2011-202577-76-benefit summary-dom-v4_benefit summary

Student Injury and Sickness
Insurance Plan for Domestic Students
Attending Mountain State University

Mountain State University is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company. All registered undergraduate students taking 9 or more credit hours, and all registered graduate students taking 6 or more credit hours or designated as full-time are eligible to enroll in this insurance Plan on a voluntary basis.
Please read the plan brochureto determine whether this planis right for you before you Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
Up to $50,000 for each Injury or Sickness Maximum Benefit for Covered coverage including benefits,Medical Expenses.
exclusions, any reductions orlimitations and the terms under $100 Deductible (Per Insured Person) (Per Policy Year) for Preferred Providers, $200 Deductible (Per Insured Person) (Per Policy Year) for Out of Network Providers.
continued in force. Copies ofthe brochure are available from 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 and maximums as described in the policy.) Prescription Drug Benefits: 80% of Usual and Customary Charges. $20 Deductible perprescription. ($500 maximum Per Policy Year.) Coverage available for eligible dependents.
Scholastic Emergency Services – Domestic Students are covered when 100 miles ormore away from their campus or home address.
If you have any questions
MyAccount, available through www.UHCSR.com, allows insured students access 24/7 to or to enroll, please
check their claim status, search for network providers, print ID cards, enter accident contact Wells Fargo
details, view EOBs and enter additional insurance information online.
Insurance Services
Customer Service by

Included with every policy, the UnitedHealth Allies® discount program provides calling (800) 853-5899 or
5% to 50% savings on dental and vision services, fitness clothing and equipment, and textbooks from McGraw-Hill Professional. The UnitedHealth Allies program is notinsurance and is offered by UnitedHealth Allies, a UnitedHealth Group company.

8/23/11 - 8/22/12 8/23/11 - 1/08/12 1/09/12 - 8/22/12 5/07/12 - 8/22/12 Undergraduate
Each Child
UnitedHealthcare StudentResources
School Benefit Summary
2011-202577-76 Domestic
PRE-EXISTING CONDITION means a physical or mental condition, 30. Pre-existing Conditions for a period of 12 months, except for regardless of the cause, for which medical advice, diagnosis, care or individuals who have been continuously insured under the school's treatment was recommended or received within the six-month period student insurance policy for at least 12 consecutive months. Credit will prior to the Insured’s Effective Date under this policy. Pregnancy is not be given for the time an Insured was continuously covered under prior considered a Pre-existing Condition.
Creditable Coverage if the coverage was in force within 63 days of theInsured’s Effective Date under this policy. The Pre-existing Condition Exclusions and Limitations
Limitation will not be applied to a Dependent newborn covered under No benefits will be paid for: a) loss or expense caused by, contributed to, Creditable Coverage within 30 days of birth or to any Dependent or resulting from; or b) treatment, services or supplies for, at, or related to: adopted child under 18 years that was covered under Creditable 1. Acne; acupuncture; allergy, including allergy testing; Coverage within 30 days of adoption or placement for adoption; 2. Addiction, such as: nicotine addiction and caffeine addiction; non- 31. Prescription Drugs, services or supplies as follows: chemical addiction, such as: gambling, sexual, spending, a) Therapeutic devices or appliances, including: hypodermic shopping, working and religious; codependency; needles, syringes, support garments and other non-medical substances, regardless of intended use, except as specifically 4. Autistic disease of childhood, hyperkinetic syndromes, milieu b) Immunization agents, biological sera, blood or blood products therapy, learning disabilities, behavioral problems, parent-child problems, attention deficit disorder, conceptual handicap, c) Drugs labeled, “Caution - limited by federal law to investigational developmental delay or disorder or mental retardation; e) Drugs used to treat or cure baldness; anabolic steroids used for f) Anorectics - drugs used for the purpose of weight control; 9. Congenital conditions, except as specifically provided for Newborn g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; 10. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy i) Refills in excess of the number specified or dispensed after one or for newborn or adopted children; removal of warts, non- 32. Reproductive/Infertility services including but not limited to: family 11. Custodial care; care provided in: rest homes, health resorts, homes planning; fertility tests; infertility (male or female), including any for the aged, halfway houses, college infirmaries or places mainly for services or supplies rendered for the purpose or with the intent of domiciliary or custodial care; extended care in treatment or inducing conception; premarital examinations; impotence, organic substance abuse facilities for domiciliary or custodial care; or otherwise; tubal ligation; vasectomy; sexual reassignment 12. Dental treatment, except for accidental Injury to Sound, Natural Teeth; surgery; reversal of sterilization procedures; 13. Elective Surgery or Elective Treatment; 33. Research or examinations relating to research studies, or any treatment for which the patient or the patient’s representative must sign an informed consent document identifying the treatment in which the 15. Eye examinations, eye refractions, eyeglasses, contact lenses, patient is to participate as a research study or clinical research study; prescriptions or fitting of eyeglasses or contact lenses, vision 34. Routine Newborn Infant Care, well-baby nursery and related correction surgery, or other treatment for visual defects and Physician charges in excess of 48 hours for vaginal delivery or 96 problems; except when due to a disease process; 16. Foot care including: flat foot conditions, supportive devices for the 35. Routine physical examinations and routine testing; preventive foot, subluxations of the foot, care of corns, bunions (except testing or treatment; screening exams or testing in the absence of capsular or bone surgery), calluses, toenails, fallen arches, weak Injury or Sickness; except as specifically provided in the policy; feet, chronic foot strain, and symptomatic complaints of the feet; 36. Services provided normally without charge by the Health Service of the 17. Health spa or similar facilities; strengthening programs; Policyholder; or services covered or provided by the student health fee; 18. Hearing examinations or hearing aids; or other treatment for 37. Skeletal irregularities of one or both jaws, including orthognathia and hearing defects and problems. "Hearing defects" means any mandibular retrognathia; temporomandibular joint dysfunction; physical defect of the ear which does or can impair normal hearing, deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery; except for 38. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, 21. Immunizations, except as specifically provided in the policy; bungee jumping, or flight in any kind of aircraft, except while riding as a preventive medicines or vaccines, except where required for passenger on a regularly scheduled flight of a commercial airline; treatment of a covered Injury or as specifically provided in the 40. Speech therapy; naturopathic services; 22. Injury caused by, contributed to, or resulting from the addiction to or 41. Suicide or attempted suicide while sane or insane (including drug use of alcohol, intoxicants, hallucinogenics, illegal drugs, or any drugs overdose); or intentionally self-inflicted Injury; or medicines that are not taken in the recommended dosage or forthe purpose prescribed by the Insured Person's Physician; 42. Supplies, except as specifically provided in the policy; 23. Injury or Sickness for which benefits are paid or payable under any 43. Surgical breast reduction, breast augmentation, breast implants or Workers' Compensation or Occupational Disease Law or Act, or breast prosthetic devics, or gynecomastia; except as specifically 24. Injury sustained while (a) participating in any interscholastic, club, 44. Travel in or upon, sitting in or upon, alighting to or from, or working intercollegiate, or professional sport, contest or competition; (b) on or around any motorcycle or recreational vehicle including but traveling to or from such sport, contest or competition as a participant; not limiting to: two- or three-wheeled motor vehicle; four-wheeled or (c) while participating in any practice or conditioning program for all terrain vehicle (ATV); jet ski; ski cycle; or snowmobile, skiing, scuba diving, surfing, roller skating, riding in a rodeo; 45. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 46. War or any act of war, declared or undeclared; or while in the 27. Organ transplants, including organ donation; armed forces of any country (a pro-rata premium will be refunded 28. Outpatient Physiotherapy; except for a condition that required upon request for such period not covered); and surgery or Hospital Confinement: 1) within the 30 days immediately 47. Weight management, weight reduction, nutrition programs, treatment preceding such Physiotherapy; or 2) within the 30 days immediately for obesity, surgery for removal of excess skin or fat. Exception: benefits following the attending Physician's release for rehabilitation; will be provided for the treatment of dehydration and electrolyte 29. Participation in a riot or civil disorder; commission of or attempt to imbalance associated with eating disorders.

Source: http://webarchive.mountainstate.edu/students-current/student-affairs/documents/Dom-BenefitSummary.pdf

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