University of California—Extension
English Language and International Education Programs
PLATINUM
2016 HEALTH INSURANCE PLAN
A student, visiting faculty, scholar, or other person with a current passport and non-immigrant visa temporarily located outside his or
her home country or country of residence who has not been granted permanent residency status in the United States while engaged in
educational activities through his or her University is required to be insured under the Policy. The University may grant a waiver to people
already insured under other government- or embassy-sponsored plans.
If you are a student engaged in Optional Practical Training (OPT) or Curricular Practical Training (CPT), you can also be covered under this
policy, provided: 1) your OPT/CPT immediately follows a course of study; and 2) your OPT/CPT is no longer than 12 months in duration.
Contact the International Student Office at your school for details.
Students may enroll in coverage up to 30 days prior to the start of their program. Students may enroll in coverage between terms.
If you enroll in the Plan, you may also enroll your spouse or child(ren) under the age of 26. Dependents must be enrolled at the same time
you enroll or within 31 days of marriage, birth, adoption, arrival in the U.S., or termination of other coverage. Contact your school to enroll
dependents.
For questions regarding benefits or claims, contact Personal Insurance Administrators, Inc., at 1-800-468-4343. To download the plan
brochure or ID cards, visit www.4studenthealth.com/extension.
ID CARD
Your school administrator will give you your insurance ID card. If you do not receive a card or lose the card you are given, you may download
an ID card at www.4studenthealth.com/extension. You should carry your insurance ID card with you at all times. Your ID card may also be
used for your covered dependents.
BENEFITS SUMMARY
ELIGIBILITY AND ENROLLMENT
Level Plan
WHERE AND HOW TO OBTAIN TREATMENT
Student Health Center
Student health centers often offer a wide range of medical treatment at a reduced cost to students. You should seek medical care at the health
center at the University where you are enrolled before seeking medical treatment off campus whenever possible. (Note: UCLA students
should go to the UCLA Medical Center, not the UCLA student health center.) The deductible is waived if you first utilize and/or are referred by
the approved student health center (this does not apply to dependents). Contact your University’s student health center to see if they accept
this insurance plan. You may be charged a visit fee, which must be paid at the time of the visit, or you may have to pay up front for services
and then submit a claim for reimbursement for the portion the Company is responsible for paying. In this case, you will need to request an
itemized billing statement and submit it with your claim.
Prescriptions
You may fill your prescriptions at any pharmacy, but you must pay for them in full at the time of pickup. You may then submit a claim for
reimbursement for the portion the Company is responsible for paying.
PPO Network
This plan has incorporated into the coverage access to a network of medical professionals, including doctors and hospitals, known as the
Preferred Provider Organization (PPO), offered through First Health Network. If you need to see a provider outside the student health center,
you should utilize a PPO provider. While you are allowed to visit any provider of your choosing, if you use a PPO doctor or facility, you will pay
less money out-of-pocket. To find a PPO provider, call First Health Network at 1-800-226-5116 or visit www.myfirsthealth.com. Contact the
provider prior to your visit to confirm their membership in the network.
Emergency Room vs. Urgent Care Center
In the case of an emergency, call 911 or go to the nearest emergency room (ER). If the health center or your doctor’s office is closed and
you need immediate attention but the illness or injury is NOT life-threatening, you should try to visit a PPO urgent care center instead of a
hospital emergency room. These facilities are often open evenings and weekends, and you will usually pay less money out-of-pocket than
you would at an ER. For a complete listing of the PPO Hospital and Doctor facilities, call 1-800-226-5116 or visit www.myfirsthealth.com.
To locate a local urgent care clinic, go to the First Health Network website and select “Urgent Care Centers” under “Providers” in the lower
left-hand side of the page.
Local PPO Urgent Care Centers and Hospitals
Please note that use of an urgent care center instead of a Hospital emergency room may decrease the Covered Person’s out-of-pocket
expenses. Urgent care centers provide medical care to treat a minor Injury or Sickness when immediate care is needed. To locate a local
urgent care center, visit www.myfirsthealth.com and select “Urgent Care Centers” under “Providers” in the lower left-hand side of the page.
A partial list of First Health Network PPO urgent care centers and hospitals is below. Always check with the provider to ensure they are still
participating in the network.
Berkeley/Oakland Area
Davis Area
Irvine Area
Los Angeles Area
• Concentra Urgent Care
• Alta Bates Summit Medical Center
• St. Francis Memorial Hospital
Riverside Area
• Loma Linda University Medical Center
• Riverside Community Hospital
• UC Davis Medical Center
• U.S. HealthWorks Medical Group
• Mercy General Hospital
• Sutter Davis Hospital
• Hoag Hospital Irvine
• Newport Urgent Care
• University Hospital Costa Mesa
• Coastal Communities Hospital
• Ronald Reagan UCLA Medical Center
• Santa Monica UCLA Medical Center
• West LA Urgent Care
• Cedars-Sinai Medical Center
• UC San Diego Medical Center
• Partners Urgent Care
• Sharp Memorial Hospital
• Scripps Memorial Hospital
• The MedCenter Urgent Care
• Goleta Valley Cottage Hospital
• Santa Barbara Cottage Hospital
• Santa Ynez Valley Cottage Hospital
• Santa Clara Urgent Care
• Santa Clara Valley Medical Center
• Regional Medical Center of San Jose
San Diego Area
Santa Barbara Area
Santa Clara/San Jose Area
This document is a brief summary of the plan. If there are any discrepancies between this document and the policy, the policy will govern.
University of California––Extension
BENEFITS SUMMARY – page 2
USING THE INSURANCE AND GETTING YOUR BILLS PAID
After you are enrolled in the plan:
1. If you need medical care, go to the health center at the University where you are enrolled before seeking medical treatment off campus
whenever possible. (Note: UCLA students should go to the UCLA Medical Center, not the UCLA student health center.) Contact your
University’s student health center to see if they accept this insurance plan. You may be charged a visit fee, which must be paid at the
time of the visit, or you may have to pay up front for services and then submit a claim for reimbursement for the portion the Company is
responsible for paying. In this case, you will need to request an itemized billing statement and submit it with your claim.
2. If you are unable to go to your health service on campus, use PPO providers. You may choose any provider, but if you use a PPO doctor
or facility you will usually pay less money out-of-pocket. To find a PPO provider, call First Health Network at 1-800-226-5116 or visit
www.myfirsthealth.com. Contact the provider prior to your visit to confirm their membership in the network.
3.
If you have an emergency, call 911 or go to the nearest hospital emergency room. Please contact American Health Holding at 1-888-638-5706
within 2 working days if you are admitted to hospital (with a stay of 18 hours or more) following an emergency.
4.
For Hospitalizations, including inpatient surgery, or for an Emergency Hospitalization, you must pre-certify 5 days in advance (in the case
of scheduled services) or provide notification within 2 working days (in the case of an Emergency Hospitalization) with American Health
Holding by calling 1-888-638-5706.
When you go to a doctor’s office, urgent care center, or hospital, show them your insurance ID card. They may call Personal Insurance
Administrators, Inc., at the number listed on the card (1-800-468-4343).
5.
6.
If you receive treatment, you will be charged the deductible first before the company will begin paying benefits (except as otherwise noted).
The covered student’s deductible will be waived if you first seek treatment at or are referred by your University’s student health center.
7.
After you receive treatment at a PPO provider, the provider may submit the charges directly to the claims administrator for you. In this
case, you will receive an Explanation of Benefits indicating what the insurance covered, and then the provider will bill you for any remaining
charges. The insurance company may contact you for follow up information.
8.
If the provider does not submit the charges directly, or if you visit a non-PPO provider, or for prescription drug reimbursement, you will be
responsible for filing a claim. Be sure to request an itemized bill after receiving treatment. You will need this to submit a claim. An itemized
medical bill is a list of procedures or services with associated charges from the hospital or doctor’s office. Then, within 90 days of treatment,
send the itemized medical bill(s), and any receipts for prescription drugs, and your referral to the address below:
Personal Insurance Administrators, Inc., P.O. Box 6040, Agoura Hills, CA 91376-6040
9.
If you visited your on-campus student health center first and received a referral, the referral must be included with the claim for the
deductible to be waived.
10. If you have questions about the status of your claim after it has been submitted or for any questions about the Plan benefits, please call
Personal Insurance Administrators, Inc., at 1-800-468-4343, Monday–Friday, 8:00 a.m. to 5:00 p.m. (4:00 p.m. on Fridays) Pacific Time.
Always keep a copy of all documents submitted for claims.
POLICY INFORMATION
Insurance Company: Nationwide Life Insurance Company
For questions regarding eligibility, benefits or claims, contact Personal Insurance Administrators, Inc., at 1-800-468-4343. To download the plan
brochure or an online ID card, visit www.4studenthealth.com/extension.
School Name
University of California, Berkeley—Extension
University of California, Davis—Extension
University of California, Irvine—Extension
University of California, Los Angeles—Extension
University of California, Riverside—Extension
University of California, San Diego—Extension
University of California, Santa Barbara—Extension
University of California, Santa Cruz—Extension
Policy Number
302-086-0413
302-085-0413
302-087-0413
302-088-0413
302-089-0413
302-091-0413
302-092-0413
302-093-0413
IMPORTANT NOTICE: This document is only a brief summary of the UC Extension English Language and International Education
Programs Health Insurance Plan. For complete provisions of the plan, including benefits, limitations, exclusions, definitions,
and claim procedure, please review the plan brochure carefully at www.4studenthealth.com/extension. If there are any
discrepancies between this document and the plan brochure, the brochure will govern.
Translated versions of this summary are available online in Arabic, Chinese, French, German, Italian, Japanese, Korean, Portuguese,
Russian, Spanish, and Turkish. Any discrepancy between the English version of a document and a translated version will be
governed by the English version.
You are eligible to utilize the services of an interpreter to have insurance documents read to you in your native or preferred
language, at no cost to you. To use this free service, call the number listed on your insurance ID card or 1-800-468-4343. For
further help, call the CA Department of Insurance at 1-800-927-4357.
2016 Health Insurance Plan
2016 SCHEDULE OF BENEFITS
Following is a condensed description of the benefits available under the Plan. Please see the Plan brochure for a more complete explanation of benefits and limitations.
PAID BY COVERED PERSON
referred by the student health center. Dependents cannot use the campus student health centers.)
PPO
$75 per Injury or Sickness
NON-PPO
$75 per Injury or Sickness
Your Office Visit Copay
not applicable
Your Coinsurance Amount (for most services, except as noted below)
0%
50%
Out-of-Pocket Maximum
$6,350 per person/ $12,700 per family, per policy year
The Covered Person is responsible for paying the $75 per Injury or Sickness Deductible before the Company will begin paying benefits, except as indicated below.
PAID BY COMPANY
MAXIMUM BENEFIT
COINSURANCE AMOUNT THE COMPANY PAYS
PREVENTIVE/WELLNESS SERVICES
Well Adult Care, Well Baby and Well Child Care, and Immunizations
only as recommended by the U.S. Department of Health and Human Services
(see brochure for further details)
INPATIENT †
NATIONWIDE LIFE INSURANCE COMPANY
Unlimited, except as noted
100% of Preferred
50% of Reasonable and
Allowance (PA)
Customary (R&C)
PPO
NON-PPO
100% of PA
50% of R&C
DEDUCTIBLE WAIVED
PPO
NON-PPO
Hospital Confinement/Room and Board and Hospital Miscellaneous
Maternity/Newborn Care
Surgeon’s Fees
Assistant Surgeon
Anesthetist
Radiology Services*
Pre-Admission Testing
Doctor Visits*
Treatment of Mental Conditions /Substance Use Disorder
100% of PA
100% of PA
100% of PA
100% of PA
100% of PA
100% of PA
100% of PA
100% of PA
100% of PA
Doctor Visits
Emergency Expense emergency room, including physician charges
Urgent Care
Surgeon’s Fees
Assistant Surgeon
Anesthetist
Day Surgery Miscellaneous
Rehabilitative/Habilitative Services
Diagnostic X-ray and Laboratory Services
Treatment of Mental Conditions /Substance Use Disorder
Radiation Therapy and Radiology Services*
Chemotherapy
Tests and Procedures
100% of PA
50% of R&C
100% of PA
100% of billed charges
100% of PA
50% of R&C
100% of PA
50% of R&C
100% of PA
50% of R&C
100% of PA
100% of R&C
100% of PA
50% of R&C
100% of PA
50% of R&C
100% of PA
50% of R&C
100% of billed charges
100% of PA
50% of R&C
100% of PA
50% of R&C
100% of PA
50% of R&C
OUTPATIENT
OUTPATIENT PRESCRIPTION DRUGS
Note: The Covered Person must pay for prescriptions in full at the time of pickup, then submit a
claim for reimbursement.
PPO
Maternity/Diagnostic Services including complications of pregnancy
Elective Termination of Pregnancy
Approved Clinical Trials for life-threatening disease or condition
ELECTIVE SERVICES
Private-Duty Nurse
Tuberculosis (TB) Testing regardless of determination of medical necessity
Dental Treatment for injury to sound, natural teeth only
Repair of Eyeglasses, Contact Lenses, or Hearing Aids as required as a direct result of Injury
Treatment in Home Country; limited to $100,000 maximum per policy year
Non-emergency Treatment Outside U.S.
NON-PPO
50% of actual charges, 100% for generic contraceptives
DEDUCTIBLE WAIVED
OTHER
Ambulance Services
Durable Medical Equipment/Braces and Appliances/Prosthetic and Orthotic Devices
Consultant Doctor Fees
Allergy Testing and Treatment
Pediatric Dental Care limited to Covered Persons under the age of 19
Pediatric Vision Care limited to Covered Persons under the age of 19
Maternity/Routine Services prenatal exams, first postnatal exam, routine tests & ultrasounds
50% of R&C
50% of R&C
50% of R&C
50% of R&C
100% of R&C
50% of R&C
50% of R&C
50% of R&C
50% of R&C
PPO
100% of R&C
NON-PPO
100% of R&C
50% of R&C
100% of PA
50% of R&C
100% of PA
50% of R&C
see brochure for details
see brochure for details
100% of PA
50% of R&C
DEDUCTIBLE WAIVED
paid as any other Sickness
100% of PA
50% of R&C
Paid as any other Sickness
100% of PA
100% of PA
50% of R&C
50% of R&C
100% of R&C
100% of PA
50% of R&C
50% of R&C
50% of R&C
MEDICAL EVACUATION/ REPATRIATION OF REMAINS
Emergency Medical Evacuation
$50,000 (DEDUCTIBLE WAIVED)
Repatriation of Remains
$25,000 (DEDUCTIBLE WAIVED)
†† Pre-certification is required for hospitalization.
* Radiology and Inpatient Doctor visits covered at 100% when treatment is received by a non-PPO provider in a PPO facility.
BENEFITS SUMMARY – page 3
Your Deductible (For students only, the deductible is waived at the student health center or if you are
University of California––Extension
English Language and International Education Programs
BENEFITS SUMMARY – page 4
2016 HEALTH INSURANCE PLAN
EXCLUSIONS
Unless specifically included, no benefits will be paid for loss or expense caused by, contributed to, or resulting from, or treatment, services, or
supplies related to:
1. Eyeglasses, contact lenses, routine eye refractions, eye examinations, except in the case of Injury; or radial keratotomy or similar surgical
procedures to correct vision, except when due to a disease process; repair or replacement of eyeglasses or contact lenses, except as required
as a direct result of an Injury. This exclusion does not apply to preventive services mandated by the Affordable Care Act.
2. Hearing aids and the fitting or repairing or replacement of hearing aids, except in the case of Accident or Injury. This exclusion does not apply
to preventive services mandated by the Affordable Care Act.
3. Cosmetic treatment, cosmetic surgery, plastic surgery, resulting complications, consequences, and aftereffects or other services and supplies
that the Company determines to be furnished primarily to improve appearance rather than a physical function or control of organic disease,
except as provided herein or for treatment of an Injury that is covered under the Policy. Improvements of physical function do not include
improvement of self-esteem, personal concept of body image, or relief of social, emotional, or psychological distress. Procedures not covered
include but are not limited to: face-lifts; sagging eyelids; prominent ears; skin scars; warts, nonmalignant moles and lesions, unless Medically
Necessary; hair growth; hair removal; correction of breast size, asymmetry, or shape by means of reduction, augmentation, or breast implants,
(except for correction of deformity resulting from mastectomies or lymph node dissections); and deviated nasal septum, including submucous
resection, except Medically Necessary treatment of acute purulent sinusitis. This exclusion does not include reconstructive surgery when the
service is incidental to or follows surgery resulting from trauma, Injury, infection, or other diseases of the involved part.
4. Sexual/gender reassignment surgery, except as provided when determined to be Medically Necessary or when treatment is otherwise
Covered under the Policy in the absence of a diagnosis of gender dysphoria. This exclusion does not include related mental health counseling
or hormone therapy.
5. Treatment, service, or supply that is not Medically Necessary for the diagnosis, care, or treatment of the Sickness or Injury involved, except as
specified herein. This applies even if they are prescribed, recommended, or approved by the student health center or by the Covered Person’s
attending Doctor or dentist.
6. Treatments that are considered to be unsafe, Experimental, or Investigational by the American Medical Association (AMA) and resulting
complications, except in connection with an Approved Clinical Trial.
7. Dental care or treatment of the teeth, gums, or structures directly supporting the teeth, except as specified herein. This exclusion does not
apply to preventive services mandated by the Affordable Care Act.
8. Reproductive/infertility services, including but not limited to: treatment of infertility (male or female), including diagnosis, diagnostic tests,
medication, surgery, supplies, and fertilization procedures rendered for the purpose or with the intent of inducing conception; premarital
examination; impotence, organic or otherwise; sterilization reversal; vasectomy reversal. Examples of fertilization procedures are ovulation
induction procedures, in vitro fertilization, artificial insemination, embryo transfer, or similar procedures that augment or enhance the
Covered Person’s reproductive ability.
9. Hospital Confinement or any other services or treatment that are received without charge or legal obligation to pay.
10. Services provided normally without charge by the health service of the Policyholder or services covered or provided by a student health fee.
11. Treatment in a government Hospital, unless there is a legal obligation for the Covered Person to pay for such treatment.
12. Any services of a Doctor or nurse who is the Covered Person’s Family Member.
13. Services received after the Covered Person’s coverage ends, except as specifically provided under the Extension of Benefits provision.
14. Under the Outpatient Prescription Drug benefit as shown in the Schedule of Benefits, any drug or medicine: a) obtainable Over the Counter
(OTC), except as specifically provided under Preventive Services; b) for alopecia (hair loss) or hirsutism (hair removal); c) for the purpose of
weight control; d) anabolic steroids used for bodybuilding; e) for the treatment of infertility; f) cosmetic, including but not limited to the
removal of wrinkles or other natural skin blemishes due to aging or physical maturation; g) drugs labeled “Caution – limited by federal law to
Investigational use” or experimental drugs; h) purchased after coverage under the Policy terminates; i) refills in excess of the number specified
or dispensed after one (1) year from date of the prescription; j) for an amount that exceeds a thirty (30) day supply; k) if the FDA determines
that the drug is contraindicated for the treatment of the condition for which the drug was prescribed or experimental for any reason, except
in connection with an Approved Clinical Trial.
15. Services for the treatment of any Injury or Sickness incurred while committing or attempting to commit a felony.
16. War or any act of war, declared or undeclared; or while on active duty in the armed forces of any country.
17. Weight reduction services.
18. For international students, treatment received in the home country in excess of $100,000 per policy year.
19. Biofeedback.
20. Diagnosis and treatment of sleep disorders, including but not limited to sleep studies.
21. Long-term care.
This document is a brief summary of the plan. If there are any discrepancies between this document and the policy, the policy will govern.