UCLA UC SHIP for 2014-2015
UC SHIP continues to be ACA compliant
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Medical copays, Rx copays and coinsurance apply to the Out Of Pocket Maximum.
Deductibles apply to the Out Of Pocket Maximum
The separate deductibles ($300, $500) and out-of-pocket limits ($2000, $3000, $6000)
do not accumulate toward each other
Changes for 2014-2015
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The undergraduate fee includes dental coverage – dental was previously a voluntary buy
in option for this group.
Psych educational testing lifetime limit increased to $3,000 life time maximum (was
$2,000).
Behavioral Health Services has removed their copayments for 2014-2015. They will no
longer be collecting the following copayments: $10 office visit/ $100 per
day hospitalization / $50 per day partial hospitalization
UC SHIP PREMIUM FEES 2014-2015
Undergraduates
Graduates
Quarter
Semester
Annual
$646.10
N/A
$1,938.32
$1,003.70
$1,505.55
$3,011.10
UC SHIP Components: Anthem Blue Cross – medical, Blue View Vision, Delta Dental,
UCLA Counseling and Psychological Services (CAPS) and Behavioral Health Services (BHS)
Definitions
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COPAYMENT: the amount an insured person must pay out of pocket for covered services
performed by an Anthem Blue Cross network provider or an Ashe clinician. Some services
subject to co-pay include: office visits, urgent care, physical therapy, occupational therapy,
speech therapy, acupuncture, chiropractic care, urgent care, and emergency room fees.
However, when students come to The Ashe Center for their care, most of the core services are
prepaid. For benefits subject to copay, there is no deductible required.
DEDUCTIBLE: the dollar amount of eligible expenses that an insured person must pay each
policy year before the insurance company pays any major benefits. The benefit year deductible
does not apply for services provided at The Ashe Center or services with co-payments.
COINSURANCE: the percentage amount of eligible expenses an insured person must pay after
the deductible is met. Please refer to the Anthem Blue Cross Summary of Benefits for coinsurance coverage information on the Ashe website and/or call Anthem Blue Cross directly at
(866) 940-8306 PRIOR to incurring expenses.
Call us at (310) 825-4073 or visit www.studenthealth.ucla.edu for plan details.
Medical Plan Benefit Summary 2014-2015
Key Benefits
The Ashe Center
Benefit Year Deductible
Annual Out-of-Pocket
Maximum
Physician Office Visit
Specialist Copay
Lab and X-ray
• CT, MRI, PET scans
• Lab
• X-Ray
Hospitalization
• In-patient
• Out-patient
Emergency Room
N/A
Urgent Care
Mental Health/Substance
Abuse
Physical & Occupational
Therapy
Acupuncture
Chiropractor
Other Professional Services
Prescription Drugs
UC Family*†
N/A
$2,000
In-Network*
Out-of-Network*
$300
$3,000
$500
$6,000
$0
$0
$10
$15
$25 (ded. waived)*
$40 (ded. waived)
40%*
40%
N/A
10%
$0
10%
10%
10%
20%
20%
20%
40%
40%
40%
N/A
N/A
N/A
10%
10%
$125
$250 per Admit + 20%
$125 per Admit + 20%
$125 (ded. waived)
$0
Counseling and Psychological
Services (CAPS) + BHS
$15
$25
Counseling and Psychological
Services (CAPS) + BHS
$15
$25 (ded. waived)
Counseling and Psychological
Services (CAPS) + BHS
$40 (ded. waived)
$500 + 40%
$250 + 40%
$125-anything above allowed
amount (ded. waived)
40%
Counseling and Psychological
Services (CAPS) + BHS
40%
$15
N/A
10%
$5 generic
$25 brand-name formulary,
30-day supply
$40 brand-name nonformulary, 30-day supply
$15
$15
10%
$10 generic
$40 brand-name formulary,
30-day supply
$60 brand-name nonformulary, 30-day supply
$40
$40
20%
$10 generic
$40 brand-name formulary,
30-day supply
$60 brand-name nonformulary, 30-day supply
40%
40%
40%
$10 generic
$40 brand-name formulary,
30-day supply
$60 brand-name nonformulary, 30-day supply
+amounts exceeding
Ventegra maximums
Note: 100% prescription coverage for FDA-approved generic prescription contraceptives and brand-name prescription
contraceptives when a generic equivalent is not available only at a Ventegra pharmacy network provider.
*Ashe Referral Required
† UC Family includes Ronald Reagan UCLA Medical Center, UCLA Medical Center, Santa Monica, UCI, UCSD, UCSF, and UCD.
Call us at (310) 825-4073 or visit www.studenthealth.ucla.edu for plan details.