UC Medicare PPO Plan

What You Need to Know

UC offers a range of health plan options to Medicare-eligible employees and retirees and their eligible family members.


All UC Medicare supplement plans protect your and your family’s health and include behavioral health coverage and virtual care options. Your Medicare coverage is primary. All plans also cover the Medicare Part A and Part B deductible in full. The difference among them comes down to things like how much you pay when you get care, how much you pay in paycheck contributions, and whether prescription drug coverage is included.

How It Works

See the plan comparison chart [PDF] for more coverage details.

Medicare Providers 

Medicare is your primary coverage. Your UC coverage is secondary. So you always want to get care from hospitals or doctors who accept Medicare. You have the option to see providers who do not accept Medicare assignment, but your out-of-pocket costs will be higher. Learn more about provider options.

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No-Cost Medicare Preventive Care

When you see a provider that accepts Medicare, Medicare covers 100% of the cost (no deductible) for annual Medicare-recommended preventive screenings and lab tests based on your age and gender. While Medicare does not cover what you might think of as a physical exam, it does cover certain wellness services focused on keeping you healthy. Here’s a quick look at the types of visits and services Medicare does and does not cover, so you’ll know what services you’re getting — and what you’ll pay. For more information, go to medicare.gov.

Annual Medicare Wellness Visit

If You’re New to Medicare (Part B)

If You’ve Been a Medicare Member 12+ Months

Ongoing Preventive Care

Coverage of Physical Exams

COVID Coverage Continues

The Public Health Emergency for COVID-19 that was declared in early 2020 ended on May 11. However, many of the vaccine, testing and treatment provisions continue.

Learn more about ongoing coverage.

What You Pay for Care


The plan covers the deductible for Medicare Part A and Part B in full. If you’re using services covered by Benefits Beyond Medicare, there is a $100 deductible per individual.

Covered Care

For other Medicare-covered services, UC generally covers 80% of the remaining in-network expenses after Medicare pays its share. Here’s what you pay.

  • Physician and specialist office visits, outpatient X-rays, pathology and lab: 20% of Medicare-approved amount after Medicare first pays its share.
  • Virtual care (LiveHealth Online): $20 copay per visit. Medical plan deductible does not apply. Copay counts toward out-of-pocket maximum.
  • Outpatient surgery in a hospital or ambulatory surgical center: 20% of Medicare-approved amount after Medicare first pays its share.
  • Inpatient non-emergency facility services, emergency room services, and ambulance for emergency or authorized transport: 20% of Medicare-approved amount after Medicare first pays its share.

Out-of-Pocket Maximum

This limits the amount you’ll pay for covered services during the year. After you meet the out-of-pocket maximum of $1,500 per covered person (which includes the deductible), you get 100% coverage for covered medical services for the remainder of the year. (There is a separate prescription drug out-of-pocket maximum.)

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Benefits Beyond Medicare

What’s Included

  • Virtual visits with a doctor or therapist through LiveHealth Online (no deductible)
  • Behavioral health office visits from providers who opt out of Medicare (do not participate in Medicare or do not accept Medicare payment for services)
  • Inpatient hospital care beyond Medicare limits
  • Acupuncture (Note: Some acupuncture services may be covered by Medicare. For details, see the Medicare and You handbook at Medicare.gov.)
  • Hearing aids
  • Care when you travel outside the U.S.
  • Certain travel immunizations
  • Skilled nursing facility care beyond Medicare limits
  • Transgender surgery

Except for LiveHealth Online visits, you’ll pay your medical plan’s annual deductible for Benefits Beyond Medicare services. After you meet the deductible, the plan covers 80% of allowable charges.2 However, when you see a non-contracted provider, you are responsible for paying any amount over the Anthem-allowed amount, which does not count toward the plan’s out-of-pocket maximum.

1. Services must be medically necessary as determined by Anthem to be covered after Medicare limits are reached.

2. The calendar-year deductible does not apply to LiveHealth Online services. However, the $20 copay will count toward the plan’s out-of-pocket maximum.

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COVID-19 Vaccines, Tests and Treatment

The Public Health Emergency (PHE) for COVID-19 that was declared in early 2020 will end May 11, 2023. However, many services will continue unchanged.

  • COVID-19 vaccines and boosters: These continue to be covered at 100% by Medicare.
  • COVID-19 PCR tests: These will continue to be covered at no cost to you when ordered by your doctor or other health care provider. You may have a cost for a doctor’s visit if you receive a COVID-19 test during the visit.
  • COVID-19 at-home tests: Medicare members will no longer receive free at-home tests.
  • COVID-19 treatment: Oral antivirals (e.g., Paxlovid and Lagevrio) will continue to be covered under Medicare Part D. You’ll pay a portion of the cost once the federal supply of oral antivirals runs out.
  • Telehealth (virtual care and video visits): Your Benefits Beyond Medicare coverage will continue to cover medical and mental telehealth and video visits through LiveHealth Online.
  • Hospital Care: During the PHE, hospitals received a 20% increase in Medicare reimbursements for COVID-19 patients. The end of PHE may indirectly increase your out-of-pocket costs.

Source: cms.gov

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Behavioral Health

You and your covered family members can use behavioral health benefits for sessions with counselors, psychologists or psychiatrists for mental health services and substance abuse treatment. If you need immediate help, call the Anthem Behavioral Health Resource Center, available 24/7 at (844) 792-5141. You can also speak to a therapist or psychologist virtually through LiveHealth Online.

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Prescription Drugs

Your prescription drug benefit includes coverage for medications on the Part D formulary, plus additional drugs not covered by Medicare Part D, called Over-the-counter drugs.

Log in to the Navitus member portal for a personalized view of your coverage and to preview drug costs, search for pharmacies, see your benefits, and view the Navitus MedicareRx Medicare Part D formulary [PDF]. (Prospective members can use these features on the unsecured Navitus portal.)

Retail network pharmacies: Fill up to a 90-day supply through the Navitus national network of retail pharmacies. Sign in to the Navitus member portal to view the complete list of network pharmacies and find a pharmacy near you.

  • Tier 1 (preferred generic): $10 (30-day supply)/$30 (90-day supply)
  • Tier 2 (preferred brand): $30 (30-day supply)/$90 (90-day supply)
  • Tier 3 (non-preferred): $45 (30-day supply)/$135 (90-day supply)
  • Tier 4 (specialty): $30 (maximum 30-day supply)

UC pharmacies and select retail pharmacies: Fill up to a 90-day supply at CVS, Walgreens, Costco, Safeway/Vons and Walmart or UC pharmacies.

  • Tier 1 (preferred generic): $20
  • Tier 2 (preferred brand): $60
  • Tier 3 (non-preferred): $90
  • Tier 4 (specialty): $30 (maximum 30-day supply)

Mail order: Fill up to a 90-day supply of maintenance medications (those taken on an ongoing basis to treat chronic conditions like asthma, diabetes, high blood pressure and high cholesterol) through the Costco Mail Order Pharmacy. Start a new prescription and request refills online or use the mail order form [PDF], and your prescription will be delivered to you by mail. Learn more about how to order through mail order [PDF].

  • Tier 1 (preferred generic): $20
  • Tier 2 (preferred brand): $60
  • Tier 3 (non-preferred): $90
  • Tier 4 (specialty): Not available

Dispense as written (DAW) penalty: If you or your doctor writes a prescription for a brand-name drug for which there is generic equivalent on the Medicare Part D formulary, you will pay the applicable brand-name (tier 2 or 3) copay plus the difference in cost between the brand-name and the generic equivalent. Your total cost will not exceed the full cost of the brand-name medication. Exceptions for medical necessity can be made with prior authorization from Navitus.

Select generic drugs: No-cost generic drugs used to treat certain chronic conditions, including diabetes, hypertension and high cholesterol — with zero out-of-pocket expense to you at any in-network retail pharmacy or the Costco Mail Order Pharmacy. For a list of covered drugs, see the Navitus MedicareRx formulary [PDF] or call Navitus MedicareRx Customer Care toll-free at (833) 837-4309. TTY users can call 711.  

Over-the-counter drugs: Coverage for medications that are often excluded from Part D coverage, including prescription medications for cough and cold, vitamins and minerals, and lifestyle drugs, including those used to treat erectile dysfunction (ED). Over-the-counter drugs do not count toward your true out-of-pocket expenses. For a list of covered drugs, see the Navitus MedicareRx formulary [PDF] or call Navitus MedicareRx Customer Care toll-free at (833) 837-4309. TTY users can call 711.

Specialty medications: Lumicera Health Services is the preferred pharmacy for specialty medications — higher-cost prescription drugs used to treat complex conditions and that generally require special handling and storage. Just visit Lumicera online or call (855) 847-3553 to get started. Lumicera offers free delivery to your home or other locations. Specialty medications administered in your doctor’s office (e.g., Botox) may be covered under your medical benefit (through CVS Specialty pharmacy). Call Anthem Health Guide toll-free at (844) 437-0486 for information about actions you or your doctor needs to take. Certain UC pharmacies also dispense specialty medications. You can also work with your provider to order specialty medications through these pharmacies.

Prescription drug out-of-pocket maximum: Medicare has a $7,400 out-of-pocket maximum for Medicare Part D prescription drugs (known as the “true out-of-pocket maximum,” or TrOOP), which is the most you will pay for covered Medicare Part D prescriptions in a calendar year. The TrOOP is separate from (and does not count toward) the medical out-of-pocket maximum and does not include over-the-counter drugs. After you meet the TrOOP, you get 100% coverage for Medicare Part D covered prescription drugs for the remainder of the year.

Coverage restrictions: Some covered drugs may have additional requirements or limits on coverage. For more details, see the Navitus MedicareRx formulary [PDF].

  • Prior authorization: Generally, your doctor must show that a particular drug is medically necessary. You and your physician will need to get approval from Navitus MedicareRx before the prescription can be filled. Log in to the Navitus member portal to learn more about prior authorization.
  • Quantity limits: For certain drugs, Navitus MedicareRx limits the amount of the drug that it will cover. For example, Imitrex (used to treat migraines) is limited to 18 tablets per prescription.
  • Step therapy: In some cases, Navitus MedicareRx requires you to first try certain drugs to treat your medical condition before it will cover another drug for that condition.
  • Prescriptions filled outside the U.S.: Medicare doesn’t cover outpatient prescription drugs filled by pharmacies outside the U.S. However, they are covered in full (after any applicable copay) through your Navitus MedicareRx plan (specific rules apply). Learn more about prescription coverage outside the U.S.

No-Cost Generic Drugs

What is a Formulary

Formulary Updates

Tips for Ordering Diabetic Supplies

Care Outside the U.S.

Access to providers for emergency and non-emergency care through the BlueCard® or Blue Cross Blue Shield Global Core network. You pay 20% of Anthem-allowed amount after the deductible.

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Filing Claims

Medical and Behavioral Health

When you see in-network providers for Benefits Beyond Medicare services, there are no claim forms to fill out. Your provider handles all the paperwork. If you see an out-of-network provider, it's up to you to submit a claim for reimbursement for services received. The easiest way to file an out-of-network claim for medical and behavioral health services is through Anthem.


When you fill prescriptions at Navitus network pharmacies, there are no claim forms to fill out. Your pharmacy handles all the paperwork.

If you use an out-of-network pharmacy, it's up to you to submit a claim for reimbursement for services received or prescriptions. File out-of-network pharmacy claims through the Navitus member portal.

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Get Help

For questions about medical coverage, claims, finding providers and more, call Anthem Health Guide at (844) 437-0486 (Monday through Friday, 5 a.m. to 8 p.m. PT) or visit the Anthem website.

For questions about prescription drug coverage and costs, call Navitus Customer Care at (833) 837-4309 or visit the Navitus member portal.

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Anthem Blue Cross Life and Health Insurance Company is the claims administrator for UC PPO Plans. On behalf of Anthem Blue Cross Life and Health Insurance Company, Anthem Blue Cross processes and reviews the medical, pharmacy and behavioral health claims submitted under the plan. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. Navitus is an independent company providing pharmacy benefit management services on behalf of the University of California. All plan benefits are provided by the Regents of the University of California. The content on this website provides highlights of your benefits under the UC PPO Plans. The official plan documents and administrative practices will govern in any and all cases.