Benefit summary

Student Injury and Sickness
Insurance Plan for 2013 - 2014
Widener University is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance
Company. Eligibility Statement: All full-time undergraduate students taking 12 or more credit hours regardless of credit
hours, are automatically enrolled in this insurance Plan at registration unless proof of comparable coverage is furnished. Eligible
Dependents of those enrolled in the plan may participate in the plan on a voluntary basis.
UnitedHealthcare Insurance Company and isbased on policy 2013-1042-1.
Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
Please read the plan brochure to determine Up to $500,000 Per Insured Person, Per Policy Year Maximum Benefit for Covered Medical Expenses.
whether this plan is right for you before you $150 Deductible for Preferred Providers Per Insured Person, Per Policy Year, $400 Deductible for Out of Network enroll. The plan brochure provides details of Providers Per Insured Person, Per Policy Year. Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and Out of exclusions, any reductions or limitations and Network benefits are payable at 60% of Usual and Customary charges (all benefits are subject to satisfaction the terms under which the coverage may be of the Deductible, specific benefit limitations, maximums and copays as described in the policy).
continued in force. Copies of the brocure are Preferred Provider Out-of-Pocket Maximum of $2,500 Per Insured Person, Per Policy Year. Out-of-Network Out-of- Pocket maximum of $5,000 Per Insured Person, Per Policy Year. After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses wil be paid at 100% up to the policy Maximum Benefit subject to any applicable benefit maximums. Refer to the plan brochure for details about how the Out-of-Pocket Maximum applies. Prescription Drug Benefits: $15 Copay for Tier 1 / $35 Copay for Tier 2 / $60 copay for Tier 3 up to a 31-day If you have any questions, please contact supply per prescription filled at a UnitedHealthcare Pharmacy (UHCP). Prescriptions must be filled at a UnitedHealthcare Pharmacy (UHCP). Mail order through UHCP at 2.5 times the retail copay.
Preventive Care Services which include, but are not limited to, annual physicals, GYN exams, routine screenings and immunizations are covered at 100% with no copay or deductible only when the services are received from a Preferred Provider. Please see www.healthcare.gov for complete details of the services provided for specific The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can be found using the following link www.firststudent.com.
FrontierMEDEX: – Domestic Students are eligible for FrontierMEDEX services when 100 miles or more away from your campus address and 100 miles or more away from your permanent home address. International Students are covered worldwide except in their home country.
How do I Enroll/Waive?
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.firststudent.com. To create an online account, select the “My Account” link and follow the simple, on
To complete the Enroll / Waive
screen directions. All you need is your 7-digit Insurance ID number or the email address on file. Insureds can process, please go to your
also visit our mobile site at my.uhcsr.com to access an electronic ID card.
Campus Cruiser webadvisor
When Do I Enroll/Waive the Plan?
and follow instructions.
OPEN ENROLLMENT PERIODS: Annual Deadline – 9/25/13;
The premium for this coverage is added to the student’s tuition bill. Students who waive coverage with proof of
comparable insurance coverage by the waiver deadline, will see the premium removed from their account.
IMPORTANT INFORMATION FOR ALL STUDENTS: Open Enrollment Periods for all Dependents and
Students: If you have eligible Dependents in the fall or, are a student in the fall semester and eligible to purchase coverage and you choose not to enroll for coverage before the Fall Enrollment Deadline of *September 25,
2013, your Dependents or you, will not be eligible to enroll again until the start of next fall unless you
experience a “Life Status” change during the year. A life status change includes marriage, divorce, birth of a child or loss of coverage through no fault of your own (i.e. aging of your parents coverage).If your Dependents or you, experience a “Life Status” change, you must submit proof of the event and enroll within 30 Days of the event, otherwise you will no longer be eligible to enroll for the remainder of the policy year.
Please contact us at customerservice@firstriskadvisors.com for cost and enrol ment information as a Life Status Change.
Your student health insurance coverage, offered by UnitedHealthcare Insurance Company
may not meet the minimum standards required by the healthcare reform law for restrictions
on annual dollar limits. The annual dollar limits ensure that consumers have sufficient access
to medical benefits throughout the annual term of the policy. Restrictions for annual dollar
limits for group and individual health insurance coverage are $1.25 million for policy years
before September 23, 2012; and $2 million for policy years beginning on or after September
23, 2012 but before January 1, 2014. Restrictions on annual dollar limits for student health
insurance coverage are $100,000 for policy years before September 23, 2012 and $500,000
for policy years beginning on or after September 23, 2012, but before January 1, 2014. Your
student health insurance coverage puts a policy year limit of $500,000 that applies to the
essential benefits provided in the Schedule of Benefits unless otherwise specified. If you have
any questions or concerns about this notice, contact Customer Service at 1-800-505-4160. Be
advised that you may be eligible for coverage under a group health plan of a parent's employer
or under a parent’s individual health insurance policy if you are under the age of 26. Contact
the plan administrator of the parent’s employer plan or the parent’s individual health insurance
issuer for more information.
UnitedHealthcare StudentResources
Full-Time Undergraduate
Each Child
8/25/13 - 8/24/14
Exclusions and Limitations
Drugs labeled, “Caution - limited by federal law to investigational No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies for, at, or related to any Drugs used to treat or cure baldness; anabolic steroids used for Anorectics - drugs used for the purpose of weight control; 2. Addiction, such as: nicotine addiction, except as specifical y provided in the Fertility agents or sexual enhancement drugs, such as Parlodel, policy; and caffeine addiction; non-chemical addiction such as: gambling, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; sexual, spending, shopping, working and religious; codependency; 3. Milieu therapy, learning disabilities, behavioral problems, parent-child Refills in excess of the number specified or dispensed after one problems, conceptual handicap, developmental delay or disorder or (1) year of date of the prescription.
26. Reproductive/Infertility services including but not limited to: family planning, fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or 6. Congenital conditions for cosmetic purposes only, except as specifically otherwise; female sterilization procedures; except as specifically provided for: Newborn or Adopted Infants; provided in the policy; vasectomy; sexual reassignment surgery; 7. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for 27. Research or examinations relating to research studies, or any treatment for which the patient or the patient’s representative must sign an 8. Custodial Care; care provided in: rest homes, health resorts, homes for informed consent document identifying the treatment in which the the aged, halfway houses, college infirmaries or places mainly for patient is to participate as a research study or clinical research study; domiciliary or Custodial Care; extended care in treatment or substance 28. Routine Newborn Infant Care, well-baby nursery and related Physician abuse facilities for domiciliary or custodial care; charges; except as specifically provided in the policy; 9. Dental treatment, except for accidental Injury to Sound, Natural Teeth; 29. Preventive care services; routine physical examinations and routine 10. Elective Surgery or Elective Treatment;as defined in the policy; except testing; preventive testing or treatment; screening exams or testing in the cosmetic surgery necessitated by a covered Injury; absence of Injury or Sickness; except as specifical y provided in the policy; 30. Services provided normally without charge by the Health Service of the 12. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction 31. Skeletal irregularities of one or both jaws, including orthognathia and surgery, or other treatment for visual defects and problems; except mandibular retrognathia; temporomandibular joint dysfunction; when due to a covered Injury or disease process; deviated nasal septum, including submucous resection and/or other 13. Flat foot conditions; supportive devices for the foot; fallen arches; surgical correction thereof; nasal and sinus surgery, except for weak feet; chronic foot strain; symptomatic complaints of the feet; and treatment of a covered Injury or treatment of chronic purulent sinusitis; routine foot care including the care, cutting and removal of corns, 32. Skydiving, recreational parachuting, hang gliding, glider flying, calluses, toenails, and bunions (except capsular or bone surgery), parasailing, sail planing, bungee jumping, or flight in any kind of 14. Health spa or similar facilities; strengthening programs; aircraft, except while riding as a passenger on a regularly scheduled 15. Hearing examinations; hearing aids; or cochlear implants; or other treatment for hearing defects and problems, except as a result of an infection or trauma. “Hearing defects” means any physical defect of 34. Speech therapy; naturopathic services; the ear which does or can impair normal hearing, apart from the 35. Supplies, except as specifically provided in the policy; 36. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices; or gynecomastia; except as specifically 18. Immunizations, except as specifically provided in the policy; preventive 37. Treatment in a Government hospital, unless there is a legal obligation medicines or vaccines, except where required for treatment of a for the Insured Person to pay for such treatment; covered Injury or as specifically provided in the policy; 38. War or any act of war, declared or undeclared; or while in the armed 19. Injury or Sickness for which benefits are paid under any Workers' forces of any country (a pro-rata premium will be refunded upon Compensation or Occupational Disease Law or Act, or similar legislation; request for such period not covered); and 20. Injury sustained while (a) participating in any intercol egiate or professional 39. Weight management, weight reduction, nutrition programs, treatment sport, contest or competition; (b) traveling to or from such sport, contest or for obesity, surgery for removal of excess skin or fat; competition as a participant; or (c) while participating in any practice or conditioning program for such sport, contest or competition; 21. Investigational services;22. Lipectomy;23. Experimental organ transplants, including organ donation; 24. Participation in a riot or civil disorder; commission of or attempt to 25. Prescription Drugs, services or supplies as follows: Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use, except as specifically provided in the Immunization agents, except as specifically provided in the policy, biological sera; blood or blood products administered on an

Source: http://www.widener.edu/campus_life/wellness/health/Flyer_Widener_hw_undergrad_v3_7-17-13-1.pdf