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UC2004

Behavioral Health Benefits for Blue Cross PLUS

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Eligibility, Enrollment and Termination Provisions

The following information applies to the University of California plan and supersedes any corresponding information

that may be contained elsewhere in the document to which this insert is attached. The University establishes its own

medical plan eligibility, enrollment and termination criteria based on the University of California Group Insurance

Regulations ("Regulations"). Portions of these Regulations are summarized below.

ELIGIBILITY

The following individuals are eligible to enroll in this Plan. If the Plan is a Health Maintenance Organization (HMO),

Point of Service (POS) or Exclusive Provider Organization (EPO) Plan, they are only eligible to enroll in the plan if

they meet the Plan's geographic service area criteria. Anyone enrolled in a non-University Medicare + Choice

Managed Care contract is not eligible for this plan.

Subscriber

Employee:

Annuitant

(including

Survivor

Annuitant):

You are eligible if you are appointed to work at least 50% time for twelve

months or more or are appointed at 100% time for three months or more or have accumulated

1,000* hours while on pay status in a twelve -month period. To remain eligible, you must maintain an

average regular paid time** of at least 17.5 hours per week and continue in an eligible appointment. If

your appointment is at least 50% time, your appointment form may refer to the time period as

follows: "Ending date for funding purposes only; intent of appointment is indefinite (for more than

one year)."

* Lecturers - see your benefits office for eligibility.

** For any month, your average regular paid time is the average number

of regular paid hours per week (excluding overtime, stipend or bonus time)

worked by you in the preceding twelve (12) month period.

(a) A month with zero regular paid hours which occurred during your

furlough or approved leave without pay will not be included in the

calculation of the average. If such absence exceeds eleven (11)

months, the averaging will be restarted.

(b) A month with zero regular paid hours which occurred during a

period when you were not on furlough or approved leave without

pay will be included in the calculation of the average. After two

consecutive such months, the averaging will be restarted.

For a partial month of zero regular paid hours due to furlough, leave

without pay or initial employment the following will apply.

(a) If you worked at least 43.75% of the regular paid hours available in

the month, the month will be included in the calculation of the

average.

(b) If you did not work at least 43.75% of the regular paid hours

available in the month, the month will not be included in the

calculation of the average.

Annuitant A former University Employee receiving monthly benefits from a

University-sponsored defined benefit plan.

Survivor Annuitant A deceased Employee's or Annuitant's Family Member

receiving monthly benefits from a University-sponsored defined benefit plan.

You may continue University medical plan coverage as an Annuitant when you start collecting

retirement or disability benefits from a University-sponsored defined benefit

plan, or as a Survivor Annuitant when you start collecting survivor benefits from a University-

sponsored defined benefit plan. You must also meet the following requirements:

(a)

you meet the University's service credit requirements for Annuitant medical eligibility;

(b)

the effective date of your Annuitant status is within 120 calendar days of the date

employment ends (or the date of the Employee/Annuitant's death for a Survivor Annuitant); and

(c) you elect to continue medical coverage at the time of retirement.

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