The document provides an overview of the student health insurance plan, including medical, dental, vision and prescription drug benefits. Key details include: the medical plan has a $250 deductible and $5,000 out-of-pocket maximum. Dental coverage is provided by Delta Dental with an $1,500 annual maximum. Prescriptions are covered through Express Scripts with $25 copays for brand drugs and $15 for generic drugs. International medical evacuation services are also available through International SOS.

1. An Overview of the Student Health Insurance Plan: Medical, Dental, Vision and Prescription Benefits

2. Student Health Insurance Plan You can download your Student Health Insurance card from: www.renstudent.com/ucsf MESVision 1 – (800) 793-9288 Discount plan: DO NOT SUBMIT BILLS OR CLAIMS www.ecndiscount.com 20% off discount plan with UCSF ID VISION Delta Dental of California 1- (800) 765-6003 P.O. Box 997330 Sacramento, CA 95899-7330 www.deltadentalins.com Group #: 271-0001 DENTAL Express Scripts, Inc. 1 - (800) 844-9096 P.O. Box 390873 Bloomington, MN 55439-0873 www.express-scripts.com RQSR RX Nationwide Life Insurance Co. 1 - (800) 468-4343 P.O. Box 6040 Agoura Hills, CA 91376-6040 www.cfmcnet.org (in California) www.myfirsthealth.com (out of California) 302-078-0407 MEDICAL UNDERWRITER: TEL NO: CLAIM ADDRESS: NETWORK PROVIDERS: POLICY NUMBERS:

3. Student Insurance Plan Eligibility The Student Health Insurance Plan Fee will be paid by students at the time of registration. Summer coverage is included for all students registered for Fall, Winter, and Spring quarters. Eligible scholars and researchers or eligible campus groups may pay the Scholars and Researchers Health Plan (SRHP) fee to obtain care coverage. Dependents of registered students and enrolled SRHP scholars have a different insurance premium pricing schedule to obtain health care coverage. Students on an approved Leave of Absence (LOA) may enroll in the Student Health Insurance Plan for one quarter per lifetime.

4. Primary Care at Student Health Parnassus or Mission Bay The following services are available at SHCS: Primary Care Mental Health Counseling (max of 10 visits per policy year) Specialty Care Referrals Chronic Care Management Immunizations and TB Testing Travel Consultations and Immunizations Nursing Advice (8 a.m. to 4:30 p.m., Mon. – Fri.) Contraceptive Counseling Discounted oral contraceptive, emergency contraceptive (Plan B), condoms and thermometers are available for purchase at SHCS. SHCS also offers an after-hours mental health crisis hotline . To connect with a therapist after-hours, call SHCS at (415) 476-1281 and select the crisis line option (option 7).

5. Medical Coverage Outside of SHCS $50 deductible per visit; waived if admitted ER Co-pay $250,000 per condition per year ($100,000 for dependents) Policy Year Limit $10,000 (contact SHCS for consultation if you expect to exceed this limit) Prescription Max All specialty visits must be pre-authorized by SHCS, except for ER or Urgent Care visits. These visits can be retro-authorized with the Director’s approval. Please send all clinical notes from the ER or Urgent Care facility to SHCS for authorization within 24 to 72 hours. $5,000 Annual Out of Pocket Maximum $250 Deductible once per year $20 Office Visit Co-pay Highlights (does not apply to Student Health)

6. Medical Coverage Outside of SHCS Enrollees who go to an authorized specialty visit at UCSF Medical Center are not responsible for the $250 deductible or remaining 30% co-insurance (UCSF Medical Center waives the remaining deductible and coinsurance for SHCS enrollees.) Enrollees are also encouraged to go to a Quest Diagnostics laboratory for blood work for 100% coverage, but need to use an authorized SHCS lab slip. 100% after $50 co-pay 100% after $50 co-pay Emergency Room 100% (surgery) 70% of R&C (x-rays, labs, etc.) 100% (surgery) 90% of R&C (x-rays, labs, etc.) Outpatient 70% & $20 co-pay 90% & $20 co-pay Urgent Care Visit 70% (hospital services) 70% (surgery) 70% & $20 co-pay (doctor’s fees) 90% (hospital services) 90% (surgery) 90% & $20 co-pay (doctor’s fees) Hospital Stay 70% & $20 co-pay 90% & $20 co-pay Office Visits Out-of-Network In-Network

7. Medical Coverage Outside of SHCS Mental Health Services (does not apply at SHCS) 90% after $20 co-pay (unlimited visits) Parity diagnosis 90% in-network; 70% out-of-network (25 days/policy year) 90% in-network; 70% out-of-network $20 co-pay ($350 max) 80% after $20 co-pay (40 visits max) Non-parity diagnosis Inpatient Hospital Inpatient MD Visit Outpatient MD Visit

8. Medical Coverage Outside of SHCS 100% for up to 15 visits per policy year. Not subject to the $250 deductible. Acupuncture or Chiropractic Care Up to $200 per policy year ($100 of cost includes treatment of the foot or treatment related to the foot). Orthopedic Appliances Limited to 2 days following vaginal delivery or 4 days following delivery by cesarean section. Newborn babies are covered with SHS dependent insurance for 31 days following birth. Well Baby Care 100%,after a $10 co-pay for the first 15 visits and a $20 co-pay for any additional visits up to 25 visits per policy year. Not subject to the $250 deductible. Physical Therapy (outpatient) In-Network or Out-of-Network Other Benefits

9. Medical Coverage Outside of SHCS 70% 100% of R & C Home Care Nurse Out-of-Network In-Network 90% Durable Medical Equipment 70% ($25,000 lifetime max per sickness or injury) 90%( $25,000 lifetime max per sickness or injury) External Prosthetic Devices 70% 90% Temporary Surgical Appliances 70% 90% Medical Supplies Other Benefits

10. Travel health assistance services and medical evacuation is available for all enrollees. When traveling abroad, students are encouraged to use International SOS Insurance benefits. SOS provides: 24 hour telephone access to health providers Assistance with emergency care Emergency evacuation On-line access to services Email health alerts Dispatch of medication and medical supplies Lost document advice & assistance Country-specific health advisories Log-in online at www.internationalsos.com with member log-in 11BSGM000060. See your insurance brochure for appropriate phone numbers from your country-of-destination. The Student Insurance Plan will not pay foreign health providers directly, but will reimburse you for authorized and medically necessary expenses. All clinical notes need to be translated into English. Medical Coverage Outside of SHCS International SOS Services

11. Exclusions and Limitations For more exclusions and limitations, refer to pg. 17 - 19 of the Insurance Brochure: https://studenthealth.ucsf.edu/sites/studenthealth.ucsf.edu/files/PDF/insurance_brochure_0910.pdf The plan does not pay benefits for: Treatment, services or supplies which are not medically necessary; Routine physical examinations (Note: These services are provided at SHCS); Premarital examinations; Genetic testing unless Medically Necessary (see insurance brochure for details); Treatment of infertility or any other form of assisted conception; Cosmetic surgery other than: a) reconstructive surgery incidental to or following surgery resulting from trauma, infection, or other diseases of the involved part; b) reconstructive surgery because of a congenital disease or anomaly as provided for Dependent newborns; Cosmetic treatment or surgery except as a result of Injury that occurred while covered under the Policy or as specifically provided for in the Policy;

12. Pre-Existing Condition There is NO coverage for Pre-existing Conditions unless the Covered Person has had six months of continuous coverage prior to the covered Person’s effective date under this plan. Prior coverage of less than six months will be credited toward satisfying the Pre-existing limitation. Continuous Coverage means the period of time that a covered person is continuously covered under the policy and/or any prior creditable coverage with no greater than a 63-day lapse between the effective date of coverage under this policy and the termination of prior creditable coverage.

13. Prescription Drug Coverage Express-Scripts has a mail service program for your convenience. $25 Co-pay ($15 Co-pay if there is no generic replacement for brand name, 30-day supply) Brand $15 Co-pay (30-day supply) Generic $10,000 (Contact SHCS if you are close to exceeding the maximum.) Policy Year Max Plan name: Express-Scripts Plan group name: RQSR 1-800-844-9096 www.express-scripts.com All enrollees must use an Express Scripts in-network pharmacies to receive benefits. Plan Contact Information Prescription Drugs

14. Dental Coverage Delta Dental of California 1-800-765-6003 Plan Contact Information 271-0001 Group No. Student Insurance Plan Member ID Enrollee ID www.deltadentalins.com 1-800-765-6003 Network $1,500 Calendar Year Max $25 Deductible Highlights

15. Dental Coverage If you have any questions about the Student Dental Insurance Plan, call the toll-free Benefit-Advice line at 1-800-765-6003. Covered only for dependent children under age 12; repairs not covered. Space maintainers 1 set per 12 months for adults and 2 set per 12 months for children under 18 years old Bitewing X-Rays 1 per 36 months Full mouth/Panoramic x-rays 2 per 12 months Fluoride treatment 2 per 12 months, including emergency exams Routine exams and cleaning Preventive Services 80% for PPO, 70% for non-PPO

16. Dental Coverage If you have any questions about the Student Dental Insurance Plan, call the toll-free Benefit-Advice line at 1-800-765-6003. Dental scaling Periodontal prophy (cleaning) - covered only after 3 months following active periodontal treatment Endodontics (root canal therapy) Sealants – only on permanent first molars through age 8 and second molars through age 15, every 2 years Simple oral surgery Complex oral surgery (includes extraction of impacted teeth) General anesthesia Amalgam, silicate composite (resin) restorations (fillings) Basic Services 80% for PPO, 40% non-PPO

17. Dental Coverage Crowns and Cast Restoration Services 80% for PPO, 40% non-PPO Crowns, Inlays, Onlays and Cast Restorations are benefits only when provided to treat cavities which cannot be restored with amalgam, silicate or direct composite (resin) restorations. Harmful Habit Appliances 80% for PPO, 40% non-PPO Temporomandibular (jaw) Joint (TMJ) including bruxism, occlusal guard and night guard appliances, covered up to the lifetime maximum of $500. When using non-PPO providers, the insured is responsible for any amount over Delta Dental’s approved amount.

18. Vision Coverage Enrollment begins in early Sept. (with a deadline of Oct. 19 th ) for coverage from Nov. 1, 2009 to Oct. 31, 2010. Enrollment Optional VSP Vision www.VSP.com www.renstudent.com/ucsfvsp Plan Contact Information $168/year Cost Please visit the above websites for specific information. 20% discount off usual charges such as routine eye exams, lenses, frames, permanent contacts, plus cosmetic extras. Eye Care Network corporate participants include LensCrafters, Walmart Optical, Sears, Optical, and Target Optical. Please see www.ecndiscount.com for a complete list of participating providers 1-800-793-9288 www.ecndiscount.com Plan Contact Information Basic Vision

19. Student Health Insurance Plan – Continuation Coverage Continuation health coverage is available for graduating students and their eligible dependents The Continuation Plan may be enrolled in for a maximum of three (3) months from the termination date of current coverage Continuation plan coverage includes all the same benefits, limitations and exclusions as the Student Health Plan, except there is a $50,000 maximum per Sickness or injury No Dental Plan coverage is included The SHCS Referral Requirement is waived for the Continuation Plan For Continuation Plan cost please call SHCS at 415-476-1281

20. Other Insurance Resources SHCS strongly encourages all students to obtain health insurance when separating from school. If the Continuation Plan does not serve your needs it is in your interest to research plans. There are both short and long term coverage options available. Here are a few resources: Long Term Coverage: Short Term and Temporary Coverage: 1-800-277-3323 www.hpainsurance.com Health Plan Administrators Ins. 1-800-909-3447 ext 2 www.healthnet.com Health Net – Quick Net Plan 1-800-977-8860 www.ehealthinsurance.com eHealthInsurance 1-800-211-6906 www.temporaryinsurance.com Assurant Health 1-800-777-6000 www.anthem.com Anthem Blue Cross www.kaiserpermanente.org Kaiser Permanente 1-800-624-6370 www.insure.com Insure.com 1-800-880-5305 www.healthyfamilies.ca.gov Healthy Families 1-800-644-3491 www.healthinsurance.com Healthinsurance.com 1-800-909-3447 ext 2 www.healthnet.com Health Net 1-800-977-8860 www.ehealthinsurance.com eHealthInsurance 1-800-777-6000 www.anthem.com Anthem Blue Cross

21. Disclaimer SHCS Parnassus 500 Parnassus Avenue Millberry Union, H-005 San Francisco, CA 94143-0722 SHCS Mission Bay 1675 Owens Street William J. Rutter Center, Room 330 San Francisco, CA 94143-3015 Information in this presentation is an overview. Please contact SHCS for more information or details about your plan. http:// studenthealth.ucsf.edu / tel: (415) 476-1281 fax: (415) 476-6137