NOTE: METHODS OF DIAGNOSIS AND TREATMENT OF INFERTILITY ARE EXCLUDED FROM COVERAGE UNDER THIS POLICY. LIMITED BENEFIT HEALTH INSURANCE COVERAGE Connecticut Community-Technical Colleges Important: Please see the Notice on the first page of this plan material concerning student health insurance coverage.
This Certificate does not provide Coverage for:Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping,or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduledflight of a commercial airline. Injury sustained while (a) participating in any intercollegiate, or professional sport, contestor competition; (b) traveling to or from such sport, contest or competition as a participant;or (c) while participating in any practice or conditioning program for such sport, contest orcompetition. Notice Regarding Student Health Insurance Coverage This Student health insurance coverage, offered by UnitedHealthcare Insurance Company, may not meet the minimum standards required by the health care 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. This student health insurance coverage puts a policy year limit of $500,000 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 an Insured Person 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 an Insured Person is 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. Table of Contents
Privacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective And Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Premium Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits After Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8UnitedHealthcare Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Accidental Death and Dismemberment Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Benefits for Accidental Ingestion of a Controlled Drug . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Hypodermic Needles or Syringes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Home Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Mental or Nervous Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Treatment of Tumors and Leukemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Reconstructive Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Mammography and Comprehensive Ultrasound Screening . . . . . . .13Benefits for Prostate Cancer Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Benefits for Ostomy Appliances and Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Benefits for Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Benefits for Cancer Clinical Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Benefits for Postpartum Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Benefits for Amino Acid Modified Preparations and
Low Protein Modified Food Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Benefits for Specialized Formulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Benefits for Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Benefits for Diabetic Outpatient Self Management Training . . . . . . . . . . . . . . . . . . .17Benefits for Lyme Disease Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Inpatient Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Treatment of Craniofacial Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Isolation Care and Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Benefits for Infertility Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Benefits for Hearing Aids for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Benefits for Early Intervention Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Benefits for Neuropsychological Testing for Children with Cancer . . . . . . . . . . . .20Benefits for Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Benefits for Epidermolysis Bullosa Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Benefits for Human Leukocyte Antigen Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Benefits for Blood Lead Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26FrontierMEDEX: Global Emergency Medical Assistance . . . . . . . . . . . . . . . . . . . . . . . . . .26Notice of Appeal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30UnitedHealth Allies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30ID Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
THIS LIMITED HEALTH BENEFITS PLAN DOES NOT PROVIDECOMPREHENSIVE MEDICAL COVERAGE. IT IS A BASIC OR LIMITEDBENEFITS POLICY AND IS NOT INTENDED TO COVER ALL MEDICALEXPENSES. THIS PLAN IS NOT DESIGNED TO COVER THE COSTSOF SERIOUS OR CHRONIC ILLNESS. IT CONTAINS SPECIFICDOLLAR LIMITS THAT WILL BE PAID FOR MEDICAL SERVICESWHICH MAY NOT BE EXCEEDED. IF THE COST OF SERVICESEXCEEDS THOSE LIMITS, THE INSURED AND NOT THE COMPANY ISRESPONSIBLE FOR PAYMENT OF THE EXCESS AMOUNTS. THESPECIFIC DOLLAR LIMITS ARE SPECIFIED IN THE SCHEDULE OFBENEFITS. Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality ofyour non-public personal information. We do not disclose any non-public personalinformation about our customers or former customers to anyone, except as permitted orrequired by law. We believe we maintain appropriate physical, electronic and proceduralsafeguards to ensure the security of your non-public personal information. You may obtaina copy of our privacy practices by calling us toll-free at 1-800-767-0700 or by visiting usat www.uhcsr.com. Eligibility
All enrolled students are eligible to enroll in this insurance Plan. Students must actively attend classes for at least the first 31 days after the date for whichcoverage is purchased. Home study, correspondence, and online courses do not fulfill theEligibility requirements that the student actively attend classes. The Company maintains itsright to investigate Eligibility or student status and attendance records to verify that thepolicy Eligibility requirements have been met. If the Company discovers the Eligibilityrequirements have not been met, its only obligation is to refund premium. Eligible students who do enroll in may also insure their Dependents. Eligible Dependentsare the student’s spouse (including a party to a civil union established according toConnecticut law) and dependent children under 26 years of age. Dependent Eligibility expires concurrently with that of the Insured student. Effective And Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m., August 25, 2013. 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 24, 2014. Coverage terminates on that date or at the end of theperiod through 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 a Non-Renewable One Year Term Policy. Premium Rates Extension of Benefits After Termination
The coverage provided under this policy ceases on the Termination Date. However, if anInsured is Totally Disabled 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 the "Extension of Benefits" provision has been exhausted, all benefits cease to exist,and under no circumstances will further payments be made. Pre-Admission Notification
UnitedHealthcare 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 to provide notification of any admissiondue to Medical Emergency.
UnitedHealthcare 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’svoice mail after hours by calling 1-877-295-0720. Schedule of Medical Expense Benefits Injury and Sickness Up To $500,000 Maximum Benefit Paid as Specified Below (Per Insured Person) (Per Policy Year) Deductible Preferred Provider: $1,000 (Per Insured Person, Per Policy Year) Deductible Out-of-Network: $2,000 (Per Insured Person, Per Policy Year) Coinsurance Preferred Provider: 80% except as noted below Coinsurance Out-of-Network: 60% except as noted below Out-of-Pocket Maximum Preferred Providers: $10,000 (Per Insured Person, Per Policy Year) Out-of-Pocket Maximum Out-of-Network: $15,000 (Per Insured Person, Per Policy Year)
The Policy provides benefits for the Covered Medical Expenses incurred by an Insured Person for loss due to a covered Injury or Sickness up to the Maximum Benefit of $500,000. The Preferred Provider for this plan is UnitedHealthcare Choice Plus. 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. Out-of-Pocket Maximum: After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses will be paid at 100% up to the policy Maximum Benefit subject to any benefit maximums that may apply. The policy Deductible, Copays and per service Deductibles, and services that are not Covered Medical Expenses do not count toward meeting the Out-of-Pocket Maximum. Even when the Out-of-Pocket Maximum has been satisfied, the Insured Person will still be responsible for per service Deductibles. Benefits are subject to the policy Maximum Benefit unless otherwise specifically stated. Benefits will be paid up to the maximum benefit for each service as scheduled below. All benefit maximums are combined Preferred Provider and Out-of-Network unless otherwise specifically stated. Covered Medical Expenses include: PA = Preferred Allowance U&C = Usual and Customary Charges INPATIENT Preferred Out-of-Network Providers Providers Room and Board Expense, daily semi-private
room rate when confined as an Inpatient; andgeneral nursing care provided by the Hospital. Intensive Care Hospital Miscellaneous Expenses, such as the
cost of the operating room, laboratory tests, x-rayexaminations, 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. INPATIENT Preferred Out-of-Network Providers Providers Routine Newborn Care,
Confined; and routine nursery care providedimmediately after birth for an Inpatient stay of atleast 48 hours following a vaginal delivery or 96hours following a cesarean delivery. If the motheragrees, the attending Physician may dischargethe newborn earlier. (See also Benefits forPostpartum Care)Physiotherapy Surgeon’s Fees, if two or more procedures are
performed 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. Assistant Surgeon Anesthetist, professional services administered
in connection with Inpatient surgery. Registered Nurse’s Services, private duty Physician’s Visits, non-surgical services when
confined as an Inpatient. Benefits do not applywhen related to surgery. Pre-Admission Testing, payable within 3 OUTPATIENT Surgeon’s Fees, if two or more procedures are
performed 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. Day Surgery Miscellaneous,
scheduled surgery performed in a Hospital,including the cost of the operating room;laboratory tests and x-ray examinations, includingprofessional fees; anesthesia; drugs ormedicines; and supplies. Usual and CustomaryCharges for Day Surgery Miscellaneous arebased on the Outpatient Surgical Facility ChargeIndex. OUTPATIENT Preferred Out-of-Network Providers Providers Assistant Surgeon Anesthetist, professional services administered
in connection with outpatient surgery. Physician’s Visits, benefits for Physician’s Visits
do not apply when related to surgery orPhysiotherapy. Physiotherapy, see exclusion number 26 for
additional limitations. Physiotherapy includes butis not limited to the following: 1) physical therapy;2) occupational therapy; 3) cardiac rehabilitationtherapy; 4) manipulative treatment; and 5)speech therapy, unless excluded in the policy. Review of Medical Necessity will be performedafter 12 visits per Injury or Sickness. Medical Emergency Expenses, facility charge
for use of the emergency room and supplies. Treatment must be rendered within 72 hours fromtime of Injury or first onset of Sickness. Diagnostic X-ray Services Radiation Therapy Chemotherapy Laboratory Services Tests & Procedures, diagnostic services and
medical procedures performed by a Physician,other than Physician's Visits, Physiotherapy, x-rays and lab procedures. The following therapieswill be paid under this benefit: inhalation therapy,infusion therapy, pulmonary therapy andrespiratory therapy. Injections, when administered in the Physician's
office and charged on the Physician's statement. OUTPATIENT Preferred Out-of-Network Providers Providers Prescription Drugs Ambulance Services, Medically Necessary Maximum allowable rate established transport. Durable Medical Equipment, a written
prescription must accompany the claim whensubmitted. Benefits are limited to the initialpurchase or one replacement purchase per PolicyYear. Durable Medical Equipment includesexternal prosthetic devices that replace a limb orbody part but does not include any device that isfully implanted into the body. ($1,000 maximumPer Policy Year) (Durable Medical Equipmentbenefits payable under the $1,000 maximum arenot included in the $500,000 Maximum Benefit.)Consultant, when requested and approved by Dental Treatment, made necessary by Injury to
Sound, Natural Teeth only. (See also Benefits forInpatient Dental Services)Maternity, benefits will be paid for an Inpatient
stay of at least 48 hours following a vaginaldelivery or 96 hours following a cesarean delivery. If the mother agrees, the attending Physician maydischarge the mother earlier. (See also Benefitsfor Postpartum Care)Preferred Out-of-Network Providers Providers Complications of Pregnancy Elective Abortion Home Health Care Preventive Care Services, medical services that
have been demonstrated by clinical evidence tobe safe and effective in either the early detectionof disease or in the prevention of disease, havebeen proven to have a beneficial effect on healthoutcomes and are limited to the following asrequired under applicable law: 1) Evidence-baseditems or services that have in effect a rating of “A”or “B” in the current recommendations of theUnited States Preventive Services Task Force; 2)immunizations that have in effect arecommendation from the Advisory Committeeon Immunization Practices of the Centers forDisease Control and Prevention; 3) with respectto infants, children, and adolescents, evidence-informed preventive care and screeningsprovided for in the comprehensive guidelinessupported by the Health Resources and ServicesAdministration; and 4) with respect to women,such additional preventive care and screeningsprovided for in comprehensive guidelinessupported by the Health Resources and ServicesAdministration. No Deductible, Copays or Coinsurance will beapplied when the services are received from aPreferred Provider. Reconstructive Breast Surgery Following Mastectomy Diabetes Services, see Benefits for Diabetes
and Benefits for Diabetic Outpatient Self-Management Training. Mental Illness Treatment, services received on
an Inpatient and outpatient basis. See alsoBenefits for Mental or Nervous Conditions. Substance Use Disorder Treatment, services
received on an Inpatient and outpatient basis. Seealso Benefits for Mental or Nervous Conditions. Approved Clinical Trials, (See Benefits for 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 Choice Plus. The availability of specific providers is subject to change without notice. Insureds should always confirm that a Preferred Provider is participating at the time services are required by calling the Company at 1-800-767-0700 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. Insureds 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 Expenses PREFERRED PROVIDERS – Eligible Inpatient expenses at a Preferred Provider will be paid at the Coinsurance percentages specified in the Schedule of Benefits, up to any limits specified in the Schedule of Benefits. Preferred Hospitals include UnitedHealthcare Choice Plus United Behavioral Health (UBH) facilities. Call (800) 767-0700 for information about Preferred Hospitals. OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a Preferred Provider, eligible Inpatient 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 Choice Plus will bepaid at the Coinsurance percentages specified in the Schedule of Benefits or up to anylimits specified in the Schedule of Benefits. All other providers will be paid according to thebenefit limits in the Schedule of Benefits. UnitedHealthcare Pharmacy Benefits
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)when dispensed by a UnitedHealthcare Pharmacy. Benefits are subject to supply limits andCopayments 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 theiruse is covered within your benefit. Prescription Drugs Products which require notification are:Actiq, Anzemet, Avita-Penderm, Avodart, Copegus, Differin-Gladerma, Diflucan, Elidel,Emend, Genotropin, Humatrope, Increlex, Infergen, Intron-A, Iplex, Kytril, Lamisil, Lotronex,Norditropin, Nutropin, Nutropin AQ, Nutropin Depot, PEG-Intron, Pegasys, Proscar,Protopic, Protropin, Provigil, Raptiva, Regranex, Relenza, Retin-A, Retin-A Micro Ortho,Rebetol, Rebetron, Restasis, Revatio, Roferon, Sporanox, Saizen, Serostim, Tamiflu, Tazorac,Tracleer, Ventavis, Wellbutrin SR, Wellbutrin XL, Zelnorm, Zofran, Zorbtive.
You are responsible for paying the applicable Copayment. Your Copayment is determined by the tier to which the Prescription Drug Product is assigned on the PDL. Tier status may change periodically and without prior notice to you. Please access www.uhcsr.com or call 855-828-7716 for the most up-to-date tier status. $15 Copay per prescription order or refill for a Tier 1 Prescription Drug up to a 31 day supply. $35 Copay per prescription order or refill for a Tier 2 Prescription Drug up to a 31 day supply. $40 Copay per prescription order or refill for a Tier 3 Prescription Drug up to a 31 day supply. Mail order Prescription Drugs are available at 2.5 times the retail Copay up to a 90 day supply. 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 for the prescription and then submit a reimbursement form for prescriptions filled at a network pharmacy along with the paid receipt in order to be reimbursed. To obtain reimbursement forms, or for information about mail-order prescriptions or network pharmacies, please visit www.uhcsr.com and log in to your online account or call 855-828-7716. When prescriptions are filled at pharmacies outside the network, the Insured must pay for the prescriptions out-of-pocket and submit the receipts for reimbursement to UnitedHealthcare StudentResources, P.O. Box 809025, Dallas, TX 75380-9025. See the Schedule of Benefits for the benefits payable at out-of-network pharmacies. Additional Exclusions
In addition to the policy Exclusions and Limitations, the following Exclusions apply toNetwork Pharmacy 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 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 Prescription Orderor Refill. Compounded drugs that are available as a similar commercially availablePrescription Drug Product. Compounded drugs that contain at least one ingredientthat 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 designated theover-the counter medication as eligible for coverage as if it were a Prescription DrugProduct 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 unless aMedical Necessity. Certain Prescription Drug Products that the Company hasdetermined are Therapeutically Equivalent to an over-the-counter drug. Suchdeterminations may be made up to six times during a calendar year, and the Companymay decide at any time to reinstate Benefits for a Prescription Drug Product that waspreviously excluded under this 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 orInjury, except as required by state mandate. 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 1-855-828-7716. Maternity Testing
This policy does not cover all routine, preventive, or screening examinations or testing. The following maternity tests and screening exams will be considered for payment according to the policy benefits 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 • 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
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) 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 1-800-767-0700. Accidental Death and Dismemberment Benefits Loss of Life, Limb or Sight
If such Injury shall independently of all other causes and within 180 days from the date of Injury solely result in any one of the following specific losses, the Insured Person or beneficiary may request the Company to pay the applicable amount below in addition to payment under the Medical Expense Benefits. For Loss Of
Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or armsand feet or legs, dismemberment by severance at or above the wrist or ankle joint; withregard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater)resulting from any one Injury will be paid. Mandated Benefits Benefits for Accidental Ingestion of a Controlled Drug
Benefits will be paid for accidental ingestion or consumption of a controlled drug asrequired by Connecticut statute. When inpatient treatment in a Hospital, whether or notoperated by the State, is required as a result of accidental ingestion or consumption of acontrolled drug, benefits will be paid for the Usual and Customary Charges incurred up toa maximum of 30 days Hospital Confinement. Benefits will be paid for outpatient treatmentresulting from accidental ingestion or consumption of a controlled drug for any oneaccident. Benefits for Hypodermic Needles or Syringes
Benefits will be paid for the Usual and Customary Charges incurred for hypodermicneedles or syringes prescribed by a licensed Physician for the purpose of administeringmedications for any Injury or Sickness, provided such medications are covered under thepolicy. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Home Health Care
Benefits will be paid as specified below for Injury or Sickness for home health care toresidents in Connecticut. Benefits payable shall be limited to eighty visits in any calendar year or in any continuousperiod of twelve months for each Insured. Each visit by a representative of a home healthagency shall be considered as one Home Health Care visit; four hours of home health aideservice shall be considered as one Home Health Care visit. Home Health Care benefits are subject to an annual Deductible of fifty dollars ($50.00) foreach Insured and will be subject to a Coinsurance provision of not less than seventy-fivepercent (75%) of the Usual and Customary Charges for such services. If an Insured iseligible for Home Health Care coverage under more than one policy, the Home HealthCare benefits shall only be provided by that Policy which would have provided the greatestbenefits for hospitalization if the person had remained or had been hospitalized. “Home Health Care” means the continued care and treatment of an Insured Person who isunder the care of a Physician if:
(1) continued hospitalization would otherwise have been required if Home Health Care
was not provided, except in the case of an Insured diagnosed by a Physician asterminally ill with a prognosis of six months or less to live, and,
(2) the plan covering the Home Health Care is established and approved in writing by
such Physician within seven days following termination of a hospital confinement asa resident Inpatient for the same or a related condition for which the Insured washospitalized, except that in the case of an Insured diagnosed by a Physician asterminally ill with a prognosis of six months or less to live, such plan may be soestablished and approved at any time irrespective of whether such Insured was soconfined or, if such Insured was so confined, irrespective of such seven-day period,and
(3) such Home Health Care is commenced within seven days following discharge, except
in the case of a covered person diagnosed by a Physician as terminally ill with aprognosis of six months or less to live.
Home Health Care shall be provided by a home health agency. “Home health agency”means an agency or organization which meets each of the following requirements:
(1) It is primarily engaged in and is federally certified as a home health agency and duly
licensed by the appropriate licensing authority to provide nursing and othertherapeutic services.
(2) Its policies are established by a professional group associated with such agency or
organization, including at least one Physician and at least one Registered Nurse, togovern the services provided.
(3) It provides for full-time supervision of such services by a Physician or by a Registered
(4) It maintains a complete medical record on each patient. (5) It has an administrator.
Home Health Care shall consist of, but shall not be limited to, the following:
(1) Part-time or intermittent nursing care by a Registered Nurse or by a licensed practical
nurse under the supervision of a Registered Nurse, if the services of a RegisteredNurse are not available;
(2) Part-time or intermittent home health aide services, consisting primarily of patient
care of a medical or therapeutic nature by other than a Registered Nurse or licensedpractical nurse;
(3) Physical, occupational or speech therapy; (4) Medical supplies, drugs and medicines prescribed by a Physician and laboratory
services to the extent such charges would have been covered under the Policy orcontract if the Insured had remained or had been confined in the Hospital;
(5) Medical social services provided to or for the benefit of a covered person diagnosed
by a Physician as terminally ill with a prognosis of six months or less to live. “Medicalsocial services” mean services rendered, under the direction of a Physician by aqualified social worker, including but not limited to:
(A) assessment of the social, psychological and family problems related to or arising
out of such covered person’s illness and treatment;
(B)appropriate action and utilization of community resources to assist in resolving
(C)participation in the development of the overall plan of treatment for such Insured
Benefits shall be subject to all other limitations and provisions of the policy. Benefits for Mental or Nervous Conditions
Benefits will be paid the same as any other Sickness for the diagnosis and treatment ofMental Illness and Substance Use Disorders. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Treatment of Tumors and Leukemia
Benefits will be paid the same as any other Sickness for the surgical removal of tumors andfor treatment of leukemia, including outpatient chemotherapy, reconstructive surgery, costof any non-dental prosthesis, including any maxillofacial prosthesis used to replaceanatomic structures lost during treatment for head and neck tumors or additionalappliances essential for the support of such prosthesis and outpatient chemotherapyfollowing surgical procedures in connection with the treatment of tumors, and a wig ifprescribed by a licensed oncologist for a patient who suffers hair loss as a result ofchemotherapy. Benefits Per Policy Year shall be at least $300.00 for prosthesis, except that for purposesof the surgical removal of breasts due to tumors the yearly benefit for prosthesis shall beat least $300.00 for each breast removed, and $350.00 for a wig. If the policy provides benefits for Prescription Drugs, benefits will be provided forprescribed orally administered anticancer medications on a basis that is no less favorablethan intravenously administered anticancer medications. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Reconstructive Breast Surgery
Benefits will be paid for the Usual and Customary Charges incurred for reconstructivesurgery on each breast on which a mastectomy has been performed, and reconstructivesurgery on a nondiseased breast to produce a symmetrical appearance. Reconstructivesurgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplastyand mastopexy. Benefits shall be provided for at least forty eight hours of Inpatient care following amastectomy or lymph node dissection, and may provide for a longer period of Inpatient careif such care is recommended by the Insured’s Physician. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Mammography and Comprehensive Ultrasound Screening
Benefits will be paid the same as any other Covered Medical Expenses as shown on theSchedule of Benefits for mammographic examinations to any woman insured under thispolicy which are equal to the following requirements: 1) a baseline mammogram for anywoman who is thirty-five to thirty-nine years of age, inclusive; and 2) a mammogram everyyear for any woman who is forty years of age or older. Additional benefits will be provided for comprehensive ultrasound screening and magneticresonance imaging, in accordance with guidelines established by the American CancerSociety or the American College of Radiology, of an entire breast or breasts if amammogram demonstrates heterogeneous or dense breast tissue based on the BreastImaging Reporting and Data System established by the American College of Radiology orif a woman is believed to be at increased risk for breast cancer due to family history or priorpersonal history of breast cancer, positive genetic testing or other indications asdetermined by a woman’s Physician or advanced practice Registered Nurse. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy
Benefits for Prostate Cancer Testing
Benefits will be paid the same as any other Sickness for laboratory and diagnostic tests,including, but not limited to, prostate specific antigen (PSA) tests to screen for prostatecancer for Insureds who are symptomatic, or whose biological father or brother has beendiagnosed with prostate cancer, and for all Insureds fifty (50) years of age or older. Benefits will also be paid for the treatment of prostate cancer, provided such treatment isMedically Necessary and in accordance with guidelines established by the NationalComprehensive Cancer Network, the American Cancer Society or the American Society ofClinical Oncology. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Ostomy Appliances and Supplies
Benefits will be paid for the Usual and Customary Charges for Medically Necessaryappliances and supplies relating to an ostomy including, but not limited to, collectiondevices, irrigation equipment and supplies, skin barriers and skin protectors up to amaximum benefit of $2,500.00 per Policy Year. “Ostomy" shall include colostomy, ileostomy and urostomy. Benefits shall not be applied to any Durable Medical Equipment benefit maximum. Benefits shall be subject to all other Deductible, Copayments, Coinsurance, limitations, orany other provisions of the policy. Benefits for Colorectal Cancer Screening
Benefits will be paid the same as any other Sickness for colorectal cancer screening,including, but not limited to: (1) an annual fecal occult blood test, and (2) colonoscopy,flexible sigmoidoscopy or radiologic imaging, in accordance with the recommendationsestablished by the American College of Gastroenterology, after their consultation with theAmerican Cancer Society and the American College of Radiology, based on the ages,family histories and frequencies provided in the recommendations. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy; however, benefits will not be subject to any Deductible,Copayments, Coinsurance or out of pocket expense for any additional colonoscopyservices ordered by a Physician within a policy year. Benefits for Cancer Clinical Trial
Benefits will be paid the same as any other Sickness for the Routine Patient Care Costsassociated with Clinical Trials. “Clinical Trial” means an organized, systematic, scientific study of therapies, tests or otherclinical interventions for purposes of treatment or palliation or therapeutic intervention for theprevention of cancer or disabling or life-threatening chronic diseases in Insured Persons. “Routine Patient Care Costs” means: 1) Medically Necessary health care services that areincurred as a result of treatment being provided to the Insured for purposes of the ClinicalTrial that would otherwise be covered if such services were not rendered pursuant to aClinical Trial. Such services shall include those rendered by a Physician, diagnostic orlaboratory tests, hospitalization or other services provided to the Insured during the courseof treatment in the Clinical Trial for a condition, or one of its complications, that is consistentwith the usual and customary standard of care and would be covered if the Insured werenot enrolled in a Clinical Trial; and 2) costs incurred for Prescription Drugs provided to theInsured, provided such Prescription Drugs have been approved for sale by the federal Foodand Drug Administration. If the policy provides Preferred Provider benefits, suchhospitalization shall include treatment at an Out-of-Network facility if such treatment is notavailable at a Preferred Provider Hospital and not eligible for reimbursement by thesponsors of such Clinical Trial.
Routine Patient Care Costs shall not include: 1) the cost of an investigational new drug ordevice that has not been approved for market for any indication by the federal Food andDrug Administration; 2) the cost of a non-health care service that an Insured may berequired to receive as a result of the treatment being provided; 3) facility, ancillary,professional services and drug costs that are paid for by grants or funding for the ClinicalTrial; 4) costs of services that are: a) inconsistent with widely accepted and establishedregional or national standards of care for a particular diagnosis; or b) performed specificallyto meet the requirements of the Clinical Trial; 5) costs that would not be covered under theInsured’s policy for investigational treatments, including, but not limited to, items excludedfrom coverage under this policy; and 6) transportation, lodging, food or any other expensesassociated with travel to or from a facility providing the Clinical Trial for the Insured or anyfamily member or companion. The Company may require that the person or entity seeking coverage for the Clinical Trialprovide: 1) evidence satisfactory to the Company that the Insured receiving coveragemeets all of the patient selection criteria for the clinical trial, including credible evidence inthe form of clinical or pre-clinical data showing that the Clinical Trial is likely to have abenefit for the Insured Person that is commensurate with the risks of participation in theClinical Trial to treat the Insured Person’s condition; and 2) evidence that the appropriateinformed consent has been received from the Insured; and 3) copies of any medicalrecords, protocols, test results or other clinical information used by the Physician orinstitution seeking to enroll the Insured in the Clinical Trial; and 4) a summary of theanticipated Routine Patient Care Costs in excess of the costs for standard treatment; and5) information from the Physician or institution regarding those items, including anyRoutine Patient Care Costs, that are eligible for reimbursement by an entity other than theCompany, including the entity sponsoring the Clinical Trial; and 6) any additional informationthat may be reasonably required for the review of a request for coverage of the Clinical Trial. The Company shall request any additional information about a Clinical Trial not later thanfive business days after receiving a request for coverage from an Insured Person or aPhysician seeking to enroll an Insured in a Clinical Trial. A Clinical Trial for the prevention of cancer shall be eligible for coverage only if it involvesa therapeutic intervention, is a phase III Clinical Trial approved by one of the entitiesidentified below and is conducted at multiple institutions. In order to be eligible forcoverage of Routine Patient Care Costs, a Clinical Trial shall be conducted under theauspices of an independent peer-reviewed protocol that has been reviewed and approvedby: 1) one of the National Institutes of Health; or 2) a National Cancer Institute affiliatedcooperative group; or 3) the federal Food and Drug Administration as part of aninvestigational new drug or device exemption; or 4) the federal Department of Defense orVeterans Affairs; or 5) qualified to receive Medicare coverage of its routine costs under theMedicare Clinical Trial Policy established under the September 19th, 2000, MedicareNational Coverage Determination, as amended from time to time. Benefits will not beprovided for any single institution Clinical Trial conducted solely under the approval of theinstitutional review board of an institution, or any trial that is no longer approved by an entityidentified hereinThe provider, Hospital or institution seeking coverage for the Routine Patient Care Costsshall submit to the Company the standardized request for coverage form as developed bythe Connecticut Insurance Department to request approval for Clinical Trial benefits. TheCompany shall not accept any other approval request form other than the standardizedrequest for coverage form. Upon receipt of the standardized form, the Company shallapprove or deny coverage for such services not later than five business days after receivingsuch request and any other reasonable supporting materials requested by the Company,except that if the Company utilizes independent experts to review such requests, it shallrespond not later than ten business days after receiving such request and supportingmaterials.
The Insured, or the provider with the Insured’s written consent, may appeal any denial ofcoverage for Medical Necessity to an external, independent review pursuant to section39a-478n of the general statutes. Such external review shall be conducted by a properlyqualified review agent whom the Connecticut Department of Insurance has determineddoes not have a conflict of interest regarding the Clinical Trial. The Company shall not provide coverage for Routine Patient Care Costs that are eligible forreimbursement by an entity other than the Company, including the entity sponsoring theClinical Trial. Routine Patient Care Costs shall be subject to the same Deductibles, Copayments,Coinsurance, terms, conditions, restrictions, exclusions and limitations of the policy,including limitations on out-of-network care, except that treatment at an out-of-networkHospital shall be made available by the out-of-network Hospital and the Company at nogreater cost to the Insured than if treatment was available at a Preferred Provider Hospital
Benefits for Postpartum Care
If an Insured and Newborn Infant are discharged from Inpatient care less than forty-eighthours after a vaginal delivery or less than ninety-six hours after a cesarean delivery, benefitswill be provided on the same basis as any other Covered Medical Expenses as shown onthe Schedule of Benefits for a follow-up visit within forty-eight hours of discharge and anadditional follow-up visit within seven days of discharge. Any decision to shorten the lengthof Inpatient stay to less than forty-eight hours after a vaginal delivery or ninety-six hoursafter a cesarean delivery shall be made by the Physician after conferring with the Insured. Follow-up services shall include, but not be limited to, physical assessment of the Newborn,parent education, assistance and training in breast or bottle feeding, assessment of thehome support system and the performance of any Medically Necessary and appropriateclinical tests. Such services shall be consistent with protocols and guidelines developed byattending providers or by national pediatric, obstetric and nursing professionalorganizations for these services and shall be provided by qualified health care personneltrained in postpartum maternal and Newborn pediatric care. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Amino Acid Modified Preparations and Low Protein Modified Food Products
Benefits will be paid the same as any other outpatient Prescription Drug for Amino AcidModified Preparations and Low Protein Modified Food Products for the treatment ofInherited Metabolic Diseases if the Amino Acid Modified Preparations or Low ProteinModified Food Products are prescribed for the therapeutic treatment of Inherited MetabolicDiseases and are administered under the direction of a Physician. If the policy does not provide benefits for outpatient Prescription Drugs, benefits will beprovided subject to the policy maximum benefit including any Deductible, Copayment orCoinsurance requirements. “Inherited Metabolic Disease” means: (A) disease for which newborn screening is requiredunder Connecticut Statute Title 38a, Chapter 700c, Section 19a-55; and (B) CysticFibrosis. “Low Protein Modified Food Product means a product formulated to have less than onegram of protein per serving and intended for the dietary treatment of an inherited metabolicdisease under the direction of a physician. “Amino Acid Modified Preparation” means a product intended for the dietary treatment ofan inherited metabolic disease under the direction of a Physician. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Specialized Formulas
Benefits will be paid the same as any other outpatient Prescription Drug for medicallynecessary Specialized Formulas for Dependent children up to age twelve when suchspecialized formulas are for the treatment of a condition for which newborn screening isrequired under section 19a-55 of the Public Health and Well Being Regulation. If the policy does not provide benefits for outpatient Prescription Drugs, benefits will beprovided subject to the policy maximum benefit including any Deductible, Copayment orCoinsurance requirements. “Specialized Formula” means a nutritional formula for children up to age twelve that isexempt from the general requirement for nutritional labeling under the statutory andregulatory guidelines of the federal Food and Drug Administration and is intended for usesolely under medical supervision in the dietary management of specific disease. Benefit shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Diabetes
Benefits will be paid the same as any other Sickness for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and non-insulin-usingdiabetes. Such coverage shall include Medically Necessary equipment, in accordance withthe Insured Person's treatment plan, drugs and supplies prescribed by a Physician. If the policy contains a Prescription Drugs maximum benefit, diabetic insulin and suppliesshall not be subject to the Prescription Drugs maximum benefit specified in the Scheduleof Benefits. Benefits shall be subject to all other Deductible, Copayments, Coinsurance,limitations, or any other provisions of the policy. Benefits for Diabetic Outpatient Self Management Training
Benefits will be paid the same as any other Sickness for outpatient self-managementtraining for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestationaldiabetes and non-insulin-using diabetes if the training is prescribed by a Physician. Outpatient self-management training includes, but is not limited to, education and medicalnutrition therapy. Diabetes self-management training shall be provided by a Physician, asdefined in the Policy, trained in the care and management of diabetes and authorized toprovide such care within the scope of the Physician’s practice. Covered Medical Expenses shall include:
1) Initial training visits provided to an Insured after the Insured is initially diagnosed
with diabetes that is Medically Necessary for the care and management ofdiabetes, including, but not limited to, counseling in nutrition and the proper use ofequipment and supplies for the treatment of diabetes, up to a maximum of tenhours.
2) Training and education that is Medically Necessary as a result of a subsequent
diagnosis by a Physician of a significant change in the Insured’s symptoms orcondition which requires modification of the Insured’s program of self-management of diabetes, up to a maximum of four hours.
3) Training and education that is Medically Necessary because of the development of
new techniques and treatment for diabetes up to a maximum of four hours.
Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Lyme Disease Treatment
Benefits will be paid the same as any other Sickness for Lyme disease treatment includingnot less than thirty days of intravenous antibiotic therapy, sixty days of oral antibiotictherapy, or both, and shall provide benefits for further treatment if recommended by aPhysician. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Inpatient Dental Services
Benefits will be paid the same as any other Sickness for general anesthesia, nursing andrelated Hospital services provided in conjunction with Inpatient, outpatient or one daydental services if the following conditions are met:
1) The anesthesia, nursing and related Hospital services are deemed Medically
Necessary by the treating Physician.
2) The Insured is either a) a person who is determined by a Physician to have a dental
condition of significant dental complexity that it requires certain dental proceduresto be performed in a Hospital, or b) a person who has a developmental disability, asdetermined by a Physician, that places the person at serious risk.
The expense of anesthesia, nursing and related Hospital services shall be deemed aCovered Medical Expense and shall not be subject to any limits on dental benefits in thePolicy. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Treatment of Craniofacial Disorders
Benefits will be paid the same as any other Sickness for Medically Necessary orthodonticprocesses and appliances for the treatment of craniofacial disorders for Insureds eighteenyears of age or younger. The processes and appliances must be prescribed by acraniofacial team recognized by the American Cleft Palate-Craniofacial Association. Nobenefits are provided for cosmetic surgery. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Pain Management
Benefits will be paid the same as any other Sickness for Pain treatment ordered by a PainManagement Specialist, which may include all means Medically Necessary to make adiagnosis and develop a treatment plan including the use of necessary medications andprocedures. “Pain” means a sensation in which a person experiences severe discomfort, distress orsuffering due to provocation of sensory nerves, and “Pain Management Specialist” meansa Physician who is credentialed by the American Academy of Pain Management or who isa board-certified anesthesiologist, neurologist, oncologist or radiation oncologist withadditional training in pain management. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Isolation Care and Emergency Care
Benefits will be paid the same as any other Injury or Sickness for isolation care andemergency services provided by the state’s mobile field Hospital. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Infertility Treatment
Benefits will be paid the same as any other Sickness for an Insured Person for themedically necessary expenses of the diagnosis and treatment of Infertility, including, but notlimited to, ovulation induction, intrauterine insemination, in-vitro fertilization, uterine embryolavage, embryo transfer, gamete intra-fallopian transfer, zygote intra-fallopian transfer andlow tubal ovum transfer. Such infertility treatment must be performed at facilities thatconform to the standards and guidelines developed by the American Society ofReproductive Medicine or the Society of Reproductive Endocrinology and Infertility. For the purposes of this section “Infertility” means the condition of a presumably healthyindividual who is unable to conceive or produce conception or sustain a successfulpregnancy during a one year period. Benefits are subject to the following limitations:
1) Benefits are available up to the Insured Person’s fortieth (40) birthday. 2) Benefits for ovulation induction are subject to a lifetime limit of four (4) cycles. 3) Benefits for intrauterine insemination are subject to a lifetime limit of [three (3)]
4) Benefits for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian
transfer, and tubal ovum transfer are subject to a lifetime limit of two (2) cycles, withnot more than two (2) embryo implantations per cycle.
5) Benefits for in-vitro fertilization, gamete intra-fallopian transfer, zygote intra-fallopian
transfer and low tubal ovum transfer are payable only to those Insured Persons who:
a) Have been unable to conceive or produce conception or sustain a successful
pregnancy through less expensive and medically viable infertility treatment orprocedures covered by this policy. However benefits will not be denied on this basisfor any Insured Person who foregoes a particular infertility treatment or procedureif the Insured Person’s Physician determines that such treatment or procedure islikely to be unsuccessful.
6) Have been covered under the school’s student insurance policy for at least 12
7) Provide disclosure of any previous infertility treatment or procedures for which such
Insured Person received coverage under a different health insurance policy.
Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Hearing Aids for Children
Benefits will be paid for Medically Necessary hearing aids for Dependent children agestwelve years or younger. Such hearing aids shall be considered Durable Medical Equipmentand shall be limited to a maximum benefit of $1000.00 within a twenty-four month period. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Early Intervention Services
Benefits will be paid as determined by the schedule published by the Director ofConnecticut’s Birth to Three program for Medically Necessary Early Intervention Servicesfor Dependent Eligible Children, from birth until the child’s third birthday, that are providedas part of an Individualized Family Service Plan pursuant to Title 17a of the Social andHuman Services and Resources, Chapter 319b, Department of Developmental Services,section, 17a-248e, up to a maximum benefit of $6,400.00 per child per calendar year andan aggregate benefit of $19,200.00 per child over the total three-year period. Benefits paidunder this benefit shall not be applied to any Policy Year maximum specified in the Policy.
To the extent that an Early Intervention Service falls into one of the essential benefitcategories issued by the Affordable Care Act (ACA) the maximum and aggregate benefitlimit will not be applied. "Early intervention services" means early intervention services, as defined in 34 CFR Part303.12, as from time to time amended. "Eligible children" means Dependent children from birth to thirty-six months of age, whoare not eligible for special education and related services pursuant to sections 10-76a to10-76h, inclusive, as amended, and who need Early Intervention Services because suchchildren are: (A) Experiencing a significant developmental delay as measured bystandardized diagnostic instruments and procedures, including informed clinical opinion, in one or moreof the following areas: (1) cognitive development; (2) physical development, including visionor hearing; (3) communication development; (4) social or emotional development; or (5)adaptive skills; or (B) Diagnosed as having a physical or mental condition that has a highprobability of resulting in developmental delay. "Individualized family service plan" means a written plan for providing Early InterventionServices to an Eligible Child and the child's family after completion of an evaluation. "Evaluation" means a multidisciplinary professional, objective assessment conducted byappropriately qualified personnel in order to determine a child's eligibility for EarlyIntervention Services. The policy Deductible, Copayment, Coinsurance limitations, or any other limitations will notbe applied to this benefit. Benefits for Neuropsychological Testing for Children with Cancer
Benefits will be paid the same as any other Sickness without prior authorization for eachDependent child diagnosed with cancer, for neuropsychological testing ordered by alicensed Physician, to assess the extent of any cognitive or developmental delays in suchchild due to chemotherapy or radiation treatment. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Autism Spectrum Disorders
Benefits will be paid the same as any other Sickness for physical therapy, speech therapy,and occupational therapy services for the treatment of Autism Spectrum Disorders, as setforth in the most recent edition of the American Psychiatric Association’s “Diagnostic andStatistical Manual of Mental Disorders”. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Epidermolysis Bullosa Treatment
Benefits will be paid for the Usual and Customary Charges for wound-care supplies thatare Medically Necessary for the treatment of Epidermolysis Bullosa provided such benefitsare administered under the direction of a Physician. “Epidermolysis Bullosa” is a genetic disorder caused by a mutation in the keratin gene. Thedisorder is characterized by the presence of extremely fragile skin and recurrent blisterformation, resulting from minor mechanical friction or trauma. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Benefits for Human Leukocyte Antigen Testing
Benefits will be paid the same as any other Sickness for expenses arising for humanleukocyte antigen testing, also referred to as histocompatibility locus antigen testing, for A,B and DR antigens for utilization in bone marrow transplantations. Such testing shall be performed in a facility a) accredited by the American Society forHistocompatibility and Immunogenetics, or its successor, and b) certified under the ClinicalLaboratory Improvement Act of 1967, 42 USC Section 263a, as amended from time to time. Benefits are limited to Insured Persons who, at the time of such testing, complete and signan informed consent form that also authorizes the results of the test to be used forparticipation in the National Marrow Donor Program. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy; however, any Deductible, Copayment, Coinsurance or otherout of pocket expense shall not exceed 20% of the cost of the testing Per Policy Year. Benefits for Blood Lead Screening
Benefits will be paid for the Usual and Customary Charges for blood lead screening andrisk assessment ordered by an Insured’s primary Physician. Benefits shall be subject to all Deductible, Copayments, Coinsurance, limitations, or anyother provisions of the policy. Definitions COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in excess of Usual and Customary Charges; 2) not in excess of the Preferred Allowance when the policy includes Preferred Provider benefits and the charges are received from a Preferred Provider; 3) not in excess of the maximum benefit amount payable per service as specified in the Schedule of Benefits; 4) made for services and supplies not excluded under the policy; 5) made for services and supplies which are a Medical Necessity; 6) made for services included in the Schedule of Benefits; and 7) in excess of the amount stated as a Deductible, if any. Covered Medical Expenses will be deemed "incurred" only: 1) when the covered services are provided; and 2) when a charge is made to the Insured Person for such services. INJURY means accidental bodily injuries sustained by the Insured Person which: 1) are the direct cause, independent of disease or bodily infirmity or any other cause; 2) are treated by a Physician within 30 days after the date of accident; and occurs while this policy is in force, subject to the policy Pre-existing Condition provisions. 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, subject to the policy Pre-existing Condition provisions. INPATIENT means an uninterrupted confinement that follows formal admission to a Hospital by reason of an Injury or Sickness for which benefits are payable under this policy. MEDICAL NECESSITY means health care services that a Physician, exercising prudent clinical judgement, would provide to an Insured for the purpose of preventing, evaluating, diagnosing or treating Sickness, Injury, or its symptoms, and that are:
1) In accordance with Generally Accepted Standards of Medical Practice;2) Clinically appropriate, in terms of type, frequency, extent, site and duration and
considered effective for the Insured’s Sickness or Injury; and
3) Not primarily for the convenience of the Insured, Physician or other health care
provider and not more costly than an alternative service or sequence of services atleast as likely to produce equivalent therapeutic or diagnostic results as to thediagnosis or treatment of the Insured’s Sickness or Injury.
For the purposes of this definition, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or otherwise consistent with the standards set forth in policy issues involving clinical judgement. OUT-OF-POCKET MAXIMUM means the amount of Covered Medical Expenses that must be paid by the Insured Person before Covered Medial Expenses will be paid at 100% for the remainder of the Policy Year according to the policy Schedule of Benefits. The following expenses do not apply toward meeting the Out-of-Pocket Maximum, unless otherwise specified in the policy Schedule of Benefits:
1) Deductibles. 2) Copays. 3) Expenses that are not Covered Medical Expenses. PRE-EXISTING CONDITION means any condition which is diagnosed, treated or recommended for treatment within the 12 months immediately prior to the Insured's Effective Date under the policy. Routine follow-up care to determine whether a breast cancer has reoccurred in a person who has been previously determined to be breast cancer free shall not be considered as medical advice, diagnosis, care or treatment unless evidence of breast cancer is found during or as a result of such follow-up. Genetic information shall not be treated as a condition in the absence of a diagnosis of the condition related to such information. Pregnancy shall not be considered a pre-existing condition. SICKNESS means sickness or disease of the Insured Person which causes loss, and originates while the Insured Person is covered under this policy, subject to the policy Pre- existing Condition provisions. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. 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. TOTALLY DISABLED means a condition of a Named Insured which, because of Sickness or Injury, renders the Insured unable to actively attend class. A totally disabled Dependent is one who is unable to perform all activities usual for a person of that age. USUAL AND CUSTOMARY CHARGES means the lesser of the actual charge or 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 of the Policyholder. The Company uses data from FAIR Health, Inc. to determine Usual and Customary Charges. 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. Exclusions and Limitations
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from;or b) treatment, services or supplies for, at, or related to any of the following:
1. Acne; 2. Acupuncture; 3. Allergy including allergy testing; 4. Milieu therapy, learning disabilities, behavioral problems, parent-child problems,
conceptual handicap, developmental delay or disorder or mental retardation, exceptas specifically provided in the Benefits for Early Intervention Services;
5. Biofeedback; 6. Congenital conditions, except as specifically provided for Newborn or adopted
7. 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;
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 care in treatment or substance abuse facilities for domiciliary or CustodialCare;
9. Dental treatment, except as specifically provided in the Policy; 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 visualdefects and problems; except when due to a covered Injury or disease process;
13. Flat foot conditions; supportive devices for the foot; fallen arches; weak feet; chronic
foot strain; symptomatic complaints of the feet; and routine foot care including thecare, cutting and removal of corns, calluses, toenails, and bunions (except capsular orbone surgery);
14. Health spa or similar facilities; strengthening programs; 15. Hearing examinations; hearing aids, except as specifically provided in the Benefits for
Hearing Aids for Children; or other treatment for hearing defects and problems,except as a result of an infection or trauma. "Hearing defects" means any physicaldefect of the ear which does or can impair normal hearing, apart from the diseaseprocess;
18. Immunizations, except as specifically provided in the policy; preventive medicines or
vaccines, except where required for treatment of a covered Injury or as specificallyprovided in the policy;
19. For Accidental Death and Dismemberment Benefit only, no indemnity will be paid for
loss caused by the voluntary use of any controlled substance as defined in Title II ofthe Comprehensive Drug Abuse Prevention and Control Act of 1970, as now orhereafter amended, unless as prescribed by his Physician for the Insured;
20. Injury or Sickness for which benefits are paid or payable under any Workers'
Compensation or Occupational Disease Law or Act, or similar legislation;
21. Injury or Sickness outside the United States and its possessions, Canada or Mexico,
except for a Medical Emergency when traveling for academic study abroad programs,business or pleasure;
22. Injury sustained by reason of a motor vehicle accident to the extent that benefits are
paid or payable by any other valid and collectible insurance;
23. Injury sustained while (a) participating in any intercollegiate, or professional sport,
contest or competition; (b) traveling to or from such sport, contest or competition asa participant; or (c) while participating in any practice or conditioning program for suchsport, contest or competition;
24. Investigational services; 25. Lipectomy; 26. Outpatient Physiotherapy; except for a condition that required surgery or Hospital
Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2)within the 30 days immediately following the attending Physician's release forrehabilitation;
27. Participation in a riot, civil disorder or a felony, except when Injury occurs when the
Insured Person has an elevated blood alcohol content or when under the influence ofintoxicating liquor or any drug or both. Participation means to voluntarily take a partor share with others assembled together in some activity. Riot means a violent publicdisturbance of the peace by a number of persons assembled together;
28. Pre-existing Conditions for a period of 12 months, except for congenital anomalies of
a Newborn Infant; or, except for individuals who have been continuously insuredunder the student insurance policy for at least 12 consecutive months. Credit will begiven for Pre-existing Conditions for newly Insured Persons who were covered underprevious Qualifying Coverage, but not covered for such Pre-existing Conditions underthe Qualifying Coverage when (a) the preceding Qualifying Coverage was continuousto a date not less than 120 days prior to their effective date under this policy; and for(b) newly Insured Persons who apply within 30 days of initial eligibility under thispolicy and whose previous Qualifying Coverage was terminated due to the involuntaryloss of employment and was continuous to a date not more than 150 days prior totheir effective date under this policy. This Pre-existing Condition Limitation will notapply to newly Insured Persons who were covered for such Pre-existing Conditions,under previous Qualifying Coverage when (a) the preceding Qualifying Coverage wascontinuous to a date not less than 120 days prior to their effective date under thispolicy; or (b) newly Insured Persons who apply within 30 days of initial eligibility underthis policy and whose previous Qualifying Coverage was terminated due to theinvoluntary loss of employment and was continuous to a date not more than 150 daysprior to their effective date under this policy. This exclusion will not be applied to anInsured Person who is under age 19;
29. Prescription Drugs, services or supplies as follows:
a) Therapeutic devices or appliances, including: hypodermic needles, and syringes,
except for hypodermic needles or syringes prescribed by a Physician for thepurpose of administering medications for medical conditions, provided suchmedications are covered under the policy, support garments and other non-medical substances, except as specifically provided in the policy;
b) Immunization agents, except as specifically provided in the policy, biological sera,
blood or blood products administered on an outpatient basis;
c) Drugs labeled, “Caution - limited by federal law to investigational use” or
experimental drugs except for drugs for the treatment of cancer that have notbeen approved by the Federal Food and Drug Administration, provided the drug isrecognized for treatment of the specific type of cancer for which the drug hasbeen prescribed in one of the following established reference compendia: (1) TheU.S. Pharmacopeia Drug Information Guide for the Health Care Professional (USPDI); (2) The American Medical Association’s Drug Evaluations (AMA DE); or (3)The American Society of Hospital Pharmacist’s American Hospital FormularyService Drug Information (AHFS-DI) ;
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,
Profasi, Metrodin, Serophene, or Viagra; except as specifically provided in theBenefits for Infertility Treatment;
i) Refills in excess of the number specified or dispensed after one (1) year of date
30. 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, except as specifically provided inthe Benefits for Infertility Treatment; premarital examinations; impotence, organic orotherwise; female sterilization procedures, except as specifically provided in thepolicy; vasectomy; sexual reassignment surgery; reversal of sterilization procedures;
31. Research or examinations relating to research studies, or any treatment for which the
patient or the patient’s representative must sign an informed consent documentidentifying the treatment in which the patient is to participate as a research study orclinical research study, except for a procedure, treatment or the use of any drug asexperimental if such procedure, treatment or drug, for the Sickness or condition beingtreated, or for the diagnosis for which it is being prescribed, has successfullycompleted a Phase III clinical trial of the Federal Food and Drug Administration; orexcept as specifically provided in the policy;
32. Routine Newborn Infant Care, well-baby nursery and related Physician charges,
except as specifically provided in the policy;
33. Preventive care services; routine physical examinations and routine testing;
preventive testing or treatment; screening exams or testing in the absence of Injuryor Sickness; except as specifically provided in the policy;
34. Services provided without charge by the Health Service of the Policyholder; or
services covered or provided by the student health fee for which the Insured is notcharged;
35. Skeletal irregularities of one or both jaws, including orthognathia and mandibular
retrognathia, except as specifically provided in the Benefits for Treatment ofCraniofacial Disorders; temporomandibular joint dysfunction; deviated nasal septum,including submucous resection and/or other surgical correction thereof; nasal andsinus surgery, except for treatment of a covered Injury or treatment of chronicpurulent sinusitis;
36. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee
jumping, or flight in any kind of aircraft, except while riding as a passenger on aregularly scheduled flight of a commercial airline;
38. Speech therapy; naturopathic services; 39. Unless specifically covered under Benefits for Mental or Nervous Conditions, Injury
resulting from suicide or attempted suicide while sane or insane (including drugoverdose); or intentionally self-inflicted Injury;
40. Supplies, except as specifically provided in the policy;
41. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic
devices, or gynecomastia; except as specifically provided in the Benefits forReconstructive Breast Surgery and Benefits for Treatment of Tumors and Leukemia;
42. Treatment in a Government hospital for which the Insured is not charged, unless there
is a legal obligation for the Insured Person to pay for such treatment;
43. 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
44. Weight management, weight reduction, nutrition programs, treatment for obesity, and
surgery for removal of excess skin or fat. 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 number indicated on the permanent ID card. Collegiate Assistance Program is staffed by Registered Nurses and Licensed Clinicianswho can help students determine if they need to seek medical care, need legal/financialadvice or may need to talk to someone about everyday issues that can be overwhelming. FrontierMEDEX: 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 FrontierMEDEX. The requirements to receive these services are as follows: International Students, insured spouse and insured minor child(ren): You are eligible to receive FrontierMEDEX services worldwide, except in your home country. Domestic Students, insured spouse and insured minor child(ren): You are eligible for FrontierMEDEX services 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. FrontierMEDEX 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 services must be arranged and provided by FrontierMEDEX; any services not arranged by FrontierMEDEX will not be considered for payment. Key Services include:
Please visit www.uhcsr.com/frontiermedex for the FrontierMEDEX brochure which includes service descriptions and program exclusions and limitations. To access services please call: (800) 527-0218 Toll-free within the United States (410) 453-6330 Collect outside the United States
Services are also accessible via e-mail at [email protected].
When calling the FrontierMEDEX Operations Center, please be prepared to provide:
1. Caller's name, telephone and (if possible) fax number, and relationship to the
2. Patient's name, age, sex, and FrontierMEDEX ID Number as listed on your Medical
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.
FrontierMEDEX is not travel or medical insurance but a service provider for emergencymedical assistance services. All medical costs incurred should be submitted to your healthplan and are subject to the policy limits of your health coverage. All assistance servicesmust be arranged and provided by FrontierMEDEX. Claims for reimbursement of servicesnot provided by FrontierMEDEX will not be accepted. Please refer to the FrontierMEDEXinformation in MyAccount at www.uhcsr.com/MyAccount for additional information,including limitations and exclusions. Notice of Appeal Rights Right to Internal Appeal Standard Internal Appeal
The Insured Person has the right to request an Internal Appeal if the Insured Persondisagrees with the Company’s denial, in whole or in part, of a claim or request for benefits. The Insured Person, or the Insured Person’s Authorized Representative, must submit awritten request for an Internal Appeal within 180 days of receiving a notice of theCompany’s Adverse Determination. The written Internal Appeal request should include:
1. A statement specifically requesting an Internal Appeal of the decision;2. The Insured Person’s Name and ID number (from the ID card);3. The date(s) of service;4. The Provider’s name;5. The reason the claim should be reconsidered; and6. Any written comments, documents, records, or other material relevant to the claim.
Please contact the Customer Service Department at 800-767-0700 with any questions regarding the Internal Appeal process. The written request for an Internal Appeal should be sent to: Claims Appeals, UnitedHealthcare StudentResources, PO Box 809025, Dallas, TX 75380-9025. Expedited Internal Appeal
For Urgent Care Requests, an Insured Person may submit a request, either orally or inwriting, for an Expedited Internal Appeal. An Urgent Care Request means a request for services or treatment where the time periodfor completing a standard Internal Appeal:
1. Could seriously jeopardize the life or health of the Insured Person or jeopardize theInsured Person’s ability to regain maximum function; or2. Would, in the opinion of a Physician with knowledge of the Insured Person’smedical condition, subject the Insured Person to severe pain that cannot be adequatelymanaged without the requested health care service or treatment.
To request an Expedited Internal Appeal, please contact Claims Appeals at 888-315-0447. The written request for an Expedited Internal Appeal should be sent to: UnitedHealthcare StudentResources, PO Box 809025, Dallas, TX 75380-9025. Right to External Independent Review
After exhausting the Company’s Internal Appeal process, the Insured Person, or the InsuredPerson’s Authorized Representative, has the right to request an External IndependentReview when the service or treatment in question:
1. Is a Covered Medical Expense under the Policy; and2. Is not covered because it does not meet the Company’s requirements for Medical
Necessity, appropriateness, health care setting, level or care, or effectiveness. Standard External Review
A Standard External Review request must be submitted in writing within 120 days of receiving a notice of the Company’s Adverse Determination or Final Adverse Determination. Expedited External Review
An Expedited External Review request may be submitted either orally or in writing when:
1. The Insured Person or the Insured Person’s Authorized Representative has received
a. The Insured Person, or the Insured Person’s Authorized Representative, has
submitted a request for an Expedited Internal Appeal; and
b. Adverse Determination involves a medical condition for which the time frame for
completing an Expedited Internal Review would seriously jeopardize the life orhealth of the Insured Person or jeopardize the Insured Person’s ability to regainmaximum function; or
2. The Insured Person or the Insured Person’s Authorized Representative has received
a. The Insured Person has a medical condition for which the time frame for
completing a Standard External Review would seriously jeopardize the life or healthof the Insured Person or jeopardize the Insured Person’s ability to regain maximumfunction; or
b. The Final Adverse Determination involves an admission, availability of care,
continued stay, or health care service for which the Insured Person receivedemergency services, but has not been discharged from a facility. Standard Experimental or Investigational External Review
An Insured Person, or an Insured Person’s Authorized Representative, may submit a request for an Experimental or Investigational External Review when the denial of coverage is based on a determination that the recommended or requested health care service or treatment is experimental or investigational. A request for a Standard Experimental or Investigational External Review must be submitted in writing within 4 months of receiving a notice of the Company’s Adverse Determination or Final Adverse Determination. Expedited Experimental or Investigational External Review
An Insured Person, or an Insured Person’s Authorized Representative, may submit an oralrequest for an Expedited Experimental or Investigational External Review when:
1. The Insured Person or the Insured Person’s Authorized Representative has received
a. The Insured Person, or the Insured Person’s Authorized Representative, has
submitted a request for an Expedited Internal Appeal; and
b. Adverse Determination involves a denial of coverage based on a determination that
the recommended or requested health care service or treatment is experimental orinvestigational and the Insured Person’s treating Physician certifies in writing thatthe recommended or requested health care service or treatment would besignificantly less effective is not initiated promptly; or
2. The Insured Person or the Insured Person’s Authorized Representative has received
a. The Insured Person has a medical condition for which the time frame for
completing a Standard External Review would seriously jeopardize the life or healthof the Insured Person or jeopardize the Insured Person’s ability to regain maximumfunction; or
b. The Final Adverse Determination is based on a determination that the
recommended or requested health care service or treatment is experimental orinvestigational and the Insured Person’s treating Physician certifies in writing thatthe recommended or requested health care service or treatment would besignificantly less effective if not initiated promptly. Where to Send External Review Requests
All types of External Review requests shall be made in writing to the Commissioner, andshall be accompanied by a $25.00 filing fee, except that no Insured Person or AuthorizedRepresentative shall pay more than $75.00 in a Policy Year. If the Commissioner finds thatthe Insured Person is indigent or unable to pay the filing fee, the Commissioner shall waivesuch fee. Upon request of an External Review, the Commissioner shall provide the InsuredPerson or the Authorized Representative with the appropriate forms to request the review. All External Review requests shall be submitted to the Commissioner at the followingaddress:
Connecticut Insurance DepartmentATTN: External AppealsPO Box 816Hartford, CT 06142-0816(860) 297-3910
Questions Regarding Appeal Rights
Contact Customer Service with questions regarding the Insured Person’s rights to anInternal Appeal and External Review. Other resources are available to help the Insured Person navigate the appeals process. Forquestions about appeal rights, your state consumer assistance program may be able toassist you at:
Connecticut Office of the Healthcare AdvocateP.O. Box 1543Hartford, CT 06144(866) 466-4446www.ct.gov/[email protected]Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs, ID Cards, network providers, correspondence and coverage information by logging in to My Account at www.uhcsr.com/myaccount. Insured students who don’t already have an online account may simply select the “create My Account Now” link. Follow the simple, onscreen directions to establish an online account in minutes using your 7-digit Insurance ID number or the email address on file. As part of UnitedHealthcare StudentResources’ environmental commitment to reducing waste, we’ve introduced a number of initiatives designed to preserve our precious resources while also protecting the security of a student’s personal health information. My Account has been enhanced to include Message Center - a self-service tool that provides a quick and easy way to view any email notifications we may have sent. In Message Center, notifications are securely sent directly to the Insured student’s email address. If the Insured student prefers to receive paper copies, he or she may opt-out of electronic delivery by going into My Email Preferences and making the change there. UnitedHealth Allies
Insured students also have access to the UnitedHealth Allies® discount program. Simply log in to My Account as described above and select UnitedHealth Allies Plan to learn more about the discounts available. When the Medical ID card is viewed or printed, the UnitedHealth Allies card is also included. The UnitedHealth Allies Program is not insurance and is offered by UnitedHealth Allies, a UnitedHealth Group company.
One way we are becoming greener is to no longer automatically mail out ID Cards. Instead, we will send an email notification when the digital ID card is available to be downloaded from My Account. An Insured student may also use My Account to request delivery of a permanent ID card through the mail. ID Cards may also be accessed via our mobile site at my.uhcsr.com. Claim Procedure
In the event of Injury or Sickness, students should:
1) Report to the Student 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 ofthe college under which the student is insured. A Company claim form is notrequired for filing a claim.
3) File claim within 30 days of Injury or first onset of Sickness. should must 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 Inquiries to:
UnitedHealthcare StudentResources P.O. Box 809025 Dallas, Texas 75380-9025 1-800-767-0700 [email protected] [email protected]
Please keep this Certificate as a general summary of the insurance. The Master Policy onfile at the college contains all of the provisions, limitations, exclusions and qualifications ofyour insurance benefits, some of which may not be included in this Certificate. The MasterPolicy is the contract and will govern and control payment of benefits.
2 April, 2001 HUNGARY, ROMANIA, UKRAINE: FLOODS appeal no. 13/01; Revised budget situation report no. 1 period covered: 9 - 28 March, 2001 The Hungarian, Romanian, and Ukrainian national societies, with the support of the Federation, have mounted an effective and professional response to the floods. The positive role played in coordinating disaster response efforts with the autho