2012-202468-1 ibenefit summary flyer - grad-v2_benefit summary

Student Injury and Sickness
Insurance Plan for
Palo Alto University - Graduates & PhD
2012-2013
Palo Alto University is pleased to offer an Injury and Sickness Insurance Plan underwritten byUnitedHealthcare Insurance Company. All full-time and part-time matriculating Graduate and Ph.D students who are registered and attending classes are automatically enrolled in this Health Insurance Program at registration, unless proof of comparable coverage is provided and a waiver is completed and submitted to the Business Affairs Office. Students on an official Leave of Absence may enroll for a maximum of one quarter (one time only), following the term in which the student was enrolled in the plan. Students enrolled in Distance Learning Programare not eligible for coverage under this plan.
Please read the plan brochureto determine whether this plan Highlights of the Coverage and Services
is right for you before youenroll. The plan brochure 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 described in the policy).
University, or may be viewedand downloaded at 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. Afterthe 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 for Tier 3 up to a 31-day supply per prescription. Prescriptions must be filled at a UnitedHealthcare Network Pharmacy. Mail order at 2.5 times the retail copay up to a 90- Coverage available for eligible dependents.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. PreferredProviders can be found using the following link,https://www.providerlookuponline.com/UHC/po7/Search.aspx 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 $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 any condition for which medical advice, 25. Outpatient Physiotherapy; except for a condition that required surgery or diagnosis, care or treatment, inlcuding the use of Prescription Drugs is Hospital Confinement: 1) within the 30 days immediately preceding such recommended or received from a Physician wihtin 6 months immediately prior Physiotherapy; or 2) within the 30 days immediately following the to the Insured’s Effective date under the policy. Pregnancy will not be attending Physician's release for rehabilitation; considered to be a Pre-Existing Condtion.
26. Participation in a riot or civil disorder; commission of or attempt to commit Exclusions and Limitations
No benefits will be paid for: a) loss or expense caused by, contributed to, Pre-Existing Conditions, except for individuals who have been or resulting from; or b) treatment, services or supplies for, at, or related continuously insured for at least 6 consecutive months under any health insurance plan or policy or employer-provided health benefit Acne; acupuncture; allergy, including allergy testing; except as arrangement. Credit for time served will be given when covered under Creditable Coverage provided the individual becomes eligible and enrolls under this policy within 63 days of termination of the prior plan; Milieu therapy, learning disabilities, behavioral problems, parent-child 28. Prescription Drug Services - no benefits will be payable for: problems, conceptual handicap, developmental delay or disorder or Therapeutic devices or appliances, including hypodermic needles, mental retardation; except as specifically provided in the policy; syringes, support garments and other non-medical substances, regardless of intended use, except as specifically provided in the Congenital conditions, except as specifically provided in benefits for Immunization agents, biological sera, blood or blood products Reconstructive Surgery or for Newborn or adopted Infants; Cosmetic procedures, except cosmetic surgery required to correct an Drugs labeled, “Caution - limited by federal law to investigational Injury for which benefits are otherwise payable under this policy or for newborn or adopted children; removal of warts, non-malignant moles and Products used for unapproved cosmetic indications; Drugs used to treat or cure baldness, and anabolic steroids used Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for Anorectics - drugs used for the purpose of weight control; domiciliary or custodial care; extended care in treatment or substance Fertility agents, such as Parlodel, Pergonal, Clomid, Profasi, abuse facilities for domiciliary or custodial care; Dental treatment, except for accidental Injury to Natural Teeth; 10. Elective Surgery or Elective Treatment; Refills in excess of the number specified or dispensed after one (1) 12. Eye examinations, eye refractions, eyeglasses, contact lenses, 29. Reproductive/Infertility services including but not limited to: family prescriptions or fitting of eyeglasses or contact lenses, vision correction planning; fertility tests; infertility (male or female), including any services surgery, or other treatment for visual defects and problems; except when or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; 13. Foot care including: flat foot conditions, supportive devices for the foot, tubal ligation; vasectomy; sexual reassignment surgery; reversal of except as provided in Benefits for Orthotic and Prosthetic Devices, if elected by the Policyholder; care of corns, bunions (except capsular or 30. Research or examinations relating to research studies, or any treatment bone surgery), calluses, toenails, fallen arches, weak feet, chronic foot for which the patient or the patient’s representative must sign an informed strain, and symptomatic complaints of the feet; consent document identifying the treatment in which the patient is to 14. Health spa or similar facilities; strengthening programs; participate as a research study or clinical research study; 15. Hearing examinations or hearing aids; or other treatment for hearing 31. Routine Newborn Infant Care, well-baby nursery and related Physician defects and problems. "Hearing defects" means any physical defect of charges; except as specifically provided in the policy; the ear which does or can impair normal hearing, apart from the disease 32. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 33. Deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for treatment 18. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered 34. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail Injury or as specifically provided in the policy; planing, bungee jumping, or flight in any kind of aircraft, except while 19. 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 similar 20. Injury or Sickness outside the United States and its possessions, 36. Speech therapy; naturopathic services; Canada, or Mexico, except for a Medical Emergency when traveling for Suicide or attempted suicide while sane or insane (including drug academic study abroad programs, business or pleasure; overdose); or intentionally self-inflicted Injury; 21. Injury sustained by reason of a motor vehicle accident to the extent that 38. Supplies, except as specifically provided in the policy; benefits are paid or payable by any other valid and collectible insurance, 39. Surgical breast reduction, breast augmentation, breast implants or breast except for automobile medical payment insurance; prosthetic devices, or gynecomastia; except as specifically provided in 22. Injury sustained while (a) participating in any intercollegiate or professional sport, contest or competition; (b) traveling to or from such 40. Treatment in a Government hospital, unless there is a legal obligation for sport, contest or competition as a participant; or (c) while participating in the Insured Person to pay for such treatment; any practice or conditioning program for such sport, contest or 41. 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 42. Weight management, weight reduction, nutrition programs, treatment for obesity, (except surgery for morbid obesity), surgery for removal ofexcess skin or fat.

Source: http://www.paloaltou.edu/sites/default/files/2012-202468-1%20iBenefit%20Summary%20Flyer%20-%20Grad-v2_061412.pdf