Brandeis University

Qualifying Student Health Insurance Plan 2008 - 2009

Summary of Benefits

This is a summary of benefits only, please refer to Student Injury and Sickness Insurance Plan brochure

for a complete summary of the plan, including exclusions and limitations

BASIC MEDICAL EXPENSE BENEFITS INJURY AND SICKNESS BENEFITS

Coinsurance to Preferred Providers is 100% of Preferred Allowance and 80% of Usual and Customary Charge for Out-of-Network Providers. The Policy provides benefits as shown below for loss incurred by an Insured Person due to a covered Injury or Sickness. If you receive care from a Preferred Provider, any Covered Medical Expenses will be paid at the applicable Preferred Provider level of benefits. If a Preferred Provider is not available in your Network Area benefits will be paid at the level of benefits shown as Preferred Provider benefits. 

If the Covered Medical Expense is incurred due to a Medical Emergency treatment, benefits will be paid at the Preferred Provider level of benefits.  In all other situations, reduced or lower benefits will be provided when an Out-of-Network Provider is used. The benefits payable are as defined in and subject to all provisions and any endorsements thereto.

Benefits will be paid up to the Maximum Benefit for each service below. 

PREFERRED PROVIDERS

Harvard Pilgrim (regional)

United HealthCare (national)

OUT-OF-NETOWRK

PROVIDERS

BENEFIT

Per Condition Aggregate Maximum Benefit

$100,000 per Injury or Sickness Per Insured Person

INPATIENT

Room and Board, daily semiprivate room rate; general nursing care provided by the Hospital

100% of Preferred Allowance

$100 copayment per admission, then 80% of Usual and Customary Charge (U&C) Charge

Intensive Care

100% of Preferred Allowance

80% of U&C Charge

Hospital Miscellaneous, includes operating room, laboratory tests, X-ray, examinations, anesthesia, drugs (excluding take home drugs) or medicines, therapeutic services, and supplies.  This will include the clinic/facility charges billed by the Hospital up to the maximum benefit for the Physician’s visit.

100% of Preferred Allowance

Routine Newborn Care

See Benefits for Maternity, Childbirth, Well-Baby and Post Partum Care

Physiotherapy

Paid Under Hospital Miscellaneous

Paid Under Hospital Miscellaneous

Surgeon’s Fees, no more than one surgical procedure will be covered when multiple procedures are performed through the same incision or in immediate succession unless medically necessary

100% of Preferred Allowance

80% of U&C Charge

Assistant Surgeon

30% of Surgery Allowance

30% of Surgery Allowance

Anesthetist, professional services in connection with Inpatient Surgery

30% of Surgery Allowance

30% of Surgery Allowance

Registered Nurse’s Services. Private Duty Nursing Care.

100% of Preferred Allowance

80% of U&C Charge

Physician’s Visits, benefits do not apply when related to surgery

100% of Preferred Allowance

80% of U&C Charge

Pre-Admission Testing, payable within 7 working days prior to admission

100% of Preferred Allowance

80% of U&C Charge

OUTPATIENT

Surgeon’s Fees, no more than one surgical procedure will be covered when multiple procedures are performed through the same incision or in immediate succession unless medically necessary

100% of Preferred Allowance

80% of U&C Charge

Day Surgery Miscellaneous, related to scheduled surgery performed in a hospital, including the cost of the operating room, laboratory, tests and X-ray examinations, including professional fees, anesthesia, drugs or medicines and supplies.  This will include the clinic facility charges billed by the Hospital, up to the maximum benefit for the Physician’s visit.

100% of Preferred Allowance

80% of U&C Charge

Assistant Surgeon

30% of Surgery Allowance

30% of Surgery Allowance

Anesthetist, professional services in connection with Outpatient Surgery

30% of Surgery Allowance

30% of Surgery Allowance

Outpatient Miscellaneous Expense, includes diagnostic X-rays, laboratory services, tests and procedures, physiotherapy, physician visits, chiropractic care and Consultant visit. 

100% of Preferred Allowance up to $5,000 maximum per condition with a $15.00 copayment per physician office visit

80% of Usual and Customary Charge up to $5,000 maximum per condition with a $15.00 copayment per physician

Hospital Outpatient Department or Walk-In Clinic Visit

Paid under Outpatient Miscellaneous

Radiation and Chemotherapy

100% of Preferred Allowance

80% of U&C Charge

Medical Emergency Expense, Benefits will be paid for the attending Physician’s charges, X-rays, laboratory procedures, injections, the use of the emergency room and supplies. 

100% of Preferred Allowance

80% of U&C Charge

ADDITIONAL BENEFITS

Prescription Drugs, prescriptions and medicines lawfully obtainable only upon written prescription of a physician and based on a 30-day supply.  Prescriptions must be filled at a MEDCO participating pharmacy. Mail Service Program available through MEDCO for a 90-day supply of a maintenance drug.

$10.00 copayment for a generic drug and a $25.00 copayment for a preferred brand name drug, and $40.00 for a non-preferred brand name drug, then covered at 100% up to $2,000  per policy year.

Mail Service Prescription Program available to obtain a 90-day supply of a prescription drug with a $25.00 copayment for a generic drug and a $63.00 copayment for a preferred brand name drug, and a $100.00 copayment for a non-preferred brand name drug (included under $2,000 per policy year maximum)

Ambulance Services

Covered at 100% of U&C Charge up to a maximum of $600 per trip

Elective Abortion

100% of Preferred Allowance

80% of U&C Charge

Complications of Pregnancy

Paid as any other Sickness

Accidental Dental Expense, Injury to sound natural teeth

100% Usual and Customary Charge up to $500.00 maximum

Durable Medical Equipment. A written prescription must accompany the claim when submitted. Replacement equipment is not covered.

100% of Preferred Allowance

80% of U&C Charge

Learning Disabilities Expense*, for the diagnostic testing of learning disabilities. Referral required from Health Center.

100% of Preferred Allowance

80% of U&C Charge

High Cost Procedures, for outpatient procedures costing over $200 including but not limited outpatient diagnostic CAT Scan, MRI and Laser Treatment

100% of Preferred Allowance up to a $2,000 maximum

80% of U&C Charge up to $2,000 maximum

Vision Benefit, one eye exam per year

100% of Actual Charges up to $100 pre policy year

Wellness Benefit, includes one annual physical, routine screenings and immunizations (including HPV)

80% of Actual Charges up to $400 per policy year

STATE MANDATED BENEFITS 

Benefits for Bone Marrow Transplants for Treatment of Breast Cancer

Paid as any other Sickness

Benefits for Cardiac Rehabilitation

Paid as any other Sickness

Benefits for Cytologic Screening and Mammography

Paid as any other Sickness

Benefits for Dependent Children Early Intervention Services

Paid as any other Sickness up to a maximum of $5,200 per policy year up to a lifetime maximum of $15,000

Benefits for Dependent Children Preventive Care

Paid as any other Sickness

Benefits for Enteral Formulas

Paid as any other Sickness up to $2,500

Benefits for Home Health Care Services

100% of Preferred Allowance

80% of U&C Charge

Benefits for Hospice Care

Paid as any other Sickness

Benefits for Hormone Replacement Therapy and Outpatient Contraceptive Services

Paid as any other Sickness

Benefits for Human Leukocyte Antigen or Histocompatibility Locus Antigen Testing

Paid as any other Sickness

Benefits for Infertility

Paid as any other Sickness

Benefits for Initial Prosthetic Device and Reconstructive Surgery

Paid as any other Sickness

Benefits for Maternity, Childbirth, Well-Baby and Post Partum Care

Paid as any other Sickness

Benefits for Newborn or Adoptive Children

Paid as any other Sickness

Benefits for Off-Label Drug Use

Paid as any other Prescription Drug

Benefits for Qualified Clinical Trials for Treatment of Cancer

Paid as any other Sickness

Benefits for Scalp Hair Prosthesis

Paid as any other Sickness up to $350.00 per policy year

Benefits for Treatment of Speech, Hearing and Language Disorders

Paid as any other Sickness

Treatment of Alcoholism, Inpatient

Paid as any other Sickness up to 30 days per policy year

Paid as any other Sickness up to 30 days per policy year

Treatment of Alcoholism, Outpatient

Paid as any other Sickness up to $500 per 12 month period

Paid as any other Sickness up to $500 per 12 moth period

Treatment of Diabetes (Services and Supplies)

Paid as any other Sickness

Treatment of Mental Disorders for Biologically-based Disorders, Inpatient

Paid as any other Sickness

Treatment of Mental Disorders for Biologically-based Disorders, Outpatient

Paid as any other Sickness. Refer to Outpatient Miscellaneous Expense

Treatment of Mental Disorders for Non-Biologically-based Disorders, Inpatient

Paid as any other Sickness up to 60 days per policy year

Paid as any other Sickness up to  60 days per policy year

Treatment of Mental Disorders for Non-Biologically-based Disorders, Outpatient

Paid as any other Sickness, after $15 copay per office visit, up to 24 visits per policy year

Paid as any other Sickness, after $15 copay per office visit, up to 24 visits per policy year