2012-1914-78 prelim flyer v2_benefit summary

Student Injury and Sickness Insurance
Denver Seminary

Denver Seminary is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company. Eligibility Statement: All registered graduate students taking 6 or more credit hours are eligible on a voluntary basis. Eligible Dependents of those enrolled in this plan may participate in the plan on a voluntary basis.
2012-1914-78. *Policy termsand conditions subject to Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
Up to $100,000 Per Insured Person, Per Policy Year Maximum Benefit for Covered Medical $250 Deductible Per Insured Person, Per Policy Year for Preferred Providers, $500 Deductible for Out of Network Providers Per Insured Person, Per Policy Year.
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 described in the policy).
the terms under which thecoverage may be continued in 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 to any applicable benefit maximums. Refer to the plan brochure for details about how the Out-of-Pocket Maximum applies.
Prescription Drug Benefits: $15 Copay for Tier 1 / $35 Copay for Tier 2 / $70 Copay forTier 3 up to a 31-day supply per prescription filled at a UnitedHealthcare Network Pharmacy (UHPS). Prescriptions must be filled at a UHPS network pharmacy. Mail order through UHPS 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 when the services are received from a Preferred Provider. Please see www.healthcare.gov for complete details of the services provided for specific age andrisk groups.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. PreferredProviders can be found using the following link, http://www.uhcsr.com/lookupredirect.aspx?delsys=52 Scholastic Emergency Services – Domestic Students are covered when 100 miles ormore away from their campus or home address. International Students are coveredworldwide except in their home country.
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 $100,000 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
8/25/12 - 8/24/13 8/25/12 - 1/27/13 1/28/13 - 5/19/13 1/28/13 - 8/24/13 5/20/13 - 8/24/13 Each Child
PRE-EXISTING CONDITION means any condition for which an Insured 26. Pre-existing Conditions for a period of 6 months, except for individuals who Person: 1) incurred charges; 2) received medical treatment; 3) consulted a have been continuously insured for at least 6 consecutive months under the health care professional; or 4) took Prescription Drugs within the 6 months school’s student insurance policy. The Pre-existing Condition exclusionary immediately prior to the Insured's Effective Date under this policy. “Pre- period will be reduced by the total number of months that the Insured existing Condition” does not include pregnancy.
provides documentation of continuous coverage under prior Creditable Exclusions and Limitations
Coverage if such Creditable Coverage was continuous to a date not more No benefits will be paid for: a) loss or expense caused by, contributed to, or than 90 days prior to the Insured’s Effective Date under this policy; This resulting from; or b) treatment, services or supplies for, at, or related to: exclusion will not be applied to an Insured Person under age 19.
Acne; acupuncture; allergy, including allergy testing; except as specifically Prescription Drugs, services or supplies as follows: Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, Milieu therapy, learning disabilities, behavioral problems, parent-child regardless of intended use;except as provided under Benefits for problems, testing (treatment is covered) and Attention Deficit Hyperactivity Disorder testing (treatment is covered), conceptual handicap, developmental Immunization agents, except as specifically provided in the policy, biological sera, blood or blood products administered on an outpatient Drugs labeled, “Caution - limited by federal law to investigational use” Congenital conditions, except as specifically provided in the policy; Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy removal of warts, Drugs used to treat or cure baldness; anabolic steroids used for body Custodial care; care provided in: rest homes, health resorts, homes for the Anorectics - drugs used for the purpose of weight control; aged, halfway houses, college infirmaries or places mainly for domiciliary or Fertility agents or sexual enhancement drugs, such as Parlodel, custodial care; extended care in treatment or substance abuse facilities for Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; Dental treatment, except for accidental Injury to Sound, Natural Teeth; Refills in excess of the number specified or dispensed after one (1) year 28. Reproductive/Infertility services including but not limited to: family planning; 12. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions fertility tests; infertility (male or female), including any services or supplies or fitting of eyeglasses or contact lenses, vision correction surgery, or other rendered for the purpose or with the intent of inducing conception; premarital treatment for visual defects and problems; except when due to a disease examinations; impotence, organic or otherwise; tubal ligation; vasectomy; process; or except as specifically provided in the policy; sexual reassignment surgery; reversal of sterilization procedures; 13. Foot care including: flat foot conditions, supportive devices for the foot, 29. Research or examinations relating to research studies, or any treatment for subluxations of the foot, care of corns, bunions (except capsular or bone which the patient or the patient’s representative must sign an informed surgery), calluses, toenails, fallen arches, weak feet, chronic foot strain, and consent document identifying the treatment in which the patient is to participate as a research study or clinical research study; 14. Health spa or similar facilities; strengthening programs; 30. Routine Newborn Infant care, well-baby nursery and related Physician 15. Hearing examinations or hearing aids, except as specifically provided in the charges; except as specifically provided in the policy; policy; or other treatment for hearing defects and problems. "Hearing 31. Routine physical examinations and routine testing; preventive testing or defects" means any physical defect of the ear which does or can impair treatment; screening exams or testing in the absence of Injury or Sickness; normal hearing, apart from the disease process; except as specifically provided 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; 18. Immunizations, except as specifically provided in the policy; preventive 33. Skeletal irregularities of one or both jaws, including orthognathia and medicines or vaccines, except where required for treatment of a covered mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal Injury or as specifically provided in the policy; septum, including submucous resection and/or other surgical correction 19. Injury or Sickness for which benefits are paid or payable under any Workers' thereof; nasal and sinus surgery, except for treatment of chronic purulent Compensation or Occupational Disease Law or Act, or similar legislation; 20. Injury or Sickness outside the United States and its possessions, Canada or 34. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, Mexico, except for a Medical Emergency when traveling for academic study bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 21. Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by any other valid and collectible insurance; 36. Speech therapy, except as specifically provided in the policy; naturopathic 22. Injury sustained while (a) participating in any intercollegiate or professional sport, contest or competition; (b) traveling to or from such sport, contest or Suicide or attempted suicide while sane (including drug overdose); or competition as a participant; or (c) while participating in any practice or conditioning program for such sport, contest or competition; 38. Supplies, except as specifically provided in the policy; 39. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the 25. Participation in a riot or civil disorder; commission of or attempt to commit a 40. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 41. War or any act of war, declared or undeclared; or while in the armed forces of any country other than the United States (a pro-rata premium will berefunded upon request for such period not covered); and 42. Weight management, weight reduction programs, weight management programs, nutrition programs, related nutritional supplies, and treatment forobesity.

Source: http://www.collegiateinsuranceresources.com/sip/plan_summary/other_forms/828_flyer_2012-13.pdf


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