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Student Health Insurance Plan
1. An Overview of the Student Health Insurance Plan: Medical, Dental, Vision and Prescription Benefits
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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)
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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
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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
![Student Health Insurance Plan ,[object Object],[object Object],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:](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)