Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: 01/01/2024– 12/31/2024

Anthem Blue Cross Life and Health Insurance Company: Coverage for: Individual + Family | Plan Type: PPO
University of California: CORE Plan
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the
plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will
be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms
of coverage, www.UChealthplans.com. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,
deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (866) 406-1182 to
request a copy.
Important Questions Answers Why This Matters:
What is the overall $3,000/individual for Generally, you must pay all of the costs from providers up to the deductible amount before
deductible? All Providers. this plan begins to pay. If you have other family members on the plan, each family member
must meet their own individual deductible until the overall family deductible is met.

Are there services Yes. Preventive care for This plan covers some items and services even if you haven’t yet met the deductible amount.
covered before you In-Network Providers. But a copayment or coinsurance may apply. For example, this plan covers certain preventive
meet your deductible? services without cost-sharing and before you meet your deductible. See a list of covered
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other No. You don’t have to meet deductibles for specific services.
deductibles for
specific services?
What is the out-of- $6,350/individual or The out-of-pocket limit is the most you could pay in a year for covered services. If you have
pocket limit for this $12,700/family for other family members in this plan, they have to meet their own out-of-pocket limits until the
plan? All Providers. overall family out-of-pocket limit has been met.

What is not included Premiums, balance-billing Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
in the out-of-pocket charges, expenses paid for
limit? infertility services, and health
care this plan doesn't cover.
Will you pay less if Yes, Prudent Buyer PPO. See This plan uses a provider network. You will pay less if you use a provider in the plan’s
you use a network www.UChealthplans.com or call network. You will pay the most if you use an out-of-network provider, and you might receive
provider? (866) 406-1182 for a list of a bill from a provider for the difference between the provider’s charge and what your plan
network providers.
pays (balance billing). Be aware your network provider might use an out-of-network provider
for some services (such as lab work). Check with your provider before you get services.

Do you need a referral No. You can see the specialist you choose without a referral.
to see a specialist?

CA/L/A/UniversityofCaliforniaCorePlan-PPO-NA/NA-NA/NA/1-21
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 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Anthem Prudent Buyer Out-of-Network Limitations, Exceptions, & Other
Services You May Need
Medical Event PPO Provider Provider Important Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an
20% coinsurance 20% coinsurance --------none--------
injury or illness
If you visit a
Specialist visit 20% coinsurance 20% coinsurance --------none--------
health care
provider’s office You may have to pay for services that
or clinic Preventive care/screening/ aren't preventive. Ask your provider if
No charge 20% coinsurance
immunization the services needed are preventive.
Then check what your plan will pay for.
Diagnostic test
20% coinsurance 20% coinsurance Cost may vary by site of service.
(x-ray, blood work)
If you have a test
Coverage for Out-of-Network Provider
Imaging (CT/PET scans, MRIs) 20% coinsurance 20% coinsurance
is limited to $280 maximum/visit.
20% coinsurance, after 20% coinsurance, after
If you need Tier 1 - Typically Generic deductible (participating deductible - 30-day
drugs to treat retail and mail order) supply Participating retail and mail order
your illness or 20% coinsurance, after 20% coinsurance, after
Tier 2 - Typically Preferred / pharmacies cover up to a 90-day supply.
condition deductible (participating deductible - 30-day
Brand Select specialty pharmacies cover up to
More information retail and mail order) supply a 30-day supply. Certain limitations may
about
20% coinsurance, after 20% coinsurance, after apply, including, for example: prior
prescription Tier 3 - Typically Non-Preferred
deductible (participating deductible - 30-day authorization and quantity limits. *See
drug coverage is / Brand
retail and mail order) supply prescription drug section of the plan or
available at
20% coinsurance, after policy.
www.navitus.com Tier 4 - Typically Specialty
deductible (select specialty
(brand and generic) N/A
pharmacies)
If you have Facility fee Coverage for Out-of-Network Provider
20% coinsurance 20% coinsurance
outpatient (e.g., ambulatory surgery center) is limited to $280 maximum/visit.
surgery Physician/surgeon fees 20% coinsurance 20% coinsurance --------none--------
20% coinsurance for Emergency Room
If you need Emergency room care 20% coinsurance Covered as In-Network
Physician Fee.
immediate
Emergency medical 20% coinsurance
medical Covered as In-Network --------none--------
transportation deductible does not apply
attention
Urgent care 20% coinsurance Covered as In-Network --------none--------

* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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 What You Will Pay
Common Anthem Prudent Buyer Out-of-Network Limitations, Exceptions, & Other
Services You May Need
Medical Event PPO Provider Provider Important Information
(You will pay the least) (You will pay the most)
Coverage for Out-of-Network Provider
is limited to $480 maximum/day. If no
If you have a Facility fee (e.g., hospital room) 20% coinsurance 20% coinsurance pre-authorization is obtained for out of
hospital stay network providers, there will be an
additional $250 copay.
Physician/surgeon fees 20% coinsurance 20% coinsurance --------none--------
Office Visit Office Visit Office Visit
20% coinsurance 20% coinsurance --------none--------
Outpatient services
Other Outpatient Other Outpatient Other Outpatient
20% coinsurance 20% coinsurance --------none--------
If you need
mental health, Coverage for Out-of-Network Provider
behavioral is limited to $480 maximum/day. If no
health, or pre-authorization is obtained for out of
substance abuse network providers, there will be an
services Inpatient services 20% coinsurance 20% coinsurance additional $250 copay. 20% coinsurance
for Inpatient Physician Fee In-Network
Providers. 20% coinsurance for
Inpatient Physician Fee Out-of-
Network Providers.
Office visits 20% coinsurance 20% coinsurance Coverage for Out-of-Network Provider
Childbirth/delivery professional is limited to $480 maximum/day.
20% coinsurance 20% coinsurance Maternity care may include tests and
services
If you are services described elsewhere in the SBC
pregnant (i.e. ultrasound.) If no pre-authorization
Childbirth/delivery facility is obtained for out of network
20% coinsurance 20% coinsurance
services providers, there will be an additional
$250 copay.
100 visits/benefit period.
Home health care 20% coinsurance Not covered
If you need help Rehabilitation services 20% coinsurance 20% coinsurance
recovering or *See Therapy Services section
Habilitation services 20% coinsurance 20% coinsurance
have other
special health 100 days limit/benefit period.
Skilled nursing care 20% coinsurance 20% coinsurance
needs
Durable medical equipment 20% coinsurance 20% coinsurance --------none--------
Hospice services 20% coinsurance Not covered --------none--------

* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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 What You Will Pay
Common Anthem Prudent Buyer Out-of-Network Limitations, Exceptions, & Other
Services You May Need
Medical Event PPO Provider Provider Important Information
(You will pay the least) (You will pay the most)
If your child Children’s eye exam Not covered Not covered
*See Vision Services section
needs dental or Children’s glasses Not covered Not covered
eye care Children’s dental check-up Not covered Not covered *See Dental Services section

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded
services.)
• Cosmetic surgery • Dental care (adult) • Dental Check-up
• Eye exams for a child • Glasses for a child • Hearing aids
• Routine eye care (adult) • Routine foot care unless you have been • Private-duty nursing
• Long-term care diagnosed with diabetes • Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture 24 visits/benefit period • Bariatric surgery • Chiropractic care 24 visits/benefit period
combined with chiropractic services. • Infertility treatment - 2 cycles per lifetime combined with acupuncture.
• Most coverage provided outside the United combined for GIFT, ZIFT and IVF (all
States. See www.bcbsglobalcore.com infertility services are excluded from OOPM)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform. Other coverage
options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about
the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is
called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan
documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights,
this notice, or assistance, contact:
ATTN: Grievances and Appeals, P.O. Box 4310, Woodland Hills, CA 91365-4310

* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare,
Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the
premium tax credit.

Does this plan meet the Minimum Value Standards? Yes

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

* For more information about limitations and exceptions, see plan or policy document at www.UChealthplans.com.
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About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will
be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost
sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare
the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow
hospital delivery) controlled condition) up care)

◼ The plan’s overall deductible $3,000 ◼ The plan’s overall deductible $3,000 ◼ The plan’s overall deductible $3,000
◼ Specialist coinsurance 20% ◼ Specialist coinsurance 20% ◼ Specialist coinsurance 20%
◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20% ◼ Hospital (facility) coinsurance 20%
◼ Other coinsurance 20% ◼ Other coinsurance 20% ◼ Other coinsurance 20%

This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services
like: like: like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $3,000 Deductibles $959 Deductibles $936
Copayments $0 Copayments $0 Copayments $0
Coinsurance $2,520 Coinsurance $240 Coinsurance $385
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0
The total Peg would pay is $5,580 The total Joe would pay is $1,254 The total Mia would pay is $1,321
NOTE: This Summary of Benefit and Coverage attempts to show you how you and the plan share the cost for covered health care services. Any summary of benefits
or cost sharing principals represents only a brief description of your benefits. Please read the booklet carefully to learn about provisions, benefits and exclusions. If
any perceived conflict exists between this summary and the Plan terms, the Plan terms govern.

The plan would be responsible for the other costs of these EXAMPLE covered services.
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By authority of the Regents, University of California Human Resources, located
in Oakland, administers all benefit plans in accordance with applicable plan
documents and regulations, custodial agreements, University of California Group
Insurance Regulations for Faculty and Staff, group insurance contracts, and state
and federal laws. No person is authorized to provide benefits information not
contained in these source documents, and information not contained in these
source documents cannot be relied upon as having been authorized by the
Regents. Source documents are available for inspection upon request
(800-888-8267). What is written here does not constitute a guarantee of plan
coverage or benefits—particular rules and eligibility requirements must be met
before benefits can be received. The University of California intends to continue
the benefits described here indefinitely; however, the benefits of all employees,
retirees and plan beneficiaries are subject to change or termination at the time of
contract renewal or at any other time by the University or other governing
authorities. The University also reserves the right to determine new premiums,
employer contributions and monthly costs at any time. Health and welfare
benefits are not accrued or vested benefit entitlements. UC’s contribution toward
the monthly cost of the coverage is determined by UC and may change or stop
altogether, and may be affected by the state of California’s annual budget
appropriation. If you belong to an exclusively represented bargaining unit, some
of your benefits may differ from the ones described here. For more information,
employees should contact their Human Resources Office and retirees should call
the UC Retirement Administration Service Center (800-888-8267).

In conformance with applicable law and University policy, the University is an

affirmative action/equal opportunity employer. Please send inquiries regarding
the University’s affirmative action and equal opportunity policies for staff to
Systemwide AA/EEO Policy Coordinator, University of California, Office of the
President, 1111 Franklin Street, 5th Floor, CA 94607, and for faculty to the Office
of Academic Personnel and Programs, University of California Office of the
President, 1111 Franklin Street, Oakland, CA 94607.

The plan would be responsible for the other costs of these EXAMPLE covered services.
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It’s important we treat you fairly
That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the
basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t
English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services
number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age,
disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance
Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and
Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-
1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.

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