(*Medications, illicit drugs, & other substances) Stewart B. Leavitt, MA, PhD; Executive Director, Pain Treatment Topics; January 2006 Reviewed but not revised June 2010 Medical Reviewers: James D. Toombs, MD; Lee Kral, PharmD, BCPS Prior Publication History 3rd Edition: November 2005 Revision/Update, Addiction Treatment Forum Special Report, ATForum.com.
Student Injury and Sickness Insurance Plan for Northern Michigan University
Who is eligible to enroll?
All eligible registered students taking credit hours are required to enroll in the plan on a Hard Waiver basis. Eligible
Dependents of students enrolled in the Student Health Insurance plan may participate in the plan on a voluntary basis. Eligible
Dependents are the student's spouse and dependent children under 26 years of age.
Where can I get more information about the benefits available?
Please read the plan brochure to determine whether this plan is right before you enroll. The plan brochure provides details of
the coverage including costs, benefits, exclusions, and reductions or limitations and the terms under which the coverage may
be continued in force. Copies of the plan brochure are available from the University and may be viewed at www.uhcsr.com.
Who can answer questions I have about the plan?
If you have questions please contact Customer Service at 1-800-767-0700 or firstname.lastname@example.org.
How much does the plan cost?
8/15/14 – 8/14/15 8/15/14 – 1/3/15
1/4/15 – 5/10/15 5/11/15 – 8/14/15
NOTE: The amounts stated above include certain fees charged by the school you are receiving coverage through. Such fees include amounts which are paid to certain non-insurer vendors or consultants by, or at the direction, of your school. This plan is underwritten by UnitedHealthcare Insurance Company and is based on policy number 2014-202604-61 The Policy is a Non-Renewable One-Year Term Policy. Highlights of the Coverage and Services offered by UnitedHealthcare StudentResources
Overall Plan Maximum
There is no overall maximum dollar limit on the policy Plan Deductible
$500 per Insured Person, per Policy $1,000 per Insured Person, per Policy Year Out-of-Pocket Maximum
$5,000 Per Insured Person, Per $10,000 Per Insured Person, Per After the Out-of-Pocket Maximum has been Policy Year. $10,000 For all Insureds Policy Year. $20,000 For all Insureds satisfied, Covered Medical Expenses will be in a Family, Per Policy Year in a Family, Per Policy Year paid at 100% for the remainder of the Policy Year subject to any applicable benefit maximums. Refer to the plan brochure for details about how the Out-of-Pocket Maximum applies.
75% of Preferred Allowance for 50% of Usual and Customary Charges All benefits are subject to satisfaction of the Covered Medical Expenses for Covered Medical Expenses Deductible, specific benefit limitations,
maximums and Copays as described in the
$10 Copay for Tier 1 Prescriptions must be filled at a UHCP $40 Copay for Tier 2 network pharmacy. Mail order through UHCP $60 Copay for Tier 3 at 2.5 times the retail copay up to a 90 day Up to a 31-day supply per prescription filled at a UnitedHealthcare Pharmacy (UHCP) Preventive Care Services
100% of Preferred Allowance Including but not limited to: annual physicals, GYN exams, routine screenings and immunizations. No copay or Deductible 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 groups.
The following services have per Service Physician's Visits: $25
Medical Emergency: $150 (The per Medical Emergency: $150 (The visit Deductible will be waived if This list is not all inclusive. Please read the Copay will be waived if admitted to admitted to the Hospital.) plan brochure for complete listing of Copays/Deductibles.
Pediatric Dental and Vision Benefits
Refer to the plan brochure for details (age limits apply). 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 their home country.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can be found using the
following link: http://www.uhcsr.com/lookupredirect.aspx?delsys=52
UnitedHealthcare StudentResources Insureds have online access to their claims status, EOBs, ID Cards, network providers,
correspondence and coverage account information by logging in to My Account at www.uhcsr.com/myaccount. To create an
online account, 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 also download our UHCSR Mobile App available on
Google Play and Apple's App Store.
Exclusions and Limitations:
No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies
for, at, or related to any of the following:
2. Conceptual handicap. Developmental delay or disorder or mental retardation. Learning disabilities. Milieu therapy. 3. Cosmetic procedures, except reconstructive procedures to: • Correct an Injury or treat a Sickness for which benefits are otherwise payable under this policy. The primary result of the procedure is not a changed or improved physical appearance. • Treat or correct Congenital Conditions which cause functional impairment or of a Newborn or adopted Infant. 4. Custodial Care. • Care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or Custodial Care. • Extended care in treatment or substance abuse facilities for domiciliary or Custodial Care. 5. Dental treatment, except: • For accidental Injury to Sound, Natural Teeth. • As described under Dental Treatment in the policy. This exclusion does not apply to benefits specifically provided in Pediatric Dental Services. 6. Elective Surgery or Elective Treatment. 7. Elective abortion. 8. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline. 9. Foot care for the following: • Flat foot conditions. • Supportive devices for the foot. • Subluxations of the foot. • Fallen arches. • Chronic foot strain. • Routine foot care including the care, cutting and removal of corns, calluses, toenails, and bunions (except capsular or This exclusion does not apply to preventive foot care for Insured Persons with diabetes. 10. Health spa or similar facilities. Strengthening programs. 11. Hearing examinations. Hearing aids. Other treatment for hearing defects and hearing loss. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process. This exclusion does not apply to: • Hearing defects or hearing loss as a result of an infection or Injury. 12. Hirsutism. 13. Hypnosis. 14. Immunizations, except as specifically provided in the policy. Preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifically provided in the policy. 15. Injury caused by, contributed to, or resulting from the addiction to or use of: • Intoxicants. • Hallucinogenics. • Illegal drugs. • Any drugs or medicines that are not taken in the recommended dosage or for the purpose prescribed by the Insured Person's Physician. This exclusion only applies when related to the Insured Person's commission of or attempt to commit a felony or being engaged in an illegal occupation. 16. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation. 17. Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by any other valid and collectible insurance. 18. Injury sustained while: • Participating in any intercollegiate, or professional sport, contest or competition. • Traveling to or from such sport, contest or competition as a participant. • Participating in any practice or conditioning program for such sport, contest or competition. 19. Investigational services. 20. Lipectomy. 21. Nuclear, chemical or biological Contamination, whether direct or indirect. "Contamination" means the contamination or poisoning of people by nuclear and/or chemical and/or biological substances which cause Sickness and/or death. 22. Participation in a riot or civil disorder. Commission of or attempt to commit a felony. 23. Prescription Drugs, services or supplies as follows: • Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use, except as specifically provided in the policy. • Immunization agents, except as specifically provided in the policy. Biological sera. Blood or blood products administered on an outpatient basis. • Drugs labeled, "Caution - limited by federal law to investigational use" or experimental drugs. • Products used for cosmetic purposes. • Drugs used to treat or cure baldness. Anabolic steroids used for body building. • Anorectics - drugs used for the purpose of weight control. • Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or • Refills in excess of the number specified or dispensed after one (1) year of date of the prescription. 24. Reproductive/Infertility services including but not limited to the following: • Procreative counseling. • Cryopreservation of reproductive materials. Storage of reproductive materials. • Infertility treatment (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception, except to diagnose or treat the underlying cause of the infertility. • Premarital examinations. • Impotence, organic or otherwise. • Reversal of sterilization procedures. • Sexual reassignment surgery. 25. 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 patient is to participate as a research study or clinical research study, except as specifically provided in the policy. 26. Routine eye examinations. Eye refractions. Eyeglasses. Contact lenses. Prescriptions or fitting of eyeglasses or contact lenses. Vision correction surgery. Treatment for visual defects and problems. This exclusion does not apply as follows: • When due to a covered Injury or disease process. • To benefits specifically provided in Pediatric Vision Services. 27. Routine Newborn Infant Care and well-baby nursery and related Physician charge, except as specifically provided in the 28. Preventive care services, except as specifically provided in the policy, including: • Routine physical examinations and routine testing. • Preventive testing or treatment. • Screening exams or testing in the absence of Injury or Sickness. 29. Services provided normally without charge by the Health Service of the Policyholder. Services covered or provided by the student health fee. 30. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia, except orthognathia surgery to correct a Congenital Condition or correct other functional impairments. Deviated nasal septum, including submucous resection and/or other surgical correction thereof. Nasal and sinus surgery, except for treatment of a covered Injury or treatment of chronic sinusitis. 31. Skydiving. Parachuting. Hang gliding. Glider flying. Parasailing. Sail planing. Bungee jumping. 32. Speech therapy, except as specifically provided in the policy. Naturopathic services. 33. Stand-alone multi-disciplinary smoking cessation programs. These are programs that usually include health care providers specializing in smoking cessation and may include a psychologist, social worker or other licensed or certified professional. 34. Suicide or attempted suicide while sane or insane (including drug overdose). Intentionally self-inflicted Injury. 35. Supplies, except as specifically provided in the policy. 36. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia, except as specifically provided in the policy. 37. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment. 38. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered). 39. Weight management. Weight reduction. Treatment for obesity (except surgery for morbid obesity). Surgery for removal of excess skin or fat. This exclusion does not apply to Physician-supervised weight loss programs or benefits specifically provided in the policy.
Servicio de atención personalizada (de lunes a viernes, de 8 a 20 h) SegurCaixa Negocio Condiciones Generales Mod. S.RE.442/01 (Ed. 11-2012) Port_Cond Negocio es.indd 1 Port_Cond Negocio es.indd 1 Cian de cuatricromía Cian de cuatricromíaMagenta de cuatricromía Magenta de cuatricromía Negro de cuatricromía Negro de cuatricromía Mod. S.RE. 442/01 Este contrato se rige por lo dispuesto en la Ley 50/1980, de 8 de octubre, de Contrato de Seguro, así como por el Real Decreto Legislativo 6/2004, de 29 de octubre, por el que se aprueba el Texto Refundido de la Ley de Ordenación y Supervisión de los Seguros Privados, y por las demás normas españolas reguladoras de los seguros privados. Asimismo, se rige por lo convenido en las Condiciones Generales y Particulares de este mismo contrato.