Insurance Forms & Fliers | UCLA Student Health

UCSHIP has a lot to offer you. Take a look at the UCSHIP Student Brochure to learn more about the full range of benefits available to students with a UCSHIP policy.

UCSHIP Documents

UCSHIP Glossary of Insurance Terms UCSHIP & You 2020-2021 Coverage Dates & Waiver Period How to Get Your UCSHIP Insurance Card 2021-2022 UCSHIP Benefit Highlight Summary Alternate Insurance Resource Guide 2021-2022 Waiver Criteria After Hours Urgent Care

Benefit Summaries & Policy Booklets

Delta Dental Summary of Benefits Delta Dental Benefit Booklet OptumRx Prescription Drug Benefit Booklet OptumRx Premium Formulary Exclusions List OptumRx Premium Formulary Anthem Blue Cross PPO Summary of Benefits Anthem Blue Cross PPO Benefit Booklet Blue View Vision Summary of Benefits Blue View Vision Plan Benefit Booklet

UCSHIP Voluntary/ Dependent Details

Voluntary UC SHIP Cost Sheet – Undergraduate Dependent UC SHIP Cost Sheet – Undergraduate Voluntary UC SHIP Cost Sheet - Graduate Dependent UC SHIP Cost Sheet - Graduate Voluntary UC SHIP Cost Sheet - Law Dependent UC SHIP Cost Sheet - Law Voluntary UC SHIP Cost Sheet - MBA Dependent UC SHIP Cost Sheet - MBA Voluntary UC SHIP Cost Sheet - Med Dependent UC SHIP Cost Sheet - Med

Claims Forms

Anthem Blue Cross Medical Claim Form Blue View Vision Claim Form Anthem Blue Cross Member Claim Form - International OptumRx Member Reimbursement Drug Claim Form Delta Dental Claim Form