Students

Health Plan Comparison Worksheet

New UC SHIP

Medical and Mental Health Benefits for Berkeley Students, Fall 2011-Spring 2012
Note: UHS refers to University Health Services—Tang Center.
Also see: Glossary of Insurance Terms

Type of Service
Student Health Insurance Plan (UC SHIP)
Your Plan
Premium $813 per semester for UCB undergraduate students  
$1075 per semester for UCB graduate students and non-immigrant international students  

Two semesters equals 12 months of continuous coverage.

 
Plan Year Deductible $200 deductible each plan year (Aug 15-Aug 14) for some services provided outside of UHS.  
Out of Area Coverage Coverage is worldwide for emergency and covered care. When in the area, students must begin all non-emergency services at UHS in Tang Center.  
Medical Office Visit At University Health Services:
$15 co-pay for Primary Care, $15 co-pay for Specialists (authorization required)

Outside of University Health Services
(An authorization by a UHS Clinician is required prior to seeking services outside of Tang or your claims will be denied):
Pays 100% after $15 co-pay for primary care, $20 co-pay for specialty care from Anthem Blue Cross Network providers, not subject to the deductible. Plan pays 60% of the allowable non-Network rates, subject to deductible.		  
Urgent Care Clinic Visit At University Health Services:
$30 co-pay for Urgent Care clinic visit

Outside of University Health Services:
 Pays 100% after $50 co-pay for Anthem Blue Cross Network provider, not subject to the deductible. Plan pays 60% of non-Network rates (subject to deductible).

  
Emergency Room Services
  • Emergency Room: Pays 100% after $100 co-pay (co-pay waived if admitted) of Anthem Blue Cross Network rates for treatment provided within 72 hours for injuries or sudden and serious illness, as determined by Blue Cross. Pays 90% of Anthem Blue Cross Network rates, or 60% of non-Network rates, for all other conditions.
  • Attending physicians: Pays 100% of Blue Cross Network rate or 60% of non-Network rate.
  
Prescription Drugs At University Health Services:
Prescriptions filled at the UHS-Tang Center Pharmacy have a co-pay of $5 for generic and $25 for brand name medications (30-day supply).

Outside of University Health Services:
Prescriptions filled outside of the Tang Center have have a co-pay of $5 for generic and $25 for brand name medications (30-day supply), $40 for "non-formulary" items

No prescription medications are subject to the deductible. The pharmacy benefit is limited to a maximum of $10,000 coverage per plan year.

  
Lab Tests and X-rays Covers 90% within Anthem Blue Cross Network, 60% outside of the Network.  
Hospitalization Pays 90% of Anthem Blue Cross Network rates, 60% of non-Network rates  
Mental Health Office Visit At University Health Services:
After five free counseling visits, pays 100% after $15 co-pay

Outside of University Health Services
(An authorization by a UHS Clinician is required prior to seeking services outside of Tang or your claims will be denied):
Pays 100% after $15 copay for Anthem Blue Cross Network providers, not subject to the deductible. Plan pays 60% of non-Network rates, subject to deductible.

  
Allergy Testing and Injections Pays 90% of Anthem Blue Cross Network rates, 60% of non-Network rates  
Surgeon Pays 90% of Anthem Blue Cross Network rates, 60% of non-Network rates  
Lifetime Maximum $400,000 lifetime maximum for all services, while enrolled in UC SHIP  
Plan Network Choice of provider significantly affects the level of coverage. For maximum payment on a claim, patients must receive care within the Anthem Blue Cross Network.  

This chart contains a partial list of benefits and does not include reimbursement information on medical coverage outside of the Anthem Blue Cross Network. Other covered benefits include ambulance, home health care, immunizations, acupuncture, chiropractic, podiatry, and skilled nursing.

For more information about these additional benefits and coverage outside of the network, look in the main insurance section of the website or contact the Student Health Insurance Office at (510) 642-5700.

 

Dental Benefits

If the care is provided by a…
Dentist who is a member of the Preferred Dentist Program, the plan covers
Dentist who is not a member of the Preferred Dentist Program, the plan covers
Your Plan
Covered Services

Preventative and Diagnostic Services:

  • Oral exams (2 per year)
  • Cleanings (2 per year)
  • X-rays
  • Fluoride treatment

100% of negotiated fees that participating dentists have agreed to accept as payment in full.

80% of reasonable and customary charges.

 

Basic Operative and Restorative Services:

  • Fillings
  • Simple extractions
  • Oral surgery
  • Periodontics
  • Endodontics

80% of negotiated fees after a $25 annual deductible.

60% of reasonable and customary charges after a $25 annual deductible. Co-payments will be higher than if you use a MetLife Preferred Dentist.

 
Major Services
  • Prosthodontics
  • Inlays/onlays
  • Crowns & cast restorations
50%
of negotiated fees after a $25 annual deductible
60%
of reasonable and customary charges after a $25 annual deductible.
Co-payments will be higher with non-Network providers than if you use an in-Network Delta Dental PPO dentist
 
Premium
Included in the cost of UC SHIP
Included in the cost of UC SHIP
 
Annual plan year maximum
(August 15-August 14)
$1,000
$1,000
 

 

Vision Benefits

Vision Care is provided through the UC Berkeley School of Optometry, at two clinics on campus and 11 other locations throughout California.

Type of Service
Student Health Insurance Plan (UC SHIP)
Your Plan
Comprehensive eye exam Annual comprehensive eye exam - $5 copay  
Frames, lenses, and contact lenses

Spectacle frame and lenses - annual allowance of $120 - $15 copay

OR

Contact lenses - annual allowance of $120 - $15 copay

  
Refractive Surgery (Lasik, PRK) 50% Discount  

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