University of California UC Care

Blue Shield of California

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.

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

Effective: January 1, 2014

UC Select

Blue Shield 1 Preferred $250 per individual/ $750 per family $3,000 per individual/ $9,000 per family None

Non-Preferred 1 Providers $500 per individual/ $1,500 per family $5,000 per individual/ $15,000 per family None Non-Preferred 1 Providers 50% 50% 50% 50%

Calendar Year Medical Deductible

(Deductible amounts do not cross accumulate)
2

None

Calendar year copayment maximum

(UC Select and Blue Shield Preferred Copayment Maximum amounts cross accumulate. UC Select/Blue Shield Preferred and Non-Preferred Copayment Maximums do not cross accumulate)

$1,500 per individual/ $4,500 per family None UC Select

LIFETIME BENEFIT MAXIMUM

Covered Services
PROFESSIONAL SERVICES Professional (Physician) Benefits Physician office visits (Includes Internist, Family Practice, OB/GYN,
Pediatrician, General Practice)

Member Copayment
Blue Shield 1 Preferred 20% 20% 20% 20%

$20 per visit $20 per visit N/A

(services covered under Blue Shield Preferred)

Specialist office visits (Includes all other provider designations) CT scans, MRIs, MRAs, PET scans, and cardiac 3 diagnostic procedures utilizing nuclear medicine
(prior authorization is required)

Other outpatient X-ray, pathology and laboratory

(Diagnostic testing by providers other than outpatient laboratory, 3 pathology, and imaging departments of hospitals/facilities)

N/A
(services covered under Blue Shield Preferred)

Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) Preventive Health Benefits Preventive Health Services (As required by applicable federal
law.)

$20 per visit No Charge

20% No Charge
(Not subject to the Calendar Year-Deductible)

50% 50%

OUTPATIENT SERVICES Hospital Benefits (Facility Services)

Outpatient surgery performed at an Ambulatory Surgery 3, 4 Center Outpatient surgery in a hospital Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation
benefits" and "Speech therapy benefits")

N/A
(services covered under Blue Shield Preferred)

20% 20% 20% 20%

50% 50% 50% 50%

$100 per surgery $20 per visit $20 per visit

CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 3 performed in a hospital (prior authorization is required) Other outpatient X-ray, pathology and laboratory 3 performed in a hospital Bariatric Surgery (prior authorization required by the Plan; medically
necessary surgery for weight loss, for morbid obesity only)
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$20 per visit $100 per surgery

20% 20%

50%

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services

No Charge $250 per admission $250 per admission

20% 20% 20%

50% 50% 50%

7 7 7

Inpatient Non-emergency Facility Services (semi-private

room and board, medically necessary services and supplies) Bariatric Surgery (prior authorization required by the Plan; medically 6 necessary surgery for weight loss, for morbid obesity only)
5

Skilled Nursing Facility Benefits

(Combined maximum of up to 100 prior authorized days per calendar year; semi-private accommodations)

Services by a free-standing Skilled Nursing Facility Skilled Nursing Unit of a Hospital

N/A
(services covered under Blue Shield Preferred)

20% 20%

50% 50%

N/A
(services covered under Blue Shield Preferred)

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)

$100 per visit

(Not subject to the Calendar Year-Deductible)

$100 per visit

(Not subject to the Calendar Year-Deductible)

$100 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 20% $20 per visit

$250 per admission 20% 20%

$250 per admission 20% 50%

Emergency room Physician Services 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.)

AMBULANCE SERVICES

Emergency or authorized transport

N/A
(services covered under Blue Shield Preferred)

20%

20%

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. N/A
(services covered under Blue Shield Preferred)

PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices (Separate office visit copay

may apply)

20% 20%

50% 50%

Orthotic equipment and devices (Separate office visit copay may

apply.)

N/A
(services covered under Blue Shield Preferred)

DURABLE MEDICAL EQUIPMENT

Durable Medical Equipment Breast Pump

N/A
(services covered under Blue Shield Preferred)

20%

50% Not Covered

N/A
(services covered under Blue Shield Preferred)

No Charge
(Not subject to the Calendar Year-Deductible)

MENTAL HEALTH SERVICES (PSYCHIATRIC)

Inpatient Hospital Services Outpatient Mental Health Services

9

Carved out to Optum

CHEMICAL DEPENDENCY SERVICES

Chemical Dependency and Substance Abuse Services

10

Carved out to Optum

10

HOME HEALTH SERVICES

visits per Calendar Year)
11

Home health care agency Services

(up to 100 prior authorized

N/A
(services covered under Blue Shield Preferred)

20% 20%

50% 50%

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

N/A
(services covered under Blue Shield Preferred)

10

OTHER Hospice Program Benefits Routine home care

10

N/A
(services covered under Blue Shield Preferred)

20% 20% 20% 20%

50% 50% 50% 50%

10

Inpatient Respite Care 24-hour Continuous Home Care General Inpatient care
11

N/A
(services covered under Blue Shield Preferred)

10

N/A
(services covered under Blue Shield Preferred)

10

N/A
(services covered under Blue Shield Preferred)

10

Chiropractic Benefits

Chiropractic services provided by a chiropractor

(Up to 24 visits per calendar year combined with acupuncture visits)
11

N/A
(services covered under Blue Shield Preferred)

20%

Not Covered

Acupuncture Benefits

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
(For inpatient hospital services, see "Hospitalization Services.")

$20 initial visit only No Charge No Charge

20%

14

50%

14

Family Planning 12 Counseling and consulting

No Charge
(Not subject to the Calendar Year-Deductible)

50% 50% 50% 50% 50% 50% 50% 50%

Tubal ligation

13

No Charge
(Not subject to the Calendar Year-Deductible)

Elective abortion 20% 8 Vasectomy 20% Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Outpatient visits (Office or outpatient facility location) $20 per visit Speech Therapy Benefits Outpatient visits ( Office or outpatient facility location) Diabetes Care Benefits Devices, equipment, and non-testing supplies (For testing

supplies, please see "Outpatient Prescription Drug Coverage Summary.") Diabetes self-management training (If billed by your provider, you will also be responsible for the office visit copayment)

13

20% 20% 20% 20% 20% 20%

$20 per visit 20% $20 per visit

Care Outside of Plan Service Area Within US: BlueCard Program

Outside of US: BlueCard Worldwide

All covered services provided through BlueCard Program, for out-ofstate emergency and non-emergency care, are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/BlueShield provider. All covered services for emergency and non-emergency care will be eligible for reimbursement when received outside of the US. Please refer to the Blue Shield Preferred Tier for covered services and corresponding member liability.

2 3

4 5 6

Member is responsible for copayment in addition to any charges above allowable amounts. The copayment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield's allowable amount 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 copayment plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar-year deductible or copayment maximum. Preferred Deductible does apply toward the Preferred calendar-year copayment maximum. Please refer to the Plan Contract for exact terms and conditions of coverage. Participating non Hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. Participating ambulatory surgery facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital with payment according to your health plan's hospital services benefits. The maximum allowed charges for non-emergency surgery and services performed in a non-participating Ambulatory Surgery Center or outpatient unit of a nonpreferred hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. Bariatric surgery is covered when pre-authorized by the Plan. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the

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Plan Contract for further benefit details. The maximum allowed charges for non-emergency hospital services received from a non-preferred hospital is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600 per day. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's preferred providers or non-preferred providers. When these services are pre-authorized, the member pays the Preferred Provider copayment. For plans with a calendar-year medical deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan medical deductible has been met. Includes insertion of IUD, as well as injectable and implantable contraceptives for women. Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. For pregnancy and maternity at the Preferred and Non-Preferred level payment noted is for the global pregnancy bill. Plan designs may be modified to ensure compliance with federal requirements.

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