Plan Documents

For previous year's documents, please visit these pages:

• Plan Year 2019-2020
• Plan Year 2018-2019
• Plan Year 2017-2018
• Plan Year 2016-2017

Campus	2020-2021 Documents
Davis	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
Hastings	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
Irvine	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
Los Angeles	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
Merced	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
Riverside	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
San Diego	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
San Francisco	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
Santa Barbara	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)
Santa Cruz	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage Delta Dental Evidence of Coverage (Spanish version) Delta Dental Evidence of Coverage (Mandarin version) OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)