| $200,000 per condition maximum benefit |
| Hospital coverage (90% PPO provider) |
| Office Visits coverage (no co-pay on campus, i.e., 90% PPO provider) |
| $3,000 prescription medication with RX card (30-day supply per prescription). $15 copy on and off-campus $25 |
| Surgery coverage, including anesthetist and assistant surgeon (i.e., PPO provider covered at 90%) |
| Emergency room coverage ($50 co-pay *waived if admitted i.e., PPO covered at 90%) |
| Ambulance coverage - Emergency transportation only (i.e., PPO provider covered at 90%) |
| Detoxification Hospitalization benefit for 3 days (i.e., PPO provider covered at 90%) |
| Laboratory coverage (no co-pay on campus, i.e., PPO provider covered at 90%) |
| Radiology coverage (no co-pay on campus, i.e., PPO provider covered at 90%) |
| Physical therapy coverage up to $1000 if post surgical (i.e., PPO provider covered at 90%) |
| Nervous and Mental Conditions Office Visits limited to 40 visits per plan year (for conditions other than those delineated in Assembly Bill 88 (i.e., PPO provider covered at 90%) |
| Repatriation benefit of $7,500 in accordance with federal J-1 visa requirements |
| Medical evacuation benefit of $10,000 in accordance with federal J-1 visa requirements |
| Benefits payable at 100%: at UCR facilities; In-network, payable at 90%; Out-of-network payable at 60%. Network: CFMC, Preferred Provider Organization Network in California and First Health, Preferred Provider Organization Network outside of California |
| $3,000 maximum out-of-pocket expense to insured (including deductible, coinsurance and copays) |
| Extension of benefits ^ 6 months for total disability |
| Basic vision coverage, designated local optometrists |
| Basic dental coverage at UCR Campus Health Dental Clinic |