2013-667-1 koster flyer-v5_benefit summary

Occidental College is pleased to offer a Student Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company. All students who are registered in a degree program are serviced by Gallagher Koster and is based automatically enrolled in the Occidental College Student Injury and Sickness Insurance Plan at registration. Eligible dependents of insured students can also be enrolled in the Occidental College Student Injury and Sickness Insurance Plan for an additional cost. Highlights of the Coverage and Services:
Up to $500,000 Per Insured Person, Per Policy Year Maximum Benefit for Covered Medical Need more Information?
Covered Medical Expenses for Preferred Providers are payable at 100% of Preferred Al owance to $5,000, then 80% thereafter and Out of Network benefits are payable at 80% of Usual and Gallagher Koster
Customary charges to $5,000, then 60% thereafter (al benefits are subject to satisfaction of the Deductible, specific benefit limitations, maximums and Copays as described in the policy). Prescription Drug Benefits: $15 co-pay for Tier 1/ $30 co-pay for Tier 2 / $50 co-pay Tier 3, up to a 31-day supply per prescription fil ed at a UnitedHealthcare Pharmacy (UHCP). Prescriptions must be fil ed at a UHCP network pharmacy. Mail order through UHCP at 2.5 times the retail Copay up to a Preventive Care Services which include, but are not limited to, annual physicals, GYN exams, routine screenings and immunizations, covered at 100%, no Copay or deductible only when the services are received from a Preferred Providers. Please seefor complete details of the services provided for specific age and risk groups. The Preferred Providers for this plan are the UnitedHealthcare Options PPO. FrontierMEDEX – Domestic Students are covered when 100 miles or more away from their campus or home address. International Students are covered worldwide except in their home country. Also available for al students at Occidental Col ege is a ful y-insured Dental Plan through UnitedHealthcare Insurance Company. To enrol please visihen Please read the brochure which provides details of the coverage including benefits, exclusions, any reductions or limitations and the terms under which the coverage may be continued in force. Copies of the brochure are available from the Col ege or may be viewed or downloaded at
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 1-877-498-5468. 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
Exclusions and Limitations
b. Immunization agents, except as specifically provided in No benefits will be paid for: a) loss or expense caused by, the policy; biological sera, blood or blood products contributed to, or resulting from; or b) treatment, services or supplies for, at, or related to any of the following: c. Drugs labeled, “Caution - limited by federal law to investigational use” or experimental drugs; d. Products used for cosmetic indications; 3. Milieu therapy, learning disabilities, behavioral problems, e. Drugs used to treat or cure baldness, and anabolic steroids parent-child problems, conceptual handicap, developmental delay or disorder or mental retardation, except as specifically f. Anorectics - drugs used for the purpose of weight control; g. Fertility agents, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, or Serophene or Viagra; 5. Congenital conditions, except as specifically provided in benefits for Reconstructive Surgery or except as specifically i. Refills in excess of the number specified or dispensed after provided for Newborn or adopted Infants; one (1) year of date of the prescription; 6. Cosmetic procedures, except cosmetic surgery required to 19. Reproductive/infertility services including but not limited to: correct an Injury for which benefits are otherwise payable family planning; fertility tests; infertility (male or female), under this policy or for newborn or adopted children; including any services or supplies rendered for the purpose or 7. Dental treatment, except for accidental Injury to Natural with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; female 8. Elective Surgery or Elective Treatment; sterilization procedures, except as specifically provided in the 9. Eye examinations, eye refractions, eyeglasses, contact lenses, policy; vasectomy; sexual reassignment surgery; reversal of prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and 20, Routine Newborn Infant Care, well-baby nursery and related problems; except when due to a covered Injury or disease Physician charges except as specifically provided in the 10. Flat foot conditions; supportive devices for the foot; fallen 21. Preventive Care Services; routine physical examinations and arches; weak feet; chronic foot strain; symptomatic routine testing; preventive testing or treatment; screening complaints of the feet; and routine foot care including the exams or testing in the absence of Injury or Sickness; except care, cutting and removal of corns, calluses, toenails, and bunions (except capsular or bone surgery); 22. Services provided normally without charge by the Health 11. Hearing examinations; hearing aids; or other treatment for Service of the Policyholder; or services covered or provided hearing defects and problems, except as a result of an by the student health fee; 23. Nasal and sinus surgery, except infection or trauma. "Hearing defects" means any physical for treatment of a covered Injury or treatment of chronic defect of the ear which does or can impair normal hearing, 24. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any 13. Immunizations, except as specifically provided in the policy; kind of aircraft, except while riding as a passenger on a preventive medicines or vaccines, except where required for regularly scheduled flight of a commercial airline; treatment of a covered Injury or as specifically provided in 25. Supplies, except as specifically provided in the policy; 26. Surgical breast reduction, breast augmentation, breast 14. Injury or Sickness for which benefits are paid or payable implants or breast prosthetic devices, or gynecomastia; under any Workers' Compensation or Occupational Disease except as specifically provided in the policy; 27 Treatment in a Government hospital, unless there is a legal 15 Injury sustained while (a) participating in any obligation for the Insured Person to pay for such treatment; interscholastic, intercollegiate or professional sport, contest 28. War or any act of war, declared or undeclared; or while in the or competition; (b) traveling to or from such sport, contest or armed forces of any country (a pro-rata premium will be competition as a participant; or (c) while participating in any refunded upon request for such period not covered); and practice or conditioning program for such sport, contest or 29. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or 17. Participation in a riot or civil disorder; commission of or 18. Prescription Drug Services - no benefits will be payable for: 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 policy;

Source: http://www.occidental.edu/sites/default/files/assets/AHVA/2013-14%20Occidental%20College%20Benefit%20Highlight%20Flyer.pdf


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