2013-101-1 benefit summary flyer v7_benefit summary

Student Injury and Sickness Insurance
Plan for American University

American University is pleased to offer an Injury and Sickness Insurance Plan underwritten byUnitedHealthcare Insurance Company. All full-time degree seeking, residential and internationalstudents with F-1 and J-1 visas enrolled at American University are required to carry healthinsurance coverage and are automatically enrolled in the health insurance plan unless a waiveris submitted before the established deadline. All students taking six or more credit hours areeligible to enroll in the Student Health Insurance Plan. Students whose status is consideredfull-time are also eligible for the Student Health Insurance Plan.
Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:

Up to $500,000 for each Injury or Sickness Maximum Benefit for Covered Medical Expenses.
$200 Deductible for Preferred Providers Per Insured Person Per Policy Year, $500 Deductible for Out of Network Providers Per Insured Person Per Policy Year.
Covered Medical Expenses for Preferred Providers are payable at 80% of PreferredAllowance 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).
Prescription Drug Benefits: $10 Copay for Tier 1 / $35 Copay for Tier 2 / $50 Copay for Tier 3 up to a 31-day supply per prescription filled at a UnitedHealthcare Pharmacy (UHCP).
Mail order through UHCP at 2.5 times the retail copay up to a 90 day supply. 60% of Usual and Customary Charges after a $10 Deductible for generic drugs / $35 Deductible for brand name up to a 31-day supply per Prescription at an Out-of-Network pharmacy.
Preventive Care Services which include, but are not limited to, annual physicals, GYN exams, routine screenings and immunizations are covered at 100% with no Copay or deductible only 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 Coverage available for eligible Dependents /Domestic Partner.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. PreferredProviders can be found using the following link, http://www.uhcsr.com/lookupredirect.aspx?delsys=52 FrontierMEDEX – 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 theirhome country.
Online Services: UnitedHealthcare StudentResources Insureds have online access to their claims status, EOBs, ID Cards, network providers, correspondence and coverage accountinformation by logging in to My Account at www.uhcsr.com/myaccount. To create an onlineaccount, 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 alsovisit our mobile site at my.uhcsr.com to access an electronic ID card.
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 for
each Injury or Sickness 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

UnitedHealthcare StudentResources
Each Child
NOTE: The amounts stated above include certain fees charged by the school you are receiving coverage through. Such fees may, forexample, cover your school’s administrative costs associated with offering this health plan.
c) Drugs labeled, “Caution - limited by federal law to No benefits will be paid for: a) loss or expense caused by, investigational use” or experimental drugs, except as contributed to, or resulting from; or b) treatment, services or supplies for, at, or related to any of the following: d) Products used for cosmetic purposes;e) Drugs used to treat or cure baldness; anabolic steroids 1. Learning disabilities, behavioral problems, developmental delay or disorder or mental retardation, except as specificallyprovided in the policy; f) Anorectics - drugs used for the purpose of weight control; 2. Cosmetic procedures, except cosmetic surgery required to g) Fertility agents or sexual enhancement drugs, such as correct an Injury for which benefits are otherwise payable Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, under this policy or for newborn or adopted children; except as specifically provided in the policy.
3. Custodial Care; care provided in: rest homes, health resorts, i) Refills in excess of the number specified or dispensed homes for the aged, halfway houses, college infirmaries or after one (1) year of date of the prescription.
places mainly for domiciliary or Custodial Care; extended 15. Reproductive/Infertility services including but not limited to; care in treatment or substance abuse facilities for domiciliary infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing 4. Dental treatment, except as specifically provided in the conception; premarital examinations; impotence, organic or otherwise; female sterilization procedures, except as 5. Elective Surgery or Elective Treatment; specifically provided in the policy; vasectomy; reversal ofsterilization procedures; except as specifically provided in the 6. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contactlenses, vision correction surgery, or other treatment for visual 16. Preventive care services; routine physical examinations and defects and problems; except when due to a covered Injury routine testing; preventive testing or treatment; screening or disease process or except as specifically provided in the exams or testing in the absence of Injury or Sickness; except as 7. Hearing examinations, except as specifically provided in the 17. Services provided normally without charge by the Health policy; hearing aids; or cochlear implants; except as Service of the Policyholder; or services covered or provided by specifically provided in the policy; or other treatment for hearing defects and problems, except as a result of an 18. Temporomandibular joint dysfunction; nasal and sinus surgery, infection or trauma. "Hearing defects" means any physical except for treatment of a covered Injury or treatment of chronic defect of the ear which does or can impair normal hearing, purulent sinusitis; except as specifically provided in the policy; 19. Flight in any kind of aircraft, except while riding as a passenger 8. Preventive medicines or vaccines, except where required for on a regularly scheduled flight of a commercial airline; treatment of a covered Injury or as specifically provided in the 20. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except 9. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease 21. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 10. Injury sustained by reason of a motor vehicle accident to the 22. War or any act of war, declared or undeclared; or while in the extent that benefits are paid or payable by any other valid and armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered); 11. Injury sustained while (a) participating in any intercollegiate, or 23. Weight management, weight reduction, nutrition programs, professional sport, contest or competition; (b) traveling to or treatment for obesity, (except surgery for morbid obesity), and from such sport, contest or competition as a participant; or (c) surgery for removal of excess skin or fat , except as specifically while participating in any practice or conditioning program for 12. Investigational services;13. Participation in a riot or civil disorder; commission of or 14 Prescription Drugs, services or supplies as follows; a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non- medical substances, regardless of intended use, except asspecifically provided in the policy; b) Immunization agents, except as specifically provided in the policy, biological sera, blood or blood productsadministered on an outpatient basis;

Source: http://as32064.http.sasm3.net/ocl/healthcenter/upload/UHCSR-13-14-Flyer.pdf

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