Your Guide to UC CareA UNIVERSITY OF CALIFORNIA PPO PLAN

January 1, 2016–December 31, 2016

Take Care with Shield ConciergeNeed help with benefits, finding providers or submitting a claim? Call Shield Concierge—now with two new numbers.

Hours of operation (domestic and international): Monday through Friday, 7:00 a.m. to 7:00 p.m. (Pacific)

Learn How UC Care Works ............................................ 1

Find Participating Providers .........................................6

Get Care Outside of California .....................................7

Know Your Medical & Pharmacy Coverage ..................8

Get After-Hours Care ..................................................10

Transition to UC Care .................................................. 12

Take Advantage of UC Care ........................................ 13

Explore Our Tools ........................................................ 14

Review the Benefits Summaries ..................................15

Know Your Terms ......................................................... 21

Get Help When You Need It ........................................22

Use this guide to find key information—and 20 helpful tips—about your coverage so you can make UC Care work for you. Visit uc-care.org to learn even more.

Welcome to UC Care!

International toll-free: 800 60004040

Domestic toll-free: 1-855-702-0477

What’s New or Changing for 2016Check out these key changes to UC Care for 2016, including the addition of several new providers in UC Select. Visit uc-care.org to learn more.

Benefit Changes for 2016

TRAVEL VACCINATIONS

Effective January 1, 2016, the UC Care plan will cover many travel immunizations and vaccinations such as Japanese encephalitis, rabies, polio, typhoid and yellow fever. These can be administered at a pharmacy or at your doctor’s office. For details, visit uc-care.org. (Select Use Your Benefits, then Pharmacy Benefits.)

AMBULATORY SURGICAL CENTERS

If you receive care from an Ambulatory Surgical Center (ASC), the following will apply:

§ In UC Select—$100 copayment per visit.

§ In Blue Shield Preferred—20% coinsurance, after deductible.

§ Out-of-Network—50% coinsurance, after deductible.

NEW! UC Select Providers

Effective January 1, 2016, the following providers will be added to UC Select:

Northern California/ Bay Area

§ John Muir Medical Center—Walnut Creek and Concord

§ John Muir Physician Network (only those with a Blue Shield PPO Contract—be sure to check when making an appointment)

Santa Barbara Area

§ Cottage Hospital—Santa Barbara and Goleta § Pacific Diagnostic Labs § Pueblo Radiology

Orange County

§ Orange County Foot and Ankle § Aurora Breast MRI of Orange County

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FIND DETAILS ONLINELooking for more details on UC Care? Visit uc-care.org.

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Learn How UC Care Works

There are three important things to know about your UC Care plan:

1. It’s a PPO, or Preferred Provider Organization—not an HMO, or Health Maintenance Organization. Generally, people select PPOs because they offer choice and flexibility. Since UC Care is a PPO, you have the flexibility to go to any provider you choose—often without a referral.

2. UC Care works with Blue Shield of California (Blue Shield) to administer your benefits through its broad coverage network of “preferred” providers. You’ll always save money when you get medical care within that network. When you see out-of-network, or non-preferred providers, you’ll pay more for your visit.

3. The plan is divided into three options, or “tiers” of coverage that give you varying levels of flexibility and choice in how you get care.

Your Choice of Networks

UC Care works with Blue Shield to contract with a group of medical providers to cover services for you and your family at a discounted rate (aka, negotiated rate). This “preferred” group of providers makes up your UC Care network. When you go to a preferred provider, the visit is “in-network.”

When you see in-network, preferred providers:

§ You pay less out of pocket.

§ You have lower deductibles or copayments.

§ UC Care pays a larger share of the allowed amount for covered services.

When you see out-of-network, non-preferred providers:

§ You pay more out of pocket.

§ You have higher deductibles.

§ You pay more for covered services, since out-of-network providers may use “balance billing.” That is, they may bill you for more than the “allowed amount” (see Know Your Terms on page 21, and Understanding Balance Billing on page 2).

Tiers of Coverage

There’s a bit more to know about networks—you have three options (or tiers) to choose from: Blue Shield Preferred and UC Select are in-network; the third tier is out-of-network.

IN-NETWORK TIER: BLUE SHIELD PREFERRED

This in-network tier:

§ Provides a full range of covered benefits.

§ Lets you choose from a more comprehensive and broad range of providers in the Blue Shield Preferred network.

§ Offers access to BlueCard® and BlueCard Worldwide® providers outside of California—in the U.S. and throughout the world.

§ Has a calendar-year, in-network deductible—the amount you pay before UC Care begins to share in the cost of covered services.

§ Includes coinsurance—the percentage you pay for covered services after you meet your deductible. UC Care pays the other piece.

USE IN-NETWORK PROVIDERS Out-of-network care can be expensive. Pay less when you use in-network providers.

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With Blue Shield Preferred, you have access to:

§ More than 70,000 providers in the Blue Shield Preferred network.

§ More than 600,000 BlueCard and BlueCard Worldwide providers outside of California—in the U.S. and abroad.

TIP 3 GET CARE WHEREVER YOU ARE

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IN-NETWORK TIER: UC SELECT

This is a special in-network tier on top of Blue Shield Preferred. With UC Select, you:

§ See only certain providers in California.

§ Generally pay less out of pocket.

§ Pay set copayments when you get covered care from UC Select providers. UC Select has no calendar-year, in-network deductible.

§ Have access to the five nationally ranked UC medical centers at Davis, Irvine, Los Angeles, San Diego and San Francisco—along with most of their affiliated facilities, physicians and other professional providers.

§ Can visit select primary care physicians and providers near every campus—even those without UC medical centers.

§ Have access to the BlueCard network if you live/work/travel outside of California—and its territories. Any care you receive will be provided at the Blue Shield Preferred coverage level—not at the UC Select coverage level.

§ Have access to the BlueCard Worldwide network if you live/work/travel outside the United States—and its territories. Any care you receive will be provided at the Blue Shield Preferred coverage level—not at the UC Select coverage level.

OUT-OF-NETWORK TIER

You also have the option to see providers outside of UC Care’s network. It’s important to know that with the out-of-network tier:

§ Care costs you more out of your pocket.

§ You have a calendar-year, out-of-network deductible that’s higher than—and totally separate from—your in-network deductible. That means what you pay toward one doesn’t count toward the other.

§ Coinsurance costs are higher than what you’d pay with in-network providers.

§ In most cases, you pay in full at the time of service. You are also responsible for submitting out-of-network claims to Blue Shield—not the provider.

§ You pay charges above the plan allowed amount, in addition to any coinsurance.

UNDERSTANDING BALANCE BILLING

It is important to know that out-of-network providers may bill you for more money than the UC Care 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.

Balance billing may occur with Emergency Room (ER) visits.

If you are balance billed for any out-of-network care—including ER visits—contact Shield Concierge before paying the bill. Shield Concierge will try to advocate on your behalf to negotiate a potentially lower amount for your bill.

You can reach Shield Concierge as follows:

§ Domestic toll-free: 1-855-702-0477

§ International toll-free: 800 60004040

Hours of operation (domestic and international): Monday through Friday, 7:00 a.m. to 7:00 p.m. (Pacific)

Please note: If you stay in-network, balance billing does not affect you. You won’t be required to pay any amount over the UC Care allowed amount.

SAVE MONEY

Choosing out-of-network providers will cost you more. Compared to in-network, Blue Shield Preferred, you’re responsible for:

§ Deductibles that are twice as much. § Coinsurance that is more than double the amount for Blue Shield Preferred—PLUS any provider charges above the allowed amount.

TIP 4

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Coverage Costs by Tier

Use the chart below to compare the costs associated with all three coverage tiers.

There is a separate copayment maximum for prescriptions—that means what you pay for medical care doesn’t count toward what you pay for prescriptions.

Find more info—including a list of covered services that do not apply to the medical out-of-pocket copayment maximum—in the 2016 UC Care Benefit Booklet. To download it, visit uc-care.org. (Select Get Help, then Plan Documents.)

In-Network Tier: UC Select1

In-Network Tier: Blue Shield Preferred

Out-of-Network Tier

Calendar-Year Deductible 2 No deductible § Individual: $250 § Family: $750

§ Individual: $500 § Family: $1,500

Professional Services § Physician and specialist office visits

§ Outpatient X-ray, pathology and lab3

See pages 15-20 for details

$20 copayment Once the in-network deductible is met:

§ UC Care pays 80% § You pay 20%

Once the in-network deductible is met:

§ UC Care pays 50% § You pay 50%4

Medical Out-of-Pocket Maximum5

§ Individual: $1,500 § Family: $4,500

§ 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/travel outside of California but in the United States—and its territories—you have access to providers for emergency and non-emergency care through the BlueCard network.Covered services received through the BlueCard network are paid at the Blue Shield Preferred in-network level of benefits.

Getting Care Outside the U.S.

When you live/work/travel outside the United States—and its territories—you have access to providers for emergency and non-emergency care through the BlueCard Worldwide program.

1. Some services are not available in UC Select, only Blue Shield Preferred. Details can be found in the 2016 UC Care Benefit Booklet. To download it, visit uc-care.org. (Select Get Help, then Plan Documents.)

2. In-network and out-of-network calendar-year deductibles are separate—what you pay toward one doesn’t count toward the other.

3. A $20 separate copayment may apply for interpretation of results by another provider. For more information about lab and diagnostic services, visit uc-care.org.

4. You may be billed for charges above the UC Care allowed amount—this is called balance billing. You will be responsible for these charges in addition to any copayment. See Understand Balance Billing on page 2 for further details.

5. In-network (UC Select and Blue Shield Preferred) medical out-of-pocket copayment maximums count toward one another. In-network and out-of-network medical copayment maximums are separate—what you pay toward one doesn’t count toward the other.

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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 providers, either in- or out-of network. If you see an out-of-network provider, you 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.

In-Network: You pay set copayments for doctors’ visits, lab tests, prescriptions and other covered services.

Out-of-Network: You must first meet a higher deductible. Then, you pay a larger share of the cost of covered services through coinsurance.

Out-of-Network: You cannot go out of the HMO network without a referral except for emergencies.

UC Care is Not an HMO

Now that you know more about what UC Care is, it’s also important to know what it’s not.

UC Care is not an HMO (Health Maintenance Organization). PPOs such as UC Care let you manage your own health. HMOs manage your care for you by setting rules for how and where you can receive services.

Here are some key differences between UC Care (a PPO) and HMOs, like those offered to UC employees—Kaiser, Health Net Blue and Gold and Western Health Advantage (Davis and Sacramento area).

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Before You Receive Care

To help save yourself time, money and hassle, ask these two questions before making an appointment with a specialist or a specialty treatment center.

DO I NEED A REFERRAL?

Since UC Care is a PPO, you can get most covered services and see specialists without a referral. Some providers, however, 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.

DO I NEED PRIOR AUTHORIZATION?

For certain services—outpatient radiology, durable medical equipment and hospital admissions—prior authorizations are required. Additionally, certain drugs may also require prior authorization. Without an approved prior authorization, your benefit payment may be reduced or denied.

Services that require prior authorization are listed in the 2016 UC Care Benefit Booklet. (Download a copy at uc-care.org. Select Get Help, then Plan Documents.)

Other specific services and procedures may require prior authorization as determined by Blue Shield. Be sure to verify before you schedule or obtain covered services. Generally:

§ Turnaround time for prior authorizations is five business days.

§ Turnaround time for expedited review of qualified prior authorization requests is 72 hours. For more information, visit uc-care.org. (Select Use Your Benefits, then Prior Authorizations.)

Emergency Care

In an emergency, call 911 or go to the nearest Emergency Room (ER).

If you are admitted to the hospital, please notify Blue Shield within 24 hours, or as soon as it is reasonably possible to do so, to avoid responsibility for additional costs.

For more information on emergency care, download the 2016 UC Care Benefit Booklet at uc-care.org. (Select Get Help, then Plan Documents.)

ASK ABOUT REFERRALS

When scheduling an appointment with a specialist or specialty treatment center, ask if a referral is required.

TIP 5

You’re not alone—you have Shield Concierge to help you get care that’s covered.

§ Domestic toll-free: 1-855-702-0477 § International toll-free: 800 60004040

Hours of operation (domestic and international): Monday through Friday, 7:00 a.m. to 7:00 p.m. (Pacific)

TIP 6 CALL SHIELD CONCIERGE

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Find Participating Providers

Since UC Care is a PPO, you have the flexibility to:

§ Choose providers from in- or out-of-network. (Remember: You’ll always pay less in-network!)

§ Manage care on your own or partner with a primary care provider (PCP)—it’s your choice. Partnering with a PCP will ensure you receive well-coordinated and appropriate preventive screenings and care.

Choose an In-Network Provider

It’s easy. Visit blueshieldca.com/uccareppo and use these five steps to search for in-network providers:

1. Click on the in-network tier you want to search—UC Select or Blue Shield Preferred.

2. Select the type of provider you’re searching for: Doctors, Facilities, Pharmacies or Equipment & Supplies.

3. Click Advanced Search, then enter your city and state, or ZIP code, to filter your search and find providers in your area.

4. Keep your search results by clicking Get Results as PDF (above the Distance field). Print or download your results (up to 200 provider records), or have them emailed to you.

5. Expand or narrow your search distance by selecting your preferred distance from the drop-down menu on the map. (The default distance/radius search is five miles.)

Find Physical, Speech and Occupational Therapists

Some health care professionals—such as physical, speech and occupational therapists—may not be listed by name in blueshieldca.com/uccareppo because they provide care through a UC Select or Blue Shield Preferred facility. These allied health professionals provide services at the UC Select or Blue Shield Preferred coverage level.

For questions regarding network participation, or for assistance with finding a physical, speech and occupational therapist, please contact Shield Concierge.

Benefits of Primary Care

Even though you don’t have to choose a Primary Care Provider (PCP) with PPOs such as UC Care, it can be helpful to have one.

Think of your PCP as a partner—someone who can advocate for you to make sure your preventive care is appropriate for your age and gender. Your PCP can also make sure your other health care services are appropriate and well coordinated.

If you already have a network PCP, well done! We encourage you to continue your relationship.

If you’re looking for one, use the steps above or contact one of the UC medical centers if you live or work nearby.

UC HEALTH PRIMARY CARE

UC Davis Medical Center 1-800-2-UC-DAVIS (282-3284)

UC Irvine Health 1-714-456-7002

UCLA Health System 1-800-UCLA-MD1 (825-2631)

UC San Diego Health System 1-800-926-8273

UCSF Medical Center 1-844-PCP-UCSF (727-8273)

Your Costs

Again, because UC Care is a PPO, you can visit in- or out-of-network providers—the choice is yours to make.

It’s important to remember that your choice of provider—including pharmacy—will impact how much you’ll pay out of pocket.

When you see in-network, preferred providers:

§ You pay less out of pocket.

§ You have lower deductibles or copayments.

§ UC Care pays a larger share of the allowed amount for covered services.

When you see out-of-network, non-preferred providers:

§ You pay more out of pocket.

§ You have higher deductibles.

§ You pay more for covered services, since out-of-network providers may bill you for more than the “allowed amount” (see Know Your Terms on page 21).

In most cases, you’ll need to pay in full when seeing an out-of-network provider. You are also responsible for charges above Blue Shield’s allowed amount, in addition to any coinsurance.

So, when scheduling an appointment with an out-of-network provider, request the cost of covered services.

TIP 8 ASK FOR COSTS UPFRONT

KNOW BEFORE YOU GO

Providers regularly change networks. That’s why it’s important to confirm coverage with the provider before your appointment.

Call the provider’s office to confirm which tier he/she is in—UC Select or Blue Shield Preferred.

TIP 7

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Get Care Outside of California

Whether you live, work or travel outside of California, you’re covered under UC Care.

Outside of California—in the United States and its Territories

If you get care outside of California, but in the United States—and its territories—you have access to BlueCard providers for emergency and non-emergency care.

Covered services you receive through BlueCard are considered in-network under Blue Shield Preferred.

IMPORTANT:

§ UC Select is unavailable outside of California, but you’re still covered (under Blue Shield Preferred) if you use a BlueCard provider.

§ If you see a non-BlueCard provider, it’s considered out-of-network. So, you may be required to make a full payment at the time of service, and you are responsible for submitting the claim to Blue Shield.

Outside of the United States—and its Territories

If you get care outside of the United States—and its territories—you have access to BlueCard Worldwide providers. You’re not required to use a BlueCard Worldwide provider, but your costs will be lower when you do.

IMPORTANT:

§ You’re covered under Blue Shield Preferred whether you see a BlueCard Worldwide provider or not.

§ If you see a non-BlueCard Worldwide provider, you may be required to make full payment at the time of service, and you are responsible for submitting the claim to Blue Shield.

Travel Tips

BEFORE YOU GO

§ Review the 2016 UC Care Benefit Booklet so you know what’s covered.

§ Check your prescription supply. Contact Shield Concierge at least five to seven business days before you travel so you can coordinate any refills you need.

§ Search bluecardworldwide.com for providers near your travel destination.

§ Take your Blue Shield member ID card with you.

§ Bring the BlueCard Worldwide Service Center phone number in case you need emergency services.

Before you travel, learn more about your UC-provided travel insurance benefits and options by visiting ucop.edu. At the top, click Organization and then Risk Services. In the upper navigation, select Loss Prevention & Control, then Travel Assistance from the menu on the left-hand side of the page.

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 some form of payment at the time of service. A non-BlueCard provider may require full payment, and you are responsible for submitting the claim to Blue Shield.

To learn how to file a claim, visit uc-care.org. (Select Use Your Benefits, Get Care Outside California, and then Outside the U.S.)

CONTACT BLUECARD

ACCESS BLUECARD WORLDWIDE

§ 1-800-810-BLUE (2583)  § provider.bcbs.com (in the U.S.)

§ Collect: 1-804-673-1177 (available 24/7)

§ bluecardworldwide.com (outside the U.S.)

TIP 9

TIP 10

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Know Your Medical & Prescription Benefits

Medical Plan Benefits

Check out the chart below for an at-a-glance overview of your medical benefits. For more information, see pages 15-20. For complete plan details, download the 2016 UC Care Benefit Booklet at uc-care.org. (Select Get Help, then Plan Documents.)

UC CARE MEDICAL BENEFITS FOR 2016

IN-NETWORK OUT-OF-NETWORKUC Select Blue Shield Preferred

Medical Calendar-Year Deductible1 No deductible $250 per individual $750 per family

$500 per individual $1,500 per family

Medical Out-of-Pocket Copayment 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

COVERED SERVICES MEMBER COPAYMENT

PROFESSIONAL BENEFITS

Physician office visit $20 20%3 after deductible 50%4 after deductible

Specialist office visit (Includes all other provider designations)

$20 20%3 after deductible 50%4 after deductible

PREVENTIVE HEALTH BENEFITS

Preventive Health visits No charge No charge (Not subject to the annual deductible)

50%4 after deductible

Pregnancy and maternity benefits $20 per visit, initial visit only 20%3 after deductible 50%4 after deductible

Outpatient X-ray, pathology and laboratory $20 per visit 20%3 after deductible 50%4 after deductible

HOSPITAL CARE

Outpatient surgery in hospital $100 per surgery (Deductible does not apply)

20%3 after deductible 50%4 after deductible

Outpatient surgery performed at an Ambulatory Surgical Center

$100 copayment per visit 20%3 after deductible 50%4 after deductible

Inpatient non-emergency facility services $250 per admission (Deductible does not apply)

20%3 after deductible 50%4 after deductible

EMERGENCY HEALTH COVERAGE

ER facility services (Not resulting in an admission)

$200 $200 (Not subject to the deductible)

$200 (Not subject to the deductible)

Emergency Room Services (Resulting in admission)

$250 $250 (Not subject to the deductible)

$250 (Not subject to the deductible)

ER Physician Services No charge No charge (Not subject to the deductible)

No charge (Not subject to the deductible)

1. In-network and out-of-network calendar-year deductibles are separate—what you pay toward one doesn’t count toward the other.

2. In-network (UC Select and Blue Shield Preferred) medical out-of-pocket copayment maximums count toward one another. In-network and out-of-network medical copayment maximums are separate—what you pay toward one doesn’t count toward the other. For a list of covered services that do not apply to the out-of-pocket maximum, see the 2016 UC Care Benefit Booklet.

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. You may be billed for charges above the UC Care allowed amount—called balance billing. You will be responsible for these charges in addition to any copayment. See Understand Balance Billing on page 2 for further details.

5. A $20 separate copayment may apply for interpretation of results by an out-of-network provider. For more information about lab and diagnostic services, visit uc-care.org.

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Again, in-network—Blue Shield Preferred and UC Select—medical out-of-pocket copayment maximums count toward one another. In-network and out-of-network medical copayment maximums are separate—what you pay toward one doesn’t count toward the other.

There is a separate out-of-pocket copayment maximum for prescriptions.

BEHAVIORAL HEALTH BENEFITS

UC Care behavioral health benefits are provided through Optum. Like medical providers, you can see any behavioral health provider you choose, but pay less and receive higher benefit coverage when you see an in-network provider. 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. You can register or visit anonymously by using access code 11280.

For additional details, visit uc-care.org. (Select Use Your Benefits, then Medical Benefits.)

Pharmacy Benefits

With UC Care, you may use any in-network or out-of-network pharmacy.

§ In-network: UC pharmacy and participating retail 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 page 19. To find UC participating pharmacies, visit uc-care.org. (Select Use Your Benefits, then Pharmacy Benefits.)

UC CARE PHARMACY BENEFITS FOR 2016

IN-NETWORKOUT-OF-

NETWORK

Pharmacy Calendar-Year Deductible1

None None

Pharmacy Out-of-Pocket Copayment Maximum

§ $3,600 per individual

§ $4,200 per family

None

1. In-network and out-of-network calendar-year deductibles are separate—what you pay toward one doesn’t count toward the other.

The pharmacy out-of-pocket copayment maximum only applies to prescription drugs received from preferred, in-network pharmacies. There is no out-of-network pharmacy copayment maximum.

The preferred out-of-pocket pharmacy copayment maximum is separate from the medical out-of-pocket copayment maximum.

FILLING PRESCRIPTIONS AT A RETAIL PHARMACY

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 maintenance medications.

For more information on how PrimeMail works, visit uc-care.org. (Select Use Your Benefits, then Pharmacy Benefits. Under Mail Service Prescriptions, click Learn More.)

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 per prescription.

If you receive behavioral health services from a medical provider, contact Shield Concierge. A representative can help with your claim.

TIP 11 GET HELP WITH YOUR CLAIM

It’s good practice to get familiar with plan formularies so you know what’s covered.

Only medications listed in the formulary are covered under UC Care. You are responsible for the full cost of drugs not listed in the formulary.

Visit uc-care.org. (Select Use Your Benefits, then Pharmacy Benefits—and scroll down to Blue Shield Formularies, located in the middle of the page.)

TIP 12 CHECK THE FORMULARIES

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Get After-Hours Care

There’s no place like home, especially when you’re not feeling well. With Teladoc® and NurseHelp 24/7,SM you can get care without getting out of bed.

Teladoc

Sometimes you need to connect with a doctor right away— not later today, tomorrow or next week.

You can contact Teladoc by phone, video or mobile app— the average wait time is 22 minutes or less.

Looking for convenient, time-saving care? Enroll in Teladoc.

THE DETAILS

WHO

All Teladoc doctors are licensed to practice medicine in the United States.

WHAT

The cost for a Teladoc consult is just $20, and in 2016, your first consult is free!

Teladoc doctors treat a variety of conditions, including:

§ Cold and flu symptoms § Allergies § Bronchitis § Ear infection § Rash, skin problems

§ Pink eye § Urinary tract infection § Respiratory infection § Sinus problems § Medical counseling

If appropriate, the Teladoc doctor can write a short-term prescription and have it sent to the pharmacy of your choice.

WHEN

Teladoc is open 24/7/365. Choose Teladoc if:

§ You are considering the ER or an urgent care center for a non-emergency issue.

§ You’re on vacation, a business trip, or away from home.

§ You need a short-term prescription.

HOW

FOLLOW THESE THREE SIMPLE STEPS:

Step 1: Enroll

You must enroll in Teladoc before you can consult with a Teladoc doctor.

§ Visit teladoc.com/uc, click on SET UP ACCOUNT and provide the following: • Your contact information—last name, first name,

email address, phone number and date of birth.• Your username. If you don’t know yours, you will be

prompted to create your own.• Your employer or insurance provider. The form

should automatically populate “University of California” in the required field.

§ If you prefer to enroll by phone, call 1-800-TELADOC (835-2362).

§ Next, complete your medical history. It’s important to have this information in the system when requesting a consultantation.

ENROLL IN TELADOC

It’s a required first step before you can use Teladoc and consult with a doctor. To enroll, visit teladoc.com/uc or call 1-800-TELADOC (835-2362).

TIP 13

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Step 2: Schedule a Consultation

Once you’re enrolled, visit teladoc.com/uc and log in to your account. You can also schedule a consultation by phone at 1-800-TELADOC (835-2362).

Teladoc will take your request and assign a U.S. board-certified physician licensed in your state. The physician will review your medical history and provide a consultation by telephone or video—the average callback time is 22 minutes.

During the consultation, the physician will listen and recommend the right treatment—just like an in-office visit. If a prescription is necessary, it will be sent to your pharmacy of choice. And with your consent, Teladoc is happy to provide information about the consultation to your primary care physician.

Step 3: Pay for Services

In 2016, there is no cost for your first Teladoc consult. After that, the cost is $20—the credit card you provided at enrollment will be charged.

NurseHelp 24/7

If you have a non-emergency health situation, but still want to talk with a professional, contact NurseHelp 24/7:

1. Call 1-877-304-0504; or

2. Log in to blueshieldca.com and talk to a nurse via online chat.

Learn more by visiting uc-care.org. (Select Use Your Benefits, then NurseHelp 24/7.)

Urgent Care

In an emergency, call 911 or go to the nearest Emergency Room (ER).

If it’s a non-emergency, consider going to an urgent care center instead of the ER. It can save you time and money.

Many urgent care centers are open after business hours and on weekends. Plus, you can expect fast and personalized treatment from qualified professionals for conditions such as:

§ Cough, sore throat and respiratory infections.

§ Earaches.

§ Back pain, body aches.

§ Colds, sinus infections, and allergies.

§ Rashes, minor cuts and scrapes.

Learn more by visiting uc-care.org. (Select Use Your Benefits, then Urgent Care vs. ER.)

Enrolled? You can schedule a phone or video consultation two ways:1. Call 1-800-TELADOC (835-2362); or2. Log in to your Teladoc account at teladoc.com/uc.

Video consultations are available from 7:00 a.m. to 9:00 p.m. Pacific every day.

When you need care quickly, don’t lose time searching for the closest in-network urgent care center! Conduct a search before you need their services.

Search blueshieldca.com/uccareppo or call NurseHelp 24/7 at 1-877-304-0504.

TIP 14

TIP 15

SCHEDULE A TELADOC CONSULT

FIND AN URGENT CARE CENTER

12

Transition to UC Care

Transitioning to a different health plan can have its challenges. Follow these five simple steps to make switching to UC Care as smooth as possible.

1. Find a Network Physician

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.

2. 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 one. Your previous doctor can tell you how to transfer your medical records.

3. Request Continuity of Care/Transition of Care

If you’re currently being treated by a doctor who’s not in the Blue Shield PPO network, you can request continuity of care.

Continuity of care allows you to keep seeing your out-of-network provider during your treatment, but still receive in-network 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 your UC Care 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:

§ Domestic toll-free: 1-855-702-0477

§ International toll-free: 800 60004040

Hours of operation (domestic and international): Monday through Friday, 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 current provider to help you transition to a new in-network provider without disrupting your care or services.

4. Transfer Your Prescription Medications

When transitioning to Blue Shield pharmacy benefits, review the Blue Shield Plus Drug Formulary at uc-care.org. (Select Use Your Benefits, then Pharmacy Benefits.) Check to see if your medication is listed in the formulary.

We encourage you to refill any maintenance medications you take so that you have a supply on hand before any change in coverage.

5. Use Your Member ID Card

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.

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.

Have questions or need to print your ID card?

Register and then log in to blueshieldca.com.

TIP 16 REGISTER WITH BLUE SHIELD

13

Take Advantage of UC Care

UC Care offers lots of valuable programs to help you manage your health. Find all the details under Manage Your Health at uc-care.org.

Manage a Condition

Blue Shield’s condition-management programs can provide support for asthma, coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), diabetes and heart failure.

Prenatal Care

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.

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, then Prevention Tips.)

Quit Tobacco for Life

As the largest quit-smoking community in the world, QuitNet® offers a dynamic, multi-modal tobacco-cessation program through online and mobile engagement via QuitNet.com, plus daily email/SMS text support and telephone-based coaching and Nicotine Replacement Therapy. Get started at uc-care.org. (Select Manage Your Health, then Quit Next.)

Wellness Discounts

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, then Wellness Discounts.)

1.2.3.

14

Explore Our Tools

Go to school at UC Care University to learn the ABCs of your plan.

UC Care University

We’ve developed a “curriculum” to help you get what you need from UC Care.

Start with Health Care 101 to help you become a more informed health care consumer. Find the basics on:

§ PPO vs. HMO

§ Key Terms

§ Paying for Care

§ Things to Know

§ How to Be a Better Health Care Consumer

Start your health care education at uc-care.org. UC Care University is on the right-hand side toward the top of the homepage.

Blue Shield

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 under Explore Our Tools at uc-care.org.

REGISTER WITH BLUE SHIELD

Access online tools to help you manage your benefits: Register at blueshieldca.com.

MOBILE ACCESS

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 copayments 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.

SYMPTOM CHECKER

Use this online interactive and educational tool to help you pinpoint symptoms and find information about what might be causing them. 

HEALTH LIBRARY

This large 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. (Select Explore Our Tools, then Glossary Terms. Find additional details under UC Care University on the homepage.)

REGISTER TO WIN

You could win a $50 gift card by registering with Blue Shield.

Already have an account? Great! Your name will automatically be entered into the drawing. 

Hurry—don’t miss your chance to win! The deadline to register is January 31, 2016 (11:59 p.m.).  Winners will be notified via email in February 2016 and have to remain a Blue Shield member until the prize is awarded.

TIP 17

15

Note: A description of the prescription drug coverage is provided separately

University of California – UC Care

Blue Shield of California

Effective: January 1, 2016 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

UC Select Blue Shield Preferred1

Non-Preferred Providers1

Calendar Year Medical Deductible (Deductible amounts do not cross accumulate)

None $250 per individual/ $750 per family

$500 per individual/ $1,500 per family

Calendar Year Out-of-Pocket Maximum2 (UC Select and Blue Shield Preferred Out-of-Pocket Maximum amounts cross accumulate. UC Select/Blue Shield Preferred and Non-Preferred Out-of-Pocket Maximums do not cross accumulate)

$1,500 per individual/ $4,500 per family

$3,000 per individual/ $9,000 per family

$5,000 per individual/ $15,000 per family

LIFETIME BENEFIT MAXIMUM None None None Covered Services Member Copayment PROFESSIONAL SERVICES UC Select Blue Shield

Preferred1 Non-Preferred

Providers1 Professional (Physician) Benefits Physician office visits (Includes Internist, Family Practice, OB/GYN,

Pediatrician, General Practice) $20 per visit

20% 50%

Specialist office visits (Includes all other provider designations) $20 per visit 20% 50%

Teladoc Program (provides access to U.S. board-certified doctors 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 1-800-Teladoc (835-2362).)

The member copayment is $20 per consult, not subject to deductible and accrues to the UC Select Out-of-Pocket Maximum

CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine3

(prior authorization is required)

$20 per visit 20%

50%

Other outpatient X-ray, pathology and laboratory3 (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)

$20 per visit 20% 50%

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)

$20 per visit 20%

20% 20%

50% 50%

Preventive Health Benefits Preventive Health Services (As required by applicable federal

law.) No Charge No Charge

(Not subject to the Calendar Year-Deductible)

50%

OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery

Center3, 4 $100 per surgery 20% 50%5

Outpatient surgery in a hospital $100 per surgery 20% 50%5 Outpatient Services for treatment of illness or injury and

necessary supplies (Except as described under "Rehabilitation benefits" and "Speech therapy benefits")

$20 per visit

20% 50%5

CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital3 (prior authorization is required)

$20 per visit

20%

50%5

Other outpatient X-ray, pathology and laboratory performed in a hospital3

$20 per visit 20% 50%5

Bariatric Surgery6 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only)

$100 per surgery

20% 50%5

16

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services No Charge 20% 50%

Inpatient Non-emergency Facility Services (semi-private room and board, medically necessary services and supplies)

Bariatric Surgery 6 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only)

$250 per admission

$250 per admission

20% 20%

50%7

50%7

Skilled Nursing Facility Benefits11 (Combined maximum of up to 100 prior authorized days per calendar year; semi-private accommodations) Services by a free-standing Skilled Nursing Facility N/A

(services covered under Blue Shield Preferred)

20% 50%7,10

Skilled Nursing Unit of a Hospital $250 per admission

20% 50%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)

$200 per visit

$200 per visit (Not subject to the Calendar

Year-Deductible)

$200 per visit (Not subject to the

Calendar Year-Deductible) Emergency Room Services resulting in admission (When

the member is admitted directly from the ER) $250 per admission

$250 per admission

(Not subject to the Calendar Year-Deductible)

$250 per admission (Not subject to the

Calendar Year-Deductible) Emergency Room Physician Services No Charge No Charge

(Not subject to the Calendar Year-Deductible)

No Charge (Not subject to the

Calendar Year-Deductible) 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.)

$20 per visit 20% 50%

AMBULANCE SERVICES Emergency or authorized transport N/A

(services covered under Blue Shield Preferred)

$200 per trip $200 per trip

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,

you will also be responsible for the office visit copayment) N/A

(services covered under Blue Shield Preferred)

20% 50%

Orthotic equipment and devices (If billed by your provider, you will also be responsible for the office visit copayment)

N/A (services covered under Blue Shield Preferred)

20% 50%

DURABLE MEDICAL EQUIPMENT Durable Medical Equipment Breast Pump

N/A (services covered under Blue Shield Preferred)

N/A (services covered under Blue Shield Preferred)

20%

No Charge (Not subject to the Calendar

Year-Deductible)

50%

Not Covered

MENTAL HEALTH SERVICES AND SUBSTANCE ABUSE SERVICES9 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

Optum Behavioral Health

17

HOME HEALTH SERVICES10 Home Health Care Agency Services (up to 100 prior

authorized visits per Calendar Year)11 N/A

(services covered under Blue Shield Preferred)

20% 50%10

Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a Home Infusion Agency

N/A (services covered under Blue Shield Preferred)

20% 50%10

OTHER Hospice Program Benefits10 Routine Home care N/A

(services covered under Blue Shield Preferred)

20% 50%10

Inpatient Respite Care N/A (services covered under Blue Shield Preferred)

20% 50%7,10

24-hour Continuous Home Care N/A (services covered under Blue Shield Preferred)

20% 50%10

General Inpatient care N/A (services covered under Blue Shield Preferred)

20% 50%7,10

Chiropractic Benefits11

Chiropractic Services (Up to 24 visits per calendar year combined with acupuncture visits)

N/A (services covered under Blue Shield Preferred)

20% 50%

Acupuncture Benefits11

Acupuncture Services (Up to 24 visits per calendar year combined with chiropractic services)

N/A (services covered under Blue Shield Preferred)

20%

20%

Pregnancy and Maternity Care Benefits Prenatal and Postnatal Physician office visits $20

initial visit only 20%8 50%8

Abortion Services (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

20% 20% 50%

Family Planning Counseling and consulting (includes insertion of IUD, as well as

injectable and implantable contraceptives for women) No Charge No Charge

(Not subject to the Calendar Year-Deductible)

50%

Tubal ligation (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility)

No Charge No Charge (Not subject to the Calendar

Year-Deductible)

50%

Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

20% 20% 50%

Infertility12 20% 20% 50% Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Outpatient visits (Office or outpatient facility location) $20 per visit 20% 50%

Speech Therapy Benefits Outpatient visits ( Office or outpatient facility location) $20 per visit 20% 50% Diabetes Care Benefits Devices, equipment, and non-testing supplies (For testing

supplies, please see "Outpatient Prescription Drug Coverage Summary.") 20% 20% 50%

Diabetes self-management training (If billed by your provider, you will also be responsible for the office visit copayment)

$20 per visit 20% 50%

Travel Vaccinations13

Immunizations and vaccinations for foreign travel No Charge No Charge (Not subject to the Calendar

Year-Deductible)

50%

18

ASO RO 090115

Care Outside of Plan Service Area Within US: BlueCard Program All covered services provided through BlueCard® Program, for out-of-

state 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. Outside of US: BlueCard Worldwide 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. 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.

2 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.

3 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 on a per provider, per visit basis according to your health plan's hospital services benefits.

4 Ambulatory surgery centers in the Blue Shield Preferred tier 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 and designated ambulatory surgery centers. Members obtaining services at a UC ambulatory surgery center or designated ambulatory surgery centers are responsible for a $100/surgery copayment. For a list of participating ambulatory surgery centers in the UC Select tier, please visit www.blueshieldca.com.

5 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.

6 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.

7 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.

8 For pregnancy and maternity services at the Preferred and Non-Preferred level, payment noted is for the global pregnancy bill. 9 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. 10 When these services are pre-authorized, the member pays the Preferred Provider copayment. 11 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. 12 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. 13 Refer to your plan benefit booklet for more information on covered vaccinations and immunizations.

19

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University of California- UC Care Outpatient Prescription Drug Coverage Blue Shield of California Effective: January 1, 2016

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.

Covered Services Member Copayment Calendar Year Drug Deductible (Prescription drug coverage benefits are not subject to the medical plan deductible) Calendar Year Drug Out-of-Pocket Maximum (Prescription drug coverage benefits are not subject to the medical plan Out-of-Pocket Maximum)

UC Pharmacy & Participating Pharmacies

Non-Participating Pharmacies

None $3,600 individual/ $4,200 family

None None

PRESCRIPTION DRUG COVERAGE1 UC Pharmacy & Participating Pharmacies

Non-Participating Pharmacies (Billed charges)

Retail Pharmacy Prescriptions (up to a 30-day supply) Contraceptive Drugs and Devices2 $0 per prescription $0 per prescription Formulary Generic Drugs $5 per prescription 50% per prescription Formulary Brand Name Drugs3, 4 $25 per prescription 50% per prescription Non-Formulary Brand Name Drugs3, 4 $40 per prescription 50% per prescription UC Pharmacies and specified Retail Pharmacies (up to a 31-90 day supply) Contraceptive Drugs and Devices2 $0 per prescription Not Covered Formulary Generic Drugs $10 per prescription Not Covered Formulary Brand Name Drugs3, 4 $50 per prescription Not Covered Non-Formulary Brand Name Drugs3, 4 $80 per prescription Not Covered Mail Service Program (up to a 90-day supply only through the Blue Shield mail service program)

Contraceptive Drugs and Devices2 $0 per prescription Not Covered Formulary Generic Drugs $10 per prescription Not Covered Formulary Brand Name Drugs3, 4 $50 per prescription Not Covered Non-Formulary Brand Name Drugs3, 4 $80 per prescription Not Covered Specialty Pharmacies and Select UC Pharmacies (up to a 30-day supply)5,8 Specialty Drugs6 30%

(Up to $150 copayment maximum per prescription)

Not Covered

Smoking Cessation Over-the-counter Drugs (requires prescription No Charge Not Covered Prescription Drugs No Charge Not Covered Diabetic Supplies (excluding syringes, needles, insulin and non-formulary test strips)7 No Charge Not Covered

Travel Immunizations and Vaccinations9 No Charge 50% per prescription

20

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 RO 090115

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.

9 Refer to your plan benefit booklet for more information on covered vaccinations and immunizations.

21

Know Your TermsStudy these important health insurance terms to help you understand and get the most from your plan.

Getting and Paying for Care

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 and BlueCard Worldwide providers outside of California—in the U.S. and throughout the world.

CALENDAR-YEAR DEDUCTIBLE. The amount you pay out of pocket for health care before UC Care begins to share in the cost of covered services.

There are two calendar-year deductibles. UC Select does not have a deductible.

§ In-network (Blue Shield Preferred) deductible applies to the in-network (Blue Shield Preferred) medical out-of-pocket maximum.

§ 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 copayment 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 calendar-year deductibles are separate and do not count toward one another.

COINSURANCE. The percentage you pay for the cost of covered health care services after you meet your calendar-year deductible. Referred to as “member copayment” by Blue Shield.

COPAYMENT. 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.

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.

OUT-OF-POCKET COPAYMENT 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.

GO TO UC CARE UNIVERSITYFind more terms at uc-care.org. UC Care University is on the right hand side toward the top of the homepage.

TIP 18

§ There are two medical in-network out- of-pocket copayment maximums—one for Blue Shield Preferred and one for UC Select. Although they are separate, what you pay toward one counts toward the other.

§ There is one medical out-of-network out-of-pocket copayment maximum and it is separate from the in-network out-of-pocket medical copayment maximums—what you pay for out-of-network doesn’t count toward in-network.

§ There is one prescription out-of-pocket copayment maximum amount. It is separate from the medical out-of-pocket copayment maximums—what you pay for prescriptions doesn’t count toward medical.

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.

PROVIDERS. Individuals or facilities that offer medical or mental health care to you and your family.

UC SELECT. An additional tier of in-network coverage in California on top of Blue Shield Preferred.

Billing and Claims

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.”

APPEALS & GRIEVANCES. A written or verbal expression of dissatisfaction about Blue Shield, Blue Shield providers or a Blue Shield vendor.

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 see an in-network provider.

CLAIM. A provider’s request to UC Care asking to be paid for a service you’ve received.

EXPLANATION OF BENEFITS (EOB). 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.

Prescriptions

BRAND NAME DRUGS. FDA-approved drugs under patent to the original manufacturer and available only under the original manufacturer’s brand name.

FORMULARY. A list of drugs maintained by Blue Shield’s Pharmacy and Therapeutics Committee to use under the Blue Shield Prescription Drug Program. The formulary is designed to assist physicians in prescribing drugs that are medically necessary and cost effective. It 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; they contain the same active ingredient as the brand name drug; they cost less than the brand name drug equivalent.

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. 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 at 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.

READ OUR BLOGSCheck out Paying for Your Care and other blogs at uc-care.org.

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Get Help When You Need It

Get help from a variety of resources at uc-care.org. Simply select Get Help to learn more.

Shield Concierge

This is THE place to call for help with:

§ Initiating prior authorization requests.

§ Requesting referrals.

§ Finding providers.

§ Understanding out-of-pocket costs of care (copayments, coinsurance).

§ Processing claims.

§ Any other questions regarding the UC Care plan.

Call Shield Concierge at:

§ Domestic toll-free: 1-855-702-0477

§ International toll-free: 800 60004040

Hours of operation (domestic and international): Monday through Friday, 7:00 a.m. to 7:00 p.m. (Pacific)

Blueshieldca.com

Log in to blueshieldca.com to find a provider, manage your claims, use the treatment cost estimator and more.

Health Care Facilitators

Contact your local Health Care Facilitator to get help with:

§ Understanding your coverage and patient rights.

§ Defining your health care issues.

§ Navigating the health care system.

§ Resolving issues with your doctor, medical group or medical plan carrier.

§ Understanding how Medicare benefits coordinate with UC-sponsored medical plans.

Find a complete list of Health Care Facilitators by campus, at ucnet.universityofcalifornia.edu/contacts/health-care-facilitators.

2016 UC Care Benefit Booklet

Visit uc-care.org to download your 2016 UC Care Benefit Booklet for complete plan information. Find it under Get Help, then Plan Documents.

Learn More

At uc-care.org, find detailed plan information, decision tools and a variety of resources—bookmark the site to stay connected.

When talking with a Shield Concierge representative:

1. Get the representative’s name.

2. Take notes in case you need to reference them later.

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