2012-300-1 prelim fly v5_benefit summary

Blanket Student Accident and
Sickness Insurance Plan for
The University of Tennessee

The University of Tennessee is pleased to offer an Accident and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company. All international students attending University of Tennessee at Chattanooga, Knoxville, Martin and Tullahoma are automatically enrolled in this plan on a hard waiver basis. Degree seeking students taking 6 or more undergraduate credit hours or 3 or more graduate credit hours and students participating in a co-op program are eligible to purchase this plan on a voluntary basis. Eligible Dependents ofenrolled students may purchase this plan on a voluntary basis.
Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
right for you before you enroll.
The plan brochure provides Up to $100,000 each Injury or Sickness Maximum Benefit for Covered Medical Expenses.
$350 Deductible for Preferred Providers per Insured Person, per Policy Year, $600 Deductible per Insured Person per Policy Year for Out of Network Providers.
Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and Out of Network benefits are payable at 60% of Usual and Customary charges (all benefits are subject to satisfaction of the Deductible, specific benefit limitations, maximums and copays as described in the policy).
Prescription Drug Benefits: $15 Copay for Tier 1 / $40 Copay for Tier 2 / $65 Copay for Tier 3 up to a 31-day supply per prescription filled at a UnitedHealthcare Network Pharmacy (UHPS). Mail order through UHPS at 2.5 times the retail copay up to a 90-day supply. Prescriptions must be filled at a UHPS network pharmacy.
Coverage available for eligible Dependents.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can be found using the following link, http://www.uhcsr.com/lookupredirect.aspx?delsys=52 Scholastic Emergency Services – Domestic Students are covered when 100 miles or more away from their campus or home address. International Students are covered worldwide except in their home country.
Optional Major Medical Maximum Benefit up to an additional $400,000 for Covered Medical Expenses. $0 Deductible. Preferred Providers are payable at 80% of Preferred Allowance and Out of Network benefits are payable at 60% of Usual and Customary charges. Additional premium required.
For more information and to enroll, visit www.studenthealthprograms.com.
Knoxville, TN 37922865-691-4652 or 1-800-874-0831 Your student health insurance coverage, offered by UnitedHealthcare Insurance
Company may not meet the minimum standards required by the healthcare reform law
for restrictions on annual dollar limits. The annual dollar limits ensure that consumers
have sufficient access to medical benefits throughout the annual term of the policy.
Restrictions for annual dollar limits for group and individual health insurance coverage
are $1.25 million for policy years before September 23, 2012; and $2 million for policy
years beginning on or after September 23, 2012 but before January 1, 2014. Restrictions
on annual dollar limits for student health insurance coverage are $100,000 for policy
years before September 23, 2012 and $500,000 for policy years beginning on or after
September 23, 2012, but before January 1, 2014. Your student health insurance coverage
puts a policy year limit of $100,000 for each Injury or Sickness that applies to the
essential benefits provided in the Schedule of Benefits unless otherwise specified. If
you have any questions or concerns about this notice, contact Customer Service at 1-
800-767-0700. Be advised that you may be eligible for coverage under a group health
plan of a parent's employer or under a parent’s individual health insurance policy if you
are under the age of 26. Contact the plan administrator of the parent’s employer plan or
the parent’s individual health insurance issuer for more information.

UnitedHealthcare StudentResources
Each Child
Each Child
All Children
* Buy Up Option increases plan maximum from $100,000 to $500,000 Per Policy Year.
Pre-Existing Condition means 1) the existence of symptoms which would 22. Pre-existing Conditions, except for individuals who have been cause an ordinarily prudent person to seek diagnosis, care or treatment continuously insured under the school's student insurance policy for within the 12 months immediately prior to the Insured's Effective Date at least 12 consecutive months; The Pre-existing Condition under the policy; or, 2) any condition which originates, is diagnosed, exclusionary period will be reduced by the total number of months treated or recommended for treatment within the 12 months immediately that the Insured provides documentation of continuous coverage prior to the Insured's Effective Date under the policy.
under a prior health insurance policy which provided benefits similar Exclusions and Limitations
to this policy; (This exclusion will not be applied to an Insured Person No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies 23. Prescription Drugs, services or supplies as follows, except as Acupuncture; except as specifically provided in the policy; Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or Immunization agents, except as specifically provided in the policy; biological sera, blood or blood products administered on Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for Drugs labeled, “Caution - limited by federal law to domiciliary or custodial care; extended care in treatment or investigational use” or experimental drugs; substance abuse facilities for domiciliary or custodial care; Dental treatment, except for accidental Injury to Sound, Natural Teeth Drugs used to treat or cure baldness; anabolic steroids used for or as specifically provided in the Benefits For Dental Expenses; Anorectics - drugs used for the purpose of weight control; Eye examinations, eye refractions, eyeglasses, contact lenses, Fertility agents or sexual enhancement drugs, such as Parlodel, prescriptions or fitting of eyeglasses or contact lenses, vision Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; correction surgery, or other treatment for visual defects and problems; except when due to a disease process; Refills in excess of the number specified or dispensed after one Foot care including: flat foot conditions, supportive devices for the (1) year of date of the prescription.
foot, care of corns, bunions (except capsular or bone surgery), 24. Reproductive/Infertility services including but not limited to: family calluses, toenails, fallen arches, weak feet, chronic foot strain, and planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of Health spa or similar facilities; strengthening programs; inducing conception; premarital examinations; impotence, organic or 10. Hearing examinations or hearing aids; or other treatment for hearing otherwise; tubal ligation; vasectomy; sexual reassignment surgery; defects and problems, except as specifically provided in the Benefits for Hearing and Speech Disorders. "Hearing defects" means any 25. Research or examinations relating to research studies, or any physical defect of the ear which does or can impair normal hearing, treatment for which the patient or the patient’s representative must sign an informed consent document identifying the treatment in which the patient is to participate as a research study or clinical 13. Immunizations, except as specifically provided in the policy; 26. Routine physical examinations and routine testing; screening exams preventive medicines or vaccines, except where required for or testing in the absence of Injury or Sickness; except as specifically treatment of a covered Injury or as specifically provided in the policy; 14. Injury caused by, contributed to, or resulting from the use of alcohol, 27. Services provided normally without charge by the Health Service of intoxicants, hallucinogenics, illegal drugs, or any drugs or medicines the Policyholder; or services covered or provided by the student that are not taken in the recommended dosage or for the purpose prescribed by the Insured Person's Physician; 28. Nasal and sinus surgery, except for treatment of chronic purulent 15. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or 29. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 16. Injury or Sickness outside the United States and its possessions 30. Supplies, except as specifically provided in the policy; except when traveling for academic study abroad programs, 31. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically 17. Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by any other valid and collectible 32. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 18. Injury sustained while (a) participating in any intercollegiate or 33. War or any act of war, declared or undeclared; or while in the armed professional sport, contest or competition; (b) traveling to or from forces of any country (a pro-rata premium will be refunded upon such sport, contest or competition as a participant; or (c) while request for such period not covered); and participating in any practice or conditioning program for such sport, 34. Weight management, weight reduction, nutrition programs, treatment for obesity, (except surgery for morbid obesity), surgery for 20. Lipectomy;21. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting except when unprovoked and in self-defense;

Source: http://studenthealth.utk.edu/files/Student_Health_Insurance_Flyer_2012-13.pdf

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