Together for a great state of health - Blue Shield of ......02 Blue Shield of California Go with the...

Together for a great state of health

Core plan Administered by Blue Shield of California

A PPO plan compatible with a health flexible spending account (FSA)

blueshieldca.com/uc Effective January 1, 2016

A plan for your personal state of health

When you choose the Core plan, administered by Blue Shield of California,

you’re on your way to quality health coverage, one of the largest provider

networks, and a wide range of programs and services that help

provide the most value from your coverage.

What’s inside

Core plan

Plan highlights 03

How the Core plan works 04

Features and medical benefits 06

Pharmacy benefits 08

How to find a network provider 10

Programs and services 11

blueshieldca.com/uc

02 Blue Shield of California

Go with the plan that’s right for you

We’re here to help

Contact Shield Concierge toll-free at (855) 339-9973 (domestic); 800 60004141 (international) from 7 a.m. to 7 p.m. PT, Monday through Friday. Visit blueshieldca.com/uc to find providers, review medical benefits, and more. Download the Blue Shield mobile app for iPhone or Android at blueshieldca.com/mobile.

During the University of California 2016 annual enrollment period, one of your medical plan options is the Core plan, administered by Blue Shield of California. This booklet offers the information you need to understand the Core plan so you can choose the right health plan for you and your family.

By choosing the Core plan, you have access to care and services from the physicians and hospitals within the plan’s network, as well as outside of the network. If maintaining a relationship with your current doctor is important to you, then the Core plan may be a good choice. The Core plan provides flexibility that allows you to continue seeing your current doctor, even if your doctor is not part of the plan’s provider network. Keep in mind that if your physician is not part of the plan’s PPO network, you will pay more for each visit.

visit blueshieldca.com/uc 03

Plan highlights

Below are a few highlights of the services covered by the Core plan. For details on copayment and coinsurance amounts, please see the benefit overview on page 7. To find network providers, see page 10.

Preventive care – Provides access to services defined as routine preventive care without having to pay a copayment or meet the plan’s deductible. You can download a list of recommended screenings and immunizations by going to blueshieldca.com/preventive.

Specialty care – You can access care through a specialist without a referral from your primary care physician.

Urgent care – Save time and money by going to an urgent care center instead of the emergency room. To find an urgent care center, visit blueshieldca.com/uc and select Find a Provider, and click on Go under “Find an Urgent Care Center” on the right side.

Emergency care – You’re covered for emergency care around the world regardless of whether the provider is in your plan’s PPO network.

Chiropractic and acupuncture services – Visit any chiropractor or acupuncturist in the Blue Shield PPO network.

Accessing care away from home – Through the BlueCard Program, Core plan members can live or travel outside the United States and still be covered for the same medical services as members living in the United States. Here is a partial list of some of the services covered by these plans:

• Physician office visits

• Specialist office visits

• Preventive health benefits

• Pregnancy and maternity care benefits

• Outpatient X-ray, pathology, and laboratory

• Hospital care (outpatient surgery in hospital)

• Emergency room services

• Acupuncture benefits

• Chiropractic benefits

• Rehabilitation (physical and occupational therapy)

For complete information on covered services while traveling, please see the Core plan Benefit Booklet or the International Brochure that can be found by going to blueshieldca.com/uc, selecting Non-Medical Plans and then Core Plan.

Another way to save: Consider a health flexible spending account

A health flexible spending account (FSA) is an account that allows you to save pre-tax dollars (through payroll contributions) to pay eligible healthcare expenses not covered by your medical, dental, or vision plans. For more information about the FSA offered through the University of California, visit: http://ucnet.universityofcalifornia.edu/forms/pdf/hfsa.pdf.


How the Core plan works

The Core plan is great for individuals and families

Estimate your medical costs

Members

Blue Shield’s Treatment Cost Estimator tool provides Core plan members with estimates of both the total cost and out-of-pocket expenses for common network medical treatments and services. These estimates provide the transparency and clarity to help you budget and plan for future healthcare expenses. To access this tool, go to blueshieldca.com/uc and select Log in to blueshieldca.com. If you don’t have an account, select Register for an online account. Once logged in, click on Help & Support and then Treatment Cost Estimator.

Non-members

If you are not currently enrolled in the Core plan, then you can estimate your medical costs through fairhealthconsumer.org, a third-party website that is not affiliated with Blue Shield.

Important Note: fairhealthconsumer.org does indicate whether providers are part of the Blue Shield network, and the estimated costs do not reflect Blue Shield negotiated network discounts. Actual costs for services may vary depending on the plan you enroll in and the providers you access for services.

FAIR Health’s agreements with third parties place limits on the number of medical and dental searches that can be done on the site. Consumers can conduct 15 searches of up to five medical codes per week and 10 searches of up to five dental codes per week. Learn more at fairhealthconsumer.org/faq.

We’re here to help

Contact Shield Concierge toll-free at (855) 339-9973 (domestic); 800 60004141 (international) from 7 a.m. to 7 p.m. PT, Monday through Friday.


How this plan works:

With the Core plan, every family member has a separate individual deductible of $3,000 for medical and pharmacy benefits.

Before the annual deductible is met, members can access preventive care services at no charge when they visit network providers.

When using the plan benefits throughout the year, the amount paid for many of these covered services will count toward the deductible.

Once the annual deductible amount of $3,000 is met, the member pays a fixed percentage (20% coinsurance) of the amount allowed for most covered services, including prescription drugs.

When one member is enrolled on the plan:

After an individual member meets the individual out-of-pocket maximum amount of $6,350 (which includes the $3,000 deductible), Blue Shield pays 100% for most covered services, including prescription drugs, for the remainder of the year.

When two or more members are enrolled on the plan:

After a family meets its family out-of-pocket maximum amount of $12,700 (which includes the $3,000 deductible per family member), Blue Shield pays 100% for most covered services, including prescription drugs, for the remainder of the year.


Network Non-network

OUT-OF-POCKET COSTS

After calendar-year deductible is met, pay a coinsurance for covered services. (Some services are available

prior to meeting the deductible.)

After calendar-year deductible is met, pay a percentage of

costs and all costs above the allowable amount.

CHOOSING A DOCTOR

Visit any PPO network physician.

Visit any non-network physician, pay for the services, and

submit claims to Blue Shield.

ACCESS TO SPECIALISTS

Visit any PPO network specialist; no referral is required.

Visit any non-network specialist and submit claims to Blue Shield.

No referral is required.

PROGRAMS AND SERVICES

Condition management programs

NurseHelp 24/7SM

QuitNet (a new tobacco cessation program effective January 2016)

Shield Concierge

Teladoc

To learn more about these programs and services, see page 11.

Core plan features


For complete benefit details, see the plan’s Benefit Booklet by going to blueshieldca.com/uc, selecting Non-Medicare Plans and then Core Plan.

Network Non-network

Calendar-year deductible $3,000 per individual

Calendar-year out-of-pocket maximum or copayment maximum

$6,350 per individual/ $12,700 per family

Member copayment/coinsurance (after calendar-year deductible is met)

Physician office visit 20% 20%

Specialist office visit 20% 20%

Teladoc provider consultation, via phone or Web (see page 11 for details)

$40 per consultation until deductible is met then 20%

Not covered

Preventive health benefitsNo charge (not subject to the

calendar-year deductible)20%

Outpatient X-ray, pathology, and laboratory 20% 20%

Outpatient surgery in hospital 20% 20%

Inpatient facility services (non-emergency)

20% 20%

Emergency room services (not resulting in admission)

20% (not subject to the calendar-year deductible)

20% (not subject to the calendar-year deductible)

Mental health services (outpatient services)

20% 20%

Pregnancy and maternity care benefits* 20% 20%

Acupuncture benefits† 20% 20%

Chiropractic benefits† (provided by a chiropractor)

20% 20%

ACA preventive travel vaccinations (hepatitis A, hepatitis B, meningitis, polio)

No charge (not subject to the calendar-year deductible)

20%

Other travel vaccinations (Japanese encephalitis, rabies, typhoid, and yellow fever)

20% 20%

* Prenatal and postnatal physician office visits. For inpatient hospital services, see “Hospitalization Services” on the benefit summary in the back of this booklet.

† Up to 24 visits per calendar year for acupuncture and chiropractic services combined.

Core plan medical benefits chart


Pharmacy benefits

Blue Shield wants you to get the most from your pharmacy benefits. Here is helpful information to get started with your pharmacy benefits.

Compare prescription drug costs – If you are a Core plan member, you can compare the costs of generic versus brand-name drugs and compare the costs of drugs at up to five network pharmacies. To access the tool, go to blueshieldca.com/uc and select Log in to blueshieldca.com. If you don’t have an account, select Register for an online account. Once logged in, select My Plan & Claims, Pharmacy Claims, and then Drug Pricing.

Drug Formulary – If you’re currently taking a medication, check the Blue Shield Plus Drug Formulary to see if your medication is in our list of preferred prescription drugs. You can download the drug formulary by going to blueshieldca.com/uc and selecting Pharmacy Benefits, then Non-Medicare Pharmacy Benefits. If you don’t have access to the Internet or need help, simply contact Shield Concierge for personal assistance or to request a copy of our formulary.

Vaccinations at pharmacies – Members can receive vaccines, including influenza, HPV, shingles, pneumococcal, meningococcal, tetanus/diphtheria/whooping cough (Td and Tdap), at select pharmacies.

Travel vaccinations – New for 2016 – Effective January 1, 2016, the Core plan will cover many travel vaccinations such as rabies, typhoid, and yellow fever. For more details, visit blueshieldca.com/uc.

Extended supply of covered maintenance drugs – If you take stabilized doses of covered long-term maintenance medications for conditions such as diabetes, you can obtain up to a 90-day supply through:

• Select UC participating pharmacies

• Select Blue Shield participating pharmacies such as Costco, Safeway/Vons, and Walgreens

• Blue Shield’s mail-service prescription drug program (PrimeMail)

To learn more, go to blueshieldca.com/uc and select Pharmacy Benefits, then Non-Medicare Pharmacy Benefits.


Pharmacy benefits at a glance

For complete benefit details, see the plan’s Benefit Booklet by going to blueshieldca.com/uc, selecting Non-Medicare Plans and then Core Plan.

Participating pharmacy Non-participating pharmacy

Calendar-year deductible Calendar-year copayment maximum

Prescription drug coverage benefits are subject to the medical plan deductible and copayment maximum.

Member coinsurance (after calendar-year deductible is met)

Retail prescriptions (for up to a 30-day supply)

Contraceptive drugs and devices No charge No charge

Formulary generic drugs 20% per prescription 20% per prescription

Formulary brand-name drugs 20% per prescription 20% per prescription

Non-formulary brand-name drugs 20% per prescription 20% per prescription

UC Maintenance Drug Program (for up to a 90-day supply, available at select UC Pharmacies)

Contraceptive drugs and devices No charge Not covered

Formulary generic drugs 20% per prescription Not covered

Formulary brand-name drugs 20% per prescription Not covered

Non-formulary brand-name drugs 20% per prescription Not covered

Mail-service prescriptions (for up to a 90-day supply)

Contraceptive drugs and devices No charge Not covered

Formulary generic drugs 20% per prescription Not covered

Formulary brand-name drugs 20% per prescription Not covered

Non-formulary brand-name drugs 20% per prescription Not covered

Travel vaccinations

ACA preventive travel vaccinations (hepatitis A, hepatitis B, meningitis, polio)

No charge (not subject to the calendar-year deductible) 20% per prescription

Other travel vaccinations (Japanese encephalitis, rabies, typhoid, and yellow fever) 20% per prescription 20% per prescription


Find a network provider

If you don’t have access to the Internet or need help, simply contact your dedicated Shield Concierge team toll-free (855) 339-9973 (domestic); 800 60004141 (international) for personal assistance or to request a provider directory.

Blue Shield has an expansive network in California. The PPO network includes more than 70,000 physicians and 350 hospitals.

Search for a network provider in California

It’s fast and easy to find a network provider online:

• Go to blueshieldca.com/uc, select Find a Provider and then choose Find providers within California under “Core Plan.”

• You will be directed to the Blue Shield website where you can click on Advanced Search to further filter your search by name, specialty, facility type, and more.

• Enter your city and state or ZIP code, then click on Find now. Find a Provider will display all the providers that fit your search criteria.

Get results as a PDF

If you prefer a printable copy of your search results with up to 200 providers, click on Get Results as PDF above the “Distance” field. You can download the pdf document or have it emailed to you.

Search for a network provider outside of California

Within the United States

• Go to provider.bcbs.com.

• Enter the first three letters of your Blue Shield member ID card (BUC).

• Search by Keyword or by Specialty.

• Enter a location and a radius to search by (default is 5 miles).

• Click on Go.

Outside of the United States

• Go to bluecardworldwide.com.

• Accept the terms and conditions.

• Enter the first three letters of your ID card (BUC).

• Click Login.

Find out your provider’s quality of care rankings

You can easily access quality scores, efficiency indicators, patient satisfaction scores, and cost information for many individual physicians, HMO medical groups, and hospitals. To see a provider’s performance profile, follow the steps above to find a provider and then click on the name of the doctor or hospital from your search results.


Programs and services

To learn more, visit blueshieldca.com/uc and select Programs and Services.

Condition management programs

These programs offer nurse support as well as education and self-management tools for members with asthma, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease.

NurseHelp 24/7

Speak with registered nurses anytime, day or night, and get answers to your health-related questions, or go online to have a one-on-one personal chat with a registered nurse anytime. The NurseHelp 24/7SM phone number is (877) 304-0504 and is conveniently located on the back of your Blue Shield member ID card.

Prenatal Education

This program gives expectant parents access to prenatal and child-rearing information including a popular pregnancy or parenting book at no additional cost.

QuitNet

As the largest quit-smoking community in the world, QuitNet* offers a dynamic, multi-modal tobacco cessation program through online and mobile engagement via QuitNet.com and daily email/SMS text support, plus telephone-based coaching and Nicotine Replacement Therapy (NRT).

Shield Concierge

The Shield Concierge team provides comprehensive information and personalized support on all aspects of care including benefits, claims, providers, care coordination, case management, health coaching, pharmacy, and more.

For personal assistance, call your dedicated Shield Concierge team toll-free at (855) 339-9973 (domestic); 800 60004141 (international) from 7 a.m. to 7 p.m. PT, Monday through Friday.

Teladoc

Teladoc† provides 24/7/365 access to a network of board-certified doctors who can treat many conditions, such as cold and flu symptoms, allergies, pink eye, bronchitis, and urinary tract infections, through the convenience of phone and online video consultations. Before consulting with a Teladoc doctor, members must enroll with Teladoc and complete a Medical History Disclosure by going to teladoc.com/uc or by calling (800) Teladoc (835-2362). Members are reimbursed $32 after the deductible is met and $40 after the out-of-pocket maximum is reached. For more information and details on how to enroll, visit blueshieldca.com/uc, select Programs and Services, then Teladoc.

* QuitNet is a trademark of MeYou Health, LLC. MeYou Health is a Healthways, Inc. company.

† Teladoc is an independent company and is not affiliated with Blue Shield of California.

Blue Shield and the Shield symbol are registered trademarks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans.


1 These discount program services are not a covered benefit of the Core plan and none of the terms or conditions of the Core plan apply.

The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy, nor does Blue Shield make any recommendations, presentations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products.

Some services offered through the discount program may already be included as part of the Core plan covered benefits. Plan participants should access those covered services prior to using the discount program.

Plan participants who are not satisfied with products or services received from the discount program may use the grievance process described in the Core plan Benefit Booklet. Blue Shield reserves the right to terminate this program at any time without notice.

Discount programs administered by or arranged through the following independent companies:

• Alternative Care Discount Program – American Specialty Health Systems, Inc. and American Specialty Health Networks, Inc.

• Discount Provider Network and MESVisionOptics.com – MESVision

• Weight control – Weight Watchers North America

• Fitness facilities – 24 Hour Fitness, ClubSport, and Renaissance ClubSport

• LASIK – Laser Eye Care of California, LLC; QualSight, Inc.; and NVISION Laser Eye Centers

Note: No genetic information, including family medical history, is gathered, shared, or used from these programs.

2 The Discount Provider Network is available throughout California. Coverage in other states may be limited. Find participating providers by going to blueshieldca.com/uc and selecting Find a Provider.

3 Requires a prescription from your doctor or licensed optical professional.

Wellness discount programs

Blue Shield offers a variety of member discounts on popular weight loss, fitness, vision, and health and wellness programs1 that can help you save money and get healthier.

• 24 Hour Fitness – Enjoy waived enrollment, processing, and initiation fees and discounts on monthly membership dues.

• Weight Watchers – Get discounts on three- and 12-month subscriptions and monthly passes.

• ClubSport and Renaissance ClubSport – Obtain a 60% discount on enrollments when joining with a month-to-month agreement. Enrollment fees are waived when joining with a 12-month agreement. (There is a one-time $25 processing fee when you enroll.)

• Alternative Care Discount Program – Get 25% off usual and customary fees for acupuncture, chiropractic services, and massage therapy, plus get discounts on health and wellness products, with free shipping on most items.

• Discount Provider Network2 – Take 20% off the published retail prices when you use a participating provider in the Discount Vision Program network for exams, frames, lenses, and more.

• MESVision Optics – Take advantage of competitive prices on contact lenses,3 sunglasses, readers, and eyecare accessories, with free shipping on orders over $50. Blue Shield vision plan members can apply their benefits to reduce their out-of-pocket costs for contact lenses.

• QualSight LASIK – Save on LASIK surgery at more than 45 surgery centers in California. Services include pre-screening, a pre-operative exam, and post-operative visits.

• NVISION Laser Eye Centers – Receive a 15% discount on LASIK surgery from experienced surgeons with offices in Southern California and Sacramento.

To learn more, visit blueshieldca.com/uc and select Programs and Services.


Notice on the availability of language assistance services to accompany vital documents issued in English IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.

You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198.

(Spanish)

重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。

這封信也可以用您所講的語言書寫。如需幫助，請立即撥打登列在您的Blue

Shield ID卡背面上的會員/客戶服務部的電話，或者撥打電話866-346-7198。 (Chinese)

QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số 866-346-7198. (Vietnamese)

Language AssistanceNotice on the availability of language assistance services to accompany vital documents issued in English.

Member confidentiality

Blue Shield protects the confidentiality and privacy of your personal and health information, including medical information and individually identifiable information such as your name, address, telephone number, and Social Security number. To ensure this, Blue Shield requires a signed authorization form for you to access health information for your spouse or dependents over the age of 18.

To request an authorization form, go to blueshieldca.com/uc and select Forms. Then, scroll down to “Other Forms” and click on Authorization of Release of Personal Health Information. If you don’t have access to the Internet, or have questions about how Blue Shield protects your privacy and confidentiality, please call our Privacy Office directly toll-free at (888) 266-8080.

JANUARY 1, 2015Coverage for active UC employees

Together fora great state

of health

Core plan Administered by Blue Shield of California

Blu

e S

hie

ld o

f Ca

lifo

rnia

is a

n in

de

pe

nd

en

t m

em

be

r o

f th

e B

lue

Sh

ield

Ass

oc

iatio

n

A46

608

-UC

-CO

RE

(10/

15)Go with Blue Shield for a healthier you

For more information on medical or pharmacy benefits, visit blueshieldca.com/uc, download the Blue Shield of California mobile app through the App StoreSM or Google Play, or call Shield Concierge toll-free at (855) 339-9973 (domestic); 800 60004141 (international) from 7 a.m. to 7 p.m. PT, Monday through Friday.

If you have eligibility questions, visit ucnet.universityofcalifornia.edu.

App Store is a service mark of Apple Inc. iPhone is a trademark of Apple Inc., registered in the U.S. and other countries.

Blue Shield and the Shield symbol are registered trademarks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans.

Register online for a chance to win $50Core, Health Savings Plan, and UC Care members have the chance to win a $50 gift card for setting up a Blue Shield online account. Members who have already set up an account will be automatically included in the drawing.

Current members who haven’t set up an online account can register by going to blueshieldca.com/uc and selecting Register for an online account. Newly enrolled members can register after their plan’s effective date.

One winner will be selected from each health plan – Health Savings Plan, Core, and UC Care – for a total of three winners. Winners will be notified via email in February 2016 and have to remain a Blue Shield member until the prize is awarded.

Hurry, don’t miss your chance to win! Deadline to register for this drawing is January 31, 2016 (11:59 p.m.).

Together for a great state of health - Blue Shield of ......02 Blue Shield of California Go with the...

Documents

Transcript of Together for a great state of health - Blue Shield of ......02 Blue Shield of California Go with the...