Primary Care Physicans
are required, and
should direct your care
In network:
$0 per visit,
deductible does not apply
Out of network:
Not covered
In network:
$30 per visit for primary care
$40 per visit for specialists
Out of network:
Not covered
In network:
$0 per visit
after deductible is met
Out of network:
Not covered
In network:
$0 per visit
after deductible is met
Out of network:
Not covered
In network:
CVS Retail Pharmacies:
$15 for up to a 30-day supply
UCHealth Retail:
$13 for up to a 30-day supply
$26 for up to a 90-day supply
UCH Mail Order:
$26 for up to a 90-day supply
Out of network:
Not covered
In network:
CVS Retail Pharmacies:
$35 for up to a 30-day supply
UCHealth Retail:
$30 for up to a 30-day supply
$60 for up t a 90-day supply
UCH Mail Order:
$60 for up to a 90-day supply
Out of network:
Not covered
In network:
CVS Retail Pharmacies:
$50 for up to a 30-day supply
UCHealth Retail:
$50 for up to a 30-day supply
$100 for up to a 90-day supply
UCH Mail Order:
$100 for up to a 90-day supply
Out of network:
Not covered
In network:
CVS Retail Pharmacies, UCHealth Retail and
UCH Mail Order:
$75 for up to a 30-day supply
Out of network:
Not covered
In network:
$0 after deductible is met
Out of network:
Not covered
In network:
No charge
Out of network:
Not covered
In network:
Emergency room care:
$250 per visit
(waived if admitted)
Emergency medical transportation:
$0 after deductible is met
Out of network:
Emergency room care:
$250 per visit
(waived if admitted)
Emergency medical transportation:
$0 after deductible is met
In network:
$30 per visit
deductible does not apply
Out of network:
$30 per visit
deductible does not apply
In network:
$0 after deductible is met
Out of network:
Not covered
In network:
Fully covered, no charge
Out of network:
Not covered
In network:
Outpatient:
$30 per office visit,
deductible does not apply
Inpatient:
$0 after deductible is met
Out of network:
Not covered
In network:
$15 copayment
for first prenatal care office visit, deductible does not apply
Out of network:
Not covered
In network:
$0 - fully covered
Out of network:
Not covered
In network:
$0 after deductible is met
Out of network:
Not covered
In network:
$0 after deductible is met
Out of network:
Not covered
In network:
Inpatient:
$0
Outpatient:
$30 per visit,
deductible does not apply
Out of network:
Not covered
In network:
Outpatient:
$30 per visit,
deductible does not apply
Out of network:
Not covered
In network:
$0 after deductible is met
Out of network:
Not covered
In network:
20% coinsurance
not subject to deductible for prosthetic appliances;
$0 after deductible for all other durable medical equipment (100% covered)
Out of network:
Not covered
In network:
$0 after deductible is met
Out of network:
Not covered
In network:
Eye exam:
$20 per visit (exam only,
deductible does not apply)
Glasses:
Not covered
Out of network:
Eye exam:
$35 maximum reimbursement
Glasses:
Not covered
In network:
Not covered
Out of network:
Not covered
Abortion (except in cases of rape, incest, or when the life of the mother is endangered)
Adult dental care
Cosmetic surgery
Infertility treatment
Long-term care
Non-emergency care
when traveling outside
the United States
Private-duty nursing
Weight-loss programs
CU Health Plan - High Deductible
Faculty
University Staff
Classified Staff
Non-Medicare-eligible retirees Non-Medicare-eligible
Surviving spouses