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Notice: Benefits may vary by state or coverage may not be available in all states. The plan is notavailable in Massachusetts, Montana, New Hampshire, New York, New Jersey, Oregon, Puerto Rico,Vermont and Washington Basic Option for Students and their Dependents The Enhanced Plan description begins on page 15 Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Choice of Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits - Basic Plan (2008-201824-2) . . . . . . . . . . . . . . . . .3UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Disclosure of Limited Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Mndated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Benefits for Maternity and Post Delivery Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Benefits for Contraceptive Drug Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Additional Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . . . . .12Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Privacy PolicyWe know that your privacy is important to you and we strive to protect the confidentiality of yournonpublic personal information. We do not disclose any nonpublic personal information about ourcustomers or former customers to anyone, except as permitted or required by law. We believe wemaintain appropriate physical, electronic and procedural safeguards to ensure the security of yournonpublic personal information. You may obtain a detailed copy of our privacy policy by calling ustoll-free at 1-866-607-4427 or by visiting us at www.uhcsr.com.
EligibilityAll students who are in attendance full time in any degree program and all interns are required toparticipate in this insurance Plan, or the Enhanced Plan (2008-201824-1) at registration unlessproof of comparable coverage is furnished. All other students may participate in the plan on avoluntary basis.
Students must actively attend classes for at least the first 31 days after the date for which coverageis purchased. Home study, correspondence, Internet, and television (tv) courses do not fulfill theEligibility requirements that the student actively attend classes. The Company maintains its right toinvestigate eligibility or student status and attendance records to verify that the policy eligibilityrequirements have been met. If the Company discovers the Eligibility requirements have not beenmet, its only obligation is refund of premium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are thespouse and unmarried children under 19 years to 23 if enrolled as a full-time student in anyaccredited school, financially dependent on the Insured. Dependent Eligibility expires concurrentlywith that of the Insured student.
Choice of PlanEach eligible student has a choice of one of the benefit Plans. Plan 1 (Enhanced Option - 201824-1) has higher benefits than Plan 2 (Basic Option - 201824-2) and it has a higher premium. Makeyour selection carefully, you cannot upgrade or downgrade coverage after the initial purchase of thePlan for the policy year. Please be aware that if you choose to upgrade coverage in any subsequentpolicy year, a new Pre-Existing Condition exclusion and waiting period will apply.
Effective and Termination DatesThe Master Policy on file at the school becomes effective September 1, 2008. The individualstudent’s coverage becomes effective on the first day of the period for which premium is paid orthe date the enrollment form and full premium are received by the Company (or its authorizedrepresentative), whichever is later. The Master Policy terminates August 31, 2009. Coverageterminates on that date or at the end of the period through which premium is paid, whichever isearlier. Dependent coverage will not be effective prior to that of the Insured student or extendbeyond that of the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces. The Policy is a Non-Renewable One Year Term Policy.
Extension of Benefits After TerminationThe coverage provided under the Policy ceases on the Termination Date. However, if an Insured isHospital Confined on the Termination Date from a covered Injury or Sickness for which benefitswere paid before the Termination Date, Covered Medical Expenses for such Injury or Sickness willcontinue to be paid as long as the condition continues but not to exceed 90 days after theTermination Date.
The total payments made in respect of the Insured for such condition both before and after theTermination Date will never exceed the Maximum Benefit. After this “Extension of Benefits”provision has been exhausted, all benefits cease to exist, and under no circumstances will furtherpayments be made.
Pre-Admission NotificationAvidyn should be notified of all Hospital Confinements prior to admission.
PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: Physician or Hospital should telephone 1-877-295-0720 at least five working days prior to the NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient’s representative, Physician or Hospital should telephone 1-877-295-0720 within two working days of the admission, or as soon as possible after the patient becomes lucid and able to communicate, to provide the notification of any admission due to Medical Emergency.
Avidyn is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m. C.S.T., Monday through Friday. Calls may be left on the Customer Service Department's voice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise payable under the policy; however, pre-notification is not a guarantee that benefits will be paid.
SCHEDULE OF BASIC MEDICAL EXPENSE BENEFITS Up to $100,000 Maximum Benefit for each Injury or Sickness Up to $50,000 for Maximum Benefit for Dependents for each Injury or Sickness Deductible Preferred Provider $350 per Insured Person, per Policy Year Deductible Out-of-Network $600 Insured Person, per Policy Year The Preferred Provider for this plan is UnitedHealthcare Options PPO.
The Policy provides benefits for the Usual and Customary Charges incurred by an Insured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of $100,000 for students and $50,000 for Dependents.
If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. If the Covered Medical Expense is incurred due to a Medical Emergency, benefits will be paid at the Preferred Provider level of benefits. In all other situations, reduced or lower benefits will be provided when an Out-of-Network provider is used.
Benefits include one routine physical exam per Policy Year.
Please be aware that if you choose to change policies to upgrade coverage in any subsequent policy year, a new Pre-existing Condition exclusion will apply.
All benefit maximums are combined Preferred Provider and Out-of-Network, unless noted below.
Benefits will be paid up to the Maximum Benefit for each service as scheduled below. Covered PA = Preferred Allowance U&C = Usual & Customary Charges Max = Maximum Hospital Expense, $3,000 aggregate 80% of PA maximum per day. Daily semi-private room rate and general nursing care provided by the Hospital.
Hospital Miscellaneous expenses such as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take home drugs) or medicines, therapeutic services, and supplies. In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge.
Routine Newborn Care, while Hospital Paid as any other Sickness / See Benefits for Confined; and routine nursery care provided immediately after birth. (See page 8)Physiotherapy Paid under Hospital Paid under HospitalExpense Surgeon’s Fees, $2,000 maximum. In 80% of PA accordance with data provided by Ingenix. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedures.
Assistant Surgeon Anesthetist, professional services administered 20% of Surgery in connection with inpatient surgery.
Registered Nurse’s Services,private duty nursing care. 80% of PA Pre-Admission Testing, payable within 3 Paid under Hospital Paid under Hosptial Physician’s Visits, benefits are limited to one 80% of PA visit per day. Benefits do not apply when relatedto surgery.
Psychotherapy, benefits are limited to one Paid as any other Paid as any other Surgeon’s Fees, $2,000 maximum. In 80% of PA accordance with data provided by Ingenix. If twoor more procedures are performed through thesame incision or in immediate succession at thesame operative session, the maximum amountpaid will not exceed 50% of the second procedureand 50% of all subsequent procedures.
Day Surgery Miscellaneous, $3,000 max. 80% of PA Related to scheduled surgery performed in a Hospital, including the cost of the operating room; laboratory tests and x-ray examinations, including professional fees; anesthesia; drugs or medicines; and supplies. Usual and CustomaryCharges for Day Surgery Miscellaneous are basedon the Outpatient Surgical Facility Charge Index.
Anesthetist, professional services administered 20% of Surgery in connection with outpatient surgery.
Outpatient Miscellaneous (Misc.) Benefit, 80% of PA designated under Outpatient Misc. Benefit.
Physician’s Visits, benefits are limited to one Paid under Outpatient Paid under Outpatient visit per day and do not apply when related to Misc. Benefit surgery or Physiotherapy.
Physiotherapy, benefits are limited to one Paid under Outpatient Paid under Outpatient additional limitations.
Medical Emergency Expenses, use of the Paid under Outpatient Paid under Outpatient emergency room and supplies. Treatment must Misc. Benefit be rendered within 72 hours from time of Injuryor first onset of Sickness.
Diagnostic X-ray Services Paid under Outpatient Paid under OutpatientMisc. Benefit Paid under Outpatient Paid under OutpatientMisc. Benefit Paid under Outpatient Paid under OutpatientMisc. Benefit Tests & Procedures, diagnostic services and Paid under Outpatient Paid under Outpatient medical procedures performed by a Physician, Misc. Benefit other than Physician’s Visits, Physiotherapy, x-rays and lab procedures.
Prescription Drugs, $1,500 maximum per United Healthcare Policy Year. Prescription Inhalants for persons Network Pharmacy / suffering from asthma or other life threatening $15 copay for Tier 1 bronchial ailments are not limited by restrictions prescription / $40 on the number of days before an inhaler may be copay for Tier 2 obtained when ordered or prescribed by the prescriptions / $60attending Physician.
copay for Tier 3prescriptions / up to a31 day supply Psychotherapy, $2,500 maximum. 50% of 80% of PA U&C incurred for counseling. Including all relatedand ancillary charges incurred as a result of aMental & Nervous Disorder.
Ambulance Services, $300 maximum. The 80% of U&C / $100 80% of U&C / $100 copay / Deductible is per transportation (and is in copay lieu of the policy Deductible).
Durable Medical Equipment, $300 max. A 80% of U&C written prescription must accompany the claimwhen submitted. Replacement is not covered.
Dental Treatment, $100 per tooth / $500 per 80% of U&C Injury max for treatment made necessary byInjury to Sound, Natural Teeth. $100 max fornon-injury related dental work. Does not includepreventative care.
Alcoholism Paid as any other Paid as any otherSickness / See Benefits Sickness / See Benefitsfor Maternity and Post for Maternity and PostDelivery Care Routine Physical Exams, $500 maximum 80% of PA / $100 copay 60% of U&C / $100 per Policy Year. The copay / Deductible is in lieu per visit UnitedHealthcare Network Pharmacy BenefitsBenefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL) whendispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supply limits (up to 31days) and copayments that vary depending on which tier of the PDL the outpatient drug is listed.
There are a few Prescription Drugs that require your Physician to notify us to verify their use iscovered within your benefit.
You are responsible for paying the applicable copayments. Your copayment is determined by thetier to which the Prescription Drug is assigned on the PDL. Tier status may change periodically andwithout prior notice to you. Please access www.uhcsr.com or call 1-866-607-4427 or the customerservice number on your ID card for the most up-to-date tier status.
$15 per prescription order or refill for a Tier 1 Prescription Drug $40 per prescription order or refill for a Tier 2 Prescription Drug $60 per prescription order or refill for a Tier 3 Prescription Drug Your maximum allowed benefit is $1,500 per Policy Year.
Please present your ID card to the network pharmacy when the prescription is filled.
If you do not present the card, you will need to pay the prescription and then submit areimbursement form for prescriptions filled at a network pharmacy along with the paid receipt inorder to be reimbursed. To obtain reimbursement forms please visit www.uhcsr.com and log in toyour online account or call 1-877-417-7345.
In addition to the policy Exclusions and Limitations, the following Exclusions apply to NetworkPharmacy Benefits: 1. Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the supply limit.
2. Experimental or Investigational Services or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by the Company to beexperimental, investigational or unproven.
3. Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration and requires a Prescription Order or Refill.
Compounded drugs that are available as a similar commercially available Prescription DrugProduct. (Compounded drugs that contain at least one ingredient that requires a PrescriptionOrder or Refill are assigned to Tier-3 . Any prescription medication that must be compoundedinto its final form by the dispensing pharmacist, Physician, or other health care provider.
4. Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless the Company has designated the over-the countermedication as eligible for coverage as if it were a Prescription Drug Product and it is obtainedwith a Prescription Order or Refill from a Physician. Prescription Drug Products that areavailable in over-the-counter form or comprised of components that re available in over-the-counter form or equivalent. Certain Prescription Drug Products that the Company hasdetermined are Therapeutically Equivalent to an over-the-counter drug. Such determinationsmay be made up to six times during a calendar year, and the Company may decide at anytime to reinstate Benefits for a Prescription Drug Product that was previously excluded underthis provision.
5. Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, even when used for the treatment of Sickness or Injury.
Prescription Drug or Prescription Drug Product means a medication, product or device thathas been approved by the U.S. Food and Drug Administration and that can, under federal or statelaw, be dispensed only pursuant to a Prescription Order or Refill. A Prescription Drug Productincludes a medication that, due to its characteristics, is appropriate for self-administration oradministration by a non-skilled caregiver. For the purpose of the benefits under the policy, thisdefinition includes insulin.
Prescription Drug List means a list that categorizes into tiers medications, products or devicesthat have been approved by the U.S. Food and Drug Administration. This list is subject to theCompany’s periodic review and modification (generally quarterly, but no more than six times percalendar year). The Insured may determine to which tier a particular Prescription Drug Product hasbeen assigned through the Internet at www.uhcsr.com or call Customer Service 1-866-607-4427.
Preferred Provider Information“Preferred Providers” are the Physicians, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. Preferred Providers in the localschool area are: UnitedHealthcare Options PPO The availability of specific providers is subject to change without notice. Insured’s should alwaysconfirm that a Preferred Provider is participating at the time services are required by calling theCompany at 1-866-607-4427 and/or by asking the provider when making an appointment for services.
“Preferred Allowance” means the amount a Preferred Provider will accept as payment in full “Out of Network” providers have not agreed to any prearranged fee schedules. Insured’s may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurancepayment are the Insured’s responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible. TheDeductible must be satisfied before benefits are paid. The Company will pay according to thebenefit limits in the Schedule of Benefits.
Inpatient Hospital ExpensesPREFERRED HOSPITALS - Eligible inpatient Hospital expenses at a Preferred Hospital will be paid at 80%, up to any limits specified in the Schedule of Benefits. Call 1-866-607-4427 for informationabout Preferred Hospitals.
OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a Preferred Provider, eligible inpatient Hospital expenses will be paid according to the benefit limits in the Schedule ofBenefits.
Outpatient Hospital ExpensesPreferred Providers may discount bills for outpatient Hospital expenses. Benefits are paid accordingto the Schedule of Benefits. Insureds are responsible for any amounts that exceed the benefitsshown in the Schedule, up to the Preferred Allowance.
Professional & Other ExpensesBenefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO will be paid at80% of Preferred Allowance up to any limits specified in the Schedule of Benefits. All otherproviders will be paid according to the benefit limits in the Schedule of Benefits.
Disclosure of Limited BenefitWARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED.
You should be aware that when you elect to utilize the services of a non-participating provider fora covered service in non-emergency situations, benefit payments to such non-participating providerare not based upon the amount billed. The basis of your benefit payment will be determinedaccording to your policy’s fee schedule, usual and customary charge (which is determined bycomparing charges for similar services adjusted to the geographical area where the services areperformed), or other method as defined by the policy.
YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICYAFTER THE PLAN HAS PAID ITS REQUIRED PORTION.
Non-participating providers may bill members for any amount up to the billed charge after the planhas paid its portion of the bill. Participating providers have agreed to accept discounted paymentsfor services with no additional billing to the member other than co-insurance and deductibleamounts. You may obtain further information about the participating status of professionalproviders and information on out-of-pocket expenses by calling the toll free telephone number onyour identification card.
Maternity TestingThis policy does not cover routine, preventive or screening examinations or testing unless MedicalNecessity is established based on medical records. The following maternity routine tests andscreening exams will be considered, if all other policy provisions have been met. This includes apregnancy test, CBC, Hepatitis B Surface Antigen, Rubella Screen, Syphilis Screen, Chlamydia, HIV,Gonorrhea, Toxoplasmosis, Blood Typing ABO, RH Blood Antibody Screen, Urinalysis, Urine BacterialCulture, Microbial Nucleic Acid Probe, AFP Blood Screening, Pap Smear, and Glucose Challenge Test(at 24-28 weeks gestation). One Ultrasound will be considered in every pregnancy, withoutadditional diagnosis. Any subsequent ultrasounds can be considered if a claim is submitted withthe Pregnancy Record and Ultrasound report that establishes Medical Necessity. Additionally, thefollowing tests will be considered for women over 35 years of age: Amniocentesis/AFP Screeningand Chromosome Testing. Fetal Stress/Non-Stress tests are payable. Pre-natal vitamins are notcovered. For additional information regarding Maternity Testing, please call the Company at 1-866-607-4427.
Excess ProvisionEven if you have other insurance, the Plan may cover unpaid balances, Deductibles and pay thoseeligible medical expenses not covered by other insurance.
Benefits will be paid on the unpaid balances after your other insurance has paid. No benefits arepayable for any expense incurred for Injury or Sickness which has been paid or is payable by othervalid and collectible insurance.
However, this Excess Provision will not be applied to the first $100 of medical expenses incurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due to penaltiesimposed on the Insured for failing to comply with Policy provisions or requirements.
Important: The Excess Provision has no practical application if you do not have other medicalinsurance or if your other insurance does not cover the loss.
BENEFITS FOR MATERNITY AND POST DELIVERY CARE Benefits will be paid the same as any other Sickness for the Insured mother and Newborn Infant forMaternity and Post Delivery Care. Benefits will be provided for inpatient stay following birth for aminimum of: 48 hours following an uncomplicated vaginal delivery; and 96 hours following an uncomplicated delivery by caesarean section.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits will be paid the same as any other Sickness for all Outpatient Contraceptive Services andall outpatient contraceptive drugs and devices approved by the United States Food and DrugAdministration. Outpatient Contraceptive Service means consultations, examinations, procedures,and medical services, provided on an outpatient basis and related to the use of contraceptivemethods (including natural family planning) to prevent an unintended pregnancy.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Additional Mandated BenefitsBenefits are provided as mandated by the state of Illinois for Benefits for Mammography, ProstheticDevice and Reconstructive Surgery, Cervical Cancer Screening Test, Prostate Cancer Screening,Diabetes, Colorectal Cancer Test, Dental Care Services and Bone Mass Measurement/Osteoporosis.
A detail of these benefits may be found in the Master Policy on file at the Seminary.
DefinitionsINJURY means bodily injury which is: 1) the direct cause of loss, independent of disease cause of loss, independent of disease or bodily infirmity; 2) a source of loss; 3) treated by a Physician within30 days after the date of accident; and 4) sustained while the Insured Person is covered under thispolicy. All injuries sustained in one accident, including all related conditions and recurrentsymptoms of these injuries will be considered one injury. Covered Medical Expenses incurred as aresult of an injury that occurred prior to this policy’s Effective Date will be considered a Sicknessunder this policy.
PRE-EXISTING CONDITION means: 1) the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 12 months immediatelyprior to the Insured's Effective Date under the policy; or, 2) any condition which originates, isdiagnosed, treated or recommended for treatment within the 12 months immediately prior to theInsured's Effective Date under the policy.
SICKNESS means sickness or disease of the Insured Person which causes loss, and first manifests itself while the Insured Person is covered under this policy. All related conditions and recurrentsymptoms of the same or a similar condition will be considered one sickness. Covered MedicalExpenses incurred as a result of an Injury that occurred prior to this policy’s Effective Date will beconsidered a sickness under this policy.
USUAL AND CUSTOMARY CHARGES means a reasonable charge which is: 1) usual and customary when compared with the charges made for similar services and supplies; and 2) madeto persons having similar medical conditions in the locality of the Policyholder. No payment will bemade under this policy for any expenses incurred which in the judgment of the Company are inexcess of Usual and Customary Charges. The definition of Usual and Customary Charges does notapply to charges made by Preferred Providers.
Exclusions and LimitationsNo benefits will be paid for: a) loss or expense caused by or resulting from; or b) treatment, servicesor supplies for, at, or related to: 1. Acne; acupuncture; allergy, including allergy testing; 2. Addiction, such as: nicotine addiction and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, shopping, working and religious; codependency; 3. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy, learning disabilities, behavioral problems, parent-child problems, attention deficit disorder, conceptual handicap,developmental delay or disorder or mental retardation, except as specifically provided in thepolicy; 5. Congenital conditions, except as specifically provided for Newborn or adopted Infants; 6. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children; 7. Removal of warts, non-malignant moles and lesions; 8. Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or custodial care; extended carein treatment or substance abuse facilities for domiciliary or custodial care; 9. Dental treatment, except as specifically provided in the Schedule of Benefits; 10.Elective Surgery or Elective Treatment; 12.Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defectsand problems; except when due to a disease process; 13.Foot care including: flat foot conditions, supportive devices for the foot, subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails, fallenarches, weak feet, chronic foot strain, and symptomatic complaints of the feet; 14.Hearing examinations or hearing aids; or other treatment for hearing defects and problems.
"Hearing defects" means any physical defect of the ear which does or can impair normalhearing, apart from the disease process; 15.Immunizations, preventive medicines or vaccines, except where required for treatment of a 16.Injury cased by or resulting from the addiction to or use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs or medicines that are not taken in therecommended dosage or for the purpose prescribed by the Insured Person's Physician;Intoxication is defined and determined by the laws of the state where the loss or cause ofthe loss was incurred.
17.Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 18.Injury sustained while (a) participating in any club, intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as aparticipant; or (c) while participating in any practice or conditioning program for such sport,contest or competition; 19.Organ transplants, only those considered experimental are excluded; 20.Outpatient Physiotherapy benefits are payable only for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or2) within the 30 days immediately following the attending Physician's release forrehabilitation.
21.Participation in a riot or civil disorder; commission of or attempt to commit a felony; or 22.Pre-existing Conditions, except for individuals who have been continuously insured under the school's student insurance policy for at least 12 consecutive months; 23.Prescription Drugs, services or supplies as follows: Therapeutic devices or appliances, including: hypodermic needles, syringes, supportgarments and other non-medical substances, regardless of intended use except asspecifically provided in the Benefits For Diabetes; Immunization agents, biological sera, blood or blood products administered on anoutpatient basis; Drugs labeled, “Caution - limited by federal law to investigational use” or experimentaldrugs; Drugs used to treat or cure baldness;anabolic steroids used for body building; Anorectics - drugs used for the purpose of weight control; Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid,Profasi, Metrodin, Serophene, or Viagra; Growth hormones, except when a Medical Necessity; or Refills in excess of the number specified or dispensed after one (1) year of date of theprescription.
24.Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose orwith the intent of inducing conception; premarital examinations; impotence, organic orotherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal of sterilizationprocedures; 25.Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; 26.Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 27.Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal septum, includingsubmucous resection and/or other surgical correction thereof; nasal and sinus surgery,except for treatment of chronic purulent sinusitis; 29.Suicide or attempted suicide while sane or insane (including drug overdose); or intentionally 30.Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 31.Treatment in a Government hospital, unless there is a legal obligation for the Insured Person 32.War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered); and 33.Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such as bulimia andanorexia. Exception: benefits will be provided for the treatment of dehydration andelectrolyte imbalance associated with eating disorders.
Collegiate Assistance ProgramInsured Students have access to nurse advice, health information, and counseling support 24 hoursa day, 7 days a week by dialing 877-643-5130. Collegiate Assistance Program is staffed byRegistered Nurses and Licensed Clinicians who can help students determine if they need to seekmedical care, need legal/financial advice or may need to talk to someone about everyday issues thatcan be overwhelming.
Scholastic Emergency Services: Global Emergency Medical AssistanceIf you are a student insured with this insurance plan, you and your insured spouse and minorchild(ren) are eligible for Scholastic Emergency Services (SES). The requirements to receive theseservices are as follows: International Students, insured spouse and insured minor child(ren): You are eligible to receive SESworldwide, except in your home country.
Domestic Students, insured spouse and insured minor child(ren): You are eligible for SES when 100miles or more away from your campus address and 100 miles or more away from your permanenthome address or while participating in a Study Abroad program.
SES includes Emergency Medical Evacuation and Return of Mortal Remains that meet the U.S. StateDepartment requirements. The Emergency Medical Evacuation services are not meant to be used inlieu of or replace local emergency services such as an ambulance requested through emergency 911telephone assistance. All SES services must be arranged and provided by SES, any services notarranged by SES will not be considered for payment.
* Medical Consultation, Evaluation and Referrals * Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Due to a Medical Incident Please log into your online account www.uhcsr.com for additional information on SES GlobalEmergency Assistance Services, including service descriptions and program exclusions andlimitations.
(877) 488-9833 Toll-free within the United States (609) 452-8570 Collect outside the United States Services are also accessible via e-mail at medservices@assistamerica.com.
When calling the SES Operations Center, please be prepared to provide:1.
Caller's name, telephone and (if possible) fax number, and relationship to the patient Patient's name, age, sex, and Reference Number Name, location, and telephone number of hospital, if applicable Name and telephone number of the attending physician Information of where the physician can be immediately reached SES is not travel or medical insurance but a service provider for emergency medical assistance services. Allmedical costs incurred should be submitted to your health plan and are subject to the policy limits of yourhealth coverage. All assistance services must be arranged and provided by SES. Claims for reimbursementof services not provided by SES will not be accepted. Please refer to your SES brochure for Program Guidelinesas well as limitations and exclusions pertaining to the SES program.
Online Access to Account InformationUnitedHealthcare StudentResources insureds have online access to claims status, EOBs,correspondence and coverage information via My Account at www.uhcsr.com. Insureds can alsoprint a temporary ID card, request a replacement ID card and locate network providers from MyAccount.
If you don’t already have an online account, simply select the “Create an Account” link from thehome page at www.uhcsr.com. Follow the simple, onscreen directions to establish an online accountin minutes. Note that you will need your 7-digit insurance ID number to create an online account.
If you already have an online account, just log in from www.uhcsr.com to access your accountinformation.
Claim ProcedureIn the event of Injury or Sickness, students should: Report to the Health Service or Infirmary for treatment or referral, or when not in school, totheir Physician or Hospital.
Mail to the address below all medical and hospital bills along with the patient's name andinsured student's name, address, social security number and name of the University underwhich the student is insured. A Company claim form is not required for filing a claim.
File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received bythe Company within 90 days of service. Bills submitted after one year will not be consideredfor payment except in the absence of legal capacity.
The Plan is Underwritten by:United HealthCare Insurance Company Submit all Claims or Inquiries to:UnitedHealthcare StudentResourcesP.O. Box 809025Dallas, Texas 75380-90251-866-607-4427 Please keep this Brochure as a general summary of the insurance. The Master Policy on file at theUniversity contains all of the provisions, limitations, exclusions and qualifications of your insurancebenefits, some of which may not be included in this Brochure. The Master Policy is the contract andwill govern and control payment of benefits.
The Basic Plan based on Policy #: 2008-201824-2 The Basic Plan description begins on page 1 Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Extension of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Schedule of Basic Medical Expense Benefits - Enhanced Plan (2008-201824-1) . . . . . . . . .18UnitedHealthcare Network Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Disclosure of Limited Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Optional Major Medical Benefits (Student Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Mandated Benefits: Benefits for Maternity Care and Post Delivery Care . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Benefits for Contraceptive Drug Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Additional Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . . . . . . . .28Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Privacy PolicyWe know that your privacy is important to you and we strive to protect the confidentiality of yournonpublic personal information. We do not disclose any nonpublic personal information about ourcustomers or former customers to anyone, except as permitted or required by law. We believe wemaintain appropriate physical, electronic and procedural safeguards to ensure the security of yournonpublic personal information. You may obtain a detailed copy of our privacy policy by calling ustoll-free at 1-866-607-4427 or by visiting us at www.uhcsr.com.
EligibilityAll students who are in attendance full time in any degree program and all interns are required toparticipate in this insurance Plan, or the Basic Plan (2008-201824-2) at registration unless proof ofcomparable coverage is furnished. All other students may participate in the plan on a voluntarybasis.
All insured students may purchase Major Medical coverage on an optional basis.
Students must actively attend classes for at least the first 31 days after the date for which coverageis purchased. Home study, correspondence, Internet, and television (tv) courses do not fulfill theEligibility requirements that the student actively attend classes. The Company maintains its right toinvestigate eligibility or student status and attendance records to verify that the policy eligibilityrequirements have been met. If the Company discovers the Eligibility requirements have not beenmet, its only obligation is refund of premium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are thespouse and unmarried children under 19 years to 23 if enrolled as a full-time student in anyaccredited school, financially dependent on the Insured. Dependent Eligibility expires concurrentlywith that of the Insured student.
Optional coverages may only be purchased simultaneously and in conjunction with the purchase ofBasic coverage at the time of initial enrollment in the Plan.
Choice of PlanEach eligible student has a choice of one of the benefit Plans. Plan 1 (Enhanced Option - 201824-1) has higher benefits than Plan 2 (Basic Option - 201824-2) and it has a higher premium. Makeyour selection carefully, you cannot upgrade or downgrade coverage after the initial purchase of thePlan for the policy year. Please be aware that if you choose to upgrade coverage in any subsequentpolicy year, a new Pre-Existing Condition exclusion and waiting period will apply.
Effective and Termination DatesThe Master Policy on file at the school becomes effective September 1, 2008. The individualstudent’s coverage becomes effective on the first day of the period for which premium is paid orthe date the enrollment form and full premium are received by the Company (or its authorizedrepresentative), whichever is later. The Master Policy terminates August 31, 2009. Coverageterminates on that date or at the end of the period through which premium is paid, whichever isearlier. Dependent coverage will not be effective prior to that of the Insured student or extendbeyond that of the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces. The Policy is a Non-Renewable One Year Term Policy.
Extension of Benefits After TerminationThe coverage provided under the Policy ceases on the Termination Date. However, if an Insured isHospital Confined on the Termination Date from a covered Injury or Sickness for which benefitswere paid before the Termination Date, Covered Medical Expenses for such Injury or Sickness willcontinue to be paid as long as the condition continues but not to exceed 90 days after theTermination Date.
The total payments made in respect of the Insured for such condition both before and after theTermination Date will never exceed the Maximum Benefit. After this “Extension of Benefits”provision has been exhausted, all benefits cease to exist, and under no circumstances will furtherpayments be made.
Pre-Admission NotificationAvidyn should be notified of all Hospital Confinements prior to admission.
PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: Physician or Hospital should telephone 1-877-295-0720 at least five working days prior to the NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient’s representative, Physician or Hospital should telephone 1-877-295-0720 within two working days of the admission, or as soon as possible after the patient becomes lucid and able to communicate, to provide the notification of any admission due to Medical Emergency.
Avidyn is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00 p.m. C.S.T., Monday through Friday. Calls may be left on the Customer Service Department's voice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise payable under the policy; however, pre-notification is not a guarantee that benefits will be paid.
SCHEDULE OF BASIC MEDICAL EXPENSE BENEFITS Up to $100,000 Maximum Benefit for each Injury or Sickness Deductible Preferred Provider $250 per Insured Person, per Policy Year Deductible Out-of-Network $500 Insured Person, per Policy Year Up to $50,000 Maximum Benefit for Dependents for each Injury or Sickness Dependent Deductible $100 for each Injury or Sickness The Preferred Provider for this plan is UnitedHealthcare Options PPO.
The Policy provides benefits for the Usual and Customary Charges incurred by an Insured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of $100,000 for each Injury or Sickness for students and $50,000 for Dependents.
If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. If the Covered Medical Expense is incurred due to a Medical Emergency, benefits will be paid at the Preferred Provider level of benefits. In all other situations, reduced or lower benefits will be provided when an Out-of-Network provider is used.
Benefits include one routine physical exam per Policy Year.
All benefit maximums are combined Preferred Provider and Out-of-Network, unless noted below.
Benefits will be paid up to the Maximum Benefit for each service as scheduled below. Covered PA = Preferred Allowance U&C = Usual & Customary Charges Max = Maximum Hospital Expense, daily semi-private room rate 80% of PA Hospital. Hospital Miscellaneous expenses such as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take home drugs) or medicines, therapeutic services, and supplies. In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge.
Routine Newborn Care, while Hospital Paid as any other Sickness / See Benefits for Confined; and routine nursery care provided immediately after birth. (See page 24)Physiotherapy Paid under Hospital Paid under HospitalExpense Surgeon’s Fees, in accordance with data 80% of PA provided by Ingenix. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 50% of all subsequent procedures.
Assistant Surgeon Anesthetist, professional services administered 20% of Surgery in connection with inpatient surgery.
Registered Nurse’s Services,private duty nursing care. 80% of PA Pre-Admission Testing, payable within 3 Paid under Hospital Paid under Hosptial Physician’s Visits, benefits are limited to one 80% of PA visit per day. Benefits do not apply when relatedto surgery.
Psychotherapy, benefits are limited to one Paid as any other Paid as any other Surgeon’s Fees, in accordance with data 80% of PA provided by Ingenix. If two or more procedures areperformed through the same incision or inimmediate succession at the same operativesession, the maximum amount paid will notexceed 50% of the second procedure and 50% ofall subsequent procedures.
Day Surgery Miscellaneous, related to 80% of PA scheduled surgery performed in a Hospital, including the cost of the operating room; including professional fees; anesthesia; drugs or medicines; and supplies. Usual and CustomaryCharges for Day Surgery Miscellaneous are basedon the Outpatient Surgical Facility Charge Index.
Assistant Surgeon Anesthetist, professional services administered 20% of Surgery in connection with outpatient surgery.
Physician’s Visits, benefits are limited to one 80% of PA visit per day and do not apply when related tosurgery or Physiotherapy.
Physiotherapy, benefits are limited to one visit 80% of PA per day.
Medical Emergency Expenses, use of the 80% of PA / $100 copay 80% of U&C / $100 emergency room and supplies. Treatment must per visit be rendered within 72 hours from time of Injuryor first onset of Sickness. The copay / Deductibleis in addition to the Policy Deductible.
Tests & Procedures, diagnostic services and 80% of PA medical procedures performed by a Physician,other than Physician’s Visits, Physiotherapy, x-rays and lab procedures.
Prescription Drugs, $3,000 maximum per United Healthcare Policy Year. Prescription Inhalants for persons Network Pharmacy / suffering from asthma or other life threatening $15 copay for Tier 1 bronchial ailments are not limited by restrictions prescription / $25 on the number of days before an inhaler may be copay for Tier 2 obtained when ordered or prescribed by the prescriptions / $40attending Physician.
copay for Tier 3prescriptions / up to a31 day supply Psychotherapy, $2,500 maximum. 75% of 80% of PA U&C incurred for counseling. Including all relatedand ancillary charges incurred as a result of aMental & Nervous Disorder.
Durable Medical Equipment, $300 max. A 80% of U&C written prescription must accompany the claimwhen submitted. Replacement is not covered.
Consultant Physician Fees, when requested 80% of PA and approved by the attending Physician.
Dental Treatment, $100 per tooth / $500 80% of U&C necessary by Injury to Sound, Natural Teeth.
$100 maximum for non-injury related dental work. Does not include preventative care.
Alcoholism Paid as any other Sickness / See Benefits for Maternity and Post Delivery Care (See page 24) Up to age 2.
Complications of Pregnancy Routine Physical Exams, $500 max per Policy 80% of PA / $25 copay 60% of U&C / $25 Year. The $25 copay / Deductible is in lieu of the per visit UnitedHealthcare Network Pharmacy BenefitsBenefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL) whendispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supply limits (up to 31days) and copayments that vary depending on which tier of the PDL the outpatient drug is listed.
There are a few Prescription Drugs that require your Physician to notify us to verify their use iscovered within your benefit.
You are responsible for paying the applicable copayments. Your copayment is determined by thetier to which the Prescription Drug is assigned on the PDL. Tier status may change periodically andwithout prior notice to you. Please access www.uhcsr.com or call 1-866-607-4427 or the customerservice number on your ID card for the most up-to-date tier status.
$15 per prescription order or refill for a Tier 1 Prescription Drug$25 per prescription order or refill for a Tier 2 Prescription Drug$40 per prescription order or refill for a Tier 3 Prescription DrugYour maximum allowed benefit is $3,000 per Policy Year.
Please present your ID card to the network pharmacy when the prescription is filled. If you do notuse a network pharmacy, you will be responsible for paying the full cost for the prescription.
If you do not present the card, you will need to pay the prescription and then submit areimbursement form for prescriptions filled at a network pharmacy along with the paid receipt inorder to be reimbursed. To obtain reimbursement forms please visit www.uhcsr.com and log in toyour online account or call 1-877-417-7345.
In addition to the policy Exclusions and Limitations, the following Exclusions apply to NetworkPharmacy Benefits: 1. Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the supply limit.
2. Experimental or Investigational Services or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by the Company to beexperimental, investigational or unproven.
3. Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration and requires a Prescription Order or Refill.
Compounded drugs that are available as a similar commercially available Prescription DrugProduct. (Compounded drugs that contain at least one ingredient that requires a PrescriptionOrder or Refill are assigned to Tier-3 . Any prescription medication that must be compoundedinto its final form by the dispensing pharmacist, Physician, or other health care provider.) 4. Drugs available over-the-counter that do not require a Prescription Order or Refill by federal or state law before being dispensed, unless the Company has designated the over-the countermedication as eligible for coverage as if it were a Prescription Drug Product and it is obtainedwith a Prescription Order or Refill from a Physician. Prescription Drug Products that areavailable in over-the-counter form or comprised of components that re available in over-the-counter form or equivalent. Certain Prescription Drug Products that the Company hasdetermined are Therapeutically Equivalent to an over-the-counter drug. Such determinationsmay be made up to six times during a calendar year, and the Company may decide at anytime to reinstate Benefits for a Prescription Drug Product that was previously excluded underthis provision.
5. Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, even when used for the treatment of Sickness or Injury.
Prescription Drug or Prescription Drug Product means a medication, product or device thathas been approved by the U.S. Food and Drug Administration and that can, under federal or statelaw, be dispensed only pursuant to a Prescription Order or Refill. A Prescription Drug Productincludes a medication that, due to its characteristics, is appropriate for self-administration oradministration by a non-skilled caregiver. For the purpose of the benefits under the policy, thisdefinition includes insulin.
Prescription Drug List means a list that categorizes into tiers medications, products or devicesthat have been approved by the U.S. Food and Drug Administration. This list is subject to theCompany’s periodic review and modification (generally quarterly, but no more than six times percalendar year). The Insured may determine to which tier a particular Prescription Drug Product hasbeen assigned through the Internet at www.uhcsr.com or call Customer Service 1-866-607-4427.
Preferred Provider Information“Preferred Providers” are the Physicians, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. Preferred Providers in the localschool area are: UnitedHealthcare Options PPO. Visit www.uhcsr.com to locate a provider near you.
The availability of specific providers is subject to change without notice. Insured’s should alwaysconfirm that a Preferred Provider is participating at the time services are required by calling theCompany at 1-866-607-4427 and/or by asking the provider when making an appointment for services.
“Preferred Allowance” means the amount a Preferred Provider will accept as payment in full “Out of Network” providers have not agreed to any prearranged fee schedules. Insured’s may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurancepayment are the Insured’s responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible. TheDeductible must be satisfied before benefits are paid. The Company will pay according to thebenefit limits in the Schedule of Benefits.
Inpatient Hospital ExpensesPREFERRED HOSPITALS - Eligible inpatient Hospital expenses at a Preferred Hospital will be paid at 80%, up to any limits specified in the Schedule of Benefits. Call 1-866-607-4427 for informationabout Preferred Hospitals.
OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a Preferred Provider, eligible inpatient Hospital expenses will be paid according to the benefit limits in the Schedule ofBenefits.
Outpatient Hospital ExpensesPreferred Providers may discount bills for outpatient Hospital expenses. Benefits are paid accordingto the Schedule of Benefits. Insureds are responsible for any amounts that exceed the benefitsshown in the Schedule, up to the Preferred Allowance.
Professional & Other ExpensesBenefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO will be paid at80% of Preferred Allowance up to any limits specified in the Schedule of Benefits. All otherproviders will be paid according to the benefit limits in the Schedule of Benefits.
Disclosure of Limited BenefitWARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING PROVIDERS ARE USED.
You should be aware that when you elect to utilize the services of a non-participating provider fora covered service in non-emergency situations, benefit payments to such non-participating providerare not based upon the amount billed. The basis of your benefit payment will be determinedaccording to your policy’s fee schedule, usual and customary charge (which is determined bycomparing charges for similar services adjusted to the geographical area where the services areperformed), or other method as defined by the policy.
YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICYAFTER THE PLAN HAS PAID ITS REQUIRED PORTION.
Non-participating providers may bill members for any amount up to the billed charge after the planhas paid its portion of the bill. Participating providers have agreed to accept discounted paymentsfor services with no additional billing to the member other than co-insurance and deductibleamounts. You may obtain further information about the participating status of professionalproviders and information on out-of-pocket expenses by calling the toll free telephone number onyour identification card.
Optional Major Medical Benefits (Students Only)$500,000 Maximum Benefit for each Injury or Sickness $0 Deductible This optional benefit is subject to payment of additional premium as specified on the enrollment card.
After the Company has paid the Basic Maximum Benefit of $100,000 under the Schedule ofBenefits, the Company will pay 100% for In-Network Providers or 80% for Out-of-NetworkProviders up to $200,000 of incurred Covered Medical Expenses. Then, after the Company has paid$200,000 of incurred Covered Medical Expenses, payment will be made for 95% for additional,incurred Covered Medical Expenses not to exceed a total Maximum Benefit of $600,000 for anyone Injury or Sickness.
The total benefit payable under Major Medical is $600,000 minus the Basic Benefits already paid.
No benefits will be paid under this Major Medical for: Room and board expenses which exceed the semi-private room rate; Services designated as "No Benefits" in the Basic Medical Expense Benefits Schedule ofBenefits; and Pre-existing Conditions; Any condition which is diagnosed; treated or recommended for treatment within the 12 months immediately prior to the Insured's Effective Date under Optional Major Medical coverage; except for individuals who have been continuously insured under Optional Major Medical coverage for at least 12 consecutive months.
Maternity TestingThis policy does not cover routine, preventive or screening examinations or testing unless MedicalNecessity is established based on medical records. The following maternity routine tests andscreening exams will be considered, if all other policy provisions have been met. This includes apregnancy test, CBC, Hepatitis B Surface Antigen, Rubella Screen, Syphilis Screen, Chlamydia, HIV,Gonorrhea, Toxoplasmosis, Blood Typing ABO, RH Blood Antibody Screen, Urinalysis, Urine BacterialCulture, Microbial Nucleic Acid Probe, AFP Blood Screening, Pap Smear, and Glucose Challenge Test(at 24-28 weeks gestation). One Ultrasound will be considered in every pregnancy, withoutadditional diagnosis. Any subsequent ultrasounds can be considered if a claim is submitted withthe Pregnancy Record and Ultrasound report that establishes Medical Necessity. Additionally, thefollowing tests will be considered for women over 35 years of age: Amniocentesis/AFP Screeningand Chromosome Testing. Fetal Stress/Non-Stress tests are payable. Pre-natal vitamins are notcovered. For additional information regarding Maternity Testing, please call the Company at 1-866-607-4427.
Excess ProvisionEven if you have other insurance, the Plan may cover unpaid balances, Deductibles and pay thoseeligible medical expenses not covered by other insurance.
Benefits will be paid on the unpaid balances after your other insurance has paid. No benefits arepayable for any expense incurred for Injury or Sickness which has been paid or is payable by othervalid and collectible insurance.
However, this Excess Provision will not be applied to the first $100 of medical expenses incurred.
Covered Medical Expenses excludes amounts not covered by the primary carrier due to penaltiesimposed on the Insured for failing to comply with Policy provisions or requirements.
Important: The Excess Provision has no practical application if you do not have other medicalinsurance or if your other insurance does not cover the loss.
BENEFITS FOR MATERNITY AND POST DELIVERY CARE Benefits will be paid the same as any other Sickness for the Insured mother and Newborn Infant forMaternity and Post Delivery Care. Benefits will be provided for inpatient stay following birth for aminimum of: 48 hours following an uncomplicated vaginal delivery; and 96 hours following an uncomplicated delivery by caesarean section.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits will be paid the same as any other Sickness for all Outpatient Contraceptive Services andall outpatient contraceptive drugs and devices approved by the United States Food and DrugAdministration. Outpatient Contraceptive Service means consultations, examinations, procedures,and medical services, provided on an outpatient basis and related to the use of contraceptivemethods (including natural family planning) to prevent an unintended pregnancy.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Additional Mandated BenefitsBenefits are provided as mandated by the state of Illinois for Benefits for Mammography, ProstheticDevice and Reconstructive Surgery, Cervical Cancer Screening Test, Prostate Cancer Screening,Diabetes, Colorectal Cancer Test, Dental Care Services and Bone Mass Measurement/Osteoporosis.
A detail of these benefits may be found in the Master Policy on file at the Seminary.
DefinitionsINJURY means bodily injury which is: 1) the direct cause of loss, independent of disease cause of loss, independent of disease or bodily infirmity; 2) a source of loss; 3) treated by a Physician within30 days after the date of accident; and 4) sustained while the Insured Person is covered under thispolicy. All injuries sustained in one accident, including all related conditions and recurrentsymptoms of these injuries will be considered one injury. Covered Medical Expenses incurred as aresult of an injury that occurred prior to this policy’s Effective Date will be considered a Sicknessunder this policy.
MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of immediate medical attention, a reasonable person could believe thiscondition would result in: Placement of the Insured's health in jeopardy; Serious dysfunction of any body organ or part; or In the case of a pregnant woman, serious jeopardy to the health of the fetus.
Expenses incurred for "Medical Emergency" will be paid only for Sickness or Injury which fulfills theabove conditions. These expenses will not be paid for minor Injuries or minor Sicknesses.
PRE-EXISTING CONDITION means: 1) the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 12 months immediatelyprior to the Insured's Effective Date under the policy; or, 2) any condition which originates, isdiagnosed, treated or recommended for treatment within the 12 months immediately prior to theInsured's Effective Date under the policy.
SICKNESS means sickness or disease of the Insured Person which causes loss, and first manifests itself while the Insured Person is covered under this policy. All related conditions and recurrentsymptoms of the same or a similar condition will be considered one sickness. Covered MedicalExpenses incurred as a result of an Injury that occurred prior to this policy’s Effective Date will beconsidered a sickness under this policy.
USUAL AND CUSTOMARY CHARGES means a reasonable charge which is: 1) usual and customary when compared with the charges made for similar services and supplies; and 2) madeto persons having similar medical conditions in the locality of the Policyholder. No payment will bemade under this policy for any expenses incurred which in the judgment of the Company are inexcess of Usual and Customary Charges. The definition of Usual and Customary Charges does notapply to charges made by Preferred Providers.
Exclusions and LimitationsNo benefits will be paid for: a) loss or expense caused by or resulting from; or b) treatment, servicesor supplies for, at, or related to: 1. Acne; acupuncture; allergy, including allergy testing; 2. Addiction, such as: nicotine addiction and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, shopping, working and religious; codependency; 3. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy, learning disabilities, behavioral problems, parent-child problems, attention deficit disorder, conceptual handicap,developmental delay or disorder or mental retardation, except as specifically provided in thepolicy; 5. Congenital conditions, except as specifically provided for Newborn or adopted Infants; 6. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children; 7. Removal of warts, non-malignant moles and lesions; 8. Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or custodial care; extended carein treatment or substance abuse facilities for domiciliary or custodial care; 9. Dental treatment, except as specifically provided in the Schedule of Benefits; 10.Elective Surgery or Elective Treatment; 12.Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defectsand problems; except when due to a disease process; 13.Foot care including: flat foot conditions, supportive devices for the foot, subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails, fallenarches, weak feet, chronic foot strain, and symptomatic complaints of the feet; 14.Hearing examinations or hearing aids; or other treatment for hearing defects and problems.
"Hearing defects" means any physical defect of the ear which does or can impair normalhearing, apart from the disease process; 15.Immunizations, preventive medicines or vaccines, except where required for treatment of a 16.Injury caused by or resulting from the addiction to or use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs or medicines that are not taken in therecommended dosage or for the purpose prescribed by the Insured Person's Physician;Intoxication is defined and determined by the laws of the state where the loss or cause ofthe loss was incurred.
17.Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 18.Injury sustained while (a) participating in any club, intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as aparticipant; or (c) while participating in any practice or conditioning program for such sport,contest or competition; 19.Organ transplants, only those considered experimental are excluded; 20.Participation in a riot or civil disorder; commission of or attempt to commit a felony; or 21.Pre-existing Conditions, except for individuals who have been continuously insured under the school's student insurance policy for at least 12 consecutive months; 22.Prescription Drugs, services or supplies as follows: Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use except as specifically provided in the Benefits For Diabetes; Immunization agents, biological sera, blood or blood products administered on an Drugs labeled, “Caution - limited by federal law to investigational use” or experimental Drugs used to treat or cure baldness;anabolic steroids used for body building; Anorectics - drugs used for the purpose of weight control; Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Growth hormones, except when a Medical Necessity; or Refills in excess of the number specified or dispensed after one (1) year of date of the 23.Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose orwith the intent of inducing conception; premarital examinations; impotence, organic orotherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal of sterilizationprocedures; 24.Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; 25.Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 26.Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal septum, includingsubmucous resection and/or other surgical correction thereof; nasal and sinus surgery,except for treatment of chronic purulent sinusitis; 28.Suicide or attempted suicide while sane or insane (including drug overdose); or intentionally 29.Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 30.Treatment in a Government hospital, unless there is a legal obligation for the Insured Person 31.War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered); and 32.Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such as bulimia andanorexia. Exception: benefits will be provided for the treatment of dehydration andelectrolyte imbalance associated with eating disorders.
Collegiate Assistance ProgramInsured Students have access to nurse advice, health information, and counseling support 24 hours a day, 7 days a week by dialing 877-643-5130. Collegiate Assistance Program is staffed by Registered Nurses and Licensed Clinicians who can help students determine if they need to seek medical care, need legal/financial advice or may need to talk to someone about everyday issues that Scholastic Emergency Services: Global Emergency Medical AssistanceIf you are a student insured with this insurance plan, you and your insured spouse and insuredminor child(ren) are eligible for Scholastic Emergency Services (SES). The requirements to receivethese services are as follows: International Students, insured spouse and insured minor child(ren): You are eligible to receive SESworldwide, except in your home country.
Domestic Students, insured spouse and insured minor child(ren): You are eligible for SES when 100miles or more away from your campus address and 100 miles or more away from your permanenthome address or while participating in a Study Abroad program.
SES includes Emergency Medical Evacuation and Return of Mortal Remains that meet the U.S. StateDepartment requirements. The Emergency Medical Evacuation services are not meant to be used inlieu of or replace local emergency services such as an ambulance requested through emergency 911telephone assistance. All SES services must be arranged and provided by SES, any services notarranged by SES will not be considered for payment.
* Medical Consultation, Evaluation and Referrals * Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Due to a Medical Incident Please log into your online account www.uhcsr.com for additional information on SES GlobalEmergency Assistance Services, including service descriptions and program exclusions andlimitations.
(877) 488-9833 Toll-free within the United States (609) 452-8570 Collect outside the United States Services are also accessible via e-mail at medservices@assistamerica.com.
When calling the SES Operations Center, please be prepared to provide:1.
Caller's name, telephone and (if possible) fax number, and relationship to the patient Patient's name, age, sex, and Reference Number Name, location, and telephone number of hospital, if applicable Name and telephone number of the attending physician Information of where the physician can be immediately reached SES is not travel or medical insurance but a service provider for emergency medical assistance services. Allmedical costs incurred should be submitted to your health plan and are subject to the policy limits of yourhealth coverage. All assistance services must be arranged and provided by SES. Claims for reimbursementof services not provided by SES will not be accepted. Please refer to your SES brochure for Program Guidelinesas well as limitations and exclusions pertaining to the SES program.
Online Access to Account InformationUnitedHealthcare StudentResources insureds have online access to claims status, EOBs,correspondence and coverage information via My Account at www.uhcsr.com. Insureds can alsoprint a temporary ID card, request a replacement ID card and locate network providers from MyAccount.
If you don’t already have an online account, simply select the “Create an Account” link from thehome page at www.uhcsr.com. Follow the simple, onscreen directions to establish an online accountin minutes. Note that you will need your 7-digit insurance ID number to create an online account.
If you already have an online account, just log in from www.uhcsr.com to access your accountinformation.
Claim ProcedureIn the event of Injury or Sickness, students should: Report to the Health Service or Infirmary for treatment or referral, or when not in school, totheir Physician or Hospital.
Mail to the address below all medical and hospital bills along with the patient's name andinsured student's name, address, social security number and name of the University underwhich the student is insured. A Company claim form is not required for filing a claim.
File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received bythe Company within 90 days of service. Bills submitted after one year will not be consideredfor payment except in the absence of legal capacity.
The Plan is Underwritten by:United HealthCare Insurance Company Submit all Claims or Inquiries to:UnitedHealthcare StudentResourcesP.O. Box 809025Dallas, Texas 75380-90251-866-607-4427 Please keep this Brochure as a general summary of the insurance. The Master Policy on file at theUniversity contains all of the provisions, limitations, exclusions and qualifications of your insurancebenefits, some of which may not be included in this Brochure. The Master Policy is the contract andwill govern and control payment of benefits.
The Enhanced Plan based on Policy #: 2008-201824-1

Source: http://www.wartburgseminary.edu/uploadedfiles/Future_Students/2008-09PlanBooklet.pdf

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