2013-1622-1 ben sum fly v1_benefit summary

Student Injury and Sickness Insurance
Plan for
Sierra Nevada College
2013-2014
Sierra Nevada College is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company. All undergraduate students are required to enroll in the insurance plan, unless proof of comparable coverage is furnished. Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
Up to $500,000 Per Insured Person, Per Policy Year Maximum Benefit for Covered Medical $250 Deductible Per Insured Person Per Policy Year for Preferred Providers, $500 Deductible Per Insured Person, Per Policy Year for Out of Network Providers.
Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and Out of Network benefits are payable at 60% of Usual and Customary charges (all benefits are subject to satisfaction of the Deductible, specific benefit limitations, maximums and Copays as Preferred Provider Out-of-Pocket Maximum of $3,500 Per Insured Person, Per Policy Year. Out-of-Network Out-of-Pocket maximum of $7,000 Per Insured Person, Per Policy Year. After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses will be paid at 100% up to the policy Maximum Benefit subject toany applicable benefit maximums. Refer to the plan certificate for details about how the Out-of-Pocket Prescription Drug Benefits: $15 Copay for Tier 1 / $35 Copay for Tier 2 / $70 Copay for Tier 3 up to a 31-day supply per prescription filled at a UnitedHealthcare Pharmacy (UHCP).
Prescriptions must be filled at a UHCP network pharmacy. Mail order through UHCP at 2.5 times the retail copay up to a 90 day supply.
Preventive Care Services which include, but are not limited to, annual physicals, GYN exams, routine screenings and immunizations are covered at 100% with no Copay or deductible only whenthe services are received from a Preferred Provider. Please see www.healthcare.gov for complete details of the services provided for specific age and risk groups.
Coverage available for eligible Dependents.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providerscan be found using the following link, http://www.uhcsr.com/lookupredirect.aspx?delsys=52 FrontierMEDEX – Domestic Students are eligible for FrontierMEDEX services when 100 miles ormore away from your campus address and 100 miles or more away from your permanent homeaddress. International Students are covered worldwide except in their home country.
Online Services: UnitedHealthcare StudentResources Insureds have online access to their claimsstatus, EOBs, ID Cards, network providers, correspondence and coverage account information bylogging in to My Account at www.uhcsr.com/myaccount. To create an online account, select the“create My Account Now” link and follow the simple, onscreen directions. All you need is your 7-digit Insurance ID number or the email address on file. Insureds can also visit our mobile site atmy.uhcsr.com to access an electronic ID card.
Your student health insurance coverage, offered by UnitedHealthcare Insurance Company
may not meet the minimum standards required by the healthcare reform law for
restrictions on annual dollar limits. The annual dollar limits ensure that consumers have
sufficient access to medical benefits throughout the annual term of the policy. Restrictions
for annual dollar limits for group and individual health insurance coverage are $1.25 million
for policy years before September 23, 2012; and $2 million for policy years beginning on or
after September 23, 2012 but before January 1, 2014. Restrictions on annual dollar limits for
student health insurance coverage are $100,000 for policy years before September 23, 2012
and $500,000 for policy years beginning on or after September 23, 2012, but before January
1, 2014. Your student health insurance coverage puts a policy year limit of $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 you may be eligible for coverage under a group
health plan of a parent's employer or under a parent’s individual health insurance policy if
you are under the age of 26. Contact the plan administrator of the parent’s employer plan
or the parent’s individual health insurance issuer for more information.
UnitedHealthcare StudentResources
Each Child
PRE-EXISTING CONDITION means a condition, regardless of the
29. Pre-Existing Conditions, except for individuals who have been cause of the condition, for which medical advice, diagnosis, care or continuously insured under the school's student insurance policy for treatment was recommended or received during the 6 months immediately at least 12 consecutive months; The period of the exclusion for a preceding the Insured's Effective Date under the new coverage. The term Pre-Existing Condition will be reduced by the aggregate period of does not include genetic information in the absence of diagnosis of the creditable coverage if the creditable coverage was continuous to a condition related to such information or pregnancy.
date not more than 63 days before the Insured’s effective date of the EXCLUSIONS AND LIMITATIONS
coverage under this policy. This exclusion will not be applied to an 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 30. Prescription Drugs, services or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use, except as specifically provided in the 4. Nicotine addiction; except as specifically provided in the policy; b) Immunization agents, except as specifically provided in the policy, 5. Milieu therapy, learning disabilities, behavioral problems, parent-child biological sera, blood or blood products administered on an outpatient problems, conceptual handicap, developmental delay or disorder or c) Drugs labeled, “Caution - limited by federal law to investigational use” 8. Congenital conditions, except as specifically provided for Newborn e) Drugs used to treat or cure baldness; anabolic steroids used for body 9. Cosmetic procedures, except cosmetic surgery required to correct f) Anorectics - drugs used for the purpose of weight control; an Injury for which benefits are otherwise payable under this policy or g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; 10. Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for i) Refills in excess of the number specified or dispensed after one (1) domiciliary or Custodial Care; extended care in treatment or substance abuse facilities for domiciliary or Custodial Care; 31. Reproductive/Infertility services including but not limited to: family 11. Dental treatment, except for accidental Injury to Sound, Natural planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of 12. Elective Surgery or Elective Treatment; inducing conception; premarital examinations; impotence, organic or otherwise; female sterilization procedures, except as specifically 14. Eye examinations, eye refractions, eyeglasses, contact lenses, provided in the policy; vasectomy; sexual reassignment surgery; prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and 32. Research or examinations relating to research studies, or any problems; except when due to a covered Injury or disease process; treatment for which the patient or the patient’s representative must 15. Flat foot conditions; supportive devices for the foot; fallen arches; sign an informed consent document identifying the treatment in weak feet; chronic foot strain; symptomatic complaints of the feet; which the patient is to participate as a research study or clinical and routine foot care including the care, cutting and removal of corns, calluses, toenails, and bunions (except capsular or bone 33. Routine Newborn Infant Care, well-baby nursery and related Physician charges, except as specifically provided in the policy; 16. Health spa or similar facilities; strengthening programs; 34. Services provided normally without charge by the Health Service of 17. Hearing examinations; hearing aids; or other treatment for hearing the Policyholder; or services covered or provided by the student defects and problems, except as a result of an infection or trauma.
"Hearing defects" means any physical defect of the ear which does 35. Skeletal irregularities of one or both jaws, including orthognathia and or can impair normal hearing, apart from the disease process; mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for 20. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for 36. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail treatment of a covered Injury, or as specifically provided in the policy; planing, bungee jumping, or flight in any kind of aircraft, except while 21. Injury or Sickness for which benefits are paid or payable under any riding as a passenger on a regularly scheduled flight of a commercial Workers' Compensation or Occupational Disease Law or Act, or 22. Injury or Sickness outside the United States and its possessions, 38. Speech therapy; naturopathic services; Canada or Mexico, except for a Medical Emergency when traveling 39. Suicide or attempted suicide while sane or insane (including drug for academic study abroad programs business or pleasure; overdose); or intentionally self-inflicted Injury; 23. Injury sustained by reason of a motor vehicle accident to the extent 40. Supplies, except as specifically provided in the policy; that benefits are paid or payable by any other valid and collectible 41. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically 24. Injury sustained while (a) participating in any intercollegiate or professional sport, contest or competition; (b) traveling to or from 42. Travel in or upon, sitting in or upon, alighting to or from, or working such sport, contest or competition as a participant; or (c) while on or around any motorcycle or recreational vehicle including but not participating in any practice or conditioning program for such sport, limiting to: two- or three-wheeled motor vehicle; four-wheeled all- terrain vehicle (ATV); jet ski; ski cycle; or snowmobile; 43. Skiing, snowboarding, scuba diving, surfing, roller skating, 27. Outpatient Physiotherapy; except for a condition that required 44. Treatment in a Government hospital, unless there is a legal obligation surgery or Hospital Confinement: 1) within the 30 days immediately for the Insured Person to pay for such treatment; preceding such Physiotherapy; or 2) within the 30 days immediately 45. War or any act of war, declared or undeclared; or while in the armed following the attending Physician's release for rehabilitation; forces of any country (a pro-rata premium will be refunded upon 28. Participation in a riot or civil disorder; commission of or attempt to request for such period not covered); and 46. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat.

Source: http://www.sierranevada.edu/assets/2013-1622-1-Ben-Sum-Fly-v1.pdf