Benefit summary

Student Injury and Sickness
Insurance Plan for Allegheny College

2013-2014
Allegheny College is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company.
Eligibility Statement: All undergraduate students will be automatically enrolled in this plan unless proof of comparable coverage is
furnished.
This plan is underwritten by UnitedHealthcareInsurance Company and is based on policy Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
Please read the certificate of coverage to Up to $500,000 Per Insured Person, Per Policy Year Maximum Benefit for Covered Medical Expenses.
determine whether this plan is right for you $150 Deductible for Preferred Providers Per Insured Person, Per Policy Year, $400 Deductible for Out of Network Providers PerInsured Person, Per Policy Year before you enroll. The certificate of coverage provides details of the coverage including Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and Out of Network benefitsare payable at 60% of Usual and Customary charges (all benefits are subject to satisfaction of the Deductible, specific benefit costs, benefits, exclusions, any reductions or limitations, maximums and copays as described in the policy).
limitations and the terms under which the Preferred Provider Out-of-Pocket Maximum of $2,500 Per Insured Person, Per Policy Year. Out-of-Network Out-of-Pocket coverage may be continued in force. Copies maximum of $5,000 Per Insured Person, Per Policy Year. After the Out-of-Pocket Maximum has been satisfied, Covered Medical of the certificate are available from the Expenses will be paid at 100% up to the policy Maximum Benefit subject to any applicable benefit maximums. Refer to the plan certificate for details about how the Out-of-Pocket Maximum applies. Prescription Drug Benefits: $15 Copay for Tier 1 / $35 Copay for Tier 2 / $60 copay for Tier 3 up to a 31-day supply perprescription filled at a UnitedHealthcare Pharmacy (UHCP). Prescriptions must be filled at a UnitedHealthcare Pharmacy If you have any questions, please contact (UHCP). Mail order through UHCP at 2.5 times the retail copay.
Customer Service at 800-505-4160 [email protected]
Preventive Care Services which include, but are not limited to, annual physicals, GYN exams, routine screenings andimmunizations are covered at 100% with no copay or deductible only when the services are received from a Preferred Provider.
The Policy is a Non-Renewable One-Year Term Please see www.healthcare.gov for complete details of the services provided for specific age and risk groups.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can be found using the
following link www.firststudent.com.
FrontierMEDEX: – Domestic Students are eligible for FrontierMEDEX services when 100 miles or more away from your campusaddress and 100 miles or more away from your permanent home address. International Students are covered worldwideexcept in their home country.
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 How do I Waive?
www.firststudent.com. To create an online account, select the “My Account” 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 visit our mobile site
Insurance waiver forms are
at my.uhcsr.com to access an electronic ID card.
available on WebAdvisor
Students: When do I Waive in the Plan?
through the due date of
Annual Waiver Deadline Date – 9/3/13
September 3, 2013. Please
Spring/Summer Waiver Deadline Date – 1/17/14 (New incoming students only)
visit:
https://webadvisor.allegheny.edu.
Please Note: You wil be automatical y enrol ed and charged for the Al egheny Col ege student health insurance plan if you fail
to complete a waiver by the published deadline. The premium for the plan wil be added to your tuition bil . Once enrol ed, there
are no refunds or cancel ations except entry into the armed forces.
IMPORTANT INFORMATION: Open Enrollment Periods for all eligible Students: If you are eligible to purchase the annual
coverage and you choose not to enroll before the Annual Enrollment Deadline, you will not be eligible to enroll again until
the following school year unless you experience a “Life Status” change during the year. Visit www.firststudent.com for
more info.
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 1-800-505-
4160. 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
Spring/Summer
The amounts stated above include certain fees charged by the school you are receiving coverage through. Such fees may, for example, cover your school’s administrative costs
associated with offering this health plan.
Exclusions and Limitations
reassignment surgery; reversal of sterilization procedures; No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) Research or examinations relating to research studies, or any treatment for which the patient or treatment, services or supplies for, at, or related to any of the following: the patient’s representative must sign an informed consent document identifying the treatment in which the patient is to participate as a research study or clinical research study; except as Addiction, such as: nicotine addiction, except as specifical y provided in the policy; and caffeine addiction; non-chemical addiction such as: gambling, sexual, spending, shopping, working and Routine Newborn Infant Care, wel -baby nursery and related Physician charges; except as Milieu therapy, learning disabilities, behavioral problems, parent-child problems, conceptual Preventive care services; routine physical examinations and routine testing; preventive testing or handicap, developmental delay or disorder or mental retardation; treatment; screening exams or testing in the absence of Injury or Sickness; except as specifical y Services provided normal y without charge by the Health Service of the Policyholder; or services Congenital conditions for cosmetic purposes only, except as specifical y provided for: Newborn covered or provided by the student health fee; Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are temporomandibular joint dysfunction; deviated nasal septum, including submucous resection otherwise payable under this policy or for newborn or adopted children; and/or other surgical correction thereof; nasal and sinus surgery, except for treatment of a Custodial Care; care provided in: rest homes, health resorts, homes for the aged, halfway covered Injury or treatment of chronic purulent sinusitis; houses, col ege infirmaries or places mainly for domiciliary or Custodial Care; extended care in Skydiving, recreational parachuting, hang gliding, glider flying, parasailing, sail planing, bungee treatment or substance abuse facilities for domiciliary or custodial care; jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly Dental treatment, except for accidental Injury to Sound, Natural Teeth; scheduled flight of a commercial airline; Elective Surgery or Elective Treatment, as defined in the policy; except cosmetic surgery Supplies, except as specifical y provided in the policy; Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices; or or contact lenses, vision correction surgery, or other treatment for visual defects and problems; gynecomastia; except as specifical y provided in the policy; except when due to a covered Injury or disease process; Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to Flat foot conditions; supportive devices for the foot; fal en arches; weak feet; chronic foot strain; symptomatic complaints of the feet; and routine foot care including the care, cutting and removal War or any act of war, declared or undeclared; or while in the armed forces of any country (a of corns, cal uses, toenails, and bunions (except capsular or bone surgery), pro-rata premium wil be refunded upon request for such period not covered); and Health spa or similar facilities; strengthening programs; Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for Hearing examinations; hearing aids; or cochlear implants; or other treatment for hearing defects and problems, except as a result of an infection or trauma. “Hearing defects” means any physicaldefect of the ear which does or can impair normal hearing, apart from the disease process; Immunizations, except as specifical y provided in the policy; preventive medicines or vaccines,except where required for treatment of a covered Injury or as specifical y provided in the policy; Injury or Sickness for which benefits are paid or payable under any Workers' Compensation orOccupational Disease Law or Act, or similar legislation; Injury sustained while (a) participating in intercol egiate or professional sport, contest orcompetition; (b) traveling to or from such sport, contest or competition as a participant; or (c)while participating in any practice or conditioning program for such sport, contest orcompetition; Experimental organ transplants, including organ donation; Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting; Prescription Drugs, services or supplies as fol ows:a) Therapeutic devices or appliances, including: hypodermic needles, syringes, supportgarments and other non-medical substances, regardless of intended use, except asspecifical y provided in the policy; Immunization agents, except as specifical y provided in the policy, biological sera; bloodor blood products administered on an outpatient basis; Drugs labeled, “Caution - limited by federal law to investigational use” or experimentaldrugs; 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 Viagra; Refil s in excess of the number specified or dispensed after one (1) year of date of theprescription.
Reproductive/Infertility services including but not limited to: family planning, fertility tests;infertility (male or female), including any services or supplies rendered for the purpose or withthe intent of inducing conception; premarital examinations; impotence, organic or otherwise;female sterilization procedures; except as specifical y provided in the policy; vasectomy; sexual

Source: http://sitesmedia.s3.amazonaws.com/finserv/files/2013/07/United-Healthcare-2013-2014.pdf

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