SHIP
Student Health
Insurance Plan
For Students at UC Berkeley
UNIVERSITY OF CALIFORNIA
Berkeley
Student Health Insurance Office
University Health Services
Tang Center
2222 Bancroft Way
Berkeley, CA 94720-4300
(510) 642-5700
www.uhs.berkeley.edu/ship
University of California, Berkeley
Student Health Insurance Plan (SHIP)
Table of Contents
Welcome to your health care program
at UC Berkeley
• How the Student Health Insurance Plan (SHIP)
fits into your health care program at Cal . . . . . . . . . . . . 1
• More about University Health Services (UHS) . . . . . . . . 2
• How SHIP works in conjunction with UHS . . . . . . . . . . . 2
The Student Health Insurance Plan (SHIP)
• What does SHIP cover? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
• When does SHIP coverage begin and end? . . . . . . . . . . . 4
• Who may enroll in SHIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
• Can my dependents enroll in SHIP? . . . . . . . . . . . . . . . . . . 4
• What is the cost of SHIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
• How do I waive SHIP coverage? . . . . . . . . . . . . . . . . . . . . . 5
• How do I use SHIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
• SHIP and your privacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
• When you are covered by SHIP
and another health plan . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
• Insurance after graduation . . . . . . . . . . . . . . . . . . . . . . . . . 8
• Important phone numbers and website addresses . . . 8
• Definitions of insurance terms . . . . . . . . . . . . . . . . . . . . . . 9
Description of SHIP benefits
• Medical and mental health benefits . . . . . . . . . . . . . . . . . 10
• SHIP Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
• Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
• Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . 18
“The majority of Berkeley students are
enrolled in SHIP. We recommend that
students keep SHIP to supplement
UHS services. The combination of UHS
and SHIP provides the best health
coverage for students’ needs.”
Claudia Covello
Executive Director
University Health Services
Welcome to your health care
program at UC Berkeley
As a registered student at Cal, you have an outstanding health
care program available to you. This brochure explains the Student
Health Insurance Plan (SHIP) and how it fits into the program.
To understand how SHIP works, it is important to understand that
your health care consists of two parts:
1. University Health Services (UHS)
University Health Services is a complete outpatient health
center for students, providing medical, mental health and
preventive care. Our clinicians serve as your “family doctor”
while you're at Cal. All registered students may use the services
of UHS, regardless of what type of major medical insurance
they have. Services are partially supported by registration fees.
Moderate fees apply to office visits and accompanying services.
2. The Student Health Insurance Plan (SHIP)
UC Berkeley requires all students to have major medical
insurance and provides the Student Health Insurance Plan
(SHIP) to meet this requirement.
SHIP is a major medical, mental health, dental and vision plan.
While UHS (above) provides primary care to students on
campus, SHIP covers care outside of UHS, including
hospitalization, off-campus or out-of-area care while traveling,
and some specialty services not available at UHS. Students
automatically are enrolled in SHIP, and there is a charge on
your campus billing statement. Students can choose to keep
SHIP or they can waive enrollment if they have comparable
coverage.
Most students keep their SHIP enrollment because it is a solid,
comprehensive and affordable plan that offers excellent
benefits. As long as students are registered, it covers them 12
months a year anywhere in the world. Also, SHIP and UHS work
hand-in-hand. (See section – How SHIP works in conjunction
with UHS)
For more information, see www.uhs.berkeley.edu/ship
1
More about UHS
• University Health Services includes a fully accredited outpatient
medical center, staffed by board-certified physicians, nurse
practitioners, physician assistants, a nutritionist and nurses.
• A comprehensive counseling center, staffed by psychiatrists,
psychologists and licensed therapists, offers individual and group
counseling, and includes a complete career counseling center.
• The health promotion unit offers programs and services for
keeping students healthy and safe, including many opportunities
for students to get involved in shaping the public health of
the campus.
UHS features
• State-of-the-art facility
• Telephone advice nurse
• Walk-in urgent care
• Professionals experienced in college
health
• In-house pharmacy, X-ray, clinical
laboratory and physical therapy
How SHIP works in conjunction with UHS
As a student, most of the health care services you will need are
available at University Health Services and are covered by SHIP.
When you need care, simply call the Tang Center to make an
appointment. Fees are charged for office visits, prescriptions and
services such as clinical laboratory procedures, X-rays, physical
therapy and certain other procedures, although UHS fees generally
are lower than those charged by local doctors’ offices and
hospitals. SHIP members pay office visit fees and copayments for
medications; for most other services, members pay only 20% of
the UHS fees. There are no claims to file for UHS visits.
If you need services at another health care facility, SHIP and
UHS work together to provide comprehensive health care.
UHS clinicians coordinate medical services, and Student Health
Insurance Office staff provide authorizations for covered services
and ensure that claims are handled accurately. For off-campus
care, SHIP contracts with Anthem Blue Cross to provide access to
medical and mental health services through an extensive network
of hospitals and providers.
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The Student Health Insurance
Plan (SHIP)
What does SHIP cover?
Note: The following is a brief summary of benefits. Please see
Description of SHIP Benefits in this brochure for
extended information.
• SHIP medical coverage uses an Anthem Blue Cross Preferred
Provider Organization (PPO). It includes 100% emergency and
90% hospital coverage, plus 80% coverage for outpatient
services such as office visits, lab work and X-rays provided by
Anthem Blue Cross network providers. A $200 annual deductible
applies to services outside UHS. SHIP members are covered for
emergency and authorized non-emergency medical care
anywhere at any time.
• SHIP mental health coverage includes 80% of UHS fees
for counseling or psychiatry visits. For care outside UHS,
SHIP pays 80% of Anthem Blue Cross rates for network providers
or 60% of non-network rates, up to 25 visits per plan year.
• SHIP dental coverage, administered by Metropolitan Life,
includes 100% of preventive services, such as exams, cleanings
and X-rays with no deductible; and 80% of general dental care
with a $25 annual deductible. Nationwide coverage includes
90,000 MetLife Preferred Dental Providers.
• SHIP vision coverage, offered by the UC Berkeley School of
Optometry, provides annual eye exams for a $5 copay, frames
and lenses or contact lenses once every 12 months for a $15
copay, a 20% discount on lens options and a 50% discount on
Lasik or PRK refractive surgeries. Services are available at two
locations on campus - Tang Center and Minor Hall - and seven
satellite locations throughout California. For your convenience,
the Minor Hall clinic is open seven days a week. For urgent
needs when the clinic is closed, you may call (510) 642-2020,
24 hours a day.
• SHIP coverage of UHS fees. SHIP members pay $15 for a primary
care office visit or $30 for an urgent care clinic visit at UHS.
Prescription medication obtained at UHS has a copayment of $15
or $25. For most other services, SHIP covers 80% of UHS fees.
There are no claims to file for SHIP members.
For more information, see www.uhs.berkeley.edu/ship
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When does SHIP coverage begin and end?
• Fall semester coverage begins August 15 and ends
January 14 each year.
• Spring semester coverage begins January 15 and ends
August 14 each year.
Registered students who enroll in SHIP for the fall and spring
semesters have year-round health insurance coverage.
Who may enroll in SHIP?
Students automatically are enrolled in the University's Student
Health Insurance Plan and charged a health insurance fee on their
registration bill. Groups eligible for SHIP include:
• All registered undergraduate and graduate students on the
UC Berkeley campus, including registered international students.
• All nonregistered "Filing Fee Status" students on the Berkeley
campus who are completing work under the auspices of the
University of California, but are not attending classes. Some
graduate students on withdrawal status may be eligible. Students
on Filing Fee and withdrawn status must purchase SHIP through
the Student Health Insurance Office (they are not automatically
enrolled). Filing Fee and withdrawal status students are allowed
to purchase SHIP for a maximum of two semesters.
•All nonregistered UC Berkeley concurrent enrollment students
who are completing degree requirements by taking courses
through UC Berkeley Extension. Concurrent enrollment students
are not automatically enrolled and must purchase SHIP through
the Student Health Insurance Office. They are limited to one
semester of coverage.
Can my dependents enroll in SHIP?
The Student Health Insurance Plan is available for registered
students only. However, several individual insurance plans not
affiliated with the University are available for spouses and children
of students. SHIP Office staff can help you find information and
sign up for plans. Call or stop by the Student Health Insurance
Office on the third floor of the Tang Center or call (510) 642-5700.
Information is also available on the website at
www.uhs.berkeley.edu/ship.
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What is the cost of SHIP?
UCB undergraduates $698 per semester
UCB graduate and international students $966 per semester
Filing fee, withdrawn, concurrent
enrollment students $1,760 per semester
How do I waive SHIP coverage?
Waiver applications are completed online during the fall semester
waiver period, April 1 through July 15:
www.uhs.berkeley.edu/ShouldIWaive
The fall semester waiver is good for one academic year and must
be completed again during the waiver period prior to each
fall semester.
There is another waiver period from December 1 through January 7
for those waiving enrollment just for spring semester. Spring
waivers are completed as above. Another waiver must be
completed in the fall for the next academic year.
How do I use SHIP?
When you are on campus and need care
• All medical care must begin at University Health Services (UHS).
When you are on campus and need medical care, call
(510) 642-2000 or go to www.uhs.berkeley.edu to make an
appointment. SHIP members pay 20% of most UHS fees, and
there are no claims to file.
• For mental health care, all care begins at UHS Counseling
& Psychological Services. To make an appointment, call
(510) 642-9494.
• For dental care, coverage is provided through MetLife's Preferred
Dentist Program. With this program, you select a provider from a
nationwide network of over 90,000 participating dentists, 100 of
whom are located within five miles of campus. When you make
your appointment, let the dentist know you have coverage
through MetLife. To find a dentist and manage your claims,
visit the MetLife website at https://mybenefits.metlife.com.
•For vision care, contact the UC Berkeley School of Optometry.
Make an appointment by calling (510) 643-2020 for the Tang
Center clinic or (510) 642-2020 for the Minor Hall clinic. You can
also request an appointment online at www.caleyecare.org.
•Be sure to bring your SHIP Anthem Blue Cross card to
your appointment.
For more information, see www.uhs.berkeley.edu/ship
5
Referrals from UHS clinicians
If you need services at another health care facility, your
UHS clinician will make the referral. You must have outside
appointments pre-authorized by the Insurance Office.
When you are off campus and need care
If you are out of the area and require care that is of medical or
mental health necessity, contact the Student Health Insurance
Office at (510) 642-5700 for authorization.
For off-campus care, SHIP contracts with Anthem Blue Cross
to provide medical and mental health services through their
extensive network of hospitals and providers. If providers or
facilities are used that are not part of the Anthem Blue Cross PPO
Provider Network, claims will be paid at a percentage of the
"limited fee schedule," which is often significantly lower than the
network rate. When you call for authorization, the SHIP staff will
help you locate an Anthem Blue Cross PPO Provider.
Emergency care
In case of emergency (see Definitions of insurance terms), students
should report directly to the emergency department of the nearest
hospital. From campus, this is Alta Bates Hospital on Ashby near
Telegraph, one mile from campus. SHIP covers emergency health
care worldwide.
Authorization for services
Most non-emergency services provided outside of UHS must
receive prior authorization or your claim may not be paid. Services
outside UHS that do not require pre-authorization include:
• Services in a hospital emergency room or urgent care center
for treatment of a sudden, serious or acute injury, illness or
condition
•Prescriptions filled outside of UHS
•Chiropractic services
•Mammograms
•Acupuncture
For all other non-emergency medical or mental health care outside
UHS, bring referrals to Student Health Insurance Office, Room
3200, Tang Center or call (510) 642-5700 for UHS pre-authorization.
Filing claims for services
For services received at the Tang Center, claims will be submitted
to Anthem Blue Cross on students’ behalf. Students should pay the
portion of the charges for which they are responsible at the time
of service.
6
When students receive care outside the Tang Center, the health
care provider may require payment of the student’s portion of fees
at the time of service or they may send a bill after SHIP has paid
the covered amount. Most health care providers will submit bills
directly to Anthem Blue Cross. If a student receives a bill for the full
cost of services, the student should send that bill to the Student
Health Insurance Office. The Insurance Office will submit a claim to
Anthem Blue Cross. Expect to receive an Explanation of Benefits
from Anthem Blue Cross, showing what was paid on your claim,
within six weeks after submitting a bill. For questions about claims
or the Explanation of Benefits, call the Student Health Insurance
Office at (510) 642-5700 or Anthem Blue Cross at (800) 888-2108.
SHIP and your privacy
University Health Services - Tang Center is committed to
protecting your privacy and the confidentiality of your health
information. Your health information will be used or disclosed
only for the purposes of your treatment, payment of your fees
and insurance claims, and for UHS and SHIP operations. Your
health information cannot be disclosed to anyone for any other
purpose, unless allowed by law, without your written authorization.
UHS and SHIP privacy policies are available on our website.
Comments or concerns about privacy issues may be sent to
myprivacy@uhs.berkeley.edu.
If students do not pay their portion of UHS fees within seven
business days, or if a UHS service is denied coverage by SHIP, the
student’s campus account (CARS) will be billed for the outstanding
amount. The CARS billing statement will state only that the charges
were incurred at UHS. No health information is released to CARS.
For services outside UHS, charges will be sent directly to the
insured’s (student’s) address.
When you are covered by SHIP
and another health plan
SHIP covers services at the Tang Center regardless of whether
students have coverage through an additional medical plan.
The Tang Center will submit claims to Anthem Blue Cross for
students. After students pay the coinsurance amount that SHIP
considers their responsibility, students may submit claims to their
other plans for reimbursement of that amount. The Tang Center
does not submit claims to plans other than SHIP.
For services received outside of the Tang Center, the student’s
other medical plan will be considered the primary plan, meaning
that plan must pay claims first. After the primary plan processes
and pays a claim, any remaining charges may be submitted to SHIP
For more information, see www.uhs.berkeley.edu/ship
7
(the secondary plan). This holds true for all medical plans except
Medi-Cal; if a student has Medi-Cal, SHIP will be the primary plan,
and Medi-Cal the secondary plan. For questions about coordination
between plans, call the Student Health Insurance Office.
Insurance after graduation
If you are graduating from Cal or if you are losing SHIP eligibility
because you are no longer a registered student at UC Berkeley, it is
important to plan ahead for continuing health coverage.
If your final semester is a spring semester, your last day of SHIP
coverage is August 14. If your final semester is a fall semester, your
last day of SHIP coverage is January 14.
A variety of plans are available to you once your SHIP coverage
ends. Plan types include short-term coverage, individual plans, a
conversion plan for persons with ongoing medical conditions, and
public health insurance programs. Visit our website for information
about these plans and dates of workshops to help you decide which
plan best meets your needs.
Important phone numbers
and website addresses
Student Health Insurance Plan website:
www.uhs.berkeley.edu/ship
Student Health Insurance Plan Office: (510) 642-5700
Anthem Blue Cross Customer Service: (800) 888-2108
Anthem Blue Cross website: www.anthem.com/ca
Metropolitan Life Customer Service: (888) 384-5155
Metropolitan Life website:
https://mybenefits.metlife.com
UC Berkeley School of Optometry - Meredith W. Morgan
University Eye Center appointments and
customer service: Tang Center: (510) 643-2020,
Minor Hall: (510) 642-2020
Website: www.caleyecare.org
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Definitions of insurance terms
Ancillary Services: Services rendered by health care providers
other than a physician (as defined below), such as laboratory,
radiology or other diagnostic imaging, physical therapy or
other services.
Anthem Blue Cross Network Rate/Negotiated Fee: Negotiated
Fee or Network Rate is the amount Participating Providers agree to
accept as payment in full for covered services. It is usually lower
than their normal charge. These rates are determined by the
Anthem Blue Cross PPO Participating Provider Agreements.
Copay: The amount that an insured person must pay for a covered
service, usually due at the time the service is provided.
Coinsurance: Coinsurance is similar to copayment, except that it is
a percentage of the total charges, rather than a set dollar amount.
Example: copayment is $10 per visit (regardless of the total
charges), coinsurance is 20% of total charges for the visit.
Customary and Reasonable (C&R): A Customary and Reasonable
charge, as determined annually by Anthem Blue Cross, is a charge
that falls within the common range of fees billed by a majority of
physicians for a procedure in a given geographic region, or that is
justified based on the complexity or the severity of treatment for a
specific case. When a non-Anthem Blue Cross PPO physician is
used, the patient is responsible for payment of all charges in
excess of the Anthem Blue Cross C&R payment.
Deductible: The amount of money you need to pay out of pocket
before the insurance carrier will pay for services.
Emergency: An emergency is a sudden, serious and unexpected
acute illness, injury or condition (including sudden and unexpected
severe pain) that you reasonably perceive could permanently
endanger your health if medical treatment is not received
immediately. Anthem Blue Cross has sole and final determination
as to whether services were rendered in connection with an
emergency.
Inpatient: A patient who is admitted to the hospital.
Non-Network/Limited Fee Schedule: The amount paid to
providers who are not members of the Anthem Blue Cross PPO
Plan, usually a percentage of their total billed charges. Only a
portion of the amount that a nonparticipating provider charges for
services is a covered expense under SHIP; the patient is
responsible for all charges above the coverage level.
Preferred Provider Organization (PPO): A group of medical
providers who contract with an insurance carrier to provide the
insured with reduced rates.
For more information, see www.uhs.berkeley.edu/ship
9
Description of SHIP benefits
Medical and mental health benefits
Please note:
• All non-emergency medical and mental health care must begin at
University Health Services. All services must be authorized by the
Student Health Insurance Office in order to ensure payment for
services. Coverage is worldwide for emergency services and
other authorized care.
• There is a $200 per-plan-year deductible for services provided
outside of UHS. The deductible applies to all services described
below except where noted.
• For maximum payment, members must receive care within the
Anthem Blue Cross PPO Network. If providers or facilities are
used that are not part of the Anthem Blue Cross PPO Network,
claims will be paid at 60% of the non-network rate (limited fee
schedule), which is often significantly lower than the network
rate. For example, 80% coverage of the network rate is going
to be less costly to the member than 60% coverage of the
non-network rate.
• For services provided at UHS, SHIP members pay the portion for
which they are responsible at the time of service. UHS files a
claim with SHIP for the remainder of charges. For authorized
services received outside of UHS, the provider or patient submits
itemized bills to Anthem Blue Cross or the Student Health
Insurance Office. Claims must be received no later than 11
months after the date the health care service is rendered.
• SHIP members are responsible for no more than $3,200 of
out-of-pocket expenses each plan year. If you have paid $3,200 in
coinsurance/copays and deductibles, you will no longer be
required to pay coinsurance/copays for the remainder of the
plan year. The out-of-pocket maximum does not apply to
amounts exceeding stated benefit limits (for example, Pharmacy
or Physical Therapy limits) or to services not covered by the plan.
• SHIP has a $400,000 lifetime maximum.
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Inpatient hospital services
Including: medical services, mental health and maternity services
Semi-private room Pays 90% of Anthem Blue Cross
Network rates, 80% of non-Network rates.
Lab tests, X-rays Pays 90% of Anthem Blue Cross Network
& imaging rates, 80% of non-Network rates.
General supplies Pays 90% of Anthem Blue Cross Network
rates, 80% of non-Network rates.
Nursing services Pays 90% of Anthem Blue Cross Network
rates, 80% of non-Network rates.
Medication Pays 90% of Anthem Blue Cross Network
rates, 80% of non-Network rates.
Physicians Pays 80% of Anthem Blue Cross Network
& specialists rates, 60% of non-Network rates.
• Inpatient hospital care in connection with childbirth will be
covered for at least 48 hours following a normal delivery
(96 hours following a cesarean section).
• Newborns are covered for the first 30 days from date of birth,
with a $25,000.00 lifetime maximum.
• Coverage of mental health inpatient treatment is limited to
30 days per plan year, except as medically indicated for severe
conditions covered by the Mental Health Parity Act of 2000.
• Coverage of inpatient hospital alcohol and drug detoxification
treatment is limited to four days per plan year.
Emergency room services
Emergency room Pays 100% of Anthem Blue Cross Network
rates for treatment provided within 72
hours of an injury or onset of a sudden and
serious illness, as determined by
Anthem Blue Cross. Pays 80% of
Anthem Blue Cross Network rates,
or 60% of non-Network rates for all
other conditions.
Attending physicians Pays 80% of Anthem Blue Cross Network
rates or 60% of non-Network rates for all
other conditions.
For more information, see www.uhs.berkeley.edu/ship
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Outpatient services
Medical At UHS: Members pay $15 for a primary
office visits care office visit or $30 for an Urgent
Care visit. Covers 80% of fees for visits
to UHS specialist physicians, procedures
and supplies, not subject to the deductible.
Outside of UHS: Pays 80% of
Anthem Blue Cross Network rates, or 60%
of non-Network rates
Mental health At UHS: Covers 80% of charges for
office visits counseling or psychiatry visits, not subject
to the deductible. There is no charge for
the first five counseling visits.
Outside of UHS: Pays 80% of
Anthem Blue Cross Network rates or 60%
of non-Network rates. For conditions that
are not covered by the Mental Health Parity
Act of 2000, pays a maximum of 25 visits
per plan year. These are not subject to
the deductible.
Psychological testing, medication
monitoring, psychotherapy services and
other conditions covered by the
Mental Health Parity Act of 2000 will
be reimbursed at 80% of the Anthem
Blue Cross-negotiated fee for Anthem
Blue Cross Network providers or 60%
of the Anthem Blue Cross limited fee
schedule for non-Network providers. These
services are subject to the $200 plan year
deductible.
Lab tests, Pays 80% of UHS charges or
imaging, X-rays, Anthem Blue Cross Network rates,
mammograms or 60% of non-Network rates.
Surgery Pays 80% of Anthem Blue Cross Network
rates, or 60% of non-Network rates, for
services of physicians and
anesthesiologists. Pays 100% of
Anthem Blue Cross Network rates for
outpatient surgery center facilities.
Non-Network surgery centers are paid a
flat rate of $540.
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Outpatient services (continued)
Prescription drugs Prescriptions filled at the UHS Pharmacy
have a copay of $15 for generic and
$25 for brand-name medications
(30-day supply). Hormonal contraceptives
have a copay of $25 for three cycles.
Prescriptions filled outside of the UHS 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. Visit the SHIP
website for information on tracking how
much of the pharmacy benefit you
have used.
Acupuncture Pays $25 per visit per day up to a
maximum of $100 per plan year.
Allergy testing Pays 80% of UHS charges or
& injections Anthem Blue Cross Network rates, or 60%
of non-Network rates, up to $1,000
maximum per plan year.
Ambulance - Pays 90% of customary and reasonable
ground charges, if patient receives emergency
treatment or is hospitalized. Paid amounts
go toward out-of-pocket maximum.
Ambulance - Pays 80% of customary and reasonable
air charges, if patient receives emergency
treatment or is hospitalized. Paid amounts
go toward out-of-pocket maximum.
Chiropractic Pays $25 per visit per day up to a
services maximum of $100 per plan year.
Dental care SHIP members receive dental coverage
through MetLife. See Dental benefits
information following this section.
Dental injury Pays 80% of Anthem Blue Cross Network
rates, or 60% of non-Network rates, for
injury to natural teeth, up to $300 per
injury, for services within 90 days of the
date of injury.
For more information, see www.uhs.berkeley.edu/ship
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Outpatient services (continued)
Durable medical Pays 80% of rental or purchase of medical
equipment equipment and supplies that are ordered
by a Physician and are of no further use
when medical need ends, when obtained
from a durable medical equipment
supplier, including rental or purchase of
diabetic equipment and supplies
(excluding insulin).
Home health visits Pays 100% of Anthem Blue Cross Network
rates, or 80% of non-Network rates, up to
100 visits per plan year.
Hospice care Pays up to $5,000 maximum for
patient's lifetime.
Immunizations Pays 80% of UHS charges or Anthem
Blue Cross Network rates, or 60% of non-
Network rates, for the following
immunizations: Diphtheria with Tetanus;
Measles, Mumps and Rubella;
Meningococcal; Varicella; Influenza;
Hepatitis A and Hepatitis B; Pneumococcal;
Polio; and Human Papillomavirus.
Maternity, prenatal Pays 80% of Anthem Blue Cross Network
care, abortion rates, or 60% of non-Network rates.
Physical therapy Pays 80% of UHS charges or Anthem
Blue Cross Network rates, or 60% of non-
Network, up to $1,500 per plan year.
Podiatric services Pays 80% of charge up to a maximum of
$125 per plan year.
Skilled nursing Pays 80% of Anthem Blue Cross Network
facility rates, or 60% of non-Network rates, up to a
maximum of 100 days per plan year.
Medical evacuation If you are in the U.S. on a non-immigrant
visa and become unable to continue
your academic program because of your
medical condition, the plan pays necessary
expenses up to $10,000 for return to your
home country when prior authorization
has determined medical necessity.
Repatriation If you are in the U.S. on a non-immigrant
visa and die while enrolled in SHIP, the
plan pays necessary expenses up to $7,500
to prepare your remains and transport
your body to your home country.
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SHIP Vision
SHIP Vision plan benefits include:
• Eye exam for a $5 copay, once every 12 months
• Frames and lenses or contact lenses, for a $15 copay, once every
12 months, up to a $120 value
• 20% discount on lens options such as Transitions ®
lenses,
anti-reflective or anti-scratch coatings, UV protection and others
• 50% discount on Lasik or PRK refractive surgeries
• 24/7 access to emergency care
You will be expected to pay the copayment and other fees at the
time of service. There are no claims to file.
If you are away from Berkeley and urgently need replacement of
prescription ophthalmic materials that were originally dispensed
by the School of Optometry, such as glasses or contact lenses, the
School will provide overnight shipping at no additional charge.
Please note:
•If lenses and frames or contact lenses are chosen that exceed
the $120 allowance, the cost above $120 is the responsibility of
the student. Contact lens wearers may be subject to a contact
lens evaluation fee or, for first-time users, a fitting fee.
•Services are covered only if they are provided by the UC
Berkeley School of Optometry.
Services are available at these UC Berkeley School of Optometry
Clinic locations throughout California:
Cal State University (CSU) Los Angeles
Student Health Centers: Northridge
East Bay (Hayward)
San Francisco
Sacramento
Community-based clinics:
Castle Family Health Atwater, CA (near Merced)
Alameda County Medical Oakland, CA
Center – Eastmont Wellness Center
For more information, see www.uhs.berkeley.edu/ship
15
Dental benefits
If the care is provided by a…
Preventive and diagnostic services:
• Oral exams (2 per year)
• Cleanings (2 per year)
• X-rays
• Fluoride treatment
Basic operative and restorative
services:
• Fillings
• Simple extractions
• Oral surgery
• Periodontics
• Endodontics
$1,000 plan year maximum for all dental benefits
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Dentist who is a Dentist who is not a
member of the member of the
Preferred Dentist Program, Preferred Dentist Program,
the plan covers... the plan covers...
100% 80%
of negotiated fees that of reasonable and
participating dentists customary charges
have agreed to accept as
payment in full
80% 60%
of negotiated fees after of reasonable and
a $25 annual deductible customary charges after
a $25 annual deductible
Copayments will be
higher than if you use a
MetLife Preferred Dentist
For more information, see www.uhs.berkeley.edu/ship
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Exclusions and Limitations
Medical care that is not covered by SHIP
(Anthem Blue Cross)
Unauthorized Services: Services not approved by the Student
Health Insurance Office, except emergency room and urgent care
center services, routine and diagnostic mammogram examinations
to detect breast cancer, acupuncture, chiropractic services and
prescription drugs.
Preventive/Elective Services: Testing, treatment or services
for any condition in the absence of Sickness or Injury, except
for (1) screening mammograms, (2) cervical cancer screening
(Pap smears), (3) prescription birth control and (4) certain
adult immunizations.
Obesity/Weight Reduction: Services primarily for weight reduction
or treatment of obesity. Treatment of morbid obesity may be a
covered benefit, subject to verification of diagnosis and utilization
review for medical appropriateness and necessity following
Anthem Blue Cross Medical Review criteria.
Nutrition Consultation: Except for diabetes education programs
covered as medical office visits.
Cosmetic Surgery: Except reconstructive surgery as a result
of accidental Injury or Sickness that occurs while eligible for
SHIP benefits.
Nasal Surgery: Except medically necessary surgical treatment for
acute sinusitis or due to a medically documented accidental Injury
that occurs while eligible for SHIP benefits.
Optometric (Vision) Services or Supplies: Optometric Services,
eye exercises, including orthoptics. Routine eye exams and routine
eye refractions. Eyeglasses or contact lenses. Note: Vision
screening and correction services are provided by UC Berkeley
School of Optometry. See Vision benefits section of this brochure.
Intercollegiate Sports Injuries: Treatment of Injury sustained while
participating in, practicing or conditioning for, or traveling in
conjunction with, any intercollegiate sport, contest or competition,
or any University-sponsored (including intramural) program in the
martial arts.
Workers' Compensation Services: Treatment of any Illness or
Injury eligible for compensation under any Workers' Compensation
or Occupational Disease Law.
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Crime, Nuclear Energy: Conditions that result from: (1) your
commission of or attempt to commit a felony; or (2) any release of
nuclear energy, whether or not the result of war, when government
funds are available for treatment of Illness or Injury arising from
such release of nuclear energy.
Organ and Tissue Transplants
Infertility Treatment: Any services or supplies furnished in
connection with the diagnosis and treatment of infertility,
including, but not limited to, diagnostic tests, medication, surgery,
artificial insemination, sterilization reversal, in vitro fertilization and
gamete intrafallopian transfer. Infertility is:
1. The presence of a condition recognized by a Physician as the
cause of infertility or
2. The inability to conceive a pregnancy or carry a pregnancy
to a live birth after a year or more of regular sexual relations
without contraception.
Dental Services or Supplies: Braces, orthodontic appliances and
orthodontic services. Dental plates, bridges, crowns, caps or other
dental prostheses, dental services, extraction of teeth or treatment
to the teeth or gums. Cosmetic dental surgery or other services for
beautification. Note: Dental care benefits are provided by MetLife.
See Dental benefits section of this brochure.
Speech Disorders: Services primarily for correction of speech
disorders, including, but not limited to, stuttering or stammering.
Hearing Aids: Including exams for fitting, except as required to
correct damage caused by an Injury that occurs while the patient is
covered by SHIP.
Services Performed by a Family Member: All medical and
psychological treatment or services performed by any member
of your immediate family.
Experimental or Unnecessary Medical Treatment/Testing:
Includes medical services that are not medically necessary or that
do not conform with medical standards of practice within the
community. Also services and supplies in connection with
experimental or investigational treatment.
Sterilization Reversal: Reversal of sterilization.
Orthopedic Supplies: Orthopedic shoes (except when joined
to braces) or shoe inserts.
Air Conditioners: Air purifiers, air conditioners or humidifiers.
For more information, see www.uhs.berkeley.edu/ship
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Exercise Equipment: Exercise equipment or any charges for
activities, instrumentalities or facilities normally intended or used
for developing or maintaining physical fitness, including but not
limited to, charges from a physical fitness instructor, health club or
gym, even if ordered by a physician.
Personal Items: Any supplies for comfort, hygiene or beautification.
Telephone and Facsimile Machine Consultations: Consultations
provided by telephone or facsimile machine.
Routine Exams or Tests: Routine physical exams or tests that do
not directly treat an actual illness, injury or condition, including
those required by employment, government authority and travel.
Unstated Treatment, Services and Supplies: SHIP will not pay
benefits for any treatment, service or supply that has not been
listed herein as a covered service or item, even if it has not been
specifically identified as an "excluded" item.
Dental care that is not covered by SHIP (MetLife)
• Services or supplies received by a plan member before coverage
starts for that person
• Services not performed by a Dentist except for those services of
a licensed dental hygienist that are supervised and billed by a
Dentist and that are for scaling and polishing of teeth; or fluoride
treatments
• Cosmetic surgery, treatment or supplies
• Services or supplies that are deemed experimental in terms of
generally accepted dental standards
• Services or supplies received as a result of dental disease, defect
or injury due to an act of war or a warlike act in time of peace
• Use of material or home health aids to prevent decay, such
as toothpaste or fluoride gels, other than the topical application
of fluoride
• Instruction for oral care such as hygiene or diet
• Periodontal splinting
• Temporary or provisional appliances
• Services or supplies to the extent that benefits are otherwise
provided under this plan or under any other plan that
UC Berkeley (or an affiliate) contributes to or sponsors
• Myofunctional therapy or correction of harmful habits
• Implantology
• Charges for broken appointments
• Charges by the Dentist for completing dental forms
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• Sterilization supplies
• Services or supplies furnished by a family member
• Major restorative services, such as dentures, bridgework, inlays,
onlays or crowns
• Orthodontia
• Intercollegiate Sports Injuries: Treatment of Injury sustained
while participating in, practicing or conditioning for, or traveling
in conjunction with, any intercollegiate sport, contest or
competition, or any university-sponsored (including intramural)
program in the martial arts
• Temporomandibular Joint Dysfunction
• Replacement of a lost, missing or stolen crown, bridge
or denture
• Services or supplies that any employer is required by law to
furnish in whole or in part
• Services or supplies received through a medical department
or similar facility that is maintained by the covered
person’s employer
• Services or supplies that are covered by any employer’s
liability laws
Vision care that is not covered by SHIP (UC Berkeley
School of Optometry Plan):
• Orthoptics or vision training
• Nonprescription glasses or contact lenses
• Medical or surgical treatment of the eyes other than laser
vision correction
• Non-FDA-approved vision services, treatment and materials
• Any other service not listed herein as a covered benefit
For more information, see www.uhs.berkeley.edu/ship
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Notes
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For more information, see www.uhs.berkeley.edu/ship
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Anthem Blue Cross Life and Health Insurance Company provides
administrative services only and does not assume any financial
risk or obligation with respect to claims. Blue Cross of California,
using the trade name Anthem Blue Cross, administers claims on
behalf of Anthem Blue Cross Life and Health Insurance Company
and is not liable for benefits payable. Independent licensees of
the Blue Cross Association. ® ANTHEM is a registered trademark
of Anthem Insurance Companies, Inc. The Blue Cross name and
symbol are registered marks of the Blue Cross Association
MCABR3364C 09/09
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