Designed Specifically for Students of Colleges andUniversities in the Wisconsin Association of IndependentColleges and Universities Table of Contents
NoticePrivacy Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Effective and Termination Dates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Extension of Benefits after Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Pre-Admission Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Schedule of Medical Expense Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3United Healthcare Network Pharmacy Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Preferred Provider Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Maternity Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Accidental Death and Dismemberment Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Continuation Privilege . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Benefits for Diabetes Expense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Benefits for Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Breast Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Childhood Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Mammography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Benefits for Skilled Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Benefits for Drugs for Treatment of HIV Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Benefits for Hospital and Ambulatory Surgery Center Charges and Anesthetics for Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Benefits for Temporomandibular Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Cancer Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Benefits for Psychotherapy (The Treatment of Mental and Nervous Disorder, Alcoholism and Drug Abuse) . . . . . . . . . . . . . . . . . . . . . . . . . .14 Benefits for Lead Poisoning Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Benefits for Autism Spectrum Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Benefits for Contraceptives and Related Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Benefits for Hearing Aids and Cochlear Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Exclusions and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Collegiate Assistance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Scholastic Emergency Services: Global Emergency Medical Assistance . . . . . . . . . . .20Online Access to Account Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Claim Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 LIMITED BENEFITS WILL BE PAID WHEN OUT OF NETWORK PROVIDERS AREUSED.
You should be aware that when you elect to utilize the services of an out of network providerfor a covered service, benefit payments to such out of network provider are not based uponthe amount billed. The basis of your benefit payment will be determined according to yourpolicy's fee schedule, Usual and Customary Charge (which is determined by comparingcharges for similar services adjusted to the geographical area of the locality of thepolicyholder). YOU RISK PAYING MORE THAN THE COINSURANCE, DEDUCTIBLEAND CO-PAYMENT AMOUNT DEFINED IN THE POLICY AFTER THE PLAN HASPAID ITS REQUIRED PORTION. Out of network providers may bill enrollees for anyamount up to the billed charge after the plan has paid its portion of the bill. Participatingproviders have agreed to accept discounted payment for covered services with noadditional billing to the enrollee other than co-payment, coinsurance and deductibleamounts. You may obtain further information about the participating status of professionalproviders and information on out-of-pocket expenses by calling the toll free telephonenumber on your identification card or visiting www.uhcsr.com.
Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality ofyour nonpublic personal information. We do not disclose any nonpublic personal informationabout our customers or former customers to anyone, except as permitted or required by law.
We believe we maintain appropriate physical, electronic and procedural safeguards toensure the security of your nonpublic personal information. You may obtain a copy of ourprivacy practices by calling us toll-free at 888-302-6182 or by visiting us at www.uhcsr.com.
All domestic full-time undergraduate students are required to purchase this insurance Plan. International students (as defined by college or university) are required to purchase thisinsurance plan, unless the school has plan 2010-202452-6 in place for their internationalstudents.
All part-time students taking 6 or more credit hours (or program equivalent as defined bycollege or university), graduate students, students in accelerated programs, and ESL andELP 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, Internet, and television (TV) coursesdo not fulfill the Eligibility requirements that the student actively attend classes. TheCompany maintains its right to investigate Eligibility or student status and attendancerecords to verify that the policy Eligibility requirements have been met. If the Companydiscovers the Eligibility requirements have not been met, its only obligation is to refundpremium.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents arethe spouse or Domestic Partner and unmarried children and grandchildren under 27 yearsof age who are not self-supporting. See the Definition section of the Brochure for thespecific requirements needed to meet Domestic Partner eligibility.
Dependent Eligibility expires concurrently with that of the Insured student.
Effective and Termination Dates
The Master Policy becomes effective August 1, 2010. The individual student’s coveragebecomes effective on the first day of the period for which premium is paid or the date theenrollment form and full premium are received by the Company (or its authorizedrepresentative), whichever is later. The Master Policy terminates July 31, 2011. Coverageterminates on that date or at the end of the period through which premium is paid,whichever is earlier. Dependent coverage will not be effective prior to that of the Insuredstudent 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.
Extension of Benefits after Termination
The coverage provided under the 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 this "Extension of Benefits" provision has been exhausted, all benefits cease to exist,and under no circumstances will further payments be made.
Pre-Admission Notification
UMR Care Management should be notified of all Hospital Confinements prior to admission.
1. PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: The patient, Physician or Hospital should telephone1-877-295-0720 at least five working days prior to the planned admission.
2. NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient's representative, Physician or Hospital should telephone 1-877-295-0720 within two working days of the admission to provide notificationof any admission due to Medical Emergency.
UMR Care Management is open for Pre-Admission Notification calls from 8:00 a.m. to 6:00p.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.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwisepayable under the policy; however, pre-notification is not a guarantee that benefits will bepaid.
Up To $15,000 Maximum Benefit Paid as Specified Below (For Each Injury or Sickness) Deductible Preferred Provider $0 (Per Insured Person) (Per Policy Year) Deductible Out-of-Network $200 (Per Insured Person) (Per Policy Year) The Policy provides benefits for the Usual & Customary Charges incurred by an InsuredPerson for loss due to a covered Injury or Sickness up to the Maximum Benefit of$15,000 for each Injury or Sickness.
The Preferred Provider for this plan is UnitedHealthcare Options PPO. If care is receivedfrom a Preferred Provider any Covered Medical Expenses will be paid at the PreferredProvider level of benefits. In all other situations, reduced or lower benefits will be providedwhen on Out-of-Network provider is used.
Student Health Center: Covered Medical Expenses will be paid at 100% when servicesare rendered at the Student Health Center. Immunizations are only covered at the StudentHealth Center.
Immunizations as required by the College or University, required age appropriateimmunizations, immunizations required for travel, and vaccinations for flu and meningitiswill be covered when provided by the SHC only.
Benefits will be paid at 100% for Covered Medical Expenses at the SHC based onapproved fee schedule, labs, routine preventive care (includes GYN exam, Pap Smear,STD screening), and prescription drugs up to a 31-day supply per prescription.
Medications for nicotine addiction will be covered at the SHC only.
Exclusion #15 will be waived and Hearing Examinations will be covered if related to asickness or symptom and the Hearing Examination is necessary for a diagnosis.
Pre-Existing Conditions are covered for full-time mandatory enrollment. All other voluntaryenrollment is subject to the Pre-Existing Condition exclusion 12 month waiting period onPre-existing Conditions.
All benefit maximums are combined Preferred Provider and Out-of-Network, unlessotherwise noted below. Benefits will be paid up to the Maximum Benefit for each serviceas scheduled below. Covered Medical Expenses include: Hospital Expense, $1,200 max per day, daily semi- private room rate; general nursing care provided bythe Hospital; Hospital Miscellaneous Expenses, suchas the cost of the operating room, laboratory testsand x-ray examinations, anesthesia, drugs (excludingtake home drugs) or medicines, therapeutic services,and supplies. In computing the number of dayspayable under this benefit, the date of admission willbe counted, but not the date of discharge. Confinement expense maximum, while HospitalConfined; and routine nursery care providedimmediately after birth.
Surgeon’s Fees, $5,000 max per Injury or Sickness, in accordance with data provided byIngenix. If two or more procedures are performedthrough the same incision or in immediatesuccession at the same operative session, themaximum amount paid will not exceed 50% of thesecond procedure and 50% of all subsequentprocedures.
Anesthetist, professional services in connection Registered Nurse’s Services, private duty nursing Physician’s Visits, benefits are limited to one visit per day and do not apply when related to surgery.
Pre-Admission Testing, payable within 3 working Psychotherapy/Alcohol & Drug Abuse, benefits Surgeon’s Fees, $5,000 max per Injury or Sickness, in accordance with data provided byIngenix. If two or more procedures are performedthrough the same incision or in immediatesuccession at the same operative session, themaximum amount paid will not exceed 50% of thesecond procedure and 50% of all subsequentprocedures.
Day Surgery Miscellaneous, $1,200 max per Injury or Sickness, related to scheduled surgeryperformed in a Hospital, including the cost of the operatingroom; laboratory tests and x-ray examinations, includingprofessional fees; anesthesia; drugs or medicines; andsupplies. Usual and Customary Charges for Day SurgeryMiscellaneous are based on the Outpatient SurgicalFacility Charge Index.
Anesthetist, professional services administered in Outpatient Miscellaneous Benefit, $1,000 max for each Injury or Sickness, includes benefits designatedas Paid under Outpatient Miscellaneous Benefit.
Physician’s Visits, benefits are limited to one visit per day. Benefits for Physician’s Visits do not apply when related to surgery or Physiotherapy.
Physiotherapy, benefits are limited to one visit per day.
emergency room and supplies. Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness. (Copay/Deductible waived ifadmitted.) Injections, when administered in the Physician’s office and charged on the Physician’s statement.
Tests & Procedures, diagnostic services and medical procedures performed by a Physician, other than Physician’s Visits, Physiotherapy, x-rays and lab procedures.
ADD/ADHD and Psychotherapy medications.) Psychotherapy/Alcohol and Drug Abuse, including all related or ancillary charges incurred as a result of a Mental or Nervous Disorder, Alcoholism and DrugAbuse, except for Prescription Drugs and DiagnosticTesting. Benefits are limited to one visit per day.
Ambulance Services, $500 max per Injury or Injury or Sickness, a written prescription mustaccompany the claim when submitted.
Replacement equipment is not covered.
Dental Treatment, $200 max per Injury, made necessary by Injury to Sound, Natural Teeth.
Intramural & Club Sports, $10,000 max per Injury.
Maternity & Complications of Pregnancy Routine Preventative Care, $300 max Per Policy Mammography, 2 mammograms Per Policy Year, starting at age 40-44. See Mandated Benefits for United Healthcare Network Pharmacy Benefits
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL)when dispensed by a UnitedHealthcare Network Pharmacy. Benefits are subject to supplylimits and copayments that vary depending on which tier of the PDL the outpatient drug islisted. There are certain Prescription Drugs that require your Physician to notify us to verifytheir use is covered within your benefit.
You are responsible for paying the applicable copayments. Your copayment is determinedby the tier to which the Prescription Drug Product is assigned on the PDL. Tier status maychange periodically and without prior notice to you. Please access www.uhcsr.com or call877-417-7345 for the most up-to-date tier status.
$15 copay per prescription order or refill for a Tier 1 prescription drug up to 31 day supply.
$35 copay per prescription order or refill for a Tier 2 prescription drug up to 31 day supply.
$60 copay per prescription order or refill for a Tier 3 prescription drug up to 31 day supply.
Your maximum allowed benefit is $250 Per Policy Year.
Please present your ID card to the network pharmacy when the prescription is filled. If youdo not use a network pharmacy, you will be responsible for paying the full cost for theprescription.
If you do not present the card, you will need to pay for the prescription and then submit areimbursement form for prescriptions filled at a network pharmacy along with the paidreceipt in order to be reimbursed. To obtain reimbursement forms, or for information aboutmail-order prescriptions or network pharmacies, please visit www.uhcsr.com and log in toyour online account or call 877-417-7345.
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 are available in over-the-counter form or equivalent. CertainPrescription Drug Products that the Company has determined are TherapeuticallyEquivalent to an over-the-counter drug. Such determinations may be made up to sixtimes during a calendar year, and the Company may decide at any time to reinstateBenefits for a Prescription Drug Product that was previously excluded under thisprovision.
5. Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, even when used for the treatment of Sickness orInjury.
Prescription Drug or Prescription Drug Product means a medication, product or devicethat has been approved by the U.S. Food and Drug Administration and that can, underfederal or state law, be dispensed only pursuant to a Prescription Order or Refill. APrescription Drug Product includes a medication that, due to its characteristics, isappropriate for self-administration or administration by a non-skilled caregiver. For thepurpose of the benefits under the policy, this definition includes insulin.
Prescription Drug List means a list that categorizes into tiers medications, products ordevices that have been approved by the U.S. Food and Drug Administration. This list issubject to the Company’s periodic review and modification (generally quarterly, but no morethan six times per calendar year). The Insured may determine to which tier a particularPrescription Drug Product has been assigned through the Internet at www.uhcsr.com or callCustomer Service at 1-877-417-7345.
Preferred Provider Information
“Preferred Providers” are the Physicians, Hospitals and other health care providers whohave contracted to provide specific medical care at negotiated prices. Preferred Providersin the local school area are: UnitedHealthcare Options PPO.
The availability of specific providers is subject to change without notice. Insureds shouldalways confirm that a Preferred Provider is participating at the time services are required bycalling the Company at 1-888-302-6182 and/or by asking the provider when making anappointment for services.
“Preferred Allowance” means the amount a Preferred Provider will accept as payment infull for Covered Medical Expenses.
“Out of Network” providers have not agreed to any prearranged fee schedules. Insured’smay incur significant out-of-pocket expenses with these providers. Charges in excess of theinsurance 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 accordingto the benefit limits in the Schedule of Benefits.
Inpatient Hospital Expenses PREFERRED HOSPITALS - Eligible inpatient Hospital expenses at a Preferred Hospitalwill be paid at the coinsurance percentages specified in the Schedule of Benefits up to anylimits specified in the Schedule of Benefits. Call 888-302-6182 for information aboutPreferred Hospitals.
OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a PreferredProvider, eligible inpatient Hospital expenses will be paid according to the benefit limits inthe Schedule of Benefits.
Outpatient Hospital Expenses Preferred Providers may discount bills for outpatient Hospital expenses. Benefits are paidaccording to the Schedule of Benefits. Insureds are responsible for any amounts thatexceed the benefits shown in the Schedule, up to the Preferred Allowance.
Professional & Other Expenses Benefits for Covered Medical Expenses provided by UnitedHealthcare Options PPO will bepaid at 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.
Maternity Testing
This policy does not cover routine, preventive or screening examinations or testing unlessMedical Necessity is established based on medical records. The following maternity routinetests and screening exams will be considered, if all other policy provisions have been met.
This includes a pregnancy test, CBC, Hepatitis B Surface Antigen, Rubella Screen, SyphilisScreen, Chlamydia, HIV, Gonorrhea, Toxoplasmosis, Blood Typing ABO, RH Blood AntibodyScreen, Urinalysis, Urine Bacterial Culture, Microbial Nucleic Acid Probe, AFP BloodScreening, Pap Smear, and Glucose Challenge Test (at 24-28 weeks gestation). OneUltrasound will be considered in every pregnancy, without additional diagnosis. Anysubsequent ultrasounds can be considered if a claim is submitted with the PregnancyRecord and Ultrasound report that establishes Medical Necessity. Additionally, the followingtests will be considered for women over 35 years of age: Amniocentesis/AFP Screeningand Chromosome Testing. Fetal Stress/Non-Stress tests are payable. Pre-natal vitaminsare not covered. For additional information regarding Maternity Testing, please call theCompany at 1-888-302-6182.
Accidental Death and Dismemberment Benefits
If such Injury shall independently of all other causes and within 180 days from the date ofInjury solely result in any one of the following specific losses, the Insured Person orbeneficiary may request the Company to pay the applicable amount below. Payment underthis benefit will not exceed the policy Maximum Benefit.
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.
Coordination of Benefits
Benefits will be coordinated with any other medical, surgical or hospital plan so thatcombined payments under all programs will not exceed 100% of charges incurred forcovered services and supplies.
Continuation Privilege
All Insured Persons who have been continuously insured under the school's regular studentPolicy for at least 3 consecutive months and who no longer meet the Eligibility requirementsunder that Policy are eligible to continue their coverage for a period of not more than ninemonths under the school's policy in effect at the time of such continuation. If an InsuredPerson is still eligible for continuation at the beginning of the next Policy Year, the insuredmust purchase coverage under the new policy as chosen by the school. Coverage underthe new policy is subject to the rates and benefits selected by the school for that policy year.
Application must be made and premium must be paid directly to UnitedHealthcareStudentResources and be received within 31 days after the expiration date of your studentcoverage. For further information on the Continuation privilege, please contactUnitedHealthcare StudentResources.
Mandated Benefits
Benefits will be paid the same as any other Sickness for the treatment of diabetes includingdiabetic self-management education programs, the installation and use of an insulininfusion pump, and all other equipment and supplies, including insulin or any otherprescription medication used in the treatment of diabetes. This benefit is limited to thepurchase of one insulin infusion pump per policy year. The Company may require theInsured Person to use an insulin infusion pump for 30 days prior to purchase.
This benefit is subject to all Deductible, copayments, coinsurance, limitations or any otherprovisions of the Policy.
Benefits will be paid for the Usual and Customary Charges for treatment of kidney diseaseincluding kidney dialysis and/or kidney transplantation. The Company will pay to or onbehalf of such Insured Person the charges incurred for the treatment of such kidneydisease up to $30,000.00 during any policy year.
If such kidney disease requires kidney transplantation, the charges incurred by both therecipient and donor of the transplanted kidney shall be considered a covered expenseunder this provision, subject to the maximum benefit of $30,000.00 during any policy year.
Any benefits provided by the terms of this provision shall reduce benefits payable under anyother benefit provisions of this policy to the extent of benefits paid under this provision.
Benefits shall be subject to all Deductible, copayments and coinsurance of the Policy.
Benefits for Breast Reconstruction Benefits will be paid the same as any other Sickness for breast reconstruction of theaffected tissue resulting from a surgical procedure known as a mastectomy.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
Benefits for Childhood Immunizations Benefits will be paid the same as any other Sickness for childhood immunization servicesand supplies for Dependent children 6 years of age and under. Childhood immunizationsinclude: Diphtheria, Pertussis, Tetanus, Polio, Measles, Mumps, Rubella, HemophilusInfluenza B, Hepatitis B. and Varicella. These services shall be exempt from any Deductible, coinsurance or any copaymentprovisions of this Policy.
Benefits will be paid the same as any other Sickness for mammography screeningaccording to the following guidelines: 1. For women from age 45 to 49, benefits will be provided for two examinations by low-dose mammography performed when the woman is age 45 to 49, if all of thefollowing are satisfied.
a. Each examination by low-dose mammography is performed at the direction of a licensed Physician or a nurse practitioner, except as provided in paragraph 3.
b. The woman has not had an examination by low-dose mammography within 2 years before the examination is performed.
If the woman had obtained one or more examinations by low-dose mammographywhile between the ages of 45 and 49 and before obtaining coverage under thisinsurance policy, benefits will be reduced to the extent that no more than the tworequired examinations between the ages of 45 and 49 are provided including theprior examinations.
2. For women age 50 or older, benefits will be provided for an annual examination by low-dose mammography to screen for the presence of breast cancer, if theexamination is performed at the direction of a licensed Physician or a nursepractitioner, except as provided in paragraph 3.
3. Benefits will be provided for an examination by low-dose mammography that is not performed at the direction of a licensed Physician or a nurse practitioner but that isotherwise required to be covered under paragraphs 1 and 2, if all of the followingare satisfied.
a. The woman does not have an assigned or regular Physician or nurse practitioner b. The woman designates a Physician to receive the results of the examination.
c. An examination by low-dose mammography previously obtained by the woman was at the direction of a licensed Physician or a nurse practitioner.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
Benefits will be provided for 30 days of skilled nursing care to patients who enter a licensedskilled nursing care facility within 24 hours after discharge from a general Hospital. Thedaily rate payable shall not exceed the maximum daily rate established for licensed skillednursing care facilities by the department of health and social services. Coverage appliesonly to skilled nursing care which is certified as Medically Necessary by the attendingPhysician and is recertified as Medically Necessary every 7 days. Skilled nursing care mustbe for the same medical or surgical condition for which the Insured has been treated at theHospital prior to entry into the skilled nursing care facility. These benefits do not apply tocare which is essentially domiciliary or custodial, or to care which is available to the Insuredwithout charge or under a governmental health care program, except Medicaid.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
If visits are required at the home of an Insured Person and such visits are provided orcoordinated by a state-licensed or Medicare-certified home health agency or a certifiedrehabilitation agency, the Company will pay to or on behalf of such Insured Person the usualand customary charges incurred for such services according to the following guidelines:Covered charges will be payable under these Home Care Benefits after receipt by theCompany of the attending physician's certification that: A. Hospitalization or confinement in a skilled nursing facility would otherwise be required if visits to the home of the Insured Person are not provided; and B. Necessary care and treatment are not available from a person who ordinarily resides in the house of the Insured Person or from any family member, and C. Includes a copy of the attending Physician's "Plan of Care" which has been reduced to writing and signed by the Physician (such "Plan of Care" to be reviewed every 2months unless the Physician indicates in writing that a longer review period issufficient). If the Insured Person was confined in a Hospital immediately prior to thecommencement of home care, the attending Physician's "Plan of Care" shall alsobe approved by the Physician who was the primary provider of services during theHospital Confinement.
Covered charges do not include any services provided by any person residing with, or anyfamily member of, any Insured Person and are limited to: 1. Visits for part-time or intermittent home nursing care by or under the supervision of 2. Visits for part-time or intermittent home health services, under the supervision of a Registered Nurse or medical social worker, and such visits consist solely of caringfor the Insured Person; 3. Visits for physical, respiratory, occupational or speech therapy;4. Visits for nutrition counseling provided by or under the supervision of a registered 5. Charges for evaluation of the need for and development of a plan by a Registered Nurse, medical social worker or Physician extender, for visits to the home of theInsured Person; 6. Charges for medical supplies, drugs and medications prescribed by a Physician;7. Charges for laboratory services provided by or on behalf of a Hospital; and which were included in the attending Physician's "Plan of Care." Covered charges will be payable on the basis that each of the following is considered asone home care visit: 1. Each visit by a person providing the service; or2. The evaluation of the need for the plan; or3. The development of the plan; or4. During any 24-hour period, visits by home health services of up to four consecutive hours will be considered to be one home care visit.
Benefits payable for covered charges Items (1) through (5) are limited to a maximum of 40visits during any policy year for any Insured Person except that any Insured Person who alsoreceives benefits under both Part A and Part B of Medicare (Title XVIII of the SocialSecurity Act) shall, in the aggregate with benefits payable under both Part A and Part B ofMedicare, be limited to a maximum of 365 visits during any policy year. Covered chargesItems (6) and (7) are payable to the same extent as they would be payable during a HospitalConfinement. Any benefits provided by the terms of this provision shall reduce benefitspayable under any other provisions of this policy to the extent of benefits paid under thisprovision.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
Benefits for Drugs for Treatment of HIV Infection Benefits will be payable for Prescription Drugs on the same basis as any other Sickness forthe treatment of HIV Infection. "HIV infection" means the pathological state produced by ahuman body in response to the presence of HIV. Such Prescription Drugs must be: (a)prescribed by the insured's physician for the treatment of HIV infection or an illness ormedical condition arising from or related to HIV infection; (b) be approved by the federalfood and drug administration for the treatment of HIV infection or an illness or medicalcondition arising from or related to HIV infection, including each investigational new drugthat is approved under 21 CFR 312.34 to 312.36 for the treatment of HIV infection or anillness or medical condition arising from or related to HIV infection and that is in, or hascompleted, a phase 3 clinical investigation performed in accordance with 21 CFR 312.20to 312.33; and (c) if the drug is an investigational new drug described in (b), it is prescribedand administered in accordance with the treatment protocol approved for the investigationalnew drug under 21 CFR 312.34 to 312.36.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
Benefits for Hospital and Ambulatory Surgery Center Charges Benefits under this section shall cover Hospital or ambulatory surgery center chargesincurred and anesthetics provided in conjunction with dental care that is provided to aninsured in a Hospital or ambulatory surgery center, if any of the following applies: 1. The Insured is a child under the age of 5.
2. The Insured has a medically established chronic disability. 3. The Insured has a medical condition that requires hospitalization or general Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
Benefits for Temporomandibular Disorders Benefits will be paid the same as any other Injury or Sickness for diagnostic procedures andmedically necessary surgical and nonsurgical treatment for the correction oftemporomandibular disorders if all the following apply: 1. The condition is caused by congenital, developmental or acquired deformity, 2. Under the accepted standards of the profession of the health care provider rendering the service, the procedure or the device is reasonable and appropriate forthe diagnosis or treatment of the condition.
3. The purpose of the procedure or device is to control or eliminate infection, pain, Benefits for nonsurgical treatment including prescribed intraoral splint therapy devices willnot exceed $1,250 annually.
Benefits will not be provided for cosmetic or elective orthodontic care, periodontic care orgeneral dental care.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
Benefits for Cancer Clinical Trials Benefits will be paid the same as any other Sickness for Routine Patient Care that isadministered to an Insured Person in all phases of a cancer clinical trial.
Routine Patient Care includes: 1) All health care services, items and drugs for the treatment of cancer.
2) All health services, items, and drugs that are typically provided in health care; including heath care services, items, and drugs provided to a patient during thecourse of treatment in a cancer clinical trial for a condition or any of itscomplications; and that are consistent with the usual and customary standard ofcare, including the type and frequency of any diagnostic modality.
Routine Patient Care does not include the health care service, item, or investigational drugthat is the subject of the cancer clinical trial; any health care service, item, or drug providedsolely to satisfy data collection and analysis needs that are not used in the direct clinicalmanagement of the patient; an investigational drug or device that has not been approvedfor market by the federal food and drug administration; transportation, lodging, food, or otherexpenses for the patient or a family member or companion of the patient that areassociated with travel to or from a facility providing the cancer clinical trial; any services,items, or drugs provided by the cancer clinical trial sponsors free of charge for any patient;or any services, items, or drugs that are eligible for reimbursement by a person other thanthe insurer, including the sponsor of the cancer clinical trial.
The cancer clinical trial must meet all of the following criteria: 1. A purpose of the trial is to test whether the intervention potentially improves the trial 2. The treatment provided as part of the trial is given with the intention of improving the trial participant's health outcomes.
3. The trial has therapeutic intent and is not designed exclusively to test toxicity or a. Tests how to administer a health care service, item, or drug for the treatment of b. Tests responses to a health care service, item, or drug for the treatment of cancer.
c. Compares the effectiveness of health care services, items, or drugs for the treatment of cancer with that of other health care services, items, or drugs for thetreatment of cancer.
d. Studies new uses of health care services, items, or drugs for the treatment of 5. The trial is approved by one of the following: a. A National Institute of Health, or one of its cooperative groups or centers, under the federal department of health and human services.
b. The federal food and drug administration.
c. The federal department of defense.
d. The federal department of veterans affairs.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
(The Treatment of Mental and Nervous Disorder, Alcoholism and Drug Abuse) Benefits will be paid the same as any other Sickness for the treatment of Mental andNervous Disorder, Alcoholism and Drug Abuse on the same basis as any other Sicknesssubject to the following limitations:Benefits while Hospital Confined, will not exceed $7,000 per policy year.
Benefits for outpatient treatment will not exceed $2,000 per policy year.
Benefits for transitional treatment arrangements will not exceed $3,000 per policy year.
“Transitional treatment arrangements” means services, as specified by rule by theCommissioner, for the treatment of nervous or mental disorders or alcoholism or other drugabuse problems that are provided to an Insured in a less restrictive manner than areinpatient Hospital services, but in a more intensive manner than are outpatient services.
As specified by the Commissioner by rule, the following are considered covered servicesand programs for Transitional Treatment Arrangements: 1) Mental health services in a Day Treatment Program offered by a provider certified by the DHSS under ss. HSS 61.75 and 61.81; 2) Services for an Insured Person with chronic Mental and Nervous Disorder provided through a community support program certified by the DHSS under s. HSS 63.03; 3) Residential treatment programs for alcohol or drug dependent persons or both certified by the DHSS under s. HSS 61.60; 4) Services for alcoholism and other drug problems provided in a Day Treatment Program certified by the DHSS under s. HSS 61.61; and 5) Intensive outpatient programs for the treatment of psychoactive substance use disorders provided by specialists in addiction medicine according to the patientplacement criteria of the American Society of Addiction Medicine.
“Day treatment programs”, also known as partial hospitalization, are nonresidentialprograms that provide case management, counseling, medical care and therapies on aroutine basis for a scheduled part of a day and a scheduled number of days per week.
Residential treatment programs are therapeutic programs for alcohol and drug dependentpersons. They include therapeutic communities and transitional facilities.
The American Society of Addiction Medicine's Patient Placement Criteria for the Treatmentof Psychoactive Substance Use Disorders is used to determine the Medical Necessity oftransitional treatment for Alcoholism and Drug Abuse. The Medical Necessity of transitionaltreatment for Mental and Nervous Disorders is based on the following criteria: 1) varying ordaily ambivalence to treatment; 2) Insured at risk of relapse or severe consequences ofrelapse; 3) existence of mild interference with daily functioning or disturbing symptoms thatsignificantly interfere with functioning. The Insured's Mental and Nervous Disorder mustmeet at least one of these criteria to qualify for transitional treatment benefits.
The benefit amounts specified above shall not include costs incurred for Prescription Drugsor diagnostic testing. Benefits for Prescription Drugs and diagnostic testing will be paid thesame as any other Sickness in addition to these benefit limits.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
Benefits for Lead Poisoning Screening Benefits will be provided for blood lead tests for children under 6 years of age, which shallbe conducted in accordance with any recommended lead screening methods and intervalscontained in any rules promulgated by the Department of Health and Family Services.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Autism Spectrum Disorders Benefits will be paid for the Usual and Customary Charges incurred for the mental healthtreatment of Autism Spectrum Disorders if the treatment is prescribed by a Physician andis provided by any of the following who are qualified to provide Intensive-level Services orNonintensive-level Services: a psychiatrist; a psychologist; a social worker who is certifiedor licensed to practice psychotherapy; a paraprofessional working under the supervision ofa psychiatrist, psychologist or social worker; a professional working under the supervisionof an outpatient mental health clinic; a speech-language pathologist; and an occupationaltherapist.
Benefits shall not exceed $50,000 maximum per Insured Person per policy year, limited to30 to 35 hours of care per week, not to exceed 4 years of treatment for Intensive-levelServices. For Nonintensive-level Services, benefits shall not exceed $25,000 maximum perInsured Person per policy year.
“Autism spectrum disorder” means any of the following: 1) autism disorder; 2) asperger’ssyndrome; 3) pervasive developmental disorder not otherwise specified.
“Intensive-level services” means evidence-based behavioral therapy that is designed to helpan individual with Autism Spectrum Disorder overcome the cognitive, social, and behavioraldeficits associated with that disorder.
“Nonintensive-level services” means evidence-based therapy that occurs after thecompletion treatment with Intensive-level Services and that is designed to sustain andmaximize gains made during treatment with Intensive-level Services or, for an individual whohas not and will not receive Intensive-level Services, evidence-based therapy that willimprove the individual’s condition.
Benefits shall be subject to all Deductibles, copayments and coinsurance that apply to anyother Sickness but shall not be subject to any other limitations (including treatment visitlimits) or exclusions of the policy.
Benefits for Contraceptives and Related Services If the policy provides benefits for outpatient services, preventive treatments and services orPrescription Drugs, benefits will be paid the same as any other Sickness for: 1)Contraceptives prescribed by a Physician; and 2) the outpatient consultations,examinations, procedures and medical services that are necessary to prescribe, administer,maintain or remove a Contraceptive if those related services are covered for any otherPrescription Drug benefits under the policy.
“Contraceptives” means drugs or devices approved by the federal Food and DrugAdministration to prevent pregnancy.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Hearing Aids and Cochlear Implants Benefits will be paid the same as any other Sickness for the cost of Hearing Aids andCochlear Implants that are prescribed by a Physician or Audiologist for an Insured Personwho is under 18 years of age and who is certified as deaf or hearing impaired by a Physicianor Audiologist.
“Hearing aid” means any externally wearable instrument or device designed for or offeredfor the purpose of aiding or compensating for impaired human hearing and any parts,attachments, or accessories of such an instrument or device, except batteries and cords.
“Cochlear implant” means any implantable instrument or device that is designed to enhancehearing.
Benefits shall include the cost of treatment related to Hearing Aids and Cochlear Implantsincluding procedures for the implantation of cochlear devices.
“Treatment” means services, diagnoses, procedures, surgery, and therapy provided by aPhysician or Audiologist.
Benefits for the cost of Hearing Aids shall not exceed the cost of one hearing aid per earper Insured Person.
Benefits shall be subject to all Deductible, copayment, coinsurance, limitations, or any otherprovisions of the Policy.
DOMESTIC PARTNER means a person who is neither married nor related by blood ormarriage to the Named Insured but who is: 1) the Named Insured's sole spousal equivalent;2) lives together with the Named Insured in the same residence and intends to do soindefinitely; and 3) is responsible with the Named Insured for each other's welfare. Adomestic partner relationship may be demonstrated by any three of the following types ofdocumentation: 1) a joint mortgage or lease; 2) designation of the domestic partner asbeneficiary for life insurance; 3) designation of the domestic partner as primary beneficiaryin the Named Insured's will; 4) domestic partnership agreement; 5) powers of attorney forproperty and/or health care; and 6) joint ownership of either a motor vehicle, checkingaccount or credit account.
INJURY means bodily injury which is: 1) directly and independently caused by specificaccidental contact with another body or object; 2) unrelated to any pathological, functional,or structural disorder; 3) a source of loss; 4) treated by a Physician within 30 days after thedate of accident; and 5) sustained while the Insured Person is covered under this policy. Allinjuries sustained in one accident, including all related conditions and recurrent symptomsof these injuries will be considered one injury. Injury does not include loss which resultswholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered MedicalExpenses incurred as a result of an injury that occurred prior to this policy's Effective Datewill be considered a Sickness under this policy.
SICKNESS means sickness or disease of the Insured Person which causes loss, andoriginates while the Insured Person is covered under this policy. All related conditions andrecurrent 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 thispolicy's Effective Date will be considered a sickness under this policy.
TOTALLY DISABLED means a condition of a Named Insured which, because of Sicknessor Injury, renders the Insured unable to actively attend classes. A totally disabled Dependentis one who is Hospital Confined.
USUAL AND CUSTOMARY CHARGES means a reasonable charge which is: 1) usualand 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.
No payment will be made under this policy for any expenses incurred which in the judgmentof 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: 1. Acupuncture; allergy testing;2. Addiction, such as: nicotine addiction and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending, shopping, working and religious; codependency; 3. Assistant Surgeon Fees;4. Autistic disease of childhood, milieu therapy, learning disabilities, behavioral problems, parent-child problems, conceptual handicap, developmental delay or disorder ormental retardation; except as specifically provided in the Benefits for AutismSpectrum Disorder; 5. Biofeedback;6. Chronic pain disorders;7. Congenital conditions, except as specifically provided for Newborn or adopted Infants;8. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children;removal of warts, non-malignant moles and lesions; 9. 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; 10. Dental treatment, except for accidental Injury to Sound, Natural Teeth; 11. Elective Surgery or Elective Treatment; 12. Elective Abortion;13. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visualdefects and problems; except when due to a disease process; 14. Foot care including: flat foot conditions, supportive devices for the foot, subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails,fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet; 15. Hearing examinations or hearing aids except as specifically provided in the Benefits for Hearing Aids and Cochlear Implants; or other treatment for hearing defects andproblems. "Hearing defects" means any physical defect of the ear which does or canimpair normal hearing, apart from the disease process; 16. Hirsutism; alopecia;17. Hypnosis;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. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 20. Injury sustained while (a) participating in any interscholastic, intercollegiate or professional sport, contest or competition; (b) traveling to or from such sport, contestor competition as a participant; or (c) while participating in any practice or conditioningprogram for such sport, contest or competition; 22. Lipectomy;23. Organ transplants, including organ donation except as specifically provided in the 24. Marital or family counseling;25. Participation in a riot or civil disorder; commission of or attempt to commit a felony;26. Pre-existing Conditions, except for individuals who have been continuously insured under the school’s student insurance policy for at least 12 consecutive months; ThePre-existing Condition exclusionary period will be reduced by the total number ofmonths that the Insured provides documentation of continuous coverage under a priorhealth insurance policy which provided benefits similar to this policy; 27. Prescription Drugs, services or supplies as follows, except as specifically provided in the policy:a) Therapeutic devices or appliances, including: support garments and other non- medical substances, regardless of intended use; b) Birth control and/or contraceptives, oral or other, whether medication or device, regardless of intended use; except as provided in the Benefits for Contraceptiveand Related Services; c) Immunization agents, biological sera, blood or blood products administered on an d) Drugs labeled, “Caution - limited by federal law to investigational use” or f) Drugs used to treat or cure baldness; anabolic steroids used for body building; g) Anorectics - drugs used for the purpose of weight control;h) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, i) Growth hormones; orj) Refills in excess of the number specified or dispensed after one (1) year of date of 28. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for thepurpose or with the intent of inducing conception; premarital examinations; impotence,organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversalof sterilization procedures; 29. 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 as provided in the Benefits for Cancer Clinical Trials; 30. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; except asspecifically provided in the policy; 31. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specificallyprovided in the policy; 32. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 33. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; deviated nasal septum, including submucous resection and/or othersurgical correction thereof; nasal and sinus surgery, except for treatment of chronicpurulent sinusitis; 34. 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; 35. Sleep disorders;36. Speech therapy; naturopathic services;37. Supplies, except as specifically provided in the policy;38. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy; 39. Treatment in a Government hospital, unless there is a legal obligation for the Insured 40. 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 41. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat, and treatment of eating disorders such asbulimia and anorexia. Exception: benefits will be provided for the treatment ofdehydration and electrolyte imbalance associated with eating disorders.
Collegiate Assistance Program
Insured Students have access to nurse advice and health information 24 hours a day, 7days a week by dialing the number indicated on the permanent ID card. The CollegiateAssistance Program is staffed by Registered Nurses who can help students determine ifthey need to seek medical care, understand their medications or medical procedures, orlearn ways to stay healthy.
Scholastic Emergency Services:
Global Emergency Medical Assistance

If you are a student insured with this insurance plan, you and your insured spouse orDomestic Partner and minor child(ren) are eligible for Scholastic Emergency Services(SES). The requirements to receive these services are as follows:International Students, insured spouse or insured Domestic Partner and insured minorchild(ren): You are eligible to receive SES services worldwide, except in your home country.
Domestic Students, insured spouse or Domestic Partner and insured minor child(ren): Youare eligible for SES services when 100 miles or more away from your campus address and100 miles or more away from your permanent home address or while participating in aStudy Abroad program.
SES services include Emergency Medical Evacuation and Return of Mortal Remains thatmeet the U.S. State Department requirements. The Emergency Medical Evacuation servicesare not meant to be used in lieu of or replace local emergency services such as anambulance requested through emergency 911 telephone assistance. All SES services mustbe arranged and provided by SES, any services not arranged by SES will not be consideredfor payment.
* Medical Consultation, Evaluation and Referrals * Prescription Assistance* Foreign Hospital Admission Guarantee * Lost Luggage or Document Assistance* Care for Minor Children Left Unattended Due to a Medical Incident Please visit your school's insurance coverage page at www.uhcsr.com for the SES GlobalEmergency Assistance Services brochure which includes service descriptions and programexclusions and limitations.
To access services please call: (877) 488-9833 Toll-free within the United States(609) 452-8570 Collect outside the United StatesServices are also accessible via e-mail at [email protected].
When calling the SES Operations Center, please be prepared to provide: 1. Caller's name, telephone and (if possible) fax number, and relationship to the patient;2. Patient's name, age, sex, and Reference Number;3. Description of the patient's condition;4. Name, location, and telephone number of hospital, if applicable;5. Name and telephone number of the attending physician; and6. Information of where the physician can be immediately reached.
SES is not travel or medical insurance but a service provider for emergency medicalassistance services. All medical costs incurred should be submitted to your health plan andare subject to the policy limits of your health coverage. All assistance services must bearranged and provided by SES. Claims for reimbursement of services not provided by SESwill not be accepted. Please refer to your SES brochure or Program Guide atwww.uhcsr.com for additional information, limitations and exclusions pertaining to the SESprogram.
Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs,correspondence and coverage information via My Account at www.uhcsr.com. Insureds canalso print a temporary ID card, request a replacement ID card and locate network providersfrom My Account. If you don’t already have an online account, simply select the “Create an Account” link fromthe home page at www.uhcsr.com. Follow the simple, onscreen directions to establish anonline account in minutes. Note that you will need your 7-digit insurance ID number tocreate an online account. If you already have an online account, just log in fromwww.uhcsr.com to access your account information.
Claim Procedure
In the event of Injury or Sickness, students should: 1) Report to the Student Health Service for treatment, or when not in school, to their 2) Mail to the address below all medical and hospital bills along with the patient's name and insured student's name, address, social security number and name of thecollege or university under which the student is insured. A Company claim form isnot required for filing a claim.
3) File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service. Bills submitted after one yearwill not be considered for payment except in the absence of legal capacity.
UnitedHealthcare StudentResourcesP.O. Box 809025Dallas, Texas [email protected]@uhcsr.com UnitedHealthcare StudentResources805 Executive Center Drive West, Suite 220St. Petersburg, FL 33702727-563-34001-800-237-0903E-Mail: [email protected] Please keep this Brochure as a general summary of the insurance. The Master Policy onfile at the Association contains all of the provisions, limitations, exclusions and qualificationsof your insurance benefits, some of which may not be included in this Brochure. The MasterPolicy is the contract and will govern and control the payment of benefits.
This Brochure is based on Policy # 2010-202452-11

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