Life and AD&D
UC Davis Residents & Fellows provides benefit eligible employees with Group Life and
Accidental Death & Dismemberment (AD&D) insurance at no cost for you.
Your group life and AD&D coverage amount is:
Group Life: Basic Life Insurance of $50,000.
AD&D: AD&D of $50,000.
Age Reduction-Coverage Amounts: To 65% reduction at age 65; to 45% reduction
at age 70 and to $35% reduction at age 75.
EAP, Short, & Long Term Disability
Employee Assistance Program (EAP) benefits help you achieve a work/life balance.
You can receive unlimited phone consulting for any of the following issues: legal
consultation, parenting, senior care, identity theft, child care, pet care, and financial
concerns.
Short Term Disability (STD) benefits help to provide you with weekly income if you
become disability and unable to work.
• Benefits pay 66.2/3% of your weekly earnings to a maximum of $700 per week.
You must be disabled at least 30 days.
• The maximum benefit period is 22 weeks. After the 22 weeks, the long term
disability benefit starts.
Long Term Disability (LTD) benefits help to provide you with monthly income if you
become disabled and are unable to work.
• Benefits pay 66.2/3% of your monthly earnings to a maximum of $3,000 per
month. You must be disabled at least 180 days.
• After total or partial disability (LTD) benefits combined have been paid to you for
24 months, you will continue to qualify for this benefit to age 65 if you are unable
to perform without reasonable continuity any gainful occupation for which you are
reasonably qualified for by education, training or experience. If you become
disabled after the age of 60, there is a maximum benefit period schedule
described in your booklet.
There is no cost to you for this coverage.
Benefits received will be considered taxable income.
Cigna
(800) 362-4462 www.cigna.com
Life Policy Number: FLX966803
AD&D Policy Number: OK968313
STD Policy Number: LK751843
2015 - 2016
Benefits at a Glance
Medical
Dental
Vision
Life / AD&D
Employee Assistance Program (EAP)
Short Term Disability
Long Term Disability
LTD Policy Number: LK964675
This material is for informational purposes only. It contains only a partial, general description of the plan or program of
benefits and does not constitute a contract. Consult your plan documents (Summary of Benefits, Group Agreement, Group
Insurance Booklet, Group Policy) to determine governing contractual provisions, including procedures, exclusions and
limitations relating to your plan. All the terms and conditions of your plan or program are subject to applicable laws,
regulations and policies. In case of a conflict between your plan document and this information, the plan documents will
always govern.
August 1, 2015 – July 31, 2016
Dental Plan – PPO
Medical/Rx Plan – HMO
PLAN HIGHLIGHTS
Pllan Highlights
IN-NETWORK
OUT-OF-NETWORK*
$40
$50
In-Network
Calendar Deductible
Annual Deductible
Individual
Individual
$0
Family
$0
Annual Out of Pocket Maximum
$120
$150
$1,500
$1,500
Office Examination
100%
100%
Teeth cleaning
100%
100%
Basic X-Rays
100%
Diagnotistic & Preventive
Individual
$1,500
Family
$2,500
Lifetime Maximum Benefit
Unlimited
Office Visit Copay
$20 Copay
Annual Preventive Exam
No Charge
Specialist Visit Copay
$20 Copay
Inpatient Hospitalization
Outpatient Surgery (Office Setting)
Emergency Room Copay
Family
Annual Maximum Benefit
100%
After Deductible
Basic Services
Fillings, anesthetics
80%
80%
No Charge
Simple Extractions
80%
80%
$20 Copay
Palliative Treatment
80%
80%
Stainless steel and resin crowns
80%
$100 Copay (Wavied if Admitted)
80%
50%
Diagnostic X-ray / Lab.
No Charge
Major Services
Complex Imaging
No Charge
Orthodontics (Adults & Children)
Prosthetic Devices
$20 Copay
*Out-of-netw ork benefits are based on reasonable and customary fees for a given geographical area.
50% to a $1,500 Lifetime Max.
(800) 765-6003 www.deltadentalins.com
Mental Health & Substance Abuse
Inpatient Physician
No Charge
Outpatient
$20 Copay
Vision Plan
Tier 1 - Typically Generic
$10 Copay
Tier 2 - Typically Brand
$30 Copay
Exam
Materials
Prescription Drug
Tier 3 - Typically Non-Preferred Brand
GROUP #: 9561-0001
$10 Copay
$25 Copay
$50 Copay
Tier 4 - Typically Specialty Drugs
20% ($100 Max)
Mail Order Drugs (90-day supply)
2.5x Retail
HMO Member Service – (888) 563-2250
www.westernhealth.com
GROUP #: 02-2160
Exam (Every 12 Months)
Lenses (Every 12 Months)
Single
Bifocal
Trifocal
Frames (Every 24 Months)
Login Information:
User Name: UCD14
Password: benefits
Elective Contacts
Medically Necessary Contacts
In-Network
Out-Of-Network
100% Covered
$45 Allowance
100% Covered
100% Covered
100% Covered
Covered up to
Plan Allowance
$130 Allowance
100% Covered
$30 Allowance
$50 Allowance
$65 Allowance
To access employee benefits portal visit:
Find a VSP Doctor:
(800) 877-7195 www.vsp.com
www.ucdavisresidentsfellows.gethrinfo.net
Policy Number: 12170630
$70 Allowance
$105 Allowance
$210 Allowance