CSUF CLUB SPORTS

Insurance Options Guide

Fall 2011

Hello Club Sports Participant,

In this packet you will find information on various health care options

available to you as a student, U.S. Citizen, or California resident. All of these

resources are available online and most can be found by following the links

provided at the beginning of each section. The beginning portion of this

packet includes a brief overview of each option. After page 9 you will find the

actual brochures and handbooks from the programs’ websites.

If you need any additional information or help deciding which option

might be best for you please call the contact centers listed on the websites or

make an appointment with the Club Sports office in TSU- 247.

CSUF Club Sports, TSU 247

(657) 278- 7622

http://campusapps2.fullerton.edu/clubsports/index.aspx

California State University, Fullerton

800 N. State College Blvd.

Fullerton, CA 92831

CSUF CLUB SPORTS

Insurance Options Guide

Why do I need health insurance? http://www.ahirc.org/orangecounty

Access to quality health care is directly tied to having health insurance. Without health

insurance or unlimited funds, you will have little or no say in the care you receive or in

the choice of providers of that care.

The cost of care is so great that a surgery, a day or two in the hospital, treatment for a

chronic condition, a prescription for on-going drug therapy, or even several hours in a

hospital emergency room can throw you into considerable, even ruinous, debt if you are

uninsured.

People without health insurance frequently delay care, and are more likely to be sicker

when they seek care. Not surprisingly, the mortality rates for cancer and other diseases

are higher among the uninsured.

1. Medical Services Initiative (MSI) http://ochealthinfo.com/medical/msi/ Application

o Are able to provide proof of legal permanent resident status or U.S. citizenship

o Can provide proof that you are an Orange County resident

o Are between the ages of 19 and 64

o Have an income that is no-more than 200% of the Federal Poverty Level (FPL)

o Are not eligible for Medi-Cal

Cost

o Free: Primary Care office visits, Specialist office visits, Emergency Room

visits

o Sometimes co-pay for prescriptions: Prescriptions will be $4.00 for each

prescription with a maximum of $32.00 in any month.

2. MEDI-CAL (more information at end) http://egov.ocgov.com/ocgov/Social%20Services%20Agency/Health%20Care/Medi-

Cal%20Program%20&%20Services

https://www.healtheapp.net/app/Learnmores.aspx?link_id=4

Application o Families with children

o Persons under 21 or 65 years of age and older

o Pregnant women

o Blind and disabled persons

o Recipients of nursing home or long term care

o Refugees

o SSI/SSP (Supplemental Security Income/State Supplemental Program)

o CalWORKs (California Work Opportunity and Responsibility to Kids)

o 65 or older

o Blind

o Disabled

o Under 21

CSUF CLUB SPORTS

Insurance Options Guide

o Pregnant

o Diagnosed with breast or cervical cancer

o In a skilled nursing or intermediate care facility.

o Refugee status during a limited period of eligibility. Adult refugees may or may

not be eligible depending upon how long they have been in the U.S.

o Parent or caretaker relative of a child under 21 and

o The child's parent is deceased or does not live with the child, or

o The child's parent is incapacitated, or

o The child's parent who is the primary wage earner is unemployed or

underemployed.

Cost o If your income is less than Medi-Cal limits for your family size, you will receive

Medi-Cal services at no cost to you. (Refer to All County Welfare Directors

Letter (ACWDL) 11-16 to view the Income Limit Chart.)

o If your income is more than Medi-Cal limits for your family size, you will have to

pay a certain amount only in the month you have medical expenses. The amount

that you pay is called your share of cost (SOC). When you pay or promise to pay

that amount, we say that you have met your SOC. Once you have met your SOC,

Medi-Cal will pay the rest of your covered medical bills for that month. For

example, if your SOC is $50, you must first pay or obligate (obtain your providers

agreement to make payments on the SOC) $50. Your provider will enter the

amount you paid or obligated into the Department's database. Your case will

certify when the amounts you paid or obligated equal the amount of your share of

cost. Once your share of cost is certified; providers checking your eligibility will

advised that you are eligible and covered services may now be billed to the Medi-

Cal program. Please note, expenses incurred by ineligible members of your family

may be used to meet the share of cost of eligible members.

o If one spouse lives in a nursing home, Medi-Cal allows the spouse remaining in

the home to keep all of the income he/she receives in his/her name regardless of

the amount. If that amount is below $2,541per month, then the spouse in the

nursing home can give income to the spouse at home to bring the spouse at home

up to $2,541 per month. Be sure to ask your county social service agency for an

MC Information Notice 007 for more information on income.

3. Partnership for Prescription Assistance https://www.pparx.org/en

The Partnership for Prescription Assistance helps qualifying patients without prescription drug

coverage get the medicines they need through the program that is right for them. Many will get

their medications free or nearly free.

4. Free / Low-Cost Health Clinic Finder https://www.pparx.org/en/prescription_assistance_programs/free_clinic_finder

CSUF CLUB SPORTS

Insurance Options Guide

5. Community Clinics: free and low-cost

For information on free or low cost medical services call the following clinics.

Para información sobre servicios médicos gratuitos / bajo costo llame a estas clínicas.

Services may change without notice / Información sujeta a cambios

Clinic

Name

(Map)

Street

Address

City Phone

Children

Adults

Dental

Mental

Health

Evenings/

Saturdays

AltaMed

Medical

Group

Anaheim 877.462.258

2 ● ● ●

Central

City

Community

Health

2237 West

Ball Rd.

Anaheim 714.490.275

0 ● ●

● ●

Puente a la

Salud

Mobil

Clinic

Anaheim 714.744.880

1 ● ●

●

UCI Family

Health

Centers

Anaheim 714.456.700

2 ● ●

Health

Care

Agency

6301 Beach

Blvd.

Buena

Park 800.914.488

7 ● ● ●

●

AltaMed

Medical

Group

Costa

Mesa 877.462.258

2 ● ●

●

Children's

Hospital of

Orange

County

(CHOC)

Costa

Mesa 714.289.485

1 ●

SOS

Organizatio

Costa

Mesa 949.650.064

0 ● ● ●

CSUF CLUB SPORTS

Insurance Options Guide

Clinic

Name

(Map)

Street

Address

City Phone

Children

Adults

Dental

Mental

Health

Evenings/

Saturdays

n / Share

Our Selves

1550

Superior

Ave.

North

Orange

County

Regional

Health

Center

901 W

Orangethorp

e Ave.

Fullerton 714.441.041

1 ● ●

●

Sierra

Health

Center

1010 S.

Brookhurst

Rd.

Fullerton 714.870.055

0 ●

●

Sierra

Health

Center

501 S.

Brookhurst

Rd.

Fullerton 714.870.071

7 ●

St. Jude

Medical

731 S.

Highland

Ave.

Fullerton 714.446.510

0 ● ●

●

AltaMed

Medical

Group

Garden

Grove 877.462.258

2 ● ●

●

Children's

Hospital of

Orange

County

(CHOC)

Garden

Grove 714.532.790

0 ●

CSUF CLUB SPORTS

Insurance Options Guide

Clinic

Name

(Map)

Street

Address

City Phone

Children

Adults

Dental

Mental

Health

Evenings/

Saturdays

Nhan Hoa

Health

Care Clinic

14221

Euclid St. #

H

Garden

Grove 714.539.999

9 ● ● ●

●

Puente a la

Salud

Mobil

Clinic

Huntingto

n Beach 714.744.880

1 ● ●

●

Friends of

Children

Health

Center

501 S. Idaho

#190

La Habra 562.690.040

0 ● ● ● ● ●

The Gary

Center

341 S.

Hillcrest St.

La Habra 562.691.326

3 ● ●

Laguna

Beach

Community

Clinic

362 Third

St.

Laguna

Beach 949.494.076

1 ● ● ● ● ●

AltaMed

Medical

Group

Orange 877.462.258

2 ● ●

●

Children's

Hospital of

Orange

County

(CHOC)

Orange 714.532.836

1 ●

●

La Amistad

Medical

Clinic

353 S. Main

St.

Orange 714.771.800

6 ● ● ●

CSUF CLUB SPORTS

Insurance Options Guide

Clinic

Name

(Map)

Street

Address

City Phone

Children

Adults

Dental

Mental

Health

Evenings/

Saturdays

Lestonnac

Free Clinic

1215 E.

Chapman

Ave.

Orange 714.633.460

0 ● ●

●

Puente a la

Salud

Mobil

Clinic

Orange 714.744.880

1 ● ●

●

Camino

Health

Center

30300

Camino

Capistrano

San Juan

Capistran

o

949.240.227

2 ● ● ●

●

AltaMed

Medical

Group

Santa Ana 877.462.258

2 ● ●

●

CHOC

Clinic at

Boys &

Girls Club

Santa Ana 714.289.484

0 ●

CHOC

Clínica

Para Niños

Santa Ana 714.289.480

0 ●

●

Health

Care

Agency

1725 W.

17th Street

Santa Ana 800.914.488

7 ● ● ●

●

Puente a la

Salud

Mobil

Clinic

Santa Ana 714.744.880

1 ● ●

●

UCI Family

Health

Centers

Santa Ana 714.456.700

2 ● ●

VNCOC Santa Ana 714.418.204 ● ● ●

●

CSUF CLUB SPORTS

Insurance Options Guide

Clinic

Name

(Map)

Street

Address

City Phone

Children

Adults

Dental

Mental

Health

Evenings/

Saturdays

Asian

Health

Center

5015 W.

Edinger

Ave., Ste.

K-L

0

AltaMed

Medical

Group

Tustin 877.462.258

2 ● ●

●

Hurtt

Family

Health

Center

One Hope

Dr.

Tustin 714.247.030

0 ● ●

●

CSUF CLUB SPORTS

Insurance Options Guide

6. Co-Payment Programs https://www.pparx.org/en/prescription_assistance_programs/co-payment_programs

Co-pay programs provide financial assistance for certain health care costs to patients who qualify

financially and medically.

AIDS Patient Assistance and Co-Payment Programs

American Kidney Fund

American Pain Foundation

The Assistance Fund, Inc.

Avon Foundation Breast Care Fund

BenefitsCheckUp

BENLYSTA Co-pay Assistance Program

CancerCare

Candlelighters Childhood Cancer Foundation

Caring Voice Coalition, Inc.

The Center for Medicare Advocacy

Chai Lifeline

Chemocare.com

Chronic Disease Fund, Inc. (CDF)

Compassionate Allowances

Diabetes Prescription Assistance

Financial Aid for Eye Care

Financial Help for Diabetes Care

Financial Help for Treatment of Kidney Failure

Geriatric Services of America

HealthWell Foundation

Hill-Burton Free and Reduced-Cost Health Care

Key to Life Program

Leukemia and Lymphoma Society

MEDBANK of Maryland, Inc.

National Children's Cancer Society

National Organization for Rare Disorders

Needy Meds

NORD’s Patient Assistance Programs

Patient Access Network Foundation (PAN)

The Patient Advocate Foundation (PAF)

Patient Advocate Foundation Co-Pay Relief

Patient Services Incorporated

Patient Travel and Lodging

Resources for Financial Assistance for Cancer Patients and Their Families

RxHope: Patient Assistance Information

Transplant Living

Understanding, Planning and Paying for Long-Term Care

Understanding Prescription Assistance Programs (PAPs)

UnitedHealthcare Children's Foundation

CSUF CLUB SPORTS

Insurance Options Guide

How Do I Apply For Medi-Cal? http://egov.ocgov.com/ocgov/Social%20Services%20Agency/Health%20Care/

Medi-Cal%20Program%20&%20Services/How%20To%20Apply

By Phone/ US Mail

Applications for the Medi-Cal Program can be requested by phone and completed via US

mail.

To begin the process you will need to contact the Social Services Regional Center that

serves your city or zip code and advise them that you would like to apply for Medi-Cal

benefits.

The Social Services Regional Center staff will take your information and send you an

application.

In Person

Applications for the Medi-Cal Program can be completed in person.

To begin the process you will need to locate the Social Services Regional Center that

serves your city or zip code.

You should be prepared to spend a minimum of two hours at the Social Services

Regional Center

Unless there is an emergent need for medical care, benefits may not be issued the same

day.

Links

Social Services Agency Regional Centers by City

Social Services Agency Regional Centers by Zip Code

Social Services Agency Regional Center Locations

Orange County Transit Authority (OCTA) Trip Planner/Bus Schedules

If you are unable to access any of these documents please call 800-281-9799 and one will be sent

to you.

How Do I Apply for Medi-Cal?

You can apply either in person or by mail. In Person You can apply at one of the local Social Services Agency offices listed on the back of this pamphlet.

By Mail Call the phone number of the office nearest you and tell them you want to apply for Medi-Cal. You may also call the county’s toll-free number. An application packet will be mailed to you. An Eligibility Technician will be assigned to process your application and will ask you for verification of income, assets and alien status. A written notice will be sent to you when an eligibility decision is made.

Where Are the Medi-Cal Offices?

Offices are open from 7:00am to 5:00pm.

Aliso Viejo Regional Center 115 Columbia

Aliso Viejo, CA 92656

(949) 389-8201

Anaheim Regional Center 3320 E. La Palma Ave.

Anaheim, CA 92806 (714) 575-2400

Garden Grove Regional Center 12912 Brookhurst St.

Garden Grove, CA 92840

(714) 741-7100 Santa Ana Regional Center

1928 S. Grand Ave. Santa Ana, CA 92705

(714) 435-5900

Medi-Cal Specialization Regional Center

Long Term Care Applications (714) 940-3933

County Community Service Center Hours Tuesday – Friday 9:00 am to 5:00 pm

15460 Magnolia St. Westminster, CA 92683

(714) 889-4105

Applications and General Medi-Cal Information

1-800-281-9799

Orange County Social Services Agency www.ssa.ocgov.com

F063-19-947 (04/11)

Information about...

MEDI-CAL Family Health

Insurance Enrollment

What Is Medi-Cal? Medi-Cal, called Medicaid in other states, is California’s health care program. It pays for a variety of medical services for children and adults who have limited resources and income.

How Can Medi-Cal Help You? Medi-Cal is a large program made up of many separate programs to assist Californians in various medical situations. Some Medi-Cal covered services include doctor visits, hospitalization, nursing home care, dental, glasses, and prescriptions.

When you apply, an Eligibility Technician will determine if you are eligible and which program is best for you and your family. Once enrolled, you will continue to receive Medi-Cal as long as you meet the eligibility requirements.

Who Is Eligible to Receive Medi-Cal Benefits?

• Families with children

• Persons under 21 or 65 years of age and older

• Pregnant women

• Blind and disabled persons

• Recipients of nursing home or long term care

• Refugees

You are automatically eligible to Medi-Cal if you are receiving cash assistance under one of these programs:

• SSI/SSP (Supplemental Security Income/State Supplemental Program)

• CalWORKs (California Work Opportunity and Responsibility to Kids)

• Foster Care or Adoption Assistance Program

• Refugee Assistance

Is Medi-Cal Free or Do I Have to Pay for It?

Depending on your monthly income, your family size and the Medi-Cal program you are eligible to, you may have to pay some of your health care bills each month before Medi-Cal pays for any expense. This is called a “share of cost”. You do not pay for Medi-Cal in months you don’t use it.

Can I Apply for Medi-Cal if I Own a Home and a Car?

The home you live in is not counted in your asset limit. One car may be exempt. Your asset limit is based on family size.

Can I Have Private Health Insurance or HMO Coverage

and Also Be On Medi-Cal? Yes. But you are required to report other private health insurance or HMO coverage you have. Generally, your other insurance will be billed first before Medi-Cal.

Do I Have To Be A U.S. Citizen to Get Medi-Cal?

No. Your citizenship and immigration status affects what Medi-Cal services you can receive. U.S. citizens, legal permanent residents, and most other legal immigrants qualify for the full range of Medi-Cal benefits.

Can an Undocumented Person Get Medi-Cal?

Yes. If you are undocumented and meet all other Medi-Cal eligibility requirements, you can receive “restricted” Medi-Cal. This covers only emergency and pregnancy-related services.

Can I Apply for Retroactive Medi-Cal?

Yes. You can apply and be evaluated for any of the three months immediately preceding the month of application. You may need to provide verification of income and property for each month requested.

How Do I Receive Medi-Cal Services?

In Orange County most beneficiaries receive their Medi-Cal services through the CalOptima system, either under a health plan or CalOptima Direct.

Orange County Health Care AgencyMSI Program

www.ochealthinfo.com/medical/msi

Member Handbook

Table of Contents

Mission Statement .....................................................................1Important Message to Enrollees ....................................................2MSI Resources ...............................................................................3

Important Telephone Numbers ..................................................3MSI Website ..............................................................................3Eligibility.....................................................................................4

General/Financial Criteria ..............................................................4Eligibility Appeals Process .........................................................5Application Process ...................................................................6

Citizenship Guidelines and Requirements ..................................... 6Medical Services .....................................................................12

Covered Medical Services ...........................................................12Non-Covered Medical Services ....................................................13

Service Locations ....................................................................13Minute Clinic Sites ........................................................................14Urgent Care Centers ....................................................................14MSI Contracted Clinics .................................................................16MSI Contracted Hospitals ............................................................19

How To Find A Medical Home ..................................................23Medical Home Policies/Guidelines ...............................................23How to Acquire a Specialist/Other Specialized Services ............. 24Patient Education Department (PED) ..........................................26

Patient/Provider Relations Office.............................................26MSI/Fraud and Recovery Department ........................................27

Outpatient Services .................................................................27Physical Therapy ..........................................................................27Diagnostic Testing (Lab, X-ray, MRI) ............................................27

Prescription Services ...............................................................28Drug Authorization ........................................................................28Service Locations .........................................................................28

Billing Process .........................................................................30Notice of Payment Denial .............................................................31Appeals Process ..........................................................................32

Applicant Rights and Responsibilities......................................32Other County Resources .........................................................34

Page 1

Please read this Handbook carefully. It provides important information to assist you to receive medical services through the MSI program.

My Medical Home (Primary Care Doctor or Community Clinic) is:

Name: ____________________________________

Address: __________________________________

Phone Number: _____________________________

County of OrangeMedical Services Initiative

(MSI) Program

Mission Statement

The Medical Services Initiative (MSI) is Orange County’s safety-net program for low-income adults providing primary, preventive, and emergent medical services through a public-private partnership between the Orange County Health Care Agency and community health care providers.

Page 2

Important Information for Members Regarding the MSI ProgramMSI Program benefits include primary and preventive medicine such as regular physicals, mammograms, age-appropriate immunizations, and other types of laboratory and diagnostic services. Additionally, MSI mem-bers have access to an assigned primary care physician or community clinic that will serve as their “medical home” (PCP) for all of their general healthcare needs.

It is important to know that acceptance to the MSI program does not guarantee that all medical services you receive are covered benefits. (See pages 12-13 of this Handbook for more information about covered and non-covered services.)

Hospital emergency room services should be used for emergency condi-tions only. You are encouraged to use your medical home/ primary care physician (PCP) for all of your general healthcare needs. See Medical Home Policies (pages 23-24).

There are times when using a MinuteClinic or MSI-contracted urgent care center may be more convenient to you. You can find listings of MinuteClincs and urgent care centers on pages 14 to 16. Please call the MSI 24/7 Nurse Line if you are unsure about where you should go.

Page 3

Important Telephone Numbers

MSI 24/7 Nurse Line ................................ (800) 381- 9221

Patient Education Department (PED) ........ (800) 417-4262

MSI Patient Relations ................................ (866) 613-5178

MSI General Information ........................... (714) 834-6248 (TTD/TTY) (714) 834-2102

SSA Eligibility Information Line .................. (866) 979-6772

Other Helpful Telephone Numbers

General Relief/Food Stamps ..................... (714) 834-8899

Medi-Cal – General Information Line......... (800) 281-9799

Social Security/Supplemental SecurityIncome (SSI) Applications ......................... (800) 772-1213

211 Orange County (General Community Resources – Shelter, Job Training, Counseling, etc.) ........................211

Public Health General Information............. (714) 834-4722

For more information and frequently asked questions, visit the MSI Web Site at

www.ochealthinfo.com/medical/msi

Page 4

Eligibility

You may be eligible for MSI benefits if you:• Are able to provide proof of legal permanent resident status or U.S.

citizenship • Can provide proof that you are an Orange County resident• Are between the ages of 19 and 64• Have an income that is no-more than 200% of the Federal Poverty

Level (FPL)• Are not eligible for Medi-Cal

NOTE: The MSI program does not have an asset test.

Call the MSI General Information at (714) 834-6248 or the SSA-Eligibility Information Line at (866) 979-6772 if you have any questions about the qualifications listed above.

MSI eligibility:• Can only be determined by the Orange County Social Services

Agency (SSA).• Is approved for twelve (12) consecutive months.• Is renewable. You must reapply every twelve (12) months.• Can be suspended or discontinued if obtained fraudulently or the MSI

program determines that you no longer meet the eligibility guidelines as stated above. Applicants must cooperate with SSA by making a good faith effort to furnish the required information upon request.

To contact a SSA Eligibility Technician, please call (866) 979-6772. An Eligibility Technician will respond to your call. Be sure to leave your name, Social Security number, current address, phone number, and the reason for your call.

Page 5

If your eligibility is denied:You will be sent a Notice of Action (NOA) letter stating why your eligibility has been denied. You may appeal this denial by completing the form on the back of your NOA letter and mailing it to:

Orange County Social Services AgencyAppeals Unit

P.O. Box 22001Santa Ana, CA 92702-2001

You may disenroll from MSI at anytime by calling the MSI Patient Educa-tion Department at (800) 417-4262. Disenrollments will take place on the last day of the month in which you make your request.

Page 6

Application Process

To apply for MSI coverage, you must:• Make an appointment with an MSI Community Clinic or MSI Hospital

to complete an application• Provide proof of Orange County residency (i.e., CA identification or

drivers license, car registration, credit card, or utility bill)• Sign a Credit Authorization release form• Provide proof of income (i.e., recent pay stubs, unemployment

benefits statement, or cancelled checks)• Provide proof of age• Provide proof of Alien status (Alien card must be provided) • Provide proof of identity and citizenship

Acceptable Citizenship and Identity DocumentsThe easiest way for U.S. citizens or nationals to provide both proof of citizenship and identity is with one of these documents:

• U.S. Passport or Passport Card issued without limitation (expired ones are acceptable)

• Certificate of Naturalization (N-550 or N-570) • Certificate of U.S. Citizenship (N-560 or N-561)

OR

If you do not have one of the documents above, then provide …

One (1) citizenship document AND one (1) identity document from the bottom columns (see pg. 7).

Page 7

1. U.S. Birth Certificate 2. Certification of Report of Birth

(DS-1350) 3. Report of Birth Abroad of a U.S.

Citizen (FS-240) 4. State Department Certification of

Birth (FS-545 or DS-1350) 5. U.S. Citizen Identification Card

(I-197 or I-179) 6. American Indian Card (I-872) 7. Northern Marianas Card (I-873) 8. Final adoption decree showing a

U.S. place of birth 9. Proof of employment by the U.S.

civil service before June 1, 1976 10. U.S. military service record that

shows a U.S. place of birth 11. U.S. hospital record established at

the time of the person’s birth*

12. Life, health, or other insurance record*

13. Federal or State census record that shows the applicant’s age and U.S. citizenship or place of birth

14. Seneca Indian tribal census record* 15. Bureau of Indian Affairs tribal cen-

sus record of the Navajo Indians* 16. U.S. State Vital Statistics birth

registration notification* 17. An amended U.S. public birth re-

cord (amended more than 5 years after the person’s birth)*

18. Statement signed by doctor or midwife present at the time of birth*

19. Admission papers from a nursing or skilled care facility, or other institution that shows a U.S. place of birth

20. Medical record (not an immuniza-tion record)*

Citizenship Documents

Identity Documents

* Must be dated at least 5 years before your 1st MSI application and show a U.S. place of birth. You must provide a document as high on the list as you can.

1. Driver’s license issued by a U.S. State or Territory with a photograph or other identifying information

2. School Identification card with a photograph

3. U.S. Military I.D. card or draft record 4. Federal, state or local government I.D.

card with same identifying information as a driver’s license

NOTE: Expired identity documents are acceptable proofs of identity)

5. U.S. Military dependent identification card

6. A U.S. passport (issued with limitation) 7. Certificate of Degree of Indian Blood

or other U.S. American Indian/Alaska Native Tribal document

8. U.S. Coast Guard Merchant Mariner Card

Page 8

If you cannot provide any of the citizenship documents listed on page 7, ask two adults to fill out and sign an Affidavit of Citizenship. Both adults must have proof of their own identity and U.S. citizenship, and only one of them may be related to you.

Obtaining a Birth Certificate in Person:Under law, individuals appearing in person will be permitted to receive an authorized copy after presenting a valid government form of identification and signing a statement sworn under penalty of perjury that the requester is an authorized person. Those who are not authorized by law to receive an authorized certified copy will receive a certified copy marked INFOR-MATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.

Vital record (birth, marriage, and death records) are located in Room 106 of the Hall of Finance and Records in Santa Ana. Office hours are Monday through Friday, from 8:00 a.m. to 4:30 p.m. Payment can be made by cash, personal check, cashier’s check, money order, or ATM/Debit card .

Obtaining a Birth Certificate by Mail:A copy of a birth certificate can be obtained by mail if the birth occurred in Orange County, unless there has been an adoption or a legal name change. There is a charge for certified copies and orders are normally processed within 5 to 10 working days. Applications submitted by mail must also include a statement, sworn under penalty of perjury, that the requester is an authorized person. It must also be notarized. Applications are available at Online Forms. Use a separate application form for each record you are requesting.

PLEASE NOTE: Only one notarized sworn statement is required for multiple certificates requested at the same time; however, the sworn statement must include the name of each individual whose record you wish to obtain and your relationship to that individual. Those who are not authorized by law (visit www.ocgov.com/recorder/) to see who is authorized) to receive an authorized certified copy will receive a certified copy marked “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.”

Page 9

Mail requests to:Orange County Clerk-Recorder

Attn: Vital Records12 Civic Center Plaza, Room 106

Santa Ana, CA 92701Make checks payable to: Orange County Clerk-Recorder

Obtaining a Birth Certificate by TelephoneYou may place your request by telephone with VitalChek, a private inde-pendent company. Acceptable methods of payment through VitalChek are MasterCard, VISA, American Express or Discover. A special handling fee collected by VitalChek will be charged on all credit card orders, in addition to the County of Orange certified copy fee.

Telephone orders will be processed within 5 working days of receipt of the Certificate of Identity Telephone orders will be returned by regular mail unless expedited delivery is requested for an additional fee. For up-to-date information and fees, please call (877) 445-8988.

Obtaining a Birth Certificate by FaxFor those in need of a quick turnaround time, you may fax your request to VitalChek, a private independent company, at (866) 559-9609. Acceptable payment methods through VitalChek are Master Card, VISA, American Express or Discover. A special handling fee collected by VitalChek will be charged on all credit card orders in addition to the County of Orange certified copy fee. For information and pricing, please call (877) 445-8988.

Fax credit card orders will be processed within 5 working days of receipt of the Certificate of Identity. Fax orders will be returned by regular mail unless expedited delivery is requested for an additional fee.

For up-to-date information and fees, please call (877) 445-8988.

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Obtaining a Birth Certificate Online

For those in need of fast turnaround time, you may place your request over the Internet with VitalChek, a private independent company. Acceptable methods of payment through VitalChek are Master Card, VISA, American Express or Discover. A special handling fee collected by VitalChek will be charged on all credit card orders, in addition to the County of Orange certified copy fee. Internet credit card orders will be processed within 5 working days of receipt of the Certificate of Identity. Internet orders will be returned by regular mail unless expedited delivery is requested for an additional fee. For information, and pricing, please call (877) 445-8988. Or visit www.vitalchek.com.

To Schedule an Appointment to ApplyThe MSI program contracts with most hospitals and community clinics in Orange County. These hospitals and clinics take MSI applications by appointment only.

For a list of the hospitals and community clinics that take MSI applications, please refer to the service locations listed on pages 14-17 of this Handbook or call MSI General Information line at (714) 834-6248 for assistance. A complete listing of all locations is available online at

www.ochealthinfo.com/medical/msi.

To make an appointment to complete an application, call the main number of the hospital or community clinic nearest to you and ask to speak to the MSI representative. The MSI representative will make an appointment for you to complete the MSI application. Ask the MSI representative what information you need to bring to the interview to complete the application process.

NOTE: It may take up to six weeks to process an application from the date you apply to the Program. Failure to provide required information may result in a delay or denial of MSI eligibility.

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To reapply to the MSI program, you must continue to meet all the eligibility requirements and follow the application process outlined above.

Note: You may complete the application in the 12th month of your current eligibility period to ensure your coverage remains in effect. It is recommended that you call at least 45 days before your eligibility terminates to schedule an appoint-ment for reapplication.

After the Social Services Agency receives your application, you: • Are sent a NOA (form 2391) informing you whether your eligibility

for the Program is approved or denied.• Must read all information sent to you.

Once your MSI application is approved you:

• Are eligible for twelve (12) months at a time• Must show each provider of service a copy of your NOA letter or

Member Identification Card• May reapply for MSI to renew your benefits for continued coverage• Must repay the MSI program for all medical services paid in the event

of a Workers’ Compensation, insurance or accident claim settlement, or if it is determined that you have fraudulently used MSI services.

If your application is approved and you are disabled, you:

• Are required to apply for Medi-Cal, State Disability, or Workers’ Compensation.

• Are encouraged to apply for Federal or State benefits such as Supplemental Security Income (SSI) or State Supplemental Program (SSP).

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Medical Services

Covered Medical ServicesAcceptance to the MSI program does not guarantee that all services you receive are covered benefits. MSI eligibles may opt to pay out-of-pocket for services (such as plastic surgery not covered through the MSI program). Please note however that your provider must accept MSI’s payment as “payment in full” for covered or authorized services. Providers are not permitted to charge you for services that would have been covered under MSI’s benefit plan.

Non-emergency medical services must be rendered in Orange County to be considered for reimbursement. Covered services include:

• Physician including Primary/Specialist care and preventive medicine. Physicians must be registered as a network provider with the MSI program to receive reimbursement.

• Hospital care (in-patient and out-patient).• Emergency ambulance transportation to an MSI contracted facility.

Paramedic services are not a covered benefit. Call your local fire department to inquire about their fees.

• Physical therapy, general x-rays, ultrasounds, MRIs, CT scans, mammograms, and other diagnostics. These services must be provided at MSI contracted facilities.

• Laboratory work including Pap smears, PSA blood levels, urine analyses including urine dip-stick for pregnancy. Laboratory services are provided through Quest Diagnostics. All laboratory specimens should be sent to Quest Diagnostics for processing.

Please note that MSI does not charge a co-pay for office visits, specialty visits, or hospitals stays.

NOTE: Most services rendered outside of your assigned Medical Home/PCP must be prior authorized. Please follow up with your provider to ensure that he/she has received proper approval before you seek specialty care.

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Medical Services Not Covered• Services received outside of your Medical Home not prior authorized.• Non-Emergency Medical Services provided at non-contracted

facilities.• Non-Emergency Medical services rendered outside of Orange

County.• Medical services that do not meet the purpose of the MSI program.• Non-formulary medications.• Pregnancy, including complications of pregnancy (exception is urine

“dip stick” to test for pregnancy). Note: Pregnant women should apply for Medi-Cal by

calling (800-281-9799).• Treatment in an extended or long-term care facility.• Adult day care services.• Acupuncture/chiropractic services.• Hearing aids and eyeglasses.• Medical transportation to non-contracted facilities.• Medical services for persons under 19 and over 64 years old.

Service Locations

Medical Care may only be provided by physicians within the network. Your Medical Home/PCP is generally the only provider who does not need an authorization to provide care. To see a complete list of Medical Home providers, please go to our website at: www.ochealthinfo.com/medical/msi/providers/news under “Medical Home Lists.”

Except for emergencies that are life or limb threatening, always contact your primary care physician for your ongoing medical needs.

NOTE: Please refer to page 23-24 for information about medical homes.

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MinuteClinics - Available throughout Orange County.Board certified practitioners are available every day to diagnose and treat common family illnesses such as strep throat, bronchitis, ear, eye, and sinus infections. MinuteClinics are open everyday and no appointments are necessary. MinuteClinics see most patients within 20 minutes of arrival.

1. Aliso Viejo: 26891 Aliso Creek Road, Aliso Viejo 926562. Buena Park: 8850 Valley View Street, Buena Park 906203. Costa Mesa: 1150 Baker Street, Costa Mesa 926264. Huntington Beach: 19121 Beach Blvd., Huntington Beach 926485. Irvine: 14330 Culver Drive, Irvine 926046. Mission Viejo: 25272 Marguerite Pkwy., Mission Viejo 926927. Orange: 1535 East Katella Avenue, Orange 928678. San Clemente: 638 Camino De Los Mares, San Clemente 926739. Seal Beach: 921 Pacific Coast Highway, Seal Beach 9074010. Yorba Linda: 18080 Imperial Highway, Yorba Linda 92886

Urgent Care CentersAvailable after hours and on weekends, urgent care centers are able to treat a wide variety of illnesses and injuries with convenient locations and hours (including evenings, weekends, and holidays.) No appointment is necessary but you should call ahead for faster service.

ALISO VIEjOSouth Coast Medical Group

5 Journey, Suite 130, Aliso Viejo, CA(949) 360-1069

Mon – Fri: 8 a.m. to 7 p.m. Sat: 9 a.m. to 3 p.m. Sun: 10 a.m. to 3 p.m.

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Urgent Care Centers (continued)

ANAHEIMGateway Urgent Care

1006 W. La Palma Ave., Anaheim, CA(714) 778-3838

Mon – Fri: 8 a.m. to 10 p.m.Sat & Sun: 9 a.m. to 5 p.m.

OC Urgent Care631 S. Brookhurst Street, Anaheim, CA

(714) 991-5700Mon – Fri: 10 a.m. – 6 p.m.

Sat: 10 a.m. – 6 p.m.

BUENA PArkCaceres Medical Group

8585 Knott Avenue, Suite 101, Buena Park, CA. (714) 821-8588

Mon – Fri: 8 a.m. to 5 p.m.Sat: 8 a.m. to 12 p.m.

FOOTHILL rANCH/LAkE FOrESTOC Urgent Care

26781 Portola Parkway, Suite 4E, Lake Forest, CA. (714) 991-5700

Mon – Fri: 10 a.m. – 6 p.m.Sat: 10 a.m. – 6 p.m.

HUNTINGTON BEACHHuntington Beach Urgent Care

17752 Beach Blvd, Suite 203, Huntington Beach, CA. (714) 841-1040

Mon – Fri: 8 a.m. to 8 p.m.Sat & Sun: 9 a.m. to 6 p.m.

IrVINEBishop karras Community Clinic Urgent Care

18021 Sky Park Circle, Bldg. 68, Suite HIrvine, CA 92614 (949) 260-0746

Mon – Fri: 24 hoursSat & Sun: 24 hours

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OrANGESunrise Multispecialty Medical Center

867 S. Tustin Avenue, Orange, CA. (714) 771-1420

Mon – Fri: 7 a.m. – 10 p.mSat & Sun: 9 a.m. – 5 p.m.

SAN jUAN CAPISTrANOPartners In Health

32241 Camino Capistrano, Suite A-105, San Juan Capistrano, CA. (949) 661-6555

Mon – Fri: 8 a.m. to 5 p.m. Sat & Sun: CLOSED

NOTE: Need help choosing between a MinuteClinic and an urgent care center? Please call our 24-hour Nurse Advice Line at (800) 381-9221 for immediate assistance.

MSI COMMUNITY CLINICS

ANAHEIMAltamed

1814 W. Lincoln Ave.Anaheim, 92801(714) 780-5690

Central City Community Health Center2235 W. Ball Rd., Anaheim, 92804

(714) 520-0855

UCI Family Health Center – Anaheim300 W. Carl Karcher Way

Anaheim, 92801(714) 456-6401

COSTA MESAShare Our Selves

1550 Superior Ave.Costa Mesa, 92627

(714) 650-0186

Urgent Care Centers (continued)

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MSI Community Clinics (continued)

FULLErTONreproductive (Sierra)

Health Care Center, Inc.501 S. Brookhurst Rd.

Fullerton, 92833(714) 870-0717

North Orange County regional Health Foundation901 W. Orangethorpe Ave.

Fullerton, CA 92832(714) 441-0411

St. jude Hospital Inc. Mobile Health Clinic

731 S. Highland Ave.Fullerton, 92835(714) 446-5100

GArdEN GrOVEAltamed

12751 Harbor Blvd.Garden Grove, 92843

(714) 636-7852

Nhan Hoa Comprehensive Health Center

14221 Euclid St., Ste. HGarden Grove, 92843

(714) 539-9999

VNCOC (Asian Health Center)9862 Chapman Ave

Garden Grove, 92841(714) 418-2040

HUNTINGTON BEACHAltamed Community Care Centers

8041 Newman Ave.Huntington Beach, 92647

(714) 847-4222

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LAGUNA BEACHLaguna Beach Community Clinic

362 Third St., Laguna Beach, 92651(949) 494-0761

LA HABrAFriends of Family Health Center

501 S. Idaho St., Ste. 100La Habra, 90631(562) 690-0400

The Gary Center341 Hillcrest, La Habra, 90631

(562) 691-3263

OrANGELa Amistad de jose Family Health

353 S. Main St., Orange, 92868(714) 771-8006

Puente A La Salud Mobile Community Clinic363 S. Main St., Suite 204

Orange, CA 92868(714) 744-8801

SANTA ANAAltamed – Central

1155 W. Central Ave., Ste. 105-107Santa Ana, 92707

(714) 557-4080

Altamed – Clinic for Women1227 W. 17th St., Santa Ana, 92706

(714) 500-0340

Altamed – Main1400 N. Main St., Santa Ana, 92701

(714) 541-6815

MSI Community Clinics (continued)

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Serve The People1206 E. 17th St., Suite 204

Santa Ana, CA 92701(714) 352-2911

UCI Family Health Center – Santa Ana

800 N. Main St., Santa Ana, 92701(714) 456-6401

SAN jUAN CAPISTrANOCamino Health Center

30300 Camino CapistranoSan Juan Capistrano, CA 92675

(949) 240-2272

STANTONCentral City Community Health Center

12116 Beach Blvd., Stanton, 90680(714) 898-2222

TUSTINOrange County rescue Mission

(Hurtt Family Clinic)One Hope Dr., Tustin, CA 92782

(714) 247-0300

HOSPITALS

ANAHEIMAnaheim General

3350 W. Ball Rd., Anaheim, 92804(714) 947-5800

Anaheim regional Medical Center111 W. La Palma Ave., Anaheim, 92801

(714) 999-6161

MSI Community Clinics (continued)

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kaiser Foundation Hospital – Anaheim441 Lakeview Ave., Anaheim, 92807(714) 279-5459 - (Monday-Friday) (714) 279-4072 - (Weekends only)

West Anaheim Medical Center3033 W. Orange Ave., Anaheim, 92804

(714) 827-3000 x 5794

Western Medical Center Hospital – Anaheim1025 S. Anaheim Blvd., Anaheim, 92805

(714) 502-2668

FOUNTAIN VALLEyFountain Valley regional Hospital and

Medical Center17100 Euclid St., Fountain Valley, 92708

(714) 966-3316

Orange Coast Memorial Medical Center9920 Talbert Ave., Fountain Valley, 92708

(714) 378-7588

FULLErTONSt. jude Medical Center

101 W. Valencia Mesa Dr., Fullerton, 92635(714) 446-5141

GArdEN GrOVEGarden Grove Hospital and Medical Center

12601 Garden Grove Blvd.Garden Grove, 92643

(714) 741-2713

HUNTINGTON BEACHHuntington Beach Hospital

17772 Beach Blvd., Huntington Beach, 92647(714) 843-5000

Hospitals (continued)

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IrVINEHoag Memorial Hospital – Irvine Campus

16200 Sand Canyon Ave., Irvine, 92618(949) 517-3167

kaiser Foundation Hospital – Irvine6640 Alton Pkwy., Irvine, 92618

(949) 932-2882

LAGUNA BEACHMission Hospital – Laguna Beach

31872 Coast Hwy., Laguna Beach, 92677(949) 347-6040

LAGUNA HILLSSaddleback Memorial Medical

Center – Laguna Hills24451 Health Center Dr., Laguna Hills, 92653

(949) 452-3177

LA PALMALa Palma Intercommunity Hospital

7901 Walker St., La Palma, 90623(714) 827-3000 x 5794

LOS ALAMITOSLos Alamitos Medical Center

3751 Katella Ave., Los Alamitos, 90720(562) 799-3116

MISSION VIEjOMission Hospital regional

Medical Center27700 Medical Center Rd., Mission Viejo, 92691

(949) 347-6040

Hospitals (continued)

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OrANGEChapman Medical Center

2601 E. Chapman Ave., Orange, 92669(714) 633-0011 x 1210

St. joseph Hospital – Orange1100 W. Stewart Dr., Orange, 92868

(714) 771-8107

University of California Irvine (UCI) Medical Center101 City Drive South, Orange, 92668

(714) 456-7328

PLACENTIAPlacentia Linda Hospital

1301 North Rose Dr., Placentia, 92670(714) 993-2000

SANTA ANACoastal Communities Hospital

2701 Bristol St., Santa Ana, 92704(714) 754-5558

Western Medical Center – Santa Ana1001 N. Tustin Ave., Santa Ana, 92705

(714) 953-3409

SAN CLEMENTESaddleback Memorial Medical Center –

San Clemente654 Camino De Los Mares

San Clemente, 92673Financial Counselor (949) 489-4960

NOTE: MSI provides emergency dental coverage for eligible members. The list of MSI Dental providers changes often, please call the MSI Information Line at (714) 834-6248 or go to the MSI website (www.ochealthinfo.com/medical/msi) to find the provider nearest you. You can also call the 24-Hour Nurse Advice Line at (800) 381-9221.

For an up-to-date listing of dental providers, please go online towww.ochealthinfo.com/medical/msi.

Hospitals (continued)

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How To Find A Primary Care Physician (Medical Home)

Your primary care physician (PCP), also known as your medical home, is a very important part of your health care team and is involved in all aspects of your health care. Your PCP helps you stay well by providing a variety of services including:

• Regular physicals.• Preventive medicine (for example: immunizations, mammograms,

pap smears, and PSA blood levels). • Referral to specialists.• Post hospital care.• Ongoing management of acute and chronic disease.

NOTE: All MSI eligibles are required to have a PCP.

Medical Home Policies and GuidelinesPart of the expansion of the MSI Program resulted in an expansion of our primary care physician (PCP) network. The purpose of this expanded network, which is made up of over 200 General Practice physicians throughout the County, is to provide improved access to primary and preventive services to MSI eligible patients. These PCPs are in addition to the contracted community clinics located in this handbook.

MSI members may change their PCP once within 30 days of their NOA letter date, and once every 6 months, thereafter.

Services provided by a PCP that you are not assigned to will not be covered unless prior authorized.

The MSI program will send you a Member Identification Card with your name, assigned PCP (Medical home), unique MSI member ID number, information about co-payments, and important phone numbers and web-sites. In addition, you will receive a letter called a Notice of Action. This document contains your MSI eligibility dates, your assigned PCP (medical home), and other pertinent MSI program information.

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NOTE: It is important to present your Notice of Action letter or Member Identification Card when you receive medical services.

How to Acquire a Specialist and Other Specialized ServicesThe utilization management department assists your PCP and other members of your health care team to coordinate inpatient and outpatient services, including referrals to physician specialists, prior-authorization for durable medical goods, home health care, selected surgeries, and limited diagnostic procedures.

Please be aware that it may take up to 5 regular working days—for the authorization staff to coordinate a request.

Please contact the member of your health care team who made the request if you have any questions or concerns.

What If My Request for a Specialist or Other Specialized Services Is Denied?MSI members have the right to file an appeal with the MSI Program. Appeals from members may be made in writing. Forms are available on each Notice of Authorization Denial and at the MSI website

(www.ochealthinfo.com/medical/msi).

Please send written appeals to the following address:

MSI ProgramP.O. Box 355

Santa Ana, CA 92701

Appeals can also be made by telephone. MSI members can call the MSI Program at (714) 834-6248 or the MSI Patient Relations line at (866) 613-5178.

Translation services are available in most languages via LinguaLinx services.

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Appeals must be filed with the MSI Program within sixty (60) calendar days of the date on the Notice of Authorization Denial.

Appeals Process

Once received, the MSI Program will examine your appeal and provide you with a determination within forty-five (45) calendar days of receipt by the MSI Program.

During the examination period, you (or your designated representative) have the right to examine all records/documents under consideration during this appeal.

If requested, you and/or your representatives will be provided a reason-able opportunity to present evidence and allegations of fact or law, in person, in writing, or by telephone, during this examination period.

Forty-five (45) days is the standard time for resolution of an appeal. However, if you feel that you cannot wait for forty-five (45) days, you may request an expedited resolution of your appeal.

This expedited review may be granted by the MSI Program. If it is not granted, the MSI Program will provide you with a written explana-tion within two (2) calendar days of your request. Your appeal will be handled within forty-five (45) days.

Resolution of Your Appeal

You will receive written a formal Notice of Appeal Resolution of your appeal within forty-five (45) calendar days. This notice will include the results of the appeal process, the final resolution, and the date of completion.

Request for State Fair Hearing and Granting of Denied Services

If you are dissatisfied with resolution of your appeal, you have the right:

1. To request a State Fair Hearing. The instructions for requesting a State Fair Hearing will be included with the Notice of Appeal Resolution. YOU

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MUST REQUEST A STATE FAIR HEARING WITHIN NINETY (90) CALENDAR DAYS FROM THE DATE ON YOUR NOTICE OF APPEAL RESOLUTION.

2. To request that MSI grant the denied services while the State Fair Hear-ing is pending. The instruction for requesting the denied services will be included with the Notice of Appeal Resolution.

Please note that if you request that MSI grant the denied services and the State Fair Hearing upholds the denial of services, you will be liable for the cost of the services provided.

If you have any questions about this section, you may contact the MSI Program at (714) 834-6248 or MSI Patient Relations at (800) 613-5178.

Patient Education Department (PED)This department is in place to guide and help you understand how the MSI program works so you may receive the medical services you need without unnecessary delay.

The PED staff will contact you via phone generally within fourteen (14) days after you are granted MSI eligibility. Some of the information/assistance they will give you includes:

• Basic introduction/overview of the MSI program.• General information about MSI program policies/procedures.• Ensure you have important MSI documents.• Direct/assign you to a PCP (medical home) if you do not already

have one.

PED staffmembers are available during regular business hours. To reach PED, please call (800) 417-4262.

Patient/Provider relations Fraud and recovery department

The Patient/Provider Relations staff is available to provide information to patients and providers of service. The MSI Patient/Provider Relations Of-fice at (866) 613-5178 has an automated phone system with a selection of important and helpful menu options to assist you.

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The Fraud and Recovery Division is responsible to identify and investigate areas of fraudulent activity within the MSI program. This office helps to ensure that all requirements for MSI eligibility and payment are met.

An MSI applicant signs the following declarations on their Rights and Responsibilities form during the application process:

• I declare under penalty of perjury that the answers I have provided in this application are correct and true to the best of my knowledge.

• I understand that the statements on this form are subject to verifica-tion and investigation and that my signature on this form constitutes authorization for such an investigation.

• I realize that if I deliberately make false statements, withhold information, or obtain or use MSI program benefits in an unlawful manner, I (or the person on behalf of whom I am acting) may lose MSI benefits and/or be prosecuted. I understand that any benefits I receive fraudulently may be subject to prosecution.

Fraudulent activity is investigated and may result in termination of MSI benefits, prosecution, and a demand for repayment to the MSI program for services received.

Outpatient Services

Where Do I Go for Outpatient Services?Outpatient services refer to treatments and procedures that do not require hospitalization. These services include physical therapy, ultrasound, gen-eral X-ray, MRI, CT scan, mammogram and blood and urine analyses. These services require a requisition from your physician, Nurse Practitioner or Physician Assistant. Your provider can work with our prior authorization department to find the nearest contracted provider.

NOTE: Your health care practitioner may need to obtain authorization for outpatient services.

Laboratory services: Blood and urine analyses are provided through Quest Diagnostics. Pap smears should be sent to Quest Diagnostic laboratories. For a list of locations call (800) 377-8448, select option 2 and enter your zip code.

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Prescription Services

Do I have a co-payment for my medications and does MSI pay for every drug available?Some MSI members may have co-pays for prescriptions. Your prescription co-pays are determined by the level of income reported by you during the application process.

For those with prescription copays, prescriptions will be $4 for each pre-scription with a maximum of $32 in any given month.

NOTE: Medications not covered through the MSI program may be available through the manufacturer at low or no cost. For more information about this service, call Partnership for Prescription Assistance (PPA) at (888) 477-2669.

Where Do I Get My Prescriptions Filled?Prescriptions can be filled at over 590 CVS/Caremark participating phar-macies throughout Orange County. Ask your local pharmacy if it is a CVS/Caremark participant. Examples of CVS/Caremark participating pharma-cies include CVS, Sav-On, Rite Aid, Walgreens, Target, Wal-Mart, and Costco. A listing, by city, of all MSI participating pharmacies is available on the MSI website (www.ochealthinfo.com/medical/msi). You may also call the CVS/Caremark Customer Support Desk at (800) 511-7453 for service locations.

The MSI program uses a list of approved, generic based medications called a drug formulary.

What if MSI Doesn’t Cover My Medication?The MSI program does not pay for all medications. Approved medications are listed on the MSI drug formulary. A copy of the formulary is available on the MSI website at www.ochealthinfo.com/medical/msi.

In special circumstances, the MSI program may approve a medication that is not on the MSI Drug Formulary. An MSI Drug Authorization form must be

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completed by your prescriber and pharmacist, and include justification for the medication. A separate form must be completed for each medication.

The MSI Drug Authorization form is available from CVS/Care-mark participating pharmacies or from the CVS/Caremark “Fax on Demand” system at (800) 511-7453 and on the MSI website at www.ochealthinfo.com/medical/msi.

The completed form is faxed to the MSI program for review. The pharmacist and prescriber are notified of the final decision.

What is the non-emergency medical transportation benefit through MSI?Non-emergency medical transportation is covered if your medical and physical condition makes it impossible for you travel by regular bus or car.

You meet MSI rules if you:• Are in a wheelchair and not able to move in or out of your chair into

a seat or move your chair on your own; or• Need to travel with specialized services, equipment, or a caregiver.

MSI does not cover public or private transportation, or transportation services to locations that are not for MSI covered services. However, if medically appropriate, MSI may authorize transportation via taxi or other mode of transportation.

If you are in a skilled nursing facility, you may receive non-emergency medical transportation services if you meet the conditions listed above, or you are returning to your facility from a hospital.

How do I receive non-emergency medical transporta-tion services?To receive non-emergency medical transportation services:

1. The physician will send a request to MSI’s Utilization Management Department (UMD) explaining the need for the services.

2. If the request is approved, the UMD will inform the physician the name of the approved transportation company.

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3. The transportation company will receive a copy of the authorization.

When will I know if I can get non-emergency medical transportation services?If your doctor’s request is complete, UMD will make the decision within five (5) business days. If the request is approved, UMD will call you one (1) business day after making the decision. If the request is denied, a letter will be mailed to you.

Advance directives

Under California law, you have the right to create an Advance Directive. If you are ever incapacitated, an Advance Directive will allow you to give instructions about your own health care or give the person you choose the power to make decisions about your health care.

For more information, please visit the website of the California Attorney General: http:ag.ca.gov and search for “Advance Directive.” The website can provide you with information, forms, and links to resources.

Billing Process

What should I do if I receive a bill from a provider of service?Immediately contact your provider(s) of service and inform them that you are an MSI eligible. Ask them to submit their bills to:

Advanced Medical Management (AMM)Attention: MSI Program

P.O. Box 30248Long Beach, CA 90853

(800) 206-6591

NOTE: Only providers may submit bills to the MSI program.

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You may receive bills from physicians, hospitals, ambulance companies or other providers, if the providers do not know you are an MSI eligible. PLEASE CONTACT THE PROVIDERS AND LET THEM KNOW THAT YOU ARE MSI ELIGIBLE! MSI eligibles are sent a NOA letter and Member I.D. card that confirms approval to the MSI program. You should send a copy of this letter (both sides) to anyone that sends you a bill. Once approved, a provider must not bill the patient directly if the service is under the scope of care of the MSI Program and the provider fails to bill MSI timely or fails to obtain a prior authorization.

You are responsible to notify your medical providers of your MSI eligibility and to provide proof of your eligibility when you seek medical care.

NOTE: It is important to notify your provider of your MSI eligibility as soon as possible since they only have 90 days from the date you receive your medical services or from the date on your NOA letter, whichever is later to bill for your care. The NOA mail date is noted on the front of the letter.

If you are not eligible for the Program when you receive a bill, contact the provider and explain that an eligibility determination is pending and that you will notify them of the outcome as soon as possible. In general, the MSI Program will only go back as far as 90 days from the first of the month in which you applied to cover any services if you do become eligible. Please refer to pages 4-6 of this Handbook if you have questions about the eligibility/application process.

Will I receive notification from the MSI program if a provider of service is denied payment?Yes. There may be several reasons why your claim may was not covered. Some examples might be:

• You were not eligible with MSI when the service was provided;• There was no prior authorization;• The non-emergency service was provided by an out-of-network

provider;• The provider did not bill the MSI Program in a timely fashion (90-day

rule);• The service provided was not within the scope of benefit of the MSI

Program.

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Acceptance to the MSI program does not guarantee that all services you receive are covered.

If the MSI program denies payment on a bill, you are sent a letter from our billing agent (AMM) called a Notice of Payment Denial. This notification is not a bill. This letter explains the reason for the denial of payment, the name of the provider of service(s), the dollar amount denied, and the date of service. It provides you the opportunity to appeal the denial.

Applicant rights and responsibilities

Applicant Rights

I have the right to:• Be treated fairly and equally regardless of my race, color, religion,

national origin, sex, age or political beliefs.• Have all the information that I provide kept in strict confidence.• Receive a written notice from SSA when a decision about my eligibil-

ity is made.• Have a hearing if I am dissatisfied with the decision made by the

Orange County Social Services Agency regarding eligibility. If I want a hearing to appeal the decision, I must ask for it in writing within 30 days of the date the NOA was mailed to me. If I do not receive a NOA, I must request a hearing within 30 days from the date I discovered the decision.

The Eligibility Appeals Unit address is:

Social Services AgencyP.O. Box 22001

Santa Ana, CA 92702-2001

Applicant Responsibilities

I have the responsibility to:• Provide proof that I am a resident of Orange County when requested.• Provide supporting documentation about my citizenship/immigration

status.

Page 33

• Provide a Social Security number for myself and/or the person requesting MSI benefits.

• Apply for and cooperate in the eligibility determination process for Medi-Cal benefits if I am blind, pregnant, the parent of a child deprived of parental support, a refugee in the U.S. for 8 months or less, or receive skilled nursing facility care.

• Apply for and cooperate in the eligibility determination process for Medi-Cal based on disability, if I have a physical or emotional prob-lem that prevents me from performing normal work and the problem is expected to last at least a year.

• Apply for Medi-Cal benefits if my medical condition gets worse or significantly limits my ability to work. I understand that Medi-Cal enables me to receive benefits throughout California and covers more medical services than are available under the MSI program.

• Report to the Orange County Social Services Agency and my health care providers any health care coverage/insurance coverage I carry or am entitled to use. If I willfully fail to provide this information, I may be guilty of a criminal offense, or may be billed by my providers for any services I have received.

• Give a copy of my NOA letter to my physician, pharmacist, com-munity clinic or any other provider. I may be responsible for my bills if I fail to do so.

• Notify the MSI program and my health care providers in the event that I receive money from an insurance claim or from an accident or injury lawsuit. I understand that I must use this money to repay the MSI program for my medical services.

• Cooperate with Orange County’s quality review team if my case is selected for review. If I refuse to cooperate, my MSI benefits may be suspended or discontinued.

Filing a Complaint with the MSI ProgramMSI members have the right to file a complaint with the MSI Program. Complaints from members may be made in writing. Forms are available on the MSI website (www.ochealthinfo.com/medical/msi).

Page 34

Please send written complaints to the following address:

MSI ProgramP.O. Box 355

Santa Ana, CA 92701

Complaints can also be made by telephone. MSI members can call the MSI Program at (714) 834-6248 or the MSI Patient Relations line at (866) 613-5178.

Translation services are available in most languages via LinguaLinx services.

Complaints must be filed with the MSI Program within sixty (60) calendar days of the incident giving rise to the complaint.

Resolution of Complaint

Once received, the MSI Program will examine your complaint and will respond to you within forty-five (45) calendar days. During this period, MSI may contact you for additional information regarding your complaint. Once a determination or resolution has been made, the MSI Program will notify you, in writing, of the disposition of your complaint.

Other County resources

Behavioral Health, Alcohol, and Drug Abuse ServicesThe MSI program works with the Health Care Agency’s Behavioral Health Services department to provide limited coverage of behavioral health services. The locations listed below are for reference only. MSI Patients should discuss behavioral health matters with their Primary Care Physi-cian/Medical Home. If you feel that you need immediate help, please contact the numbers below for an evaluation.

Page 35

Behavioral Health, Adult Inpatient and Evaluation and Treatment Services (ETS)

BEHAVIOrAL HEALTH AdULT OUTPATIENT SErVICES

ANAHEIM2035 E. Ball Road, Suite #200

(714) 517-6300

COSTA MESA3115 Redhill Avenue

(714) 850-8463

FULLERTON211 W. Commonwealth Avenue

(714) 447-7000

MISSION VIEjO23228 Madero(949) 454-3940

SANTA ANA1200 N. Main Street, Suite #201

(714) 480-6767

WESTMINSTER 14140 Beach Boulevard, Suite #223

(714) 896-7566

Page 36

OUTPATIENT ALCOHOL ANd drUG ABUSE SErVICES

(CUrrENTLy, AVAILABLE FrOM BHS ONLy)

ALISO VIEjO5 Mareblu, #100(949) 643-6930

ANAHEIM2035 E. Ball Road

Suite #100(714) 517-6146

COSTA MESA3115 Redhill Avenue

(714) 850-8431

FULLERTON211 W. Commonwealth Avenue

Suite #204(714) 447-7099

SANTA ANA1725 W. 17th Street

(714) 834-8600 (Methadone)

SANTA ANA1200 N. Main, Suite #301

(714) 480-6660

WESTMINSTER14140 Beach Boulevard, Suite #200

Behavioral Health – Alcohol and Drug Abuse Services(714) 896-7574

DTP334 (10/11)

Provider MSI Provider Name Street City Zip Phone

Community Clinic Altamed Community Care Center 1814 W. Lincoln Avenue Anaheim 92801 (714) 780-5690

Community Clinic Central City Community Health Center 2235 W. Ball Road Anaheim 92804 (714) 520-0855

Community Clinic UCI Family Health Center - Anaheim 300 W. Carl Karcher Way Anaheim 92801 (714) 456-6401

Community Clinic Share Our Selves 1550 Superior Avenue Costa Mesa 92627 (949) 650-0186

Community Clinic Reproductive (Sierra) Health Care Center, Inc. 501 S. Brookhurst Road Fullerton 92833 (714) 870-0717

Community Clinic St. Jude Hospital Inc.Mobile Health Clinic 731 S. Highland Avenue Fullerton 92835 (714) 446-5100

Community Clinic Altamed Community Care Center 12751 Harbor Boulevard Garden Grove 92843 (714) 636-7852

Community Clinic Nhan Hoa Comprehensive Health Center 14221 Euclid Street, Suite H Garden Grove 92843 (714) 539-9999

Community Clinic VNCOC (Asian Health Center) 9862 Chapman Avenue Garden Grove 92844 (714) 418-2040

Community Clinic Altamed Community Care Center 8041 Newman Avenue Huntington Beach 92647 (714) 847-4222

Community Clinic Friends of Family Health Center 501 S. Idaho Street, Suite 100 La Habra 90631 (562) 690-0400

Community Clinic The Gary Center 341 Hillcrest Street La Habra 90631 (562) 691-3263

Community Clinic Laguna Beach Community Clinic 362 Third Street Laguna Beach 92651 (949) 494-0761

Community Clinic La Amistad De Jose Family Health 353 S. Main Street Orange 92868 (714) 771-8006

Community Clinic Camino Health Center 30300 Camino Capistrano San Juan Capistrano 92675 (949) 240-2272

Community Clinic Altamed - Clinic for Women 1227 W. 17th Street Santa Ana 92706 (714) 500-0340

Community Clinic Altamed Community Care Center 1155 W. Central Avenue, Suites 105-107 Santa Ana 92707 (714) 557-4080

Community Clinic Altamed Community Care Center 1400 N. Main Street Santa Ana 92701 (714) 541-6815

Community Clinic UCI Family Health Center-Santa Ana 800 N. Main Street Santa Ana 92701 (714) 456-6401

Community Clinic Orange County Rescue Mission (Hurtt Family Clinic) One Hope Drive Tustin 92782 (714) 247-0300

Hospital Anaheim General 3350 W. Ball Road Anaheim 92804 (714) 947-5800

Hospital Anaheim Regional Medical Center 1111 W. La Palma Avenue Anaheim 92801 (714) 999-6161

Hospital Kaiser Foundation Hospital - Anaheim 441 Lakeview Avenue Anaheim 92807 (714) 279-5459 (Monday - Friday)

(714) 279-4072 (Saturday & Sunday)Hospital West Anaheim Medical Center 3033 W. Orange Avenue Anaheim 92804 (714) 827-3000 ext. 5794

Hospital Western Medical Center Hospital - Anaheim 1025 S. Anaheim Boulevard Anaheim 92805 (714) 502-2668

Hospital Fountain Valley Regional Hospital & Medical Center 17100 Euclid Street Fountain Valley 92708 (714) 966-3316

Hospital Orange Coast Memorial Medical Center 9920 Talbert Avenue Fountain Valley 92708 (714) 378-7588

Hospital St. Jude Medical Center 101 E. Valencia Mesa Drive Fullerton 92635 (714) 446-5141

Hospital Garden Grove Hospital & Medical Center 12601 Garden Grove Boulevard Garden Grove 92643 (714) 741-2713

Hospital Huntington Beach Hospital 17772 Beach Boulevard Huntington Beach 92647 (714) 843-5000

Hospital Hoag Memorial Hospital - Irvine Campus 16200 Sand Canyon Avenue Irvine 92618 (949) 517-3167

Hospital Kaiser Foundation Hospital - Irvine 6640 Alton Parkway Irvine 92618 (949) 932-2882

Hospital La Palma Intercommunity Hospital 7901 Walker Street La Palma 90623 (714) 827-3000 ext. 5794

Hospital Mission Hospital - Laguna Beach 31872 Coast Highway Laguna Beach 92677 (949) 347-6040

Hospital Saddleback Memorial Medical Center – Laguna Hills 24451 Health Center Drive Laguna Hills 92653 (949) 452-3177

Hospital Los Alamitos Medical Center 3751 Katella Avenue Los Alamitos 90720 (562) 799-3116

Hospital Mission Hospital Regional Medical Center 27700 Medical Center Road Mission Viejo 92691 (949) 347-6040

Hospital Hoag Memorial Hospital Presbyterian One Hoag Drive Newport Beach 92663 (949) 764-4624

Hospital Chapman Medical Center 2601 E. Chapman Avenue Orange 92869 (714) 633-0011 ext. 1210

Hospital St. Joseph Hospital - Orange 1100 W. Stewart Drive Orange 92868 (714) 771-8107

Hospital University of California Irvine Medical Center 101 City Drive South Orange 92868 (714) 456-7328

Hospital Placentia Linda Hospital 1301 North Rose Drive Placentia 92670 (714) 993-2000

Hospital Saddleback Memorial Medical Center – San Clemente 654 Camino De Los Mares San Clemente 92673 (949) 489-4960

Hospital Coastal Communities Hospital 2701 Bristol Street Santa Ana 92704 (714) 754-5558

Hospital Western Medical Center - Santa Ana 1001 N. Tustin Avenue Santa Ana 92705 (714) 953-3409

If you are applying or re-applying for the Orange County Medical Services Initiative (MSI) Program your application can be taken at any of the

MSI contracted Community Clinics and Hospitals below.

Please call the number listed to schedule your appointment to apply for MSI.

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Directory of PhRMA Member Company Patient Assistance Programs

20

11

New Medicines. New Hope.®

Partnership for Prescription Assistancewww.PPARx.org

1-888-4PPA-NOW

PPA-DIRFORM

PhRMA companies have long been worldwide leaders not only in pharmaceutical innovation, but also in philanthropic initiatives-and their long-standing patient assistance programs are especiallyhelpful. This Directory, www.PPARx.org and 1-888-4PPA-NOW(1-888-477-2669), further their goal of helping to make medicinesavailable to those who need them.

AbbottAbbott Patient Assistance FoundationP 1-800-222-6885 | F 1-866-898-1473

Abbott Patient Assistance Foundation (Humira)P 1-800-222-6885 | F 1-866-250-2803

Abbott Patient Assistance Foundation (Lupron Depot)P 1-866-441-4138 | F 1-866-884-5909

Abbott Patient Assistance Foundation (Virology Program)P 1-800-222-6885 | F 1-866-483-1305

Abbott Patient Assistance Foundation (Androgel, Prometrium, Creon)P 1-800-222-6855 or 1-800-256-8918 | F 1-800-276-9901

AmgenENcourage Foundation® (Enbrel)P 1-800-282-7752 | F 1-888-508-8083

The Safety Net FoundationP 1-888-SN-AMGEN (762-6436) | F 1-866-549-7239

Astellas Pharma US Inc.Patient Assistance Program for AmeviveP 1-866-263-8483 | F 1-866-250-2145

Patient Assistance Program for Organ TransplantP 1-800-477-6472 | F 1-866-317-6235

Patient Assistance Program for ProtopicP 1-866-263-8483 | F 1-866-250-2145

Stock Replacement Program (Adenoscan, AmBisome, Mycamine, Vaprisol)P 1-800-477-6472 | F 1-866-317-6235

AstraZeneca Pharmaceuticals, LPAZ&Me™ Prescription Savings ProgramsP 1-800-AZandMe (292-6363) | F 1-800-961-8323

Bayer HealthCare PharmaceuticalsArch Foundation (Mirena)P 1-877-393-9071 | F 1-877-229-1421

Bayer Patient Assistance ProgramP 1-866-575-5002 | F 1-866-575-6568

Betaseron Patient Assistance ProgramP 1-877-836-5724 | F 1-877-744-5615

Kogenate Factor SolutionsP 1-800-288-8374 | F 1-800-390-1826

Nexavar REACH ProgramP 1-866-322-4448 | F 1-866-639-5181

Boehringer Ingelheim Pharmaceuticals, Inc.Boehringer Ingelheim Cares Foundation, Inc.P 1-800-556-8317 | F 1-866-851-2827

Bristol-Myers Squibb CompanyBristol-Myers Squibb Destination Access (Erbitux®, Ixempra™,Sprycel®)P 1-800-861-0048 | F 1-888-776-2370

Bristol-Myers Squibb Patient Assistance Foundation, Inc.P 1-800-736-0003 | F 1-800-736-1611

Bristol-Myers Squibb Patient Assistance Foundation, Inc. (Abilify®)P 1-800-736-0003 | F 1-866-598-5561

Bristol-Myers Squibb Access Virology Patient Assistance Foundation, Inc.P 1-888-281-8981 | F 1-888-281-8985

Bristol-Myers Squibb Patient Assistance Foundation, Inc. (Oncology)P 1-800-736-0003 | F 1-866-694-2545

Bristol-Myers Squibb Patient Assistance Foundation, Inc. (Orencia®)P 1-800-736-0003 | F 1-866-694-2545

Bristol-Myers Squibb & Gilead SciencesAtripla Patient Assistance ProgramP 1-866-290-4767 | F 1-866-290-4487

Celgene CorporationCelgene Patient Support®P 1-800-931-8691 | F 1-800-822-2496

Daiichi Sankyo, Inc.Daiichi Sankyo Open Care ProgramP 1-866-268-7327 | F 1-866-217-7171

Eisai Inc.Aciphex Patient Assistance ProgramP 1-800-523-5870 | F 1-888-526-5168

Aricept Patient Assistance ProgramP 1-800-226-2072 | F 1-800-226-2059

Eisai Oncology Patient Assistance ProgramP 1-866-613-4724 | F 1-866-573-4724

Patients in Need (Banzel and Zonegran)P 1-866-694-2550 | F 1-866-803-5631

EMD Serono, Inc.EGRIFTA™ AXIS Center™ Patient Assistance ProgramP 1-877-714-2947 | F 1-866-823-9554

MS LifeLines® Patient Assistance ProgramsP 1-877-447-3243 | F 1-866-227-3243

Saizen® Connections for Growth® Patient Assistance ProgramP 1-800-582-7989 | F 1-877-408-4288

Serostim® AXIS Center™ Patient Assistance ProgramP 1-877-714-2947 | F 1-866-823-9554

Serono Compassionate Care (Fertility LifeLines™)P 1-866-538-7879

Genzyme CorporationThe Charitable Access Program (CAP)P 1-800-745-4447, press 2

GlaxoSmithKlineBridges to AccessP 1-866-728-4368

GSK AccessP 1-866-518-4357 | F 1-866-518-3994

Johnson & Johnson Patient Assistance Foundation, Inc.Patient Assistance ProgramP 1-800-652-6227 | F 1-888-526-5168

Lilly USA, LLCForteo Connect Patient Assistance ProgramP 1-866-436-7836

Humatrope Reimbursement CenterP 1-800-847-6988

Lilly CaresP 1-800-545-6962

Lilly Medicare Answers Patient Assistance ProgramP 1-877-795-4559

Patient One Lilly Oncology Patient Assistance ProgramP 1-866-472-8663

Merck and Co., Inc.The ACT ProgramP 1-866-363-6379 | F 1-866-363-6389

The Merck Patient Assistance ProgramP 1-800-727-5400

The SUPPORT Program for Isentress™ and/or Crixivan®

Reimbursement Support and Patient Assistance ServicesP 1-800-850-3430 | F 1-866-410-1913

Millennium Pharmaceuticals, Inc.VELCADE Reimbursement Assistance ProgramP 1-866-835-2233

Novartis Pharmaceuticals CorporationClozaril® Patient Assistance ProgramP 1-800-277-2254

EPASS™ Exjade Patient Assistance ProgramP 1-888-903-7277 | F 1-888-891-4924

Extavia® Patient Assistance ProgramP 1-866-925-2333

Gilenya™ Support ProgramP 1-877-408-4974

Ilaris® Patient Assistance ProgramP 1-866-972-8315

Novartis Oncology Patient Assistance ProgramP 1-866-884-5906

Novartis Patient Assistance FoundationP 1-800-277-2254

Novartis Patient Assistance Program for Specialty MedicinesP 1-800-277-2254

Reclast® Patient Assistance ProgramP 1-800-833-0166

TOBI® Patient Assistance ProgramP 1-877-862-4423 | F 1-866-899-8624

Novo Nordisk Inc.Novo Nordisk Diabetes Patient Assistance ProgramP 1-866-310-7549 | F 1-866-441-4190

Novo Nordisk Hormone Therapy Patient Assistance ProgramP 1-866-668-6336

SevenSecureP 1-800-826-6993

Pfizer IncPfizer Helpful Answers®

Pfizer Helpful Answers® is a family of assistance programs for theuninsured and underinsured who need help getting Pfizer medicines.These programs provide Pfizer medicines for free or at a savings topatients who qualify. Some programs also offer reimbursement sup-port services for people with insurance.P 1-866-706-2400

Pfizer specialty product patient assistance programs:

Pfizer FirstResource® (Oncology)P 1-877-744-5675 | F 1-800-708-3430

Pfizer Bridge Program® (Endocrine care)P 1-800-645-1280 | F 1-800-479-2562

Pfizer RSVPP 1-888-327-7787 | F 1-888-773-0121

Sanofi-AventisEligard Reimbursement Hotline and Patient Assistance ProgramP 1-877-354-4273 | F 1-866-354-4273

Hyalgan Reimbursement Hotline and Patient Assistance ProgramP 1-800-992-9022 | F 1-877-366-0584

Lovenox Reimbursement Services and Patient Assistance ProgramP 1-888-632-8607 | F 1-888-875-9951

Multaq Reimbursement Services and Patient Assistance ProgramP 1-888-968-5827 | F 1-866-910-9024

PACT+ Program (Sanofi-Aventis Oncology)P 1-800-996-6626 | F 1-800-996-6627

Rilutek Continuity and Patient Assistance ProgramP 1-800-745-8835 | F 1-866-217-7178

Sanofi-Aventis Patient Assistance ProgramP 1-800-221-4025 | F 1-866-734-7372

Sculptra Patient Assistance ProgramP 1-866-310-7551 | F 1-866-364-2016

Sanofi PasteurSanofi Pasteur Patient Assistance ProgramP 1-866-801-5655 | F 1-866-734-7371

Sigma-Tau Pharmaceuticals, Inc.Carnitor Medication Assistance (NORD)P 1-800-999-6673, x-336

Matulane Medication Assistance (NORD)P 1-800-999-6673, x-457

Takeda Pharmaceuticals North America, Inc.Takeda Patient Assistance ProgramP 1-800-830-9159 | F 1-800-497-0928

Together Rx Access™A free savings card. Participating companies include: Abbott,Bristol-Myers Squibb, GlaxoSmithKline, members of the Johnson &Johnson Family of Companies, King Pharmaceuticals, Pfizer, Stiefel,Takeda and ViiV Healthcare.P 1-800-444-4106

Domestic

Student Health InsuranceCal State Fullerton

www.csuhealthlink.com

2011

-201

2

Brokered by: Wells Fargo Insurance Services USA, Inc.

Student Insurance Division

Underwritten by:Anthem Blue Cross Life and Health Insurance Company

Policy #175125

• 2 • Cal State Fullerton - Domestic

CSU DOMESTIC STUDENT HEALTH PLANPromotion of good health for our students has always been our concern. This brochure summarizes how the Student Health Insurance Plan works, what it covers and how the plan will help you with medical costs. After you’ve read about the Student Health Insurance Plan, keep these important facts in mind:

� Keep your insurance card with you at all times, and show it to the physician or hospital when you seek medical treatment.

� Learn about your University’s Student Health Center (SHC), its location, hours of operation, and the types of services it offers. Go first to your Univer-sity’s SHC for treatment during their regular hours of operation. SHC can help you locate medical providers when you need additional care or specialists.

� You may choose any provider you wish, but if you use an Anthem Blue Cross Life and Health provider, it may save you money. You can locate them on the web at www.anthem.com/ca or call (800) 888-2108.

WHO IS ELIGIBLE TO ENROLL?Regularly matriculated students who are enrolled in 9 or more credit hours, or registered graduate students are eligible to enroll. All eligible students must have paid fees to the University, and be actively attending classes on main campus. To be an Insured Person under the Plan, the student must have paid the required premium and his/her name, student number and date of birth must have been included in the declaration made by the School or the Administrative Agent to the Insurer. All students must actively attend classes on the main campus for 45 consecutive days following their effective date for the term purchased, except in the case of medical withdrawal (one semester only) or during school authorized breaks. Please note that course credits received from TV, Internet, video, satellite or any off-campus classes do not fulfill the eligibility requirement.The Company maintains its right to investigate student status and attendance records to verify that eligibility requirements have been met. If and whenever the Company discovers that eligibility requirements have not been met, its only obligation is a refund of premium.Eligible students who involuntarily lose coverage under another group insur-ance plan are also eligible to purchase the University Student Health Insurance Plan. These students must provide The Company with proof that they have lost insurance through another group (certificate and letter of ineligibility) within 30 days of the qualifying event. The effective date would be the later of the date the student enrolls and pays the premium or the day after prior coverage ends.DEPENDENT COVERAGE - Eligible Insured Students may also purchase Depen-dent coverage at the time of student’s enrollment in the plan; or within 31 days of one of the following qualified events: marriage, addition of domestic partner, birth, or adoption. Eligible dependents are the spouse or legally registered and valid domestic partner which resides with the Insured Student and the student’s, the spouse’s, or the domestic partner’s unmarried natural child, stepchild or legally adopted child under nineteen years of age, who are not self-supporting and reside with the Insured Student. A “Newborn” will automatically be covered for Injury or Sickness from birth until 31 days old, providing that the student is covered under this plan. Coverage may be continued for that child when the Company is notified in writing within 31 days from the date of birth and by pay-ment of any additional premium. Dependents must be enrolled for the same term of coverage for which the Insured Student enrolls. Dependent cover-age expires concurrently with that of the Insured Student and Dependents must re-enroll when coverage terminates to maintain coverage.

Your student health insurance coverage, offered by Anthem Blue Cross Life and Health Insurance Company, may not meet the minimum standards proposed by title XXVII of the Public Health Service Act. Specifically, the coverage will not be renewed when you are no longer enrolled as a student at Cal State Fullerton; and the restrictions on annual dollar limits on your benefits may not be the same as other types of coverage. If you have any questions or concerns about this notice, contact Wells Fargo Insurance Services USA, Inc., Student Insurance Division, (800)853-5899.

Cal State Fullerton - Domestic • 3 •

WHEN COVERAGE BEGINSCoverage under the Plan will become effective at 12:01 a.m. on the later of:

� The Policy effective date; � The beginning date of the term for which premium has been paid; � The day after the Enrollment Form (if applicable) and premium payment are

received by the Company, Authorized Agent or University; or � The day after the date of postmark if the Enrollment Form is mailed.

IMPORTANT NOTICE - Premiums will not be pro-rated if the Insured enrolls past the first date of coverage for which he or she is applying.

The below enrollments will be allowed a 30 day grace period from the term start date to enroll whereby the effective date will be backdated a maximum of 30 days. No policy shall ever start prior to the term start date: 1. All hard-waiver and mandatory (insurance is required as a condition of

enrollment on campus) insurance programs.2. All re-enrollments into the same exact policy if re-enrollment occurs within

30 days of the prior policy termination date.

WHEN COVERAGE ENDSCoverage of all Insured Persons terminates at 12:01 a.m. on the earlier of:

� The date the policy terminates for all Insured Persons; � The end of the period of coverage for which premium has been paid; � The date the Insured Person ceases to be eligible for the insurance; or � The date the Insured Person enters military service. � In the event there is overlapping coverage under the same master policy

number, the policy with the earliest effective date will stay in force through its termination date and the subsequent policy will go into effect immedi-ately afterward with no gap in coverage.

COVERAGE IS NOT AUTOMATICALLY RENEWED. Eligible Persons must re-enroll when coverage terminates to maintain coverage.

REFUNDSREFUNDS - A refund of premium will be granted for the reasons below only. No other refunds will be granted.1. If you withdraw from school within the first 45 days of the coverage

period, you will receive a full refund of the insurance premium provided that you did not file a medical claim during this period. Written proof of withdrawal from the school must be provided. If you withdraw after 45 days of the coverage period, your coverage will remain in effect until the end of the term for which you have paid the premium.

2. If you enter the armed forces of any country you will not be covered under the Policy as of the date of such entry. A pro-rata refund of premium will be made for such person, upon written request received by WFIS within 45 days of entry into service.

Refund requests should be directed to Wells Fargo Student Insurance at 800-853-5899. Approved refunds will be assessed a $25 processing fee.

CERTIFICATE OF CREDITABLE COVERAGEYour coverage under this Insurance Plan is creditable coverage under Federal Law. When your coverage terminates, you can request a Certificate of Creditable Coverage, which is evidence of your coverage under this health insurance plan. You need such certificate if you become covered under a group health plan or other health plan within 63 days after your coverage under this health insurance plan terminates. If the subsequent health plan excludes or limits coverage for medical conditions you have before you enroll, this certificate may be used to reduce or eliminate those exclusions or limitations. A Certificate of Creditable Coverage may be requested in writing from The Company.

REIMBURSEMENT FOR ACTS OF THIRD PARTIES

Under some circumstances, an insured person may need services under this plan for which a third party may be liable or legally responsible by reason of negli-gence, an intentional act or breach of any legal obligation. In that event, the insurer will provide the benefits of this plan subject to the following:1. The Insurer will automatically have a lien, to the extent of benefits provided,

upon any recovery, whether by settlement, judgment or otherwise, that you receive from the third party, the third party’s insurer, or the third party’s guarantor. The lien will be in the amount of benefits the Insurer has paid under this plan for the treatment of the illness, disease, injury or condition for which the third party is liable.

2. You must advise the Insurer in writing, within 60 days of filing a claim against the third party and take necessary action, furnish such information and as-sistance, and execute such papers as the Insurer may require to facilitate enforcement of their rights. You must not take action which may prejudice the insurer’s rights or interests under your plan. Failure to give the Insurer such notice or to cooperate with the Insurer, or actions that prejudice the Insurer’s rights or interests will be a material breach of this plan and will result in your being personally responsible for reimbursing the Insurer.

3. The Insurer will be entitled to collect on their lien even if the amount you or anyone recovered for you (or your estate, parent or legal guardian) from or for the account of such third party as compensation for the injury, illness or condition is less than the actual loss you suffered.

• 4 • Cal State Fullerton - Domestic

COMPLAINT NOTICEShould you have any complaints or questions regarding your coverage, you should first contact Wells Fargo Insurance Services USA, Inc. You may also contact Anthem Blue Cross Life and Health at:

Anthem Blue Cross Life and Health Insurance Company(Anthem Blue Cross Life and Health)

Customer Service21555 Oxnard Street

Woodland Hills, CA 91367(800) 888-2108

If the problem is not resolved, you may also contact the California Department of Insurance at:

California Department of InsuranceClaims Service Bureau, 11th Floor

300 South Spring StreetLos Angeles, California 90013

(800) 927-HELP (4357) – In California(213) 897-8921 – Out of California

(800) 482-4833 – Telecommunication Device for the DeafE-mail Inquiry: “Consumer Services” link at www.insurance.ca.gov

PPO PRUDENT BUYER NETWORKPLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Covering all Cali fornia ZIP codes, the Prudent Buyer network is the most geographically extensive PPO network in the state. The suitcase icon on your Medical ID card indicates that this plan can be used outside of California. The PPO network allows Insured’s easy access to a wide range of medical providers. Insured’s have the option to receive care from a provider who is not participating in the PPO network. The trade-off is higher out-of-pocket expenses.Participating providers (PPO Providers) agree to provide services to covered persons at discounted rates as payment in full. This is the incentive for Insured’s to use PPO providers and protects them from being balance-billed (except for coinsurance, co-payments and deductible amounts). Providers working within a PPO facility (ex. a hospital) may not always be PPO providers. You should request that all of your provider services be performed by a PPO Provider when you use a PPO facility. When Non-PPO providers are used, you may be subject to higher out-of-pocket expenses.Additionally, PPO physicians agree to admit their patients to network hospitals, guaranteeing that discounted charges and utilization management savings will occur.With no claim forms to file, Insured’s can focus on their health, not paperwork. Insured’s can find a PPO physician in their area by calling Anthem at (800) 888-2108, or by accessing the “Find a Doctor” link on www.anthem.com/ca.

EXCESS COVERAGEThe Insurer will reduce the amount payable under the Plan to the extent expenses are covered under any Other Plan. The Insurer will determine the amount of benefits provided by Other Plans without reference to any coordination of benefits, non-duplication of benefits, or other similar provisions. The amount from Other Plans includes any amount to which the Insured Per-son is entitled, whether or not a claim is made for the benefits. The Plan is secondary coverage to all other policies.

Cal State Fullerton - Domestic • 5 •

DEFINITIONSContracting Hospital: is a Hospital that has a contract with Anthem Blue Cross Life and Health to provide care to covered persons; however, this does not necessarily make it a Participating Hospital. Verify participation with your Physician.Co-payment: is the amount of Covered Expenses you are responsible for paying. Co-payment does not include charges for services that are not Covered Services or charges in excess of Covered Expenses.Covered Expense: is the expense you incur for Covered Services, but for some services the amount of Covered Expenses will be limited to a maximum amount that is described in the benefit section of this brochure.Covered Services: are services that are Medically Necessary services or supplies which are listed in the benefit section of this brochure and for which you are entitled to receive benefits.Customary and Reasonable Charge: as determined annually by Anthem Blue Cross Life and Health, is a charge which falls within the common range of fees billed by a majority of Physicians for a procedure in a given geographic region. If it exceeds that range, the expense must be justified based on the complexity or severity of treatment for a specific case.The Company: is Wells Fargo Insurance Services USA, Inc., Inc. which admin-isters the Plan.Deductible: means the amount of Covered Expense you must pay for Covered Services before any benefits are available to you under this plan. Your Plan Year Deductible is stated on page 6.Emergency: is a sudden, serious and unexpected acute illness, injury, condition (including without limitation sudden and unexpected severe pain), or a psychiatric emergency medical condition, which the insured person reasonably perceives could permanently endanger health if medical treatment is not received immediately. Anthem Blue Cross Life and Health will have sole and final determination as to whether services were rendered in connection with an emergency.The Insurer: is Anthem Blue Cross Life and Health Insurance Company. Insured Person: is the student or dependent.Medically Necessary: are procedures, supplies, equipment or services that are considered to be:

� Appropriate and necessary for the diagnosis or treatment of a medical condition, and

� Provided for the diagnosis or direct care and treatment of the medical condition, and

� Within the standards of good medical practice within the organized medical community, and

� Not primarily for the convenience of the patient’s Physician or another provider, and

� The most appropriate procedure, supply, equipment or service which can be safely provided that must satisfy the following requirements: 1) there must be valid scientific evidence demonstrating that the expected health benefits from the procedure, supply, equipment or service are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for the patient with the particular medical condition being treated than other possible alternatives; and 2) generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and 3) for Hospital stays, acute care as an inpatient is necessary due to the kind of services the patient is receiving or the severity of the medical condition, and that safe and adequate care cannot be received as an outpatient or in a less intensified medical setting.

Negotiated Rate: means the amount a Prudent Buyer Provider will accept as payment in full for Covered Services.Non-Contracting Hospital: is a Hospital that does not have a standard contract nor a Prudent Buyer Participating Agreement with Anthem Blue Cross Life and Health. Only a portion of the amount which a Non-Contracting Hospital charges for services will be Covered Expense. The Insured will be responsible for any billed charges over the amount allowed under this plan.Non-Prudent Buyer Provider (Non-PPO): is a provider who does NOT have a Prudent Buyer Plan Participating Provider Agreement with Anthem Blue Cross Life and Health in effect at the time services are rendered.Only a portion of the amount which a Non-Prudent Buyer Provider charges for services will be Covered Expense. The Insured will be responsible for any billed charges over the amount allowed under this plan.Physician means: 1) A doctor of medicine (M.D.) or a doctor of osteopathy (D.O.) who is licensed to practice where the care is provided, or 2) One of the following providers, but only when the provider is licensed to practice where the care is provided, is rendering a service within the scope of that license, is providing a service within the scope of that license and such license is required to render that service, is providing a service for which benefits are specified in this brochure, and when benefits would be payable if the services were provided by a Physician as defined above:

� A dentist (D.D.S. or D.M.D.); � An optometrist (O.D.); � A dispensing optician; � A podiatrist or chiropodist (D.P.M., D.S.P. or D.S.C.); � A licensed clinical psychologist; � A chiropractor (D.C.); � An acupuncturist (A.C.); � A licensed clinical social worker (L.C.S.W.); � A marriage and family therapist (M.F.T.); � A physical therapist (P.T. or R.P.T.); � A speech pathologist*; � An audiologist*; � An occupational therapist (O.T.R.)*; � A respiratory care practitioner (R.C.P.)*; � A psychiatric mental health nurse (R.N.); � A nurse midwife; � A registered dietician (R.D.)* for the provision of diabetic medical

nutrition therapy onlyNote: The providers indicated by asterisks (*) are covered only by referral of a Physician (M.D. or D.O.) as defined in 1 above.Prudent Buyer Provider (PPO): is one of the following providers which has a Prudent Buyer Plan Participating Provider Agreement with Anthem Blue Cross Life and Health in effect at the time services are rendered.

� A Hospital � A Physician � An Ambulatory Surgical Center � A durable medical equipment outlet � A clinical laboratory � A Skilled Nursing Facility � A facility which provides diagnostic imaging services � A Home Health Agency � A Home Infusion Therapy provider

• 6 • Cal State Fullerton - Domestic

SCHEDULE OF BENEFITSNote: this is a limited pay plan. Insured persons are responsible for any billed charges in excess of any maximums.

STUDENT HEALTH CENTERWhen medical care is needed, you are strongly encouraged to use the Student Health Center (SHC) on your campus. Services obtained at the SHC are reimbursed at the PPO rate. A SHC referral to an off campus provider does not guarantee that the provider is in network, nor that services received will be considered eligible expenses under the plan, nor is it a guarantee of payment. Insured dependents are not eligible to use the Student Health Center. The coverage under this Plan is second-ary coverage to all other policies.

In addition to dollar and percentage co-pays, insured persons (students & dependents) are responsible for deductibles, as described below. Please review the deductible information to know if a deductible applies to a specific covered service. Insured persons are also responsible for all costs over the plan maximums. Plan maximums and other important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Plan.

Explanation of Covered ExpensePlan payments are based on covered expense, which is the lesser of the charges billed by the provider or the following:

PPO Providers—PPO negotiated rates. Insured persons are not responsible for the difference between the provider’s usual charges & the negotiated amount.Non-PPO Providers & Other Health Care Providers (includes those not represented in the PPO provider network)—The customary & reasonable charge for professional services or the reasonable charge for institutional services.

When using Non-PPO and Other Health Care Providers, insured persons are responsible for any difference between the covered expense & actual charges, as well as any deductible, percentage and/or dollar co-pay.

School Plan year deductible for all providers $250/insured person; $750/familyDeductible for non-PPO hospital or residential treatment center $500/admission (waived for emergency admission)Deductible for non-PPO hospital or residential treatment center if services not preauthorized

$500/admission (waived for emergency admission)

Deductible for emergency room services $100/visit (waived if admitted directly from ER)Benefit Year Maximum $100,000/insured person/benefit year

Covered Services PPO: Per Insured Person Co-pay

Non-PPO: Per Insured Person Co-pay 1

Hospital Services (preauthorization required for inpatient services; waived for emergency admissions)Semi-private room, meals & special diets, & ancillary services Outpatient medical care, surgical services & supplies (hospital care other than emergency room care)

20% 20%

50%50%

Ambulatory Surgical Centers Outpatient surgery, services & supplies

20%

50%

Related Outpatient Medical Services & Supplies Ground or air ambulance transportation, services & disposable supplies Blood transfusions, blood processing & the cost of unreplaced blood & blood products Autologous blood (self-donated blood collection, testing, processing & storage for planned surgery)

20%2

20%2

20%2

Emergency Care Emergency room services & supplies ($100 deductible waived if admitted)Inpatient hospital services & supplies

Physician services

20%20%

20%

20%20% first 48 hours; 50%after 48 hours (unless insured person can’t be

moved safely)50%

Physician Medical Services Office & home visits Hospital & skilled nursing facility visits Surgeon & surgical assistant; anesthesiologist or anesthetist

$30/visit3

(deductible waived)20%20%

50%

50%50%

Diagnostic X-ray & Lab (including mammograms, Pap smears & prostate cancer screenings)(pre-authorization required for CT scans, MRA scans, MRI scans, MRS scans, NC scans & PET scans) 20% 50%

Cal State Fullerton - Domestic • 7 •

Covered Services PPO: Per Insured Person Co-pay

Non-PPO: Per Insured Person Co-pay 1

Mental or Nervous Disorders Facility-based care (preauthorization required; waived for emergency admissions; limited to $175/day)Inpatient or outpatient physician visits for psychotherapy & psychological testing (limited to 12 visits/benefit year)

20%5

20%5

50%5

50%5

Substance Abuse Facility-based care (preauthorization required; waived for emergency admissions; limited to $175/day & 30 days/benefit year; the 30 days/benefit year limit does not apply to inpatient detoxification)Inpatient or outpatient physician visits (limited to 12 visits/benefit year)

20%

20%

50%

50%

Outpatient Drugs and Medications Drugs and medication, including oral contraceptives & insulin, when dispensed by a physician or licensed pharmacist. (limited to $500/benefit year) (Benefit is on a reimbursement basis of a 30 day supply only)

20%SHC & PPO Pharmacy 50%

Well Baby & Well-Child Care for Dependent Children Routine physical examinations (birth through age six)

Immunizations (birth through age six)

$30/exam (deductible waived)

No co-pay(deductible waived)

50% (limited to $20/exam)

50% (limited to $12/immunization)

Preventative Care for Insured persons Ages Seven & Older Routine physical exams, immunizations, diagnostic X-ray & lab for routine physical exam (limited to $250/benefit year)

Adult Preventive Screening for cervical cancer, mammography testing & prostate cancer

$30/visit

(deductible waived)20%

(deductible waived)

Not covered

50% (deductible waived)

Physical Therapy, Physical Medicine & Occupational Therapy, including Chiropractic Services (limited to 12 visits/benefit year; additional visits may be authorized) 20% 50%

(limited to $25/visit)Speech Therapy

Outpatient speech therapy following injury or organic disease 20% 50%Acupuncture

Services for the treatment of disease, illness or injury (limited to $30/visit & 12 visits/benefit year) 20%4 50%4

Temporomandibular Joint Disorders Splint therapy & surgical treatment 20% 50%

Pregnancy & Maternity CarePhysician office visits Prescription drug for elective abortion (mifepristone)

Normal delivery, cesarean section, complications of pregnancy & abortion (newborn routine nursery care covered when natural mother is insured student or insured spouse or domestic partner)Inpatient physician services Hospital & ancillary services

$30/visit3

(deductible waived)20%

20%20%

50%

50%

50%50%

24/7 NurseLine A 24-hour service that connects insured persons to a nurse or audio library with a toll-free call; the number is (800) 977-0027

No co-pay (deductible waived)

Diabetes Education Programs (requires physician supervision)Teach insured persons & their families about the disease process, the daily management of diabetic therapy & self-management training

$30/visit(deductible waived) 50%

Prosthetic Devices Coverage for breast prostheses; prosthetic devices to restore a method of speaking; surgical implants; artificial limbs or eyes; the first pair of contact lenses or eyeglasses when required as a result of eye surgery; and therapeutic shoes & inserts for Insureds with diabetes

20% 50%

Durable Medical Equipment (DME)Rental or purchase of DME including hearing aids, dialysis equipment & supplies (limited to a maximum of $5,000/benefit year)

20%

50%

• 8 • Cal State Fullerton - Domestic

Covered Services PPO: Per Insured Person Co-pay

Non-PPO: Per Insured Person Co-pay 1

Skilled Nursing Facility (preauthorization required)Semi-private room, services & supplies (medical conditions & severe mental disorders limited to 100 days/benefit year; care in a residential treatment center for treatment of substance abuse limited to 30 days/benefit year and is charged against Skilled Nursing Facility maximum)

20%

50%

Hospice Care Inpatient or outpatient services for insured persons with up to one year life expectancy; family bereavement services

20%2

Home Health Care (preauthorization required)Services & supplies from a home health agency (limited to 100 visits/benefit year, one visit by a home health aide equals four hours or less; not covered while insured person receives hospice care)

20%

50%

Home Infusion Therapy (preauthorization required)Includes medication, ancillary services & supplies; caregiver training & visits by provider to monitor therapy; durable medical equipment; lab services

20%

50% (limited to $600/

day)1 The percentage co-pay for non-emergency services from non-PPO providers is based on the lesser of billed charges or Customary and Reasonable amount.2 These providers are not represented in the PPO network.3 The dollar co-pay applies only to the visit itself. An additional 20% co-pay applies for any services performed in office (i.e., X-ray, lab, surgery).4 Acupuncture services can be performed by a certified acupuncturist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D.P.M.), or a dentist (D.D.S.).5 These limitations, co-pays and benefit maximums do not apply to severe mental disorders, including schizophrenia, schizoaffective disorder, bipolar disorder, major depression, panic disorder, obsessive-compulsive disorder, pervasive

developmental disorder or autism, anorexia, bulimia, and serious emotional disturbances of children as defined in California state law (other than primary substance abuse or developmental disorder). Severe mental disorders are subject to the same co-pays and benefit maximums applicable to other medical conditions for covered services. In order to receive maximum benefits, services must be rendered by a Participating behavioral health provider. Please see the Certificate for complete information.

ID CARDS

Cal State Fullerton - Domestic • 9 •

Unless specifically provided for elsewhere under the Plan, the Plan does not cover loss caused by or resulting from, nor is any premium charged for the following:1. Not Medically Necessary. Services or supplies that are not medically neces-

sary, as defined.2. Experimental or Investigative. Any experimental or investigative procedure

or medication. But, if you are denied benefits because it is determined that the requested treatment is experimental or investigative, you may request an independent medical review.

3. Crime or Nuclear Energy. Conditions that result from: (1) your commission of or attempt to commit a felony as long as any injuries are not a result of a medical condition or an act of domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when government funds are available for treat-ment of illness or injury arising from such release of nuclear energy.

4. Uninsured. Services received before your effective date or after your coverage ends, except as specifically stated under CONTINUATION OF BENEFITS AFTER TERMINATION.

5. Excess Amounts. Any amounts in excess of covered expense or the BenefitYear Maximum.

6. Work-Related. Work-related conditions if benefits are recovered or can be re-covered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if you do not claim those benefits. If there is a dispute or substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers’ compensation, benefits will be provided subject to the right of recovery and reimbursement under California Labor Code Section 4903, and as described in REIMBURSEMENT FOR ACTS OF THIRD PARTIES.

7. Government Treatment. Any services you received if you are not required to pay for them or they are given to you for free that were provided by a local, state, or federal government agency, or by a public school system or school district, except when payment under this plan is expressly required by federal or state law.

8. Services of Relatives. Professional services received from a person who lives in your home or who is related to you by blood or marriage.

9. Voluntary Payment. Services for which you are not legally obligated to pay. Services for which you are not charged. Services for which no charge is made in the absence of insurance coverage, except services received at a non-govern-mental charitable research hospital. Such a hospital must meet the following guidelines:a. It must be internationally known as being devoted mainly to medical

research;b. At least 10% of its yearly budget must be spent on research not directly

related to patient care;c. At least one-third of its gross income must come from donations or

grants other than gifts or payments for patient care;d. It must accept patients who are unable to pay; ande. Two-thirds of its patients must have conditions directly related to the

hospital’s research.10. Not Specifically Listed. Services not specifically listed in this plan as

covered services.11. Private Contracts. Services or supplies provided pursuant to a private contract

between the insured person and a provider, for which reimbursement under the Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act.

12. Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been per-formed safely on an outpatient basis.

13. Mental or Nervous Disorders. Academic or educational testing. Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these conditions, except as specifically stated.

14. Nicotine Use. Smoking cessation programs or treatment of nicotine or tobacco use. Smoking cessation drugs.

15. Orthodontia. Braces and other orthodontic appliances or services.16. Dental Services or Supplies. Dental plates, bridges, crowns, caps or other

dental prostheses, dental implants, dental services, extraction of teeth, or treat-ment to the teeth or gums, or treatment to or for any disorders for the jaw joint, except as specifically stated. Cosmetic dental surgery or other dental services for beautification.

17. Hearing Aids or Tests. Hearing aids, except as specifically stated.

EXCLUSIONS & LIMITATIONS

• 10 • Cal State Fullerton - Domestic

18. Optometric Services or Supplies. Optometric services, eye exercises including orthoptics. Routine eye exams and routine eye refractions, except as specifi-cally stated. Eyeglasses or contact lenses, except as specifically stated.

19. Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health agency, hospice or home infusion therapy provider as specifically stated.

20. Outpatient Speech Therapy. Outpatient speech therapy except as stated.21. Cosmetic Surgery. Cosmetic surgery or other services performed solely for

beautification or to alter or reshape normal (including aged) structures or tissues of the body to improve appearance. This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct deformities caused by congenital or developmental abnormalities, illness, or injury for the purpose of improving bodily function or symptomatology or to create a normal appearance), including surgery performed to restore symmetry following mas-tectomy. Cosmetic surgery does not become reconstructive surgery because of psychological or psychiatric reasons.

22. Scalp hair prostheses. Including wigs or any form of hair replacement.23. Commercial Weight Loss Programs. Weight loss programs, whether or not they

are pursued under medical or physician supervision, unless specifically listed as cov-ered under the Plan. This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting pro-grams. This exclusion does not apply to medically necessary treatments for morbid obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of anorexia nervosa or bulimia nervosa. Surgical treatment for morbid obesity is not covered.

24. Sex Transformation. Procedures or treatments to change characteristics of the body to those of the opposite sex.

25. Reversal of Sterilization.26. Infertility Treatment. Any services or supplies furnished in connection with the

diagnosis and treatment of infertility, including, but not limited to, diagnostic tests, medication, surgery, artificial insemination, in vitro fertilization, steriliza-tion reversal, and gamete intrafallopian transfer.

27. Orthopedic Supplies. Orthopedic shoes (other than shoes joined to braces) or non-custom molded and cast shoe inserts, except for therapeutic shoes and inserts for the prevention and treatment of diabetes-related foot complications as specifically stated.

28. Air Conditioners. Air purifiers, air conditioners, or humidifiers.29. Custodial Care or Rest Cures. Inpatient room and board charges in connec-

tion with a hospital stay primarily for environmental change or physical therapy. Custodial care or rest cures, except as specifically stated. Services provided by a rest home, a home for the aged, a nursing home or any similar facility. Services provided by a skilled nursing facility, except as specifically stated.

30. Chronic Pain. Treatment of chronic pain, except as specifically stated.31. Health Club Memberships. Health club memberships, exercise equipment,

charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to health spas.

32. Personal Items. Any supplies for comfort, hygiene or beautification.33. Education or Counseling. Educational services, or nutritional counseling, or

any services that are educational, vocational, or training in nature, except as specifically stated.

34. Telephone and Facsimile Machine Consultations. Consultations provided by telephone or facsimile machine.

35. Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual illness, injury or condition, including those required by employ-ment or government authority, except as specifically stated.

36. Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of correcting refractive defects of the eye such as nearsightedness (myo-pia) and/or astigmatism. Contact lenses and eyeglasses required as a result of this surgery.

37. Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical medicine, except as stated.

38. Outpatient Prescription Drugs and Medications. Outpatient prescription drugs or medications and insulin, except as specifically stated. Non-prescription, over-the-counter patent or proprietary drugs or medicines. Cosmetics, health or beauty aids.

39. Contraceptive Devices. Contraceptive devices prescribed for birth control ex-cept as specifically stated.

40. Private Duty Nursing. Inpatient or outpatient services of a private duty nurse.41. Lifestyle Programs. Programs to alter one’s lifestyle which may include but

are not limited to diet, exercise, imagery or nutrition. This exclusion will not apply to cardiac rehabilitation programs approved by the Insurer.

42. Clinical Trials. Services and supplies in connection with clinical trials, except as specifically stated.

43. Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by any other valid and collectible insurance, ex-cept for automobile medical payments insurance.

44. Services provided normally without charge by the Recognized Student Health Center or services covered or provided by the student health fee, except as specifi-cally provide in this plan.

45. Organ or tissue transplant, except as specifically stated.46. Diagnosis and treatment of acne and sebaceous cyst.47. Loss due to war, declared or undeclared; service in the armed forces of any

country or international authority; riot; civil commotion; or acts of terrorism.48. Riding in any aircraft, except as a passenger on a regularly scheduled airline

or charter flight.49. Loss arising from participation in interscholastic, intercollegiate, club and profes-

sional sports, scuba diving, hang gliding, parachuting or bungee jumping, except as specifically provided.

50. Non-Licensed Providers. Treatment or services rendered by non-licensed health care providers and treatment or services for which the provider of services is not required to be licensed. This includes treatment or services from a non-licensed provider under the supervision of a licensed physician, except as specifically provided or arranged by us.

51. Surrogate Mother Services. For any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple).

52. Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this plan or as required by law. This exclusion includes, but is not limited to, those nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not require either a written prescription or dispensing by a licensed pharmacist.

EXCLUSIONS & LIMITATIONS (CONTINUED)

Cal State Fullerton - Domestic • 11 •

ONLINE STUDENT ASSISTANCE PROGRAM

Everyone experiences challenges in life. Usually, we can find our own solutions. But when we can’t, those problems can affect our daily lives. This plan includes the An-them Blue Cross OnLine Student Assistance Program. With OnLine, helpful informa-tion and resources for the everyday problems of living are just a mouse click away.

When you need solutions, Anthem Blue Cross OnLine can help.With the OnLine Student Assistance Program, you and your family can access an online library of valuable articles covering mental and physical health, relationships/family issues, stress and emotional concerns and substance abuse. Browse the legal and financial resource center for general information on these topics. OnLine also provides important links to some of the most valuable Web resources available, as well as pertinent reading lists and helpful self-assessment tools.

How to access the Anthem Blue Cross OnLine ProgramYou and your family members can take advantage of this online resource by going to www.AnthemEAP.com. Simply enter your Program Name: CSU for access to helpful information and resources to assist you with the normal challenges of living. Many of the OnLine resources are also available in Spanish.

MANDATED BENEFITSThe following benefits are mandated coverages in the state of California. They will be included in all School plans issued under the Policy. Unless specified otherwise, all such coverage will be subject to any deductible, co-payment and coinsurance conditions of the Plan, as well as all other terms and conditions applicable to any other Covered Sickness. Mandated benefits as required by the state in which the Policy is issued include: PKU Treatment Benefit; Hospital Dental Procedures; Mastectomy-Reconstructive Surgery and Rehabilitation; Laryngectomy-Prosthetic Devices; Osteoporosis Benefit; Experi-mental or Investigational Therapies Treatment; Diabetes Equipment, Supplies and Service; and Severe Mental Illness Treatment Benefit, which is a separate benefit from Mental and Nervous Disorders. See the policy on file with The Company.

GUIDELINES FOR CANCER SCREENING TESTS

Anthem Blue Cross Life and Health will pay the charges incurred for the following cancer screening tests, subject to any deductibles, co-payments or coinsurance:1. Screening mammogram performed according to the following schedule: a)

A baseline mammogram for women age 35 to 39 inclusive; b) A mam-mogram for women age 40 to 49, inclusive, every two years or more frequently based on a Physician’s recommendation; or c) A mammogram every year for women age 50 and over.

2. PAP tests for women 18 years of age and older as recommended by a Physician; and

3. Prostate cancer screening, including digital rectal examinations and prostate-specific antigen tests if recommended by a Physician, at least once a year for men 50 years of age and older.

4. Other generally accepted cancer screening tests, subject to all terms and conditions that would otherwise apply.

• 12 • Cal State Fullerton - Domestic

ONLINE HEALTH CARE ADVISORSubimo™ is an innovative and interactive website that provides valuable tools to help covered persons make informed decisions regarding their specific health care needs. Covered persons link to Subimo from the Anthem website through “Member Services” located on the home page at www.anthem.com/ca and log-ging in to the Secure Member Services site. First time users will need to register.

24-HOUR NURSE ADVICE LINEStudents and insured dependents may utilize the 24/7 NurseLine, the 24-Hour Nurse Advice Line, anytime they need confidential medical advice. Callers must be enrolled in the Student Health Insurance Plan in order to be eligible to utilize the 24/7 NurseLine program. This program gives access to a toll-free nurse information line, or an audio library, 24 hours a day, 7 days a week.

HERE’S HOW EASY IT IS:1. The insured student or insured dependent calls the 24-Hour 24/7 NurseLine.2. A registered nurse asks questions and assesses the caller’s condition.3. If you speak a language other than English or Spanish, the registered nurse

can utilize an interpreter, that will work with the nurse and the member. 4. The nurse provides information regarding care options to help the caller develop

a proactive plan which could include: proceed to an urgent care or emergency facility, follow-up with your primary care provider, or develop a home care plan.

5. The nurse can provide information about your PPO network providers in the geographic area closest to your school.

One toll-free phone call is all it takes to access a wealth of useful health care information at (800)977-0027.

MEMBER DISCOUNTS

SpecialOffers— Online Discounts that Connect to YouTo help support your healthy lifestyle the Insurer provides information on discounts on a variety of dental, vision, fitness, massage therapy, yoga and hypnotherapy products and services offered by independent vendors. Here are a few examples of potential savings:

� Up to 30% off, frames, lenses and special savings on LASIK � 25% up to 60% off health club memberships at nationally recognized health clubs

and up to 30% off weight loss programs � 5% off non-prescription items at drugstore.com and up to 15% off allergen avoid-

ance products at natlallergy.com � up to 30% off of smoking cessation, stress management, alcohol management

and other self-help programs up to 40% off of wellness productsThe independent vendors participating in the Anthem SpecialOffers program of-fer you choice, flexibility and freedom through discounts that save you money! Discounts advertised may change without notice, for a current listing and more information about specific vendors and discounts please visit the SpecialOffers link at www.anthem.com/ca.

CONTINUATION OF BENEFITS AFTER TERMINATION

Anthem Blue Cross Life and Health will extend benefits under the Plan for 30 days after the Insured’s coverage would otherwise end if on that date he or she is 1) Hospital Confined for an Injury or Sickness covered by the Plan, and 2) under a physician’s care. Any benefits payable under this provision will not exceed the benefit maximums shown in the Schedule of Benefits. The cost of the Continuation of Benefits is one month’s premium.

CONTINUOUS COVERAGEThis Plan may be replacing a Prior Plan with another insurer. Prior Plan means (a) the Student Health Insurance policy or policies issued to the Cali-fornia State University immediately before the current Policy; (b) other poli-cies providing Creditable Coverage as defined in this Plan. Injury or Sickness shall include an Injury sustained, or a Sickness first manifesting itself, while the Insured Person is continuously insured under the Prior Plan and became insured under this Plan without a break in coverage. But no benefits shall be payable for such Injury or Sickness to the extent that such benefits are payable under the Prior Plan for the same expenses. This will apply even though the Prior Plan provided that it will not duplicate the benefits under another Policy. Also, the total amount of benefits payable for Injury or Sickness under this Plan and the Prior Plan cannot exceed the Per Benefit Year Maximum.

ARBITRATION AGREEMENTAny dispute or claim, of whatever nature, arising out of, in connection with, or in relation to this plan or the policy or breach or rescission thereof, or in relation to care or delivery of care, including any claim based on contract, tort, or statute, must be resolved by arbitration if the amount sought exceeds the jurisdictional limit of the small claims court. Any dispute or claim within the jurisdictional limits of the small claims court will be resolved in such court.The Federal Arbitration Act will govern the interpretation and enforcement of all proceedings under this Binding Arbitration provision.The insured person and Anthem Blue Cross Life and Health agree to be bound by this Binding Arbitration provision and acknowledge that they are each giving up their right to a trial by court or jury.The insured person and Anthem Blue Cross Life and Health agree to give up the right to participate in class arbitration against each other.The arbitration findings will be final and binding except to the extent that Cali-fornia or Federal law provides for the judicial review of arbitration proceedings.The arbitration is begun by the insured person making written demand on Anthem Blue Cross Life and Health. The arbitration will be conducted by Judicial Arbitration and Mediation Services (“JAMS”) according to its applicable Rules and Procedures. If, for any reason, JAMS is unavailable to conduct the arbitra-tion, the arbitration will be conducted by another neutral arbitration entity, by mutual agreement of the insured person and Anthem Blue Cross Life and Health, or by order of the court, if the insured person and Anthem Blue Cross Life and Health cannot agree. The arbitration shall be held in the State of California.

Cal State Fullerton - Domestic • 13 •

ID CARDSMedical ID cards may be shipped before or within 3 weeks of your policy ef-fective date. New ID cards will not be sent if you are renewing coverage with Anthem Blue Cross Life and Health and there are no benefit changes between plan years. Providers need your Member ID # from your ID card to identify you, verify your coverage and bill Anthem Blue Cross Life and Health. If you need to seek medical treatment prior to receiving your ID card, please use the temporary card and write in your Member # or call Wells Fargo Insurance Services at (800)853-5899 to obtain your Member #. Renewing students will maintain the same Member #. Without a Member ID you can still seek medical treatment and submit a claim form for reimbursement.

HOW DO I FILE A CLAIM?Usually, all providers of health care will bill Anthem Blue Cross Life and Health directly for services to Insureds. This is the preferred procedure - you are not bothered with claim forms, and Anthem Blue Cross Life and Health often needs more details than are ordinarily provided on bills to patients.But sometimes a physician or an ambulance company may not bill Anthem Blue Cross Life and Health and may send the bill directly to you. Also, your Stu-dent Health Center and pharmacies will not bill Anthem Blue Cross Life and Health. In these instances, Anthem Blue Cross Life and Health Insurance has no way of knowing about your claim. So, you must mail the bills or paid receipts to Anthem Blue Cross Life and Health within 90 days of treatment and include a claim form. Claim forms are available at www.csuhealthlink.com. You are urged to send Anthem Blue Cross Life and Health each bill immediately upon receipt. Mail to:

Anthem Blue Cross Life and Health Insurance CompanyAttention: Student Health Customer Service Manager

21555 Oxnard Street; AC4GWoodland Hills, CA 91367

Complete instructions for use of the claim form are on the form.

PRE-EXISTING CONDITION LIMITATIONBenefits are not payable for a pre-existing condition during the first six (6) months following the effective date of a Covered Person’s coverage. However, this limitation will not apply if, during the period immediately preceding the effective date of cover-age under this plan, a Covered Person was covered under a prior creditable coverage as defined below, for six (6) consecutive months. Prior creditable coverage of less than six (6) months will be credited toward satisfying the pre-existing condition limi-tation. This waiver of the pre-existing condition limitation will be effective provided a Covered Person becomes eligible under this plan within 63 days of termination of a creditable coverage and applies for coverage under the Plan within 31 days of his or her eligibility date.CREDITABLE COVERAGE means any individual or group plan that provides medical, hospital, and surgical coverage, including continuation or conversion coverage, cov-erage under Medicare or Medicaid, TRICARE, the Federal Employees Health Benefit Plan, programs of the Indian Health Services or of a tribal organization, a state health benefits risk pool, coverage through the Peace Corps, the State Children’s Health Insur-ance Program, or a public health plan established or maintained by a state, the United States government, or a foreign country. Creditable coverage does not include accident only, credit, coverage for onsite medical clinics, disability income, coverage only for a specified disease or condition, hospital indemnity or other fixed indemnity insurance, Medicare supplement, long-term care insurance, dental, vision, workers’ compensation insurance, automobile insurance, no-fault insurance, or any medical coverage designed to supplement other private or governmental plans. Creditable coverage is used to reduce the length of pre-existing under this plan and/or to set up eligibility rules for children who cannot get a self-sustaining job due to a physical or mental condition.

OES - ONLINE ENROLLEE SERVICES

Setting up your OES Account:1. Go to www.csuhealthlink.com2. Click on “Access My Account Online”3. Enter the requested information to create your personal account

After setting up your account you can: � View a summary of your plan information � Update your address and phone number � Request a new ID card � View your plan brochure � View Other Insurance Plans such as: Short term Plans, Dental Plans, Vision

Plans, and Travel Coverage � Print a letter of creditable coverage � View Frequently Asked Questions

• 14 • Cal State Fullerton - Domestic

Anthem Blue Cross Life and Health Notice of Privacy Practices

Effective April 1, 2010Information that’s important to youEvery year, we’re required to send you specific information about your rights, your benefits and more. This can use up a lot of trees, so we’ve combined a couple of these required annual notices. Please take a few minutes to read about:

� State notice of privacy practices � HIPAA notice of privacy practices � Breast reconstruction surgery benefits

Want to save more trees? Go to anthem.com/ca and sign up to receive these types of notices by e-mail.State notice of privacy practicesAs mentioned in our Health Insurance Portability and Accountability Act (HIPAA) notice, we must follow state laws that are stricter than the federal HIPAA privacy law. This notice explains your rights and our legal duties under state law. This ap-plies to life insurance benefits, in addition to health, dental and vision benefits that you may have.Your personal informationWe may collect, use and share your nonpublic personal information (PI) as described in this notice. PI identifies a person and is often gathered in an insurance matter. We may collect PI about you from other persons or entities, such as doctors, hospitals or other carriers. We may share PI with persons or entities outside of our company — without your OK in some cases. If we take part in an activity that would require us to give you a chance to opt out, we will contact you. We will tell you how you can let us know that you do not want us to use or share your PI for a given activity. You have the right to access and correct your PI. Because PI is defined as any informa-tion that can be used to make judgements about your health, finances, character, habits, hobbies, reputation, career and credit, we take reasonable safety measures to protect the PI we have about you. A more detailed state notice is available upon request. Please call the phone number printed on your ID card.HIPAA notice of privacy practicesThis notice describes how health, vision and dental information about you may be used and disclosed, and how you can get access to this information with regard to your health benefits. Please review it carefully. We keep the health and financial information of our current and former members private, as required by law, ac-creditation standards and our rules. This notice explains your rights. It also explains our legal duties and privacy practices. We are required by federal law to give you this notice.Your Protected Health InformationWe may collect, use and share your Protected Health Information (PHI) for the following reasons and others as allowed or required by law, including the HIPAA Privacy rule:For payment: We use and share PHI to manage your account or benefits; or to pay claims for health care you get through your plan. For example, we keep informa-tion about your premium and deductible payments. We may give information to a doctor’s office to confirm your benefits.For health care operations: We use and share PHI for our health care operations. For example, we may use PHI to review the quality of care and services you get. We may also use PHI to provide you with case management or care coordination services for conditions like asthma, diabetes or traumatic injury.For treatment activities: We do not provide treatment. This is the role of a health care provider, such as your doctor or a hospital. But, we may share PHI with your health care provider so that the provider may treat you.

To you: We must give you access to your own PHI. We may also contact you to let you know about treatment options or other health-related benefits and services. When you or your dependents reach a certain age, we may tell you about other products or programs for which you may be eligible. This may include individual cov-erage. We may also send you reminders about routine medical checkups and tests.To others: You may tell us in writing that it is OK for us to give your PHI to someone else for any reason. Also, if you are present and tell us it is OK, we may give your PHI to a family member, friend or other person. We would do this if it has to do with your current treatment or payment for your treatment. If you are not present, if it is an emergency, or you are not able to tell us it is OK, we may give your PHI to a family member, friend or other person if sharing your PHI is in your best interest. As allowed or required by law: We may also share your PHI, as allowed by federal law, for many types of activities. PHI can be shared for health oversight activities. It can also be shared for judicial or administrative proceedings, with public health authori-ties, for law enforcement reasons, and with coroners, funeral directors or medical examiners (about decedents). PHI can also be shared with organ donation groups for certain reasons, for research, and to avoid a serious threat to health or safety. It can be shared for special government functions, for Workers’ Compensation, to re-spond to requests from the U.S. Department of Health and Human Services, and to alert proper authorities if we reasonably believe that you may be a victim of abuse, neglect, domestic violence or other crimes. PHI can also be shared as required by law. If you are enrolled with us through an employer-sponsored group health plan, we may share PHI with your group health plan. We and/or your group health plan may share PHI with the sponsor of the plan. Plan sponsors that receive PHI are required by law to have controls in place to keep it from being used for reasons that are not proper. Authorization: We will get an OK from you in writing before we use or share your PHI for any other purpose not stated in this notice. You may take away this OK at any time, in writing. We will then stop using your PHI for that purpose. But, if we have already used or shared your PHI based on your OK, we cannot undo any ac-tions we took before you told us to stop.Genetic Information: If we use or disclose PHI for underwriting purposes, we are prohibited from using or disclosing PHI that is genetic information of an individual for such purposes.Your rightsUnder federal law, you have the right to:

� Send us a written request to see or get a copy of certain PHI, or ask that we correct your PHI that you believe is missing or incorrect. If someone else (such as your doctor) gave us the PHI, we will let you know so you can ask him or her to correct it.

� Send us a written request to ask us not to use your PHI for treatment, pay-ment or health care operations activities. We are not required to agree to these requests.

� Give us a verbal or written request to ask us to send your PHI using other means that are reasonable. Also, let us know if you want us to send your PHI to an address other than your home if sending it to your home could place you in danger.

� Send us a written request to ask us for a list of certain disclosures of your PHI.Call Customer Service at the phone number printed on your identification (ID) card to use any of these rights. Customer Service representatives can give you the ad-dress to send the request. They can also give you any forms we have that mayhelp you with this process.

Cal State Fullerton - Domestic • 15 •

How we protect informationWe are dedicated to protecting your PHI, and have set up a number of policies and practices to help make sure your PHI is kept secure. We keep your oral, written and electronic PHI safe using physical, electronic, and procedural means. These safeguards follow federal and state laws. Some of the ways we keep your PHI safe include securing offices that hold PHI, password protecting computers, and locking storage areas and filing cabinets. We require our employees to protect PHI through written policies and procedures. These policies limit access to PHI to only those employees who need the data to do their job. Employees are also required to wear ID badges to help keep people who do not belong out of areas where sensitive data is kept. Also, where required by law, our affiliates and nonaffiliates must protect the privacy of data we share in the normal course of business. They are not allowed to give PHI to others without your written OK, except as allowed by law.Potential impact of other applicable lawsHIPAA (the federal privacy law) generally does not preempt, or override, other laws that give people greater privacy protections. As a result, if any state or federal privacy law requires us to provide you with more privacy protections, then we must also follow that law in addition to HIPAA. ComplaintsIf you think we have not protected your privacy, you can file a complaint with us. You may also file a complaint with the Office for Civil Rights in the U.S. Department of Health and Human Services. We will not take action against you for filing a complaint. Contact informationPlease call Customer Service at the phone number printed on your ID card. Repre-sentatives can help you apply your rights, file a complaint or talk with you about privacy issues.Copies and changesYou have the right to get a new copy of this notice at any time. Even if you have agreed to get this notice by electronic means, you still have the right to a paper copy. We reserve the right to change this notice. A revised notice will apply to PHI we already have about you, as well as any PHI we may get in the future. We are required by law to follow the privacy notice that is in effect at this time. We may tell you about any changes to our notice in a number of ways. We may tell you about the changes in a member newsletter or post them on our website. We may also mail you a letter that tells you about any changes.”Breast reconstruction surgery benefits If you ever need a benefit-covered mastec-tomy, we hope it will give you some peace of mind to know that your benefits com-ply with the Women’s Health and Cancer Rights Act of 1998, which provides for:

� Reconstruction of the breast(s) that underwent a covered mastectomy. � Surgery and reconstruction of the other breast to restore a symmetrical ap-

pearance. � Prostheses and coverage for physical complications related to all stages of a

covered mastectomy, including lymphedema.All applicable benefit provisions will apply, including existing deductibles, copayments and/or co-insurance. Contact Customer Service for more information.

• 16 • Cal State Fullerton - Domestic

Optional PPO Dental Plus Plan Includes AD&D, Student Assistance

Program and SpecialOffers Discounts(Student Only)

The PPO Dental Plan is an optional benefit plan, and an additional premium must be paid if you choose this coverage. See your enrollment form for rates. You may enroll online at www.csuhealthlink.com or call (800) 853-5899.This PPO Dental Plan (a Preferred Provider Organization plan from Anthem Blue Cross Life and Health) provides you with the freedom to select virtually any licensed dentist. This dental plan also includes Accidental Death & Dismemberment benefits, as well as, access to the online student assistance program and SpecialOffers discounts. You are responsible for the plan year deductible, the Plan’s coinsurance for covered services provided by participating dentists, and any amount greater than the maximum payment amount shown in the Reimbursement Schedule for covered services provided by non-participating dentists. A list of covered services and the maximum payment amounts for non-participating dentists are available by calling (800) 627-0004.

PARTICIPATING & NON-PARTICIPATING DENTISTIf you choose a Plan participating dentist, you can take advantage of negotiated rates. The negotiated rate is the amount a participating dentist agrees to accept as payment in full for covered services. The negotiated rate is usually lower than the participating dentist’s usual charge. By choosing a participating dentist, you will not be responsible for any amount in excess of the negotiated rate for covered services. If you choose a non-participating dentist, a licensed dentist who does not participate in the PPO Dental Plan network, you are not eligible for negotiated rates and your out-of-pocket expenses may be greater. You are responsible for any amount over the maximum payment amount that is shown in the Reimbursement Schedule. You may also be asked to pay your portion of the bill at the time of service and submit claim forms for reimbursement. If you have a particular dentist in mind and he or she is not in the directory, you may call the toll-free Customer Service number on your ID card to see if the dentist has recently joined the network.

BENEFIT WAITING PERIODYou will need to wait six months before you have coverage for simple extractions. However, you are covered immediately for examinations, routine X-rays and fillings.

FILING A CLAIMWhen you use a participating dentist, your participating dentist will submit a claim form for covered dental expenses to Anthem Blue Cross Life and Health. Anthem Blue Cross Life and Health will pay the benefits of the plan directly to your dentist. If your dentist is not in the network, you may have to complete and submit your own claim forms.

PRE-AUTHORIZATIONWhen the anticipated expense for any course of treatment exceeds $350, it is recommended that you submit a request for pre-authorization. If you use a participating dentist, your dentist will submit the authorization form for you. If your dentist is non-participating, you will have to submit a pre-authorization form to your dentist for completion and then send it to Anthem Blue Cross Life and Health for approval.

CONDITIONS OF SERVICEServices must be provided by a licensed dentist and must be for the prevention and treatment of dental disease, defect or injury, and are subject to any Exclusions and Limitations or Benefit Maximums specified under the PPO Dental Plan.

BENEFIT MAXIMUMSDental benefits are limited to a maximum payment for expenses incurred by each insured person during a plan year. Please refer to the amount on the chart below.

CONTINUING COVERAGEAs required by federal law, certain restrictions and conditions apply to the right to continue coverage and are described in your Certificate of Insurance.

Plan Year Deductible $25 per plan year for each insured person for covered services

Annual Maximum Payment $500 per plan year for each insured person

Predetermination of Benefits Charges in excess of $350Covered Services Please refer to the Benefit Schedule.

PPO DENTAL PLAN SCHEDULE OF BENEFITS

The following are the ONLY Covered Services:

COVERED SERVICES IN-NETWORK OUT-OF-NETWORK

Examination* 100% Maximum payment amount.

Routine X-Rays 100% Maximum payment amount.

Regular Cleanings* 100% Maximum payment amount.

Fluoride Application* 100% Maximum payment amount.

Fillings 80% Maximum payment amount.

Simple Extractions** 50% Maximum payment amount.

* Limited to two per year ** After 6 months waiting period Resin fillings in posterior teeth covered as an amalgam benefit. Other limitations and exclusions also apply, please refer to the Certificate of Insurance for a complete list.

ACCIDENTAL DEATH & DISMEMBERMENT

The Insurer will pay the benefit stated below if an Insured Student suffers a covered Injury resulting in any of the losses stated below within 365 days after the date the covered Injury is incurred:

LOSS BENEFITLoss of Life .........................................................100% of the Principal SumLoss of one hand ...................................................50% of the Principal SumLoss of one foot ....................................................50% of the Principal SumLoss of sight of one eye .........................................50% of the Principal SumLoss of more than one of the above losses due to one accident ..........................100% of the Principal Sum

CLASS OF INSURED PRINCIPAL SUMCovered Student ..........................................................................$ 5,000

Please Refer to Enrollment Form for Dental Rates.

Cal State Fullerton - Domestic • 17 •

NOTES

• 18 • Cal State Fullerton - Domestic

This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the Policy #175125 issued to CSURMA The policy is subject to the laws of the state in which it was issued. Coverage may not be available in all states or certain terms may be different if required by state law. Please keep this information as a reference.

CLAIMS ADMINISTERED BY:Claims, Eligibility and Coverage Questions

Anthem Blue Cross Life and Health Insurance Company(800) 888-2108www.anthem.com/ca

TO FIND A DOCTOR OR PROVIDER:Preferred Provider

PPO Prudent Buyer Plan(800) 888-2108www.anthem.com/ca

24-HOUR NURSE ADVICE LINE: 24/7 NurseLine(800) 977-0027

THE POLICY ADMINISTERED BY: Enrollment, Complaints, General Questions

Wells Fargo Insurance Services USA, Inc.Student Insurance DivisionCA License No. 0D0840811017 Cobblerock Drive, Suite 100Rancho Cordova, CA 95670(800) 853-5899 or (916) 231-3399Fax: (916) 231-3398studentinsurance.wellsfargo.comwww.csuhealthlink.com

THE UNDERWRITING COMPANY: Anthem Blue Cross Life and Health Insurance Company

Anthem Blue Cross Life and Health Insurance Company and Anthem Blue Cross are Independent Licenses of the Blue Cross Association. Anthem Blue Cross is the trade name of Blue Cross of California. ® ANTHEM is a registered

trademark. The Blue Cross name and symbol are registered service marks of the Blue Cross Association.

WELLS FARGO INSURANCE SERVICES USA, INC. PRIVACY POLICYWe know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public personal information about our customers or former customers to anyone, except as permitted or required by law. We believe we maintain appropriate physical, electronic and procedural safeguards to ensure the security of your non-public personal information. You may obtain a detailed copy of our privacy policy through your school, or by calling us toll-free at (800) 853-5899 or by visiting us at www.csuhealthlink.com.

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TO ANY PROVIDERThe bearer of this Student Identification Card has purchased Medical Insurance through a program with the University. This card is provided to facilitate admittance into a lawfully operated hospital, other than a government facility, during the period the bearer’s coverage is in force. Benefits are payable to the Insured, but may be assigned upon written request.Possession of this card does not guarantee the bearer’s insurance coverage is in force on the date of presentation. The Company assumes no liability unless benefits are verified in written form by:

Anthem Blue Cross Life and Health Insurance Company21555 Oxnard Street

Woodland Hills, CA 91367(800) 888-2108

Identification CardUnderwritten by: Anthem Blue Cross Life and Health Insurance Company

PRINT NAME

MEMBER ID #

(See temporary ID card instructions on page 13)

Important Phone Numbers On Reverse

2011-2012 Policy #175125Both the effective and termination dates of coverage are at 12:01 A.M.

and are subject to verification by the Administration. (Address on reverse side)

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Wells Fargo Medical ID#

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Underwritten by: Anthem Blue Cross Life and Health Insurance Company 11-CSUFUL-D

Anthem Blue Cross Life and Health Insurance CompanyCAL STATE FULLERTON DOMESTIC STUDENT HEALTH INSURANCE

2011-2012 ENROLLMENT FORMYou may also purchase the insurance plan online at www.csuhealthlink.com

STUDENT’S NAME Last First MI

STUDENT ID # DATE OF BIRTH

U.S. MAILING ADDRESS Street Apt. #

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DO YOU HAVE OTHER INSURANCE? NO YES: INSURANCE COMPANY POLICY #

LIST DEPENDENTS TO BE INSURED BELOW. DEPENDENT COVERAGE IS AVAILABLE ONLY IF THE STUDENT IS ALSO INSURED.DEPENDENTS MUST BE ENROLLED ON THE DATE THE STUDENT IS ENROLLED OR WITHIN 31 DAYS OF A QUALIFYING EVENT.

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2011-2012 Underwritten by Anthem Blue Cross Life and HealthCAL STATE FULLERTON DOMESTIC STUDENT HEALTH INSURANCE ENROLLMENT FORM

OPTIONAL STUDENT DENTAL PLAN (REQUIRES ADDITIONAL PREMIUM)9/1/11 - 9/1/12 9/1/11 - 3/1/12 3/1/12 - 9/1/12

Student Only $ 357 $ 179 $ 179

I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief, it is true and accurate with no omissions or misstatements and I have read and understand the Plan Brochure. My signature below certifies that I have read and understand the Student Health Insurance Plan brochure and agree to accept as applicable to me the terms and conditions stated therein. It also authorizes my school to provide Wells Fargo of California Insurance Services, Inc. with required information necessary in the event of a medical emergency.

SIGNATURE OF STUDENT DATE

REQUIREMENT FOR BINDING ARBITRATION The following provision does not apply to class actions:IF YOU ARE APPLYING FOR COVERAGE, PLEASE NOTE THAT ANTHEM BLUE CROSS AND ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY REQUIRE BINDING ARBITRATION TO SETTLE ALL DISPUTES INCLUDING BUT NOT LIMITED TO DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN OR ANY OTHER ISSUES RELATED TO THE PLAN AND CLAIMS OF MEDICAL MALPRACTICE, IF THE AMOUNT IN DISPUTE EXCEEDS THE JURISDICTIONAL LIMIT OF SMALL CLAIMS COURT. California Health and Safety Code Section 1363.1 and Insurance Code Section 10123.19 require specified disclosures in this regard, including the following notice: “It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.” THIS MEANS THAT YOU AND ANTHEM BLUE CROSS AND/OR ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY ARE WAIVING THE RIGHT TO A JURY TRIAL FOR BOTH MEDICAL MALPRACTICE CLAIMS, AND ANY OTHER DISPUTES INCLUDING DISPUTES RELATING TO THE DELIVERY OF SERVICE UNDER THE PLAN OR ANY OTHER ISSUES RELATED TO THE PLAN.

PLEASE READ CAREFULLY AND SIGN BELOW

PAYMENT METHOD : Check/Money Order MAKE CHECKS PAYABLE TO: Wells Fargo Insurance Services ($25.00 fee for insufficient funds)Credit Card: Visa MasterCard You may also purchase the insurance plan online at www.csuhealthlink.comAccount No.

Expires:

Cardholder’s Name:

MAIL PAYMENT & ENROLLMENT FORM TO: Wells Fargo Insurance Services, 11017 Cobblerock Drive, Suite 100, Rancho Cordova, CA 95670.COVERAGE IS NOT AUTOMATICALLY RENEWED. Coverage will end on the last date specified in the plan you select, unless you enroll to continue insurance for an additional term. Premiums are calculated based on the plan term and will not be pro-rated. It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment or fine. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

PAYMENT IN FULL IS REQUIRED FOR THE TERM PURCHASEDPROGRAM COSTS

ANNUAL8/22/11 - 8/22/12

FALL8/22/11 - 1/22/12

SPRING/SUMMER1/22/12 - 8/22/12

SUMMER6/1/12 - 8/22/12

Enrollment Deadlines 10/7/11 10/7/11 3/18/12 7/1/12Student, age 24 & under* $ 1,925 $ 843 $ 1,078 $ 450Student, age 25-30* $ 2,595 $ 1,143 $ 1,444 $ 614Student, age 31-40* $ 3,548 $1,568 $ 1,980 $ 834Student, age 41-49* $ 4,027 $1,772 $ 2,252 $ 942Student, age 50 & over* $ 8,463 $3,738 $ 4,737 $ 1,980Spouse** $ 6,184 $2,730 $ 3,455 $ 1,432Per Child age 18 & under** $ 3,783 $1,666 $ 2,104 $ 875*Premium is calculated based upon the age of the Covered Person on the date the insurance becomes effective. **Dependent coverage is in addition to student coverage.