Santa Clara University

Department of Human Resources

Blue Cross HMO Standard Option Medical Plan

 

Phone: 1-800-227-3771
Group no: 175028H001
ID no: Member ID (on ID card)
Website: www.anthem.com/ca

Description:  Select a Primary Care Physician (PCP) from a group of physicians who are a part of the Blue Cross network (see www.bluecrossca.com for the directory of participating physicians).  Your PCP will coordinate all of your care. Therefore, specialty care must be referred by your PCP. A PCP is defined as an internist, general practitioner, family practitioner and pediatrician.  All non-emergency treatment must be received by one of these providers. In exchange for lower per pay period premiums, you pay more money out-of-pocket when you receive services.

Benefit Coverage/Copay
Deductible None
Inpatient Hospital $1,000 copay per day (3 day copay maximum)
Physician Office Visits $30 copay
Routine Physical Exams No copay
Routine GYN Exams No copay
Maternity Care Office Visits $30 copay
Well-Baby Care
No copay
Prescription Drugs

$10 copay generic;$25 copay for non-generic formulary brand;$50 copay for non-generic non-formulary brand

Prescriptions that fall under Specialty Pharmacy will be covered at 80% after a $150 copay for a 30 day supply (currently a 90 day supply is available for specialty pharmacy).
Emergency Room (waived if admitted) $150 copay
Chiropractic $15 copay, (maximum 20 visits per year)
Mental Health (Outpatient)*
 
$30/visit; No copay for Facility-based care (pre-authorization required)  
Mental Health (Inpatient)
No copay for visits; $1,000/day, up to 3 day max for Facility-based care (pre-authorization required)
Vision Benefit provided through Vision Service Plan See VSP Summary for covered benefits


*SCU provides additional mental health benefits through its Employee Assistance Program (EAP) and Mental Health Benefits Program with United Behavioral Health (UBH).

This is a summary of the benefits provided. Once enrolled, members will receive a Combined Evidence of Coverage and Disclosure Form, which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail. Under all circumstances, policy form and wording take precedence over information contained in this summary.

 
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Established 1851