Medical Plan

To learn more about UC SHIP, go to the UC SHIP website or see the Brief Plan Description. For a detailed and complete explanation of the plan, see the UC SHIP 2012-2013 Student Medical Plan. Referrals are needed for all off-campus practitioners during the academic year. Make an appointment at Student Health Services for your referral.

Prescriptions

Express Scripts is the pharmacy network for the UC SHIP. This means you should be able to use the same pharmacies you have in the past.

Prescription Drug Coverage at Anthem network pharmacies:

$5 generic
$25 brand formulary
$40 brand non-formulary

FDA approved Contraceptive Prescription Drug coverage at Anthem network pharmacies:

$0 generic
$0 brand formulary when there is no generic equivalent
$25 brand multisource (a generic is available)
$40 brand multisource NON-formulary

There is also a mail order option that can be quite cost effective. The co-pay structure for a 90-day supply is:

Prescription Drug coverage

$10 generic
$50 brand formulary
$80 brand non-formulary

FDA approved Contraceptive Prescription Drug Coverage

$0 generic
$0 brand formulary when there is no generic equivalent
$25 brand multisource (a generic is available)
$40 brand multisource NON-formulary

The mail order option can result in some real savings. For example, if you take a brand formulary drug for 90 days it would cost you $75 at a retail pharmacy and $50 through the mail order option.

To participate in the mail order option,get your provider to write a 90-day prescription for you with the appropriate number of refills (not a 30-day prescription with refills). The provider can fax the prescription with the required form (Physician Mail Order Form) to 800-905-9815 or you can mail the prescription in with your co-pay and the patient form, available at Student Health Services. Details can be found on the Anthem website after you log in with your Anthem member number. The form for the provider to fill out is also on the SHCS website - see the Forms & Brochures section. For future refills, you would log on to the pharmacy site through the Anthem UC SHIP website to order and pay for the refill.

Dental Care

Students are automatically enrolled in the dental plan, provided they are covered under the Graduate Student Insurance Plan (UC SHIP). For more information about your plan please read the Dental Benefits Summary or go to the Delta Dental website.

Dental Plan

Annual Deductible:	$25 in-network / 50% out-of-network
Annual Maximum Benefit:	$1000 in-network / $750 out-of-network
Diagnostic & Preventative Services:	100% in-network / 80% out-of-network
Basic Services:	80% in-network / 60% out-of-network
Crowns and Cast Restoration Services:	70% in-network / 40% out-of-network
Prosthodontics:	70% in-network / 40% out-of-network
*Limitations or waiting periods may apply for some benefits; some services may be excluded. Please refer to your Evidence of Coverage or Summary Plan Description for waiting periods and a list of benefit limitations and exclusions.
**Fees are based on PPO fees for in-network dentists and the maximum plan allowance (MPA) for out-of-network dentists. Reimbursement is paid on Delta Dental contract allowances and not necessarily each dentist's actual fees.

Vision Plan

All those enrolled in the Graduate Student Health Insurance Plan (UC SHIP) are automatically enrolled in the Anthem Blue View Vision Plan.

For information on vision benefits please read The UC SHIP 2012-2013 Blue View Vision Full Plan.

To find a provider, please select the following prompts on the Vision Blue Network.

- Vision Providers
- Blue View Vision Insight

Co-pay	Maximum Benefit	Limitations
Exam:	$10	$120	One in 12 months
Lenses:	$25 - single vision	$120 graded for lens upgrade	One in 12 months
Frames:	$15	$120 with a 20% discount	One in 12 months
Contacts:	$15	$120 with 15% discount	One in 12 months

Dependent Care

Students enrolled in UC SHIP may enroll their dependents in the plan. Dependent benefits differ slightly from student benefits. To learn more about UC SHIP Dependent Benefits, see the UC SHIP 2012-2013 Dependent Medical Plan Summary. For information on Dependent Prescription Coverage, see the UC SHIP 2012-2013 Dependent Prescription Plan Summary.

Eligible dependents must complete a UC SHIP 2012-2013 Dependent Enrollment Form, submit payment directly to WellsFargo Insurance Services (address and fax listed on form) and provide one of the following:

For spouse, Marriage Certificate

For same-sex domestic partner, a Declaration of Domestic Partnership issued by the State of California or of same-sex legal union other than marriage formed in another jurisdiction.
For opposite-sex domestic partner, proof that the Graduate student or partner is age 62 or older and eligible to receive Social Security benefits
For natural child, a birth certificate showing the student is parent of the child
For stepchild, a birth certificate and a marriage certificate showing that one of the parents listed on the birth certificate is married to the student
For adopted or foster child, documentation from the placement agency showing that the student has the legal right to control the child's health care

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