2012-752-1 prelim flyer v1_benefit summary

Student Injury and Sickness Insurance
Plan for
Niagara University
2012-2013
Niagara University is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company of New York. Eligibility Statement: All students registered and attending classes are eligible to enroll in the plan on a voluntary basis.
International students are required to participate in the plan on a hard waiver basis. Eligible Dependents of enrolled students may purchase this plan on a voluntary basis.
Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
Up to $100,000 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).
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. After the 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 certificate 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 filled at a UnitedHealthcare Network Pharmacy (UHPS). Prescriptions must be filled at a UHPS network pharmacy. Mail orderthrough UHPS at 2.5 times the retail copay up to a 90-day supply. contact Customer Service at800-767-0700 or 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 ordeductible 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 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 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 $100,000 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
Each Child
PRE-EXISTING CONDITION means any condition for which managing research, or costs which would not be covered under this medical advice, diagnosis, care or treatment was recommended or policy for non-experimental or non-investigational treatments received within the 6 months immediately prior to the Insured's 15. Participation in a felony, riot or insurrection; Exclusions and Limitations
16. Pre-existing Conditions, except for individuals who have been No benefits will be paid for: a) loss or expense caused by, continuously insured under the school's student insurance policy for contributed to, or resulting from; or b) treatment, services or supplies at least 12 consecutive months. The Pre-existing Condition exclusionary period will be reduced by the total number of months Cosmetic procedures, except that cosmetic procedures does not that the Insured was covered under Creditable Coverage which was include reconstructive surgery when such surgery is incidental to or continuous to a date not more than 63 days prior to the Insured’s follows surgery resulting from trauma, infection or other disease of enrollment date under this policy. This exclusion will not be applied to the involved part and reconstructive surgery because of a congenital disease or anomaly of a covered Dependent child which has resulted 17. Prescription Drugs, services or supplies as follows, except as in a functional defect. It also does not include breast reconstructive Therapeutic devices or appliances, including: hypodermic Custodial Care; care provided in: rest homes, health resorts, homes needles, syringes, support garments and other non-medical for the aged, halfway houses, college infirmaries or places mainly for substances, regardless of intended use, except as specifically domiciliary or Custodial Care; extended care in treatment or substance abuse facilities for domiciliary or Custodial Care; Drugs labeled, “Caution - limited by federal law to Dental treatment, except for accidental Injury to Sound, Natural Teeth investigational use” or experimental drugs; Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra, Eye examinations, eyeglasses, contact lenses, prescriptions or fitting Drugs used for tobacco cessation, except as specifically of eyeglasses or contact lenses. Vision correction or other treatment for visual defects and problems; except when due to a covered Injury Refills in excess of the number specified or dispensed after one or disease process or a Medical Necessity; (1) year of date of the prescription.
Foot care in connection with corns, calluses, flat feet, fallen arches, 18. Preventive medicines, serums, vaccines or immunizations; except as weak feet, chronic foot strain or symptomatic complaints of the feet; Hearing examinations; hearing aids; or cochlear implants; except as 19. Routine Newborn Infant Care, well-baby nursery and related specifically provided in the policy; or other treatment for hearing Physician charges except as specifically provided in the policy; defects and problems, except as a result of an infection or trauma.
20. Preventive care services; routine physical examinations and routine "Hearing defects" means any physical defect of the ear which does testing; preventive testing or treatment; screening exams or testing in or can impair normal hearing, apart from the disease process; the absence of Injury or Sickness; except as specifically provided in The Insured’s being intoxicated or under the influence of any narcotic unless administered on the advice of a Physician; 21. Services provided normally without charge by the Health Service of 10. Injury or Sickness for which benefits are paid or payable under any the Policyholder; or services covered or provided by the student Workers' Compensation or Occupational Disease Law or Act, or 22. Flight in any kind of aircraft, except while riding as a passenger on a 11. Injury or Sickness outside the United States and its possessions, regularly scheduled flight of a commercial airline; Canada or Mexico, except for a Medical Emergency when traveling 23. Suicide or attempted suicide or intentionally self-inflicted Injury; for academic study abroad programs business or pleasure; 24. Supplies, except as specifically provided in the policy; 12. Injury sustained by reason of a motor vehicle accident to the extent 25. Treatment in a Government hospital, unless there is a legal obligation that benefits are paid or payable by mandatory automobile no-fault for the Insured Person to pay for such treatment; 26. Treatment, service or supply which is not a Medical Necessity, 13. Injury sustained while (a) participating in any interscholastic sport, subject to Article 49 of N.Y. Insurance Law; and contest or competition; (b) traveling to or from such sport, contest or 27. War or any act of war, declared or undeclared; or while in the armed competition as a participant; or (c) while participating in any practice forces of any country (a pro-rata premium will be refunded upon or conditioning program for such sport, contest or competition; request for such period not covered).
14. Investigational services or experimental treatment, except for experimental or investigational treatment approved by an ExternalAppeal Agent in accordance with Insured Persons Right to anExternal Appeal. If the External Appeal Agent approves benefits ofan experimental or investigational treatment that is part of a clinicaltrial, this policy will only cover the costs of services required toprovide treatment to the Insured according to the design of the trial.
The Company shall not be responsible for the cost of investigationaldrugs or devices, the costs of non-health care services, the cost of

Source: http://niagara.edu/assets/healthservices/2012-752-1-Prelim-Flyer-v1.pdf