2011-201824-1-2-3 brochure-v2_layout

Notice: Benefits may vary by state or coverage may not be available in all states. The planis not available in Massachusetts, New Hampshire, New York, New Jersey, North Carolina,Oregon, Puerto Rico, Vermont and Washington.
Table of Contents
Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility Statement - Plan 1, 2 & 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Choice of Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Basic Medical Expense Benefits (Plan 1 - Cost Share Plan) . . . . . . . . . . . .3Schedule of Basic Medical Expense Benefits (Plan 2 - Core Plan) . . . . . . . . . . . . . . . . . .6Schedule of Basic Medical Expense Benefits (Plan 3 - Enhanced Plan) . . . . . . . . . . . . .9UnitedHealthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Optional Major Medical Benefits (Plan 1 - Cost Share Plan) . . . . . . . . . . . . . . . . . . . . . . . .14Optional Major Medical Benefits (Plan 2 - Core Plan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Optional Major Medical Benefits (Plan 3 - Enhanced Plan) . . . . . . . . . . . . . . . . . . . . . . . . .15Disclosure of Limited Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Excess Provision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Benefits for Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Benefits for Mastectomy, Prosthetic Device and Reconstructive Surgery . . . . . . . . . . .17Benefits for Colorectal Cancer Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Benefits for Cervical Cancer Screening Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Prostate Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Dental Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Bone Mass Measurement/Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . .23Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personal informationabout our customers or former customers to anyone, except as permitted or required by law.
We believe we maintain appropriate physical, electronic and procedural safeguards toensure the security of your nonpublic personal information. You may obtain a detailed copyof our privacy policy by calling us toll-free at 1-866-607-4427 or by visiting us atwww.uhcsr.com.
Eligibility Statement - Plan 1, 2 & 3
All Seminary Students who are registered full-time in any degree program and all interns
are automatically enrolled in Plan 2 (Core Plan 2011-201824-2) at registration, unless they
choose to enroll in Plan 1 (Cost Share Plan 2011-201824-1), Plan 3 (Enhanced Plan 2011-
201824-3), or provide proof of comparable coverage.
Dependents are not eligible to enroll in Plan 1 (Cost Share 2011-201824-1). Plan 1
(Cost Share Plan 2011-201824-1) is a student only plan.
Post Graduate Students and Part-Time Students are eligible and may only enroll in Plan 2
(Core Plan 2011-201824-2).
Dependents are eligible to enroll in Plan 2 (Core Plan 2011-201824-2) or Plan 3
(Enhanced Plan 2011-201824-3) and may only enroll in the same plan as the student.
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
coverage is purchased. Home study, correspondence, Internet, and television (TV) courses
do not fulfill the Eligibility requirements that the student actively attend classes. The
Company maintains its right to investigate student status and attendance records to verify
that the policy eligibility requirements have been met. If the Company discovers the Eligibility
requirements have not been met, its only obligation is refund of premium.
Eligible Dependents are the spouse and unmarried children under 19 years to 23 if enrolled
as a full-time student in any accredited school, financially dependent on the Insured.
Dependent Eligibility expires concurrently with that of the Insured student.
Optional coverages may only be purchased simultaneously and in conjunction with the
purchase of Basic coverage at the time of initial enrollment in the Plan. Students may
purchase Optional coverage for themselves (all plans) or for themselves and all family
members (plans 2 and 3 only).
Choice of Plan
Each eligible student has a choice of one of the benefit Plans. Plan 2 has higher benefitsthan Plan 1 and it has a higher Premium. Plan 3 has the highest benefits and the highestpremium. Make your selection carefully, you cannot upgrade or downgrade coverage afterthe initial purchase of the Plan for the policy year. Please be aware that if you choose toupgrade coverage in any subsequent policy year, a new Pre-Existing Condition exclusionand waiting period will apply.
Effective and Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m., September 1, 2011.
The individual student’s coverage becomes effective on the first day of the period for whichpremium is paid or the date the enrollment form and full premium are received by theCompany (or its authorized representative), whichever is later. The Master Policy terminatesat 11:59 p.m., August 31, 2012. Coverage terminates on that date or at the end of the periodthrough which premium is paid, whichever is earlier. Dependent coverage will not beeffective prior to that of the Insured student or extend beyond that of the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces. The Policy is aNon-Renewable One Year Term Policy.
Extension of Benefits After Termination
The coverage provided under the Policy ceases on the Termination Date. However, if anInsured is Hospital Confined on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit. After this “Extension ofBenefits” provision has been exhausted, all benefits cease to exist, and under nocircumstances will further payments be made.
Pre-Admission Notification
UMR Care Management should be notified of all Hospital Confinements prior to admission.
1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS:
The patient, Physician or Hospital should telephone 1-877-295-0720 at least fiveworking days prior to the planned admission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient,
patient’s representative, Physician or Hospital should telephone 1-877-295-0720within two working days of the admission, or as soon as possible after the patientbecomes lucid and able to communicate, to provide the notification of anyadmission due to Medical Emergency.
UMR Care Management 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
COST SHARE PLAN (2011-201824-1)
Up to $50,000 Maximum Benefit for each Injury or Sickness Deductible $250 Per Insured Person, Per Policy Year The Policy provides benefits for the Usual and Customary Charges incurred by an InsuredPerson for loss due to a covered Injury or Sickness up to the Maximum Benefit of$50,000 for each Injury or Sickness. The Preferred Provider for this plan is UnitedHealthcare Options PPO.
If care is received from a Preferred Provider, any Covered Medical Expenses will be paidat the Preferred Provider level of benefits. If the Covered Medical Expense is incurred dueto 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-Networkprovider is used. All benefit maximums are combined Preferred Provider and Out-of-Network, unless notedbelow. Benefits will be paid up to the Maximum Benefit for each service as scheduledbelow. Covered Medical Expenses include: PA = Preferred Allowance U&C = Usual & Customary Charges Max = Maximum INPATIENT
Preferred Providers Out-of-Network
Providers
Hospital Expense, $1,500 Max per day, daily 80% of PA
semi-private room rate and general nursing careprovided by the Hospital. Hospital MiscellaneousExpenses 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 computingthe number of days payable under this benefit,the date of admission will be counted, but not thedate of discharge.
Intensive Care, $1,200 Max first day, $400
Routine Newborn Care, while Hospital
Paid as any other Sickness / 4 days Hospital Confined; and routine nursery care provided Physiotherapy
Surgeon’s Fees, $1,500 Max, in accordance 80% of PA
with data provided by FAIR Health, Inc. If two ormore procedures are performed through thesame incision or in immediate succession at thesame operative session, the maximum amountpaid will not exceed 50% of the secondprocedure and 50% of all subsequentprocedures.
Assistant Surgeon
Anesthetist, professional services administered
in connection with inpatient surgery.
Registered Nurse’s Services, private duty 80% of PA
INPATIENT
Preferred Providers Out-of-Network
Providers
Pre-Admission Testing, payable within 3
Physician’s Visits, benefits are limited to one 80% of PA
visit per day. Benefits do not apply whenrelated to surgery.
Psychotherapy, $750 Max, benefits are 80% of PA
limited to one visit per day. Psychiatric Hospitalsare not covered.
OUTPATIENT
Surgeon’s Fees, $1,500 Max, in accordance 80% of PA
with data provided by FAIR Health, Inc. If twoor more procedures are performed throughthe same incision or in immediate successionat the same operative session, the maximumamount paid will not exceed 50% of thesecond procedure and 50% of all subsequentprocedures.
Day Surgery Miscellaneous, $1,500 Max, 80% of PA
related to scheduled surgery performed in aHospital, including the cost of the operatingroom; laboratory tests and x-ray examinations,including professional fees; anesthesia; drugsor medicines; and supplies. Usual andCustomary Charges for Day SurgeryMiscellaneous are based on the OutpatientSurgical Facility Charge Index.
Assistant Surgeon
Anesthetist, professional services administered
in connection with outpatient surgery.
Physician’s Visits, $75 Max per day, benefits 80% of PA / $20
are limited to one visit per day and do not apply copay per visit when related to surgery or Physiotherapy.
Physiotherapy, $25 Max per day / $200 80% of PA
Max Per Policy Year, benefits are limited to onevisit per day. Medical Emergency Expenses, $500 Max 80% of PA / $75
per visit, use of the emergency room and copay per visit supplies. Treatment must be rendered within72 hours from time of Injury or first onset ofSickness.
Diagnostic X-ray Services, $150 Max
Chemotherapy, $500 Max
Radiation Therapy
Laboratory Services, $200 Max
OUTPATIENT
Preferred Providers Out-of-Network
Providers
Tests & Procedures, diagnostic services and
medical procedures performed by a Physician,other than Physician’s Visits, Physiotherapy, x-rays and lab procedures.
Injections, $250 Max, when administered in
the Physician’s office and charged on thePhysician’s statement. Prescription Drugs, $350 Max Per Policy UnitedHealthcare
Network Pharmacy /$20 copay for Tier 1prescription / $30copay for Tier 2prescriptions / $50copay for Tier 3prescriptions / up to a31 day supply perprescription Psychotherapy, $500 Max Per Policy Year 80% of PA
including all related or ancillary chargesincurred as result of a Mental & NervousDisorder. Benefits are limited to one visit perday.
Ambulance Services, $250 Max
Durable Medical Equipment, $250 Max, a 80% of U&C
written prescription must accompany theclaim when submitted. Replacementequipment is not covered.
Consultant Physician Fees,
requested and approved by the attendingPhysician.
Dental Treatment, $100 per tooth / $500 80% of U&C
per Injury Max, for treatment made necessaryby Injury to Sound, Natural Teeth. Alcoholism, $500 Max
Drug Abuse, $500 Max
Maternity
Complications of Pregnancy
CAT Scan / MRI, $1,000 Max
SCHEDULE OF BASIC MEDICAL EXPENSE BENEFITS
CORE PLAN (2011-201824-2)
Up to $100,000 Maximum Benefit for Students for each Injury or Sickness Up to $50,000 Maximum Benefit for Dependents for each Injury or Sickness Deductible Preferred Provider $350 Per Insured Person, Per Policy Year (The Deductible will be limited to three Deductibles per family or $1,050 maximum) Deductible Out-of-Network $600 Per Insured Person, Per Policy Year (The Deductible will be limited to three Deductibles per family or an $1,800 maximum) The Policy provides benefits for the Usual and Customary Charges incurred by an InsuredPerson for loss due to a covered Injury or Sickness up to the Maximum Benefit of$100,000 for Students and $50,000 for Dependents for each Injury or Sickness.
The Preferred Provider for this plan is UnitedHealthcare Options PPO.
If care is received from a Preferred Provider any Covered Medical Expenses will be paidat the Preferred Provider level of benefits. If the Covered Medical Expense is incurred dueto 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-Networkprovider is used. Please be aware that if you choose to change policies to upgrade coverage in anysubsequent policy year, a new Pre-existing Condition exclusion will apply.
All benefit maximums are combined Preferred Provider and Out-of-Network, unless notedbelow. Benefits will be paid up to the Maximum Benefit for each service as scheduledbelow. Covered Medical Expenses include: PA = Preferred Allowance U&C = Usual & Customary Charges Max = Maximum INPATIENT
Preferred Providers Out-of-Network
Providers
Hospital Expense, $3,000 Aggregate Max per
day, daily semi-private room rate and general nursing care provided by the Hospital. Hospital Miscellaneous Expenses such as the cost of the examinations, anesthesia, drugs (excluding takehome drugs) or medicines, therapeutic services,and supplies. In computing the number of dayspayable under this benefit, the date of admissionwill be counted, but not the date of discharge.
Intensive Care
Routine Newborn Care, while Hospital Confined;
and routine nursery care provided immediatelyafter birth.
Physiotherapy
Surgeon’s Fees, $2,000 Aggregate Max per 80% of PA
day, in accordance with data provided by FAIRHealth, Inc. 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%of all subsequent procedures.
INPATIENT
Preferred Providers Out-of-Network
Providers
Assistant Surgeon
Anesthetist, professional services administered
in connection with inpatient surgery.
Registered Nurse’s Services, private duty 80% of PA
Pre-Admission Testing, payable within 3
Physician’s Visits, benefits are limited to one 80% of PA
visit per day. Benefits do not apply whenrelated to surgery.
Psychotherapy, benefits are limited to one visit
per day. Psychiatric Hospitals are not covered.
OUTPATIENT
Surgeon’s Fees, $2,000 Max, in accordance 80% of PA
with data provided by FAIR Health, Inc. If twoor more procedures are performed throughthe same incision or in immediate successionat the same operative session, the maximumamount paid will not exceed 50% of thesecond procedure and 50% of all subsequentprocedures.
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 andCustomary Charges for Day SurgeryMiscellaneous are based on the OutpatientSurgical Facility Charge Index.
Assistant Surgeon
Anesthetist, professional services administered
in connection with outpatient surgery.
Outpatient Miscellaneous (Misc.) Benefit, 80% of PA
$3,000 Max, includes benefits as designatedunder Outpatient Misc. Benefit.
Physician’s Visits, benefits are limited to one
visit per day and do not apply when related tosurgery or Physiotherapy.
Physiotherapy
Medical Emergency Expenses, use of the
emergency room and supplies. Treatmentmust be rendered within 72 hours from time ofInjury or first onset of Sickness.
OUTPATIENT
Preferred Providers Out-of-Network
Providers
Diagnostic X-ray Services
Chemotherapy & Radiation Therapy
Laboratory Services
Tests & Procedures, diagnostic services and
medical procedures performed by a Physician,other than Physician’s Visits, Physiotherapy, x-rays and lab procedures.
Injections, $250 Max
Prescription Drugs, $1,500 Max Per Policy UnitedHealthcare
Network Pharmacy /$15 copay for Tier 1prescription / $40copay for Tier 2prescriptions / $60copay for Tier 3prescriptions / up to a31 day supply perprescription Psychotherapy, $3,000 Max, including all 80% of PA
related or ancillary charges incurred as a resultof Mental & Nervous Disorder. Benefits arelimited to one visit per day.
Ambulance Services, $300 Max, the copay / 80% of U&C / $100
Durable Medical Equipment, $300 Max, a 80% of U&C
written prescription must accompany the claimwhen submitted. Replacement equipment isnot covered.
Consultant Physician Fee, when requested 80% of PA
and approved by the attending Physician.
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 notinclude preventative care.
Alcoholism
Drug Abuse
Maternity/Complications of Pregnancy
Routine Physical Exams,
benefits include one routine physical exam Per copay per visit SCHEDULE OF BASIC MEDICAL EXPENSE BENEFITS
ENHANCED PLAN (2011-201824-3)
Up to $100,000 Maximum Benefit for Students for each Injury or Sickness Up to $50,000 Maximum Benefit for Dependents for each Injury or Sickness Deductible Preferred Provider $250 Per Insured Person, Per Policy Year (The Deductible will be limited to three per family or a $750 maximum) Deductible Out-of-Network $500 Per Insured Person, Per Policy Year (The Deductible will be limited to three per family or a $1,500 maximum) The Policy provides benefits for the Usual and Customary Charges incurred by an InsuredPerson for loss due to a covered Injury or Sickness up to the Maximum Benefit of$100,000 for Students and $50,000 for Dependents for each Injury or Sickness.
The Preferred Provider for this plan is UnitedHealthcare Options PPO.
If care is received from a Preferred Provider any Covered Medical Expenses will be paidat the Preferred Provider level of benefits. If the Covered Medical Expense is incurred dueto 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-Networkprovider is used.
Please be aware that if you choose to change policies to upgrade coverage in anysubsequent policy year, a new Pre-existing Condition exclusion will apply.
All benefit maximums are combined Preferred Provider and Out-of-Network, unless notedbelow. Benefits will be paid up to the Maximum Benefit for each service as scheduledbelow. Covered Medical Expenses include: PA = Preferred Allowance U&C = Usual & Customary Charges Max = Maximum INPATIENT
Preferred Providers
Out-of-Network
Providers
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 computingthe number of days payable under this benefit,the date of admission will be counted, but notthe date of discharge.
Intensive Care
Routine Newborn Care, while Hospital
Confined; and routine nursery care providedimmediately after birth.
Physiotherapy
Surgeons Fees, in accordance with data 80% of PA
provided by FAIR Health, Inc. If two or moreprocedures are performed through the sameincision or in immediate succession at the sameoperative session, the maximum amount paidwill not exceed 50% of the second procedureand 50% of all subsequent procedures.
Assistant Surgeon
INPATIENT
Preferred Providers
Out-of-Network
Providers
Anesthetist, professional services administered
in connection with inpatient surgery.
Registered Nurse’s Services, private duty 80% of PA
Physician’s Visits, benefits are limited to one 80% of PA
visit per day and do not apply when related tosurgery.
Pre-admission Testing, payable within 3 80% of PA
Psychotherapy, benefits are limited to one visit
per day. Psychiatric Hospitals are not covered.
OUTPATIENT
Surgery, in accordance with data provided by 80% of PA
FAIR Health, Inc. If two or more proceduresare performed through the same incision or inimmediate succession at the same operativesession, the maximum amount paid will notexceed 50% of the second procedure and50% of all subsequent procedures.
Day Surgery Miscellaneous, related to 80% of PA
scheduled surgery performed in a Hospital, including the cost of the operating room; laboratory tests and x-ray examinations,including professional fees; anesthesia; drugs ormedicines; and supplies. Usual and CustomaryCharges for Day Surgery Miscellaneous arebased on the Outpatient Surgical Facility ChargeIndex.
Assistant Surgeon
Anesthetist, professional services administered
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.
Physiotherapy, benefits are limited to one 80% of PA
visit per day. (Review of Medical Necessity will
be performed after 12 visits per Injury or
Sickness. )
Medical Emergency, use of the emergency 80% of PA
rendered within 72 hours from time of Injury X-Rays and Laboratory
Radiation Therapy
Tests & Procedures, diagnostic serviced and 80% of PA
medical procedures performed by a Physician,other than Physician’s Visit’s, Physiotherapy, x-rays and lab procedures.
OUTPATIENT
Preferred Providers
Out-of-Network
Providers
Injections, $500 Max
Chemotherapy
Prescription Drugs, $3,000 Max Per Policy UnitedHealthcare
prescriptions / $40copay for Tier 3prescriptions / up to a31 day supply perprescription Psychotherapy, $3,000 Max Per Policy 80% of PA
Year, including all related and ancillarycharges incurred as a result of a Mental &Nervous Disorder. Benefits are limited to onevisit per day.
Ambulance, $500 Max
Durable Medical Equipment, $300 Max, a 80% of U&C
written prescription must accompany theclaim when submitted. Replacementequipment is not covered.
Consultant Physician Fees,
requested and approved by the attending physician.
Dental Treatment, $100 per tooth / $500 80% of U&C
per Injury Max for treatment made necessaryby Injury to Sound, Natural Teeth. $100 Maxfor non-injury related dental work. Does notinclude preventative care.
Alcoholism
Drug Abuse
Maternity and Complications of Pregnancy
Routine Well-Baby Care, $350 Max
Routine Physical Exams, $500 Max, 80% of PA / $25
benefits include one routine physical exam copay per visit UnitedHealthcare Network Pharmacy Benefits
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)
when dispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supply
limits and copayments that vary depending on which tier of the PDL the outpatient drug is
listed. There are certain Prescription Drugs that require your Physician to notify us to verify
their use is covered within your benefit.
You are responsible for paying the applicable copayments. Your copayment is determined
by the tier to which the Prescription Drug is assigned on the PDL. Tier status may change
periodically and without prior notice to you. Please access www.uhcsr.com or call 1-877-
417-7345 for the most up-to-date tier status.
Plan 1:
$20 per prescription order or refill for a Tier 1 Prescription Drug, up to 31 day supply
$30 per prescription order or refill for a Tier 2 Prescription Drug, up to 31 day supply
$50 per prescription order or refill for a Tier 3 Prescription Drug, up to 31 day supply
Your maximum allowed benefit is $350 Per Policy Year.
$15 per prescription order or refill for a Tier 1 Prescription Drug, up to 31 day supply
$40 per prescription order or refill for a Tier 2 Prescription Drug, up to 31 day supply
$60 per prescription order or refill for a Tier 3 Prescription Drug, up to 31 day supply
Your maximum allowed benefit is $1,500 per Policy Year.
$15 per prescription order or refill for a Tier 1 Prescription Drug, up to 31 day supply
$25 per prescription order or refill for a Tier 2 Prescription Drug, up to 31 day supply
$40 per prescription order or refill for a Tier 3 Prescription Drug, up to 31 day supply
Your maximum allowed benefit is $3,000 per Policy Year.
Please present your ID card to the network pharmacy when the prescription is filled. If youdo not use a network pharmacy, you will be responsible for paying the full cost for theprescription.
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 paidreceipt in order to be reimbursed. To obtain reimbursement forms please visitwww.uhcsr.com and log in to your online account or call 1-877-417-7345.
Additional Exclusions:
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 determinedby the Company to be experimental, 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 PrescriptionOrder or Refill. Compounded drugs that are available as a similar commerciallyavailable Prescription Drug Product. Compounded drugs that contain at least oneingredient that requires a Prescription Order or Refill are assigned to Tier-3.
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 designatedthe over-the counter medication as eligible for coverage as if it were a PrescriptionDrug Product and it is obtained with a Prescription Order or Refill from a Physician.
Prescription Drug Products that are available in over-the-counter form or comprisedof components that re available in over-the-counter form or equivalent. CertainPrescription Drug Products that the Company has determined are TherapeuticallyEquivalent to an over-the-counter drug. Such determinations may be made up to sixtimes during a calendar year, and the Company may decide at any time to reinstateBenefits for a Prescription Drug Product that was previously excluded under thisprovision.
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 treatmentof Sickness or Injury.
Definitions
Prescription Drug or Prescription Drug Product means a medication, product or device
that has been approved by the U.S. Food and Drug Administration and that can, under
federal or state law, be dispensed only pursuant to a Prescription Order or Refill. A
Prescription Drug Product includes a medication that, due to its characteristics, is
appropriate for self-administration or administration by a non-skilled caregiver. For the
purpose of the benefits under the policy, this definition includes insulin.
Prescription Drug List means a list that categorizes into tiers medications, products or
devices that have been approved by the U.S. Food and Drug Administration. This list is
subject to the Company’s periodic review and modification (generally quarterly, but no more
than six times per calendar year). The Insured may determine to which tier a particular
Prescription Drug Product has been assigned through the Internet at www.uhcsr.com or call
Customer Service 1-877-417-7345.
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 local school area are: UnitedHealthcare Options PPO.
The availability of specific providers is subject to change without notice. Insured’s should
always confirm that a Preferred Provider is participating at the time services are required by
calling the Company 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 for Covered Medical Expenses.
“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
insurance payment are the Insured’s responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible.
The Deductible must be satisfied before benefits are paid. The Company will pay according
to the benefit limits in the Schedule of Benefits.
Inpatient Hospital Expenses
PREFERRED 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 information about Preferred Hospitals.
OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a
PreferredProvider, eligible inpatient Hospital expenses will be paid according to the benefit
limits in the Schedule of Benefits.
Outpatient Hospital Expenses
Preferred Providers may discount bills for outpatient Hospital expenses. Benefits are paid
according to the Schedule of Benefits. Insureds are responsible for any amounts that
exceed the benefits shown in the Schedule, up to the Preferred Allowance.
Professional & Other Expenses
Benefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO will bepaid at 80% of Preferred Allowance up to any limits specified in the Schedule of Benefits.
All other providers will be paid according to the benefit limits in the Schedule of Benefits.
Optional Major Medical Benefits (Plan 1 - Cost Share Plan)
$50,000 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. Optional Benefits may only be purchased at the time of initial
enrollment in the plan and may not be added later.
The Major Medical Benefit begins payment after the Basic Maximum Benefit of $50,000has been paid by the Company.
The Company will pay 80% for In-Network Providers or 60% for Out-of-Network Providersfor additional Covered Medical Expenses incurred up to the Major Medical Maximum of$50,000.
The total benefit payable under Major Medical is $100,000 minus the Basic Benefitsalready paid.
Optional Major Medical Benefits (Plan 2 - Core Plan)
$100,000 Maximum Benefit for Student $50,000 Maximum Benefit for Dependent (For
each Injury or Sickness) $0 Deductible.
This optional benefit is subject to payment of additional premium as specified on
the enrollment card. Optional Benefits may only be purchased at the time of initial
enrollment in the plan and may not be added later.
The Major Medical Benefit begins payment after the Basic Maximum Benefit of $100,000for Student and $50,000 for Dependent has been paid by the Company.
The Company will pay 80% for In-Network Providers or 60% for Out-of-Network Providersfor additional Covered Medical Expenses incurred up to the Major Medical Maximum of$100,000 for Student and $50,000 for Dependent. The total benefit payable under Major Medical is $200,000 for Student and $100,000 forDependent minus the Basic Benefits already paid.
Optional Major Medical Benefits (Plan 3 - Enhanced Plan)
$400,000 Maximum Benefit for Student $50,000 Maximum Benefit for Dependent (For
each Injury or Sickness) $0 Deductible.
This optional benefit is subject to payment of additional premium as specified on
the enrollment card. Optional Benefits may only be purchased at the time of initial
enrollment in the plan and may not be added later.
The Major Medical Benefit begins payment after the Basic Maximum Benefit of $400,000
for Student and $50,000 for Dependent has been paid by the Company.
The Company will pay 80% for In-Network Providers or 60% for Out-of-Network Providers
for additional Covered Medical Expenses incurred up to the Major Medical Maximum of
$400,000 for Student and $50,000 for Dependent.
The total benefit payable under Major Medical is $500,000 for Student and $100,000 for
Dependent minus the Basic Benefits already paid.
No benefits will be paid under Plans 1, 2 or 3, Major Medical for:
1. Room & Board / Hospital Miscellaneous Expenses which exceed $1,500 maximum per day (Plan 1); $3,000 maximum per day (Plan 2); or The semi private
room rate (Plan 3);
2. Intercollegiate sports;3. Dental treatment is limited to $100 per tooth;4. Psychotherapy;5. Pre-existing Conditions; Any condition which is diagnosed; treated or recommended for treatment within the 12 months immediately prior to the Insured’sEffective Date under Optional Major Medical coverage; except for individuals whohave been continuously insured under Optional Major Medical coverage for at least12 consecutive months. The Pre-existing Condition exclusionary period will bereduced by the total number of months that the Insured provides documentation ofcontinuous coverage under a prior health insurance policy which provided benefitssimilar to this coverage; Disclosure of Limited Benefit
WARNING, LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATINGPROVIDERS ARE USED.
You should be aware that when you elect to utilize the services of a non-participatingprovider for a covered service in non-emergency situations, benefit payments to such non-participating provider are not based upon the amount billed. The basis of your benefitpayment will be determined according to your policy’s fee schedule, usual and customarycharge (which is determined by comparing charges for similar services adjusted to thegeographical area where the services are performed), or other method as defined by thepolicy.
YOU CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED INTHE POLICY AFTER THE PLAN HAS PAID ITS REQUIRED PORTION.
Non-participating providers may bill members for any amount up to the billed charge afterthe plan has paid its portion of the bill. Participating providers have agreed to acceptdiscounted payments for services with no additional billing to the member other than co-insurance and deductible amounts. You may obtain further information about theparticipating status of professional providers and information on out-of-pocket expenses bycalling the toll free telephone number on your identification card.
Maternity Testing
This policy does not cover routine, preventive or screening examinations or testing
unless Medical Necessity is established based on medical records. The following
maternity routine tests and screening exams will be considered if all other policy provisions
have been met: Initial screening at first visit – Pregnancy test: Urine human chorionic
gonatropin (HCG), Asymptomatic bacteriuria: Urine culture, Blood type and Rh antibody,
Rubella, Pregnancy-associated plasma protein-A (PAPPA) (first trimester only), Free beta
human chorionic gonadotrophin (hCG) (first trimester only), Hepatitis B: HBsAg, Pap smear,
Gonorrhea: Gc culture, Chlamydia: chlamydia culture, Syphilis: RPR, HIV: HIV-ab; and
Coombs test; Each visit – Urine analysis; Once every trimester – Hematocrit and
Hemoglobin; Once during first trimester – Ultrasound; Once during second trimester
– Ultrasound (anatomy scan); Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen
test Alpha-fetoprotein (AFP), Estriol, hCG, inhibin-a; Once during second trimester if
age 35 or over - Amniocentesis or Chorionic villus sampling (CVS); Once during second
or third trimester – 50g Glucola (blood glucose 1 hour postprandial); and Once during
third trimester - Group B Strep Culture. Pre-natal vitamins are not covered. For additional
information regarding Maternity Testing, please call the Company at 1-800-607-4427.
Excess Provision
Even if you have other insurance, the Plan may cover unpaid balances, Deductibles and pay
those eligible medical expenses not covered by other insurance.
Benefits will be paid on the unpaid balances after your other insurance has paid. No
benefits are payable for any expense incurred for Injury or Sickness which has been paid
or is payable by other valid 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
penalties imposed 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
medical insurance or if your other insurance does not cover the loss.
Benefits for Mammography
Benefits will be paid the same as any other Sickness for screening by Low-doseMammography for the presence of occult breast cancer according to the followingguidelines: 1. A baseline mammogram for women thirty-five to thirty-nine years of age.
2. An annual mammogram for women forty years of age or older.
3. A mammogram at the age and intervals considered medically necessary by the woman’s Physician for women under 40 years of age and having a family history ofbreast cancer or other risk factors.
"Low-dose mammography" means the x-ray examination of the breast using equipment
dedicated specifically for mammography, including the x-ray tube, filter, compression device,
and image receptor, with radiation exposure delivery of less than one rad per breast for 2
views of an average size breast.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any other
provisions of the policy.
Benefits for Mastectomy, Prosthetic Device and Reconstructive
Surgery
Benefits will be paid the same as any other Sickness for the surgical procedure known asa mastectomy and the prosthetic device or reconstructive surgery incident to themastectomy.
Benefits for breast reconstruction in connection with a mastectomy shall include: 1. Reconstruction of the breast upon which the mastectomy has been performed;2. Surgery and reconstruction of the other breast to produce a symmetrical 3. Prosthesis and treatment for physical complications at all stages of mastectomy, When a mastectomy is performed and there is no evidence of malignancy, benefits will belimited to the cost of the prosthesis or reconstructive surgery to within 2 years after the dateof the mastectomy. Benefits for the prosthetic device and reconstructive surgery shall besubject to the Deductible and coinsurance provisions applied to the mastectomy and allother terms and conditions applicable to other benefits under the policy.
"Mastectomy" means the removal of all or part of the breast for medically necessaryreasons as determined by a licensed Physician.
Benefits for Colorectal Cancer Test
Benefits will be paid the same as any other Sickness for colorectal cancer examinations andlaboratory tests for colorectal cancer as prescribed by a Physician, in accordance with thepublished American Cancer Society guidelines on colorectal cancer screening or otherexisting colorectal cancer screening guidelines issued by nationally recognized professionalmedical societies or federal government agencies, including the National Cancer Institute,the Centers for Disease Control and Prevention, and the American College ofGastroenterology.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Cervical Cancer Screening Test
Benefits will be paid the same as any other Sickness for an annual cervical smear or papsmear test and annual Surveillance Tests for ovarian cancer for female Insureds who are AtRisk for Ovarian Cancer.
Surveillance Tests for ovarian cancer means annual screening using (1) CA-125 serumtumor marker testing, (2) transvaginal ultrasound, and (3) pelvic examination.
At Risk for Ovarian Cancer means: 1) having a family history (i) with one or more first-degree relatives with ovarian cancer, (ii) of clusters of women relatives with breast cancer,or (iii) of nonpolyposis colorectal cancer, or 2) testing positive for BRCA1 or BRCA2mutations.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Prostate Cancer Screening
Benefits will be paid the same as any other Sickness for an annual digital rectal examinationand a prostate-specific antigen test upon the recommendation of a licensed Physician forasymptomatic men age 50 and over; African-American men age 40 and over; and men age40 and over with a family history of prostate cancer.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Dental Care Services
Benefits will be paid the same as any other Sickness for anesthetics and associatedHospital or ambulatory facility charges provided in conjunction with dental care for: 1. a child age 6 or under;2. an individual with a medical condition that requires hospitalization or general This benefit does not cover charges for the dental care itself, only the charges for theanesthesia and associated Hospital or ambulatory facility charges.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Bone Mass Measurement/Osteoporosis
Benefits will be paid the same as any other Sickness for medically necessary bone massmeasurement and for the diagnosis and treatment of osteoporosis.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Diabetes
Benefits will be paid as specified below for an Insured Person with type 1, type 2 or
gestational diabetes mellitus for Medically Necessary equipment, supplies, foot care exams,
and Diabetes Self-Management Training including medical nutrition therapy when
prescribed by a Physician.
Diabetes Self-Management Training:
Diabetes Self-Management Training means instruction in an outpatient setting whichenables a diabetic patient to understand the diabetic management process and dailymanagement of diabetic therapy as a means of avoiding frequent hospitalization andcomplications. Diabetes Self-Management Training includes the content areas listed in theNational Standards for Diabetes Self-Management Education Programs as published bythe American Diabetes Association, including medical nutrition therapy, which shall have thesame meaning ascribed to “medical nutrition care” in the Dietetic and Nutrition ServicesPractices Act.
Diabetes Self-Management Training, including nutrition education, may be provided as apart of an office visit, group setting or home visit as authorized by the Insured’s Physician.
Benefits are limited to the following: 1) Up to 3 medically necessary visits to a Physician with expertise in diabetes management upon initial diagnosis of diabetes by the Insured’s Physician.
2) Up to 2 medically necessary visits to a Physician with expertise in diabetes management upon a determination by an Insured’s Physician that a significantchange in the Insured’s symptoms or medical condition has occurred.
A “significant change” means symptomatic hyperglycemia (greater than 250 mg/dl on
repeated occasions), severe hypoglycemia (requiring assistance of another person), onset
or progression of diabetes, or a significant change in medical condition that would require
a significantly different treatment regimen.
Foot Care Exams: Benefits will be paid the same as any other Sickness for regular foot
care exams by a Physician.
Durable Medical Equipment: If the policy provides benefits for Durable Medical
Equipment, benefits will be paid the same as any other Sickness for the following medically
necessary equipment when prescribed by the Insured’s Physician:
1) blood glucose monitors;2) blood glucose monitors for the legally blind;3) cartridges for the legally blind; and4) lancets and lancing devices.
Pharmaceuticals and Supplies: If the policy provides benefits for Prescription Drugs,
benefits will be paid the same as any other Sickness for the following medically necessary
pharmaceuticals and supplies when prescribed by the Insured’s Physician:
1) insulin;2) syringes and needles;3) test strips for glucose monitors; 4) FDA approved oral agents used to control blood sugar; and 5) Glucagons emergency kits.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy. Definitions
INJURY 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 within 30 days after the date of accident; and 4) sustained while the Insured
Person is covered under this policy. All injuries sustained in one accident, including all
related conditions and recurrent symptoms of these injuries will be considered one injury.
Covered Medical Expenses incurred as a result of an injury that occurred prior to this
policy’s Effective Date will be considered a Sickness under 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
immediately prior to the Insured's Effective Date under the policy; or, 2) any condition which
originates, is diagnosed, treated or recommended for treatment within the 12 months
immediately prior to the Insured’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 recurrent symptoms of the same or a similar condition will be considered one sickness.
Covered Medical Insured's Effective Date under the policy.
Expenses incurred as a result of an Injury that occurred prior to this policy’s Effective Date
will be considered 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) made to persons having similar medical conditions in the locality where services are
rendered. No payment will be made under this policy for any expenses incurred which in the
judgment of the Company are in excess of Usual and Customary Charges. The definition
of Usual and Customary Charges does not apply to charges made by Preferred Providers.
Exclusions and Limitations
No benefits will be paid for: a) loss or expense caused by or resulting from; or b) treatment,services or 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 asspecifically provided in the policy; 4. Circumcision, except if medically necessary due to injury, disease or functional congenital disorder; (Plan 1 - Cost Share Plan only)
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;removal of warts, non-malignant moles and lesions; 7. 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 care in treatment or substance abuse facilities for domiciliary or custodialcare; 8. Dental treatment, except as specifically provided in the Schedule of Benefits;9. Elective Surgery or Elective Treatment; 11. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visualdefects and problems; except when due to a disease process; 12. 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,fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet; 13. 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 canimpair normal hearing, apart from the disease process; 14. Hirsutism; alopecia; (Plan 1 - Cost Share Plan only)
15. Immunizations, preventive medicines or vaccines, except where required for treatment
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’sPhysician; Intoxication is defined and determined by the law of the state where theloss or cause of the 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, 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 suchsport, 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. ThePre-existing Condition exclusionary period will be reduced by the total number ofmonths that the Insured provides documentation of continuous coverage under a priorhealth insurance policy which provided benefits similar to this policy; 22. Prescription Drugs, services or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended useexcept as specifically provided in the policy; b) Immunization agents, biological sera, blood or blood products administered on an c) Drugs labeled, “Caution - limited by federal law to investigational use” or d) Products used for cosmetic purposes;e) Drugs used to treat or cure baldness; anabolic steroids used for body building;f) Anorectics - drugs used for the purpose of weight control;g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, h) Growth hormones, except when a Medical Necessity; ori) Refills in excess of the number specified or dispensed after one (1) year of date of 23. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; premarital examinations; impotence,organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversalof sterilization procedures; 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, including submucous resection and/or other surgical correction thereof; nasal and sinussurgery, except for treatment of chronic purulent sinusitis; 28. Suicide or attempted suicide while sane or insane (including drug overdose); or 29. Supplies, except as specifically provided in the policy; 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 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 notcovered); 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 asbulimia and anorexia. Exception: benefits will be provided for the treatment ofdehydration and electrolyte imbalance associated with eating disorders.
Collegiate Assistance Program
Insured Students have access to nurse advice, health information, and counseling support24 hours a day, 7 days a week by dialing the access number indicated on the permanentID card. Collegiate Assistance Program is staffed by Registered Nurses and LicensedClinicians who can help students determine if they need to seek medical care, needlegal/financial advice or may need to talk to someone about everyday issues that can beoverwhelming.
Scholastic Emergency Services:
Global Emergency Medical Assistance
If you are a student insured with this insurance plan, you and your insured spouse and minor
child(ren) are eligible for Scholastic Emergency Services (SES). The requirements to
receive these services are as follows:
International Students, insured spouse and insured minor child(ren): You are eligible to
receive SES worldwide, except in your home country.
Domestic Students, insured spouse and insured minor child(ren): You are eligible for SES
when 100 miles or more away from your campus address and 100 miles or more away from
your permanent home address or while participating in a Study Abroad program.
SES includes Emergency Medical Evacuation and Return of Mortal Remains that meet the
US State Department requirements. The Emergency Medical Evacuation services are not
meant to be used in lieu of or replace local emergency services such as an ambulance
requested through emergency 911 telephone assistance. All SES services must be
arranged and provided by SES, Inc.; any services not arranged by SES, Inc. will not be
considered for payment.
Key Services include:
* Medical Consultation, Evaluation and Referrals * Prescription Assistance* Foreign Hospital Admission Guarantee * Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Due to a Medical Incident Please visit your school's insurance coverage page at www.uhcsr.com for the SES Global
Emergency Assistance Services brochure which includes service descriptions and program
exclusions and limitations.
To access services please call:
(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;2. Patient's name, age, sex, and Reference Number;3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.
SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES, Inc. Claims for reimbursement of services not provided bySES will not be accepted. Please refer to your SES brochure or Program Guide atwww.uhcsr.com for additional information, including limitations and exclusions pertaining tothe SES program.
Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs,
correspondence and coverage information via My Account at www.uhcsr.com. Insureds can
also print a temporary ID card, request a replacement ID card and locate network providers
from My Account.
If you don’t already have an online account, simply select the “Create an Account” link from
the home page at www.uhcsr.com. Follow the simple, onscreen directions to establish an
online account in 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 account information.
Claim Procedure
In the event of Injury or Sickness, students should: 1) Report to the Health Service or Infirmary for treatment or referral, or when not in school, to their Physician or Hospital.
2) Mail to the address below all medical and hospital bills along with the patient's name and insured student's name, address, social security number and name of theUniversity under which the student is insured. A Company claim form is not requiredfor filing a claim. 3) File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service. Bills submitted after one yearwill not be considered for payment except in the absence of legal capacity.
The Plan is Underwritten by:
Submit all Claims or Customer Service Inquiries to:
UnitedHealthcare StudentResources
P.O. Box 809025
Dallas, Texas 75380-9025
1-866-607-4427
Email: customerservice@uhcsr.com
Email: claims@uhcsr.com
Please keep this Brochure as a general summary of the insurance. The Master Policy onfile at the University contains all of the provisions, limitations, exclusions and qualificationsof your insurance benefits, some of which may not be included in this Brochure. The MasterPolicy is the contract and will govern and control payment of benefits.
This Brochure is based on Policy Numbers:
2011-201824-1
2011-201824-2
2011-201824-3

Source: http://www.luthersem.edu/business/2011-12_ELCA_Brochure.pdf