The University-sponsored Student Health Plan is designed to provide comprehensive medical coverage for the student and his/her eligible dependent(s). It is not an insurance program. The plan includes coverage for hospital care, surgery, emergency care, prescription drugs, and more. Generally, to be eligible for reimbursement under the provisions of the plan, expenses must be incurred while coverage is in effect. Expenses incurred before plan coverage becomes effective or after 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 vision or dental coverage available. Please see the Loma Linda University Web site for Student Health Services for a complete explanation of the Student Health Plan (<http://www.llu.edu/central/studenthealth/index.page>).
The enrollment form must be returned to Risk Management as specified in order to gain access to the services provided.
The health plan has been developed as a PPO (preferred provider) plan. Benefits for services utilized outside the preferred provider structure will be reduced.
The plan benefit year is a fiscal year and runs from July 1 through June 30.
If a student or patient has not maintained continuous "creditable coverage" under another health plan during the twelve months prior to the student's date of enrollment, or prior to the coverage effective date, the following pre-existing condition exclusion will apply: This plan will not cover any medical condition, illness, or injury for which medical advice, diagnosis, care, or treatment was recommended or received by the student or patient during the six months prior to the student's date of enrollment or during the six months prior to the effective date of health plan coverage. Treatment includes receiving services and supplies, consultations, diagnostic tests, or prescribed medications. This exclusion will apply for twelve months from the coverage effective date, or date of enrollment if the individual was enrolled at the time of enrollment to the University, unless such an individual remains treatment free during the six-month term beginning with the date of enrollment or effective date of coverage. If the individual remains treatment free during this six-month term, the pre-existing condition exclusion will apply only during this six-month period. This exclusion will not apply to pregnancy-related medical expenses or to medical treatment for a newborn or adopted child. (A student who was covered by another health plan prior to enrollment at this University should read the following section entitled "Health Insurance Portability and Accountability Act.")
A student who has a pre-existing condition should check with any prior insurer to obtain complete information regarding his/her rights to COBRA coverage during this pre-existing condition exclusion period.
If a student has been covered under a medical plan during the past twelve months, all or part of the pre-existing condition exclusion may be waived when s/he comes under the University plan. In order for a determination to be made regarding the student's coverage, the former insurance company or employer must provide to Risk Management a certificate verifying the previous coverage. If the student has any pre-existing medical conditions, it is imperative that this certificate be returned to Risk Management along with the health plan enrollment form.
A student is eligible for benefits if s/he:
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 thirty days of a status change (i.e., within thirty days of marriage or within thirty days of the birth of a child) and pay the appropriate quarterly student contribution, as outlined below:
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. No invoices or reminders are sent to students who are buying into the plan. The Department of Risk Management cannot add Student Health Plan fees to the student's account. All payments must be made by check or money order. A newborn child must also be enrolled in the plan within thirty 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 coverageA fee of $390 per quarter for the student plus one of the amounts below for dependents is charged for extension/continuation coverage:
Each enrolled student will be given a CVS/Caremark health care identification card, which can be used at any participating pharmacy displaying the CVS/Caremark decal. The cost of the prescription will be billed directly to the plan after the student pays a copayment. Prescriptions filled through CVS/Caremark will be limited to a maximum of a thirty-day supply. The copayment amounts will be $15 for generic drugs and $30 for brand-name* drugs that are dispensed at the health plan's preferred pharmacies: the LLUMC Pharmacy, the Campus Pharmacy (located in the Loma Linda Market), the Faculty Professional Pharmacy (located in the Faculty Medical Offices), and the LLU Community Pharmacy.
If the prescription is filled at any other participating CVS/Caremark pharmacy, there will be a $25 copayment for generic products or a $40 copayment for brand-name* drugs. Prescriptions not filled by the CVS/Caremark system will not be covered under the plan. There is a $5,000 maximum deductible per individual per fiscal plan year.
*The copayment when a name brand is purchased because no generic substitute is available; however, if a student chooses a name brand over a generic drug, the student will be responsible for the generic copayment plus any difference in cost between the two medications.
All services that require preadmission review or prior authorization must be processed through the Department of Risk Management. The types of services that require prior authorization include:
Please refer to the plan document for a complete description of required authorizations. Participants in this plan must follow the preadmission review process in order to receive full hospitalization benefits. If a participant does not follow the preadmission review process, hospitalization benefits will be reduced by 50 percent.
In order to fully understand plan benefits, students need to obtain a University Student Health Plan Document, which describes all of the plan coverage, limitations, and exclusions. Questions regarding the plan should be directed by telephone to the Department of Risk Management at 909/558-4386.