2016–2017 Student Injury and Sickness Insurance Plan
Designed Especially for the Students of

14-BR-CO (PY16)

05-4059-1

Table of Contents
Privacy Policy ............................................................................................................................................................................................................... 1
Eligibility ........................................................................................................................................................................................................................ 1
Effective and Termination Dates .............................................................................................................................................................................. 1
Extension of Benefits after Termination ................................................................................................................................................................. 1
Pre-Admission Notification ....................................................................................................................................................................................... 2
Preferred Provider Information ................................................................................................................................................................................. 2
Schedule of Medical Expense Benefits ................................................................................................................................................................. 3
UnitedHealthcare Pharmacy Benefits .................................................................................................................................................................... 6
Medical Expense Benefits – Injury and Sickness ................................................................................................................................................ 8
Mandated Benefits ................................................................................................................................................................................................... 14
Coordination of Benefits Provision ....................................................................................................................................................................... 17
Definitions ................................................................................................................................................................................................................... 17
Exclusions and Limitations ...................................................................................................................................................................................... 21
UnitedHealthcare Global: Global Emergency Services .................................................................................................................................. 22
Online Access to Account Information ................................................................................................................................................................ 23
ID Cards ...................................................................................................................................................................................................................... 24
UHCSR Mobile App ................................................................................................................................................................................................. 24
UnitedHealth Allies ................................................................................................................................................................................................. 24
Claim Procedures for Injury and Sickness Benefits .................................................................................................................................... 24
Pediatric Dental Services Benefits ....................................................................................................................................................................... 24
Pediatric Vision Care Services Benefits .............................................................................................................................................................. 31
Notice of Appeal Rights ............................................................................................................................................................................................ 1


Privacy Policy
We know that your privacy is important to you and we strive to protect the confidentiality of your nonpublic personal
information. We do not disclose any nonpublic personal information about our customers or former customers to anyone,
except as permitted or required by law. We believe we maintain appropriate physical, electronic and procedural safeguards to
ensure the security of your nonpublic personal information. You may obtain a copy of our privacy practices by cal ing us toll-free
at 1-866-458-4954 or visiting us at www.uhcsr.com/csm.
Eligibility
Al degree-seeking U.S. citizens and permanent resident students and al international students regardless of degree-seeking
status are automatical y enrol ed in this insurance plan at registration, unless proof of comparable coverage is furnished.

Accident coverage for Intercollegiate Sports injuries is provided under a separate policy number 2016-4059-8. Contact the
school for information on the Intercollegiate Sports plan. Plan information is also available at www.uhcsr.com/csm.

Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. Home study,
correspondence, and online courses do not fulfil the Eligibility requirements that the student actively attend classes. The
Company maintains its right to investigate Eligibility or student status and attendance records to verify that the policy Eligibility
requirements have been met. If the Company discovers the Eligibility requirements have not been met, its only obligation is to
refund premium.

Students who are taking an approved medical leave of absence from CSM may request enrol ment in the CSM policy in effect
for two academic semesters, provided they were enrol ed in the CSM policy in effect for the period of coverage immediately
preceding the period of absence.
Effective and Termination Dates
The Master Policy on file at the school becomes effective at 12:01 a.m., August 17, 2016. The individual student’s coverage
becomes effective on the first day of the period for which premium is paid or the date the enrollment form and full premium are
received by the Company (or its authorized representative), whichever is later. The Master Policy terminates at 11:59 p.m.,
August 20, 2017. Coverage terminates on that date or at the end of the period through which premium is paid, whichever is
earlier.

Refunds of premiums are al owed only upon entry into the armed forces.

The Policy is a Non-Renewable One Year Term Policy.
Extension of Benefits after Termination
The coverage provided under the Policy ceases on the Termination Date. However, if an Insured is Hospital Confined on the
Termination Date from a covered Injury or Sickness for which benefits were paid before the Termination Date, Covered Medical
Expenses for such Injury or Sickness wil continue to be paid as long as the condition continues but not to exceed 90 days after
the Termination Date.

The total payments made in respect of the Insured for such condition both before and after the Termination Date wil never
exceed the Maximum Benefit.

After this "Extension of Benefits" provision has been exhausted, al benefits cease to exist, and under no circumstances wil
further payments be made.


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Pre-Admission Notification
UnitedHealthcare should be notified of al Hospital Confinements prior to admission.

1.
PRE-NOTIFICATION OF MEDICAL NON-EMERGENCY HOSPITALIZATIONS: The patient, Physician or Hospital
should telephone 1-877-295-0720 at least five working days prior to the planned admission.
2.
NOTIFICATION OF MEDICAL EMERGENCY ADMISSIONS: The patient, patient’s representative, Physician or Hospital
should telephone 1-877-295-0720 within two working days of the admission to provide notification of any admission
due to Medical Emergency.

UnitedHealthcare is open for Pre-Admission Notification cal s from 8:00 a.m. to 6:00 p.m. C.S.T., Monday through Friday. Cal s
may be left on the Customer Service Department’s voice mail after hours by cal ing 1-877-295-0720.
IMPORTANT: Failure to follow the notification procedures wil not affect benefits otherwise payable under the policy; however,
pre-notification is not a guarantee that benefits wil be paid.
Preferred Provider Information
“Preferred Providers” are the Physicians, Hospitals and other health care providers who have contracted to provide specific
medical care at negotiated prices. Preferred Providers in the local school area are:

UnitedHealthcare Choice Plus.

The availability of specific providers is subject to change without notice. Insureds should always confirm that a Preferred
Provider is participating at the time services are required by cal ing the Company at 1-866-458-4954 and/or by asking the
provider when making an appointment for services.
“Preferred Allowance” means the amount a Preferred Provider wil accept as payment in ful for Covered Medical Expenses.

“Out-of-Network” providers have not agreed to any prearranged fee schedules. Insureds may incur significant out-of-pocket
expenses with these providers. Charges in excess of the insurance payment are the Insured’s responsibility.

Regardless of the provider, each Insured is responsible for the payment of their Deductible. The Deductible must be satisfied
before benefits are paid. The Company wil pay according to the benefit limits in the Schedule of Benefits.
Inpatient Expenses
PREFERRED PROVIDERS - Eligible Inpatient expenses at a Preferred Provider wil be paid at the Coinsurance percentages
specified in the Schedule of Benefits, up to any limits specified in the Schedule of Benefits. Preferred Hospitals include
UnitedHealthcare Choice Plus United Behavioral Health (UBH) facilities. Cal 1-866-458-4954 for information about Preferred
Hospitals.
OUT-OF-NETWORK PROVIDERS - If Inpatient care is not provided at a Preferred Provider, eligible Inpatient expenses wil be
paid according to the benefit limits in the Schedule of Benefits.
Outpatient Hospital Expenses
Preferred Providers may discount bil s for outpatient Hospital expenses. Benefits are paid according to the Schedule of
Benefits. Insureds are responsible for any amounts that exceed the benefits shown in the Schedule, up to the Preferred
Al owance.
Professional & Other Expenses
Benefits for Covered Medical Expenses provided by UnitedHealthcare Choice Plus wil be paid at the Coinsurance
percentages specified in the Schedule of Benefits or up to any limits specified in the Schedule of Benefits. Al other providers
wil be paid according to the benefit limits in the Schedule of Benefits.




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Schedule of Medical Expense Benefits
Metallic Level - Platinum with actuarial value of 90.373%
Injury and Sickness Benefits

No Overall Maximum Dollar Limit (Per Insured Person, Per Policy Year)


Deductible Preferred Providers
$0

Deductible Out-of-Network
$1,000 (Per Insured Person, Per Policy Year)

Coinsurance Preferred Providers
90% except as noted below

Coinsurance Out-of-Network
70% except as noted below

Out-of-Pocket Maximum Preferred Providers
$1,500 (Per Insured Person, Per Policy Year)

Out-of-Pocket Maximum Out-of-Network
$3,000 (Per Insured Person, Per Policy Year)

The Preferred Provider for this plan is UnitedHealthcare Choice Plus.

If care is received from a Preferred Provider any Covered Medical Expenses wil be paid at the Preferred Provider level of
benefits. If the Covered Medical Expense is incurred for Emergency Services when due to a Medical Emergency, benefits wil
be paid at the Preferred Provider level of benefits. In al other situations, reduced or lower benefits wil be provided when an
Out-of-Network provider is used.

The Policy provides benefits for the Covered Medical Expenses incurred by an Insured Person for loss due to a covered Injury
or Sickness.

Out-of-Pocket Maximum: After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses wil be paid at
100% for the remainder of the Policy Year, subject to any benefit maximums or limits that may apply. Separate Out-of-Pocket
Maximums apply to Preferred Provider and Out-of-Network benefits. Any applicable Copays or Deductibles wil be applied to
the Out-of-Pocket Maximum. Services that are not Covered Medical Expenses do not count toward meeting the Out-of-Pocket
Maximum.

Coulter Student Health Center Benefits: The Deductible wil be waived and benefits wil be paid at 100% for Covered Medical
Expenses incurred when treatment is rendered at or referred by the Coulter Student Health Center for the fol owing services:
- Certain laboratory services
- Travel Clinic
- Immunizations – as indicated on the approved SHC Fee Schedule

Benefits are calculated on a Policy Year basis unless otherwise specifical y stated. When benefit limits apply, benefits wil be
paid up to the maximum benefit for each service as scheduled below. Al benefit maximums are combined Preferred Provider
and Out-of-Network unless otherwise specifical y stated. Please refer to the Medical Expense Benefits – Injury and Sickness
section for a description of the Covered Medical Expenses for which benefits are available. Covered Medical Expenses include:

Inpatient
Preferred Provider
Out-of-Network
Room and Board Expense
Preferred Al owance
Usual and Customary Charges

$250 Copay per Hospital Confinement
$750 Deductible per Hospital Confinement
Intensive Care
Preferred Al owance
Usual and Customary Charges
Hospital Miscellaneous Expenses Preferred Al owance
Usual and Customary Charges
Routine Newborn Care
Paid as any other Sickness
Paid as any other Sickness
Surgery
Preferred Al owance
Usual and Customary Charges
If two or more procedures are
performed through the same incision
or in immediate succession at the
same operative session, the
maximum amount paid wil not
exceed 50% of the second
procedure and 50% of al
subsequent procedures.
Assistant Surgeon Fees
Preferred Al owance
Usual and Customary Charges
Anesthetist Services
Preferred Al owance
Usual and Customary Charges
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Inpatient
Preferred Provider
Out-of-Network
Registered Nurse's Services
Preferred Al owance
Usual and Customary Charges
Physician's Visits
Preferred Al owance
Usual and Customary Charges
Pre-admission Testing
Preferred Al owance
Usual and Customary Charges
Payable within 7 working days prior
to admission.

Outpatient
Preferred Provider
Out-of-Network
Surgery
Preferred Al owance
Usual and Customary Charges
If two or more procedures are
performed through the same incision
or in immediate succession at the
same operative session, the
maximum amount paid wil not
exceed 50% of the second
procedure and 50% of al
subsequent procedures.
Day Surgery Miscellaneous
Preferred Al owance
Usual and Customary Charges
Usual and Customary Charges for
$250 Copay per date of service
$750 Deductible per date of service
Day Surgery Miscellaneous are
based on the Outpatient Surgical
Facility Charge Index.
Assistant Surgeon Fees
Preferred Al owance
Usual and Customary Charges
Anesthetist Services
Preferred Al owance
Usual and Customary Charges
Physician's Visits
100% of Preferred Al owance
Usual and Customary Charges

$25 Copay per visit
$25 Deductible per visit
Physiotherapy
Preferred Al owance
Usual and Customary Charges
Review of Medical Necessity wil be
$25 Copay per visit
performed after 12 visits per Injury or
Sickness.
Medical Emergency Expenses
Preferred Al owance
Usual and Customary Charges
Treatment must be rendered within
$100 Copay per visit
$100 Deductible per visit
72 hours from the time of Injury or
first onset of Sickness. The
Copay/per visit Deductible wil be
waived if admitted to the Hospital.
Diagnostic X-ray Services
Preferred Al owance
Usual and Customary Charges
Radiation Therapy
Preferred Al owance
Usual and Customary Charges
Laboratory Procedures
Preferred Al owance
Usual and Customary Charges
Tests & Procedures
Preferred Al owance
Usual and Customary Charges
Injections
Preferred Al owance
Usual and Customary Charges
Chemotherapy
Preferred Al owance
Usual and Customary Charges
Prescription Drugs
UnitedHealthcare Pharmacy (UHCP)
No Benefits
$15 Copay per prescription for Tier 1
$30 Copay per prescription for Tier 2
$60 Copay per prescription for Tier 3
up to a 31 day supply per prescription
(Mail order Prescription Drugs through
UHCP at 2.5 times the retail Copay up
to a 90 day supply.)


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Other
Preferred Provider
Out-of-Network
Ambulance Services
100% of Preferred Al owance
100% of Usual and Customary Charges
Benefit includes air ambulance payable $200 Copay per trip
$200 Deductible per trip
at 90% of Preferred Al owance In-
Network / 70% of Usual and
Customary Charges Out-of-Network.
Durable Medical Equipment
Preferred Al owance
Usual and Customary Charges
Consultant Physician Fees
100% of Preferred Al owance
Usual and Customary Charges

$25 Copay per visit
$25 Deductible per visit
Dental Treatment
Preferred Al owance
90% of Usual and Customary Charges
Benefits paid on Injury to Sound,
Natural Teeth only.
Mental Illness Treatment
Paid as any other Sickness
Paid as any other Sickness
See also Benefits for Biological y
Based Mental Il ness.
Substance Use Disorder Treatment
Paid as any other Sickness
Paid as any other Sickness
See also Benefits for Biological y


Based Mental Il ness.
Maternity
Paid as any other Sickness
Paid as any other Sickness
Elective Abortion
No Benefits
No Benefits
Complications of Pregnancy
Paid as any other Sickness
Paid as any other Sickness
Preventive Care Services
100% of Preferred Al owance
No Benefits
No Deductible, Copays or
Coinsurance wil be applied when the
services are received from a Preferred
Provider. See also Benefits for
Preventive Health Care.
Please visit
https://www.healthcare.gov/preventive-
care-benefits for a complete list of
services provided for specific age and
risk groups.
Reconstructive Breast Surgery
Paid as any other Sickness
Paid as any other Sickness
Following Mastectomy
Diabetes Services
See Benefits for Diabetes
See Benefits for Diabetes
Home Health Care
Preferred Al owance
Usual and Customary Charges
Hospice Care
Preferred Al owance
Usual and Customary Charges
Inpatient Rehabilitation Facility
Preferred Al owance
Usual and Customary Charges
Skilled Nursing Facility
Preferred Al owance
Usual and Customary Charges
$250 Copay per Inpatient admission
$750 Deductible per Inpatient admission
Copayment waived if admitted directly
to a Skil ed Nursing Facility from an
Inpatient acute facility.
Urgent Care Center
Preferred Al owance
Usual and Customary Charges
$35 Copay per visit
$35 Deductible per visit
Hospital Outpatient Facility or Clinic Preferred Al owance
Usual and Customary Charges
Approved Clinical Trials
Paid as any other Sickness
Paid as any other Sickness
Transplantation Services
Paid as any other Sickness
Paid as any other Sickness
TMJ Disorder
Paid as any other Sickness
Paid as any other Sickness
Vision
100% of Preferred Al owance
Usual and Customary Charges
One exam Per Policy Year. Coverage
$25 Copay per visit
$25 Deductible per visit
includes exam, refractions and
associated fittings for either
eyeglasses or contact lenses. No
copay applies to visits for fittings of
eyeglasses or contacts.
Acupuncture
100% of Preferred Al owance
Usual and Customary Charges
12 visits maximum Per Policy Year
$25 Copay per visit
$25 Deductible per visit
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Other
Preferred Provider
Out-of-Network
Allergy Injections
Preferred Al owance
Usual and Customary Charges
If not bil ed with a physician's office


visit.
Learning Disability Testing
Paid as any other Sickness
No Benefits
$600 maximum (Per Policy Year)
Benefits payable for learning disability
testing
UnitedHealthcare Pharmacy Benefits
Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL) when dispensed by a
UnitedHealthcare Pharmacy. Benefits are subject to supply limits and Copayments that vary depending on which tier of the
PDL the outpatient drug is listed. There are certain Prescription Drugs that require your Physician to notify us to verify their use
is covered within your benefit.

You are responsible for paying the applicable Copayments. Your Copayment is determined by the tier to which the Prescription
Drug Product is assigned on the PDL. Tier status may change periodical y and without prior notice to you. Please access
www.uhcsr.com or cal 1-855-828-7716 for the most up-to-date tier status.

$15 Copay per prescription order or refil for a Tier 1 Prescription Drug up to a 31 day supply.

$30 Copay per prescription order or refil for a Tier 2 Prescription Drug up to a 31 day supply.

$60 Copay per prescription order or refil for a Tier 3 Prescription Drug up to a 31 day supply.

Mail order Prescription Drugs are available at 2.5 times the retail Copay up to a 90 day supply.
Specialty Prescription Drugs – if you require Specialty Prescription Drugs, we may direct you to a Designated Pharmacy with
whom we have an arrangement to provide those Specialty Prescription Drugs. If you choose not to obtain your Specialty
Prescription Drug from a Designated Pharmacy, you wil be responsible for the entire cost of the Prescription Drug.
Designated Pharmacies – if you require certain Prescription Drugs including, but not limited to, Specialty Prescription Drugs,
we may direct you to a Designated Pharmacy with whom we have an arrangement to provide those Prescription Drugs. If you
choose not to obtain these Prescription Drugs from a Designated Pharmacy, you wil be responsible for the entire cost of the
Prescription Drug.

Please present your ID card to the network pharmacy when the prescription is fil ed. If you do not use a network pharmacy, you
wil be responsible for paying the ful cost for the prescription.

If you do not present the card, you wil need to pay for the prescription and then submit a reimbursement form for prescriptions
fil ed at a network pharmacy along with the paid receipt in order to be reimbursed. To obtain reimbursement forms, or for
information about mail-order prescriptions or network pharmacies, please visit www.uhcsr.com and log in to your online
account or cal 1-855-828-7716 or the customer service number on your ID card.
Additional Exclusions:
In addition to the policy Exclusions and Limitations, the following Exclusions apply to Network Pharmacy Benefits:

1.
Coverage for Prescription Drug Products for the amount dispensed (days' supply or quantity limit) which exceeds the
supply limit.
2.
Coverage for Prescription Drug Products for the amount dispensed (days’ supply or quantity limit) which is less than
the minimum supply limit.
3.
Experimental or Investigational Services or Unproven Services and medications; medications used for experimental
indications and/or dosage regimens determined by the Company to be experimental, investigational or unproven.
4.
Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that the Company
determines do not meet the definition of a Covered Medical Expense.
5.
Certain New Prescription Drug Products and/or new dosage forms until the date they are reviewed and assigned to a
tier by our PDL Management Committee.
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6.
Compounded drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug
Administration and requires a Prescription Order or Refil . Compounded drugs that are available as a similar
commercial y available Prescription Drug Product. Compounded drugs that contain at least one ingredient that
requires a Prescription Order or Refil are assigned to Tier-3.
7.
Drugs available over-the-counter that do not require a Prescription Order or Refil by federal or state law before being
dispensed, unless the Company has designated the over-the-counter medication as eligible for coverage as if it were a
Prescription Drug Product and it is obtained with a Prescription Order or Refil from a Physician. Prescription Drug
Products that are available in over-the-counter form or comprised of components that are available in over-the-counter
form or equivalent. Certain Prescription Drug Products that the Company has determined are Therapeutical y
Equivalent to an over-the-counter drug. Such determinations may be made up to six times during a calendar year, and
the Company may decide at any time to reinstate Benefits for a Prescription Drug Product that was previously
excluded under this provision.
8.
Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of
disease, even when used for the treatment of Sickness or Injury, except as required by state mandate.
9.
A Prescription Drug Product that contains (an) active ingredient(s) available in and Therapeutical y Equivalent to
another covered Prescription Drug Product.
10.
A Prescription Drug Product that contains (an) active ingredient(s) which is (are) a modified version of and
Therapeutical y Equivalent to another covered Prescription Drug Product.

Definitions:
Designated Pharmacy means a pharmacy that has entered into an agreement with the Company or with an organization
contracting on the Company’s behalf, to provide specific Prescription Drug Products, including, but not limited to, Specialty
Prescription Drug Products. The fact that a pharmacy is a Network Pharmacy does not mean that it is a Designated Pharmacy.
Prescription Drug or Prescription Drug Product means a medication, product or device that has been approved by the U.S.
Food and Drug Administration and that can, under federal or state law, be dispensed only pursuant to a Prescription Order or
Refil . A Prescription Drug Product includes a medication that, due to its characteristics, is appropriate for self-administration or
administration by a non-skilled caregiver. For the purpose of the benefits under the policy, this definition includes insulin.

New Prescription Drug Product means a Prescription Drug Product or new dosage form of a previously approved
Prescription Drug Product, for the period of time starting on the date the Prescription Drug Product or new dosage form is
approved by the U.S. Food and Drug Administration (FDA) and ending on the earlier of the following dates:

The date it is assigned to a tier by our PDL Management Committee.

December 31st of the fol owing calendar year.

Prescription Drug List means a list that categorizes into tiers medications, products or devices that have been approved by
the U.S. Food and Drug Administration. This list is subject to the Company’s periodic review and modification (general y
quarterly, but no more than six times per calendar year). The Insured may determine to which tier a particular Prescription Drug
Product has been assigned through the Internet at www.uhcsr.com or cal Customer Service at 1-855-828-7716.

Specialty Prescription Drug Product means Prescription Drug Products that are general y high cost, self-injectable
biotechnology drugs used to treat patients with certain il nesses. Insured Persons may access a complete list of Specialty
Prescription Drug Products through the Internet at www.uhcsr.com or cal Customer Service at 1-855-828-7716.
Insured Person’s Right to Request an Exclusion Exception for UnitedHealthcare Pharmacy (UHCP) Prescription Drug
Benefits
When a Prescription Drug Product is excluded from coverage, the Insured Person or the Insured’s representative may request
an exception to gain access to the excluded Prescription Drug Product. To make a request, contact the Company in writing or
cal 1-866-458-4954. The Company wil notify the Insured Person of the Company’s determination within 72 hours.
Urgent Requests
If the Insured Person’s request requires immediate action and a delay could significantly increase the risk to the Insured
Person’s health, or the ability to regain maximum function, cal the Company as soon as possible. The Company wil provide a
written or electronic determination within 24 hours.



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External Review
If the Insured Person is not satisfied with the Company’s determination of the exclusion exception request, the Insured Person
may be entitled to request an external review. The Insured Person or the Insured Person’s representative may request an
external review by sending a written request to the Company at the address set out in the determination letter or by cal ing 1-
866-458-4954. The Independent Review Organization (IRO) wil notify the Insured Person of the determination within 72
hours.

Expedited External Review
If the Insured Person is not satisfied with the Company’s determination of the exclusion exception request and it involves an
urgent situation, the Insured Person or the Insured’s representative may request an expedited external review by cal ing 1-866-
458-4954 or by sending a written request to the address set out in the determination letter. The IRO wil notify the Insured
Person of the determination within 24 hours.
Medical Expense Benefits – Injury and Sickness
This section describes Covered Medical Expenses for which benefits are available in the Schedule of Benefits.

Benefits are payable for Covered Medical Expenses (see "Definitions") less any Deductible incurred by or for an Insured Person
for loss due to Injury or Sickness subject to: a) the maximum amount for specific services as set forth in the Schedule of
Benefits; and b) any Coinsurance, Copayment or per service Deductible amounts set forth in the Schedule of Benefits or any
benefit provision hereto. Read the "Definitions" section and the "Exclusions and Limitations" section carefully.

No benefits wil be paid for services designated as "No Benefits" in the Schedule of Benefits or for any matter described in
"Exclusions and Limitations." If a benefit is designated, Covered Medical Expenses include:
Inpatient

1. Room and Board Expense.
Daily semi-private room rate when confined as an Inpatient and general nursing care provided and charged by the
Hospital.

2. Intensive Care.
If provided in the Schedule of Benefits.

3. Hospital Miscellaneous Expenses.
When confined as an Inpatient or as a precondition for being confined as an Inpatient. In computing the number of
days payable under this benefit, the date of admission wil be counted, but not the date of discharge.

Benefits wil be paid for services and supplies such as:
 The cost of the operating room.
 Laboratory tests.
 X-ray examinations.
 Anesthesia.
 Drugs (excluding take home drugs) or medicines.
 Therapeutic services.
 Supplies.

4. Routine Newborn Care.
While Hospital Confined and routine nursery care provided immediately after birth.

Benefits wil be paid for an inpatient stay of at least:
 48 hours following a vaginal delivery.
 96 hours following a cesarean section delivery.

If the mother agrees, the attending Physician may discharge the newborn earlier than these minimum time frames.




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5. Surgery (Inpatient).
Physician's fees for Inpatient surgery.

6. Assistant Surgeon Fees.
Assistant Surgeon Fees in connection with Inpatient surgery.

7. Anesthetist Services.
Professional services administered in connection with Inpatient surgery.

8. Registered Nurse's Services.
Registered Nurse’s services which are al of the fol owing:
 Private duty nursing care only.
 Received when confined as an Inpatient.
 Ordered by a licensed Physician.
 A Medical Necessity.

General nursing care provided by the Hospital, Skil ed Nursing Facility or Inpatient Rehabilitation Facility is not covered
under this benefit.

9. Physician's Visits (Inpatient).
Non-surgical Physician services when confined as an Inpatient. Benefits do not apply when related to surgery.

10. Pre-admission Testing.
Benefits are limited to routine tests such as:
 Complete blood count.
 Urinalysis.
 Chest X-rays.

If otherwise payable under the policy, major diagnostic procedures such as those listed below wil be paid under the
“Hospital Miscel aneous” benefit:
 CT scans.
 NMR's.
 Blood chemistries.

Outpatient

11. Surgery (Outpatient).
Physician's fees for outpatient surgery.

When these services are performed in a Physician's office, benefits are payable under Physician's Visits (Outpatient).

12. Day Surgery Miscellaneous (Outpatient).
Facility charge and the charge for services and supplies in connection with outpatient day surgery; excluding non-
scheduled surgery; and surgery performed in a Hospital emergency room; trauma center; Physician's office; or clinic.

13. Assistant Surgeon Fees (Outpatient).
Assistant Surgeon Fees in connection with outpatient surgery.

14. Anesthetist Services (Outpatient).
Professional services administered in connection with outpatient surgery.

15. Physician's Visits (Outpatient).
Services provided in a Physician’s office for the diagnosis and treatment of a Sickness or Injury. Benefits do not apply
when related to Physiotherapy.

Benefits include the following services when performed in the Physician’s office:
 Surgery.

Physician’s Visits for preventive care are provided as specified under Preventive Care Services.
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16. Physiotherapy (Outpatient).
Includes but is not limited to the following rehabilitative services (including Habilitative Services):
 Physical therapy.
 Occupational therapy.
 Cardiac rehabilitation therapy.
 Manipulative treatment, unless excluded in the policy.
 Speech therapy.

17. Medical Emergency Expenses (Outpatient).
Only in connection with a Medical Emergency as defined. Benefits wil be paid for the facility charge for use of the
emergency room and supplies.

Al other Emergency Services received during the visit wil be paid as specified in the Schedule of Benefits.

18. Diagnostic X-ray Services (Outpatient).
Diagnostic X-rays are only those procedures identified in Physicians' Current Procedural Terminology (CPT) as codes
70000 - 79999 inclusive. X-ray services for preventive care are provided as specified under Preventive Care Services.

19. Radiation Therapy (Outpatient).
See Schedule of Benefits.

20. Laboratory Procedures (Outpatient).
Laboratory Procedures are only those procedures identified in Physicians' Current Procedural Terminology (CPT) as
codes 80000 - 89999 inclusive. Laboratory procedures for preventive care are provided as specified under Preventive
Care Services.

21. Tests and Procedures (Outpatient).
Tests and procedures are those diagnostic services and medical procedures performed by a Physician but do not
include:
 Physician's Visits.
 Physiotherapy.
 X-rays.
 Laboratory Procedures.

The fol owing therapies wil be paid under the Tests and Procedures (Outpatient) benefit:
 Inhalation therapy.
 Infusion therapy.
 Pulmonary therapy.
 Respiratory therapy.

Tests and Procedures for preventive care are provided as specified under Preventive Care Services.

22. Injections (Outpatient).
When administered in the Physician's office and charged on the Physician's statement. Immunizations for preventive
care are provided as specified under Preventive Care Services.

23. Chemotherapy (Outpatient).
See Schedule of Benefits.

24. Prescription Drugs (Outpatient).
See Schedule of Benefits.

Other

25. Ambulance Services.
See Schedule of Benefits.


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26. Durable Medical Equipment.
Durable Medical Equipment must be al of the following:
 Provided or prescribed by a Physician. A written prescription must accompany the claim when submitted.
 Primarily and customarily used to serve a medical purpose.
 Can withstand repeated use.
 General y is not useful to a person in the absence of Injury or Sickness.
 Not consumable or disposable except as needed for the effective use of covered durable medical equipment.

For the purposes of this benefit, the following are considered durable medical equipment:
 Braces that stabilize an injured body part and braces to treat curvature of the spine.
 External prosthetic devices that replace a limb or body part but does not include any device that is fully implanted
into the body. Repair is covered unless necessitated by misuse.
 Orthotic devices that straighten or change the shape of a body part.

If more than one piece of equipment or device can meet the Insured’s functional needs, benefits are available only for
the equipment or device that meets the minimum specifications for the Insured’s needs. Dental braces are not durable
medical equipment and are not covered. Benefits for durable medical equipment are limited to the initial purchase or
one replacement purchase per Policy Year. No benefits wil be paid for rental charges in excess of purchase price.

27. Consultant Physician Fees.
Services provided on an Inpatient or outpatient basis.

28. Dental Treatment.
Dental treatment when services are performed by a Physician and limited to the fol owing:
 Injury to Sound, Natural Teeth.

Breaking a tooth while eating is not covered. Routine dental care and treatment to the gums are not covered. Pediatric
dental benefits are provided in the Pediatric Dental Services provision.

29. Mental Illness Treatment.
Benefits wil be paid for services received:
 On an Inpatient basis while confined to a Hospital including partial hospitalization/day treatment received at a
Hospital.
 On an outpatient basis including intensive outpatient treatment.

See also Benefits for Biological y Based Mental Illness.

30. Substance Use Disorder Treatment.
Benefits wil be paid for services received:
 On an Inpatient basis while confined to a Hospital including partial hospitalization/day treatment received at a
Hospital.
 On an outpatient basis including intensive outpatient treatment.
See also Benefits for Biologicaly Based Mental Illness.

31. Maternity.
Same as any other Sickness.

Benefits wil be paid for an inpatient stay of at least:
 48 hours following a vaginal delivery.
 96 hours following a cesarean section delivery.

If the mother agrees, the attending Physician may discharge the mother earlier than these minimum time frames.

32. Complications of Pregnancy.
Same as any other Sickness.



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33. Preventive Care Services.
Medical services that have been demonstrated by clinical evidence to be safe and effective in either the early detection
of disease or in the prevention of disease, have been proven to have a beneficial effect on health outcomes and are
limited to the following as required under applicable law:
 Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the
United States Preventive Services Task Force.
 Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention.
 With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for
in the comprehensive guidelines supported by the Health Resources and Services Administration.
 With respect to women, such additional preventive care and screenings provided for in comprehensive guidelines
supported by the Health Resources and Services Administration.

See also Benefits for Preventive Health Care.

34. Reconstructive Breast Surgery Following Mastectomy.
Same as any other Sickness and in connection with a covered mastectomy.

Benefits include:
 Al stages of reconstruction of the breast on which the mastectomy has been performed.
 Surgery and reconstruction of the other breast to produce a symmetrical appearance.
 Prostheses and physical complications of mastectomy, including lymphedemas.

35. Diabetes Services.
See Benefits for Diabetes.

36. Home Health Care.
Services received from a licensed home health agency that are:
 Ordered by a Physician.
 Provided or supervised by a Registered Nurse in the Insured Person’s home.
 Pursuant to a home health plan.

Benefits wil be paid only when provided on a part-time, intermittent schedule and when skil ed care is required. One
visit equals up to four hours of skil ed care services.

37. Hospice Care.
When recommended by a Physician for an Insured Person that is terminal y il with a life expectancy of six months or
less. Al hospice care must be received from a licensed hospice agency.

Hospice care includes:
 Physical, psychological, social, and spiritual care for the terminal y il Insured.
 Short-term grief counseling for immediate family members while the Insured is receiving hospice care.

38. Inpatient Rehabilitation Facility.
Services received while confined as a full-time Inpatient in a licensed Inpatient Rehabilitation Facility. Confinement in
the Inpatient Rehabilitation Facility must follow within 24 hours of, and be for the same or related cause(s) as, a period
of Hospital Confinement or Skil ed Nursing Facility confinement.

39. Skilled Nursing Facility.
Services received while confined as an Inpatient in a Skil ed Nursing Facility for treatment rendered for one of the
following:
 In lieu of Hospital Confinement as a full-time inpatient.
 Within 24 hours fol owing a Hospital Confinement and for the same or related cause(s) as such Hospital
Confinement.





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40. Urgent Care Center.
Benefits are limited to:
 The facility or clinic fee bil ed by the Urgent Care Center.

Al other services rendered during the visit wil be paid as specified in the Schedule of Benefits.

41. Hospital Outpatient Facility or Clinic.
Benefits are limited to:
 The facility or clinic fee bil ed by the Hospital.

Al other services rendered during the visit wil be paid as specified in the Schedule of Benefits.

42. Approved Clinical Trials.
Routine Patient Care Costs incurred during participation in an Approved Clinical Trial for the treatment of cancer or
other Life-threatening Condition. The Insured Person must be clinical y eligible for participation in the Approved
Clinical Trial according to the trial protocol and either: 1) the referring Physician is a participating health care provider
in the trial and has concluded that the Insured’s participation would be appropriate; or 2) the Insured provides medical
and scientific evidence information establishing that the Insured’s participation would be appropriate.

“Routine patient care costs” means Covered Medical Expenses which are typical y provided absent a clinical trial and
not otherwise excluded under the policy. Routine patient care costs do not include:
 The experimental or investigational item, device or service, itself.
 Items and services provided solely to satisfy data col ection and analysis needs and that are not used in the direct
clinical management of the patient.
 A service that is clearly inconsistent with widely accepted and established standards of care for a particular
diagnosis.

“Life-threatening condition” means any disease or condition from which the likelihood of death is probable unless the
course of the disease or condition is interrupted.

“Approved clinical trial” means a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the
prevention, detection, or treatment of cancer or other life-threatening disease or condition and is described in any of
the following:
 Federal y funded trials that meet required conditions.
 The study or investigation is conducted under an investigational new drug application reviewed by the Food and
Drug Administration.
 The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

43. Transplantation Services.
Same as any other Sickness for organ or tissue transplants when ordered by a Physician. Benefits are available when
the transplant meets the definition of a Covered Medical Expense.

Donor costs that are directly related to organ removal are Covered Medical Expenses for which benefits are payable
through the Insured organ recipient’s coverage under this policy. Benefits payable for the donor wil be secondary to
any other insurance plan, service plan, self-funded group plan, or any government plan that does not require this policy
to be primary.

No benefits are payable for transplants which are considered an Elective Surgery or Elective Treatment (as defined)
and transplants involving permanent mechanical or animal organs.

Travel expenses are not covered. Health services connected with the removal of an organ or tissue from an Insured
Person for purposes of a transplant to another person are not covered.

44. TMJ Disorder.
Same as any other Sickness and limited to the following services only:
 Diagnostic X-ray Services.
 Laboratory procedures.
 Physical therapy.
 Surgery.
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Mandated Benefits
BENEFITS FOR TELEMEDICINE SERVICES

Benefits wil be paid for Covered Medical Expenses on the same basis as services provided through a face-to-face
consultation for services provided through Telemedicine for an Insured residing in a county with one hundred fifty thousand or
fewer residents. “Telemedicine” means the use of interactive audio, video, or other electronic media to deliver health care. The
term includes the use of electronic media for diagnosis, consultation, treatment, transfer of medical data and medical education.
The term does not include services performed using a telephone or facsimile machine.

Nothing in this provision shal require the use of Telemedicine when in-person care by a participating provider is available to an
Insured Person within the Company’s network and within the Insured’s geographic area.

Benefits shal be subject to al Deductible, Copayment, Coinsurance, limitations, or any other provisions of the policy.

BENEFITS FOR PROSTATE CANCER SCREENING

Benefits wil be paid for actual charges incurred for an annual screening by a Physician for the early detection of prostate
cancer. Benefits wil be payable for one screening per year for any male Insured 50 years of age or older. One screening per
year shal be covered for any male Insured 40 to 50 years of age who is at risk of developing prostate cancer as determined by
the Insured’s Physician. The screening shal consist of the following tests:

1) A prostate-specific antigen (PSA) blood test; and
2) Digital rectal examination.

The policy Deductible wil not be applied to this benefit and this benefit wil not reduce any diagnostic benefits otherwise
al owable under the policy.

Benefits shal be subject to al Copayment, Coinsurance, limitations, or any other provisions of the policy.

BENEFITS FOR BIOLOGICALLY BASED MENTAL ILLNESS

Benefits wil be paid the same as any other Sickness for the treatment of Biological y Based Mental Il ness and Mental
Disorders as defined below. The benefit provided wil not duplicate any other benefits provided in this policy.
“Biologically Based Mental Illness” means schizophrenia, schizoaffective disorder, bipolar affective disorder, major
depressive disorder, specific obsessive-compulsive disorder, and panic disorder.

“Mental Disorder” means posttraumatic stress disorder, drug and alcohol disorders, dysthymia, cyclothymia, social phobia,
agoraphobia with panic disorder, and general anxiety disorder. Mental Disorder also includes anorexia nervosa and bulimia
nervosa to the extent those diagnoses are treated on an out-patient, day treatment, and in-patient basis, exclusive of residential
treatment.

Benefits shal be subject to al Deductible, Copayment, Coinsurance, limitations, or any other provisions of the policy.

BENEFITS FOR DIABETES
Benefits wil be paid for the Usual and Customary Charges for al medicaly appropriate and necessary equipment, supplies,
and outpatient diabetes self-management training and educational services including nutritional therapy if prescribed by a
Physician.

Diabetes outpatient self-management training and education shal be provided by a Physician with expertise in diabetes.

Benefits shal be subject to al Deductible, Copayment, Coinsurance, limitations, or any other provisions of the policy.



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BENEFITS FOR CERVICAL CANCER VACCINES

Benefits are payable for the cost of cervical cancer vaccinations for al female Insured Persons for whom a vaccination is
recommended by the Advisory Committee on Immunization practices of the United States Department of Health and Human
Services.

BENEFITS FOR MEDICAL FOODS
Benefits are payable for Medical Foods needed to treat inherited enzymatic disorders caused by single gene defects involved in
the metabolism of amino, organic, and fatty acids as specified below.

If the policy provides benefits for Prescription Drugs, benefits wil be paid the same as any other Sickness for Medical Foods, to
the extent Medical y Necessary, for home use for which a Physician has issued a written, oral or electronic prescription.
Benefits wil not be provided for alternative medicine.

Coverage includes but is not limited to the following diagnosed conditions: phenylketonuria; maternal phenylketonuria; maple
syrup urine disease; tyrosinemia; homocystinuria; histidinemia; urea cycle disorders; hyperlysinemia; glutaric acidemias;
methylmalonic acidemia; and propionic acidemia. Benefits do not apply to cystic fibrosis patients or lactose- or soy-intolerant
patients.

There is no age limit on the benefits provided for inherited enzymatic disorders except for phenylketonuria. The maximum age to
receive benefits for phenylketonuria is twenty-one years of age; except that the maximum age to receive benefits for
phenylketonuria for women who are of child-bearing age is thirty-five years of age.

Medical foods means prescription metabolic formulas and their modular counterparts, obtained through a pharmacy that are
specifical y designed and manufactured for the treatment of inherited enzymatic disorders caused by single gene defects
involved in the metabolism of amino, organic, and fatty acids and for which medical y standard methods of diagnosis, treatment,
and monitoring exist. Such formulas are specifical y processed or formulated to be deficient in one or more nutrients and are to
be consumed or administered enteral y either via tube or oral route under the direction of a Physician.

Benefits shal be subject to al Deductible, Copayment, Coinsurance, limitations, or any other provisions of the policy.

BENEFITS FOR CLEFT LIP OR CLEFT PALATE
Benefits wil be paid the same as any other Sickness for treatment of newborn children born with cleft lip or cleft palate or both.
Benefits shal include the Medical y Necessary care and treatment including oral and facial surgery; surgical management; the
Medical y Necessary care by a plastic or oral surgeon; prosthetic treatment such as obturators, speech appliances, feeding
appliances; Medical y Necessary orthodontic and prosthodontic treatment; habilitative speech therapy, otolaryngology
treatment; and audiological assessments and treatment.

Benefits shal be subject to al Deductible, Copayment, Coinsurance, limitations, or any other provisions of the policy.

BENEFITS FOR HEARING AIDS FOR MINOR CHILDREN
Benefits wil be paid for Covered Medical Expenses for Hearing Aids for a Minor Child who has a hearing loss that has been
verified by a licensed Physician and a licensed Audiologist. The Hearing Aid shal be medical y appropriate to meet the needs of
the Minor Child according to accepted professional standards.

Benefits shal include the purchase of the fol owing:
1) Initial Hearing Aids and replacement Hearing Aids not more frequently than every five years;
2) A new Hearing Aid when alterations to the existing Hearing Aid cannot adequately meet the needs of the Minor Child;
and
3) Services and supplies including, but not limited to, the initial assessment, fitting, adjustments, and auditory training that is
provided according to professional standards.
“Hearing Aid” means amplification technology that optimizes audibility and listening skills in the environments commonly
experienced by the patient, including a wearable instrument or device designed to aid or compensate for impaired human
hearing. “Hearing Aid” shal include any parts or ear molds.


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“Minor Child” means an Insured Person under the age of eighteen.

Benefits shal be subject to al Deductible, Copayment, Coinsurance, limitations, or any other provisions of the policy.

BENEFITS FOR THE TREATMENT OF AUTISM SPECTRUM DISORDERS

Benefits wil be paid the same as any other Sickness for Covered Medical Expenses related to the assessment, diagnosis and
treatment, including Applied Behavior Analysis, of Autism Spectrum Disorders. Treatment for Autism Spectrum Disorders must
be prescribed or ordered by a licensed Physician or license psychologist.

“Applied behavior analysis” means the use of behavior analytic methods and research findings to change social y important
behaviors in meaningful ways.
“Autism Spectrum Disorders” include the folowing neurobiological disorders: autistic disorder, asperger’s disorder, and
atypical autism as a diagnosis within pervasive developmental disorder not otherwise specified, as defined in the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders at the time of diagnosis.

“Treatment for Autism Spectrum Disorders” shal be for treatments that are Medical y Necessary, appropriate, effective, or
efficient. Treatment for Autism Spectrum Disorders shal include:
1) Evaluation and assessment services;
2) Behavior training and behavior management and applied behavior analysis, including but not limited to, consultations,
direct care, supervision, or treatment, or any combination thereof, provided by autism services providers;
3) Habilitative or rehabilitative care, including but not limited to, occupational therapy, physical therapy, or speech therapy,
or any combination of those therapies;
4) Psychiatric care;
5) Psychological care, including family counseling;
6) Therapeutic care; and
7) Pharmacy care and medication if provided for in the policy.

Benefits shal be subject to al Deductible, Copayment, Coinsurance, limitations, or any other provisions of the policy.

BENEFITS FOR PREVENTIVE HEALTH CARE

Benefits wil be provided for the cost of the following Preventive Health Care services, in accordance with the A or B
Recommendations of the Task Force for the particular Preventive Health Care service:

1) Alcohol misuse screening and behavioral counseling interventions for adults by their Physician;
2) Cervical Cancer Screening;
3) Breast Cancer Screening with Mammography:
a) Benefits shal be determined on a Policy Year basis and shal in no way diminish or limit diagnostic benefits
otherwise al owable under the policy;
b) If an Insured Person who is eligible for a preventive mammography screening has not utilized the benefit during
the Policy Year, then the coverage shal apply to one diagnostic screening for that same Policy Year. Any other
diagnostic screenings shal be subject to al applicable policy provisions;
c) Benefits shal also be provided for an annual breast cancer screening with mammography for an Insured Person
possessing at least one risk factor including, but not limited to, a family history of breast cancer, being forty years
of age or older, or a genetic predisposition to breast cancer;
4) Cholesterol screening for lipid disorders;
5) Colorectal cancer screening coverage for tests for the early detection of colorectal cancer and adenomatous polyps.
Benefits shal also be provided to an Insured Person who is at a high risk for colorectal cancer, including an Insured
Person who has a family medical history of colorectal cancer; a prior occurrence of cancer or precursor neoplastic
polyps; a prior occurrence of a chronic digestive disease condition such as inflammatory bowel disease, Crohn’s
disease, or ulcerative colitis; or other predisposing factors as determined by a Physician;
6) Child health supervision services and childhood immunizations pursuant to the schedule established by the ACIP;
7) Influenza vaccinations pursuant to the schedule established by the ACIP;
8) Pneumococcal vaccinations pursuant to the schedule established by the ACIP; and
9) Tobacco use screening of adults and tobacco cessation interventions by the Insured Person’s Physician.
10) Any other preventive services included in the A or B Recommendation of the Task Force or required by federal law.

“ACIP” means the advisory committee on immunization practices to the centers for disease control and prevention in the
federal Department of Health and Human Services, or any successor entity.

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“A Recommendation” means a recommendation adopted by the task force that strongly recommends that clinicians provide a
preventive health care service because the task force found there is a high certainty that the net benefit of the preventive health
care service is substantial.

“B Recommendation” means a recommendation adopted by the task force that recommends that clinicians provide a
preventive health care service because the task force found there is a high certainty that the net benefit is moderate or there is
moderate certainty that the net benefit is moderate to substantial.

“Task force” means the U.S. preventive services task force, or any successor organization, sponsored by the agency for
healthcare research and quality, the health services research arm of the federal Department of Health and Human Services.

The policy Deductible Copays and Coinsurance wil not be applied to this benefit.

Benefits shal be subject to al other limitations or any other provisions of the policy.

BENEFITS FOR ORAL ANTICANCER MEDICATION

Benefits wil be provided for prescribed, oral y administered anticancer medication that has been approved by the Federal Food
and Drug Administration and is used to kil or slow the growth of cancerous cel s.

The oral y administered medication shal be provided at a cost to the Insured not to exceed the Coinsurance percentage or the
Copayment amount as is applied to an intravenously administered or an injected cancer medication prescribed for the same
purpose.

The medication provided pursuant to this benefit shal :

1) only be prescribed upon a finding that it is Medical y Necessary by the treating Physician for the purpose of kil ing or
slowing the growth of cancerous cells in a manner that is in accordance with national y accepted standards of medical
practice;
2) be clinical y appropriate in terms of type, frequency, extent site, and duration; and
3) not be primarily for the convenience of the Insured or Physician.

This benefit does not require the use of oral y administered medications as a replacement for other cancer medications, nor
does it prohibit the Company from applying an appropriate formulary or other clinical management to any medication described
in this benefit.

Benefits shal be subject to al Deductible, Copayment, Coinsurance, limitations, or any other provisions of the policy.
Coordination of Benefits Provision
Benefits wil be coordinated with any other eligible medical, surgical or hospital plan or coverage so that combined payments
under al programs wil not exceed 100% of al owable expenses incurred for covered services and supplies.
Definitions
COINSURANCE means the percentage of Covered Medical Expenses that the Company pays.
COMPLICATION OF PREGNANCY means a condition: 1) caused by pregnancy; 2) requiring medical treatment prior to, or
subsequent to termination of pregnancy; 3) the diagnosis of which is distinct from pregnancy; and 4) which constitutes a
classifiably distinct complication of pregnancy. A condition simply associated with the management of a difficult pregnancy is
not considered a complication of pregnancy.
CONGENITAL CONDITION means a medical condition or physical anomaly arising from a defect existing at birth.
COPAY/COPAYMENT means a specified dollar amount that the Insured is required to pay for certain Covered Medical
Expenses.


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COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in excess of Usual and Customary Charges; 2)
not in excess of the Preferred Al owance when the policy includes Preferred Provider benefits and the charges are received
from a Preferred Provider; 3) not in excess of the maximum benefit amount payable per service as specified in the Schedule of
Benefits; 4) made for services and supplies not excluded under the policy; 5) made for services and supplies which are a
Medical Necessity; 6) made for services included in the Schedule of Benefits; and 7) in excess of the amount stated as a
Deductible, if any.

Covered Medical Expenses wil be deemed "incurred" only: 1) when the covered services are provided; and 2) when a charge
is made to the Insured Person for such services.
CUSTODIAL CARE means services that are any of the following:

1) Non-health related services, such as assistance in activities.
2) Health-related services that are provided for the primary purpose of meeting the personal needs of the patient or
maintaining a level of function (even if the specific services are considered to be skilled services), as opposed to
improving that function to an extent that might al ow for a more independent existence.
3) Services that do not require continued administration by trained medical personnel in order to be delivered safely and
effectively.

DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or any endorsement to this policy as a deductible, it
shal mean an amount to be subtracted from the amount or amounts otherwise payable as Covered Medical Expenses before
payment of any benefit is made. The deductible wil apply as specified in the Schedule of Benefits.

ELECTIVE SURGERY OR ELECTIVE TREATMENT means those health care services or supplies that do not meet the health
care need for a Sickness or Injury. Elective surgery or elective treatment includes any service, treatment or supplies that: 1) are
deemed by the Company to be research or experimental; or 2) are not recognized and general y accepted medical practices in
the United States.
EMERGENCY SERVICES means with respect to a Medical Emergency:

1) A medical screening examination that is within the capability of the emergency department of a Hospital, including
ancil ary services routinely available to the emergency department to evaluate such emergency medical condition; and
2) Such further medical examination and treatment to stabilize the patient to the extent they are within the capabilities of
the staff and facilities available at the Hospital.

HABILITATIVE SERVICES means outpatient occupational therapy, physical therapy and speech therapy prescribed by the
Insured Person’s treating Physician pursuant to a treatment plan to develop a function not currently present as a result of a
congenital, genetic, or early acquired disorder.

Habilitative services do not include services that are solely educational in nature or otherwise paid under state or federal law for
purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential
treatment are not habilitative services.

A service that does not help the Insured person to meet functional goals in a treatment plan within a prescribed time frame is
not a habilitative service. When the Insured Person reaches his/her maximum level of improvement or does not demonstrate
continued progress under a treatment plan, a service that was previously habilitative is no longer habilitative.

HOSPITAL means a health institution planned, organized, operated, and maintained to offer facilities, beds, and services over a
continuous period exceeding twenty four (24) hours to individuals requiring diagnosis and treatment for il ness, Injury, deformity,
abnormality, or pregnancy. Clinical laboratory, diagnostic X-ray, and definitive medical treatment under an organized medical
staff shal be provided within the institution. Treatment facilities for emergency and surgical services shal be provided either
within the institution or by contractual agreement for those services with another licensed Hospital. Services provided by
contractual agreement shal be documented by a well-defined plan for the provision of contracted services, related to
community needs. Definitive medical treatment may include obstetrics, pediatrics, psychiatry, physical medicine and
rehabilitation, X-ray therapy, and similar specialized treatment.
HOSPITAL CONFINED/HOSPITAL CONFINEMENT means confinement as an Inpatient in a Hospital by reason of an Injury or
Sickness for which benefits are payable.

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INJURY means bodily injury which is al of the following:

1) directly and independently caused by specific accidental contact with another body or object.
2) unrelated to any pathological, functional, or structural disorder.
3) a source of loss.
4) treated by a Physician within 30 days after the date of accident.
5) sustained while the Insured Person is covered under this policy.

Al injuries sustained in one accident, including al related conditions and recurrent symptoms of these injuries wil be
considered one injury. Injury does not include loss which results wholly or in part, directly or indirectly, from disease or other
bodily infirmity. Covered Medical Expenses incurred as a result of an injury that occurred prior to this policy’s Effective Date wil
be considered a Sickness under this policy.
INPATIENT means an uninterrupted confinement that follows formal admission to a Hospital, Skiled Nursing Facility or
Inpatient Rehabilitation Facility by reason of an Injury or Sickness for which benefits are payable under this policy.
INPATIENT REHABILITATION FACILITY means a long term acute inpatient rehabilitation center, a Hospital (or special unit of
a Hospital designated as an inpatient rehabilitation facility) that provides rehabilitation health services on an Inpatient basis as
authorized by law.
INSURED PERSON means the Named Insured. The term "Insured" also means Insured Person.
INTENSIVE CARE means: 1) a specificaly designated facility of the Hospital that provides the highest level of medical care;
and 2) which is restricted to those patients who are critical y il or injured. Such facility must be separate and apart from the
surgical recovery room and from rooms, beds and wards customarily used for patient confinement.

They must be: 1) permanently equipped with special life-saving equipment for the care of the critical y il or injured; and 2)
under constant and continuous observation by nursing staff assigned on a full-time basis, exclusively to the intensive care unit.
Intensive care does not mean any of these step-down units:

1) Progressive care.
2) Sub-acute intensive care.
3) Intermediate care units.
4) Private monitored rooms.
5) Observation units.
6) Other facilities which do not meet the standards for intensive care.
MEDICAL EMERGENCY means the occurrence of a sudden, serious and unexpected Sickness or Injury. In the absence of
immediate medical attention, a reasonable person could believe this condition would result in any of the fol owing:

1) Death.
2) Placement of the Insured's health in jeopardy.
3) Serious impairment of bodily functions.
4) Serious dysfunction of any body organ or part.
5) In the case of a pregnant woman, serious jeopardy to the health of the fetus.

Expenses incurred for "Medical Emergency" wil be paid only for Sickness or Injury which fulfil s the above conditions. These
expenses wil not be paid for minor Injuries or minor Sicknesses.
MEDICAL NECESSITY/MEDICALLY NECESSARY means those services or supplies provided or prescribed by a Hospital or
Physician which are al of the fol owing:

1) Essential for the symptoms and diagnosis or treatment of the Sickness or Injury.
2) Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury.
3) In accordance with the standards of good medical practice.
4) Not primarily for the convenience of the Insured, or the Insured's Physician.
5) The most appropriate supply or level of service which can safely be provided to the Insured.


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The Medical Necessity of being confined as an Inpatient means that both:

1) The Insured requires acute care as a bed patient.
2) The Insured cannot receive safe and adequate care as an outpatient.

This policy only provides payment for services, procedures and supplies which are a Medical Necessity. No benefits wil be
paid for expenses which are determined not to be a Medical Necessity, including any or al days of Inpatient confinement.
MENTAL ILLNESS means a Sickness that is a mental, emotional or behavioral disorder listed in the mental health or psychiatric
diagnostic categories in the current Diagnostic and Statistical Manual of the American Psychiatric Association. Mental Illness
does not mean a Biological y Based Mental Illness or a Mental Disorder as defined in the Benefits for Biological y Based Mental
Illness. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does
not mean that treatment of the disorder is a Covered Medical Expense. If not excluded or defined elsewhere in the policy, al
mental health or psychiatric diagnoses are considered one Sickness.
NAMED INSURED means an eligible registered student of the Policyholder, if: 1) the student is properly enrolled in the
program; and 2) the appropriate premium for coverage has been paid.
NEWBORN INFANT means any child born of an Insured while that person is insured under this policy. Newborn Infants wil be
covered under the policy for the first 31 days after birth. Coverage for such a child wil be for Injury or Sickness, including
medical y diagnosed congenital defects, birth abnormalities, prematurity and nursery care; benefits wil be the same as for the
Insured Person who is the child's parent.
OUT-OF-POCKET MAXIMUM means the amount of Covered Medical Expenses that must be paid by the Insured Person
before Covered Medical Expenses wil be paid at 100% for the remainder of the Policy Year. Refer to the Schedule of Benefits
for details on how the Out-of-Pocket Maximum applies.
PHYSICIAN means a legaly qualified licensed practitioner of the healing arts who provides care within the scope of his/her
license, other than a member of the person’s immediate family.
The term “member of the immediate family” means any person related to an Insured Person within the third degree by the laws
of consanguinity or affinity.
PHYSIOTHERAPY means short-term outpatient rehabilitation therapies (including Habilitative Services) administered by a
Physician.
POLICY YEAR means the period of time beginning on the policy Effective Date and ending on the policy Termination Date.
PRESCRIPTION DRUGS mean: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a
prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon
written prescription of a Physician; and 4) injectable insulin.
REGISTERED NURSE means a professional nurse (R.N.) who is not a member of the Insured Person's immediate family.

SICKNESS means sickness or disease of the Insured Person which causes loss while the Insured Person is covered under this
policy. Al related conditions and recurrent symptoms of the same or a similar condition wil be considered one sickness.
Covered Medical Expenses incurred as a result of an Injury that occurred prior to this policy’s Effective Date wil be considered
a sickness under this policy.
SKILLED NURSING FACILITY means a Hospital or nursing facility that is licensed and operated as required by law.
SOUND, NATURAL TEETH means natural teeth, the major portion of the individual tooth is present, regardless of filings or
caps; and is not carious, abscessed, or defective.
SUBSTANCE USE DISORDER means a Sickness that is listed as an alcoholism and substance use disorder in the current
Diagnostic and Statistical Manual of the American Psychiatric Association. Substance use disorder does not mean a Mental
Disorder as defined in the Benefits for Biological y Based Mental Il ness. The fact that a disorder is listed in the Diagnostic and
Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a Covered Medical
Expense. If not excluded or defined elsewhere in the policy, al alcoholism and substance use disorders are considered one
Sickness.

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URGENT CARE CENTER means a facility that provides treatment required to prevent serious deterioration of the Insured
Person’s health as a result of an unforeseen Sickness, Injury, or the onset of acute or severe symptoms.

USUAL AND CUSTOMARY CHARGES means the lesser of the actual charge or a reasonable charge which is: 1) usual and
customary when compared with the charges made for similar services and supplies; and 2) made to persons having similar
medical conditions in the locality where service is rendered. The Company uses data from FAIR Health, Inc. to determine Usual
and Customary Charges. No payment wil be made under this policy for any expenses incurred which in the judgment of the
Company are in excess of Usual and Customary Charges.
Exclusions and Limitations
No benefits wil 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:

1.
Behavioral problems. Conceptual handicap. Developmental delay or disorder or mental retardation. Learning
disabilities. Milieu therapy. Parent-child problems.
This exclusion does not apply to benefits specifical y provided in the policy.
2.
Biofeedback.
3.
Circumcision.
4.
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 of a Newborn Infant.
5.
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.
6.
Dental treatment, except:
 For accidental Injury to Sound, Natural Teeth.
This exclusion does not apply to benefits specifical y provided in Pediatric Dental Services.
7.
Elective Surgery or Elective Treatment.
8.
Elective abortion.
9.
Health spa or similar facilities. Strengthening programs.
10.
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.
 Hearing Aids specifical y provided for in Benefits for Hearing Aids for Minor Children.
 Hearing exams and tests to determine the need for hearing correction.
11.
Hypnosis.
12.
Immunizations, except as specifical y provided in the policy. Preventive medicines or vaccines, except where required
for treatment of a covered Injury or as specifical y provided in the policy.
13.
Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease
Law or Act, or similar legislation.
14.
Injury or Sickness outside the United States and its possessions.
15.
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.
16.
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.
17.
Investigational services.
18.
Lipectomy.
19.
Manipulative treatment (the therapeutic application of chiropractic and osteopathic manipulative treatment with or
without ancil ary physiologic treatment and/or rehabilitative methods rendered to restore/improve motion, reduce pain
and improve function).
20.
Marital or family counseling.
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. Fighting.
23.
Prescription Drugs, services or supplies as fol ows:
 Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-
medical substances, regardless of intended use, except as specifical y provided in the policy.
 Immunization agents, except as specifical y provided in the policy. Biological sera.
14-BR-CO (PY16)
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 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
Viagra.
 Growth hormones.
 Refil s 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 fol owing:
 Genetic counseling and genetic testing.
 Cryopreservation of reproductive materials. Storage of reproductive materials.
 Fertility tests.
 Infertility treatment (male or female), including any services or supplies rendered for the purpose or with the intent
of inducing conception.
 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 specifical y provided in the policy.
26.
Residential treatment of eating disorders, such as anorexia or bulimia.
27.
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 specifical y provided in Pediatric Vision Services.
 To benefits specifical y provided in the policy.
28.
Routine Newborn Infant Care and well-baby nursery and related Physician charge, except as specifical y provided in
the policy.
29.
Services provided normal y 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. Temporomandibular joint
dysfunction, except as specifical y provided in the policy. 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.
Supplies, except as specifical y provided in the policy.
32.
Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia, except
as specifical y provided in the policy.
33.
Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment.
34.
War or any act of war, declared or undeclared; or while in the armed forces of any country other than the United States
(a pro-rata premium wil be refunded upon request for such period not covered).
35.
Weight management. Weight reduction programs. Weight management programs. Nutrition programs and related
nutritional supplies. Treatment for obesity (except surgery for morbid obesity.) This exclusion does not apply to benefits
specifical y provided in the policy.
UnitedHealthcare Global: Global Emergency Services
If you are a member insured with this insurance plan, you are eligible for UnitedHealthcare Global Emergency Services. The
requirements to receive these services are as fol ows:

International students: you are eligible to receive UnitedHealthcare Global services worldwide, except in your home country.

Domestic students: you are eligible for UnitedHealthcare Global services when 100 miles or more away from your campus
address and 100 miles or more away from your permanent home address or while participating in a Study Abroad program.

The Emergency Medical Evacuation services are not meant to be used in lieu of or replace local emergency services such as an
ambulance requested through emergency 911 telephone assistance. Al services must be arranged and provided by
UnitedHealthcare Global; any services not arranged by UnitedHealthcare Global wil not be considered for payment. If the
condition is an emergency, you should go immediately to the nearest physician or hospital without delay and then contact the
24-hour Emergency Response Center. UnitedHealthcare Global wil then take the appropriate action to assist you and monitor
your care until the situation is resolved.

14-BR-CO (PY16)
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Key Services include:
 Transfer of Insurance Information to Medical Providers
 Monitoring of Treatment
 Transfer of Medical Records
 Medication, Vaccine
 Worldwide Medical and Dental Referrals
 Dispatch of Doctors/Specialists
 Emergency Medical Evacuation
 Facilitation of Hospital Admittance up to $5,000.00 payment
 Transportation to Join a Hospitalized Participant
 Transportation After Stabilization
 Coordinate the replacement of Corrective Lenses and Medical Devices
 Emergency Travel Arrangements
 Hotel Arrangements for Convalescence
 Continuous Updates to Family and Home Physician
 Return of Dependent Children
 Replacement of Lost or Stolen Travel Documents
 Repatriation of Mortal Remains
 Worldwide Destination Intelligence Destination Profiles
 Legal Referral
 Transfer of Funds
 Message Transmittals
 Translation Services
 Security and Political Evacuation Services
 Natural Disaster Evacuation Services

Please visit www.uhcsr.com/UHCGlobal for the UnitedHealthcare Global brochure which includes service descriptions and
program exclusions and limitations.

To access services please cal :
(800) 527-0218 Toll-free within the United States
(410) 453-6330 Collect outside the United States

Services are also accessible via e-mail at assistance@UHCGlobal.com.

When cal ing the UnitedHealthcare Global Operations Center, please be prepared to provide:
 Cal er’s name, telephone and (if possible) fax number, and relationship to the patient;
 Patient's name, age, sex, and UnitedHealthcare Global ID Number as listed on your Medical ID Card;
 Description of the patient's condition;
 Name, location, and telephone number of hospital, if applicable;
 Name and telephone number of the attending physician; and
 Information of where the physician can be immediately reached.

UnitedHealthcare Global is not travel or medical insurance but a service provider for emergency medical assistance services.
Al medical costs incurred should be submitted to your health plan and are subject to the policy limits of your health coverage.
Al assistance services must be arranged and provided by UnitedHealthcare Global. Claims for reimbursement of services not
provided by UnitedHealthcare Global wil not be accepted. Please refer to the UnitedHealthcare Global information in My
Account at www.uhcsr.com/MyAccount for additional information, including limitations and exclusions.
Online Access to Account Information
UnitedHealthcare StudentResources Insureds have online access to claims status, EOBs, ID Cards, network providers,
correspondence and coverage information by logging in to My Account at www.uhcsr.com/myaccount. Insured students who
don’t already have an online account may simply select the “create My Account Now” link. Follow the simple, onscreen
directions to establish an online account in minutes using your 7-digit Insurance ID number or the email address on file.

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As part of UnitedHealthcare StudentResources’ environmental commitment to reducing waste, we’ve adopted a number of
initiatives designed to preserve our precious resources while also protecting the security of a student’s personal health
information.

My Account now includes Message Center - a self-service tool that provides a quick and easy way to view any email
notifications we may have sent. In Message Center, notifications are securely sent directly to the Insured student’s email
address. If the Insured student prefers to receive paper copies, he or she may opt-out of electronic delivery by going into My
Email Preferences and making the change there.
ID Cards
One way we are becoming greener is to no longer automatical y mail out ID Cards. Instead, we wil send an email notification
when the digital ID card is available to be downloaded from My Account. An Insured student may also use My Account to
request delivery of a permanent ID card through the mail.
UHCSR Mobile App
The UHCSR Mobile App is available for download from Google Play or Apple’s App Store. Features of the Mobile App include
easy access to:
 ID Cards – view, save to your device, fax or email directly to your provider.

Provider Search – search for In-Network participating Healthcare or Mental Health providers, cal the office or facility; view
a map.

Find My Claims – view claims received within the past 60 days; includes Provider, date of service, status, claim amount
and amount paid.
UnitedHealth Allies
Insured students also have access to the UnitedHealth Al ies® discount program. Simply log in to My Account as described
above and select UnitedHealth Allies Plan to learn more about the discounts available. When the Medical ID card is viewed or
printed, the UnitedHealth Al ies card is also included. The UnitedHealth Al ies Program is not insurance and is offered by
UnitedHealth Al ies, a UnitedHealth Group company.
Claim Procedures for Injury and Sickness Benefits
In the event of Injury or Sickness, students should:
1. Report to the Student Health Service for treatment, or when not in school, to their Physician or Hospital.

2.
Mail to the address below al medical and hospital bil s along with the patient's name and insured student's name,
address, SR ID number (insured’s insurance company ID number) and name of the university under which the student
is insured. A Company claim form is not required for filing a claim.

3.
Submit claims for payment within 90 days after the date of service. If the Insured doesn’t provide this information within
one year of the date of service, benefits for that service may be denied at our discretion. This time limit does not apply
if the Insured is legal y incapacitated.

Submit the above information to the Company by mail:

UnitedHealthcare StudentResources
P.O. Box 809025

Dal as, TX 75380-9025

Pediatric Dental Services Benefits
Benefits are provided for Covered Dental Services for Insured Persons under the age of 19. Benefits terminate on the earlier of:
1) last day of the month the Insured Person reaches the age of 19 or 2) the date the Insured Person's coverage under the
policy terminates.

14-BR-CO (PY16)
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Section 1: Accessing Pediatric Dental Services

Network and Non-Network Benefits
Network Benefits apply when the Insured Person chooses to obtain Covered Dental Services from a Network Dental Provider.
Insured Persons general y are required to pay less to the Network Dental Provider than they would pay for services from a non-
Network provider. Network Benefits are determined based on the contracted fee for each Covered Dental Service. In no event,
wil the Insured Person be required to pay a Network Dental Provider an amount for a Covered Dental Service in excess of the
contracted fee.

In order for Covered Dental Services to be paid as Network Benefits, the Insured must obtain al Covered Dental Services
directly from or through a Network Dental Provider.

Insured Persons must always verify the participation status of a provider prior to seeking services. From time to time, the
participation status of a provider may change. Participation status can be verified by cal ing the Company and/or the provider. If
necessary, the Company can provide assistance in referring the Insured Person to a Network Dental Provider.

The Company wil make a Directory of Network Dental Providers available to the Insured Person. The Insured Person can also
cal Customer Service at 877-816-3596 to determine which providers participate in the Network. The telephone number for
Customer Service is also on the Insured’s ID card.
Non-Network Benefits apply when Covered Dental Services are obtained from non-Network Dental Providers. Insured
Persons general y are required to pay more to the provider than for Network Benefits. Non-Network Benefits are determined
based on the Usual and Customary Fee for similarly situated Network Dental Providers for each Covered Dental Service. The
actual charge made by a non-Network Dental Provider for a Covered Dental Service may exceed the Usual and Customary Fee.
As a result, an Insured Person may be required to pay a non-Network Dental Provider an amount for a Covered Dental Service
in excess of the Usual and Customary Fee. In addition, when Covered Dental Services are obtained from non-Network Dental
Providers, the Insured must file a claim with the Company to be reimbursed for Eligible Dental Expenses.
Covered Dental Services
Benefits are eligible for Covered Dental Services if such Dental Services are Necessary and are provided by or under the
direction of a Network Dental Provider.

Benefits are available only for Necessary Dental Services. The fact that a Dental Provider has performed or prescribed a
procedure or treatment, or the fact that it may be the only available treatment for a dental disease, does not mean that the
procedure or treatment is a Covered Dental Service.

Pre-Treatment Estimate
If the charge for a Dental Service is expected to exceed $500 or if a dental exam reveals the need for fixed bridgework, the
Insured Person may receive a pre-treatment estimate. To receive a pre-treatment estimate, the Insured Person or Dental
Provider should send a notice to the Company, via claim form, within 20 calendar days of the exam. If requested, the Dental
Provider must provide the Company with dental x-rays, study models or other information necessary to evaluate the treatment
plan for purposes of benefit determination.

The Company wil determine if the proposed treatment is a Covered Dental Service and wil estimate the amount of payment.
The estimate of benefits payable wil be sent to the Dental Provider and wil be subject to al terms, conditions and provisions of
the policy.

A pre-treatment estimate of benefits is not an agreement to pay for expenses. This procedure lets the Insured Person know in
advance approximately what portion of the expenses wil be considered for payment.
Pre-Authorization
Pre-authorization is required for al orthodontic services. The Insured Person should speak to the Dental Provider about
obtaining a pre-authorization before Dental Services are rendered. If the Insured Person does not obtain a pre-authorization, the
Company has a right to deny the claim for failure to comply with this requirement.


14-BR-CO (PY16)
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Section 2: Benefits for Pediatric Dental Services

Benefits are provided for the Dental Services stated in this Section when such services are:
A. Necessary.
B. Provided by or under the direction of a Dental Provider.
C. Clinical situations that can be effectively treated by a less costly, dental appropriate alternative procedure wil be assigned
a benefit based on the least costly procedure.
D. Not excluded as described in Section 3: Pediatric Dental Services exclusions.
Dental Services Deductible
Benefits for pediatric Dental Services are not subject to the policy Deductible stated in the policy Schedule of Benefits.
Instead, benefits for pediatric Dental Services are subject to a separate Dental Services Deductible. For any combination of
Network and Non-Network Benefits, the Dental Services Deductible per Policy Year is $500 per Insured Person.
Out-of-Pocket Maximum
Any amount the Insured Person pays in Coinsurance for pediatric Dental Services under this benefit applies to the Out-of-
Pocket Maximum stated in the policy Schedule of Benefits.
Benefits
When benefit limits apply, the limit stated refers to any combination of Network Benefits and Non-Network Benefits unless
otherwise specifical y stated. Benefit limits are calculated on a Policy Year basis unless otherwise specifical y stated.

Benefit Description and Limitations
Network Benefits
Non-Network Benefits
Benefits are shown as a
Benefits are shown as a
percentage of Eligible Dental
percentage of Eligible Dental
Expenses.
Expenses.
Diagnostic Services
Intraoral Bitewing Radiographs (Bitewing X-ray)
50%
50%
Limited to 2 series of films per 12 months.
Panorex Radiographs (Ful Jaw X-ray) or
50%
50%
Complete Series Radiographs (Full Set of X-rays)
Limited to 1 time per 36 months.
Periodic Oral Evaluation (Checkup Exam)
50%
50%
Limited to 2 times per 12 months. Covered as a
separate benefit only if no other service was done
during the visit other than X-rays.
Preventive Services
Dental Prophylaxis (Cleanings)
50%
50%
Limited to 2 times per 12months.
Fluoride Treatments
50%
50%
Limited to 2 treatments per 12 months. Treatment
should be done in conjunction with dental
prophylaxis.
Sealants (Protective Coating)
50%
50%
Limited to once per first or second permanent
molar every 36 months.
Space Maintainers (Spacers)
50%
50%
Benefit includes al adjustments within 6 months
of instal ation.
Minor Restorative Services, Endodontics, Periodontics and Oral Surgery
Amalgam Restorations (Silver Fil ings)
50%
50%
Multiple restorations on one surface wil be
treated as a single fil ing.
Composite Resin Restorations (Tooth Colored
50%
50%
Fil ings)
For anterior (front) teeth only.
Endodontics (Root Canal Therapy)
50%
50%
14-BR-CO (PY16)
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Benefit Description and Limitations
Network Benefits
Non-Network Benefits
Benefits are shown as a
Benefits are shown as a
percentage of Eligible Dental
percentage of Eligible Dental
Expenses.
Expenses.
Periodontal Surgery (Gum Surgery)
50%
50%
Limited to 1 quadrant or site per 36 months per
surgical area.
Scaling and Root Planing (Deep Cleanings)
50%
50%
Limited to 1 time per quadrant per 24 months.
Periodontal Maintenance (Gum Maintenance)
50%
50%
Limited to 4 times per 12 month period in
conjunction with dental prophylaxis fol owing
active and adjunctive periodontal therapy,
exclusive of gross debridement
Simple Extractions (Simple tooth removal)
50%
50%
Limited to 1 time per tooth per lifetime.
Oral Surgery, including Surgical Extraction
50%
50%
Adjunctive Services
General Services (including Dental Emergency
50%
50%
treatment)

Covered as a separate benefit only if no other
service was done during the visit other than X-
rays.

General anesthesia is covered when clinical y
necessary.

Occlusal guards limited to 1 guard every 12
months.
Major Restorative Services
Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for
payment is limited to 1 time per 60 months from initial or supplemental placement.
Inlays/Onlays/Crowns (Partial to Ful Crowns)
50%
50%
Limited to 1 time per tooth per 60 months.
Covered only when silver fil ings cannot restore
the tooth.
Fixed Prosthetics (Bridges)
50%
50%
Limited to 1 time per tooth per 60 months.
Covered only when a fil ing cannot restore the
tooth.
Removable Prosthetics (Full or partial dentures)
50%
50%
Limited to 1 per 60 months. No additional
al owances for precision or semi-precision
attachments.
Relining and Rebasing Dentures
50%
50%
Limited to relining/rebasing performed more than
6 months after the initial insertion. Limited to 1
time per 12 months.
Repairs or Adjustments to Full Dentures, Partial
50%
50%
Dentures, Bridges, or Crowns
Limited to repairs or adjustments performed more
than 12 months after the initial insertion. Limited
to 1 per 6 months.


14-BR-CO (PY16)
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Benefit Description and Limitations
Network Benefits
Non-Network Benefits
Benefits are shown as a
Benefits are shown as a
percentage of Eligible Dental
percentage of Eligible Dental
Expenses.
Expenses.
Implants
Implant Placement
50%
50%
Limited to 1 time per 60 months.
Implant Supported Prosthetics
50%
50%
Limited to 1 time per 60 months.
Implant Maintenance Procedures
50%
50%
Includes removal of prosthesis, cleansing of
prosthesis and abutments and reinsertion of
prosthesis. Limited to 1 time per 60 months.
Repair Implant Supported Prosthesis by Report
50%
50%
Limited to 1 time per 60 months.
Abutment Supported Crown (Titanium) or
50%
50%
Retainer Crown for FPD - Titanium
Limited to 1 time per 60 months.
Repair Implant Abutment by Support
50%
50%
Limited to 1 time per 60 months.
Radiographic/Surgical Implant Index by Report
50%
50%
Limited to1 time per 60 months.
MEDICALLY NECESSARY ORTHODONTICS
Benefits for comprehensive orthodontic treatment are approved by the Company, only in those instances that are related to an
identifiable syndrome such as cleft lip and or palate, Crouzon’s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome,
hemi-facial atrophy, hemi-facial hypertrophy; or other severe craniofacial deformities which result in a physical y handicapping
malocclusion as determined by the Company's dental consultants. Benefits are not available for comprehensive orthodontic
treatment for crowded dentitions (crooked teeth), excessive spacing between teeth, temporomandibular joint (TMJ) conditions
and/or having horizontal/vertical (overjet/overbite) discrepancies.
Al orthodontic treatment must be prior authorized.
Orthodontic Services
50%
50%
Services or supplies furnished by a Dental
Provider in order to diagnose or correct
misalignment of the teeth or the bite. Benefits are
available only when the service or supply is
determined to be medical y necessary.

Section 3: Pediatric Dental Exclusions

Except as may be specifical y provided under Section 2: Benefits for Covered Dental Services, benefits are not provided for the
following:
1. Any Dental Service or Procedure not listed as a Covered Dental Service in Section 2: Benefits for Covered Dental
Services.
2. Dental Services that are not Necessary.
3. Hospitalization or other facility charges.
4. Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures
that improve physical appearance.)
5. Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, Injury, or Congenital
Condition, when the primary purpose is to improve physiological functioning of the involved part of the body.
6. Any Dental Procedure not directly associated with dental disease.
7. Any Dental Procedure not performed in a dental setting.
8. Procedures that are considered to be Experimental or Investigational or Unproven Services. This includes
pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics.
The fact that an Experimental, or Investigational or Unproven Service, treatment, device or pharmacological regimen is
the only available treatment for a particular condition wil not result in benefits if the procedure is considered to be
Experimental or Investigational or Unproven in the treatment of that particular condition.
9. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office
during the patient visit.
14-BR-CO (PY16)
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10. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.
11. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal.
Treatment of malignant neoplasms or Congenital Conditions of hard or soft tissue, including excision.
12. Replacement of complete dentures, fixed and removable partial dentures or crowns and implants, implant crowns and
prosthesis if damage or breakage was directly related to provider error. This type of replacement is the responsibility of
the Dental Provider. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of
replacement.
13. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery
(including surgery related to the temporomandibular joint). Orthognathic surgery, jaw alignment, and treatment for the
temporomandibular joint.
14. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.
15. Expenses for Dental Procedures begun prior to the Insured Person’s Effective Date of coverage.
16. Dental Services otherwise covered under the policy, but rendered after the date individual coverage under the policy
terminates, including Dental Services for dental conditions arising prior to the date individual coverage under the policy
terminates.
17. Services rendered by a provider with the same legal residence as the Insured Person or who is a member of the
Insured Person’s family, including spouse, brother, sister, parent or child.
18. Foreign Services are not covered unless required for a Dental Emergency.
19. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.
20. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).
21. Bil ing for incision and drainage if the involved abscessed tooth is removed on the same date of service.
22. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.
23. Acupuncture; acupressure and other forms of alternative treatment, whether or not used as anesthesia.
24. Orthodontic coverage does not include the instal ation of a space maintainer, any treatment related to treatment of the
temporomandibular joint, any surgical procedure to correct a malocclusion, replacement of lost or broken retainers
and/or habit appliances, and any fixed or removable interceptive orthodontic appliances previously submitted for
payment under the policy.

Section 4: Claims for Pediatric Dental Services

When obtaining Dental Services from a non-Network provider, the Insured Person wil be required to pay al bil ed charges
directly to the Dental Provider. The Insured Person may then seek reimbursement from the Company. The Insured Person must
provide the Company with al of the information identified below.
Reimbursement for Dental Services
The Insured Person is responsible for sending a request for reimbursement to the Company, on a form provided by or
satisfactory to the Company.
Claim Forms
It is not necessary to include a claim form with the proof of loss. However, the proof must include al of the fol owing
information:

Insured Person's name and address.

Insured Person's identification number.

The name and address of the provider of the service(s).

A diagnosis from the Dental Provider including a complete dental chart showing extractions, fil ings or other dental
services rendered before the charge was incurred for the claim.

Radiographs, lab or hospital reports.

Casts, molds or study models.

Itemized bil which includes the CPT or ADA codes or description of each charge.

The date the dental disease began.

A statement indicating that the Insured Person is or is not enrolled for coverage under any other health or dental insurance
plan or program. If enrolled for other coverage the Insured Person must include the name of the other carrier(s).



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To file a claim, submit the above information to the Company at the fol owing address:

UnitedHealthcare Dental

Attn: Claims Unit

P.O. Box 30567

Salt Lake City, UT 84130-0567

Submit claims for payment within 90 days after the date of service. If the Insured doesn’t provide this information within one
year of the date of service, benefits for that service may be denied at our discretion. This time limit does not apply if the Insured
is legal y incapacitated.

If the Insured Person would like to use a claim form, the Insured Person can request one be mailed by cal ing Customer Service
at 1-877-816-3596. This number is also listed on the Insured’s Dental ID Card.
Section 5: Defined Terms for Pediatric Dental Services
The fol owing definitions are in addition to the policy DEFINITIONS:
Covered Dental Service – a Dental Service or Dental Procedure for which benefits are provided under this endorsement.
Dental Emergency - a dental condition or symptom resulting from dental disease which arises suddenly and, in the judgment
of a reasonable person, requires immediate care and treatment, and such treatment is sought or received within 24 hours of
onset.
Dental Provider - any dentist or dental practitioner who is duly licensed and qualified under the law of jurisdiction in which
treatment is received to render Dental Services, perform dental surgery or administer anesthetics for dental surgery.
Dental Service or Dental Procedures - dental care or treatment provided by a Dental Provider to the Insured Person while the
policy is in effect, provided such care or treatment is recognized by the Company as a general y accepted form of care or
treatment according to prevailing standards of dental practice.

Dental Services Deductible - the amount the Insured Person must pay for Covered Dental Services in a Policy Year before
the Company wil begin paying for Network or Non-Network benefits in that Policy Year.
Eligible Dental Expenses - Eligible Dental Expenses for Covered Dental Services, incurred while the policy is in effect, are
determined as stated below:

For Network Benefits, when Covered Dental Services are received from Network Dental Providers, Eligible Dental
Expenses are the Company's contracted fee(s) for Covered Dental Services with that provider.

For Non-Network Benefits, when Covered Dental Services are received from Non-Network Dental Providers, Eligible
Dental Expenses are the Usual and Customary Fees, as defined below.
Experimental, Investigational, or Unproven Service - medical, dental, surgical, diagnostic, or other health care services,
technologies, supplies, treatments, procedures, drug therapies or devices that, at the time the Company makes a determination
regarding coverage in a particular case, is determined to be:

Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not
identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as
appropriate for the proposed use; or

Subject to review and approval by any institutional review board for the proposed use; or

The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2, or 3 clinical trial set forth in the FDA
regulations, regardless of whether the trial is actual y subject to FDA oversight; or

Not determined through prevailing peer-reviewed professional literature to be safe and effective for treating or diagnosing
the condition or Sickness for which its use is proposed.

Foreign Services - services provided outside the U.S. and U.S. Territories.


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Necessary - Dental Services and supplies which are determined by the Company through case-by-case assessments of care
based on accepted dental practices to be appropriate and are al of the following:

Necessary to meet the basic dental needs of the Insured Person.

Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the Dental Service.

Consistent in type, frequency and duration of treatment with scientifical y based guidelines of national clinical, research, or
health care coverage organizations or governmental agencies that are accepted by the Company.

Consistent with the diagnosis of the condition.

Required for reasons other than the convenience of the Insured Person or his or her Dental Provider.

Demonstrated through prevailing peer-reviewed dental literature to be either:

Safe and effective for treating or diagnosing the condition or sickness for which their use is proposed; or

Safe with promising efficacy

For treating a life threatening dental disease or condition.

Provided in a clinical y controlled research setting.

Using a specific research protocol that meets standards equivalent to those defined by the National Institutes
of Health.

(For the purpose of this definition, the term life threatening is used to describe dental diseases or sicknesses or conditions,
which are more likely than not to cause death within one year of the date of the request for treatment.)

The fact that a Dental Provider has performed or prescribed a procedure or treatment or the fact that it may be the only
treatment for a particular dental disease does not mean that it is a Necessary Covered Dental Service as defined in this
endorsement. The definition of Necessary used in this endorsement relates only to benefits under this endorsement and differs
from the way in which a Dental Provider engaged in the practice of dentistry may define necessary.
Network - a group of Dental Providers who are subject to a participation agreement in effect with the Company, directly or
through another entity, to provide Dental Services to Insured Persons. The participation status of providers wil change from
time to time.
Network Benefits - benefits available for Covered Dental Services when provided by a Dental Provider who is a Network
Dentist.

Non-Network Benefits - benefits available for Covered Dental Services obtained from Non-Network Dentists.
Usual and Customary Fee - Usual and Customary Fees are calculated by the Company based on available data resources of
competitive fees in that geographic area.

Usual and Customary Fees must not exceed the fees that the provider would charge any similarly situated payor for the same
services.

Usual and Customary Fees are determined solely in accordance with the Company's reimbursement policy guidelines. The
Company's reimbursement policy guidelines are developed by the Company, in its discretion, fol owing evaluation and
validation of al provider bil ings in accordance with one or more of the following methodologies:

As indicated in the most recent edition of the Current Procedural Terminology (publication of the American Dental
Association).

As reported by general y recognized professionals or publications.

As utilized for Medicare.

As determined by medical or dental staff and outside medical or dental consultants.

Pursuant to other appropriate source or determination that the Company accepts.
Pediatric Vision Care Services Benefits
Benefits are provided for Vision Care Services for Insured Persons under the age of 19. Benefits terminate on the earlier of: 1)
last day of the month the Insured Person reaches the age of 19; or 2) the date the Insured Person's coverage under the policy
terminates.
Section 1: Benefits for Pediatric Vision Care Services
Benefits are available for pediatric Vision Care Services from a Spectera Eyecare Networks or non-Network Vision Care
Provider. To find a Spectera Eyecare Networks Vision Care Provider, the Insured Person may cal the provider locator service at
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1-800-839-3242. The Insured Person may also access a listing of Spectera Eyecare Networks Vision Care Providers on the
Internet at www.myuhcvision.com.

When Vision Care Services are obtained from a non-Network Vision Care Provider, the Insured Person wil be required to pay
al bil ed charges at the time of service. The Insured Person may then seek reimbursement from the Company as described
under Section 3: Claims for Vision Care Services. Reimbursement wil be limited to the amounts stated below.

When obtaining these Vision Care Services from a Spectera Eyecare Networks Vision Care Provider, the Insured Person wil
be required to pay any Copayments at the time of service.
Network Benefits
Benefits for Vision Care Services are determined based on the negotiated contract fee between the Company and the Vision
Care Provider. The Company's negotiated rate with the Vision Care Provider is ordinarily lower than the Vision Care Provider's
bil ed charge.
Non-Network Benefits
Benefits for Vision Care Services from non-Network providers are determined as a percentage of the provider's bil ed charge.
Policy Deductible
Benefits for pediatric Vision Care Services are not subject to any policy Deductible stated in the policy Schedule of Benefits.
Any amount the Insured Person pays in Copayments for Vision Care Services does not apply to the policy Deductible stated in
the policy Schedule of Benefits.
Benefit Description
When benefit limits apply, the limit stated refers to any combination of Network Benefits and Non-Network Benefits unless
otherwise specifical y stated. Benefit limits are calculated on a Policy Year basis unless otherwise specifical y stated.

Benefits are provided for the Vision Care Services described below, subject to Frequency of Service limits and Copayments
and Coinsurance stated under each Vision Care Service in the Schedule of Benefits below.

Routine Vision Examination
A routine vision examination of the condition of the eyes and principal vision functions according to the standards of care in the
jurisdiction in which the Insured Person resides, including:

A case history that includes chief complaint and/or reason for examination, patient medical/eye history, and current
medications.

Recording of monocular and binocular visual acuity, far and near, with and without present correction (for example, 20/20
and 20/40).

Cover test at 20 feet and 16 inches (checks eye alignment).

Ocular motility including versions (how well eyes track) near point convergence (how well eyes move together for near
vision tasks, such as reading), and depth perception.

Pupil responses (neurological integrity).

External exam.

Retinoscopy (when applicable) – objective refraction to determine lens power of corrective lenses and subjective
refraction to determine lens power of corrective lenses.

Phorometry/Binocular testing – far and near: how wel eyes work as a team.

Tests of accommodation and/or near point refraction: how well the Insured sees at near point (for example, reading).

Tonometry, when indicated: test pressure in eye (glaucoma check).

Ophthalmoscopic examination of the internal eye.

Confrontation visual fields.

Biomicroscopy.

Color vision testing.

Diagnosis/prognosis.

Specific recommendations.

Post examination procedures wil be performed only when materials are required.

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Or, in lieu of a complete exam, Retinoscopy (when applicable) - objective refraction to determine lens power of corrective
lenses and subjective refraction to determine lens power of corrective lenses.
Eyeglass Lenses - Lenses that are mounted in eyeglass frames and worn on the face to correct visual acuity limitations.
Eyeglass Frames - A structure that contains eyeglass lenses, holding the lenses in front of the eyes and supported by the
bridge of the nose.
Contact Lenses - Lenses worn on the surface of the eye to correct visual acuity limitations. Benefits include the
fitting/evaluation fees and contacts.

The Insured Person is eligible to select only one of either eyeglasses (Eyeglass Lenses and/or Eyeglass Frames) or Contact
Lenses. If the Insured Person selects more than one of these Vision Care Services, the Company wil pay benefits for only one
Vision Care Service.

Necessary Contact Lenses - Benefits are available when a Vision Care Provider has determined a need for and has
prescribed the contact lens. Such determination wil be made by the Vision Care Provider and not by the Company. Contact
lenses are necessary if the Insured Person has any of the following:

Keratoconus.

Anisometropia.

Irregular corneal/astigmatism.

Aphakia.

Facial deformity.

Corneal deformity.

Pathological myopia.

Aniseikonia.

Aniridia.

Post-traumatic disorders.
Low Vision – Benefits are available to an Insured Person who has severe visual problems that cannot be corrected with regular
lenses and only when a Vision Care Provider has determined a need for and has prescribed the service. Such determination
wil be made by the Vision Care Provider and not by the Company.

This benefit includes:

Low vision testing: Complete low vision analysis and diagnosis which includes a comprehensive examination of visual
functions, including the prescription of corrective eyewear or vision aids where indicated.

Low vision therapy: Subsequent low vision therapy if prescribed.

Schedule of Benefits

Vision Care Service
Frequency of Service
Network Benefit
Non-Network Benefit
Routine Vision Examination or
100% after a
50% of the
Refraction only in lieu of a complete exam.
Once per year.
Copayment of $20.
bil ed charge.
Eyeglass Lenses
Once per year.



100% after a
50% of the

Single Vision

Copayment of $40.
bil ed charge.

100% after a
50% of the

Bifocal

Copayment of $40.
bil ed charge.

100% after a
50% of the

Trifocal

Copayment of $40.
bil ed charge.

100% after a
50% of the

Lenticular

Copayment of $40.
bil ed charge.


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Vision Care Service
Frequency of Service
Network Benefit
Non-Network Benefit
Lens Extras
Once per year.



100% of the

Polycarbonate Lenses

100%
bil ed charge.

100% of the

Standard scratch-resistant coating

100%
bil ed charge.
Eyeglass Frames
Once per year.


 Eyeglass frames with a retail cost
50% of the

100%
up to $130.
bil ed charge.
 Eyeglass frames with a retail cost of
100% after a
50% of the

$130 - 160.
Copayment of $15.
bil ed charge.
 Eyeglass frames with a retail cost of
100% after a
50% of the

$160 - 200.
Copayment of $30.
bil ed charge.
 Eyeglass frames with a retail cost of
100% after a
50% of the

$200 - 250.
Copayment of $50.
bil ed charge.
 Eyeglass frames with a retail cost
50% of the

60%
greater than $250.
bil ed charge.
Contact Lenses
Limited to a


12 month supply.

100% after a
50% of the

Covered Contact Lens Selection

Copayment of $40.
bil ed charge.

100% after a
50% of the

Necessary Contact Lenses

Copayment of $40.
bil ed charge.
Low Vision Services
Note that benefits for these services wil be
paid as reimbursements. When obtaining
these Vision Services, the Insured wil be
required to pay al bil ed charges at the
Once every 24 months.


time of service. The Insured may then
obtain reimbursement from the Company.
Reimbursement wil be limited to the
amounts stated.

100% of the
75% of the

Low Vision Testing

bil ed charge.
bil ed charge.

100% of the
75% of the

Low Vision Therapy

bil ed charge.
bil ed charge.

Section 2: Pediatric Vision Exclusions
Except as may be specifical y provided under Section 1: Benefits for Pediatric Vision Care Services, benefits are not provided
for the following:
1. Medical or surgical treatment for eye disease which requires the services of a Physician and for which benefits are
available as stated in the policy.
2. Non-prescription items (e.g. Plano lenses).
3. Replacement or repair of lenses and/or frames that have been lost or broken.
4. Optional Lens Extras not listed in Section 1: Benefits for Vision Care Services.
5. Missed appointment charges.
6. Applicable sales tax charged on Vision Care Services.
Section 3: Claims for Pediatric Vision Care Services
When obtaining Vision Care Services from a non-Network Vision Care Provider, the Insured Person wil be required to pay al
bil ed charges directly to the Vision Care Provider. The Insured Person may then seek reimbursement from the Company.


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Reimbursement for Vision Care Services
To file a claim for reimbursement for Vision Care Services rendered by a non-Network Vision Care Provider, or for Vision Care
Services covered as reimbursements (whether or not rendered by a Spectera Eyecare Networks Vision Care Provider or a non-
Network Vision Care Provider), the Insured Person must provide al of the fol owing information at the address specified below:

Insured Person's itemized receipts.

Insured Person's name.

Insured Person's identification number.

Insured Person's date of birth.

Submit the above information to the Company:

By mail:
Claims Department
P.O. Box 30978
Salt Lake City, UT 84130

By facsimile (fax):
248-733-6060

Reimbursement for Low Vision Services
To file a claim for reimbursement for Low Vision Services, the Insured Person must provide al of the following information at the
address specified below:

Insured Person's itemized receipts.

Insured Person's name.

Insured Person's identification number.

Insured Person's date of birth.

Submit the above information to the Company:

By mail:
Claims Department
P.O. Box 30978
Salt Lake City, UT 84130

By facsimile (fax):
248-733-6060

Submit claims for payment within 90 days after the date of service. If the Insured doesn’t provide this information within one
year of the date of service, benefits for that service may be denied at our discretion. This time limit does not apply if the Insured
is legal y incapacitated.

Section 4: Defined Terms for Pediatric Vision Care Services
The fol owing definitions are in addition to the policy DEFINITIONS:
Covered Contact Lens Selection - a selection of available contact lenses that may be obtained from a Spectera Eyecare
Networks Vision Care Provider on a covered-in-full basis, subject to payment of any applicable Copayment.
Spectera Eyecare Networks - any optometrist, ophthalmologist, optician or other person designated by the Company who
provides Vision Care Services for which benefits are available under the policy.
Vision Care Provider - any optometrist, ophthalmologist, optician or other person who may lawfully provide Vision Care
Services.

Vision Care Service - any service or item listed in Section 1: Benefits for Pediatric Vision Care Services.

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Notice of Appeal Rights
Right to Internal Appeal
Standard Internal Appeal
The Insured Person has the right to request an Internal Appeal if the Insured Person disagrees with the Company’s denial, in
whole or in part, of a claim or request for benefits. The Insured Person, or the Insured Person’s Designated Representative,
must submit a written request for an Internal Appeal within 180 days of receiving a notice of the Company’s Adverse
Determination. In order to secure an Internal Review after the receipt of the notification of a benefit denied due to a contractual
exclusion, the Insured Person must be able to provide evidence from a medical professional that there is a reasonable medical
basis that the policy exclusion does not apply to the denied benefit.

The written Internal Appeal request should include:

1. A statement specifical y requesting an Internal Appeal of the decision;
2. The Insured Person’s Name and ID number (from the ID card);
3. The date(s) of service;
4. The Provider’s name;
5. The reason the claim should be reconsidered; and
6. Any written comments, documents, records, or other material relevant to the claim.

Please contact the Customer Service Department at 1-866-458-4954 with any questions regarding the Internal Appeal
process. The written request for an Internal Appeal should be sent to: UnitedHealthcare StudentResources, PO Box 809025,
Dal as, TX 75380-9025.
Expedited Internal Appeal
For Urgent Care Requests, an Insured Person or a Designated Representative may submit a request, either oral y or in writing,
for an Expedited Internal Appeal (EIR) of an Adverse Determination:

1. involving Urgent Care Requests; and
2. related to a concurrent review Urgent Care Request involving an admission, availability of care, continued stay or health
care service for an Insured Person who has received emergency services, but has not been discharged from a facility.

Al necessary information, including the Company’s decision, shal be transmitted to the Insured Person or a Designated
Representative via telephone, facsimile or the most expeditious method available. The Insured Person or the Designated
Representative shal be notified of the EIR decision no more than seventy-two (72) hours after the Company’s receipt of the
EIR request.

If the EIR request is related to a concurrent review Urgent Care Request, benefits for the service wil continue until the Insured
Person has been notified of the final determination.

At the same time an Insured Person or a Designated Representative files an EIR request, the Insured Person or the Designated
Representative may file:

1. An Expedited External Review (EER) request if the Insured Person has a medical condition where the timeframe for
completion of an EIR would seriously jeopardize the life or health of the Insured Person or would jeopardize the Insured
Person’s ability to regain maximum function; or
2. An Expedited Experimental or Investigational Treatment External Review (EEIER) request if the Adverse Determination
involves a denial of coverage based on the a determination that the recommended or requested service or treatment is
experimental or investigational and the Insured Person’s treating Physician certifies in writing that the recommended or
requested service or treatment would be significantly less effective if not promptly initiated.

To request an Expedited Internal Appeal, please contact Claims Appeals at 888-315-0447. The written request for an
Expedited Internal Appeal should be sent to: Claims Appeals, UnitedHealthcare StudentResources, PO Box 809025, Dal as,
TX 75380-9025.


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Right to External Independent Review
After exhausting the Company’s Internal Appeal process, the Insured Person, or the Insured Person’s Designated
Representative, has the right to request an External Independent Review when the service or treatment in question:

1. Is a Covered Medical Expense under the Policy; and
2. Is not covered because it does not meet the Company’s requirements for Medical Necessity, appropriateness, health
care setting, level or care, or effectiveness, or the treatment is determined to be experimental or investigational.
Standard External Review
A Standard External Review request must be submitted in writing within 4 months of receiving a notice of the Company’s
Adverse Determination or Final Adverse Determination.
Expedited External Review
An Expedited External Review request may be submitted either oral y or in writing when:

1. The Insured Person or the Insured Person’s Designated Representative has received an Adverse Determination, and
a. The Insured Person, or the Insured Person’s Designated Representative, has submitted a request for an Expedited
Internal Appeal; and
b. Adverse Determination involves a medical condition for which the time frame for completing an Expedited Internal
Review would seriously jeopardize the life or health of the Insured Person or jeopardize the Insured Person’s ability
to regain maximum function;
or
2. The Insured Person or the Insured Person’s Designated Representative has received a Final Adverse Determination,
and
a. The Insured Person has a medical condition for which the time frame for completing a Standard External Review
would seriously jeopardize the life or health of the Insured Person or jeopardize the Insured Person’s ability to
regain maximum function; or
b. The Final Adverse Determination involves an admission, availability of care, continued stay, or health care service
for which the Insured Person received emergency services, but has not been discharged from a facility.

The Insured Person or Insured Person’s Designated Representative’s request for an Expedited External Review must include a
Physician’s Certification that the Insured Person’s medical condition meets the above criteria.

An EER may not be provided for retrospective Adverse Determinations or Final Adverse Determinations.

Where to Send External Review Requests
Al types of External Review requests shal be submitted to the Company at the following address:


Claims Appeals

UnitedHealthcare StudentResources

PO Box 809025

Dal as, TX 75380-9025

888-315-0447

Questions Regarding Appeal Rights
Contact Customer Service at 1-866-458-4954 with questions regarding the Insured Person’s rights to an Internal Appeal and
External Review.










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The Plan is Underwritten by:
UNITEDHEALTHCARE INSURANCE COMPANY

UnitedHealthcare StudentResources
P.O. Box 809025
Dal as, Texas 75380-9025
1-866-458-4954
customerservice@uhcsr.com
claims@uhcsr.com

Sales/Marketing Services:
UnitedHealthcare StudentResources
805 Executive Center Drive West, Suite 220
St. Petersburg, FL 33702
1-800-237-0903
E-mail: info@uhcsr.com

Please keep this Brochure as a general summary of the insurance. The Master Policy on file at the University contains al of the
provisions, limitations, exclusions and qualifications of your insurance benefits, some of which may not be included in this
Brochure. The Master Policy is the contract and wil govern and control the payment of benefits.

This Brochure is based on Policy # 2016-4059-1.



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Document Outline