![]() Click here to view the Uniform Glossary of Coverage and Medical Terms.Ĭarrier specific notices, disclaimers and fees A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. The Summary of Benefits & Coverage can be found at.Insurance companies reserve the right to change the terms of a policy upon proper notification. The insurance company always determines your actual premium. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The quotes or rates shown above are estimates only. Please check below for information regarding the plans and carriers you selected. These amounts are subject to change.Įach insurance carrier may have unique Notices, Disclaimers, and Fees. The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network. Only the terms and conditions of coverage benefits listed in the policy are binding. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. The information shown here is a summary of benefits for informational purposes only. ![]() ![]() Out-of-Network Annual Out-of-Pocket LimitĮlectronic Signature for Application Available No Charge, limited to 1 Visit(s) per Year No Charge, limited to 1 Visit(s) per 6 Months Inpatient Hospital Services: 40% Coinsurance after deductible Inpatient Physician and Surgical Services: 40% Coinsurance after deductibleĤ0% Coinsurance after deductible, limited to 100 Days per Benefit PeriodĤ0% Coinsurance after deductible, limited to 100 Visit(s) per Year ![]() Outpatient Rehabilitation Services (PT, OT, ST) Outpatient Lab: $40 Copay X-rays: 40% Coinsurance after deductible Outpatient Surgery Physician/Surgical Services: 40% Coinsurance after deductible Outpatient Facility Fee: 40% Coinsurance after deductible Generic Drugs: $18 Copay after deductible Preferred Brand Drugs: 40% Coinsurance after deductible Non-Preferred Brand Drugs: 40% Coinsurance after deductible Specialty Drugs: 40% Coinsurance after deductible $65 Copay for first 3 visits then $65 Copay after deductible first 3 combined visits for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits covered in full Office Visit for Other Practitioner (Nurse, Physician Assistant) $95 Copay for first 3 visits then $95 Copay after deductible $65 Copay for first 3 visits then $65 Copay after deductible The Bruin Health Pharmacy will always be their most affordable option for medications.Office Visit for Primary Doctor Find Doctors They offer a full range of prescription and over-the-counter medications. When students need to fill a prescription, we recommend going to the Bruin Health Pharmacy located in Ackerman Union (A-Level). UC SHIP Prescription Benefits are administered through Optum Rx.Ĭlick here for an infographic about how to use UC SHIP Medical Benefits. UC SHIP Medical Benefits are administered through Anthem Blue Cross.
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