Insurance Policy Details of Insurance for International Students

The information below is a synopsis of the Blue Cross Blue Shield policy information, and is subject to change.

• 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.

Proof of Insurance Card

Blue Cross Blue Shield sends one card per school year to policyholders. In your first semester of coverage you should receive an insurance card 2-4 weeks after Census Day. (Because eligibility for the UT Dallas Student Health Insurance Plan is contingent upon enrollment at UT Dallas, insurance cards cannot be sent until all students are officially registered, which is Census Day.) You may also print a card from the Blue Cross Blue Shield website at that time.

Interim Coverage Letter

Because your student health insurance coverage must be renewed each semester, the dates of your coverage coincide with each respective semester. Should you need to receive medical treatment or fill a prescription between the start date of the current semester’s insurance policy and census day of the current semester? The Interim Coverage Letter will serve as your temporary proof of insurance until the insurance company is able to mail your official insurance card, which will be sometime after census day.
If you need to add dependents or extend dependent coverage on your policy, you will need to request that your coverage be updated directly with the insurance company. Dependent enrollment cannot be processed until the student’s enrollment has been updated to reflect the current semester’s coverage. To add or extend dependent coverage, please complete the International Dependent Enrollment Form at  http://insurancenews4all.blogspot.com/.

 

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

*Tuition billed; Dependent upon enrollment in classes

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

Repatriation and Evacuation

In the event of the insured's death, repatriation benefits will be paid for preparing and transporting the deceased to his/her home country. Evacuation benefits will be paid if the insured person is hospitalized for at least five consecutive days and recommended and approved by the attending physician for the evacuation of the insured to his/her home country.
Repatriation and medical evacuation coverage is included in the UT Dallas Student Health Insurance Plan. Students who are approved for SHI fee waivers with alternative insurance that do not include repatriation and medical evacuation coverage will be charged each semester at the student rate below. Students who wish to add spouses and/or dependents to that coverage can do so through the Student Health Center or directly with Blue Cross Blue Shield.

Repatriation and Medical Evacuation
Period name	Coverage dates	Student	Spouse	Each child	Student, Spouse & One Child
Fall 2014	8/1/14-12/31/14	$40	$40	$40	$120
Spring 2015	1/1/15-5/31/15	$40	$40	$40	$120
Summer 2015	6/1/15-7/31/15	$16	$16	$16	$48

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.