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Microsoft word - 2014-202726-1 summary brochure-v



2014–2015
Student Injury and Sickness Insurance Plan for College of Coastal Georgia
Who is eligible to enroll?
All students enrolled for six (6) or more credits per term or participating in Cooperative Education Programs are eligible to enroll in the
insurance plan, excluding those students that are required to enroll in the plan as stated below. Eligible Dependents of enrolled
students may participate in the plan on a voluntary basis.
The students required to enroll in the plan are as follows:
1. All undergraduate and ESL international students holding F or J visas.
2. All undergraduate students enrolled in programs that require proof of health insurance.
3. All graduate students receiving a full tuition waiver as part of their graduate assistantship award.
4. All graduate international students and visiting scholars holding F or J visas.
5. All graduate students enrolled in programs that require proof of health insurance.
6. All graduate students receiving fellowships that fully fund their tuition.
Eligible Dependents are the student's legal spouse and dependent children under 26 years of age.
Where can I get more information about the benefits available?
Please read the plan brochure to determine whether this plan is right before you enroll. The plan brochure provides details of the
coverage including costs, benefits, exclusions, and reductions or limitations and the terms under which the coverage may be
continued in force. Copies of the plan brochure are available from the University and may be viewed at www.uhcsr.com/usg.
Who can answer questions I have about the plan?
If you have questions please contact Customer Service at 1-866-403-8267 or customerservice@uhcsr.com.
What important dates or deadlines should I be aware of?
Online waivers must be submitted by September 20, 2014.
How much does the plan cost?
8/1/14 – 7/31/15
8/1/14 – 12/31/14
1/1/15 – 7/31/15
6/1/15 – 7/31/15
Student $1,795.00 $5,255.00 $2,203.00 $3,052.00 $878.00 Child $2,422.00 $1,015.00 $1,407.00 $405.00 Children $4,627.00 $1,940.00 $2,687.00 $773.00 This plan is underwritten by UnitedHealthcare Insurance Company and is based on policy number 2014-202726-1. The Policy is a Non-Renewable One-Year Term Policy. 14PPOSB-202726-1 UnitedHealthcare StudentResources
Highlights of the Coverage and Services offered by UnitedHealthcare StudentResources
Preferred Providers
Out-of-Network Providers
Overall Plan Maximum
There is no overall maximum dollar limit on the policy Plan Deductible
$500 Per Insured Person, $800 Per Insured Person, $1,250 For all Insureds in a Family, $1,450 For all Insureds in a Family, SHC Benefits
The Deductible will be waived for Covered Medical Expenses incurred when treatment is rendered at the Student Health Center. Out-of-Pocket Maximum
$6,350 Per Insured Person, $10,500 Per Insured Person, After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses will be $12,700 For all Insureds in a Family, $33,500 For all Insureds in a Family, paid at 100% for the remainder of the Policy Year subject to any applicable benefit maximums. Refer to the plan brochure for details about how the Out-of-Pocket Maximum applies. Coinsurance
80% of Preferred Allowance for 60% of Usual and Customary Charges All benefits are subject to satisfaction of the Covered Medical Expenses for Covered Medical Expenses Deductible, specific benefit limitations, maximums and Copays as described in the plan brochure. Prescription Drugs
$25 Copay for Tier 1 $25 Deductible for generic drugs Mail order through UHCP at 2.5 times the $50 Copay for Tier 2 $50 Deductible for brand name drugs retail copay up to a 90 day supply. $75 Copay for Tier 3 Up to a 31-day supply per prescription Up to a 31-day supply per prescription filled at a UnitedHealthcare Pharmacy (UHCP) University Health Center Pharmacy: Copay waived for generic drugs / $5 Copay per prescription for brand name drugs, $10 Copay per prescription for non-formulary drugs / up to a 31 day supply per prescription if prescription is filled at the University Health Center Pharmacy. Preventive Care Services
100% of Preferred Allowance 100% of Usual and Customary Including but not limited to: annual physicals, GYN exams, routine screenings and immunizations. No copay or Deductible when the 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. The following services have per Service
Physician's Visits: $20 This list is not all inclusive. Please read the plan brochure for complete listing of Copays/Deductibles. Pediatric Dental and Vision Benefits
Refer to the plan brochure for details (age limits apply). Domestic Students are eligible for FrontierMEDEX services when 100 miles or more away from your campus address and 100 miles or more away from your permanent home address. International Students are covered worldwide except in their home country. 14PPOSB-202726-1 UnitedHealthcare StudentResources
Preferred Providers
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can be found using the
following link: http://www.uhcsr.com/lookupredirect.aspx?delsys=52
Online Services
UnitedHealthcare StudentResources Insureds have online access to their claims status, EOBs, ID Cards, network providers,
correspondence and coverage account information by logging 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 download our UHCSR Mobile App available on
Google Play and Apple's App Store.
Other Coverage
Accident coverage for Intercollegiate sports injury is provided under a separate policy, 2014-202726-8.
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:
Cosmetic procedures, except reconstructive procedures to:  Correct an Injury or treat a Sickness for which benefits are otherwise payable under this policy. The primary result of the procedure is not a changed or improved physical appearance.  Treat or correct Congenital Conditions of a Newborn or adopted Infant. Dental treatment, except:  For accidental Injury to Sound, Natural Teeth.  As described under Dental Treatment in the policy. This exclusion does not apply to benefits specifically provided in Pediatric Dental Services. Elective Surgery or Elective Treatment. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline. Foot care for the following:  Flat foot conditions.  Supportive devices for the foot, except as specifically provided in Benefits for the Management and Treatment of  Fallen arches.  Chronic foot strain.  Routine foot care including the care, cutting and removal of corns, calluses, toenails, and bunions (except capsular or bone surgery). This exclusion does not apply to preventive foot care for Insured Persons with diabetes. Hearing examinations. Hearing aids. Other treatment for hearing defects and hearing loss. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process. This exclusion does not apply to:  Hearing defects or hearing loss as a result of an infection or Injury. Hirsutism. Alopecia. Preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifically provided in the policy. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation. Injury sustained while:  Participating in any intercollegiate or professional sport, contest or competition.  Traveling to or from such sport, contest or competition as a participant.  Participating in any practice or conditioning program for such sport, contest or competition. Investigational services. Participation in a riot or civil disorder. Commission of or attempt to commit a felony. Prescription Drugs, services or supplies as follows:  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 policy.  Immunization agents, except as specifically provided in the policy. Biological sera. Blood or blood products administered on an outpatient basis.  Drugs labeled, "Caution - limited by federal law to investigational use" or experimental drugs, except as specifically provided in the policy.  Products used for cosmetic purposes. 14PPOSB-202726-1 UnitedHealthcare StudentResources
 Drugs used to treat or cure baldness. Anabolic steroids used for body building.  Anorectics - drugs used for the purpose of weight control.  Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or  Growth hormones.  Refills in excess of the number specified or dispensed after one (1) year of date of the prescription. Reproductive/Infertility services including but not limited to the following:  Procreative counseling.  Genetic counseling and genetic testing.  Cryopreservation of reproductive materials. Storage of reproductive materials.  Infertility treatment (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception, except to diagnose or treat the underlying cause of the infertility.  Premarital examinations.  Impotence, organic or otherwise.  Female sterilization procedures, except as specifically provided in the policy.  Reversal of sterilization procedures.  Sexual reassignment surgery. Routine eye examinations. Eye refractions. Eyeglasses. Contact lenses. Prescriptions or fitting of eyeglasses or contact lenses. Vision correction surgery. Treatment for visual defects and problems. This exclusion does not apply as follows:  When due to a covered Injury or disease process.  To benefits specifically provided in Pediatric Vision Services.  To benefits specifically provided under Vision Correction in the policy.  To lenses following surgical removal of the lenses of the eye Services provided normally without charge by the Health Service of the Policyholder. Services covered or provided by the student health fee. Deviated nasal septum, including submucous resection and/or other surgical correction thereof. Skydiving. Parachuting. Hang gliding. Glider flying. Parasailing. Sail planing. Bungee jumping. Sleep disorders. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia, except as specifically provided in the policy. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment. 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 not covered). Weight management. Weight reduction. Nutrition programs. Treatment for obesity. Surgery for removal of excess skin or fat. 14PPOSB-202726-1 UnitedHealthcare StudentResources

Source: https://www2.ccga.edu/HealthCenter/files/UHCSRRates2014_2015.pdf

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