Insurance Policy Details for Domestic Students

The information below is a synopsis of the Blue Cross Blue Shield policy information, and is subject to change. To view the most up-to-date information, view the online brochure at Blue Cross Blue Shield.

• Unlimited maximum per insured person, per policy year
• $500 PPO Network deductible per insured person per policy year; $1,500 for a family
• $1000 Non-network deductible per insured person per policy year; $3,000 for a family
• $6,250 PPO Network out-of-pocket maximum per insured person per policy year; $12,700 for a family
• $12,500 Non-network out-of-pocket maximum per insured person per policy year; $37,500 for a family
• $20 payment for primary care physician PPO Network consolation (excluding prescriptions)^1,2
• $40 payment for specialist PPO Network consultation (excluding prescriptions)^1,2
• 60/40 payment for Non-network services (excluding prescriptions)² and subject to deductible
• 100% coverage for services rendered at the Student Health Center
• 100% coverage for preventive services
• 100% medical evacuation and repatriation costs
• There is no maximum on the prescription benefit
• $100 co pay for ER visit then 80% payment for PPO Network or 20% payment for Non-network
• $40 co pay for Urgent Care services for PPO Network or 60/40 payment for Non-network services and subject to deductible³

1 Other services - deductible applies.

2 After deductible is met, Blue Cross Blue Shield pays 80% of remaining eligible costs that were accrued using medical staff and/or services listed with the Blue Cross Blue Shield Choice PPO network. The student pays 20%.
If the student uses staff and/or services not listed on the Blue Cross Blue Shield network, the student pays a higher percentage of the bill, 40% of Usual and Customary charges plus 100% or any charges above Usual and Customary prices. It benefits you financially to stay within the assigned network.
3 In Network Urgent Care does NOT cover the following at 100%: Surgery, Physical Medicine, Psychological testing, hearing aids and Dialysis. These are subject to DED 80% payment for PPO Network and 20% payment for Non-network.

Prescription Benefits

There is not a maximum on the prescription benefit. You must purchase the prescription in full from a pharmacy of your choice. Prescription coverage for PPO Network pharmacies are covered at 100% after:

• $15 co pay for Generic drugs
• $30 co pay for Preferred Brand drugs
• $50 co pay for Name Brand drugs

To get the most of out of your prescription benefit, ask your doctor if generic drugs are available. If you need to file a claim for reimbursement through Prime Therapeutics, see the claims page.

Medical Policy Cost and Coverage Dates

2014-2015 Academic Year

Student Health Insurance Coverage
Period name	Coverage dates	Student	Spouse	All children	Student, Spouse & All Children
Fall 2014	8/1/14-12/31/14*	$779	$2,207	$1,213	$4,199
Spring 2015	1/1/15-5/31/15*	$769	$2,179	$1,197	$4,145
Summer 2015	6/1/15-7/31/15*	$311	$880	$484	$1,675

*Actual start date of the coverage period will depend on the date of enrollment in the medical insurance plan; Date of coverage commencement will start on the next business day after enrollment if the coverage period has already commenced.

Dental Policy Cost and Coverage Dates

2014-2015 Academic Year

Dental Coverage
Period name	Coverage dates	Student	Spouse	All children	Student, Spouse & All Children
Fall 2014	8/1/14-12/31/14*	$101	$101	N/A	N/A
Spring 2015	1/1/15-5/31/15*	$100	$100	N/A	N/A
Summer 2015	6/1/15-7/31/15*	$40	$40	N/A	N/A

*Actual start date of the coverage period will depend on the date of enrollment in the dental insurance plan; Date of coverage commencement will start on the next business day after enrollment if the coverage period has already commenced.

Exclusions and Limitations

Examples of Exclusions:

• Assistant surgeon fees
• Acne
• Dental
• Vision
• Hearing

Examples of Limitations:

• No more than one surgical procedure will be covered when multiple procedures are performed through the same incision or in immediate succession
• Outpatient physical therapy except for a condition that required surgery or a hospital confinement

Also, allergy medicines are covered and included in the $1,000 maximum under prescription drugs. Benefits for treatment of sexually transmitted diseases are covered up to $500 maximum per policy year, etc.