Below are very brief injury and illness benefit highlights of the 2017-18 Premier Plan Summary. Refer to the Description of Benefits brochure for benefit details, specific exclusions, and limitations.
- Prescriptions have a separate $150 Plan Year Deductible from the medical and mental health deductibles in Schedules 2, and 3.
- Not applicable under Schedule 1. (The Student Health Center and Counseling and Psychiatric Service are Schedule 1 Providers.)
- Students must pay the first $200 per Plan Year under Schedule 2 before the Plan pays for Medically Necessary Covered Expenses. (The UnitedHealthcare [UHC] Options PPO Network are Schedule 2 Providers.)
- Students must pay the first $250 per Plan Year under Schedule 3 before the Plan pays for Medically Necessary Covered Expenses. Any Deductible met under Schedule 2 is applied to the Schedule 3 Deductible. (Non-PPO Providers, including worldwide Providers, are Schedule 3 Providers.)
CO-PAYMENT COLLECTED AT THE TIME OF SERVICE:
- $15 co-payment for covered Tier 1 medications,
- $10 for a Schedule 1, Covered and Medically Necessary Outpatient Primary Care or Mental Health Visit (no deductible, 100% of Student Health Center or Counseling and Psychiatric Service billed charges after co-pay),
- $25 for a Schedule 2, Covered and Medically Necessary Outpatient Physician Visit or Mental Health Visit (deductible applies, 100% of visit charge after co-pay, 80% of most other charges),
- $50 for a Schedule 2 & 3, Covered and Medically Necessary Urgent Care Visit (deductible applies, 100% of reasonable visit charge after co-pay, 80% of most other charges), and
$100 for a Schedule 2 & 3, Covered Emergency Room Services that meet the definition of Medical Emergency in the Plan documents (deductible applies, 100% of reasonable charges after co-pay).
Co-insurance is the percent of Covered Expenses that the Plan will pay after applicable Deductibles and Co-payments. Insureds are responsible for the balance of remaining charges. The following represents typical co-insurance for the Premier Plan:
- Tier 2 and 3 mediations, 80% of medication, pre-authorization (PA) is required for some specialty medications,
- Schedule 1, 100% of Student Health Center and Counseling and Psychiatric Covered Expenses,
- Schedule 2, 80% of Preferred Allowance of UHC PPO Option Network Provider's Covered Expenses, and
- Schedule 3, 70% of other worldwide Provider's Covered Expenses.
STUDENT ONLY PLAN OUT-OF-POCKET MAXIMUM:
Once a student has met the applicable out-of-pocket maximum, the Plan pays 100%. The Out-Of-Pocket maximum for Covered Medical and Mental Health Expenses is:
- $6,350 per insured for In-Network benefits; and,
- $12,500 per insured for Out-of-Network benefits.