Forms and Documents

What you need to know

The forms below are for the 2022/2023 academic year. Prior year forms and documents are available upon request.

New Student Resources

UC SHIP Benefits Overview: UCSB [PDF]
Care You Can Count On Brochure [PDF]

Medical

Benefit Booklet [PDF]

Medical Summary of Benefits & Coverage (SBC) [PDF]

Anthem Medical Claim Form [PDF]

Prescription Drugs

OptumRx Formulary [PDF]

OptumRx Formulary Exclusions [PDF]

OptumRx Prescription Drug Claim Form [PDF]

Prescription Drug Plan Booklet [PDF]

Dental

Delta Dental Benefit Booklet [PDF]

Delta Dental Claim Form [PDF]

Delta Dental Benefit Highlights (Keep Smiling) Flyer [PDF]

Vision

Blue View Vision Plan Benefit Booklet (English) [PDF]

Blue View Vision Plan Benefit Booklet (Mandarin) [PDF]

Blue View Vision Plan Benefit Booklet (Spanish) [PDF]

Blue View Vision Claim Form [PDF]