LOMA LINDA UNIVERSITY HEALTH CARE HEALTH PLAN

LOMA LINDA UNIVERSITY STUDENT HEALTH PLAN

07-01-19

The LLU Student Health Plan provides comprehensive medical coverage and limited dental coverage for

eligible students. Contrary to most other plans, our plan has no deductibles and provides 100% coverage

for office visits at the Student Health Service as well as 100% coverage for inpatient hospital and

physician services and outpatient diagnostic services. The plan also funds 100% coverage for counseling

services provided through the Student Assistance Program. Most other outpatient specialty services are

subject to a $40 co-payment per visit. On-campus prescription drug coverage is subject to co-payments of

$15 and $30 for generic and brand drugs respectively. Expenses incurred before your plan coverage

becomes effective or after your plan coverage has terminated will not be covered. This plan will only

provide medical coverage on an excess basis. This means that all medical expenses must first be

submitted to any other available source of health care coverage. There is no optical coverage available.

PREFERRED PROVIDER PLAN: The health plan has been developed as a PPO (Preferred Provider)

plan. You may utilize services outside of the preferred provider structure; however it will be at reduced

benefits. The Medical PPO Directory can be viewed by visiting

https://myllu.llu.edu/livingwhole/preferredproviders.

The Dental PPO Directory on this site does not apply to the LLU Student Health Plan. LLU School of

Dentistry Clinic is the only PPO provider for LLU Student Health Plan with limited dental coverage as

outlined in the attached schedule of benefits.

PLAN YEAR The Plan benefit year is a fiscal year and runs from July 1 through June 30.

ELIGIBILITY You are eligible for benefits if you:

• Are attending Loma Linda University as a graduate or undergraduate; and

• Are a degree track student. Students who are accepted into a degree program and registered for more

than 0 units will be charged the enrollment fee regardless of the number of units they’re registered

for.

• Are a non-degree student registered for more than 4 units (SAHP 5 units). A student who is not

accepted into a degree program but who is registered as a non-degree student for more than 4 units

(SAHP 5 units) will be eligible. However, a non-degree student registered for 4 units (SAHP 5 units)

or fewer will not be eligible and will not be eligible to buy-in to the Student Health Plan.

However, non-degree students registered for 4 units or less will not be charged the fee and will not be

eligible to buy in to the Student Health Plan.

• Were previously covered under the Plan and are on an approved leave of absence from your academic

program.

• IS and IP Only student. Those students who are working on “In Progress” courses, and who are not

registered for any other units, will be charged the enrollment fee.

Additional information regarding eligibility:

• Students who drop before the deadline will not be charged nor covered. Any student who is charged

the fee and drops all units before the last day for a full refund (generally 1 week after the first day of

classes), will receive a full refund of the enrollment fee and they will have no access to any

University benefits. Please refer to the Student Finance 100% refund policy.

• LLUH employees who are “full time benefit eligible” will not be charged the fee. The fee will not

apply regardless of whether employees are using the education benefit or not. Spouses of employees

who are using the employee education benefit will be charged the enrollment fee.

• Those students participating in an off campus or online program will not be charged the enrollment

fee unless the program specifically requires.

• An eligible student’s coverage will become effective on the first day of class or student orientation,

whichever occurs first

BUY-IN PROVISION Under the following provisions a student may obtain coverage under this health

plan or extend coverage to a spouse or dependent children each quarter. In order to receive any coverage

under this Plan, a student must apply for coverage during an open enrollment period, within 30 days of a

status change i.e.(within 30 days of marriage or within 30 days of the birth of a newborn child) and pay

the appropriate quarterly student contribution as outlined below:

1. Spouse/Dependent Children – If you are a student covered under this plan, you may extend health

plan coverage to your spouse or dependent children.

2. Leave of Absence (LOA) – If you are a student who has been covered under the Plan up until the

time that you leave school on an approved leave of absence (LOA), you may extend your

coverage under the Plan for the length of the approved LOA, up to a maximum extension of one

year.

3. Continuation Coverage – If you have been covered under this Plan and no longer meet the

eligibility requirements, (for example, if you were not attending classes during any quarter,

including Summer-you would need to buy-in) you and your eligible dependents may continue

your coverage for up to one (1) quarter through this buy-in provision.

The open enrollment period for eligible students and dependents is the last two weeks of each

calendar quarter. Buy-in coverage will be effective from January 1 to March 31, April 1 to June

30, July 1 to September 30 and October 1 to December 31. There are no invoices or reminders

sent to students who are buying in to the Plan. The Department of Risk Management cannot

add Student Health Plan fees to your student account. All payments must be made by check,

money order, or credit card with the Visa or MasterCard logo by calling (909) 651-4010. A

newborn child must also be enrolled in the plan within 30 days of birth or adoption in order to

receive any coverage under this plan. There is no automatic or temporary coverage provided

for any dependents, including adopted or newborn children.

Extension/Continuation Coverage

Student $ 535.00 per quarter

Spouse $ 700.00 per quarter

One or more children of a covered student $ 420.00 per quarter

Spouse and Children $1,120.00 per quarter

PRESCRIPTION DRUG COVERAGE The standard co-payment amounts are $15.00 for generic drugs

and $30.00 for brand name drugs that are dispensed by the LLUMC Outpatient Pharmacy, the Faculty

Pharmacy (located in the FMO building), the LLU Community Pharmacy (located in the Professional

Plaza), the Meridian Pharmacy, the Highland Springs Pharmacy (located at Highland Springs Medical

Plaza), the LLU Home Delivery Pharmacy and the LLUMC-Murrieta pharmacy.

For standard prescriptions filled at any other participating CVS Caremark pharmacy, there will normally

be a $25.00 co-payment for generic products or a $40.00 co-payment for brand name drugs.

If a student voluntarily chooses to obtain a brand name drug when a generic equivalent drug is available,

the student will be required to pay the difference in cost between the brand drug and the generic

alternative in addition to the generic drug co-payment amount.

3. Mail Order Prescriptions

For drugs that are taken on an ongoing basis, Plan members also have the option of obtaining prescription

drugs through the CVS mail order program. With this program, employees can save time and money with

the convenience of mail delivery at no additional cost. After a one-time set up process, CVS will arrange

for automatic prescription refills. Through this program, members may obtain up to a 30-day supply of

drugs with a single co-payment and up to a 90-day supply of drugs with the payment of two (2) co-

payments. This means that a student obtaining a 90-day supply of medication can save four co-payments

per year by using the mail order option. This mail order option is only offered through the CVS Mail

Order Pharmacy. Note that the normal co-payment is waived for generic medications that are filled

through the mail-order program and are used for the treatment of asthma, cholesterol, diabetes, heart

failure and hypertension.

Additional prescription drug information and resources are also available at the CVS Caremark website

www.caremark.com and with the free CVS Caremark mobile app. These resources allow you to obtain

refills on-line, scan your prescription bar code, set up mail order delivery, view your prescription history,

track your prescription spend and check drug coverage and costs.

To sign up for mail delivery service, go to caremark.com/mailservice. This site will allow you to register

or sign-in to your account. Please have your health plan/prescription drug card available. Alternatively,

you can call CVS Caremark Customer Care at 1-800-966-5772 to fill a prescription or obtain more

information.

If you submit your prescription through the mail, the prescription will be delivered to your home address

and your co-payment (if any) will be billed to your credit card. CVS Caremark cannot accept cash or

checks for co-payments.

CVS MINUTE CLINIC SERVICES

Select CVS retail pharmacy locations also offer basic medical treatment through on site “Minute Clinics”.

These clinics are staffed by nurse practitioners and physician assistants who follow nationally recognized

clinical guidelines to diagnose and treat a range of minor illnesses and injuries including; bronchitis,

insect stings, flu, strep throat, bladder infections and minor burns or cuts. For more information and a

complete list of the conditions treated, visit www.cvs.com/minuteclinic/services/minor-illnesses. A

member may receive medical services at any Minute Clinic location with the payment of a $10 co-

payment.

Minute Clinics are open 7 days a week and appointments are not necessary. By using the CVS app, you

can identify nearby clinic locations, view waiting times and hold your place in line.

DENTAL SERVICES

1. Covered Services and Expenses

The Plan provides limited coverage for dental services provided at the LLU School of Dentistry Clinic.

The Plan does not provide coverage for any services provided outside of the School of Dentistry.

Coverage is provided for;

Preventive Services including:

• bi-annual routine exams, including four (4) bitewing and four (4) periapical x-rays per year

• full mouth x-rays and panorex limited to once every three years

• teeth cleaning (twice yearly)

• fluoride treatment (twice yearly for eligible dependents under 18 years old)

Basic Services including:

• clinic visit and exam

• necessary diagnostic x-rays and pathology

• restorations (fillings) - amalgam, silicate cement, plastic and composite restorations

• endodontics - root canals, pulp capping

• non-surgical tooth extractions

2. Limitations:

• bitewing and periapical x-rays are not covered during any year that the patient receives full mouth

x-rays

• sealants will only be covered on un-restored bicuspids and first and second molars, every three

years

3. Exclusions:

• dental crowns, cast restorations, inlays, onlays, implants, dentures or a fixed bridge

• diagnosis or treatment by any method of any condition related to the temporomandibular (jaw)

joint or associated musculature, nerves and other tissues

• hospital costs and any additional fees charged by the dentist for hospital treatment (please note,

however, that these may be included as medical benefits (see section IV. Medical Benefits))

• oral surgery including wisdom tooth removal

• orthodontia services

• periodontics and root planning

UTILIZATION REVIEW All services that require pre-admission review or prior authorization must be

processed through the Department of Risk Management. The types of services that require prior

authorization are as follows:

• All hospital admissions

• Scheduled admissions must be authorized prior to entrance to the hospital.

• For emergency admissions, notification must be within 48 hours or the next business day.

• All outpatient surgeries

• Home health services, skilled nursing facilities

• Orthotics and purchase or rental of durable medical equipment

Please refer to the Plan Document for a complete description of required authorizations. Participants in

this Plan must follow the pre-admission review process in order to receive full hospitalization benefits.

IF A PARTICIPANT DOES NOT FOLLOW THE PRE-ADMISSION REVIEW PROCESS,

HOSPITALIZATION BENEFITS WILL BE REDUCED BY 50%.

SUMMARY: This is a summary of the coverage available under the LLU Student Health Plan. In order

to fully understand your Plan benefits you will need to obtain a LLU Student Health Plan Document,

which will describe all of the Plan coverage, limitations, and exclusions. We are also enclosing a

Schedule of Benefits for your reference. If you have any questions regarding the Plan, please contact the

Department of Risk Management at (909) 651-4010.

07-01-19

LOMA LINDA UNIVERSITY

STUDENT HEALTH PLAN

SCHEDULE OF BENEFITS

7/1/2019

This schedule of benefits only provides a summary of the medical and dental coverage, limits, co-payments and co-insurance that

apply to the Plan. For a complete description of the services covered under the Plan, as well as applicable benefit limitations,

exclusions and conditions that apply to your coverage, please refer to the applicable section within the Plan document.

A. MEDICAL COVERAGE

Annual Out-of-Pocket Limits

Out-of-pocket co-payment and co-insurance maximum for medical services:

$3,500 per individual and $7,000 per family

Out-of-pocket co-payment and co-insurance maximum for prescription drugs:

$3,500 per individual and $7,000 per family

Co-insurance for out-of-network services and any co-payments or co-insurance for orthotics, prosthetics and any additional co-

insurance for failure to obtain pre-admission authorization, charges above reasonable and customary limits or any other non-covered

expenses will not apply toward the individual or family out-of-pocket maximum. In addition, these services are not subject to the

maximum out-of-pocket limit.

Annual

Maximum Coverage for Services Coverage at

Hospitalization and Surgery* Benefit At LLUH Facilities Other Hospitals

Medical, Surgical or Intensive

Care Room and Board Expenses

Miscellaneous Inpatient Expenses

Surgery and Anesthesia

Obstetrics (in-patient care)

Inpatient Professional Fees 100% 25% of Allowable Charges

Skilled Nursing Facility

Skilled Nursing Facility* 60 days No PPO 100% of Allowable Charges

NOTE: FAILURE TO OBTAIN PRE-ADMISSION CERTIFICATION FOR NON-EMERGENCY HOSPITALIZATION OR

SURGERY WILL RESULT IN A 50% REDUCTION IN BENEFITS.

Annual

Maximum Coverage % for Out-of-Network

Medical Outpatient Service Benefit Preferred Providers Provider Coverage %

Preventive Care 100% 25% of Allowable Charges

Office Visits & Consultations $40.00 co-pay/visit 25% of Allowable Charges

E-visits (a physician visit consultation 100% N/A

via My Chart)

CVS Minute Clinic Visit $10.00 co-pay/visit N/A

Laboratory and X-ray Services 100% 25% of Allowable Charges

Diagnostic Medical Services & Testing 100% 25% of Allowable Charges

Maternity Care (outpatient) $400.00 co-pay/delivery 25% of Allowable Charges

Outpatient Surgery Charges*

Facility Charges 100% 25% of Allowable Charges

Professional Fees 100% 25% of Allowable Charges

Home Care Services* 60 visits 100% 25% of Allowable Charges

Annual

Maximum Coverage % for Out-of-Network

Benefit Preferred Providers Provider Coverage %

Outpatient Psychiatric Care/Counseling

Professional Counseling $10.00 co-pay/visit 25% of Allowable Charges

(including drug or alcohol treatment)

A single visit is limited to one (1) hour of therapy

Electroconvulsive therapy (ECT) $40.00 co-pay/treatment 25% of Allowable Charges

Outpatient Health Related Services

Outpatient Medical Supplies* 80% 25% of Allowable Charges

Orthotics/Prosthetics* $10,000 80% 25% of Allowable Charges

Physical/Occupational/Speech Therapy* $40.00 Co-pay/visit 25% of Allowable Charges

One-year maximum, with required authorization

Other Health-Related Professionals* $40.00 Co-pay/visit 25% of Allowable Charges

Rental or purchase of authorized

durable medical equipment* 80% 25% of Allowable Charges

Manual wheelchair* $500 80% 25% of Allowable Charges

Electric wheelchair* $2,500 80% 25% of Allowable Charges

Purchase of Breast Pump $500 No PPO 100% of Allowable Charges

Hospice Care* 100% 25% of Allowable Charges

Accident or Emergency Treatment

Urgent Care Services $40.00 Co-pay/visit 25% of Allowable Charges

Emergency Room Outpatient Visit $200.00 Co-pay/visit $200.00 Co-pay/visit

NOTE: Emergency services are only covered if the patient is being treated for an emergency medical condition and services

are required for the alleviation of severe pain, or the diagnosis and treatment of unforeseen medical conditions that if not

immediately treated would lead to disability, dysfunction or death. If a patient is admitted to a hospital through the

emergency department, the co-payment will normally be waived. If a patient seeks services at an out-of-network hospital

emergency department for a condition that meets the Plan’s definition of an emergency medical condition, coverage shall

apply in the same manner that coverage would have applied for services at a preferred provider. However, if a patient seeks

services at an out-of-network hospital emergency department for a condition that does not meet the Plan definition of an

emergency medical condition or if the services could have been reasonably provided by a Loma Linda provider, the out-of-

network provider student co-insurance will apply.

Ambulance/Emergency Medical Evacuation

Ambulance or Medical Evacuation $50,000 No PPO $200.00 Co-payment/trip

(for life threatening conditions only)

Repatriation

Repatriation Expenses $25,000 No PPO 100% of Allowable Charge

Annual

Maximum Coverage % for Out-of-Network

Benefit Preferred Providers Provider Coverage %

Vision Care

Initial and Routine Examinations No PPO $40.00 co-pay/visit

Prescription Glasses & Contact Lenses No Coverage No Coverage

Hearing Care

Audiometricians (by physician referral) No PPO $40.00 co-pay/visit

Hearing Specialists $40.00 co-pay/visit 25% of Allowable Charges

Hearing Aids No Coverage No Coverage

Prescription Drugs

Mail Order Prescriptions – CVS Mail Order Pharmacy ONLY, (up to a 90-day supply)

$10.00 co-payment per generic prescription with use of CVS Caremark card (up to a 90-day supply)

$60.00 co-payment per brand name prescription with use of CVS Caremark card, when no generic is alternative is available (up

to a 90-day supply)

Plan members with chronic medical conditions, the co-payment for generic medications filled through the CVS mail-order

program will be waived, providing members with 100% coverage for these conditions. This includes generic medications for the

treatment of asthma, cholesterol, diabetes, heart failure and hypertension.

Standard Drugs obtained at a retail pharmacy (up to a 31-day supply)

LLUMC Pharmacy, Faculty Pharmacy, Meridian Pharmacy, LLU Community Pharmacy, Highland Springs Pharmacy and

LLUMC-Murrieta Pharmacy:

$15.00 co-payment per generic prescription with use of CVS Caremark card

$30.00 co-payment per brand name prescription with use of CVS Caremark card (when no generic alternative is available)

All other CVS Caremark pharmacies:

$25.00 co-payment per generic prescription with use of CVS Caremark card

$40.00 co-payment per brand name prescription with use of CVS Caremark card (when no generic alternative is available)

If a member voluntarily chooses to obtain a brand name prescription when a generic prescription is available, the member will be

required to pay the difference in cost between the brand name and the generic in addition to the generic drug co-payment

(applicable to both retail and mail order prescriptions).

Impotency Drugs

Co-insurance equal to 50% of the Allowable Charges will apply to all prescriptions for drugs used to treat impotency.

Impotency drugs are only covered for male members over the age of 18 with a diagnosis of organic erectile dysfunction and are

limited to 6 doses per month and requires prior authorization through CVS Caremark.

Specialty drugs not available through CVS Caremark No PPO 80% of Allowable Charges

(Requires prior approval from Risk Management)

B. DENTAL COVERAGE

Annual

Maximum % Coverage at the % Coverage for

Benefit School of Dentistry Other Dental Providers

Per Individual up to $1,000/year

Dental Care

Preventive Services 100% No Coverage

(routine exam & cleaning)

Basic Services 80% No Coverage

Major Services No Coverage No Coverage

* Prior Authorization Required. Failure to obtain prior authorization will result in a 50% reduction in any benefits that

require prior authorization.

NO PPO -- There are no preferred providers for this service