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Medical Plan ComparisonLaura MorganUCSB Human Resources, Benefits
This presentation is intended for communication purposes only. Please see plan document and http://atyourservice.ucop.edu for complete information.
Big changes New choices
11/2013
Updated 11/22/13
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Topics
• Open Enrollment Overview• Medical Plan Design 101• Medical Plan Comparisons
◊ Residence requirements◊ Choice of physician◊ Cost of care & prescription drugs◊ Out of Pocket Maximum◊ Health Savings Account◊ Behavioral Health
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Open Enrollment
• Ends Tuesday, November 26, 5:00 pm
• Make changes online - sign in to account http://atyourservice.ucop.edu
• All changes are effective January 1, 2014
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Actions
• Change medical and/or dental plan• Enroll in medical, dental, vision• Add eligible family members• Enroll or re-enroll in Health Flexible
Spending Account (FSA) ◊ unless you select the Blue Shield Health
Saving Plan)
• Enroll or re-enroll in Dependent Care FSA
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Review Options for 2014atyourservice.ucop.edu/
oeBooklet
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Medical Plan Chooser
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2014 Medical Plans
2013 2014
Anthem PPO UC Care PPO(administered by Blue Shield)Anthem PLUS
Anthem HRA-PPOBlue Shield
Health Savings Plan (PPO)
Health Net Blue & Gold HMO Health Net Blue & Gold
HMOHealth Net HMO
Kaiser HMO Kaiser HMO
Core Core
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Default Medical Plans2013 Medical Plan 2014 Medical Plan
Health Net Blue & Gold
HMO
Health Net Blue & Gold HMO
Health Net HMO (full) Health Net Blue & Gold HMO
Kaiser HMO Kaiser HMO
Anthem PLUS UC Care
Anthem PPO UC Care
Anthem Lumenos HRA Blue Shield Health Savings
Plan
Anthem Core Blue Shield Core
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What is your priority?
• Cost to enroll – monthly premium
• Cost of care ◊ Predictable, low cost copays◊ Pay a % of each service
• Choice of providers◊ HMO medical group physicians◊ PPO preferred network or any provider
• Effort to manage – coordinating care &
bills
Medical Plan Design 101
HMOPPOPOS
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HMO – Health Maintenance Organization
• Insurance plan delegates your care to a “medical group” (e.g. Sansum, SB Select IPA)
• Care is coordinated by a Primary Care Physician (PCP) and medical group
• Member selects PCP, PCP refers to specialists
• Predictable, low cost, copay for services - no deductibles
• Emergency and urgently needed care when away
Health Net Blue & Gold HMOKaiser HMO
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HMO Network and Access to Care
Primary Care PhysiciansSpecialistsLabsRadiologyDurable Medical EquipUrgent CareHospitals
When you need care go to your PCP
PCP refers you to specialist, x-ray, lab,
hospital
HMO Medical Group
Medical Group authorizes referrals to some specialists and
treatment
Access to Care
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PPO – Preferred Provider Organization
• You direct your own care, you decide where to receive services
• You pay annual deductibles before plan pays• After deductible, you share the cost of each
service with the plan - coinsurance• Your costs are lower if you select preferred
providers• “Out-of-pocket Maximum” limits your
financial liability
UC Care Blue Shield Health Savings Plan
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Deductible, Coinsurance, OOPM
JanuaryCalendar Year
December
Deductible
You pay
CoinsuranceCopay
You share cost with plan
Out-of-Pocket
Maximum
Plan pays 100%
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Allowed Amount – In Network
In-Network Example
Discounted rate that plan negotiates for each service with “preferred” or participating providers
• You pay the in-network coinsurance on the discounted rate.
• Provider can’t “balance bill”
20% Coinsurance
Provider charge: $200Allowed amount: $100
Plan pays 80%: $80
You pay 20% $20
Provider write-off:$100
PPO plans negotiate “allowed” rates to process claims.
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Allowed Amount – Out of Network
Out-of-Network Example
Value that plan assigns to a service when provider is NOT a “preferred provider” (not participating)
• Plan pays out-of-network coinsurance on the allowed amount.
• Provider can “balance bill”
50% Coinsurance
Provider charge: $200Allowed amount: $100
Plan pays 50%: $50(50% of $100)
You pay 50%: $50
You pay balance: $100
PPO plans assign “allowed” rates to process claims.
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PPO Claims, EOBs & Bills
You receive servicesYou pay nothing at the time of service for in-network care
Provider sends claim for services to health plan
Health plan sends EOBExplanation of Benefits (EOB) outlines allowed charges, deductible and co-insurance. “This is not a bill”.
Provider sends billThe bill should match the EOB. It should reflect the in-network discount and any payments received from health plan.
You pay provider
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PPO Resources
Fair Health Consumer• http://www.fairhealthconsumer.org/
Health Care Blue Book• https://www.healthcarebluebook.com/
Good Rx – drug costs• http://www.goodrx.com
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POS - Point of Service
• Combines HMO and PPO plan designs• Limit costs by using HMO providers• Can use providers outside HMO
group, but cost for service will be higher
Anthem PLUS in 2013 - discontinued
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Anthem PLUS Dilemma – PPO or HMO
PPO• Use physicians out
of the HMO medical group
• Use out-of-network behavioral health
• Deductible & Coinsurance
HMO• Use PCP and
specialists in the HMO medical group
• Use Optum behavioral health
• Predictable copays
How do you use your plan?
2014 Medical Plans
Health Net Blue & Gold HMOKaiser HMO
UC CareBlue Shield Health Savings Plan
Core
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UC Care PPO
UC Select Providers
• Customized for UC Care• UC Health System + Select Blue Shield providers
Blue Shield Preferred Providers
• Similar to the standard in network cost-share of the previous Anthem PPO plan
Non-Preferred Providers
• Flexibility to use services from any provider outside the UC Select or Blue Shield Preferred network
Blue Shield of California – claims administrator & network
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Blue Shield Health Savings Plan
Blue Shield PPO +
High deductible medical plan paired with a Health Savings Account
Health Savings Account
• The Health Savings Account is not a component of the medical plan as HRA is with Lumenos.
• It is a separate account that can be used to pay medical and other health expenses.
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Preventive Care
• All medical plans cover preventive care at 100% with in-network providers
• Preventive care includes:◊ Annual well visit and labs◊ Well woman visits and labs◊ Preventive screening tests◊ Immunizations
• See list of preventive services on the plan websites
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Residence LimitationsHMO (Health Net, Kaiser)
• Employee must live in California
• PCP must be within 30 miles of where you live or work (in most cases)
Blue Shield Health Savings• Employee must live in US
• Employee may live anywhere
• Worldwide services
CORE
UC Care
• Employee may live anywhere
• Worldwide services
• Employee may live anywhere
• Worldwide services
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When traveling out of USHMO (Health Net, Kaiser)
• Limited to emergency and urgent care only
• No routine care when away from medical group
Blue Shield Health Savings• Limited to emergency and urgent care only
• No routine care
• Comprehensive coverage
• Plan pays Preferred benefit.
CORE
UC Care
• Comprehensive coverage
• Plan pays out-of-network benefit.
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Choice of PhysicianHMO (Health Net,
Kaiser)• You select PCP• PCP coordinates care• PCP refers to specialists• Specialists limited to
physicians in medical group
Blue Shield Health SavingIn-Network
• You select Blue Shield PPO
Out-of-Network• You select non-Blue
Shield
In-Network – You select• UC Select• Blue Shield Preferred
PPOOut-of-Network• You select non-Blue
ShieldCORE
UC Care
In-Network • You select Blue Shield
PPOOut-of-Network• You select non-Blue
Shield
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UC Care: In-Network Providers
• UC Select ◊ All UC medical centers, facilities and
physicians◊ Additional select Blue Shield PPO providers
in areas where UC medical centers and physicians are not accessible
• Blue Shield Preferred PPO in California◊ 97% of Anthem PPO are also Blue Shield
Preferred• Blue Shield outside of CA and US
◊ Blue Cross Blue Shield Network out of CA◊ BlueCard Network out of US
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UC Care: UC Select near UCSB
• UC Select providers in◊ Santa Barbara – Sansum Clinic◊ Santa Maria◊ Lompoc◊ Ventura
• Currently, Sansum Clinic is the only UC Select provider in Santa Barbara area◊ High cost hospital and medical groups◊ Still negotiating
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UC Care: Blue Shield Preferred
• Most Anthem Plus and PPO providers are also in the UC Care “Blue Shield Preferred” network
• Cottage Hospital and Sansum Clinic are Blue Shield Preferred providers
UC Care Provider directory blueshieldca.com/uccareppo
Search tool defaults to UC Select network“Change selection” to find Blue Shield Preferred
UC Care http://uc-care.org/ Blue Shield Concierge 1-855-201-2067
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Office Visit Cost
Medical Plan Copay
Deductible Coinsurance
HMO $20 None None
UC Care PPOUC Select $20 None None
Preferred $250 indiv $750 family
You pay 20%
Out-of-Network
$500 indiv$1,500 family
Plan pays 50% of allowed rate
You pay balance
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UC Care Costs
UC Select(Tier 1)
Copay
Blue ShieldPreferred
(Tier 2)
Deductible
Coinsurance
Non-PreferredOut-of-Network
(Tier 3)
Deductible
Coinsurance
• Your costs are based on the tier/network that the provider is in
• Not all services are covered at the UC Select benefit tier
• Some services are covered only at the Blue Shield Preferred and Non-Preferred tiers
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Deductible, Coinsurance, OOPM
You pay You share cost with plan
Plan pays100%
$250Deductibl
e20% Coinsurance $3000
OOPM
UC CareIndividual Coverage
Blue Shield Preferred (Tier 2)
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Deductible: Individual vs Family
$250 Individual / $750 Family
Coinsurance
Adult 1 Paid $250 20%Adult 2 Paid $100
Child 1 Paid $ 75
Child 2 Paid $250 20%
Adult 2 Paid $175 20%
20%
UC Care ExampleFamily Deductible
Blue Shield Preferred (Tier 2)
Office Visit Costs
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Blue Shield HSP
Preferred$1,250 single$2,500 family
You pay 20%
Out-of-Network
$2,500 single$5,000 family
Plan pays 60% of allowed rate
Full family deductible must be met before plan shares cost
COREPreferred
$3000 per individual
You pay 20%
Out-of-Network
Plan pays 80% of allowed rate
Medical Plan Copay
Deductible Coinsurance
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Deductible, Coinsurance, OOPM
You pay You share cost with plan
Plan pays100%
$1250Deductibl
e20% Coinsurance $4000
OOPM
Blue Shield Health Savings Plan Individual (Single)
Preferred Providers
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Deductible, Coinsurance, OOPM
You pay You share cost with plan
Plan pays100%
$2500Deductibl
e20% Coinsurance $6400
OOPM
Blue Shield Health Savings Plan Family
Preferred Providers
The full family deductible must be met before plan shares costs
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Hospitalization Costs
Medical Plan Copay
Deductible Coinsurance
HMO $250 None None
UC Care PPOUC Select $250 None None
Preferred $250 indiv $750 family
You pay 20%
Out-of-Network
$500 indiv$1,500 family
Plan pays 50% of allowed rate
You pay balance
Hospitalization Costs
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Blue Shield HSP
Preferred$1,250 single$2,500 family
You pay 20%
Out-of-Network
$2,500 single$5,000 family
Plan pays 60% of allowed rate
Full family deductible must be met before plan shares cost
COREPreferred
$3000 per individual
You pay 20%
Out-of-Network
Plan pays 80% of allowed rate
Medical Plan Copay
Deductible Coinsurance
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Emergency Room Costs
Medical Plan Copay
Deductible Coinsurance
HMO $75 None None
UC Care PPOUC Select $100 None You pay 20%
of ER physician
Preferred $100 Waived You pay 20% of ER physician
Out-of-Network
$100 Waived You pay 20% of ER physician
Emergency Room Costs
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Blue Shield HSP
Preferred$1,250 single$2,500 family
You pay 20%
Out-of-Network
$2,500 single$5,000 family
You pay 20%
Full family deductible must be met before plan shares cost
COREPreferred
Waived for facility fee
You pay 20%
Out-of-Network
You pay 20%
Medical Plan Copay
Deductible Coinsurance
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Out-of-Pocket Maximum
Medical Plan OOPM Notes
Health Net HMO $1,000 indiv$3,000 family
Family = 3 or more
Kaiser HMO $1,500 indiv$3,000 family
Family = 2 or more
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Out-of-Pocket Maximum
Medical Plan OOPM Notes
UC Care PPOUC Select $1,500 indiv
$4,500 family
Family = 3 or more
In-Network providerscross accumulate
Preferred $3,000 indiv
$9,000 family
Out of Network
$5,000 indiv
$15,000 family
Family = 3 or more
Out-of-network accumulates separately
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Out-of-Pocket Maximum
Medical Plan OOPM Notes
Blue Shield HSP
Preferred $4,000 indiv (single) $6,400 family
Full family OOPM must be met before plan pays 100% for
any enrollee
In & Out-of-network accumulate separately
Medical & Drug expenses apply
Non-Preferred(Out-of-Network)
$8,000 indiv (single)$16,000 family
CORE $6,350 indiv$12,700 family
Family = 2 or more
Medical & Drug expenses apply
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Prescription Drugs
HMOUC Care
Blue Shield HSP CORE
Retail (30 day)• Generic• Brand• Non-formulary
$5$25$40
You pay full cost of medication until you satisfy the deductible
After deductible, you pay 20% at preferred pharmacies
Mail Order (90 day) • Generic• Brand• Non-formulary
$10$50$80
Preferred Drug List (Formulary) is different for each carrier
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Blue Shield Health Savings Plan
Blue Shield PPO +
High deductible medical plan paired with a Health Savings Account
Health Savings Account
• The Health Savings Account is not a component of the medical plan as HRA is with Lumenos.
• It is a separate account that can be used to pay medical and other health expenses.
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Lumenos vs Blue Shield HSP
Deductible Health
Reimbursement Account (HRA)
Member pays
PPO Coinsurance
Lumenos Blue Shield PPO
Deductible Member pays
PPO Coinsurance
UC Contributions
Member Contributions
Lumenos HRA Rollover
Health Savings Account
Lumenos HRA Rollover• Remaining Lumenos HRA money will roll-over
into the Health Savings Account (4/1/14)• Lumenos HRA $ are treated differently than
HSA $ by IRS• Lumenos HRA $ becomes a “Post Deductible
Health Reimbursement Account” = PDHRA• You must pay the Blue Shield HSP deductible
with other funds BEFORE you can use the PDHRA to pay eligible expenses.
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Example: Lumenos PDHRA
• Single Deductible $1,250• UC Contribution to HSA $500• Remaining balance $750
◊ Pay with personal fundsorPay with your contributions to HSA
• Lumenos PDHRA can be used to pay 20% coinsurance after deductible is satisfied
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Why is HSA better?
• You keep the money even if you change jobs or insurance plans
• You can make contributions at any time
• It has triple tax advantage • No Federal taxes on contributions • No taxes when funds are used• No taxes on earnings
• HSA funds rollover from year to year; no use it or lose it as with Health FSA
Employees can maximize savings
• UC Contribution (1/1/14) ◊ $500 individual ◊ $1000 family
• You can contribute up to (optional):
◊ Single-coverage: $2,800◊ Family-coverage: $5,550◊ Catch-up contribution, age 55+:
$1,000
Tip: Contribute the money you would have put in your Health FSA.
Who is eligible for HSA?
To own an HSA you need to:
• Be covered ONLY by an HSA-qualified health plan◊ Other health coverage may disqualify you,
including Health FSA, Medicare or traditional health plan
◊ Health FSA must have a $0 balance on Dec. 31, 2013 (complete any claims reimbursement by Dec. 31, 2013)
• Not be claimed as a dependent on someone else’s tax return
How does HSA work?
• UC makes annual contribution for plans that start on January 1.
• You may contribute through payroll deduction or make post-tax contributions to HealthEquity
• Use a HSA debit card to pay for health expenses
• Use HealthEquity website to pay medical and other health claims
• Invest HSA dollars when account balance reaches $2000 – no fees to invest
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HSA vs FSA
• The HSA is NOT like the Health FSA where you have access to the entire annual contribution starting on January 1
• The HSA is like a checking account – the money must be in the account before you can spend it
◊ You make monthly contributions through payroll deduction, you can change the contribution amount during the year
◊ You can make one time contributions through Health Equity
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Use the HSA to pay for…
• Deductible• Coinsurance• Any IRS Publication 502 Expenses, including:
◊ Medical◊ Dental◊ Vision◊ Prescription drug◊ Long Term Care insurance premiums
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Using your Health Savings Plan
1. Go to your doctor.
2. Later – check your HealthEquity account online to see required payment to the doctor.
3. Pay with your HSA funds through your HealthEquity online account.ORPay with another source (e.g. check, credit card)
• Give doctor’s office your Blue Shield card so BSC can…
process the claim and get you their special provider discounts and
send info about your amount of claim responsibility to Health Equity
For more information
HealthEquity Member Services is available every hour of every day
Call the Blue Shield/UC dedicated line 1.855.201.8375
say“Health Savings Account”
www.healthequity.com/ed/uc
www.blueshieldca.com/uc
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Optum (formerly United Behavioral Health)
• Optum coordinates behavioral health care for all medical plans (except CORE)◊ psychiatrist◊ psychologist◊ therapist◊ substance abuse treatment
• No referral required from physician• Call Optum to notify prior to first visit
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Behavioral/Mental Health
Medical Plan
OPTUM Network
Out of Network
Health Net Blue & Gold
Visits 1–3 no copayVisits 4+ $20
$250 inpatient hospitalization
Emergency only
Kaiser
(Optum & Kaiser Providers)
Emergency only
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Behavioral/Mental HealthMedical Plan
OPTUM Network Out-of-Network
UC Care Visits 1-3 no copayVisits 4+ $20Inpatient $250
$500 deductiblePlan pays 50% allowed
You pay balance
Blue Shield HSP
Deductible:$1,250 indiv $2,500 family
You pay 20%
Deductible:$2,500 indiv$5,000 family
Plan pays 60% allowedYou pay balance
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Behavioral/Mental Health
Medical Plan
Blue Shield Network
Out of Network
Core $3000 deductible
You pay 20% Plan pays 80% allowedYou pay balance
Note for all plans:• The medical and behavioral health deductibles cross-
accumulate.• The medical and behavioral health coinsurance cross-
accumulate toward a common out-of-pocket maximum.• In-network and out-of-network deductibles and out-of-
pocket maximums do NOT cross accumulate.
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Chiropractic & AcupunctureMedical Plan Providers Costs
HMO American Specialty Health
25% discount
UC Care Preferred Blue Shield
After deductible,You pay 20%
Out-of-Network
Non-Blue Shield After deductible,
Acupuncture:Plan pays 80% allowed
Chiropractic:Plan pays 60% allowed
Note: Benefit is limited to 24 visits per calendar year combined for Acupuncture and Chiropractic visits
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Chiropractic & AcupunctureMedical Plan Providers Costs
Blue Shield HSP
PreferredBlue Shield
After deductible,You pay 20%
Out-of-Network
Non-Blue Shield
After deductible,
Acupuncture:Plan pays 80% of allowed
Chiropractic:Plan pays 60% of allowed
Note: Benefit is limited to 24 visits per calendar year combined for Acupuncture and Chiropractic visits
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Chiropractic & Acupuncture
Medical Plan Provider Out of Network
CorePreferred Blue Shield
After deductible,You pay 20%
Out-of-network
Non-Blue Shield
After deductible,
Acupuncture:Plan pays 80% allowed
Chiropractic:Plan pays 80% allowed
Note: Plan payment maximum up to $500 per calendar year
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http://atyourservice.ucop.edu/oe
• Resources◊ Plan contacts◊ Plan rates
• Medical Plans◊ Benefit summaries◊ Links to plan websites◊ Links to provider directories
• Other plans◊ Dental, vision, FSA
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