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2013-1604-1 bro-v1_layout 22013-2014
Designed Especially for the Students of
Important: Please see the Notice on the first page
of this plan material concerning student health
Notice Regarding Your Student Health Insurance Coverage
Your 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. 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.
Table of Contents
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 1-800-767-0700 or by visiting us atwww.uhcsr.com.
All undergraduate students taking 9 credit hours or more and all graduate students taking6 credit hours or more are automatically enrolled in this insurance Plan at registration,unless proof of comparable coverage is furnished. 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 may also insure their Dependents. Eligible Dependents arethe student’s spouse (husband or wife) 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 1, 2013. Theindividual 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., July 31, 2014. Coverage terminates on that date or at the end of the periodthrough which premium is paid, whichever is earlier. Dependent coverage will not beeffective prior to that of the Insured student or extend beyond that of the Insured student.
Refunds of premiums are allowed only upon entry into the armed forces.
The Policy is 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 Hospital Confined on the Termination Date from a covered Injury or Sickness forwhich benefits were paid before the Termination Date, Covered Medical Expenses for suchInjury or Sickness will continue to be paid as long as the condition continues but not toexceed 90 days after the Termination Date.
The total payments made in respect of the Insured for such condition both before and afterthe Termination Date will never exceed the Maximum Benefit. After this “Extension ofBenefits” provision has been exhausted, all benefits cease to exist, and under nocircumstances will further payments be made.
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 the 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's
voice mail after hours by calling 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise
payable under the policy; however, pre-notification is not a guarantee that benefits will be
Accidental Death and Dismemberment Benefits
Loss of Life, Limb or Sight
If such Injury shall independently of all other causes and within 90 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.
Schedule of Medical Expense Benefits
Injury and Sickness
Maximum Benefit: $500,000 Paid as Specified Below
(Per Insured Person) (Per Policy Year)
Deductible Preferred Provider: $500 (Per Insured Person) (Per Policy Year)
Deductible Out-of-Network: $1,000 (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 Provider: $2,500
(Per Insured Person, Per Policy Year)
Out-of-Pocket Maximum Out-of-Network: $5,000
(Per Insured Person, Per Policy Year)
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.
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
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. Separate Out-of-Pocket Maximums
apply to Preferred Provider and Out-of-Network benefits. 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 Copays and
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:
Room and Board Expense, daily semi-private room
rate when confined as an Inpatient; and generalnursing care provided by the Hospital.
Hospital Miscellaneous Expenses, such as the cost
of the operating room, laboratory tests, x-rayexaminations, anesthesia, drugs (excluding take homedrugs) or medicines, therapeutic services, and supplies.
In computing the number of days payable under thisbenefit, the date of admission will be counted, but notthe date of discharge.
Routine Newborn Care, while Hospital Confined; and
routine nursery care provided immediately after birthfor an Inpatient stay of at least 48 hours following avaginal delivery or 96 hours following a cesareandelivery. If the mother agrees, the attending Physicianmay discharge the newborn earlier.
Surgeon’s Fees, if two or more procedures are
performed through 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 administered in
Registered Nurse’s Services, private duty nursing
Physician’s Visits, non-surgical services when
confined as an Inpatient. Benefits do not apply whenrelated to surgery.
Pre-Admission Testing, payable within 3 working
Surgeon’s Fees, if two or more procedures are
performed through the same incision or in immediatesuccession at the same operative session, the maximumamount paid will not exceed 50% of the secondprocedure and 50% of all subsequent procedures.
Day Surgery Miscellaneous, related to scheduled
surgery performed in a Hospital, including the cost ofthe operating room; laboratory tests and x-rayexaminations, including professional fees; anesthesia;drugs or medicines; therapeutic services and supplies.
Usual and Customary Charges for Day SurgeryMiscellaneous are based on the Outpatient SurgicalFacility Charge Index.
Anesthetist, professional services administered in
Physician’s Visits, benefits for Physician’s Visits do
not apply when related to surgery or Physiotherapy.
Physiotherapy, Physiotherapy includes but is not
limited to the following: 1) physical therapy; 2)occupational therapy; 3) cardiac rehabilitation therapy;4) manipulative treatment; and 5) speech therapy.
Speech therapy will be paid only for the treatment ofspeech, language, voice, communication and auditoryprocessing when the disorder results from Injury,trauma, stroke, surgery, cancer or vocal nodules.
Review of Medical Necessity will be performed after 12visits per Injury or Sickness.
Medical Emergency Expenses, facility charge for
use of the emergency room and supplies. Treatmentmust be rendered within 72 hours from time of Injury orfirst onset of Sickness. Diagnostic X-ray Services
Tests & Procedures, diagnostic services and medical
procedures performed by a Physician, other thanPhysician’s Visits, Physiotherapy, X-Rays and LabProcedures. The following therapies will be paid underthis benefit: inhalation therapy, infusion therapy,pulmonary therapy and respiratory therapy.
Injections, when administered in the Physician's office
and charged on the Physician's statement.
Durable Medical Equipment, a written prescription
must accompany the claim when submitted. Benefitsare limited to the initial purchase or one replacementpurchase per Policy Year. Durable Medical Equipmentincludes external prosthetic devices that replace a limbor body part but does not include any device that is fullyimplanted into the body. ($5,000 maximum Per PolicyYear) (Durable Medical Equipment benefits payableunder the $5,000 maximum are not included in the$500,000 Maximum Benefit.) Consultant Physician Fees, when requested and
Dental Treatment, made necessary by Injury to Sound,
Natural Teeth only.
($5,000 maximum Per Policy Year) (Benefits are notsubject to the $500,000 Maximum Benefit.) Preferred
Mental Illness Treatment, services received on an
Inpatient and outpatient basis. Institutions specializingin or primarily treating Mental illness and SubstanceUse Disorders are not covered.
Substance Use Disorder Treatment, services
received on an Inpatient and outpatient basis.
Institutions specializing in or primarily treating MentalIllness and Substance Use Disorders are not covered.
Maternity, benefits will be paid for an Inpatient stay of
at least 48 hours following a vaginal delivery or 96hours following a cesarean delivery. If the motheragrees, the attending Physician may discharge themother earlier. Complications of Pregnancy
Preventive Care Services, medical services that have
been demonstrated by clinical evidence to be safe andeffective in either the early detection of disease or inthe prevention of disease, have been proven to have abeneficial effect on health outcomes and are limited tothe following as required under applicable law: 1)Evidence-based items or services that have in effect arating of “A” or “B” in the current recommendations ofthe United States Preventive Services Task Force; 2)immunizations that have in effect a recommendationfrom the Advisory Committee on ImmunizationPractices of the Centers for Disease Control andPrevention; 3) with respect to infants, children, andadolescents, evidence-informed preventive care andscreenings provided for in the comprehensiveguidelines supported by the Health Resources andServices Administration; and 4) with respect to women,such additional preventive care and screeningsprovided for in comprehensive guidelines supported bythe Health Resources and Services Administration.
No Deductible, Copays or Coinsurance will be appliedwhen the services are received from a PreferredProvider.
Reconstructive Breast Surgery Following
Mastectomy, in connection with a covered
Mastectomy for 1) all stages of reconstruction of the
breast on which the mastectomy has been performed;
2) surgery and reconstruction of the other breast to
produce a symmetrical appearance; and 3) prostheses
and physical complications of mastectomy, including
Diabetes Services, in connection with the treatment
of diabetes. (See Benefits for Diabetes) 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. Insured’s
may incur significant out-of-pocket expenses with these providers. Charges in excess of
the insurance payment are the Insured’s responsibility.
Regardless of the provider, each Insured is responsible for the payment of their Deductible.
The Deductible must be satisfied before benefits are paid. The Company will pay according
to the benefit limits in the Schedule of Benefits.
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 1-800-767-0700 for information about
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 and
Copayments that vary depending on which tier of the PDL the outpatient drug is listed.
There are certain Prescription Drugs that require your Physician to notify us to verify their
use is covered within your benefit.
You are responsible for paying the applicable Copayments. Your Copayment is determined
by the tier to which the Prescription Drug Product is assigned on the PDL. Tier status may
change periodically and without prior notice to you. Please access www.uhcsr.com or call 1-
855-828-7716 for the most up-to-date tier status.
$10 Copay per prescription order or refill for a Tier 1 Prescription Drug up to a 31 day supply.
$25 Copay per prescription order or refill for a Tier 2 Prescription Drug up to a 31 day supply.
$50 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 use a network pharmacy, you will be responsible for paying the full cost for the
If you do not present the card, you will need to pay 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 1-855-828-7716.
In addition to the policy Exclusions and Limitations, the following Exclusions apply to
Network 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 prescriptionorder or refill. Compounded drugs that are available as a similar commerciallyavailable Prescription Drug Product. Compounded drugs that contain at least oneingredient that requires a prescription order or refill are assigned to Tier-3.
4. Drugs available over-the-counter that do not require a prescription order or refill by federal or state law before being dispensed, unless the Company has designatedthe over-the-counter medication as eligible for coverage as if it were a PrescriptionDrug Product and it is obtained with a prescription order or refill from a Physician.
Prescription Drug Products that are available in over-the-counter form or comprisedof components that 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 tosix times during a calendar year, and the Company may decide at any time toreinstate Benefits for a Prescription Drug Product that was previously excludedunder 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 treatmentof Sickness or Injury.
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 at 1-855-828-7716.
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) Pregnancy-associated plasma protein-A (PAPPA) (first trimester only)
Free beta human chorionic gonadotrophin (hCG) (first trimester only)
Each visit: Urine analysis
Once every trimester: Hematocrit and Hemoglobin
Once during first trimester: Ultrasound
Once during second trimester:
Triple Alpha-fetoprotein (AFP), Estriol, hCG or Quad screen test Alpha-fetoprotein(AFP), Estriol, hCG, inhibin-a Once during second trimester if age 35 or over: Amniocentesis or Chorionic villus sampling
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.
Coordination of Benefits Provision
Benefits will be coordinated with any other eligible medical, surgical or hospital plan orcoverage so that combined payments under all programs will not exceed 100% of allowableexpenses incurred for covered services and supplies.
Benefits for Mammography
Benefits will be paid the same as any other Sickness for a screening mammography asfollows: 1) For women who are thirty-five years of age and older but younger than forty years of age, one base-line mammogram between thirty-five and forty years of age; 2) For women who are forty years of age and older but younger than fifty years of age, one mammogram every two years or more frequently based on the patient’sPhysician’s recommendation; and 3) For women who are fifty years of age or older, one mammogram every year.
Benefits shall be subject to all Deductible, Copayment, Coinsurance, limitations, or any otherprovisions of the policy.
Benefits for Diabetes
Benefits will be paid the same as any other Sickness for equipment, supplies, medication,and outpatient self-management training, including medical nutrition therapy, for thetreatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, andnon-insulin-using diabetes if prescribed by a Physician. Benefits shall include the following equipment, supplies, medication, and patient self-management training for the use of the equipment such as: blood glucose monitors, bloodglucose monitors for the legally blind, test strips for glucose monitors, urine testing strips,insulin, injection aids, lancet and lancet devices, syringes, insulin pumps and all supplies forthe pump, insulin infusion devices, oral agents for controlling blood sugars, glucose agentsand glucagon kits, insulin measurement and administration aids for the visually impaired,patient management material that provide essential diabetes self-management information,and podiatric appliances for the prevention of complications associated with diabetes.
Benefits shall cover home visits when Medically Necessary and prescribed by a Physician.
Diabetes self-management training, including medical nutrition therapy, shall be provided byan American Diabetes Association Recognized Diabetes Self-Management EducationProgram or a Physician.
Physician prescribed diabetes self-management training shall be covered at diagnosis,when symptoms or conditions change, and when new medications or treatments areprescribed. Diabetes self-management education must be deemed to be MedicallyNecessary by a Physician to be eligible for coverage.
“Patient self-management” means educational and training services furnished to anindividual with diabetes in an outpatient setting by an individual or entity with experience indiabetes, in consultation with the Physician who is managing the patient’s condition, whichPhysician certifies that such services are needed under a comprehensive plan of carerelated to the individual’s condition to ensure therapy or compliance or to provide theindividual with necessary skills and knowledge, including skills related to the self-administration of injectable drugs which participate in the management of the individual’scondition.
Benefits shall be subject to all Deductibles, Copayment, Coinsurance, limitations, or anyother provisions of the policy.
Benefits for Colorectal Cancer Screening
Benefits will be paid the same as any other Sickness for Colorectal Cancer examinationand laboratory tests for cancer for any non-symptomatic Insured Person fifty years of ageand older. Benefits shall include: 1) one screening fecal occult blood test annually;2) a flexible sigmoidoscopy every five years;3) a colonoscopy every ten years, or a barium enema every five to ten years, or any 4) the most reliable, medically recognized screening test available. The screenings selected shall be as deemed appropriate by a Physician and the Insured Person.
Benefits shall be subject to all Deductibles, Copayment, Coinsurance, limitations, or anyother provisions of the policy.
COINSURANCE means the percentage of Covered Medical Expenses that the Company
COPAY/COPAYMENT means a specified dollar amount that the Insured is required to pay
for certain Covered Medical Expenses.
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.
DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or any
endorsement to this policy as a deductible, it shall mean an amount to be subtracted from
the amount or amounts otherwise payable as Covered Medical Expenses before payment
of any benefit is made. The deductible will apply as specified in the Schedule of Benefits.
INJURY means bodily injury which is all of the following:
1) directly and independently caused by specific accidental contact with another body 2) unrelated to any pathological, functional, or structural disorder. 3) a source of loss.
4) treated by a Physician within 30 days after the date of accident.
5) sustained while the Insured Person is covered under this policy.
All injuries sustained in one accident, including all related conditions and recurrent
symptoms of these injuries will be considered one injury. Injury does not include loss which
results wholly or in part, directly or indirectly, from disease or other bodily infirmity. 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.
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 EMERGENCY means the occurrence of a sudden, serious and unexpected
Sickness or Injury. In the absence of immediate medical attention, a reasonable person
could believe this condition would result in any of the following:
2) Placement of the Insured's health in jeopardy.
3) Serious impairment of bodily functions.
4) Serious dysfunction of any body organ or part.
5) In the case of a pregnant woman, serious jeopardy to the health of the fetus.
Expenses incurred for "Medical Emergency" will be paid only for Sickness or Injury which
fulfills the above conditions. These expenses will not be paid for minor Injuries or minor
MEDICAL NECESSITY means those services or supplies provided or prescribed by a
Hospital or Physician which are all of the following:
1) Essential for the symptoms and diagnosis or treatment of the Sickness or Injury.
2) Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury.
3) In accordance with the standards of good medical practice.
4) Not primarily for the convenience of the Insured, or the Insured's Physician.
5) The most appropriate supply or level of service which can safely be provided to theInsured.
The Medical Necessity of being confined as an Inpatient means that both: 1) The Insured requires acute care as a bed patient.
2) The Insured cannot receive safe and adequate care as an outpatient.
This policy only provides payment for services, procedures and supplies which are a Medical
Necessity. No benefits will be paid for expenses which are determined not to be a Medical
Necessity, including any or all days of Inpatient confinement.
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:
3) Expenses that are not Covered Medical Expenses.
PRE-EXISTING CONDITION means: 1) the existence of symptoms which would cause
an ordinarily prudent person to seek diagnosis, care or treatment within the 12 months
immediately prior to the Insured's Effective Date under the policy; or, 2) any condition which
originates, is diagnosed, treated or recommended for treatment within the 12 months
immediately prior to the Insured's Effective Date under the policy.
SICKNESS means sickness or disease of the Insured Person which causes loss, and
originates while the Insured Person is covered under this policy. All related conditions and
recurrent symptoms of the same or a similar condition will be considered one sickness.
Covered Medical Expenses incurred as a result of an Injury that occurred prior to this
policy's Effective Date will be considered a Sickness under this policy.
USUAL AND CUSTOMARY CHARGES means 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
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. Addiction, such as: nicotine addiction, except as specifically provided in the policy; and caffeine addiction; non-chemical addiction, such as: gambling, sexual, spending,shopping, working and religious; codependency; 5. Milieu therapy, behavioral problems, intensive behavioral therapies, such as applied behavioral analysis; parent-child problems, conceptual handicap, developmental delayor disorder or mental retardation; 8. Congenital conditions, except as specifically provided for Newborn Infants;9. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn children; 10. 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; 11. Dental treatment, except for accidental Injury to Sound, Natural Teeth; 12. Elective Surgery or Elective Treatment; 13. Elective abortion;14. 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; 15. Flat foot conditions; supportive devices for the foot; subluxations of the foot; fallen arches; weak feet; chronic foot strain; symptomatic complaints of the feet; and routinefoot care including the care, cutting and removal of corns, calluses, toenails, andbunions (except capsular or bone surgery); 16. Health spa or similar facilities; strengthening programs; 17. Hearing examinations; hearing aids; or cochlear implants; or other treatment for hearing defects and problems, except as a result of an infection or trauma. "Hearingdefects" means any physical defect of the ear which does or can impair normalhearing, apart from the disease process; 20. 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; 21. Injury caused by, contributed to, or resulting from the addiction to or use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs or medicines that are not takenin the recommended dosage or for the purpose prescribed by the Insured Person'sPhysician; 22. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 23. Injury sustained while (a) participating in any club, 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. Organ transplants, including organ donation; 27. Participation in a riot or civil disorder; commission of or attempt to commit a felony; 28. 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 aprior health insurance policy which provided benefits similar to this policy. Thisexclusion will not be applied to an Insured Person who is under age 19; 29. 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 Benefits for Diabetes; 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 on the basis that the drug or combination ofdrugs has not been approved by the federal Food and Drug Administration for thetreatment of another specific type of cancer if (a) the drug or combination of drugsis recognized for treatment of the other specific type of cancer in the United StatesPharmacopeia-Drug Information and the drug or combination of drugs is approvedfor sale by the federal Food and Drug Administration or (b) the drug or combinationof drugs is recognized for treatment of the other specific type of cancer in medicalliterature and the drug or combination of drugs is approved for sale by the federalFood and Drug Administration; or any drug or combination of drugs on the basisthat the drug or combination of drugs has not been approved by the federal Foodand Drug Administration for the treatment of human immunodeficiency virus oracquired immunodeficiency syndrome if (a) the drug or combination of drugs isrecognized for treatment of human immunodeficiency virus or acquiredimmunodeficiency syndrome in the United States Pharmacopeia-Drug Informationand the drug or combination of drugs is approved for sale by the federal Food andDrug Administration or (b) the drug or combination of drugs is recognized fortreatment of human immunodeficiency virus or acquired immunodeficiencysyndrome in medical literature and the drug or combination of drugs is approved forsale by the federal Food and Drug Administration; d) Products used for cosmetic purposes;e) Drugs used to treat or cure baldness; anabolic steroids used for body building;f) Anorectics - drugs used for the purpose of weight control;g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, h) Growth hormones; ori) Refills in excess of the number specified or dispensed after one (1) year of date of 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; premarital examinations;impotence, organic or otherwise; female sterilization procedures, except as specificallyprovided in the policy; vasectomy; sexual reassignment surgery; reversal ofsterilization 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; 32. Preventive care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness;except as specifically provided in the policy; 33. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 34. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal septum, includingsubmucous resection and/or other surgical correction thereof; nasal and sinussurgery, except for treatment of a covered Injury or treatment of chronic purulentsinusitis; 35. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 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.
Collegiate Assistance Program
Insured Students have access to nurse advice, health information, and counseling support24 hours a day by dialing the number listed on the permanent ID card. CollegiateAssistance Program is staffed by Registered Nurses and Licensed Clinicians who can helpstudents determine if they need to seek medical care, need legal/financial advice or mayneed 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 minorchild(ren) are eligible for FrontierMEDEX. The requirements to receive these services areas follows:International Students, insured spouse and insured minor child(ren): You are eligible toreceive FrontierMEDEX services worldwide, except in your home country.
Domestic Students, insured spouse and insured minor child(ren): You are eligible forFrontierMEDEX 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.
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 firstname.lastname@example.org.
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: 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 the Insured Person’s ability to regain maximum function; or 2. Would, in the opinion of a Physician with knowledge of the Insured Person’s medical 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: Claims Appeals,
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 4 months ofreceiving a notice of the Company’s Adverse Determination or Final Adverse Determination. Experimental or Investigational External Review when the denial of coverage is based on adetermination that the recommended or requested health care service or treatment isexperimental or investigational.
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 an Adverse Determination, anda. 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 Final Adverse Determination, anda. The Insured Person has a medical condition for which the time frame for completing a Standard External Review would seriously jeopardize the life orhealth of the Insured Person or jeopardize the Insured Person’s ability to regainmaximum function; 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 an Adverse Determination, anda. 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 isexperimental or investigational and the Insured Person’s treating Physiciancertifies in writing that the recommended or requested health care service ortreatment would be significantly less effective is not initiated promptly; or 2. The Insured Person or the Insured Person’s Authorized Representative has received a Final Adverse Determination, anda. The Insured Person has a medical condition for which the time frame for completing a Standard External Review would seriously jeopardize the life orhealth of the Insured Person or jeopardize the Insured Person’s ability to regainmaximum function; 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 submitted to Claims Appeals at the followingaddress: Claims Appeals
PO Box 809025
Dallas, TX 75380-9025
Questions Regarding Appeal Rights
Contact Customer Service at 1-800-767-0700 with questions regarding the InsuredPerson’s rights to an Internal Appeal and External Review.
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.
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
In the event of Injury or Sickness, students should: 1) Report to the Student Health Service for treatment or referral, or when not in school, 2) Mail to the address below all medical and hospital bills along with the patient's name and insured student's name, address, social security number and name of theuniversity under which the student is insured. A Company claim form is not requiredfor filing a claim.
3) File claim within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90 days of service. Bills submitted after one yearwill not be considered for payment except in the absence of legal capacity.
The Plan is Underwritten by:
Submit all Claims or Inquiries to:
805 Executive Center Drive West, Suite 220 Please keep this Brochure as a general summary of the insurance. The Master Policy onfile at the University contains all of the provisions, limitations, exclusions and qualificationsof your insurance benefits, some of which may not be included in this Brochure. The MasterPolicy is the contract and will govern and control the payment of benefits.
This Brochure is based on
Aula Magna do Prof. Pasquale Cipro Neto na Escola de Especialistas de Aeronáutica Natural de Guaratinguetá-SP, Pasquale Cipro Neto cursou Letras (Espanhol-Português) na Universidade de São Paulo. É professor de português desde 1975 e colunista dos jornais Folha de São Paulo, Correio Popular (de Campinas), O Povo (de Fortaleza), A Tribuna (de Santos), entre outros. Idealizou e apresentou