternity
Inpatient Care

Well BabyCare

UC Blue & Gold HMO(HMO)$250 copayment
per admittanceNo charge$125 (waived if admitted)

No charge

$20

$20

No charge

No charge

No charge$250 copayment
per admittanceNo charge

Kaiser—CA(HMO)$250 copayment
per admittanceNo charge$125 (waived if admitted)

No charge

$20

$20

No charge

No charge

No charge$250 copayment
per admittanceNo charge

UC CareIn-Network: UC Select(PPO)$250 copayment

No charge

Facility: $300 copay per visit
not resulting in admission,$250 if admitted
ER Physician Services:
No charge (not subject tocalendar year deductible)

N/A (services $20
coveredunder
AnthemPreferred)$20

No charge

No charge$20 (initial visit
only)$250 copayment
per admittanceNo charge

UC CareIn-Network: Anthem
Preferred
(PPO)

30%

30%

Facility: $300 copay per visit
not resulting in admission,$250 if admitted
ER Physician Services:
No charge (not subject tocalendar year deductible)$200/trip(not subject
to calendar
year
deductible)$20 (not subject 30%
to calendar year
deductible)30%

No charge (notsubject tocalendar year
deductible)

30%

30%

No charge(not subject
to calendar
year
deductible)

UC CareOut-of-Network(PPO)

50% (non-preferred 50%
hospitals subject tomaximum paymentof $300/day)

Facility: $300 copay per visit
not resulting in admission,$250 if admitted
ER Physician Services:
No charge (not subject tocalendar year deductible)$200/trip(not subject
to calendar
year
deductible)

50%

50%

50%

50%11

50%11

50% (nonpreferred
hospitals subject
to maximum
payment of $300/
day)

50%

UC Health Savings Plan
In-Network
(PPO)

20%

20%

20%

20%

20% after
deductible

20%

20%

No charge(not subject tocalendar year
deductible)

20%

20%

No charge(not subject
to calendar
year
deductible)

UC Health Savings Plan
Out-of-Network(PPO)

40% (out-of40%
network hospitals
subject tomaximum paymentof $360/day)

20%

20%

40% after
deductible

40%

40%

40%11

40%

40% (out-of40%
network hospitals
subject tomaximum paymentof $360/day)

CORE
(PPO)

20% (out-of20%
network hospitals
subject tomaximum paymentof $480/day)

20%

20%

20% after
deductible

20%

20%

No charge(not subject tocalendar year
deductible)20%

20% (out-ofnetwork hospitals
subject tomaximum paymentof $480/day)

No charge(not subject
to calendar
year
deductible)

Medical Benefits Summary: 2024
(Non-Medicare)
PLAN

OTHER BENEFITS

Hospice Inpatient andOutpatient

Home Health Care

Skilled Nursing Facility

Outpatient
X-Ray and Lab

Eye Exams

Chiropractor

Acupuncture

UC Blue & Gold HMO(HMO)

No charge

No charge

No charge (up to 100 days/
calendar year)

No charge$20 (no charge if partof a preventive careexam)

$20 (24-visit
limit/calendar
year combined with acupuncture)$20 (24-visit
limit/calendar
year combined with chiropractor)

Kaiser—CA(HMO)

No charge

No charge (up to 100
visits/calendar year)

No charge (up to 100 days/
calendar year)

No charge

No charge if part of aroutine physical exam

$15 (24-visit
limit/calendar
year combined with acupuncture)$15 (24-visit
limit/calendar
year combined with chiropractor)

UC CareIn-Network: UC Select(PPO)

N/A (services covered
under Anthem
Preferred)

N/A (services covered
under Anthem
Preferred)

N/A (services covered under
Anthem Preferred)$20

No charge if part of aroutine physical exam,
otherwise $20

N/A (services covered under
Anthem Preferred)

N/A (services covered under
Anthem Preferred)

UC CareIn-Network: Anthem
Preferred
(PPO)

30%

30% (up to 100 visits/
calendar year)

30% (up to 100 days/
calendar year)30%

No charge if part of aroutine physical exam,
otherwise 30%

30% (preferred providers and24-visit limit/calendar year
combined with acupuncture)

30% (preferred providers and24-visit limit/calendar year
combined with chiropractor)

UC CareOut-of-Network(PPO)

50% (non-preferred
hospitals subject tomaximum payment of$300/day)

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 Preferredtier; otherwise, subject tomaximum payment of $300/
day.

50%11

50%

50% (up to allowed amountand 24-visit limit/calendar year
combined with acupuncture)

30% (up to allowed amountand 24-visit limit/calendar year
combined with chiropractor)

UC Health Savings Plan
In-Network
(PPO)

20%

20% (up to 100 visits/
calendar year)

20% (up to 100 days/calendar
year)

20%

No charge if part of aroutine physical exam,
otherwise 20%

20% (24-visit limit/calendar year
combined with acupuncture)

20% (24-visit limit/calendar year
combined with chiropractor)

UC Health Savings Plan
Out-of-Network(PPO)

Not covered unlessprior authorized. If
authorized, in-network
benefit applies.

Not covered unlessprior authorized. If
authorized, in-network
benefit applies.

20% (up to 100 days/calendar
year)

40%

40%

40% (up to allowed amountand 24-visit limit/calendar year
combined with acupuncture)

20% (up to allowed amountand 24-visit limit/calendar year
combined with chiropractor)

CORE
(PPO)

20%

20% (up to 100 visits/
calendar year)(out-of-network notcovered)20% (up to 100 days/calendar
year)

20%

No charge if part of aroutine physical examwith an in-network
provider, otherwise
20%

20% (24-visit limit/calendar year
combined with acupuncture)

20% (24-visit
limit/calendar year combined withchiropractor)

Medical Benefits Summary: 2024
(Non-Medicare)
PLAN

BEHAVIORAL HEALTH 10

PRESCRIPTION DRUGSRetail(Up to 30-day supply)

Mail Order(Up to 90-day supply)

Mental Health Inpatient

Mental Health Outpatient
VisitsSubstance Abuse Inpatient

Substance Abuse
Outpatient Visits

UC Blue & Gold HMO(HMO)

Generic: $59
Brand: $255, 9
Non-Formulary: $405, 9

Generic: $10
Brand: $505
Non-Formulary: $805

$250 copayment per
admittance or course oftreatment (preauthorization
required)

Visits 1–3: No copayment
Visits 4+: $20 (non-routine
visits: $0 copay for 4+ visits)$250 copayment per
admittance or course oftreatment (preauthorization
required)

Visits 1–3: No copayment
Visits 4+: $20 (non-routine
visits: $0 copay for 4+ visits)

Kaiser—CA(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

Kaiser: $250 copayment per
admittance
Optum: $250 copayment
per admittance or course oftreatment (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 oftreatment (preauthorization
required)

Kaiser: $20 for individual visit;$5 for group visit.
Optum: Visits 1–3: No
copayment. Visits 4+: $20

UC CareIn-Network: UC Select(PPO)

At Navitus network pharmacies:
Tier 1: $56, 7, 9
Tier 2: $256, 7, 9
Tier 3: $406, 7, 9

Tier 1: $106, 7
Tier 2: $506, 7
Tier 3: $806, 7$250 copayment per
admittance or course oftreatment

Visits 1–3: No copayment
Visits 4+: $20$250 copayment per
admittance or course oftreatment

Visits 1–3: No copayment
Visits 4+: $20

UC CareIn-Network: Anthem
Preferred(PPO)

At Navitus network pharmacies:
Tier 1: $56, 7, 9
Tier 2: $256, 7, 9
Tier 3: $406, 7, 9

Tier 1: $106, 7
Tier 2: $506, 7
Tier 3: $806, 7$250 copayment per
admittance or course oftreatment

Visits 1–3: No copayment
Visits 4+: $20$250 copayment per
admittance or course oftreatment

Visits 1–3: No copayment
Visits 4+: $20

UC CareOut-of-Network(PPO)

50% (of billed charges perprescription)8

Not covered

50%
Additional $250 copayment
for failure to preauthorize

50%

50%
Additional $250 copayment
for failure to preauthorize

50%

UC Health Savings Plan
In-Network(PPO)

20%8, 9

20%8

20%

20%

20%

20%

UC Health Savings Plan
Out-of-Network
(PPO)

40%8

Not covered

40%$250 for failure topreauthorize

40%

40%
$250 for failure topreauthorize

40%

CORE
(PPO)

20%8, 9Preferred: 20%8
Non-preferred: Not covered

20%

20%

20%
Additional $250 copayment
for failure to preauthorize
with an out-of-network
provider20%Note: Benefits show what member pays.
This is a summary only. Important details—such as limitations, exclusions, exceptions, and otherqualifiers—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.
Service areas: To determine if a medical plan provides service where you live, call the plan directly.
For plan website links, visit ucal.us/plancontacts
Anthem Blue Cross is the medical plan administrator and Navitus is the pharmacy benefit managerof the UC Care, UC Health Savings, and CORE plans.
Health Net is the administrator of the UC Blue & Gold HMO plan.
5

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 counttowards 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.

6

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)

7

When a generic drug is available and you or your physician choose the brand-name drug, you must pay the applicable brandcopay 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.

8

When a generic drug is available and you or your physician choose the brand-name drug, you must pay coinsurance on thecost of the brand drug plus the difference between the cost of the brand-name drug and the generic equivalent. With priorauthorization, exceptions for medical necessity can be made and you pay coinsurance on the cost of the brand-name drug.

99 0-day supply available for maintenance medication at UC Medical Center pharmacies at plan’s mail order copay benefit
level. UC Blue & Gold HMO plan members can access this benefit at CVS walk-up pharmacies. UC PPO plan members can also
access this benefit at additional Navitus Preferred Retail Pharmacies.

10

PPO members receive behavioral health benefits through their medical plan. UC Blue & Gold HMO members receive
behavioral health benefits through Health Net Behavioral Health. Kaiser members have access to the Kaiser benefit shown, in
addition to the Optum in-network benefits and network of providers.

11

Note about out-of-network providers: In addition to any deductible and coinsurance, you are responsible for any billed chargethat exceeds Anthem’s maximum allowed amount for services. These additional amounts do not apply toward your out-of- 		
pocket maximum.

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, Universityof California Group Insurance Regulations, group insurance contracts, and state and federal laws. No person
is authorized to provide benefits information not contained in these source documents, and information notcontained 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 affectedby 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).
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides for continued coverage
for a certain period of time at applicable monthly COBRA rates if you, your spouse, or your dependents lose
group medical, dental, or vision coverage because you terminate employment (for reasons other than grossmisconduct); your work hours are reduced below the eligible status for these benefits; you die, divorce, or are
legally separated; or a child ceases to be an eligible dependent. Note: The continuation period is calculated fromthe earliest of these qualifying events and runs concurrently with any other UC options for continued coverage.
See your Benefits Representative for more information.
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.

2100-MS 11/23