Understanding your Accident & Sickness Health Insurance Coverage

INSURANCE DEFINITIONS

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

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

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

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

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. 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.

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

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

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

BENEFITS

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

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

Deductible (Dependents) $ In – Network per policy year $ In – Network per policy year $ Out of Network per policy year $ Out of Network per policy year

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

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

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

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

Claims Tell the doctor or medical facilities to send your bills to: Tell the doctor or medical facilities to send your bills to: Student Insurance Student Insurance P.O. Box P.O. Box Dallas, TX Dallas, TX 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.