What you need to know
The CORE plan is a high-deductible PPO that generally provides the same level of coverage, whether you receive care at an in-network provider or an out-of-network provider.
Have questions or need help?
How it works
See the plan comparison chart [PDF] for more coverage details.
CORE is a high-deductible medical plan that includes prescription drug coverage.
Did you switch from the UC Health Savings Plan to another medical plan?
No-cost preventive care
Preventive care, including services such as screenings, immunizations and exams for you and all covered family members when you see an in-network provider. (Out-of-network preventive care covered at 20% after the deductible.) Learn more about preventive care.
What you pay for care
Deductible
For all services except in-network preventive care, you first pay a deductible of $3,000 per covered person.
Cost for care
After you meet the deductible, you pay 20% of the cost for most covered services.
Out-of-pocket maximum
This limits the amount you’ll pay for covered services during the year to a maximum of $6,350 (individual coverage) or $12,700 (family coverage), including the deductible. After you meet the out-of-pocket maximum, Anthem pays 100% for most covered medical services and Navitus pays for 100% of most prescription drugs, for the rest of the year.
No surprises
Did you know that if you receive emergency care or are treated by an out-of-network doctor or specialist at a hospital or ambulatory surgical center in your plan’s network, you are protected from surprise billing?
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 use treatment. If you need help finding a provider and booking and appointment, call Accolade at (866) 406-1182 Monday–Friday, 5 a.m.–8 p.m. PT. You can also speak to a therapist or psychologist virtually through Accolade Care Telehealth and Virtual Visits.
Prescription drugs
Your prescription drug coverage includes medications that are part of the Navitus formulary. You can view the formulary, preview drug costs and search for pharmacies on the Navitus portal. For personalized information about coverage and claims, log into the Navitus member portal.
DOWNLOAD THE NAVITUS APP
The Navitus app offers mobile access to your digital ID card to view drug prices, find local pharmacies, and more.
At network pharmacies, you pay the full cost of prescriptions until you reach the plan deductible. After that, you pay 20% for most covered drugs. At out-of-network pharmacies, you pay 20% of the cost.
No-cost drugs: The plan provides $0 coverage for drugs covered by the Affordable Care Act, including over-the-counter smoking cessation products and prescription drugs and diabetes supplies (excluding syringes, needles and non-formulary test strips).
Specialty medications: You can fill prescription drugs used to treat complex conditions through either Lumicera Health Services or select UC pharmacies [PDF]. To get started with Lumicera, visit the website or call them at (855) 847-3553, or work with your provider to use a UC pharmacy. Lumicera offers free delivery to your home or other locations.
Money-saving options:
- Tablet splitting: Buy fewer tablets by breaking a higher-strength drug tablet in half to deliver the same prescribed dose as a full tablet. For medications that can easily be cut in half without compromising efficacy, you can save up to 50% on out-of-pocket costs by having your doctor write a prescription for double the strength (e.g., 20 mg instead of 10 mg) and simply splitting the tablets in half.
Coverage restrictions:
- Brand-name drug penalty: When a generic drug is available and you or your physician choose the brand-name drug, you must pay the tier 3 (non-preferred) copay plus the difference between the cost of the brand-name drug and the generic equivalent. If a prior authorization is approved for a medical necessity exception, you will pay the Tier 3 (non-preferred) cost.
- Prior authorization: Generally, your doctor must show that a particular drug is medically necessary. You or your physician will need to get approval from Navitus before the prescription can be filled. Log in to the Accolade digital member portal to learn more about prior authorization.
- Quantity limits: Taking too much medication or using it too often isn’t safe and may even increase your costs. If you refill a prescription too soon or your doctor prescribes an amount higher than recommended guidelines, the Navitus pharmacy system will reject your claim. If your doctor believes your situation requires an exception, the doctor can contact Navitus to request prior authorization review.
- Step therapy: In some cases, if your doctor prescribes a more expensive drug to treat your medical condition when a lower-cost alternative is available, Navitus requires you to first try the lower-cost drug before it will cover another drug for that condition. This includes medications used to treat ADHD, diabetes, high cholesterol and multiple sclerosis.
What is a formulary?
What is a formulary?
A formulary is an extensive list of safe, effective medications covered by a health plan. Every pharmacy benefit manager (Navitus, for the UC PPO plans) uses its own formulary and it changes over time as new drugs enter the market and brand-name patents expire. Generally, if drugs aren’t on the formulary, they aren’t covered by the plan.
Before filling a prescription, first find out if the drug is covered. A quick search of the Navitus formulary will tell you. Download the Navitus app to have the formulary with you at the doctor’s office. If the drug the doctor recommends isn’t listed, you can look for alternatives in real time. If you don’t see the drug on the formulary, you or your doctor can contact Navitus Customer Care at (833) 837-4308 for help.
If there’s a generic version of a drug you are prescribed and your doctor or you choose the brand-name drug instead, you’ll pay a penalty.
Formulary updates
Formulary updates
December 2024
| Drug Name | Change Type |
|---|---|
| TAZORAC CREAM | Add to Tier 3 |
| FEMLYV TAB | Add to $0 tier |
| TREMFYA INJ 200MG/2ML | Add to specialty tier |
| COMBIPATCH | Add to Tier 2 |
| tiopronin tab delayed release | Add to Tier 1 |
| ONDANSETRON TAB | Move to Not Covered |
| disulfiram tab 500mg | Move to Not Covered |
| OXYCODONE TAB | Move to Not Covered |
| JYNNEOS INJ | Add to $0 Tier |
| OXBRYTA TAB | Move to Not Covered |
November 2024
| Drug Name | Change Type |
|---|---|
| ELMIRON CAP | Move to Not Covered |
| FUZEON INJ | Move to Not Covered |
October 2024
| Drug Name | Change Type |
|---|---|
| LIVMARLI SOLN 19MG/ML | Add to specialty tier |
| TALTZ INJ 20MG/0.25ML TALTZ INJ 40 MG/0.5ML | Add to specialty tier |
| LIRAGLUTIDE SOLN PEN-INJECTOR | Add to Tier 2 |
| VICTOZA INJ | Add to Tier 2 |
September 2024
| Drug Name | Change Type |
|---|---|
| CAPVAXIVE INJ | Add at $0 |
| MRESVIA INJ | Add at $0 |
| AREXVY INJ | Add quantity limit |
| ABRYSVO INJ | Add quantity limit |
| INGREZZA SPRINKLE CAP | Add to specialty tier |
| VIJOICE GRANULES PACKET | Add to specialty tier |
| SCEMBLIX TAB | Add to specialty tier |
| SCEMBLIX TAB 100 MG | Add to specialty tier |
| VALTOCO NASAL SPRAY | Remove Restricted to Specialist edit |
August 2024
| Drug Name | Change Type |
|---|---|
| SPEVIGO INJ | Add to specialty tier |
| BETASERON INJ | Add to specialty tier |
| EXTAVIA INJ | Move to Not Covered |
| CIMETIDINE SOLN | Move to Not Covered |
| QUINAPRIL/HCTZ TAB | Move to Not Covered |
| quinapril/hydrochlorothiazide tab | Move to Not Covered |
| ACCURETIC TAB | Remove from formulary (no active products remaining) |
July 2024
| Drug Name | Change Type |
|---|---|
| STRIVERDI RESPIMAT INHALER | Move to Tier 2 |
| SEREVENT DISKUS INHALER | Move to Not Covered |
| FLUTICASONE DISKUS INHALER | Move to Tier 3 |
FLUTICASONE PROPIONATE DISKUS INHALER 50MCG/ACT FLUTICASONE PROPIONATE DISKUS INHALER 100MCG/ACT FLUTICASONE PROPIONATE DISKUS INHALER 250MCG/ACT | Move to Tier 3 |
| FLUTICASONE HFA INHALER | Move to Tier 3 |
| ORAVIG TAB | Move to Not Covered |
| TOLMETIN TAB | Move to Not Covered |
| TOLMETIN CAP | Move to Not Covered |
| SOOLANTRA CREAM | Add to Tier 3 |
| ivermectin cream | Add to Tier 1 |
| NEXLETOL TAB | Remove Prior Authorization |
| NEXLIZET TAB | Remove Prior Authorization |
| REPATHA INJ | Remove Prior Authorization |
| REPATHA PUSHTRONEX INJ | Remove Prior Authorization |
| ivermectin tab | Remove Prior Authorization |
| STROMECTOL TAB | Remove Prior Authorization |
| AUGTYRO CAP | Add to Specialty Tier |
| FRUZAQLA CAP | Add to Specialty Tier |
| OJJAARA TAB | Add to Specialty Tier |
| TRUQAP TAB | Add to Specialty Tier |
| ZURZUVAE CAP | Add to Specialty Tier |
June 2024
| Drug Name | Change Type |
|---|---|
| OPILL TAB | Add to $0 Tier |
| SIMLANDI INJ | Add to Specialty Tier |
| RIDAURA CAP | Move to Not Covered |
| VIIBRYD TAB | Add to Tier 3 |
| vilazodone hcl tab | Add to Tier 2 |
| lithium oral solution | Add to Tier 1 |
| LOKELMA PAK | Move to Not Covered |
| VYVANSE CAP | Add to Tier 3 |
| VYVANSE CHEW TAB | Add to Tier 3 |
| ADDERALL XR CAP | Add to Tier 3 |
| LATUDA TAB | Add to Tier 3 |
| COMBIGAN OPHTH SOLN | Add to Tier 3 |
| BYSTOLIC TAB | Add to Tier 3 |
Infertility support
The journey to parenthood is not always easy. If you are struggling to conceive, WINFertility is here to help.
UC families enrolled in the Anthem UC Care, HSP, and CORE medical plans are provided a 2-cycle lifetime maximum benefit toward eligible expenses related to fertility treatment and related fertility medications. Coverage includes IVF, GIFT, and ZIFT coverage with 50% coinsurance (after deductible), up to a combined limit of two treatment cycles per lifetime, per member.
The benefit also includes artificial/intrauterine insemination (IUI) cycles, assisted reproductive technologies (ART), and related services as well as infertility specialty medications (also subject to coverage maximums). It does not cover expenses for surrogacy, fees associated with surrogacy or expenses for procuring donated oocytes or sperm.
All fertility services are subject to medical necessity and prior authorization by WINfertility, which will also provide a range of support services.
What you can expect
WIN will help you better understand your options so you can maximize your benefit and choose the best course of treatment. More importantly, WIN knows this can be an extremely stressful and emotional time in your life, and is here to support you through your fertility journey.
- 24/7 access to WIN’s Nurse Care Managers for emotional guidance and support
- Assistance in selecting a high-quality, in-network provider based on your individual treatment needs
- Expertise in understanding complex information and decisions regarding infertility causes, testing and treatment option success rates and risk
- Guidance to help increase the efficient use of hormonal medications to avoid wastage and over-stimulation
- Education on your pharmacy dosing usage, storage, and medication side effects and also assistance in maximizing your infertility medication benefit
WINFertility will assist you in selecting the right provider and navigating the system, your care and benefits. Working together with your health plan network of doctors and pharmacies, WIN provides you with total support and coordination of care.
What it costs
After any applicable deductible, you pay 50% coinsurance for each treatment cycle. (Maximum of two combined cycles per lifetime for each covered member.) Your costs do not count toward the plan’s out-of-pocket maximum.
Get started
For benefit details and eligibility, contact WINFertility at (877) 451-3077, or visit managed.winfertility.com/universityofcalifornia. Service team members are available Monday–Friday 6 a.m.–4:30 p.m. PT. And download the WINFertility Companion app from Google Play or the App Store to take advantage of your benefits on the go. (App code: UCA23.)
For more details, see the WINFertility flyer [PDF] and detailed coverage information [PDF].
Coverage for COVID testing
Provider-ordered tests: PCR testing is covered based on your plan’s benefits. You pay 20% of the cost after the $1,650 (individual)/$3,300 (family) in-network deductible.
Over-the-counter (OTC) tests: Effective Jan. 1, 2025, OTC tests are no longer covered. You have one year from the date of purchase to submit a claim form for reimbursement for any tests purchased in 2024. Complete sections 1 and 2 of the form and sign where indicated. Mail the claim form and your receipts for the OTC COVID tests purchased to Anthem Blue Cross, PO Box 60007, Los Angeles, CA 90060-0007. (Do not submit claims through the Anthem member portal or Sydney app.) Claim processing can take up to 45 days. If you do not receive your reimbursement after 45 days or have any questions about your submission, contact Accolade at (866) 406-1182 for help.
Find care
The UC PPO plans give you a range of options to get care when you need it—from in person to virtual care (telehealth), and urgent care and emergency services through University of California Health Providers, the Anthem provider network, and Accolade Virtual Care and 2nd.MD. (Your primary care doctor and specialists may also offer virtual appointment options. Contact their office for more information.) You’re even covered when you’re traveling out of state or out of the country. Find the right care for your need.
Referrals and prior authorizations
Some specialists — and specialty treatment centers (like nephrology or infusion) — may require a referral from your primary care doctor or prior authorization from Accolade before you can make an appointment. When scheduling an appointment, call Accolade at (866) 406-1182, Monday–Friday, 5 a.m.–8 p.m. PT to ask if a preservice review or precertification is required prior to your initial visit.
Certain services, such as a planned surgery with an overnight hospital stay, require prior authorization from Accolade. If you have a procedure scheduled or a condition that will require treatment, you may need a preservice review. For assistance, call Accolade at (866) 406-1182, Monday–Friday, 5 a.m.–8 p.m. PT.
Filing claims
Medical and behavioral health
When you see in-network providers, there are no claim forms to fill out. Your provider handles all the paperwork.
If you see an out-of-network provider for medical or behavioral health services or use an out-of-network pharmacy, it's up to you to submit a claim for reimbursement for services received or prescriptions.
The easiest way to file an out-of-network claim is to start with Accolade. Call (866) 406-1182 (Monday–Friday, 5 a.m.–8 p.m. PT) or visit the digital member portal. Accolade will direct you to the correct forms and answer any questions you have.
If you prefer, you can file out-of-network medical and behavioral health claims directly with Anthem through the Anthem member portal or the Sydney Health app. Download it through the App Store or Google Play.
Pharmacy
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. The easiest way to file an out-of-network claim is through the Navitus member portal.
Get help
For questions about medical coverage, claims, finding providers and more, start with Accolade. Call (866) 406-1182 (Monday–Friday, 5 a.m.–8 p.m. PT) or visit the Accolade website.
For questions about prescription drug coverage and costs, call Navitus Customer Care at (833) 837-4308 or visit the Navitus member portal.
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 PPO plans. 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 for the PPO plans. Accolade is an independent company providing benefits advocacy services on behalf of the University of California for the PPO plans. Health Net is the claims administrator for the UC Blue & Gold HMO. Health Net processes and reviews the medical, pharmacy and behavioral health claims submitted under the UC Blue & Gold HMO. 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 non-Medicare PPO Plans plans and the Blue & Gold HMO. The official plan documents and administrative practices will govern in any and all cases.