UC Care PPO Plan
JANUARY 1, 2015–DECEMBER 31, 2015
Table of Contents
Know These Terms..........................1–2
What’s New or
Changing for 2015..........................3–4
UC Care Providers............................... 5
How UC Care Works......................6–8
Getting Care Outside
of California........................................... 9
Medical and
Prescription Benefits.................10–11
Transitioning to UC Care............... 12
Manage Your Health.........................13
Explore Our Tools.............................. 14
Benefits Summaries................. 15–20
Get Help................................................ 21
UC Care University........................... 21
Take Cover with Shield Concierge
Need help with benefits, finding providers or submitting a claim?
Call Shield Concierge, toll-free, at 1-855-201-2087. Shield Concierge is
available Monday through Friday, from 7:00 a.m. to 7:00 p.m. (Pacific).
Know These Terms
To understand your plan, you need to know these important health insurance terms.
Find more at uc-care.org and click on UC Care University in the middle of the page.
Getting and Paying for Care
PROVIDERS. Individuals or facilities that offer medical or
mental health care to you and your family.
BLUE SHIELD PREFERRED. An in-network tier that lets
you choose from more than 70,000 providers in California’s
Blue Shield Preferred network. Also offers access to more
than 600,000 BlueCard® providers outside of California—
in the U.S. and throughout the world.
UC SELECT. An additional tier of in-network coverage in
California on top of Blue Shield Preferred.
IN-NETWORK. A group of health care providers that
Blue Shield contracts with at a set payment rate for the
UC Care plan.
OUT-OF-NETWORK. Providers that are not in Blue Shield
Preferred or UC Select, have not contracted with Blue Shield
and have not agreed to certain rates for the UC Care plan.
PREMIUM. Your health care costs begin with your
premium—the amount that’s deducted from your paycheck
for your UC Care coverage, depending on your salary band.
COINSURANCE. The percentage you pay for the cost
of covered health care services, after you meet your
deductible. Referred to as “member copayment” in the
2015 UC Care Benefit Booklet.
COPAY. A set dollar amount you pay for doctor visits,
prescriptions and other covered health care services—only
available when you see in-network, UC Select providers.
OUT-OF-POCKET MAXIMUM. The most you’ll pay
for covered health care services in a calendar year.
Once you reach it, UC Care pays 100% of the costs for
covered services.
For 2015, there are two separate medical in- and out-ofnetwork, out-of-pocket maximums for covered benefits
and a separate in-network prescription, out-of-pocket
maximum for covered prescription benefits.
§§ In-network (UC Select and Blue Shield Preferred) medical
out-of-pocket maximum amounts cross accumulate.
§§ In-network and out-of-network (non-preferred), out-ofpocket maximum amounts do not cross accumulate.
§§ Medical and prescription out-of-pocket maximums do
not cross accumulate.
CALENDAR-YEAR DEDUCTIBLE. The amount you pay out
of pocket for health care before UC Care begins to share in
the cost for covered services. There are two calendar-year
deductibles. There is no calendar-year deductible for care
delivered in UC Select.
§§ The in-network (Blue Shield Preferred) deductible
applies to the in-network (Blue Shield Preferred) medical
out-of-pocket maximum.
§§ The out-of-network or non-preferred deductible—for
when you get out-of-network care—does accrue to the
out-of-network (non-preferred) medical out-of-pocket
maximum. Charges in excess of the allowed amounts do
not count toward the deductible.
§§ In-network (Blue Shield Preferred) and out-of-network
(non-preferred) medical deductibles do not cross
accumulate.
1
Billing and Claims
EXPLANATION OF BENEFITS. After you get care, you’ll
receive an Explanation of Benefits (EOB) from Blue
Shield, UC Care’s claims administrator. The EOB provides
information about how your claim was paid, including how
much you owe or will be reimbursed.
BALANCE BILLING. A bill for the difference between the
amount UC Care reimburses for covered services—the
allowed amount—and what your provider chooses to
charge. You are not required to pay this amount if you
access care with an in-network provider.
CLAIM. A request to the UC Care claims administrator from
a provider asking to be paid for a service you’ve received.
APPEALS & GRIEVANCES. A written or oral expression of
dissatisfaction about Blue Shield, Blue Shield providers or
a Blue Shield vendor.
ALLOWED AMOUNT. The maximum amount on which
payment is based for covered health care services. This
may be called “eligible expense,” “payment allowance,”
or “negotiated rate.”
Prescriptions
FORMULARY. A comprehensive list of drugs maintained
by Blue Shield’s Pharmacy and Therapeutics Committee
for use under the Blue Shield Prescription Drug Program,
which is designed to assist physicians in prescribing
drugs that are medically necessary and cost effective.
The formulary is updated periodically. If not otherwise
excluded, the formulary includes all generic drugs.
GENERIC DRUGS. Approved by the FDA as a therapeutic
equivalent to the brand name drug; (2) contain the same
active ingredient as the brand name drug; and (3) cost less
than the brand name drug equivalent.
BRAND NAME DRUGS. FDA-approved drugs under patent
to the original manufacturer and available only under the
original manufacturer’s brand name.
2
MAINTENANCE MEDICATIONS. Prescribed to treat
chronic health conditions—such as asthma, diabetes, high
blood pressure or high cholesterol—and are taken on an
ongoing, regular basis to maintain health.
SPECIALTY MEDICATIONS. Specialty drugs are those
drugs used to treat complex or chronic conditions that
usually require close monitoring, such as multiple sclerosis,
hepatitis, rheumatoid arthritis, cancer and other conditions
that are difficult to treat with traditional therapies.
Specialty drugs may be self-administered in the home by
injection (under the skin or into a muscle), by inhalation,
by mouth or on the skin. These drugs may also require
special handling, special manufacturing processes and may
have limited prescribing or limited pharmacy availability.
Specialty drugs are obtained from a Blue Shield specialty
pharmacy, and may require prior authorization for medical
necessity by Blue Shield.
What’s New or Changing for 2015
Here are highlights of key changes to UC Care for 2015. Visit uc-care.org to learn more.
For Your Convenience
We’re expanding coverage at in-network pharmacies to make
it more convenient for you and your family to get the services
you need. Starting in 2015, you can receive:
MAINTENANCE PRESCRIPTIONS AT RETAIL PHARMACIES
If you are on maintenance medication for a chronic condition,
you can now receive up to a 90-day supply from:
§§ Participating UC pharmacies.
§§ PrimeMail, Blue Shield’s mail service pharmacy.
§§ NEW! Participating in-network retail pharmacies, including
Walgreens, Safeway/Vons and Costco.
NEW! VACCINATION COVERAGE FOR ADULTS
The following vaccinations will be covered under UC Care’s
medical and pharmacy benefits:
§§ Tetanus/diphtheria/whooping cough
SIMPLIFIED EMERGENCY ROOM BENEFITS
We have also changed the way you’ll pay for emergency room
and ambulance benefits in 2015.
Emergency Room benefits
not resulting in a hospital admission
Today
you pay:
$100 ER facility fee + 20% coinsurance
for physician services
In 2015,
you’ll pay:
$200 flat ER facility fee that covers lab
tests, X-rays and procedures performed
during the ER visit and no charge for ER
physician services
Ambulance for Emergency or Authorized Transport
Today
you pay:
20% coinsurance
In 2015,
you’ll pay:
$200 flat fee, per transport
§§ Pneumonia (pneumococcal)
§§ Meningitis (meningococcal)
§§ Human Papillomavirus (HPV)
§§ Shingles (herpes zoster)
For more information, please see the 2015 UC Care
Benefit Booklet.
Preventive health benefits* Immunizations/vaccinations
Today
§§Covered under your medical plan
§§At a doctor’s office
§§$0 copay
In 2015
§§Covered under your medical plan
§§At a doctor’s office or an in-network pharmacy
§§$0 copay
*Based on your age and gender. On uc-care.org, click on Manage Your
Health then Prevention Tips to learn more.
3
Expanding Care Through Technology
Health Care Reform, UC Care and You
In 2015, you’ll have access to a new program that can enhance
care through technology.
PRESCRIPTION BENEFITS
NEW! TELADOC®
Available 24/7 year-round, you can use Teladoc® to speak
with a doctor by phone or online chat for only $20. Designed
to enhance the care you already receive from your personal
physician, Teladoc® can help:
§§ When you are considering the ER or urgent care for
non-emergency medical issues
§§ After normal office hours
§§ When your primary care physician is not available
There will be a calendar year in-network prescription
out-of-pocket maximum ($3,600 for individual coverage,
$4,200 for family coverage) for covered prescriptions filled
by UC and other in-network pharmacies. There is no out-ofnetwork, out-of-pocket maximum for prescriptions filled at
out-of-network pharmacies.
This is a mandate of the Affordable Care Act (ACA) and a
change from your 2014 benefits.
However, your medical out-of-pocket maximums for 2015
remain the same.
§§ With pediatric care
Learn more about the change to prescription benefits on
page 11 of this booklet.
§§ Within rural areas that have limited access to emergency
or urgent care
OVER-THE-COUNTER TOBACCO-CESSATION PRODUCTS
Their U.S. board-certified doctors can also diagnose,
recommend and prescribe medication for many of your
medical issues, including:
Under ACA rules, you can now purchase any FDA-approved
tobacco-cessation products without prior authorization and
with no copay.
§§ Cold and flu symptoms
This covers both prescription and over-the counter medications
used for a 90-day treatment regimen when prescribed by a
health care provider.
§§ Bronchitis or respiratory infections
§§ Allergies
§§ Urinary tract infections
§§ Ear infections
Request a consultation anytime, day or night—you’re
guaranteed to talk to a doctor within one hour. To learn
more, visit uc-care.org. Select Use Your Benefits from the
upper navigation. Then, click on What’s Changing for 2015,
followed by Teladoc.
Other Benefits Changes
In 2015:
§§ New ID Cards will include the subscriber name, plus the
name(s) of the subscriber’s dependents.
§§ Out-of-network chiropractic benefits will increase from
40% to 50% coinsurance.
Visit uc-care.org, select Use Your Benefits and then
2015 Benefits Overview to learn more.
4
UC Care Providers
UC Care is a PPO plan, so you have the flexibility to go to most providers without a referral.
Visit blueshieldca.com/uccareppo to find in-network doctors, facilities, pharmacies or
equipment and supplies. Use Advanced Search to expand or narrow your search.
Know Before You Go
Providers often change networks, so contact your
doctor before your appointment to get up-to-date
information regarding his/her availability and whether
he/she is in-network.
In-network, Blue Shield Preferred
§§ Provides a full range of covered benefits.
§§ Lets you choose from more than 70,000 providers in
Blue Shield of California’s Preferred network.
§§ Offers access to more than 600,000 BlueCard® providers
outside of California—in the U.S. and throughout the world.
§§ Pays a significant share of your costs once you meet your
in-network deductible.
Once you meet your in-network deductible, UC Care pays 80%
and you pay 20% of the cost for covered services. Your 20%
share is called coinsurance.
A Special In-Network Option in California:
UC Select
UC Select is an additional in-network option on top of Blue
Shield Preferred. In general, care received from UC Select
providers will cost you less out-of-pocket. You pay set copays
with no deductible when you get covered care* from UC Select
providers, including:
§§ UC medical centers.
§§ UC doctors.
§§ Select primary care physicians and providers near every
campus—even those without UC medical centers.
UC Select providers are only available in California. If you live
or travel outside of California, you have access to the BlueCard®
network. Any care you receive from the BlueCard® network will
be provided at the Blue Shield Preferred level of coverage.
For more details, visit uc-care.org, choose Find a Provider and
then UC Select.
Out-of-Network
You can also receive care from out-of-network providers that
aren’t contracted with UC Select or Blue Shield Preferred.
Choosing out-of-network providers costs more, and also means
managing more paperwork. If you get care from a non-network
provider, you are responsible for charges above Blue Shield’s
allowed amount, in addition to any coinsurance.
Here’s how coinsurance works with out-of-network benefits:
§§ You must first meet a calendar-year deductible—$500
(individual) or $1,500 (family) before UC Care shares in the
cost of covered services.
§§ In most cases, you have to pay the provider in full at the
time of service, and then submit a claim to Blue Shield.
§§ Once you’ve met your calendar-year deductible, UC Care
pays 50% of the allowed amount for covered services. Blue
Shield will reimburse you 50% for the allowed amount.
§§ You’ll also have to pay any differences between the
provider’s charge and Blue Shield’s allowable amount.
§§ Any amounts in excess of the allowed amounts do not count
toward your out-of-network deductible or out-of-network,
out-of-pocket maximum.
Before getting care from an out-of-network provider, ask how
much your charges will be before the visit. Then refer to the
2015 UC Care Benefit booklet for the amount that you will be
responsible for based on the plan’s benefits.
For more details, visit uc-care.org, choose Find a Provider and
then UC Select.
Provider Balance Billing
If you see an out-of-network provider in an emergency
situation, you still might receive an EOB that shows the amount
you owe (listed as “member responsibility”) is more than the
allowed amount. Contact Shield Concierge if this happens.
It’s important to know that providers may bill you for
more money than the Blue Shield allowed amount—often
substantially more. As a result, the amount you owe may be
considerably more than 50% of the allowed amount when you
use out-of-network services.
* Some services are not available in UC Select—only through Blue Shield Preferred.
5
How UC Care Works
UC Care and Blue Shield of California—the plan and network administrator—have agreed to
pay in-network providers a contracted (or allowed) amount for covered health care services.
When you see in-network providers:
§§ You pay less out-of-pocket.
§§ You have lower deductibles.
§§ The plan pays a larger share of the allowed amount for
covered services.
When you see out-of-network providers:
§§ You pay more out of pocket.
§§ You have higher deductibles.
§§ You pay a larger share of the allowed amount for covered
services, since out-of-network providers may bill you for
more than the allowed amount.
PPO vs. HMO
UC Care is a PPO, or Preferred Provider Organization. That
means UC Care has contracted with a network of “preferred”
providers to care for you and your covered family members.
PPOs such as UC Care let you choose your providers, and you
can go to most without a referral. However, some specialists—
as well as certain treatments and procedures—require a
referral, so it’s important to verify before you go.
UC Care is not an HMO (Health Maintenance Organization).
UC employees have three HMO options: Kaiser, Health Net
Blue & Gold and Western Health Advantage.
LET’S REVIEW SOME OF THE DIFFERENCES BETWEEN UC CARE (A PPO) AND AN HMO
UC Care PPO
HMO
How It Works
With UC Care, you manage your health. You may
need to submit claim forms and the required
paperwork for out-of-network services. You’ll get
an Explanation of Benefits (EOB) after every
covered service you receive, regardless of coverage
or eligibility.
An HMO coordinates your care. You don’t have to
complete paperwork—you pay your copayment at
the time of service, and you won’t receive bills for
covered services.
Providers
You choose your provider, either in- or out-of
network. If you choose an out-of-network provider,
you will pay more for your care.
You must receive your care from in-network HMO
doctors, hospitals and other providers.
Primary Care
Providers
You can select a PCP if you like, but it is not
required. That said, a PCP can help coordinate your
care and provide referrals when you need them.
You must choose a PCP. He/she will direct how you
access and receive care for covered services from
the HMO network of physicians and facilities.
Specialists
You do not need a referral to see a specialist.
However, some specialists may require a referral, so
it’s important to verify before you go.
Your PCP must provide a referral for you to see a
specialist within the HMO network, typically in
your PCP’s same medical group or IPA (independent
practice association).
Laboratory Services
When you go to an in-network provider, you pay a
set copayment or coinsurance for laboratory tests.
If a separate physician reviews the test, you may
receive two separate bills—one for the test and one
for reading of the test.
Your PCP must provide a referral for you to see a
laboratory within the HMO network and you’re
typically not charged for approved services.
Paying for Care
In-Network: You pay set copayments for covered
services if you go to a UC Select provider. If you visit
a Blue Shield preferred provider, you must first meet
a deductible and then pay a share of the cost of
covered services through coinsurance.
Out-of-Network: You must first meet a higher
deductible. Then, you pay a larger share of the cost
of covered services through coinsurance.
In-Network: You pay set copayments for doctors’
visits, lab tests, prescriptions and other covered
services.
Out-of-Network: You cannot go out of the HMO
network without a referral except for emergencies.
If the service isn’t covered, you must pay the entire billed charges. Any payments made for non-covered services will not apply to your
deductible or out-of-network, out-of-pocket maximum.
6
When you enroll in an HMO, you are required to select a
primary care physician (PCP) to coordinate your care. Your
PCP provides all of your basic health care. When you need care
beyond the basics, your PCP must provide a referral to other
HMO network providers. If you see a provider outside the
HMO network, you will pay the full cost of your care.
Referrals
Since UC Care is a PPO, you can get services and see specialists
without a referral. However, some providers may require a
referral before you can schedule and receive treatment.
Also, some specialists and specialty treatment centers (such as
nephrology or infusion) may require a referral from your PCP
or Specialist before you can make an appointment.
Prior Authorizations
For certain services such as outpatient radiology, durable
medical equipment and hospital admissions, prior
authorizations are required. Without an approved prior
authorization, your benefit payments may be reduced or denied.
Certain drugs also require prior authorization. Visit uc-care.org,
select Use Your Benefits and then Prior Authorizations to
learn more.
Services that require prior authorization are listed in the
2015 UC Care Benefit Booklet.
Verify if prior authorization is necessary before scheduling
or obtaining services. For more information, see the 2015
UC Care Benefit Booklet or call Shield Concierge, toll-free, at
1-855-201-2087. Shield Concierge is available Monday through
Friday, from 7:00 a.m. to 7:00 p.m. (Pacific). In general:
Be Prepared
§§ Turnaround time for prior authorizations is five business days.
When scheduling an appointment with a specialist or
specialty treatment center, ask the provider’s office staff
if a referral is required.
§§ Turnaround time for expedited review of qualified prior
authorization requests is 72 hours.
Tiers of Coverage
Understand these tiers so you’ll better understand how to use and get the most from UC Care. For a list of covered services that do not
apply to the medical out-of-pocket maximum, see the 2015 UC Care Benefit Booklet.
Coverage Terms
In-Network: Blue Shield Preferred
Out-of-Network
Calendar Year
Deductible
§§Individual: $250
§§Family: $750
§§Individual: $500
§§Family: $1,500
Coinsurance
Once you meet your in-network deductible:
You pay 20%, UC Care pays 80%
Once you meet your out-of-network deductible:
You pay 50%, UC Care pays 50%
Medical Out-of-pocket
Maximum
§§Individual: $3,000
§§Family: $9,000
§§Individual: $5,000
§§Family: $15,000
Getting Care
Outside of California —
in the U.S.
When you live, work or travel outside of California but in the U.S., you have access to providers—for
emergency and non-emergency care—through the BlueCard® Program.
Covered services received through the BlueCard® Program are paid at the Blue Shield Preferred
in-network level of benefits.
For more information, see the 2015 UC Care Benefit Booklet.
Getting Care
Outside the U.S.
When you live, work or travel abroad, you have access to providers—for emergency and non-emergency
care—through the BlueCard® Worldwide Program.
For more information, see the 2015 UC Care Benefit Booklet.
7
Emergency Care
In the event of an emergency, go to the closest
Emergency Room.
If you are balance billed, call Shield Concierge, toll-free,
at 1-855-201-2087. Shield Concierge is available Monday
through Friday, from 7:00 a.m. to 7:00 p.m. (Pacific).
If you are admitted to the hospital, Blue Shield should
be notified within 24 hours, or as soon as it is reasonably
possible to do so, to avoid you being responsible for
additional costs.
For more information on Emergency Admission Notification
and the emergency service claims review process, refer to
the 2015 UC Care Benefit Booklet.
A Special In-Network Option in California:
UC Select
UC Select is a separate and smaller group of in-network
providers on top of and in addition to the many Blue Shield
Preferred providers available to UC Care members. Here’s
how UC Select works:
Coverage Terms
In-Network: UC Select*
Calendar-Year
Deductibles
None
Copay
§§$20 for physician and specialist
office visits
§§$20 for outpatient X-ray,
pathology and lab
§§$20 for consults through Teladoc
See page 10 for additional copays.
Medical
Out-of-pocket
Maximum*
§§Individual: $1,500
§§Family: $4,500
*Some services are not available in UC Select and are only available
under Blue Shield Preferred. To learn more, see the Benefit Summaries
that begin on page 15.
Again, it is important to note that in-network UC Select and
Blue Shield medical out-of-pocket maximum amounts cross
accumulate. In-network and out-of-network, out-of-pocket
maximum amounts do not cross accumulate.
There is a separate out-of-pocket maximum for prescriptions
that does not cross accumulate with the medical out-of-pocket
maximum amounts.
8
Call Shield Concierge for Help
Shield Concierge is THE place to call for help with:
§§ Initiating prior authorization requests.
§§ Requesting referrals.
§§ Finding providers.
§§ Understanding out-of-pocket costs of care (copays,
coinsurance).
§§ Processing claims.
§§ Any other questions regarding the UC Care plan.
Call Shield Concierge, toll-free, at 1-855-201-2087. Shield
Concierge is available Monday through Friday, from 7:00
a.m. to 7:00 p.m. (Pacific).
Here are two tips when talking with a
Shield Concierge representative:
1. Get the representative’s name.
2.Take notes in case you need to reference
them later.
Getting Care Outside of California
Outside of California—in the U.S.
Travel Tips
When you live, work or travel outside of California but in the
U.S., you have access to providers—for emergency and
non-emergency care—through the BlueCard® Program.
BEFORE YOU GO
§§ Covered services received through the BlueCard® Program
are paid at the in-network level of benefits.
§§ Check your prescription supply. Contact Shield Concierge
at least five business days before you travel so you can
coordinate any refills you may need.
§§ You can locate a BlueCard® provider any time by calling 1-800-810-BLUE (2583) or searching provider.bcbs.com.
Two important notes:
§§ Review the 2015 UC Care Benefit Booklet so you know
what’s covered.
§§ Search bluecardworldwide.com for providers near your
travel destination.
1. The narrow UC Select network of providers is only available
in California. There is no UC Select network outside of the
U.S. You can only receive in-network care at the Blue Shield
Preferred level by using a BlueCard® provider.
§§ Take your Blue Shield member ID card with you.
2.A non-BlueCard® provider is considered an out-of-network
provider, and may require full payment at the time of
service. You will be responsible for submitting the claim to
Blue Shield.
Before you travel, learn more about your UC provided travel
insurance benefits and options by visiting ucop.edu. At the
top, click on Organization and then Risk Services. In the upper
navigation, select Loss Prevention & Control and then Travel
Assistance from the menu on the left hand side of the page.
Outside of the U.S.
When you work or travel abroad, you have access to
providers—for emergency and non-emergency care—through
the BlueCard® Worldwide Program.
§§ You’re not required to use a BlueCard® Worldwide provider,
but your costs will be lower when you do.
§§ You can locate a BlueCard® Worldwide provider by calling the
toll-free BlueCard® Access number at 1-800-810-BLUE (2583)
or call collect at 1-804-673-1177, 24 hours a day, seven days
a week or by searching bluecardworldwide.com.
Two important notes:
§§ Bring the BlueCard® Worldwide Service Center phone
number as well (1-804-673-1177), in case you need
emergency services.
WHILE YOU’RE AWAY
§§ If you are admitted to the hospital, notify the BlueCard®
Worldwide Service Center by calling 1-804-673-1177.
§§ Be prepared to make payment at the time of service. A
non-BlueCard® provider may require full payment, and
you are responsible for submitting the claim to the plan
administrator.
Visit uc-care.org. From the upper navigation, choose Use Your
Benefits then Get Care Outside California. Then, select Outside
the U.S. to learn how to file a claim.
§§ UC Care members are covered under the Blue Shield
Preferred level of benefits, whether you choose to see a
BlueCard® Worldwide provider or not.
§§ A non-BlueCard® Worldwide provider may require full
payment at the time of service, and you are responsible for
submitting the claim to Blue Shield.
9
Medical and Prescription Benefits
UC Care provides coverage for medical and prescription benefits. See pages 15–20 for details.
Medical Plan Benefits
An overview of covered medical plan benefits is provided below. For more information, see page 15–18.
Please see the 2015 UC Care Benefit Booklet for complete plan details, including covered and non-covered services.
UC CARE MEDICAL BENEFITS FOR 2015
UC Select
IN-NETWORK
Blue Shield Preferred
OUT-OF-NETWORK
Calendar-year Deductible1
No deductible
$250 per individual
$750 per family
$500 per individual
$1,500 per family
Medical Out-of-pocket
Maximum2
$1,500 per individual
$4,500 per family
$3,000 per individual
$9,000 per family
$5,000 per individual
$15,000 per family
Physician office visit
$20 copay
20% coinsurance3
after deductible
50% coinsurance4
after deductible
Specialist office visit (includes all
other provider designations)
$20 copay
20% coinsurance3
after deductible
50% coinsurance4
after deductible
No charge
No charge (not subject
to the deductible)
50% coinsurance4
after deductible
Pregnancy and
maternity benefits
$20 copay per visit,
initial visit only
20% coinsurance3
after deductible
50% coinsurance4
after deductible
Outpatient X-ray, pathology
and laboratory
$20 copay per visit
20% coinsurance3
after deductible
50% coinsurance4
after deductible
Outpatient surgery in hospital
$100 copay per surgery
20% coinsurance3
after deductible
50% coinsurance4
after deductible
Inpatient non-emergency
facility services
$250 copay per admission
20% coinsurance3
after deductible
50% coinsurance4
after deductible
ER facility services (not
resulting in an admission)
$200 copay
$200 copay (not subject
to the deductible)
$200 copay (not subject
to the deductible)
Emergency Room Services
(resulting in admission)
$250 copay
$250 copay (not subject
to the deductible)
$250 copay (not subject
to the deductible)
ER Physician Services
No charge
No charge (not subject
to the deductible)
No charge (not subject
to the deductible)
Professional Benefits
Preventive Health Benefits
Hospital Care
Emergency health coverage
1. Calendar-year deductibles are separate for preferred (in-) and non-preferred (out-of-network) and do not cross accumulate.
2. Medical out-of-pocket maximums accumulate between in-network tiers. Covered services provided by UC Select providers will count toward your
Blue Shield Preferred medical out-of-pocket maximum amount. Your out-of-network out-of-pocket maximums do not accumulate between in-network
and out-of-network. For a list of covered services that do not apply to the out-of-pocket maximum, see the 2015 UC Care Benefit Booklet. There is a
separate out-of-pocket maximum for prescriptions. See page 11.
3. UC Care pays up to the allowed amount, the maximum amount on which payment is based for covered health care services. This may be called “eligible
expense,” “payment allowance,” or “negotiated rate.”
4. If your provider charges more than the allowed amount, you may have to pay the difference.
10
Behavioral Health Benefits
FILLING PRESCRIPTIONS AT A RETAIL PHARMACY
UC Care behavioral health benefits are provided through
Optum. You can see in-network and out-of-network providers,
but will pay less and receive higher benefit coverage when you
see an in-network provider. Please note that some services
may require prior authorization.
To learn more about your behavioral health benefits, coverage
and the services that require pre-authorization, call Optum
at 1-888-440-8225 or visit liveandworkwell.com. Instead of
ID cards, Optum offers a printable wallet card that includes
contact information. Find the wallet card at uc-care.org.
Select Use Your Benefits from the upper navigation and then
choose Medical Plan Benefits. You’ll find a link under Behavioral
Health Benefits.
For additional details, visit uc-care.org. In the upper
navigation, select Use Your Benefits and then Medical Benefits.
Pharmacy Benefits
With UC Care you have the flexibility to use any pharmacy,
including:
You can fill your prescriptions—up to a 30-day supply—at a
retail pharmacy. If you are on a maintenance medication for a
chronic condition, you can receive up to a 90-day supply from
participating in-network retail pharmacies or UC pharmacies.
MAIL SERVICE PRESCRIPTIONS
You can receive up to a 90-day supply when you use
PrimeMail, Blue Shield’s mail service pharmacy. As a reminder,
you can also use the mail service pharmacy to fill stabilized
dosages of maintenance medications. For more information
on how PrimeMail works, go to uc-care.org; select Use Your
Benefits from the upper navigation, then Pharmacy Benefits.
Click on the Learn More link under Mail Service Prescriptions.
SPECIALTY MEDICATION PRESCRIPTIONS
You can fill your Specialty Medication prescriptions—up
to a 30-day supply—from participating in-network retail
pharmacies or UC pharmacies with a 30% coinsurance up
to a $150 copayment maximum per prescription.
§§ In-network: Participating retail pharmacies and
UC Pharmacies.
§§ Out-of-network: Non-participating pharmacies. You pay
up front and will be reimbursed by Blue Shield at 50% of
billed charges for covered drugs.
For a list of covered pharmacy benefits, see pages 19–20. To
find UC participating pharmacies, visit uc-care.org, select
Use Your Benefits, then Pharmacy Benefits.
UC CARE PHARMACY BENEFITS FOR 2015
In-Network
Out-of-Network
Calendar-year
Deductible
None
None
Pharmacy
Out-of-pocket
Maximum
$3,600 per individual
$4,200 per family
None
The pharmacy out-of-pocket maximum only applies to
prescription drugs received from in-network pharmacies.
There is no out-of-network pharmacy out-of-pocket maximum.
The pharmacy out-of-pocket maximum is separate from the
medical out-of-pocket maximum.
11
Transitioning to UC Care
These “how-tos” can help you transition to UC Care.
Find a Network Physician
Transfer Your Prescription Medications
With UC Care, you have access to one of the largest PPO
networks in California. Visit blueshieldca.com/uccareppo
to find your current or new physician.
When transitioning to Blue Shield pharmacy benefits, review
the Blue Shield Plus Drug Formulary at uc-care.org. Select
Use Your Benefits from the upper navigation, then choose
Pharmacy Benefits. Check to see if your medication is listed in
the formulary.
Transfer Your Medical Records
If you select a new physician, you’ll need to transfer your
medical records from your previous doctor to your new Blue
Shield doctor. Your previous doctor can give you instructions
on transferring your medical records to your new doctor.
Use Your Member ID Card
Request Continuity of Care &
Transition of Care
You’ll have to present your new UC Care ID card when you
visit your doctor for the first time or have your next
prescription filled.
If you are currently under the care of a provider who’s not in the
Blue Shield PPO network, you can request continuity of care.
When you receive your new ID card, review it carefully. Make
sure all of the information is correct, then replace your old
health plan ID card(s) with the new one.
Continuity of care allows you to continue to see your current
non-network provider during your course of treatment and still
receive network-level benefits.
Examples of conditions that may qualify for continuation of
care include:
§§ An acute condition that has a limited duration.
§§ A serious chronic condition.
§§ Pregnancy, including the immediate postpartum period.
§§ Care for a child, from newborn to 36 months of age.
§§ A surgery or other treatment that was previously
recommended and documented by your doctor to take place
within 180 days of the effective date of coverage.
§§ A terminal illness that has a high probability of causing
death within one year or less.
Download the request for continuity of care form at
uc-care.org. Select Get Help then Forms. Or contact Shield
Concierge, toll-free, at 1-855-201-2087. Shield Concierge
is available Monday through Friday, from 7:00 a.m. to
7:00 p.m. (Pacific).
If you do not meet the qualifications for continuity of care, Blue
Shield will work with your provider to help you transition to an
in-network provider without disrupting your care or services.
12
We encourage you to refill any maintenance medications you
take so that you have a supply on hand before any change in
coverage.
Get Help
Have questions or need to print your ID cards? Log on to
blueshieldca.com.
1.
2.
3.
Manage Your Health
UC Care offers lots of valuable programs to help you manage your health. Find all the details
at uc-care.org and select Manage Your Health from the upper navigation.
MANAGE A CONDITION
UC LIVING WELL
Blue Shield’s condition-management programs can
provide support for asthma, coronary artery disease (CAD),
chronic obstructive pulmonary disease (COPD), diabetes
and heart failure.
UC Care participates in UC Living Well, a systemwide
wellness initiative. The University partners with Optum to
offer innovative programs and services to UC employees and
retirees. Learn more at uclivingwell.ucop.edu.
PRENATAL CARE
WELLNESS DISCOUNTS
Enroll in Blue Shield’s prenatal care program to receive a
variety of tools, tips and resources that guide expectant
parents from the first trimester through postnatal care.
Access Blue Shield member discounts on popular weight-loss,
fitness and health, wellness and vision programs that can help
you get healthy and save money. Start saving at uc-care.org.
Select Manage Your Health from the upper navigation, then
choose Wellness Discounts.
PREVENTION TIPS
Preventive care is all about building healthy habits; Blue
Shield’s prevention guidelines offer recommendations for the
entire family. Learn more at uc-care.org; select Manage Your
Health from the upper navigation, then choose Prevention Tips.
QUIT TOBACCO FOR LIFE
Get an expert Quit Coach® to help you follow a Quitting Plan
customized to your needs and lifestyle. Plus, free nicotine gum,
patches or lozenges may be part of your plan. You’ll also have
one-on-one coaching over the phone and online, whenever you
need it. Get started at uc-care.org; select Manage Your Health
and then choose Quit Tobacco for Life.
NurseHelp 24/7SM If you have a non-emergency medical concern and
aren’t sure what to do, call NurseHelp 24/7SM at 1-877-304-0504, or log on to blueshieldca.com to chat
privately online with a nurse.
Experienced nurses can help you improve self-care,
evaluate treatment options and determine whether to
see a doctor—all at no cost. Get immediate answers and
reliable information on:
§§ Minor illnesses and injuries.
§§ Chronic conditions.
§§ Medical tests and medications.
§§ Preventive care.
13
Explore Our Tools
Through our partnership with Blue Shield, UC Care offers a variety of tools to help you get the
most out of your plan. You’ll find them at uc-care.org; select Explore our Tools. If you’re already
a UC Care member and log in to blueshieldca.com, you’ll have access to even more tools for
you and your family.
REGISTER WITH BLUE SHIELD
SYMPTOM CHECKER
Access online tools to help you manage your plan: Register
at blueshieldca.com.
Use this interactive, educational tool to help you pinpoint
symptoms and find information about their possible cause. MOBILE ACCESS
HEALTH LIBRARY
With Blue Shield’s mobile website, you have quick
and easy access to tools and resources on the go. Just
enter blueshieldca.com into your mobile device’s Internet
browser to: see copays for common services, download your
member ID card, get directions to the closest urgent
care center or emergency room, search for a provider, view
final claims and more.
This comprehensive health library can help you:
§§ Research a specific health topic or condition.
§§ Learn about complementary treatments.
§§ Understand how the body works.
§§ Find information, tools and other materials provided
by Healthwise.
GLOSSARY TERMS
Find definitions for key health care terms at uc-care.org.
From the upper navigation, select Explore Our Tools, then
Glossary Terms.
14
University of California – UC Care
THIS MATRIX IS INTENDED TO BE USED TO HELP
YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE PLAN CONTRACT SHOULD
BE CONSULTED FOR A DETAILED DESCRIPTION
OF COVERAGE BENEFITS AND LIMITATIONS.
Blue Shield of California
Note: A description of the prescription drug coverage is provided separately
Effective: January 1, 2015
Calendar Year Medical Deductible
(Deductible amounts do not cross accumulate)
Calendar Year Out-of-Pocket Maximum
2
(UC Select and Blue Shield Preferred Out-of-Pocket Maximum amounts cross
accumulate. UC Select/Blue Shield Preferred and Non-Preferred Out-ofPocket Maximums do not cross accumulate)
LIFETIME BENEFIT MAXIMUM
Covered Services
Blue Shield
1
Preferred
Non-Preferred
1
Providers
None
$250 per individual/
$750 per family
$500 per individual/
$1,500 per family
$1,500 per individual/
$4,500 per family
$3,000 per individual/
$9,000 per family
$5,000 per individual/
$15,000 per family
None
None
Blue Shield
1
Preferred
Non-Preferred
1
Providers
$20 per visit
20%
50%
$20 per visit
20%
50%
None
UC Select
PROFESSIONAL SERVICES
Professional (Physician) Benefits
•
Physician office visits (Includes Internist, Family Practice, OB/GYN,
Pediatrician, General Practice)
•
UC Select
Specialist office visits (Includes all other provider designations)
Member Copayment
The member copayment is $20 per consult, not subject to deductible and accrues to the UC
Select Out-of-Pocket Maximum
•
Teladoc Program (provides access to U.S. board-certified doctors
•
CT scans, MRIs, MRAs, PET scans, and cardiac
3
diagnostic procedures utilizing nuclear medicine
$20 per visit
20%
50%
Other outpatient X-ray, pathology and laboratory
$20 per visit
20%
50%
$20 per visit
20%
20%
20%
50%
50%
No Charge
50%
N/A
20%
50%
5
$100 per surgery
20%
50%
5
•
24/7/365 via phone or online video consults for urgent, non-emergency
medical assistance, including prescriptions, when you are unable to see
your primary care physician. This service is available by calling 1-800Teladoc (835-2362).)
(prior authorization is required)
(Diagnostic testing by providers other than outpatient laboratory,
3
pathology, and imaging departments of hospitals/facilities)
Allergy Testing and Treatment Benefits
•
Office visits (includes visits for allergy serum and injections)
•
Allergy serum purchased separately for treatment (allergy serum
not administered during an office visit)
Preventive Health Benefits
•
Preventive Health Services (As required by applicable federal
law.)
No Charge
OUTPATIENT SERVICES
Hospital Benefits (Facility Services)
•
Outpatient surgery performed at an Ambulatory Surgery
3, 4
Center
(services covered under Blue
Shield Preferred)
(Not subject to the Calendar
Year-Deductible)
•
Outpatient surgery in a hospital
•
Outpatient Services for treatment of illness or injury and
necessary supplies (Except as described under "Rehabilitation
$20 per visit
20%
50%
5
CT scans, MRIs, MRAs, PET scans, and cardiac
diagnostic procedures utilizing nuclear medicine
3
performed in a hospital (prior authorization is required)
$20 per visit
20%
50%
5
Other outpatient X-ray, pathology and laboratory
3
performed in a hospital
Bariatric Surgery (prior authorization required by the Plan; medically
$20 per visit
20%
50%
5
$100 per surgery
20%
50%
5
•
•
•
benefits" and "Speech therapy benefits")
6
necessary surgery for weight loss, for morbid obesity only)
15
HOSPITALIZATION SERVICES
Hospital Benefits (Facility Services)
•
Inpatient Physician Services
•
•
Inpatient Non-emergency Facility Services (semi-private
room and board, medically necessary services and supplies)
Bariatric Surgery (prior authorization required by the Plan; medically
6
necessary surgery for weight loss, for morbid obesity only)
Skilled Nursing Facility Benefits
No Charge
20%
50%
$250 per admission
20%
50%
7
$250 per admission
20%
50%
7
5
(Combined maximum of up to 100 prior authorized days per calendar year; semi-private accommodations)
•
Services by a free-standing Skilled Nursing Facility
•
Skilled Nursing Unit of a Hospital
N/A
20%
50%
$250 per admission
20%
50%
(services covered under
Blue Shield Preferred)
7
7
EMERGENCY HEALTH COVERAGE
•
•
•
Emergency Room Services not resulting in admission (ER
facility copay does not apply if the member is directly admitted to the
hospital for inpatient services)
Emergency Room Services resulting in admission (When
the member is admitted directly from the ER)
Emergency Room Physician Services
$200 per visit
$250 per admission
No Charge
Urgent Care Benefits
•
Urgent Care Services (For urgent care services performed at a
center affiliated with a licensed hospital please refer to the Emergency
Room services.)
$200 per visit
$200 per visit
(Not subject to the Calendar
Year-Deductible)
(Not subject to the
Calendar Year-Deductible)
(Not subject to the Calendar
Year-Deductible)
(Not subject to the
Calendar Year-Deductible)
$250 per admission
No Charge
$250 per admission
No Charge
(Not subject to the Calendar
Year-Deductible)
(Not subject to the
Calendar Year-Deductible)
$20 per visit
20%
50%
N/A
$200 per trip
$200 per trip
AMBULANCE SERVICES
•
Emergency or authorized transport
(services covered under
Blue Shield Preferred)
PRESCRIPTION DRUG COVERAGE
Outpatient Prescription Drug Benefits
A description of your outpatient prescription drug coverage is provided separately. If you
do not have the separate drug summary that goes with this benefit summary, please
contact your benefits administrator or call Customer Service.
PROSTHETICS/ORTHOTICS
•
Prosthetic equipment and devices (If billed by your provider,
•
Orthotic equipment and devices (If billed by your provider, you
will also be responsible for the office visit copayment)
you will also be responsible for the office visit copayment)
N/A
20%
50%
N/A
20%
50%
N/A
20%
50%
No Charge
Not Covered
(services covered under
Blue Shield Preferred)
(services covered under
Blue Shield Preferred)
DURABLE MEDICAL EQUIPMENT
16
•
Durable Medical Equipment
•
Breast Pump
(services covered under
Blue Shield Preferred)
N/A
(services covered under
Blue Shield Preferred)
(Not subject to the Calendar
Year-Deductible)
MENTAL HEALTH SERVICES AND SUBSTANCE ABUSE
9
SERVICES
•
Inpatient Hospital Services
•
Residential Care
Inpatient Physician Services
•
Routine Outpatient Mental and Substance Abuse
•
Services (includes professional/physician visits)
Non-Routine Outpatient Mental Health and Substance
•
Abuse Services (includes behavioral health treatment,
Carved out to Optum
electroconvulsive therapy, intensive outpatient programs, office-based
opioid treatment, partial hospitalization programs, and transcranial
magnetic stimulation. For partial hospitalization programs, a higher
copayment and facility charges may apply per episode of care)
10
HOME HEALTH SERVICES
•
Home Health Care Agency Services
11
(up to 100 prior
authorized visits per Calendar Year)
Home infusion/home intravenous injectable therapy and
infusion nursing visits provided by a Home Infusion
Agency
OTHER
•
Hospice Program Benefits
•
Routine Home care
Inpatient Respite Care
•
24-hour Continuous Home Care
•
General Inpatient care
11
Chiropractic Benefits
Chiropractic Services (Up to 24 visits per calendar year combined
with acupuncture visits)
Acupuncture Benefits
•
11
Acupuncture Services
(Up to 24 visits per calendar year combined with chiropractic services)
Pregnancy and Maternity Care Benefits
•
Prenatal and Postnatal Physician office visits
(For inpatient hospital services, see "Hospitalization Services."
Abortion Services
Family Planning
12
•
Counseling
•
•
20%
50%
10
N/A
20%
50%
10
N/A
20%
50%
10
N/A
20%
50%
N/A
20%
50%
N/A
20%
50%
N/A
20%
50%
N/A
20%
20%
(services covered under
Blue Shield Preferred)
10
•
•
N/A
(services covered under
Blue Shield Preferred)
13
Tubal ligation
(services covered under
Blue Shield Preferred)
(services covered under
Blue Shield Preferred)
(services covered under
Blue Shield Preferred)
(services covered under
Blue Shield Preferred)
(services covered under
Blue Shield Preferred)
(services covered under
Blue Shield Preferred)
$20
initial visit only
20%
No Charge
Diabetes Care Benefits
•
Devices, equipment, and non-testing supplies (For testing
•
supplies, please see "Outpatient Prescription Drug Coverage Summary.")
Diabetes self-management training (If billed by your provider,
you will also be responsible for the office visit copayment)
20%
7,10
50%
14
50%
50%
No Charge
50%
20%
20%
50%
50%
20%
50%
$20 per visit
20%
50%
20%
20%
50%
$20 per visit
20%
50%
No Charge
8
Speech Therapy Benefits
•
Outpatient visits ( Office or outpatient facility location)
14
10
No Charge
Vasectomy
20%
15
20%
•
Infertility
Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy)
•
Outpatient visits (Office or outpatient facility location)
$20 per visit
•
20%
7,10
(Not subject to the Calendar
Year-Deductible)
(Not subject to the Calendar
Year-Deductible)
17
Care Outside of Plan Service Area
Within US: BlueCard Program
•
Outside of US: BlueCard Worldwide
1
Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. Preferred providers agree to accept Blue Shield's allowable amount
plus the plan’s and any applicable member’s payment as full payment for covered services. Non-Preferred providers can charge more than these amounts. When
members use non-Preferred providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable
amount. Charges above the allowable amount do not count toward the calendar-year deductible or out-of-pocket maximum.
Preferred deductible does apply toward the Preferred out-of-pocket maximum. The Non-Preferred deductible applies to the non-preferred out-of-pocket maximum.
Please refer to the Plan Contract for exact terms and conditions of coverage.
Preferred non Hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities centers may not be available in all areas. Regardless of their
availability, you can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment
according to your health plan's hospital services benefits.
Preferred ambulatory surgery facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a
hospital or an ambulatory surgery center affiliated with a hospital with payment according to your health plan's hospital services benefits. Ambulatory surgery services
may be obtained at participating UC Medical Center facilities. Members obtaining services at a UC ambulatory surgery center are responsible for a $100/visit copay.
The maximum allowed charges for non-emergency surgery and services performed in a non-Preferred Ambulatory Surgery Center or outpatient unit of a non-Preferred
hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350.
Bariatric surgery is covered when pre-authorized by the Plan. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San
Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric
surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other Preferred provider and there is no coverage for
bariatric services from non-Preferred providers. In addition, if prior authorized by the Plan, a member in a Designated County who is required to travel more than 50
miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the
Plan Contract for further benefit details.
The maximum allowed charges for non-emergency hospital services received from a non-Preferred hospital is $600 per day. Members are responsible for 50% of this
$600 per day, plus all charges in excess of $600 per day.
If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply.
Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification
are accessed through Blue Shield using Blue Shield's Preferred providers or non-Preferred providers.
When these services are pre-authorized, the member pays the Preferred Provider copayment.
For plans with a calendar-year medical deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether
the plan medical deductible has been met.
Includes insertion of IUD, as well as injectable and implantable contraceptives for women.
Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment
may apply.
For pregnancy and maternity services at the Preferred and Non-Preferred level, payment noted is for the global pregnancy bill.
Covered for studies and tests of the cause of infertility. Excludes treatment of the cause of infertility, in-vitro fertilization, injectables for infertility, artificial insemination,
GIFT and ZIFT.
2
3
4
5
6
7
8
9
10
11
12
13
14
15
All covered services provided through BlueCard Program, for out-ofstate emergency and non-emergency care, are provided at the
Preferred level of the local Blue Plan allowable amount when you use
a Blue Cross/BlueShield provider.
All covered services for emergency and non-emergency care will be
eligible for reimbursement when received outside of the US. Please
refer to the Blue Shield Preferred Tier for covered services and
corresponding member liability.
Plan designs may be modified to ensure compliance with federal requirements.
ASO RO 101314
18
®
•
THIS MATRIX IS INTENDED TO BE USED TO HELP
YOU COMPARE COVERAGE BENEFITS AND IS A
SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE
CONSULTED FOR A DETAILED DESCRIPTION OF
COVERAGE BENEFITS AND LIMITATIONS.
University of California- UC Care
Outpatient Prescription Drug Coverage
Blue Shield of California
Effective: January 1, 2015
Covered Services
Member Copayment
UC Pharmacy &
Participating Pharmacies
NonParticipating Pharmacies
Calendar Year Drug Deductible (Prescription drug coverage benefits are not
None
None
Calendar Year Drug Out-of-Pocket Maximum (Prescription drug coverage
$3,600 individual/
$4,200 family
None
UC Pharmacy &
Participating Pharmacies
Non-Participating
Pharmacies
subject to the medical plan deductible)
benefits are not subject to the medical plan Out-of-Pocket Maximum)
1
PRESCRIPTION DRUG COVERAGE
(Billed charges)
Retail Prescriptions (up to a 30-day supply)
2
•
Contraceptive Drugs and Devices
•
Formulary Generic Drugs
•
Formulary Brand Name Drugs
$0 per prescription
$0 per prescription
$5 per prescription
50% per prescription
$25 per prescription
50% per prescription
$40 per prescription
50% per prescription
$0 per prescription
$10 per prescription
$50 per prescription
$80 per prescription
Not Covered
Not Covered
Not Covered
Not Covered
Mail Service Program (up to a 90-day supply only through the Blue Shield mail service program)
2
•
Contraceptive Drugs and Devices
$0 per prescription
Not Covered
•
3, 4
Non-Formulary Brand Name Drugs
3, 4
UC Maintenance Drug Program (up to a 90 day supply available at select,
specified retail pharmacy or UC Walk-Up pharmacy)
•
•
•
•
2
Contraceptive Drugs and Devices
Formulary Generic Drugs
3, 4
Formulary Brand Name Drugs
3,4
Non-Formulary Brand Name Drugs
•
Formulary Generic Drugs
•
Formulary Brand Name Drugs
•
3, 4
Non-Formulary Brand Name Drugs
3, 4
Specialty Pharmacies and Select UC Pharmacies (up to a 30-day supply)
•
Specialty Drugs
Not Covered
$50 per prescription
Not Covered
$80 per prescription
Not Covered
30%
Not Covered
No Charge
Not Covered
No Charge
Not Covered
5,8
6
(Up to $150 copayment maximum
per prescription)
Smoking Cessation
•
Over-the-counter Drugs (requires prescription)
•
$10 per prescription
Prescription Drugs
7
Diabetic Supplies (excluding syringes, needles, insulin and non-formulary test strips)
No Charge
No Charge
19
1 Amounts paid through the outpatient prescription drug benefit copayments do not accrue to the member's medical calendar-year out-of-pocket maximum. Please refer to the Plan
Contract for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductible credit, if applicable, from the previous plan during
the calendar year will not carry forward to your new plan.
2 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will not be subject to the calendar-year deductible. If a brand-name contraceptive is requested
when a generic equivalent is available, the member will be responsible for paying the difference between the cost to Blue Shield for the brand-name contraceptive and its generic drug
equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment.
3 Select formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, or when effective, lower cost alternatives are available.
4 If the member or physician requests a brand-name drug when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield
for the brand-name Drug and its generic drug equivalent, as well as the applicable generic drug Copayment. This difference in cost that the member must pay is not applied to their
calendar-year deductible and is not included in the calendar-year out-of-pocket maximum responsibility calculations.
5 Specialty Drugs are specific Drugs used to treat complex or chronic conditions which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers,
and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered
in the home by injection by the patient or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special
manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy &
Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy and may require prior authorization for Medical Necessity by Blue Shield. Infused or Intravenous (IV)
medications are not included as Specialty Drugs.
6 Specialty drugs are covered only when dispensed by select pharmacies in the Specialty Pharmacy Network and certain UC Pharmacies unless Medically Necessary for a covered
emergency.
7 Syringes, needles and insulin are covered at the applicable brand name copayment and non-formulary test strips are covered at the applicable non-formulary copayment..
8 Specialty Drugs are limited to a quantity not to exceed a 30-day supply; however initial prescriptions for select Specialty Drugs may be limited to a quantity not to exceed a 15-day supply.
In such circumstances the applicable specialty drug will be pro-rated based upon the number of days supply.
Important Prescription Drug Information
You can find details about your drug coverage three ways:
1. Check your Plan Contract.
2. Go to blueshieldca.com and log onto My Health Plan from the home page.
3. Call Member Services at the number listed on your Blue Shield member ID card.
At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online to
the Pharmacy section of blueshieldca.com and select the Drug Database and Formulary to access a variety of useful drug information
that can affect your out-of-pocket expenses, such as:
•
Look up non-formulary drugs with formulary or generic equivalents;
•
Look up drugs that require step therapy or prior authorization;
•
Find specifics about your prescription copayments;
•
Find local network pharmacies to fill your prescriptions.
TIPS!
Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenance
drug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail service
pharmacy with a reduced copayment. Call the mail service pharmacy at (866) 346-7200. Members using TTY equipment can call
TTY/TDD 866-346-7197.
Plan designs may be modified to ensure compliance with federal requirements.
ASO (1/15) RO 092314
20
Get Help
Get help from a variety of resources
uc-care.org. Simply select Get Help
to learn more.
UC Care
University
Shield Concierge
Call Shield Concierge, toll-free, at 1-855-201-2087. Shield
Concierge is available Monday through Friday, from 7:00 a.m.
to 7:00 p.m. (Pacific).
Blueshieldca.com
Welcome to UC Care University!
We’ve developed a “curriculum” to help you use
UC Care so you can get the most value from the plan.
Log in to blueshieldca.com to find a provider, manage your
claims, use the treatment cost estimator and more.
We start with the basics—we’re calling it UC Care
101—to help you become a better health plan
consumer with information about:
Health Care Facilitators
§§ PPO vs. HMO
You can contact your local Health Care Facilitator to get
help with:
§§ Key Terms
§§ Paying for Care
§§ Understanding your coverage and patient rights.
§§ Things to Know
§§ Defining your health care issues.
§§ How to Be a Better Health Care Consumer
§§ Navigating the health care system.
§§ Resolving issues with your doctor, medical group or medical
plan carrier.
Start your health care education at uc-care.org.
UC Care University is in the middle of the page.
§§ Understanding how Medicare benefits coordinate with
UC-sponsored medical plans.
Visit uc-care.org and select Get Help. You’ll find Health Care
Facilitators information, including a downloadable brochure, in
the middle of the page.
2015 UC Care Plan Booklet
Visit uc-care.org to view your 2015 UC Care Plan Booklet for
complete plan information.
Learn More
With uc-care.org, you have 24/7 access to detailed plan
information, decision tools and a variety of resources—
bookmark the site to stay connected.
21
uccare-oebklt-14