2016–2017
Student Injury and
Sickness Plan for
Colorado School of
Mines

Who is eligible to enroll?
Al degree-seeking U.S. citizens and permanent resident students and al international students regardless of degree-seeking
status are automatical y enrolled in this insurance plan at registration, unless proof of comparable coverage is furnished.
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. Plan information is also available at www.uhcsr.com/csm.
Where can I get more information about the benefits available?
Please read the plan brochure to determine whether this plan is right for you before you enroll. The plan brochure provides
details of the coverage including costs, benefits, exclusions, and reductions or limitations and the terms under which the
coverage may be continued in force. Copies of the plan brochure are available from the School and may be viewed at
www.uhcsr.com/csm.
Who can answer questions I have about the plan?
If you have questions please contact Customer Service at 1-866-458-4954 or customerservice@uhcsr.com.
How much does the plan cost?

Spring/Summer
Rates
Annual
Fall
8/17/16 – 8/20/17
8/17/16 – 1/9/17
1/10/17 – 8/20/17
New Students
Student
$1,740.00
$870.00
$1,065.00

Rates
Summer 1
Summer 2
5/15/17 – 8/20/17
6/26/17 – 8/20/17
Student
$470.00
$278.00

NOTE: The amounts stated above include certain fees charged by the school you are receiving coverage through. Such fees may include
amounts which are retained by your school (to, for example, cover your school’s administrative costs associated with offering this health plan)
as well as amounts which are paid to certain non-insurer vendors or consultants by, or at the direction of, your school.

This plan is underwritten by UnitedHealthcare Insurance Company and is based on policy number 2016-4059-1.
The Policy is a Non-Renewable One-Year Term Policy.

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Highlights of the Coverage and Services offered by UnitedHealthcare StudentResources
Metallic Level - Platinum with actuarial value of 90.373%

Preferred Providers
Out-of-Network Providers
Overall Plan Maximum
There is no overal maximum dollar limit on the policy
Plan Deductible
$0
$1,000 per Insured Person, per Policy
Year
Out-of-Pocket Maximum
$1,500 Per Insured Person, Per
$3,000 Per Insured Person, Per Policy
After the Out-of-Pocket Maximum has been
Policy Year
Year
satisfied, Covered Medical Expenses will be
paid at 100% for the remainder of the Policy
Year subject to any applicable benefit
maximums. Refer to the plan brochure for
details about how the Out-of-Pocket
Maximum applies.
Coinsurance
90% of Preferred Al owance for
70% of Usual and Customary Charges
All benefits are subject to satisfaction of the
Covered Medical Expenses
for Covered Medical Expenses
Deductible, specific benefit limitations,
maximums and Copays as described in the
plan brochure.
Prescription Drugs
$15 Copay for Tier 1
No Benefits
Prescriptions must be filled at a UHCP
$30 Copay for Tier 2
network pharmacy. Mail order through UHCP $60 Copay for Tier 3
at 2.5 times the retail Copay up to a 90 day
Up to a 31-day supply per
supply.
prescription fil ed at a
UnitedHealthcare Pharmacy (UHCP)
Preventive Care Services
100% of Preferred Al owance
No Benefits
Including but not limited to: annual physicals,
GYN exams, routine screenings and
immunizations. No Copay or Deductible
when the services are received from a
Preferred Provider. Please visit
https://www.healthcare.gov/preventive-care-
benefits for a complete list of services
provided for specific age and risk groups.
The following services have per Service
Physician’s Visits: $25
Physician’s Visits: $25
Copays/Deductibles
Medical Emergency: $100
Medical Emergency: $100
This list is not all inclusive. Please read the
(Waived if admitted to the Hospital)
(Waived if admitted to the Hospital)
plan brochure for complete listing of
Urgent Care: $35
Urgent Care: $35
Copays/Deductibles.
Pediatric Dental and Vision Benefits
Refer to the plan brochure for details (age limits apply).
UnitedHealthcare Global: Global
Domestic Students are eligible for UnitedHealthcare Global services when
Emergency Services
100 miles or more away from your campus address and 100 miles or more
away from your permanent home address. International Students are covered
worldwide except in their home country.
Preferred Providers
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can be found using the
following link: http://www.uhcsr.com/lookupredirect.aspx?delsys=52
Online Services
UnitedHealthcare StudentResources Insureds have online access to their claims status, EOBs, ID Cards, network providers,
correspondence and coverage account information by logging in to My Account at www.uhcsr.com/myaccount. To create an
online account, select the “create My Account Now” link and fol ow the simple, onscreen directions. Al you need is your 7-digit
Insurance ID number or the email address on file. Insureds can also download our UHCSR Mobile App available on Google
Play and Apple’s App Store.


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Other Coverage
Accident coverage for Intercollegiate sports injury is provided under a separate policy, 2016-4059-8. Contact the school for
information on the Intercol egiate Sports plan.
Healthiest You: National Telehealth Service
Starting on the effective date of your policy, you have 24/7 access to medical advice through HealthiestYou, a national
telehealth service. By cal ing the toll-free number listed on the front of your medical ID card or visiting
www.telehealth4students.com, you have access to board-certified physicians via phone and/or video, where permitted. This
service is especial y helpful for minor il nesses, such as al ergies, sore throat, earache, pink eye, etc. Based on the condition
being treated, the doctor can also prescribe certain medications, saving you a trip to the doctor’s office. Using HealthiestYou
can save you money and time, while avoiding costly trips to a doctor’s office, urgent care facility, or emergency room. As an
insured with StudentResources, there is no consultation fee for this service.* Every cal with a HealthiestYou doctor is covered
100% during your policy period.

This service is meant to compliment your Student Health Center. If possible, we encourage you to visit your SHC first before
using this service.

HealthiestYou is not health insurance. HealthiestYou is designed to complement, and not replace, the care you receive from
your primary care physician. HealthiestYou physicians are an independent network of doctors who advise, diagnose, and
prescribe at their own discretion. HealthiestYou physicians provide cross coverage and operate subject to state regulations.
Physicians in the independent network do not prescribe DEA control ed substances, non-therapeutic drugs and certain other
drugs which may be harmful because of their potential for abuse. HealthiestYou does not guarantee that a prescription wil be
written. Not available in Arkansas; limited services in California, Idaho, Iowa, Louisiana, and Texas.

*If you are an Insured under this insurance Plan, and you cal prior to the plan effective date, you wil be charged a $40 service
fee before being connected to a board-certified physician.
Student Assistance
Insureds have immediate access to the Student Assistance Program, a service that coordinates care using a network of
resources. Services available include counseling, financial and legal advice, as wel as mediation. Counseling services are
offered by Licensed Clinicians who can provide insureds with someone to talk to when everyday issues become
overwhelming. Financial services, provided by licensed CPA’s and Certified Financial Planners offer consultations on issues
such as financial planning, credit and col ection issues, home buying and renting and more. Legal Services are provided by
fully credentialed attorneys with at least 5 years of experience practicing law. Mediation services are available to help resolve
family-related disputes. Translation services are available in over 170 languages for most services. Insureds also have access
to LiveAndWorkWell.com where they can take health risk assessments, use health estimators to calculate things like their
target heart rate and BMI, and participate in personalized self-help programs. More information about these services is
available by logging into My Account at www.uhcsr.com/MyAccount.
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.


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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.
 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.
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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.

NOTE: The information contained herein is a summary of certain benefits which are offered under a student health
insurance policy issued by UnitedHealthcare. This document is a summary only and may not contain a full or
complete recitation of the benefits and restrictions/exclusions associated with the relevant policy of insurance. This
document is not an insurance policy document and your receipt of this document does not constitute the issuance or
delivery of a policy of insurance. Neither you nor UnitedHealthcare has any rights or responsibilities associated with
your receipt of this document. Changes in federal, state or other applicable legislation or regulation or changes in Plan
design required by the applicable state regulatory authority may result in differences between this summary and the
actual policy of insurance.



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