International Student Health Insurance Program (ISHIP)

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1 Medical Plan Summary for International Students Translation Services If you need an interpreter to help with oral translation services, you may contact the LifeWise Customer Service team at to guide you through the service. Coverage Periods The ISHIP coverage plan year begins September 20, 2014 and ends September 19, Quarter Coverage Period Fall Sept. 20 Jan. 4 Winter Jan. 5 Mar. 29 Spring Mar. 30 June 12 Summer June 13 Sept. 19 SUMMARY OF YOUR COSTS This is a summary of your costs for covered services. Your costs are subject to the all of the following. The allowed amount. This is the most this plan allows for a covered service. The copays. These are set dollar amounts you pay at the time you get services. There is no deductible when you pay a copay, unless shown below. The deductible. The costs shown below are what you pay after the deductible is met. Sometimes the deductible is waived. This is also shown below. When services are subject to in-network benefit level or cost shares, the innetwork deductible applies. Hall Health In-Network Out-of-Network Providers Providers Providers Individual Deductible $100 per quarter/ None Deductible waived at Hall Health $400 per plan year Family deductible $200 per quarter/ Not Available Deductible waived at Hall Health $800 per plan year The out-of-pocket maximum. This is the most you pay each plan year for services. Hall Health and other Out-of-Network Providers In-Network Providers Individual Out-of-Pocket Maximum $3,400 $6,400 Family Out-of-Pocket Maximum $6,800 $12,800 Prior authorization. Some services must be authorized by us in writing before you get them, in order to be eligible for benefits. See Prior Authorization in the Plan Booklet for details. For services provided in a facility or hospital, benefits may also be subject to the deductible and coinsurance when related to facility fees billed by the hospital. See Hospital Services in the Plan Booklet for these costs. The conditions, time limits and maximum limits are described in this booklet. Some services have special rules. See Covered Services in the Plan Booklet for these details.

2 Provider Networks Not all services are provided at Hall Health. You may use this option at any time You may use this option at any time Maximum Benefit Unlimited Deductible The costs shown below are what you pay after the deductible is met. Sometimes the deductible is waived. This is also shown below. When services are subject to in-network benefit level or cost shares, the in-network deductible applies. Individual None $100 per quarter / $400 per plan year Family None $200 per quarter / $800 per plan year Coinsurance Out-of-Pocket Maximum: This is the most you pay each plan year for services. Includes deductibles, copays and coinsurance. Individual $3,400 $6,400 Family $6,800 $12,800 COMMON MEDICAL SERVICES Office and Clinic Visits You may have additional costs for other services such as x-rays lab, therapeutic injections and hospital facility charges. See those covered services for details. Office visits Office visit with your Gynecologist Non-hospital urgent care centers All other Provider office visits Preventive Care: Benefits for preventive care that meet the federal guidelines are not subject to the deductible, copay or coinsurance when care is provided by Hall Health or an in-network provider. Exams, screenings and immunizations are limited in how often you can get them based on age and gender No Charge No Charge Not Covered Seasonal immunizations at a pharmacy No Charge No Charge Paid at 100%, deductible waived Health education and tobacco cessation programs No Charge No Charge Not Covered Contraception Management and Sterilization No Charge No Charge Paid at 60%

3 Diagnostic X-ray, Lab and Imaging Preventive care screening and testing Basic diagnostic x-ray, lab and imaging Major diagnostic x-ray and imaging No Charge No Charge Paid at 60% Paid at 75%, deductible waived Paid at 75%, deductible waived Paid at 60% Pediatric Care: Limited to members under age 19 Pediatric Vision Services Routine exams limited to one per plan year One pair glasses per plan year, frames and lenses One pair of contacts per plan year in lieu of glasses, or a year supply of disposable contacts. Contact lenses required for medical reasons One comprehensive low vision evaluation and four follow up visits in a five plan year period, deductible waived Low vision devices, high powered spectacles, medical vision hardware, magnifiers and telescopes when medically necessary Pediatric Dental Services Class I Services Not Available Paid at 90% Paid at 70% Class II Services Not Available Paid at 80% Paid at 60% Class III Services Not Available Paid at 50% Paid at 50% Medically Necessary Orthodontia Not Available Paid at 50% Paid at 50%

4 Prescription Drugs - Retail Pharmacy: Up to a 30-day supply. The quarterly deductible is waived. Maximum copay/coinsurance of up to $150 per prescription. In-Network providers include UMC/UWP. Preventive drugs No Charge No Charge Formulary generic drugs $20 copay $20 copay Formulary brand name drugs $30 copay $30 copay Non-Formulary drugs $45 copay $45 copay Paid at 50% (deductible waived) up to $150 maximum per prescription based on billed charge Specialty drugs Paid at 50% (deductible waived) Paid at 50% (deductible waived) Surgery Services Inpatient hospital Outpatient hospital, ambulatory surgical center Professional services Emergency Room Facility fees. The copay is waived if you are admitted as an impatient through the emergency room. Not Available $100 copay, then deductible, Paid at 75% $100 copay, then deductible, Paid at 75% Professional, diagnostic services, other services and supplies Not Available Paid at 75% Paid at 75% Emergency Ambulance Services Not Available Paid at 75% Paid at 75% Urgent Care Centers Hospital Services Inpatient Care Outpatient Care Mental Health and Chemical Dependency Office visits (there are no fees at the Counseling Center for registered students) Inpatient and residential

5 Maternity and Newborn Care Prenatal, postnatal, delivery, inpatient care and termination of pregnancy. See also Diagnostic X-ray, Lab and Imaging. For specialty care see also Office and Clinic Visits. Hospital Birthing center or short-stay facility Diagnostic tests during pregnancy Professional Home Health Care Limited to 130 visits per plan year Hospice Care Home visits Respite care, inpatient or outpatient (limited to 14 days lifetime) Habilitation Therapy (Neurodevelopmental) Neuropsychological testing to diagnose is not subject to any maximum. Please see Mental Health and Chemical Dependency for therapies provided for mental health conditions such as autism. Inpatient (limited to 30 days per plan Outpatient (limited to 25 visits per plan Rehabilitation Therapy Please see Mental Health and Chemical Dependency for therapies provided for mental health conditions such as autism. Inpatient (limited to 30 days per plan Outpatient (limited to 25 visits per plan Skilled Nursing Facility and Care Skilled nursing facility care limited to 60 days per plan year Skilled nursing care in the long-term care facility limited to 60 days per plan year Home Medical Equipment (HME), Supplies, Devices, Prosthetics and Orthotics Shoe inserts and orthopedic shoes limited to $300 per plan year, except when diabetes-related.

6 OTHER COVERED SERVICES Acupuncture Limited to 12 visits per plan year. Allergy Testing and Treatment Chemotherapy, Radiation Therapy and Kidney Dialysis Clinical Trials Not Available Covered as any other service Covered as any other service Dental Accidents Not Available Covered as any other service Covered as any other service Dental Anesthesia When medically necessary Foot Care Routine care that is medically necessary for the treatment of diabetes Infusion Therapy Mastectomy and Breast Reconstruction Medical Foods Spinal or Other Manipulative Treatment Limited to 10 visits per plan year Temporomandibular Joint (TMJ) Disorders Office visits Inpatient facility fees Other professional services Therapeutic Injections Transplants All approved transplant centers covered at in-network benefit level. Office visits Paid at 75% Paid at 75% Not Covered Inpatient facility fee Not Available Paid at 75% Not Covered Other professional services Not Available Paid at 75% Not Covered Travel and lodging, $5,000 limit per transplant Not Available Paid at 100% Paid at 100% Abortion Transgender Surgery Maximum of $35,000 per plan. Services do not apply toward the out-of-pocket maximum shown above.

7 Vision for Adults The services below do not apply toward the out-of-pocket maximum. For vision exams and hardware for a child under age 19, see Pediatric Vision Services. Vision exams Limited to 1 per plan year up to $150 limit per plan year. Vision hardware Not Available Not Covered Not Covered Dental for Adults Maximum of $300 per plan year, $25 individual / $75 family deductible per plan year. The services below do not apply toward the out-of-pocket maximum amounts shown above. For dental care for a child under age 19, see Pediatric Dental Services. Preventive Services Includes routine exams and cleanings. See the Dental for Adults section of the Plan Booklet for more details. Not Available Paid at 100% Paid at 100% Restorative Services Not Covered Not Covered Not Covered Emergency Medical Evacuation and Repatriation of Remains Emergency Medical Evacuation $100,000 lifetime maximum Repatriation of Remains $25,000 maximum Not Available No Charge No Charge Not Available No Charge No Charge This is a summary of benefits only. We have made every effort to be accurate; however, the underlying contracts, master policies, and other legal plan documents, together with LifeWise Assurance Company and trustee decisions, will govern in answering any questions and resolving any discrepancies. 1 2 Network providers are healthcare providers that have a contractual arrangement with LifeWise Assurance Company. Non-network providers include all other doctors and hospitals. These providers may bill you for charges over the allowable charge. Note: This plan is a Preferred Provider plan (PPO). This means that your plan provides you benefits for covered services from providers of your choice. It also gives you access to the LifeWise provider network and to networks in other states with which we have arranged to provide covered services to you. Hospitals, physicians and other providers in these networks are called "in-network providers." A list of in-network providers is available in our LifeWise provider directory. These providers are listed by geographical area, specialty and in alphabetical order to help you select a provider that is right for you. LifeWise updates this directory regularly, but it is subject to change. We suggest that you call LifeWise for current information and to verify that your provider and their office location or provider group are included in the LifeWise network before you receive services. The provider directory is available online at

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