|
Type of Service
|
Student Health Insurance Plan (SHIP)
|
Your Plan
|
| Premium |
$638 per semester for UCB undergraduate students |
|
| $849 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
services provided outside of UHS. All covered benefits described
below are subject to the deductible except services provided at
UHS and where otherwise noted. |
|
| 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 |
No charge to see a UHS primary care clinician. |
|
| Pays 80% of non-UHS office visits within Blue Cross
network. |
|
| Urgent Care Clinic Visit |
No charge to be seen at UHS Urgent Care Clinic. |
|
| Pays 80% of non-UHS office visits within Blue Cross
network. |
|
| Emergency Room Services |
For severe or life-threatening emergencies, covers
100% hospital charges for treatment within 72 hours of injuries,
or sudden and serious illness as determined by Blue Cross |
|
| Covers 80% for all other conditions. |
|
| Covers 80% of attending physicians' fees and ancillary
services. |
|
| Prescription Drugs |
Prescriptions filled at the UHS-Tang Center Pharmacy
have a co-pay of $15 for generic and $25 for brand name medications
(30-day supply). Hormonal contraceptives have a co-pay of $25 for
3 cycles. |
|
| Prescriptions filled outside of the Tang
Center are reimbursed at 70% of billed charges. |
|
|
No prescription medications are subject to the deductible. The
pharmacy benefit is limited to a maximum of $5,000 coverage per
plan year.
|
|
| Lab Tests and X-rays |
Covers 80% within Blue Cross Network. Covers less
outside of the Network. |
|
| Hospitalization |
Pays 90% of hospital charges within Blue
Cross Network. |
|
| Covers 80% of attending physicians' fees and ancillary
services within Blue Cross Network. |
|
| Mental Health Hospitalization |
Pays 90% of hospital charge within Blue Cross Network,
up to 30 days maximum per plan year. |
|
| Covers 80% of attending physicians' fees and ancillary
services within Blue Cross Network. |
|
| Mental Health Office Visit |
UHS Counseling: No charge for first 3 visits, then pays 80% of
charges for up to 25 visits/year.
|
|
| UHS Psychiatry: Pays 80% of charges. |
|
| Non-UHS: Pays 80% of non-UHS office visits within
Blue Cross network, up to 25 visits/year, not subject to deductible. |
|
| Covers 80% of charges, subject to the deductible,
for psychological testing and for medically necessary, authorized
visits for conditions covered by the Mental Health Parity Act of
2000. |
|
| Allergy Testing and Injections |
$1,000 maximum reimbursement per plan year. |
|
| Surgeon |
Covers 80% within Blue Cross Network.
|
|
| Lifetime Maximum |
$400,000 lifetime maximum for all services,
while enrolled in SHIP |
|
| Plan Network |
Choice of provider significantly affects
the level of coverage. For maximum payment on a claim, patients
must receive care within the Blue Cross Network. |
|
|
This chart contains a partial list of benefits and does not
include reimbursement information on medical coverage outside
of the 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.
|
| 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.
|
|
|
Premium
|
Included in the cost of SHIP
|
Included in the cost of SHIP
|
|
|
Calendar year maximum
|
$1,000
|
$1,000
|
|
Vision Care is provided through the UC Berkeley School of Optometry,
at two clinics on campus and 11 other locations throughout California.
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