Your UC Medicare Medical Plans. UC Medicare PPO UC Medicare PPO without Prescription Drugs UC High Option Supplement to Medicare ucppoplans.

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1 Your UC Medicare Medical Plans UC Medicare PPO UC Medicare PPO without Prescription Drugs UC High Option Supplement to Medicare 2018 ucppoplans.com

2 Contents What s New or Changing for Your UC Medicare Medical Plan Options... 4 UC Medicare PPO... 8 UC Medicare PPO without Prescription Drugs... 8 UC High Option Supplement to Medicare Find a Doctor...15 Contacts Summary of Benefits Definitions...30 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. If you belong to an exclusively represented bargaining unit, some of your benefits may differ from the ones described here.

3 What s New or Changing for 2018 The changes described below are effective January 1, The Big Headlines» The medical, behavioral health, and pharmacy benefits for the UC Medicare supplement PPO plans will be managed by Anthem Blue Cross. The pharmacy benefits will be managed under the Blue Cross MedicareRx (PDP) with Senior Rx Plus plan. This means you ll be able to get information about all of these benefits from one vendor (Anthem Blue Cross) and website.» Anthem Health Guide will continue to provide support for medical and behavioral health services. Help with Medicare Part D prescription drug questions will be provided through a new, separate toll-free phone number.» You ll get a new medical ID card in December If you enroll in a plan that includes prescription drug coverage, each covered family member will receive a separate ID card from Anthem for prescription drugs.» There s a new online resource for your medical, pharmacy and behavioral health benefits information: ucppoplans.com. During open enrollment, learn about and compare your choices. Then, during the rest of the year, get more detailed information about your medical plan and find links to other resources at your convenience and from any device. For more details about the pharmacy changes, see the Prescription Drug section on page 2. Your UC Medicare Medical Plans 1

4 The changes described below are effective January 1, Medical Plan Benefits ALL PLANS You ll get new ID cards. In late December, you and each covered family member will get one new ID card from Anthem that you ll use beginning January 1, 2018, for medical and behavioral health services. If you enroll in a plan that includes prescription drug coverage, each covered family member will receive an additional ID card from Anthem for prescription drugs. If you re not yet Medicare-eligible but will be in 2018, you ll receive information from Anthem from 60 to 90 days before your 65th birthday to help you transition to a UC Medicare medical and prescription drug plan. All the UC Medicare Supplement plans will include benefits beyond Medicare. This means that Anthem will cover certain services not covered by Medicare. Anthem will also pay for certain services when your Medicare services are exhausted. (Special criteria apply.) Prescription Drug Benefits UC MEDICARE PPO AND UC HIGH OPTION SUPPLEMENT TO MEDICARE PLAN The 2018 Centers for Medicare & Medicaid Services true out-of-pocket limit for Medicare Part D is increasing from $4,950 to $5,000. Anthem is replacing OptumRx as the pharmacy benefit manager (PBM) the administrator of prescription drug benefits. Anthem will process claims, create a network of pharmacies, and set clinical policy and guidelines. Anthem will also run the home delivery service for maintenance medications and use a specialty pharmacy Accredo for complex drugs (specialty medications). If you are enrolled in a UC Medicare PPO plan for 2018, in late December, you ll get a welcome kit from Anthem with all the details about your Medicare Part D prescription drug plan. Most open prescriptions will transfer automatically:* If you have an open prescription at a retail pharmacy, simply show your new ID card when you get your first prescription filled in Most open mail-order prescriptions will be transferred to the Anthem mail service vendor, Express Scripts. You ll get more information about this, including any steps you need to take, directly from Anthem by early In late December, you and each covered family member will get a new prescription ID card from Anthem that you ll use beginning January 1, 2018: It s critical that you show your new ID card for prescription drugs beginning January 1, 2018; otherwise, your claims may be delayed or processed incorrectly. * By law certain prescriptions cannot be automatically transferred. Anthem will notify you if your active prescription cannot be transferred. 2 Your UC Medicare Medical Plans

5 Your copayment or coinsurance for each drug tier will be the same as your current plan. However, drugs may be classified differently (in a different tier or coverage level), which could affect your out-of-pocket costs. For example, the Anthem drug list features four tiers of medications, including generic (with the lowest copayments) and brand-name drugs. This is different from the way OptumRx classifies and prices drugs, which means that you might pay more, or less, for your prescriptions than you do today. Anthem will mail information to you about any changes to your prescription tier by early Many commonly prescribed generic drugs to treat conditions like diabetes, hypertension and high cholesterol will be available at $0 out-of-pocket cost at retail network pharmacies, UC Medical Center pharmacies and through the Anthem mail-order pharmacy, Express Scripts. These are known as Select Generics. You may also have coverage for certain additional drugs not covered by Medicare Part D plans, known as Extra Covered Drugs. For details, go to ucppoplans.com > Medicare Plans > 4 Things to Know About the New Rx Administrator. There is a separate, toll-free number to call for help with Medicare Part D prescription drug questions through Anthem Medicare Prescription Drug Member Services. The toll free number is (833) Prescription Drug Transition To-Do List ü Check the Anthem drug list and prescription drug costs. Anthem uses a different drug list than OptumRx. View the Anthem drug list at ucppoplans.com > What's Changing in Talk to your doctor about alternatives to lower your cost. Get help: If you re taking a drug that s not on the Anthem drug list, or have other questions, call Anthem Medicare Prescription Drug Member Services at (833) Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific). For other questions, call Anthem Health Guide at (844) , Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific). BEFORE DECEMBER 31 ü Get refills of any daily medication so that you have enough to last through early ü Register If your refills will expire on or around January 1, ask your doctor to write a new prescription (with refills) that you can submit to Anthem in January. Active prescriptions will be automatically transferred.* with optumrx.com for access to 2017 prescription information. ON OR AFTER JANUARY 1, 2018 ü Show your new ID card at the pharmacy on your first visit in 2018; otherwise, your claims may be delayed or processed incorrectly. Register on anthem.com/ca to access cost information and the prescription drug mail-order pharmacy. After registering, click on Benefits > Pharmacy. On your first visit, register on the Express Scripts website. After that, you ll be able to access medical and pharmacy information just by logging on to anthem.com/ca. * By law certain prescriptions cannot be automatically transferred. Anthem will notify you if your active prescription cannot be transferred. Your UC Medicare Medical Plans 3

6 Your UC Medicare Medical Plan Options UC offers three different Medicare supplement plans (available only to Medicare members) to meet different health needs and budgets. With a Medicare supplement plan, your Medicare coverage is your primary insurance and your UC coverage is secondary. This means that when you have a Medicare-covered expense, Medicare first pays its share of the cost. Then the UC plan pays a portion, if not all, of the remaining cost, based on the Medicare-approved amount for that service. Medicare determines what is covered and what is medically necessary. See medicare.gov for details. The UC Medicare supplement plans also pay in addition to what Medicare pays for certain services, such as inpatient hospital care, physical therapy and more. The Medicare supplement plans cover a percentage of the cost when you exhaust Medicare limits. The plans also cover certain services not covered by Medicare Parts A & B, such as acupuncture, behavioral health services from providers who don t accept Medicare (Medicare opt-out providers), hearing aids and more. 4 Your UC Medicare Medical Plans

7 Medicare Supplement Plans at a Glance UC Medicare PPO Lower premiums in exchange for some out-of-pocket costs when you get care. Generally pays 80% of the remaining cost after Medicare pays its share. Highest prescription drug out-of-pocket maximum that s separate from the medical plan prescription drug out-of-pocket maximum. UC Medicare PPO without Prescription Drugs Lowest premium because the plan does not provide prescription drug coverage. Designed for people enrolled in prescription drug coverage outside of UC, such as through a spouse, current or former employer or TRICARE. High Option Supplement to Medicare Highest premium in exchange for 100% coverage for many Medicare-covered expenses after Medicare pays its share. Lower deductible and out-of-pocket maximum for medical services not covered by Medicare. Lowest prescription drug out-of-pocket maximum. UC Medicare PPO: Generally covers 80% of the cost of Medicare-covered services after Medicare pays its share. The plan also includes prescription drug coverage through Medicare Part D and covers certain lifestyle drugs, over-the-counter medications and vitamins that Medicare doesn t cover (referred to as Extra Covered Drugs). UC Medicare PPO without Prescription Drugs: Generally covers 80% of the cost of Medicarecovered services after Medicare pays its share, but does not include prescription drug coverage. UC High Option Supplement to Medicare: For many Medicare-covered services, this plan pays 100% of the cost after Medicare pays its share and covers certain lifestyle drugs, over-the-counter medications and vitamins that Medicare doesn t cover (referred to as Extra Covered Drugs). All of the plans offer: Behavioral health coverage and resources Help with all aspects of your medical care through Anthem Health Guide Medical care that travels with you outside the U.S. 24/7 access to coverage information and plan resources through the Anthem website Your UC Medicare Medical Plans 5

8 Coverage by Provider Type This chart applies to all UC Medicare supplement plans. It is intended to provide a more-detailed comparison of coverage levels based on the type of provider. See the Definitions section for more information about the different provider types. For complete coverage details, go to the specific plan Summary Plan Description (SPD) found on ucppoplans.com. Medicare Participating Provider Medicare Covered Services UC High Option: Covers 100% of remaining costs after Medicare pays its share UC Medicare PPO plans: Covers 80% of remaining costs after Medicare pays its share Medicare Covered Services, After Medicare Limits are Reached* This includes inpatient medical and some services where Medicare has a cap or limit. (Certain criteria must be met to qualify for extension.) UC High Option: Covers 80% (after any applicable deductible) UC Medicare PPO plans: Covers 80% (after any applicable deductible) Benefits Beyond Medicare: Services Not Covered by Medicare but Covered by Anthem N/A Applies only to acupuncture, hearing aids and marriage and family counseling. *Services must be medically necessary to be covered after Medicare limits are reached. 6 Your UC Medicare Medical Plans

9 Coverage for Medicare-covered services is based on Medicare allowed amounts. Coverage for services covered by the UC Medicare Supplement plans but not covered by Medicare is based on Anthem allowed amounts. Medicare Non-Participating Provider Opt-out Providers UC High Option: Covers 100% of remaining costs after Medicare pays its share; balance billing may apply UC Medicare PPO plans: Covers 80% of remaining costs after Medicare pays its share; balance billing may apply Behavioral health/substance misuse only; otherwise, not covered UC High Option: Covers 80% of cost for behavioral health/substance misuse services only UC Medicare PPO plans: Covers 80% of cost for behavioral health/ substance misuse services only UC High Option: After deductible, covers 80% of Anthem allowed amount; balance billing may apply UC Medicare PPO plans: After deductible, covers 80% of Anthem allowed amount; balance billing may apply N/A N/A UC High Option: After deductible, covers 100% of Anthem allowed amount; balance billing may apply UC Medicare PPO plans: After deductible, covers 80% of Anthem allowed amount; balance billing may apply Your UC Medicare Medical Plans 7

10 UC Medicare PPO and UC Medicare PPO without Prescription Drugs These two plans cover the same services and provide the same level of benefits for services. The only difference is that UC Medicare PPO without Prescription Drugs does not cover prescription drugs. MEDICAL PLAN HIGHLIGHTS You receive the highest level of benefits when you get care from hospitals or physicians 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 (possibly much higher). The plan covers the deductibles for Medicare Parts A and B. Medicare covers 100% of the cost of preventive care. When you get other types of Medicarecovered services, Anthem generally covers 80% of the remaining expenses, after Medicare pays its share. The plan also pays a percentage of the cost when you exhaust Medicare limits and for certain services that are not covered by Medicare, such as acupuncture, behavioral health from Medicare opt-out providers and hearing aids You pay a $100-per-person calendar-year deductible for Medicare services exhausted or not covered by Medicare that are covered by Anthem. Because many behavioral health providers do not accept Medicare, you can choose any behavioral health provider including psychiatrists, psychologists, marriage and family therapists (MFTs), and marriage, family and child counselors (MFCCs) not just those who accept Medicare. An out-of-pocket maximum of $1,500 per covered person (which includes the deductible) limits your financial liability for covered medical expenses. After you meet this amount, you get 100% coverage for most covered medical services for the remainder of the year. The UC Medicare PPO has a $5,000 outof-pocket maximum for Medicare Part D prescription drugs that is separate from (and does not count toward) the medical out-ofpocket maximum. This is known as the true out-of-pocket maximum, or TrOOP. TAKE A CLOSER LOOK: Go to ucppoplans.com 8 Your UC Medicare Medical Plans

11 Why the UC Medicare PPO Plan Works for Me We re both pretty healthy for our age and only see a doctor a few times a year for minor illnesses. I ve been enrolled in the High Option Supplement to Medicare plan for a few years because I liked the predictability of costs when I got care. But because we don t need much care, this year I m eyeing the UC Medicare PPO plan. I don t want to pay more for coverage that we don t use. I ll put the difference in premium into my savings account to build a cushion for any unexpected expenses. Why the UC Medicare PPO Plan without Prescription Drugs Works for Me I retired from UC a few years ago. Before my career with UC, I served in the military for many years, and I have prescription drug coverage through TRICARE. I m enrolled in the UC PPO Plan without Prescription Drugs. It gives me the medical coverage I need, and I don t have to pay extra for prescription drug coverage that I don t need. I m using my retirement years to explore the world and revisit countries I was stationed in during my military career. I like knowing that my UC plan covers me just about anywhere I go. Your UC Medicare Medical Plans 9

12 UC High Option Supplement to Medicare PLAN HIGHLIGHTS You receive the highest level of benefits when you get care from hospitals or physicians 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. The plan covers the deductibles for Medicare Parts A and B. Medicare covers 100% of the cost of preventive care. In exchange for higher premiums, the plan covers 100% of the cost that Medicare does not for many Medicare-covered services, including doctor s office visits and hospitalization. The plan also pays a percentage of the cost when you exhaust Medicare limits and for certain services that are not covered by Medicare, such as acupuncture and behavioral health from Medicare opt-out providers, and hearing aids. You pay a $50-per-person calendar-year deductible for Medicare services exhausted or not covered by Medicare that are covered by Anthem. Because many behavioral health providers do not accept Medicare, you can choose any behavioral health provider including psychiatrists, psychologists, marriage and family therapists (MFTs), and marriage, family and child counselors (MFCCs) not just those who accept Medicare. An out-of-pocket maximum of $1,050 per covered person limits your financial liability for covered medical expenses. After you meet this amount, you get 100% coverage for most covered medical services for the remainder of the year. There is a $1,000 out-of-pocket maximum for Medicare Part D prescription drugs that is separate from (and does not count toward) the medical out-of-pocket maximum. If you meet the out-of-pocket maximum, you will no longer be charged for prescriptions, even if you haven't met the $5,000 Medicare Part D true out-of-pocket maximum (TrOOP). The out-of-pocket maximum for this plan is lower than the TrOOP. That means that, once you've paid $1,000 out of pocket, your costs for covered prescriptions are covered 100% for the rest of the year. TAKE A CLOSER LOOK: Go to ucppoplans.com 10 Your UC Medicare Medical Plans

13 Why UC High Option Supplement to Medicare Works for Me Last year I switched to UC High Option Supplement to Medicare. Both my wife and I have ongoing health conditions and see the doctor pretty frequently. An asthma attack put me in the hospital for a few days, too. Our providers all accept Medicare, so our out-of-pocket costs are relatively low and predictable. That s important to me because I can t afford surprise expenses. I d rather pay more in premiums in exchange for knowing up front what my costs are going to be when I get care. Your UC Medicare Medical Plans 11

14 What s the Difference Between the Plans? While all the plans cover services such as preventive care, doctor s office visits and hospitalization, there are important differences between them both in what you pay for coverage (the monthly premium) and what you pay when you get care (your out-of-pocket costs). For prescription drug information, see the chart beginning on pages UC Medicare PPO UC Medicare PPO without Prescription Drugs UC High Option Supplement to Medicare Premiums The amount that you pay for coverage each month. Higher premium than UC Medicare PPO without Prescription Drugs, but lower than UC High Option Supplement to Medicare. Lowest premium. Highest premium of the Medicare Supplement plans. Deductible The amount you pay for medical or behavioral health services before the plan begins to share in the cost for covered services. Deductible applies to non-medicare covered services and to Medicarecovered services not paid by Medicare but paid by the plan. (These plans also cover the Medicare Part A and Part B deductibles.) $100 per covered person $50 per covered person Out-of-Pocket Maximum The most you ll pay for covered medical or behavioral health services in a calendar year. (Does not include prescription drugs.) $1,500 per covered person (includes deductible) $1,050 per covered person (includes deductible) 12 Your UC Medicare Medical Plans

15 UC Medicare PPO UC Medicare PPO without Prescription Drugs UC High Option Supplement to Medicare WHAT YOU PAY FOR CARE Preventive care Medicare providers: $0, no deductible Medicare providers: $0, no deductible Doctor and specialist visits Hospitalization Medicare providers: after Medicare Facility: $0 up to 60 days, then after Medicare up to lifetime reserve, then after deductible Doctor: after Medicare Medicare providers: $0 after Medicare Facility: $0 up to lifetime reserve, then after deductible Doctor: $0 after Medicare WHAT YOU PAY FOR PRESCRIPTION DRUGS Deductible None N/A None Out-of-pocket maximum None N/A $1,000 True out-of-pocket maximum (TrOOP) The most you ll pay for covered Medicare Part D prescriptions in a calendar year. $5,000 1 N/A $5, For PPO plan members: You continue to pay the cost of Extra Covered Drugs, even after the TrOOP is reached. For members enrolled in the High Option Supplement plan: Once you reach the $1,000 Drug Plan Maximum Out of Pocket, you are no longer responsible for a copay or coinsurance for prescription drugs until the next calendar year begins. Out-of-pocket costs for Extra Covered Drugs apply toward the $1,000 out-of-pocket maximum but not the TrOOP. If you qualify for the Coverage Gap Discount, you could reach the $5,000 TrOOP before the $1,000 out-of-pocket maximum because out-of-pocket expenses covered by the Coverage Gap Discount apply only toward the TrOOP, but not the out-of-pocket maximum. If this happens, you will continue to pay a copay for Extra Covered Drugs until you reach the $1,000 out-of-pocket maximum. After that, the plan will pay 100% for all covered drugs (including Extra Covered Drugs). Your UC Medicare Medical Plans 13

16 UC Medicare PPO WHAT YOU PAY FOR PRESCRIPTION DRUGS UC Medicare PPO without Prescription Drugs UC High Option Supplement to Medicare Retail network pharmacies (30-day supply) UC pharmacies and select retail pharmacies CVS, Walgreens, Costco, Safeway/Vons (90-day supply) Retail network pharmacies (90-day supply) Generic: $10 Preferred Brand: $30 Non-Preferred Brand: $45 High-Cost: $30 Generic: $20 Preferred Brand: $60 Non-Preferred Brand: $90 High-Cost: $60 Generic: $30 Preferred Brand: $90 Non-Preferred Brand: $135 High-Cost: $90 Not covered Generic: $10 Preferred Brand: $30 Non-Preferred Brand: $45 High-Cost: $30 Not covered Generic: $20 Preferred Brand: $60 Non-Preferred Brand: $90 High-Cost: $60 Not covered Generic: $30 Preferred Brand: $90 Non-Preferred Brand: $135 High-Cost: $90 Mail order (90-day supply) Generic: $20 Preferred Brand: $60 Non-Preferred Brand: $90 High-Cost: $60 Not covered Generic: $20 Preferred Brand: $60 Non-Preferred Brand: $90 High-Cost: $60 Medicare Coverage Gap Discount Program If you are not receiving help to pay drug costs through the Low Income Subsidy (LIS) program or the Program of All-Inclusive Care for the Elderly (PACE), you qualify for the Medicare Coverage Gap Discount Program, which offers a discount on the cost of covered brand name prescription drugs. Once your 2018 prescription drug costs reach $3,750, the discount automatically kicks in on Medicare Part D-qualified brand name drugs until the cost paid by you and the discount reaches $5,000. The discount does not apply to Extra Covered Drugs. 14 Your UC Medicare Medical Plans

17 Find a Doctor Your Medicare coverage is primary insurance, and your UC coverage is secondary. When you have a Medicare-covered expense, Medicare first pays its share of the cost. Then the UC plan pays a portion, if not all, of the remaining cost, based on the Medicare-approved amount for that service. Medicare determines what is covered and what is medically necessary. See medicare.gov for details. The UC Medicare supplement plans also pay in addition to what Medicare pays for certain services, such as inpatient hospital care, physical therapy and more. They also cover a percentage of the cost when you exhaust Medicare limits and for certain services not covered by Medicare Parts A & B, such as acupuncture, behavioral health services from providers who don t accept Medicare (Medicare opt-out providers), hearing aids and more. Find a provider for services that are... Covered by Medicare Part A or B In addition to Medicare Part A or B or Not covered by Medicare Go to medicare.gov to find providers near you that accept Medicare. For the highest level of benefits, choose Anthem network providers. Go to anthem.com/ca/uc and click on Find a Doctor, Hospital or Urgent Care (under Resources & Tools). Click on the plan name you want to search (e.g., UC Medicare PPO). Enter the type of provider you re looking for, such as acupuncture or behavioral health. Enter your location and the distance you re willing to travel. You can also call Anthem Health Guide toll-free at (844) , Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific) for help. Not all Providers Accept Medicare Rates There may be times when you use what Medicare calls a non-participating provider. Because these providers are not bound by Medicare, they can charge you more than the amount allowed by Medicare. This means you may be responsible for any costs beyond what Medicare will pay. (This is known as balance billing.) In addition, if you choose a provider who "opts-out" of Medicare, you will pay the full cost of the services you receive, with the exception of office visits to a behavioral health provider, for which the UC plan covers a portion of the cost. For the lowest costs, use Medicare-participating providers whenever possible. Your UC Medicare Medical Plans 15

18 Contacts For information about the UC Medicare Supplement plans, start at ucppoplans.com. Contact any of the resources below for more details. Anthem Register with Anthem to: Check a medical or pharmacy (Medicare PPO and High Option Supplement to Medicare only) claim status Find a doctor, hospital or pharmacy Get mail-order pharmacy fills and refills, view drug pricing and the drug list Log on to anthem.com/ca Anthem Health Guide Personalized support to: Find Anthem providers Understand out-of-pocket costs, such as copayments and coinsurance Check on the status of a claim and explain how a claim was processed Answer questions about your UC Medicare supplement plan ConditionCare: Manage the symptoms of asthma, diabetes, COPD, heart failure and coronary artery disease ComplexCare: Support for major orthopedic, heart, nerve or cancer-related health issues Future Moms: Nurse coaching for a successful pregnancy and delivery Toll-free (844) Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific) Anthem Medicare Prescription Drug Member Services Provides answers to questions about whether your prescription drug is covered, the cost of your copay, or the location of the nearest pharmacy Toll free (833) Monday through Friday, 5:00 a.m. to 8:00 p.m. (Pacific) Anthem 24/7 Nurse Line Instant access to registered nurses who can help with medical issues (800) available 24/7 Anthem Behavioral Health Resource Center No-cost help for depression, substance misuse and more (844) available 24/7 Blue Cross Blue Shield Global Core Service Center Provides help in locating a doctor or hospital when you are traveling around the world in nearly 200 countries and territories bcbsglobalcore.com Toll free 24/7 (800) (BLUE), or collect (804) Your UC Medicare Medical Plans

19 Castlight Find Anthem providers Review past expenses See patient ratings and reviews Log on to anthem.com/ca LiveHealth Online and LiveHealth Online Psychology Virtual doctor visits by video chat 24/7 and therapist visits by phone This is not a covered benefit; all charges apply livehealthonline.com Medicare View the Medicare and You handbook and get information about benefits covered by Original Medicare (Parts A and B) medicare.gov Toll-free (800) or (877) (TTY) Mobile Health Consumer Access health plan data with programs, resources and personalized content specific to your health Download from Google Play or the App Store mystrength Online and mobile applications for depression, anxiety and substance misuse Log on to anthem.com/ca UC Health Care Facilitators Get help with: Understanding your coverage and patient rights Defining your health care issues Navigating the health care system Resolving issues with your doctor, medical group or Anthem Understanding how Medicare benefits coordinate with UC-sponsored medical plans Health Care Facilitators by campus ucnet.universityofcalifornia.edu/contacts/ health-care-facilitators Welvie Surgery decision support Log on to anthem.com/ca Toll-free (888) (TTY: 711) Monday through Friday, 8:00 a.m. to 7:00 p.m. (Eastern) Anthem s SpecialOffers Log on to anthem.com/ca Your UC Medicare Medical Plans 17

20 Effective: January 1, 2018 UC Medicare PPO Plan Please Note: this medical plan is a complement to your existing Medicare plan. Medicare benefits are primary and then the benefits of this plan are calculated to coordinate up to the Medicare allowable expense. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal UC Medicare PPO Benefit Booklet. If there is a difference between this summary and the UC Medicare PPO Benefit Booklet, the UC Medicare PPO Benefit Booklet, will prevail. Prescription drug benefits are provided separately. COVERED MEDICAL BENEFITS Your Cost Calendar Year Medical Deductible Deductible applies to Medicare covered services and services not covered by Medicare $100 individual but covered by this Plan. (This Plan also covers Medicare Part A and B Deductibles in full) Calendar Year Out-of-Pocket-Limit Out-of-Pocket Limit applies to all medical plan Member liability within Medicare $1,500 individual allowable amount for Medicare covered services and Plan allowed amounts for non- (includes Medicare covered services that are covered by this Plan. When you meet your out-ofpocket limit, you will no longer have to pay cost-shares during the remainder of the deductible) calendar year. Prescription drug benefits are provided separately. COVERED MEDICAL BENEFITS Doctor Home and Office Services Preventive care/screening/immunization No Charge Primary care visit to treat an injury or illness Specialist care visit Prenatal and Post-natal Care Other practitioner visits: Chiropractor services Acupuncture (Coverage is limited to 24 visit limit per benefit period. These services are not covered by Medicare.) Other services in an office: Allergy testing and treatment Chemo/radiation therapy Hemodialysis Office based injectable (For drugs dispensed in the office thru infusion/injection when covered by Medicare Part B) Diagnostic Services Lab: Office Freestanding Lab Outpatient Hospital 18 Your UC Medicare Medical Plans

21 X-ray: Office Freestanding Lab Outpatient Hospital Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office Freestanding Lab Outpatient Hospital Emergency and Urgent Care Emergency room facility services Emergency room doctor and other services Ambulance (air and ground) Urgent Care (office setting) Outpatient/Inpatient Mental/Behavioral Health and Substance Abuse Doctor office visit when covered by Medicare Doctor office visit when not covered by Medicare (Deductible applies) Facility fees Outpatient Surgery Facility fees: Hospital Freestanding Surgical Center Doctor and other services Hospital Stay (all inpatient stays including maternity, mental/ behavioral health, and substance abuse) Facility fees (for example, room & board) for first 60 days Facility fees 61st through 91st day Facility fees beyond lifetime reserve Facility fees beyond the additional 365 days Doctor and other services Recovery & Rehabilitation Home health care Rehabilitation services (for example, physical/speech/occupational therapy): Office Outpatient hospital Habitation services Cardiac rehabilitation Office Outpatient hospital Skilled nursing care (in a facility) 21st through 100th day 101st day and after Not covered Your UC Medicare Medical Plans 19

22 Hospice Durable Medical Equipment Prosthetic Devices Hearing Aids Coverage is limited to 2 hearing aids per 36 months. These services are not covered by Medicare. Notes: Only retirees enrolled in Medicare parts A & B are eligible for this plan. Medicare will always pay primary for Medicare covered services. All medical services subject to a coinsurance are also subject to the annual medical deductible. Annual Out-of-Pocket Maximums include deductible and coinsurance. Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV, diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services, HIV testing) and additional preventive care for women provided for in the guidance supported by Health Resources and Service Administration. Certain services are subject to the utilization review program. Before scheduling services, the member must make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not paid, according to the plan. Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health coverage so that the services received from all group coverage do not exceed 100% of the covered expense 20 Your UC Medicare Medical Plans

23 Your 2018 Prescription Drug Benefit Chart for UC Medicare PPO Effective January 1, 2018 Your retiree drug coverage includes Medicare Part D drug benefits and non-medicare supplemental drug benefits. The cost shown below is what you pay after all benefits under your retiree drug coverage have been provided. Formulary Closed Deductible $0 Covered Services What you pay Part D Initial Coverage Below is your payment responsibility until the amount paid by you and the Coverage Gap Discount Program for covered Part D prescriptions reaches your True Out of Pocket limit of $5,000. Retail Pharmacy per 30-day supply Select Generics $0 copay Generics $10 copay Preferred Brands $30 copay Non-Preferred Brands $45 copay Specialty Drugs (Generic and Brand) $30 copay Diabetic Supplies Alcohol Swabs and Gauze Diabetic Supplies Insulin Syringes $10 copay $30 copay Part D Preventive Vaccines $0 copay Typically retail pharmacies dispense a 30-day supply of medication. Many of our retail pharmacies can dispense more than a 30-day supply of medication. If you purchase more than a 30-day supply at these retail pharmacies, you will need to pay one copay for each full or partial 30-day supply filled. For example, if you order a 90-day supply, you will need to pay three 30-day supply copays. If you get a 45-day or 50-day supply, you will need to pay two 30-day copays. If you purchase more than a 30-day supply at one of the UC Medical Center retail pharmacies or Costco, CVS, Vons/Safeway or Walgreens, you only pay the mail-order copay shown below. Y0114_18_30790_I 02/24/ Custom ASO 10/30/45/30 University of California_PPO Full Gap E4TC (7)_ECDMLP_SG CA 09/06/2017 Your UC Medicare Medical Plans 21

24 Covered Services Mail-Order Pharmacy What you pay per 90-day supply Select Generics Generics Y0114_18_30790_I 02/24/2017 $0 copay $20 copay Preferred Brands $60 copay Non-Preferred Brands $90 copay Specialty Drugs (Generic and Brand) $60 copay Diabetic Supplies Alcohol Swabs and Gauze Diabetic Supplies Insulin Syringes $20 copay $60 copay Part D Catastrophic Coverage Your payment responsibility changes after the cost you and the Coverage Gap Discount Program have paid for covered drugs reaches your True Out of Pocket limit of $5,000. Select Generics $0 copay Generic Drugs $0 copay Brand-Name Drugs $0 copay Extra Covered Drugs These are drugs that are covered by your retiree drug plan that are often excluded from Part D coverage. These drugs do not count towards your True Out of Pocket expenses. They do not qualify for lower Catastrophic copays. These drugs are covered by your Senior Rx Plus benefits. Cough and Cold Vitamins and Minerals Lifestyle Drugs, including Erectile Dysfunction (ED) See Formulary for complete list of drugs covered Generics You pay your Retail or Mail-Order copay Preferred Brands You pay your Retail or Mail-Order copay Non-Preferred Brands You pay your Retail or Mail-Order copay Part B Diabetic Supplies Lancets, Blood Sugar Diagnostics, Calibration Solutions and Glucometers Prescription $0 copay Part B Preventive Vaccines Influenza, Pneumonia and Hepatitis B Per Vaccine $0 copay Extra Covered Drugs - California These are drugs that are covered on retiree drug plans issued in California. Contraceptive Devices Limit 1 per year; Copay or coinsurance per Covered Device Prescription $0 copay 22 Your UC Medicare Medical Plans

25 Smoking Cessation Drugs: Your plan includes coverage for smoking cessation drugs prescribed by a physician. See Formulary for a complete list of drugs covered. Transgender Changes or Gender Identity Disorder Drugs: You pay the applicable drug tier copay under retail or mail order. See Formulary for a complete list of drugs covered. Vaccines: Medicare covers some vaccines under Part B medical coverage and other vaccines under Part D drug coverage. Your UC drug plan provides coverage for both Part B and Part D vaccines at no cost when purchased at a network pharmacy. You also have coverage for vaccines administered at a physician s office, however the physician will only submit a claim for a Part B vaccine. If you want to get a Part D vaccine at your physician s office you will pay for the entire cost of the vaccine and its administration and then ask your UC drug plan to pay its share of the cost. Please see your Evidence of Coverage for complete details on what you pay for vaccines covered by Part D. A list of Part D covered vaccines are included in your formulary. Part B covered vaccines are listed in the benefit chart. Coverage for Out of Country Drugs: Outpatient prescription drugs are not covered by Medicare Part D plans when they are filled by pharmacies outside of the United States. Your plan provides coverage for outpatient prescription drugs when all of the following apply: 1. You are outside the 50 United States, District of Columbia, and all U.S. Territories, other than the U.S. Virgin Islands, for less than six months, 2. You remain a permanent resident of the United States while you are out of country, 3. The drug is approved by the Food and Drug Administration (FDA), and 4. The drug would be a covered drug by your plan if the drug was filled by a pharmacy located within the United States. When you receive coverage for outpatient prescription drugs filled at a pharmacy outside the United States, you will need to pay the full cost of the drug and request that we reimburse you for our share. Your share of a covered outpatient drug will be your coinsurance or copayment amount. Please see How to ask us to pay you back for detailed instructions. Y0114_18_30790_I 02/24/2017 Your UC Medicare Medical Plans 23

26 Effective: January 1, 2018 UC High Option Supplement to Medicare Plan Please Note: this medical plan is a complement to your existing Medicare plan. Medicare benefits are primary and then the benefits of this plan are calculated to coordinate up to the Medicare allowable expense. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal UC High Option Supplement to Medicare Benefit Booklet. If there is a difference between this summary and the UC High Option Supplement to Medicare Benefit Booklet, the UC High Option Supplement to Medicare Benefit Booklet will prevail. Prescription drug benefits are provided separately. COVERED MEDICAL BENEFITS Calendar Year Medical Deductible Deductible applies to Medicare covered services and services not covered by Medicare but covered by this Plan. (This Plan also covers Medicare Part A and B Deductibles in full) Calendar Year Out-of-Pocket-Limit Out-of-Pocket Limit applies to all medical plan Member liability within Medicare allowable amount for Medicare covered services and Plan allowed amounts for non- Medicare covered services that are covered by this Plan. When you meet your out-ofpocket limit, you will no longer have to pay cost-shares during the remainder of the calendar year. Prescription drug benefits are provided separately. COVERED MEDICAL BENEFITS Doctor Home and Office Services Preventive care/screening/immunization Primary care visit to treat an injury or illness Specialist care visit Prenatal and Post-natal Care Other practitioner visits: Chiropractor services Acupuncture (Coverage is limited to 24 visit limit per benefit period. These services are not covered by Medicare.) Other services in an office: Allergy testing and treatment Chemo/radiation therapy Hemodialysis Office based injectable (For drugs dispensed in the office thru infusion/injection when covered by Medicare Part B) Your Cost $50 individual $1,050 individual (includes deductible) 24 Your UC Medicare Medical Plans

27 Diagnostic Services Lab: Office Freestanding Lab Outpatient Hospital X-ray: Office Freestanding Lab Outpatient Hospital Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office Freestanding Lab Outpatient Hospital Emergency and Urgent Care Emergency room facility services Emergency room doctor and other services Ambulance (air and ground) Urgent Care (office setting) Outpatient/Inpatient Mental/Behavioral Health and Substance Abuse Doctor office visit when covered by Medicare Doctor office visit when not covered by Medicare (Deductible applies) Facility fees Outpatient Surgery Facility fees: Hospital Freestanding Surgical Center Doctor and other services Hospital Stay (all inpatient stays including maternity, mental/ behavioral health, and substance abuse) Facility fees (for example, room & board) Facility fees beyond lifetime reserve Facility fees beyond the additional 365 days Doctor and other services Recovery & Rehabilitation Home health care Rehabilitation services (for example, physical/speech/occupational therapy): Office Outpatient hospital Habitation services Cardiac rehabilitation Office Outpatient hospital Skilled nursing care (in a facility) 21st through 100th day 101st day and after Not covered Your UC Medicare Medical Plans 25

28 Hospice Durable Medical Equipment Prosthetic Devices Hearing Aids Coverage is limited to 2 hearing aids per 36 months. These services are not covered by Medicare. Notes: Only retirees enrolled in Medicare parts A & B are eligible for this plan. Medicare will always pay primary for Medicare covered services. All medical services subject to a coinsurance are also subject to the annual medical deductible. Annual Out-of-Pocket Maximums include deductible and coinsurance. Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV, diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services, HIV testing) and additional preventive care for women provided for in the guidance supported by Health Resources and Service Administration. Certain services are subject to the utilization review program. Before scheduling services, the member must make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not paid, according to the plan. Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health coverage so that the services received from all group coverage do not exceed 100% of the covered expense. 26 Your UC Medicare Medical Plans

29 Your 2018 Prescription Drug Benefit Chart for UC High Option Supplement to Medicare Effective January 1, 2018 Your retiree drug coverage includes Medicare Part D drug benefits and non-medicare supplemental drug benefits. The cost shown below is what you pay after all benefits under your retiree drug coverage have been provided. Formulary Closed Deductible $0 Drug Plan Maximum Out of Pocket per calendar year $1,000 Covered Services What you pay Part D Initial Coverage Below is your payment responsibility until the amount paid by you and the Coverage Gap Discount Program for covered Part D prescriptions reaches your True Out of Pocket limit of $5,000. Important Note: Once you reach your $1,000 Drug Plan Maximum Out of Pocket, you no longer pay a copay or coinsurance for your drugs until the next calendar year begins. Retail Pharmacy per 30-day supply Select Generics $0 copay Generics $10 copay Preferred Brands $30 copay Non-Preferred Brands $45 copay Specialty Drugs (Generic and Brand) $30 copay Diabetic Supplies Alcohol Swabs and Gauze $10 copay Diabetic Supplies Insulin Syringes $30 copay Part D Preventive Vaccines $0 copay Typically retail pharmacies dispense a 30-day supply of medication. Many of our retail pharmacies can dispense more than a 30-day supply of medication. If you purchase more than a 30-day supply at these retail pharmacies, you will need to pay one copay for each full or partial 30-day supply filled. For example, if you order a 90-day supply, you will need to pay three 30-day supply copays. If you get a 45-day or 50-day supply, you will need to pay two 30-day copays. If you purchase more than a 30-day supply at one of the UC Medical Center retail pharmacies or Costco, CVS, Vons/Safeway or Walgreens, you only pay the mail-order copay shown below. Y0114_18_30790_I 02/24/ Custom ASO 10/30/45/30 University of California_High Full Gap E4TC (7)_ECDMLP_SG CA 09/06/2017 Your UC Medicare Medical Plans 27

30 Covered Services Mail-Order Pharmacy What you pay per 90-day supply Select Generics Generics Y0114_18_30790_I 02/24/2017 $0 copay $20 copay Preferred Brands $60 copay Non-Preferred Brands $90 copay Specialty Drugs (Generic and Brand) $60 copay Diabetic Supplies Alcohol Swabs and Gauze Diabetic Supplies Insulin Syringes $20 copay $60 copay Part D Catastrophic Coverage If you have not already met your $1,000 Drug Plan Maximum Out of Pocket, your payment responsibility changes after the cost you and the Coverage Gap Discount Program have paid for covered drugs reaches your True Out of Pocket limit of $5,000. Select Generics $0 copay Generic Drugs $0 copay Brand-Name Drugs $0 copay Extra Covered Drugs These are drugs that are covered by your retiree drug plan that are often excluded from Part D coverage. These drugs do not count towards your True Out of Pocket expenses. They do not qualify for lower Catastrophic copays. These drugs are covered by your Senior Rx Plus benefits. Cough and Cold Vitamins and Minerals Lifestyle Drugs, including Erectile Dysfunction (ED) See Formulary for complete list of drugs covered Generics You pay your Retail or Mail-Order copay Preferred Brands You pay your Retail or Mail-Order copay Non-Preferred Brands You pay your Retail or Mail-Order copay Part B Diabetic Supplies Lancets, Blood Sugar Diagnostics, Calibration Solutions and Glucometers Prescription $0 copay Part B Preventive Vaccines Influenza, Pneumonia and Hepatitis B Per Vaccine $0 copay Extra Covered Drugs - California These are drugs that are covered on retiree drug plans issued in California. Contraceptive Devices Limit 1 per year; Copay or coinsurance per Covered Device Prescription $0 copay 28 Your UC Medicare Medical Plans

31 Smoking Cessation Drugs: Your plan includes coverage for smoking cessation drugs prescribed by a physician. See Formulary for a complete list of drugs covered. Transgender Changes or Gender Identity Disorder Drugs: You pay the applicable drug tier copay under retail or mail order. See Formulary for a complete list of drugs covered. Vaccines: Medicare covers some vaccines under Part B medical coverage and other vaccines under Part D drug coverage. Your UC drug plan provides coverage for both Part B and Part D vaccines at no cost when purchased at a network pharmacy. You also have coverage for vaccines administered at a physician s office, however the physician will only submit a claim for a Part B vaccine. If you want to get a Part D vaccine at your physician s office you will pay for the entire cost of the vaccine and its administration and then ask your UC drug plan to pay its share of the cost. Please see your Evidence of Coverage for complete details on what you pay for vaccines covered by Part D. A list of Part D covered vaccines are included in your formulary. Part B covered vaccines are listed in the benefit chart. Drug Plan Maximum Out of Pocket: Once the cost you have paid for covered drugs reaches $1,000 your plan will cover 100% of the cost of these covered drugs. You will no longer have to pay a copay or coinsurance for covered drugs until the next calendar year begins. Coverage for Out of Country Drugs: Outpatient prescription drugs are not covered by Medicare Part D plans when they are filled by pharmacies outside of the United States. Your plan provides coverage for outpatient prescription drugs when all of the following apply: 1. You are outside the 50 United States, District of Columbia, and all U.S. Territories, other than the U.S. Virgin Islands, for less than six months, 2. You remain a permanent resident of the United States while you are out of country, 3. The drug is approved by the Food and Drug Administration (FDA), and 4. The drug would be a covered drug by your plan if the drug was filled by a pharmacy located within the United States. When you receive coverage for outpatient prescription drugs filled at a pharmacy outside the United States, you will need to pay the full cost of the drug and request that we reimburse you for our share. Your share of a covered outpatient drug will be your coinsurance or copayment amount. Please see How to ask us to pay you back for detailed instructions. Y0114_18_30790_I 02/24/2017 Your UC Medicare Medical Plans 29