Plan Documents

Campus	2021-2022 Documents
Davis	Student Medical Summary of Benefits & Coverage (SBC) Anthem Benefit Booklet Delta Dental Evidence of Coverage 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 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 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 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 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 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 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 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 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 OptumRx Pharmacy Plan Booklet OptumRx Pharmacy Formulary OptumRx Pharmacy Formulary Exclusions Vision Plan Booklet Vision Plan Booklet (Spanish version) Vision Plan Booklet (Mandarin version)