Summary of Health Benefits for UCSF Residents and Fellows effective July 1, 2007
This brochure describes all of the benefit plans provided by UCSF for Residents and Fellows as insured by Blue Cross of California. Inside, a Health Plan Comparison Chart provides important details about the benefits available to you by the Blue Cross of California’s Preferred Health Plan. Open Enrollment Period Each year, during the Open Enrollment Period (JuneJuly), you have the opportunity to elect a medical carrier through one of two UCSF sponsored health plans: Blue Cross of California or Health Net. You should carefully read all of the material provided and attend the Orientation meetings, if necessary, to learn as much as you can about the many benefits provided. Preferred Health Plan Benefits
When you or any of your covered dependents receive treatment from these preferred providers primary care physicians, specialists, x-ray and lab facilities, and hospitals - your out-of-pocket expense is limited to the office visit copay. All other charges are covered in full. No Claim Forms when using Preferred Providers There are no claims forms to file - the preferred providers take care of the billing through Blue Cross of California. The goal of Blue Cross of California is to provide you with the best health care possible while protecting you from potentially large medical costs. We urge you to use your health care dollars wisely.
Blue Cross of California’s Health Plan provides full If you have any questions, please contact Blue coverage for treatment through the plan’s preferred Cross of California at: providers; with only a $20 office visit copay for doctor’s Medical office visits. No “primary care physician” referral is Blue Cross of California necessary; self-referral for specialist care is permissible. P. O. Box 60007 Blue Cross of California’s extensive list of preferred Los Angeles, CA 90060-0007 providers will be made available to you. This list (800) 759-3030 includes all UCSF/Mt. Zion faculty and facilities. Pharmacy (800) 700-2541 Mail-order (866) 274-6825 Website www.bluecrossca.com
Preferred Plan Benefits Blue Cross of California Blue Cross of California is the insurer for our Medical plan. Blue Cross of California is a financially strong Healthcare and Life company with assets of over $6 billion. Blue Cross of California is also a recognized leader in providing responsive customer service and innovative managed health care programs. Benefits for Primary Care Services Benefits for office visits, diagnostic x-ray and lab, and well baby and childcare (through age 16) are covered in full after a $20 copay. In addition, up to $500 per year is covered for wellness and preventive services for children (age 2 to 16) and $250 per year for adults (from age 17 and older) including immunizations.
Benefits for Other Services For all other covered services, the plan covers 80% of the charges. There is no deductible. Refer to the Medical Plan The Blue Cross of California’s Preferred Health Plan Comparison Chart for a description of these enhanced features enhanced benefits through the Prudent Buyer benefits. Network of health care providers, which includes all UCSF physicians and facilities. The network includes hospitals, Low Out-of-Pocket Expenses primary care physicians, specialists and other ancillary You can reduce your overall out-of-pocket expenses by services. Treatment from Prudent Buyer Preferred using Prudent Buyer preferred providers. A $20 copay is Providers is covered in full, except for a $20 office visit required for some services. copay, does not require a referral by a “primary care physician”. Hospital Charges covered at 80% Benefits for most inpatient hospital charges are covered at If you need information regarding participating providers, 80% at Prudent Buyer participating hospitals. please check the Blue Cross of California’s, an affiliate of Blue Cross of California’s website www.bluecrossca.com No Claim Forms or if you have specific questions regarding participating If you use a Prudent Buyer provider, you generally do not providers please call Blue Cross of California Customer need to file a claim form with Blue Cross of California. Service directly at 1-800-759-3030. Prudent Buyer providers will transmit claims directly to Blue Cross of California and you will receive a statement from a Prudent Buyer provider, call the Blue Cross of California Claims Office at 1-800-759-3030 for assistance. Prudent Buyer Preferred Providers Freedom of Choice The Preferred Health Plan features both tradition fee-forservice coverage and coverage through preferred providers (on the basis of self referral). You may choose to use a combination of providers at any time, even during a course of treatment. However, your out-of-pocket expense will always be lower when you use preferred providers. If you have any questions regarding your benefits, call Blue Cross of California at 1-800-759-3030
Health Plan Highlights
How to Use the Preferred Health Plan If you are enrolled in the Blue Cross of California Preferred Health Plan, you will receive and ID card and a Prudent Buyer directory listing all preferred providers-hospitals, doctors and other health care facilities. You must show your ID card when using preferred providers, so that the providers will know to send the bill to Blue Cross of California. For office visits, present your card and pay the $20 copay-it’s that easy. For other services, the providers will send the claim form to Blue Cross of California and you will receive an Explanation of Benefits (EOB) showing the amount of benefits paid. The EOB will also show the balance due, if any, for your share of the covered charges. Open Enrollment Period The annual Open Enrollment period is your opportunity to select the health program that best meets your needs. Each year, during June and July, you have the choice of participating in one of the health plans offered by UCSF-the Blue Cross of California Health Plan or the Health Net Plan. Each Plan differs in philosophy and in a way in which health care is delivered. You should carefully consider each of them in terms of their ability to match your health care needs, preferences and pattern of use. It is important to learn as much as you can about the health care options available to you. We encourage you to read the material provided carefully, attend the Orientation meetings, and ask questions of the plan representatives who will be on-site during this period. For more information about..... Eligibility or Enrollment, call UCSF Office at 1-415-476-8093 Health Benefits, call Blue Cross of California at 1-800-759-3030 or visit the web site at: www.bluecrossca.com Prudent Buyer Preferred Providers, call 1-800-759-3030
Health Plan Provisions
Covered Medical Expenses Your booklet provides specific information regarding benefits for covered medical expenses. Covered medical expenses include necessary medical care including, but not limited to: inpatient and outpatient hospital services; physician and surgeon services; diagnostic x-ray and laboratory services; prescription drugs and medicines; physical therapy; home health care and skilled nursing services and facilities; hospice services; durable medical equipment; and treatment of mental/nervous conditions and substance abuse. *Please note that the benefit payments for office visits vary depending on place of service (for example services at a hospital based facility will be paid at 80%). The plan pays for services for all well-baby care through age 16, up to $500 per plan year. California state mandates for child health services apply. In addition, the plan covers wellness and preventive services, including immunizations for adults, age 17 and older, up to $250 per policy year. These benefits are available only through preferred providers. The plan pays 100% after a $20 copay per prescription for brand named drugs, through WellPoint participating pharmacy. If a generic is used, then the copay is only $10 and $40 for a non-formulary drug. Additionally, you may obtain up to a 90-day supply for maintenance drugs by utilizing the mail order drug program for a $20 copay for generic, $40 copay for brand and $80 copay for non-formulary drugs. Oral contraceptives are a covered expense. Information and forms are available through the Postdoctoral Education Office. The plan provides benefits for treatment by licensed mental health providers. There is a $20 office visit copay and the deductible is waived for outpatient mental health treatment and marriage counseling. Note: The diagnosis and treatment of severe mental illness is considered as any other illness by the health plan. Inpatient non-severe mental treatment is limited to 30 days per policy year and paid at 80% subject to a $250 copay per admission. Programs are built in to help you get the most of your health care dollars. Prior authorization is required for all hospital admissions. If authorization is not obtained for all non-participating hospitals, benefits will be reduced by $500 per hospital admission. You should ask your doctor to contact Blue Cross of California directly to obtain this authorization. The Blue Cross of California prior authorization number is listed below and also on the back of your identification card. (800) 274-7767 The plan does not cover the following: cosmetic surgery except for repair due to an accident (while insured) or a congenital birth defect; non-prescribed drugs; care of a custodial nature or charges which are not medically necessary; work related accident or illness; charges which exceed the usual and customary charges in the area; surgery to correct vision; and charges for Infertility/In-vitro fertilization.
Preventive and Wellness Benefits
Prescription Drugs and Medicines
Counseling and Therapy BenefitsBehavioral Health
Pre-Hospital Authorization
Health Plan Limitations
This Health Plan Summary provides a brief description of the insured plans with Blue Cross of California as of July 1, 2007. The actual Plan Documents and Summary Plan Descriptions govern at all times. Should any inconsistency exist between this brochure and the Plan Document, the Plan Document will govern. UCSF reserves the right to make Plan changes at any time.
Health Plan Comparison Chart
Choice of Doctor, Hospital and Other Health Care Providers
Preferred Benefits Prudent Buyer Providers Any preferred provider may be used; primary care physician referral is not required
Standard Benefits All Other Providers Any licensed provider may be used; benefits are based on treatment provided
Plan Features Deductible (policy year) Stop Loss Maximum Maximum Benefits - Lifetime Overall Maximum - Treatment for Substance Abuse - Treatment for Mental Illness
(see note on pg. 6 under Counseling & Therapy)
None
$200 per person/ $600 family $5,000 plus deductible (if applicable) $5,000,000 per person Outpatient Maximum: 100% up to 30 visits per plan year Inpatient Maximum: 80% (PPO Only) - 30 days per plan year (combined with Inpatient mental)
Inpatient Maximum: $250 Copay per admission – 80% - 30 days per plan year Deductible waived for non-par (combined with Inpatient substance abuse) 100%, after $20 copay 100%, after $20 copay 100%, after $20 copay 60%. 60% Not Covered
Primary Medical Care Physician Office Visit* Well-Child Care (through age 6) Preventive Care for children (age 2 – 16) $500 per plan year; for Adults (age17 & older) $250 per plan year. Hospital & Surgical Hospital Inpatient Charges Hospital Outpatient - Emergency Room Charges – ER copay waived if admitted - Outpatient Surgery Charges (ASC) - Pre-Admission Testing Charges Second Surgical Opinion Inpatient Surgery Charges Other Medical Services Prescription Drugs through participating WellPoint pharmacies Mail Order Drugs through Precision Pharmacy Durable Medical Equipment Back Treatment Outpatient non-severe Mental Health Treatment & Marriage Counseling Home Health Care (100 visits/year) Skilled Nursing Facility Care (100 visits/year)
80% 100% after $50 ER copay 100% 100% 100% 80%
60% 70% after $50 ER copay and Plan Ded. (Non-Certified Deductible - $500) 100% 100% 100%, deductible waived 60%
100%, after $10 copay per generic drug or $20 copay per brand prescription and $40 copay for non-formulary – 34 day supply 100% after $20 copay per generic drug or $40 copay per brand prescription and $80 copay for non-formulary – 90 day supply 80% 60% 80% 60% $20 office visit copay to 30 visits per plan year 80% 80% 60% 60%
Hospice Care All Other Covered Services
100% 80% 60%
WellPoint Prescription Plan for University of California, San Francisco
2007
Drug copayment at a WellPoint participating * Copayment at a non-participating pharmacy* $10 Generic, $20 Brand and $40 for nonformulary prescription You must pay 100% of prescription price. Submit a Wellpoint Claim Form for full reimbursement of the Blue Cross of California negotiated price; minus your copayment. Up to a 34-day supply plus refills, depending on the drug prescribed. $20 generic, 40 brand and $80 nonformulary prescription Up to a 90-day supply plus refills depending on the drug prescribed.
Supply per prescription
Mail Order copayment Supply per prescription
* WellPoint negotiates prescription discounts with its participating pharmacies. Prescriptions filled at a non-participating pharmacy do not benefit from these discounts. You will pay the retail pharmacy copay of $10 Generic, $20 Brand or $40 Non-Formulary plus 50% of the covered expense.
What’s Covered, What’s Not
Your WellPoint Prescription Plan covers: Federal Legend Drugs Prenatal Vitamins with a written prescription Fluoride Desi Drugs Ritalin Oral Contraceptives Compounded Medications Other Legend Vitamins Insulin Needles/Syringe with Prescription, Test Strips, Lancets Retin-A Insulin with Prescription Diabetic Testing Supplies Retrovir (AZT)
Your WellPoint Prescription Plan does not cover: Over the counter items and state restricted drugs. Therapeutic devices or appliances including contraceptive devices, support stockings, other non-medical products. Any drug labeled “Caution: Limited by Federal law to investigational use or experimental drugs.” Charges for the administration or injection of any drug. Medication taken/administered to an individual in any type of institution, or a similar institution which operates or allows to be operated on its premises, a facility which dispenses pharmaceuticals. Prescription which an eligible person is entitled to receive without charge from a Worker’s Compensation Law or a Municipal, State or Federal program. Growth Hormones Minoxidil (Rogaine) Non-legend Drugs, including insulin Fertility Drugs The following drugs are standardly excluded under Mail Order: Growth Hormones Minoxidil (Rogaine) Desi Drugs Non-legend Drugs, including Fertility Drugs Insulin