Understanding your Accident & Sickness Health Insurance Coverage

1. Understanding yourAccident & Sickness Health Insurance Coverage

2. INSURANCE DEFINITIONS

3. PREFERRED PROVIDERS(IN-NETWORK PROVIDERS) Physicians, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices.

4. OUT OF NETWORKPROVIDERS • Providers who have not agreed to any prearranged fee schedules. Insured may incur significant out-of-pocket expenses with these providers.

5. INJURY • Bodily injury which is directly and independently caused by specific accidental contact with another body or object.

6. SICKNESS Sickness or disease of the insured person which causes loss while the Insured Person is covered under this policy.

7. Medical Emergency • The occurrence of a sudden, serious and unexpected sickness or injury. In the absence of immediate medical attention, a reasonable person could believe that these conditions would result in serious impairment of bodily functions or death. If the Emergency Room Doctor states your visit is a non-emergency, the insurance company may not pay your bills.

8. Deductible • This is the amount of money you will pay toward a medical bill before the insurance company pays.

9. Co-Pay • Is the specific dollar amount which you must pay to a provider at the time of service.

10. Procedures to seea Doctor • Go to the Campus Health Center first • The Nurse will refer you • If the Health Center is closed, locate a medical provider from the PPO Network www.studentinsuranceagency.com • Let the doctor know to mail all medical bills to the claims office

11. BENEFITS

12. Maximum Benefit In Network & Out of Network $250,000 per occurrences for students In Network & Out of Network $100,000 per occurrences for dependents

13. Deductible(Students) $0.00 (zero) In Network $200.00 Out of Network per policy year

14. Deductible (Dependents) • $100.00 In – Network per policy year • $200.00 Out of Network per policy year

15. Co-Payments • $20.00 co-pay – In Network OfficeVisits/Tests/Procedures/Lab/Xray/Radiation/Chemotherapy. • $20.00 + 20% U&C – Out of Network OfficeVisits/Tests/Procedures/Lab/Xray/Radiation/Chemotherapy. • (refer to the brochure)

16. Emergency Room • $50.00 co-pay – In Network • $50.00 co-pay + 20% U&C Out of Network • Co-pay waived if admitted

17. Pap Smear(Women Well Care) • $20.00 Co-Pay – In Network OfficeVisits/Tests/Procedures/Lab/Xray/Radiation/Chemotherapy. • $20.00 Co-Pay + 20% Out of Network • OfficeVisits/Tests/Procedures/Lab/Xray/Radiation/Chemotherapy.

18. Prescriptions • $10.00 co pay for generic • $25.00 for preferred brand • $50% U&C non-preferred brand

19. Claims • Tell the doctor or medical facilities to send your bills to: • Student Insurance • P.O. Box 809025 • Dallas, TX 75380-9025 If you receive a bill, bring it to the I.E.P office so that it can be faxed to Student Insurance. You must fill out a PRA (Personal Representative Appointment) giving your authorization to discuss your bills.