Student Health Insurance Program Designed for the Students ... Broch...BSAS MA L25 000 0614 2 3 Student Health Insurance Program Designed for the Students of Eastern Nazarene College

BSAS MA L25 000 0614 2 3

Student Health Insurance Program

Designed for the Students ofEastern Nazarene College

Quincy, Massachusetts2015-2016

Nationwide Life Insurance CompanyColumbus, Ohio

Policy Number: 302-111-2013

Effective August 15, 2015 toAugust 14, 2016

Group Number: S210206IMPORTANT NOTICE

This brochure provides a brief description of the importantfeatures of the Policy. It is not a Policy. Terms andconditions of the coverage are set forth in the Policy. Wewill notify Covered Persons of all material changes to thePolicy. Please keep this material with your importantpapers.

NONDISCRIMINATORYHealth care services and any other benefits to which aCovered Person is entitled are provided on anondiscriminatory basis, including benefits mandated bystate and federal law.

This health plan satisfies Minimum CreditableCoverage standards and will satisfy theindividual mandate that you have healthinsurance.

FIRST HEALTH PREFERRED PROVIDER NETWORKBy enrolling in this Insurance Program, you have FirstHealth Network. A complete listing is available atwww.firsthealth.com.A Preferred Provider may require a Covered Person to payan annual fee for inclusion within the Preferred Providerspanel of patients. Any services that are represented to be apart of the Preferred Provider’s annual service agreementare part of that separate agreement and are not part of thisInsurance Program.THE PROGRAM DOES NOT REQUIRE YOU TO USE APREFERRED PROVIDER.If a Preferred Provider is not available in a particular areaor specialty, the Policy will cover at the Preferred Providerlevel until a provider has been added.Coverage will be provided at the Preferred Provider levelfor a provider who is not a Preferred Provider for the firstthirty (30) days from the effective date of coverage if aCovered Person is undergoing an ongoing course oftreatment or the provider is the Covered Person’s primarycare provider.If the Covered Person is a female who is in her second(2nd) or third (3rd) trimester of pregnancy and whoseprovider in connection with her pregnancy is involuntarilydisenrolled, other than disenrollment for quality-relatedreasons or fraud, treatment will be allowed with saidprovider, according to the terms of the Policy, for the periodup to and including the Covered Person's first postpartumvisit.If a Covered Person is terminally ill and the provider inconnection with said Sickness is involuntarily disenrolled,other than for quality related reasons or fraud, the CoveredPerson will be allowed to continue treatment with saidprovider, according to the terms of the Policy, until thedeath of the Covered Person.Continued coverage is conditioned upon the provideragreeing to: Accept reimbursement at the rates applicable prior to

notice of disenrollment as payment in full and not toimpose cost sharing with respect to the CoveredPerson in an amount that would exceed the costsharing that could have been imposed if the providerhad not been disenrolled; and

Adhere to the Policy’s quality assurance standards andto provide necessary medical information related to thecare provided; and

Adhere to Our policies and procedures.Physician profiling information may be available from theBoard of Registration in Medicine for physicians licensed topractice in Massachusetts.We will provide coverage for pediatric specialty care toCovered Persons requiring such services, including mentalhealth services, by a person with recognized expertise inspecialty pediatrics.Eastern Nazarene College can access directories listingFirst Health Preferred Providers by visitingwww.firsthealth.com or www.chpstudent.com.

STUDENT ELIGIBILITY AND ENROLLMENTAll registered full-time students taking three-quarter (¾) offull-time credit hours or more at Eastern Nazarene Collegeare automatically enrolled in the Student Health InsurancePlan. If You are eligible to be covered under this Program,You are automatically enrolled unless You can certify thatYou have comparable coverage.You may enroll in this Insurance Program only during thethirty-one (31) day periods beginning with the start of thefirst and second terms. If You are eligible for coverage andwish to enroll in the Program after these enrollmentopportunities, You must present documentation from Yourformer insurance company that it is no longer providingYou with personal accident and health insurance coverage.Your effective date under this Program will be the dateYour former insurance expired, if You make the request forcoverage within sixty (60) days after it expires. Otherwise,the effective date will be the first (1st) of the month followingYour request. Your premium for this coverage mustaccompany the request.

MASSACHUSETTS REQUIREMENTTO PURCHASE HEALTH INSURANCE

As of January 1, 2009, the Massachusetts Health CareReform Law requires that Massachusetts residents,eighteen (18) years of age and older, must have healthcoverage that meets the Minimum Creditable Coveragestandards set by the Commonwealth Health InsuranceConnector, unless waived from the health insurancerequirement based on affordability or individualhardship. For more information call the Connector at 1-877-MA-ENROLL or visit the Connector website(www.mahealthconnector.org).This health plan satisfies Minimum Creditable Coveragestandards that are effective during the term of coverage as

4 5 6

part of the Massachusetts Health Care Reform Law. If youpurchase this plan, you will satisfy the statutoryrequirements that you have health insurance meeting thesestandards.THIS DOCUMENT IS FOR MINIMUM CREDITABLECOVERAGE STANDARDS THAT ARE EFFECTIVEJANUARY 1, 2009. BECAUSE THESE STANDARDS MAYCHANGE, REVIEW YOUR PLAN MATERIAL EACH YEARTO DETERMINE WHETHER YOUR PLAN MEETS THELATEST STANDARDS.If you have questions about this notice, you maycontact the Division of Insurance by calling (617) 521-7794 or visiting its website at www.mass.gov/doi.

PREMIUMThe insurance under Eastern Nazarene College StudentHealth Insurance Plan for the Annual Policy is effective12:01 a.m. on August 15, 2015. The Annual Policyterminates at 11:59 a.m. on August 14, 2016 or at the endof the period through which the premiums are paid,whichever is earlier.

Annual Fall Spring8/15/15-8/14/16

8/15/15-1/12/16

1/13/16-8/14/16

Student $2,662 $1,116 $1,576The above rates include an administrative fee retained bythe servicing agent.

PREMIUM REFUND POLICYIn the case of medical withdrawal, any Insured withdrawingfrom school must submit documentation or certification ofthe medical withdrawal to Us at least thirty (30) days priorto the medical leave of absence from the school, if themedical reason for the absence and the absence areforeseeable, or thirty (30) days after the start date of themedical leave of absence from school. Any Insuredvoluntarily withdrawing from school during the first thirty-one (31) days of the period for which Coverage ispurchased, will not be covered under this Policy and a fullrefund of Premium will be made minus the cost of anyclaim Benefits made by Us. Insureds withdrawing aftersuch thirty-one (31) days will remain covered under thePolicy for the term purchased and no refund will be allowedexcept as otherwise specified herein or unless required inaccordance with Massachusetts State Law.

TERMINATIONCoverage will terminate at 12:01 a.m. standard time at thePolicyholder’s address on the earliest of: The Termination Date of the Policy; The last day of the term of Coverage for which Premium

has not been paid; The date a Covered Person enters full time active military

service. Upon written request within ninety (90) days ofleaving school, We will refund any unearned pro-rataPremium with respect to such person.

A Covered Person’s coverage may be cancelled, or itsrenewal refused, only in the following circumstances: failure bythe Covered Person or other responsible party to makepayments under the Policy; misrepresentation or fraud on thepart of the Covered Person; commission of acts of physical orverbal abuse by the Covered Person which pose a threat toproviders or other insureds and which are unrelated to theCovered Person’s physical or mental condition; relocation ofthe Covered Person outside the Policy’s service area; or non-renewal or cancellation of the Policy through which theCovered Person receives coverage or the Covered Person isno longer a student.

INVOLUNTARY DISENROLLMENTThe number of Covered Persons involuntarily disenrolled inthe past two (2) years is zero (0).

EXTENSION OF BENEFITSThe Coverage provided under this Policy ceases on theCovered Person’s Termination Date. However, if an InsuredPerson is: Hospital Confined on the Termination Date from a

covered Injury or Sickness for which Benefits were paidbefore the Termination Date, Covered Expenses for suchInjury or Sickness will continue to be paid for a period ofthirty (30) days.

GENERAL DEFINITIONSThe terms listed below, if used, have the meaning stated.Accident: An event that is sudden, unexpected, andunintended, and over which the Covered Person has nocontrol.Biologically Based Mental Illness: A mental, nervous, oremotional condition that is caused by a biological disorderof the brain and results in a clinically significant,psychological syndrome or pattern that substantially limits

the functioning of the person with the Illness. Suchbiologically based mental illnesses are defined asSchizophrenia; Schizoaffective disorder; Major depressivedisorder; Bipolar disorder; Paranoia and other psychoticdisorders; Obsessive-Compulsive disorder; Panic disorder;Delirium and dementia; Affective disorders; Eatingdisorders; Post traumatic stress disorder; Substance abusedisorders; and Autism.Condition: Sickness, ailment, Injury, or pregnancy of aCovered Person.Copayment: A specified dollar amount a Covered Personmust pay for specified Covered Charges. The Copaymentis separate from and not a part of the Deductible orCoinsurance.Covered Charge(s) or Covered Expense: As used hereinmeans those charges for any treatment, services orsupplies: for Preferred Providers, not in excess of the Preferred

Allowance; for Out-of-Network Providers not in excess of the

Reasonable and Customary expense; and not in excess of the charges that would have been made

in the absence of this insurance; and not otherwise excluded under this Policy; and incurred while this Policy is in force as to the Covered

Person.Covered Services: Means the services and supplies,procedures and treatment described herein, subject to theterms, conditions, limitations, and exclusions of the Policy.Deductible: The amount of expenses for CoveredServices and supplies which must be incurred by theCovered Person before specified Benefits become payable.Elective Treatment: Those services that do not fall underthe definition of Essential Health Benefits. Medicaltreatment which is not necessitated by a pathologicalchange in the function or structure in any part of the bodyoccurring after the Covered Person’s Effective Date ofCoverage. Elective Benefits is shown on the Schedule ofBenefits, as applicable.Emergency: An Illness, Sickness or Injury for whichimmediate medical treatment is sought at the nearestavailable facility. The Condition must be one whichmanifests itself by acute symptoms which are sufficientlysevere that a reasonable person would seek care right

7 8 9

away to avoid serious impairment to body function, orserious dysfunction of any body organ or part, or, withrespect to a pregnant woman, serious jeopardy to thefetus.A Covered Person has the option of calling the local pre-hospital emergency medical service system by dialing theemergency telephone access number 911, or its localequivalent, whenever a Covered Person is confronted withan Emergency Medical Condition which in the judgment ofa prudent layperson would require pre-hospital emergencyservices. No Covered Person shall in any way bediscouraged from using the local pre-hospital emergencymedical services system, the 911 telephone number, or thelocal equivalent, or be denied coverage for medical andtransportation expenses incurred as a result of suchemergency medical condition.Emergency does not include the recurring symptoms of achronic Condition unless the onset of such symptoms couldreasonably be expected to result in the above listedcomplications.Essential Health Benefits: Has the meaning found insection 1302(b) of the Patient Protection and AffordableCare Act and as further defined by the Secretary of theUnited States Department of Health and Human Services,and includes the following categories of Covered Services:ambulatory patient services; emergency services;hospitalization; maternity and newborn care; mental healthand substance use disorder services, including behavioralhealth treatment; prescription drugs; rehabilitative andhabilitative services and devices; laboratory services;preventive and wellness services and chronic diseasemanagement; and pediatric services, including oral andvision care in accordance with the applicable state orfederal benchmark plan.Experimental/Investigational: The service or supply hasnot been demonstrated in scientifically valid clinical trialsand research studies to be safe and effective for aparticular indication.Health Care Facility: A Hospital, Skilled Nursing, or otherduly licensed, certified and approved health care institutionwhich provides care and treatment for sick or injuredpersons.Home Country: The Insured’s country of regular domicile.Injury: Bodily Injury due to a sudden, unforeseeable,external event which results independently of disease,bodily infirmity or any other causes. All injuries sustainedin any one Accident, including all related conditions and

recurrent symptoms of these injuries, are considered asingle Injury.In-Network Benefit: The level of payment made by Us forCovered Services received by a Preferred Provider underthe terms of the Policy. Payment is based on the PreferredAllowance unless otherwise indicated.Insured: The Covered Person who is enrolled at andmeets the eligibility requirements of the Policyholder’sschool.Insured Percent: That part of the Covered Charge that ispayable by the Company after the Deductible and/orCopayment has been paid, and subject to the Policy Year,Maximum or Maximum Benefit, as applicable.Maximum Benefit: The maximum payment We will makeunder the Policy for each Covered Person for CoveredServices. This amount is shown on the Schedule ofBenefits, as applicable.Mental Condition(s): Nervous, emotional, and mentaldisease, Illness, syndrome or dysfunction classified in themost recent addition of the Diagnostic and StatisticalManual of Mental Disorders (DSM IV) or its successor, as aMental Condition on the date of medical care or treatmentis rendered to a Covered Person.Out-of-Network Benefit Level: The lowest level ofpayment made by Us for Covered Services under theterms of the Policy. Payment is based on Reasonable andCustomary charges unless otherwise indicated.Out-of-Network Provider: Physicians, Hospitals and otherProviders who have not agreed to any pre-arranged feeschedules. See the definition of Out-of-Network BenefitLevel.Out-of-Pocket: means the most You will pay during aPolicy Year before your coverage pays at 100%. Thisincludes deductibles, copayments (medical andprescription) and any coinsurance paid by You. This doesnot include non-covered medical expenses and electiveservices.Physician: A health care professional, including aPhysician Assistant, practicing within the scope of his orher license and is duly licensed by the appropriate StateRegulatory Agency to perform a particular service which iscovered under the Policy, and who is not: the Insured Person; a Family Member of the Insured Person; or a person employed or retained by the Policyholder.

Policy Year Maximum: The maximum amount of Benefitswe will pay for all Conditions under this Policy each PolicyYear for each Covered Person. This amount is shown onthe Schedule of Benefits.Preferred Providers: Physicians, Hospitals and otherhealthcare Providers who have contracted to providespecific medical care at negotiated prices. See thedefinition of In-Network Benefit.Prescription Drugs: Drugs which may only be dispensedby written prescription under Federal law and is:1. approved for general use by the U.S. Food and Drug

Administration (FDA); and2. prescribed by a licensed Physician for the treatment of

a Life Threatening Condition, or prescribed by alicensed Physician for the treatment of a Chronic andSeriously Debilitating Condition, the drug is medicallynecessary to treat that Condition, and the drug is onthe Formulary, if any; and

3. the drug has been recognized for treatment of thatCondition by one of the Standard Medical ReferenceCompendia or in the Medical Literature asrecommended by current American MedicalAssociation (AMA) policies, even if the prescribeddrug has not been approved by the FDA for thetreatment of that specific Condition.

The Drugs must be dispensed by a licensed pharmacyProvider for out of Hospital use. Prescription DrugCoverage shall also include medically necessary suppliesassociated with the administration of the drug.Preventive Care: Provides for periodic health evaluations,immunizations and laboratory services in connection withperiodic health evaluations, as specified in the Schedule ofBenefits. Well Baby and Child Care, and Well Adult Carebenefits will be considered based on the following:a) Evidenced-based items or services that have in effect

a rating of “A” or “B” in the current recommendationsof the United States Preventive Services Task Force,except that the current recommendations of the UnitedStates Preventive Service Task Force regardingbreast cancer screening, mammography, andprevention of breast cancer shall be considered themost current other than those issued in or aroundNovember 2009;

b) Immunizations that have in effect a recommendationfrom the Advisory Committee on ImmunizationPractices of the Centers for Disease Control andPrevention with respect to the individual involved;

10 11 12

c) With respect to infants, children, and adolescents,evidence-informed preventive care and screeningsprovided for in the comprehensive guidelinessupported by the Health Resources and ServicesAdministration; and

d) With respect to women, such additional preventivecare and screenings, not described in paragraph (a)above, as provided for in comprehensive guidelinessupported by the Health Resources and ServicesAdministration.

Provider: A Physician, Nurse Practitioner, Health CareFacility, or Urgent Care Facility that is licensed or certifiedto provide medical services or supplies. Physician profilinginformation may be available from the Board ofRegistration in Medicine for physicians licensed to practicein Massachusetts.Reasonable and Customary (R&C): The most commoncharge for similar professional services, drugs, procedures,devices, supplies or treatment within the area in which thecharge is incurred. The most common charge means thelesser of: The actual amount charged by the Provider; The fee often charged for in the geographical area where

the service was performed.The Reasonable Charge is determined by comparingcharges for similar services to a national database adjustedto the geographical area where the services or proceduresare performed, by reference to the, 80th percentile of, FairHealth Inc. schedules. The Insured Person may beresponsible for the difference between the ReasonableCharge and the actual charge from the Provider.Sickness: Illness, disease or condition, includingpregnancy and Complications of Pregnancy that impairs aCovered Person’s normal functioning of mind or body andwhich is not the direct result of an Injury or Accident. Allrelated conditions and recurrent symptoms of the same ora similar condition will be considered the same Sickness.We, Our and Us: Nationwide Life Insurance Company.You and Your: The Covered Person or Eligible Person asapplicable.

STUDENT HEALTH INSURANCEThis brochure is a brief description of the Student HealthInsurance Plan available for all students who meet theeligibility requirement as shown above. The exactprovisions governing this insurance are contained in theMaster Policy underwritten by Nationwide Life Insurance

Company, serviced by administered by ConsolidatedHealth Plans.Benefits for Covered Medical Expenses will be paidaccording to the Schedule of Benefits and anyexclusions, limitations, or state mandated provisionsas follows.

STATE MANDATED BENEFITSBenefits are subject to applicable deductible, coinsurance,and co-payments as outlined in the Schedule of Benefits.Autism Spectrum Disorder: Benefits provided for thediagnosis and treatment of autism spectrum disorder (ASD)in individuals. ASD includes any of the pervasivedevelopmental disorders, as defined by the most recentedition of the Diagnostic and Statistical Manual of MentalDisorders, including autistic disorder, Asperger’s disorderand pervasive developmental disorders not otherwisespecified.Treatment of autism spectrum disorders includes thefollowing medically necessary care prescribed, provided orordered for an individual diagnosed with an ASD by alicensed Physician or a licensed psychologist: Habilitative or Rehabilitative Care: Professional,

counseling and guidance services and treatmentprograms, including, but not limited to, applied behavioralanalysis supervised by a board certified behavior analyst,that are necessary to develop, maintain and restore, tothe maximum extent practicable, the function of anindividual. Applied behavior analysis includes the design,implementation and evaluation of environmentalmodifications, using behavioral stimuli andconsequences, to produces socially significantimprovement in human behavior, including the use ofdirect observation, measurement and functional analysisof the relationship between environment and behavior.

Pharmacy Care: Medications prescribed by a licensedPhysician and health-related services deemed medicallynecessary to determine the need or effectiveness of themedications, to the same extent that pharmacy care isprovided for other medical conditions.

Psychiatric Care: Direct or consultative services providedby a licensed psychiatrist.

Psychological Care: Direct or consultative servicesprovided by a licensed psychologist.

Therapeutic Care: Services provided by licensed orcertified speech therapists, occupational therapist,physical therapists or social workers.

Benefits are payable the same as any other physicalIllness.Biologically Based Mental Disorders: Coverage will beprovided the same as any other physical Illness for thefollowing Biologically Based Mental Disorders:1. Schizophrenia;2. Schizoaffective disorder;3. Major depressive disorder;4. Bipolar disorder;5. Paranoia and other psychotic disorders;6. Obsessive-Compulsive disorder;7. Panic disorder;8. Delirium and dementia;9. Affective disorders;10. Eating disorders;11. Post-traumatic stress disorder;12. Substance abuse disorders; and13. Autism.Bone Marrow Transplants for Breast Cancer: Coverageis provided as any other physical illness for bone marrowtransplants for persons who have been diagnosed withbreast cancer that has progressed to metastatic breastdisease.Breast Reconstruction Incident to Mastectomy:Coverage is provided for construction in connection withsuch mastectomy, coverage for: (1) reconstruction of thebreast on which the mastectomy has been performed; (2)surgery and reconstruction of the other breast to produce asymmetrical appearance; and (3) prostheses and physicalcomplications all stages of mastectomy, includinglymphedemas; in a manner determined in consultation withthe Attending Physician and the patient.Cardiac Rehabilitation Coverage: Coverage is providedfor Cardiac rehabilitation expense if a Covered Person hasdocumented cardiovascular disease. This benefit includesmultidisciplinary treatment provided in either a Hospital orother setting. Treatment must meet standards promulgatedby the Commissioner of Public Health. Cardiacrehabilitation must be initiated within 26 weeks after thediagnosis of the disease.Coverage for Human Leukocyte Antigen Testing forCertain Individuals and Patients: Coverage is providedas any other physical Illness for Human leukocyte antigentesting or histocompatibility locus antigen testing that isnecessary to establish bone marrow transplant donorsuitability. Coverage will cover the costs of testing for A, Bor DR antigens, or any combination thereof, consistent with

13 14 15

rules, regulations and criteria established by thedepartment of public health.Cytological screening and mammograms: Coverage isprovided for cytological screening (pap smear) andmammograms, payable as any other physical illness, forCovered female persons: One cytological (pap smear) screening for ages eighteen

(18) and over; A baseline mammogram for ages thirty-five (35) through

thirty-nine (39); A mammogram every year age forty (40) and over.Diabetes Diagnosis and Treatment Expense: Coverageis provided for diabetes diagnosis and treatment expensefor treatment of insulin dependent, insulin using,gestational and non-insulin dependent diabetes. ThisBenefit includes expense for blood glucose monitors; bloodglucose monitoring strips for home use; voice synthesizersfor blood glucose monitors for use by the legally blind;visual magnifying aids for use by the legally blind; urineglucose strips; ketone strips; lancets; insulin; insulinsyringes; prescribed oral diabetes medications thatinfluence blood sugar levels; laboratory tests, includingglycosylated hemoglobin, or HbAlc tests;urinary/protein/microalbumin and lipid profiles; insulinpumps and insulin pump supplies; insulin pens, so called;therapeutic/molded shoes and shoe inserts for people whohave severe diabetic foot disease when the need fortherapeutic shoes and inserts has been certified by thetreating doctor and prescribed by a podiatrist or otherqualified Physician and furnished by a podiatrist, orthotist,prosthetist or pedorthist; supplies and equipment approvedby the FDA for the purposes for which they have beenprescribed and diabetes outpatient self-managementtraining and education, including medical nutrition therapy.Early Intervention Services: medically necessaryservices provided by certified early intervention specialistfor children from birth until their third birthday.Reimbursement of costs for such services is not subject toco-payments, coinsurance or deductibles, however subjectto other Policy provision limitations.Hearing Aids for Children: Coverage is provided forhearing aids for children who are twenty-one (21) years ofage or younger when prescribed by a licensed audiologistor hearing instrument specialist. Coverage includes theinitial hearing aid evaluation, fitting, adjustments, andsupplies, including ear molds up to $2,000 per hearing aid

per hearing impaired ear in each thirty-six (36) monthperiod.Hormone Replacement Therapy and ContraceptiveServices:Benefits will be provided for hormone replacement therapyand contraceptive services. Coverage is provided for hormone replacement therapy

services for peri and post menopausal women andoutpatient contraceptive services under the same termsand conditions as for such other outpatient services.Outpatient contraceptive services mean consultations,examinations, procedures and medical services providedon an outpatient basis and related to the use of allcontraceptive methods to prevent pregnancy that havebeen approved by the United States Food and DrugAdministration.

Provides benefits for outpatient Prescription Drugsand devices that provide benefits for hormonereplacement therapy for peri and post menopausalwomen and for outpatient prescription contraceptivedrugs or devices which have been approved by theUnited States Food and Drug Administration under thesame terms and conditions as for such otherprescription drugs or devices, provided that incovering all FDA approved prescription contraceptivemethods.

Hospice for Terminally Ill (Hospice Care): Coverage isprovided for licensed hospice services to terminally illpatients with a life expectancy of six months or less. Theseservices shall include, but not be limited to, Physician’sservices, nursing care provided by or under the supervisionof a registered nurse, social services, volunteer servicesand counseling services provided by professional orvolunteer staff under professional supervision.Infertility Benefits: The diagnosis and treatment ofInfertility is payable the same as any other pregnancyrelated procedures. Infertility-related drugs will not betreated different from those imposed on any otherPrescription Drugs. This Benefit includes expense incurredfor the following non-experimental infertility procedures: Artificial insemination; In vitro fertilization and embryo placement; Gamete Intra-Fallopian Transfer; Zygote intrafallopian transfer; Intracyloplasmic sperm injection for the treatment of male

factor infertility; and

Sperm, egg, and/or inseminated egg procurement andprocessing, and banking of sperm or inseminated egg, tothe extent such costs are not covered by the donor’sinsurer, if any. Coverage is not limited to sperm providedby the insured’s spouse.“Infertility” means the Condition of an individual who isunable to conceive or produce conception during aperiod of 1 year if the female is age 35 or younger orduring a period of 6 months if the female is over theage of 35. For purposes of meeting the criteria forinfertility in this section, if a person conceives but isunable to carry that pregnancy to live birth, the periodof time she attempted to conceive prior to achievingthat pregnancy shall be included in the calculation ofthe 1 year or 6 month period, as applicable.

Maternity expense: Includes expenses for prenatal care,childbirth and postpartum care (including well baby care)on the same basis as any other physical Illness. Expensesfor childbirth include Hospital inpatient care for forty-eight(48) hours following vaginal delivery and ninety-six (96)hours following a cesarean section. Any decision to shortenmaternity stays will be made by the Attending Physician inconsultation with the mother, in accordance withregulations promulgated by the Department of PublicHealth. The Covered Person is entitled to one home visitshould they elect to participate in an early discharge.Attending Physician includes the attending obstetrician,pediatrician, or certified nurse midwife attending the motherand newly born child.Mental Health Benefits for Children and Adolescentsunder age Nineteen (19): Coverage will be provided thesame as any other physical Illness for children andadolescents under age nineteen (19) for the diagnosis andtreatment of non-Biologically-Based Mental, behavioral oremotional disorders, as described in the most recentedition of the DSM. The following requirements must bemet: The disorders substantially interfere with or

substantially limit the functioning and socialinteractions of such a child or adolescent; provided,that said interference or limitation is documented byand the referral for said diagnosis and treatment ismade by the primary care Physician, primarypediatrician or a licensed mental health professional.

The child or adolescent is evidenced by conduct,including, but not limited to:

16 17 18

a) an inability to attend school as a result of such adisorder;

b) the need to hospitalize the child or adolescent asa result of such a disorder, or

c) a pattern of conduct or behavior caused by sucha disorder which poses a serious danger to selfor others.

Benefits will continue to be provided to any adolescent whois engaged in an ongoing course of treatment beyond theadolescent's nineteenth birthday until said course oftreatment, as specified in said adolescent's treatment plan,is completed and while the benefit contract under whichsuch benefits first became available remains in effect, orsubject to a subsequent benefits contract which is in effect.Mental Health Related Alcohol and ChemicalDependency Treatment in conjunction with BiologicallyBased Mental Disorders: The limitation on benefits forthe treatment of Alcoholism or chemical dependency willnot apply when treatment is rendered in conjunction withtreatment for Biologically Based Mental Disorders.Newborn Hearing: Coverage is provided for the cost of anewborn hearing screening test performed before thenewborn infant is discharged from the Hospital or birthingcenter to the care of the parent or guardian or as providedby regulations of the department of public health.Non-Prescription Enteral Formulas for Home Use:Coverage is provided for nonprescription enteral formulasfor home use for which a Physician has issued a writtenorder and which are medically necessary for the treatmentof malabsorption caused by Crohn's disease, ulcerativecolitis, gastroesophageal reflux, gastrointestinal motility,chronic intestinal pseudo-obstruction, and inheriteddiseases of amino acids and organic acids.Coverage for inherited diseases of amino acids andorganic acids includes food products modified to be lowprotein.Nurse Midwife Coverage: Benefits provided for servicesof a certified nurse midwife; provided, however, thatexpenses for such services are reimbursed when suchservices are performed by any other duly licensedpractitioner; and provided, further, that such services arewithin the lawful scope of practice for a certified nursemidwife.Off-Label Use of Drugs for the treatment of Cancer andHIV/AIDS: Coverage provided for the off-label use ofdrugs for the treatment of cancer and HIV/AIDS.

Coverage provided for any such drug used for thetreatment of cancer on the grounds that the off-labeluse of the drug has not been approved by the UnitedStates Food and Drug Administration for thatindication; provided, however, that drug is recognizedfor treatment of such indication in one of the standardreference compendia, or in the medical literature, orby the commissioner. Subject to Medical Necessity.

Coverage provided for any such drug for HIV/AIDStreatment on the grounds that the off-label use of thedrug has not been approved by the federal Food andDrug Administration for that indication, if the drug isrecognized for treatment of such indication in one ofthe standard reference compendia, or in the medicalliterature, or by the commissioner. Subject to MedicalNecessity.

Other Mental Disorders: Mental Illness treatment of allother mental disorders, which are described in the mostrecent edition of DMS, consisting of inpatient, intermediateand outpatient services, including home-based servicesdelivered in such offices or settings rendered by a licensedmental health professional acting within the scope of hislicense, that permit active and noncustodial treatment totake place in the least restrictive clinically appropriatesetting.Inpatient Services may be provided in a general hospitallicensed to provide such services, in a facility under thedirection and supervision of the department of mentalhealth, in a private mental Hospital licensed by theDepartment of Mental Health, or in a substance abusefacility licensed by the Department of Public Health.Intermediate Services means a range of non-inpatientservices that provide more intensive and extensivetreatment interventions when outpatient services alone arenot sufficient to meet the patient’s needs. IntermediateServices, include, but are not limited to the following: acuteand other residential treatment; clinically manageddetoxification services; partial hospitalization; intensiveoutpatient programs; day treatment; crisis stabilization; in-home therapy services.The duration of authorized intermediate care services willvary according to that person’s individual needs.Authorizations are based on Medical Necessity rather thanany arbitrary number of days or number of visits.Preventive and Primary Care Services: Coverage isprovided for the following services to the dependent child of

an Insured from the date of birth through the attainment ofsix (6) years of age: Physical examination, history, measurements, sensory

screening, neuropsychiatric evaluation anddevelopment screening, and assessment at thefollowing intervals: six (6) times during the child’s firstyear after birth, three (3) times during the next year,annually until age six (6).

Such services also include hereditary and metabolicscreening at birth, screening for lead poisoning,appropriate immunizations, and tuberculin tests,hematrocrit, hemoglobin or other appropriate bloodtests, and urinalysis as recommended by thephysician.

Coverage is provided for pediatric specialty care, includingmental health care, by persons with recognized expertise inspecialty pediatrics to Insureds requiring such services.Prosthetic Coverage: Coverage provided for prostheticdevices and repairs under the same terms and conditionsthat apply to other Durable Medical Equipment coveredunder the Policy, except as otherwise provided in thissection. “Prosthetic device" means an artificial limb deviceto replace, in whole or in part, an arm or leg.Psychopharmacological and NeuropsychologicalAssessment Service: Coverage is provided forPsychopharmacological services and neuropsychologicalassessment services expenses.Qualified Clinical Trials: Coverage and reimbursement forpatient care services provided pursuant to a qualifiedclinical trial to the same extent as they would be coveredand reimbursed if the patient did not receive care in aqualified clinical trial.Rape Related Mental or Emotional Disorders: Coveragewill be provided for the diagnosis and treatment of rape-related or emotional disorders to victims of a rape orvictims of assault with intent to commit rape, whenever thecosts of such diagnosis and treatment exceed themaximum compensation awarded to such victims.Scalp Hair Prosthesis for Cancer Patients: Coverageprovided for scalp hair prosthesis expense for prosthesisworn for hair loss suffered as a result of the treatment ofany form of cancer or leukemia, payable up to $500 perPolicy Year."Prosthesis," an artificial appliance used to replace a lostnatural structure; provided, however, that prosthesis shall

19 20 21

include, but not be limited to, artificial arms, legs, breasts,scalp hair or glass eyes."Scalp hair prosthesis," an artificial substitute for scalp hair.Special Medical Formulas: Coverage provided for newlyborn infants and adoptive children prescribed by aPhysician and are medically necessary for treatment ofphenylketonuria, tyrosinemia, homocystinuria, maple syrupurine disease, propionic acidemia, or methylmalonicacidemia in infants and children or to protect the unbornfetuses of pregnant women with phenylketonuria.Speech, Hearing, and Language Disorders: Coverage isprovided for the diagnosis and treatment of speech,hearing and language disorders by individuals licensed asspeech language pathologists or audiologists if suchservices are rendered within the (lawful scope of practicefor such speech language pathologists or audiologistsregardless of whether the services are provided in aHospital, clinic or private office. Benefits are payable thesame as any other Sickness. Coverage does not extend tothe diagnosis or treatment of speech, hearing andlanguage disorders in a school based setting.Treatment of Cleft Palate and Cleft Lip for Children:Coverage is provided for the treatment of cleft palate andcleft lip for children under the age of eighteen (18).Coverage includes medical, dental, oral and facial surgery,surgical management and follow-up care by oral andplastic surgeons, orthodontic treatment and management,preventive and restorative dentistry to ensure good healthand adequate dental structures for orthodontic treatmentand prosthetic management therapy, speech therapy,audiology, and nutrition services when medically necessaryservices are prescribed by the treating Physician orsurgeon.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITIf the Eligible Person, within 365 days from the date of anAccident which occurs while Coverage is in force dies asthe result of an Injury from such Accident, We will pay theEligible Person’s beneficiary the amount for loss of life asshown in the Schedule of Benefits. If the Eligible Person,within 365 days from the date of an Accident, which occurswhile Coverage is in force, suffers dismemberment as theresult of Injury from such Accident, We will pay the EligiblePerson the amount set opposite such loss, as shown onthe Schedule of Benefits. If more than one (1) such loss issustained as the result of one (1) Accident, We will pay

only one (1) amount, the largest to which the EligiblePerson or his or her beneficiary would be entitled.The following table shows the amounts We will pay for lossof:Life .............................................................................$5,000Two hands..................................................................$5,000Two feet .....................................................................$5,000Sight of two eyes........................................................$5,000One hand and one foot ..............................................$5,000One hand and sight of one eye ..................................$5,000One foot and sight of one eye ....................................$5,000One hand or one foot or one eye ..................................$500Loss of hand or foot means loss by severance at or abovethe wrist or ankle joint. Loss of sight must be entire andirrecoverable. Loss of a thumb and index fingers meansloss by severance at or above the metacarpophalangealjoints, which are the joints between the fingers and thehand.This Benefit is subject to all the terms, Conditions andexclusions of the Policy.

EMERGENCY MEDICAL EVACUATION BENEFITIf the Insured cannot continue his academic programbecause he sustains an Accidental Injury or EmergencySickness while Insured under the Policy and is more than a100 mile radius from his current place of primary residenceor outside of his Home Country, We will pay for the actualcharge Incurred for an emergency medical evacuation ofthe Covered Person to or back to the Insured’s home state,country, or country of regular domicile. No payment will bemade under this provision unless the evacuation follows aHospital Confinement of at least five (5) consecutive days.Before We make any payment, We require writtencertification by the Attending Physician that the evacuationis necessary. Any expense for medical evacuationrequires Our prior approval and coordination. Forinternational students, once evacuation is made outside thecountry, Coverage terminates. This Benefit does notinclude the transportation expense of anyoneaccompanying the Covered Person or visitation expenses.

REPATRIATION OF REMAINS BENEFITIf the Covered Person dies while Insured under the Policyand is more than 100 miles from his permanent residenceor outside of his Home Country, We will pay for the actual

charge incurred for embalming, and/or cremation andreturning the body to his place of permanent residence inhis home state, country or country of regular domicile.Expenses for repatriation of remains require thePolicyholder’s and Our prior approval. If You are a UnitedStates citizen, Your Home Country is the United States.This Benefit does not include the transportation expense ofanyone accompanying the body, visitation or lodgingexpenses or funeral expenses.

GENERAL EXCLUSIONS AND LIMITATIONSUnless specifically included, no Benefits will be paid for: a)loss or expense caused by, contributed to, or resultingfrom; b) treatment, services, or supplies for, at, or relatedto:1. Eyeglasses, contact lenses, routine eye refractions,

eye examinations except as in the case of Injury,prescriptions or fitting of eyeglasses or contact lenses,vision correction surgery, or repair or replacement ofeye glasses or contact lens except when required as adirect result of an Injury.

2. Hearing Screenings (except as specifically provided inthe Policy) or hearing examinations or hearing aids(except as provided) and the fitting or repairing orreplacement of hearing aids, except in the case ofAccident or Injury.

3. Treatment (other than surgery) of chronic Conditionsof the foot including weak feet, fallen arches, flat foot,pronated foot, subluxations of the foot, foot strain,care of corns, calluses, toenails or bunions (exceptcapsular or bone surgery), any type of massageprocedure on or to the foot, corrective shoes, shoeinserts and Orthotic Device; except for treatment ofInjury, infection or disease except as provided herein.

4. Cosmetic treatment, cosmetic surgery, plastic surgery,resulting complications, consequences and aftereffects or other services and supplies that Wedetermine to be furnished primarily to improveappearance rather than a physical function or controlof organic disease except as provided herein or fortreatment of an Injury that is covered under the Policy.Improvements of physical function does not includeimprovement of self-esteem, personal concept of bodyimage, or relief of social, emotional, or psychological

22 23 24

distress. Procedures not covered include, but are notlimited to: face lifts; sagging eyelids; prominent ears;skin scars; warts, non-malignant moles and lesions;hair growth hair removal; correction of breast size,asymmetry or shape by means of reduction,augmentation, or breast implants includinggynecomastia (except for correction or deformityresulting from mastectomies or lymph nodedissections); lipectomy services and supplies relatedto surgical suction assisted lipectomy; rhinoplasty;nasal and sinus surgery; and deviated nasal septum,including submucous resection except when medicallynecessary treatment of acute purulent sinusitis. Thisexclusion does not include Reconstructive Surgerywhen the service is incidental to or follows surgeryresulting from trauma, Injury, infection or otherdiseases of the involved part.

5. Circumcision.6. Treatments which are considered to be unsafe,

Experimental, or Investigational by the AmericanMedical Association (AMA), and resultingcomplications.

7. Custodial Care; Care provided in a: rest home, homefor the aged, halfway house, health resort, collegeinfirmary, or any similar facility for domiciliary orCustodial Care, or that provides twenty-four (24) hournon-medical residential care or day care (except asprovided for Hospice care).

8. Dental care or treatment of the teeth, gums orstructures directly supporting the teeth, includingsurgical extractions of teeth, (except as specifiedherein).

9. Temporomandibular Joint Dysfunction (TMJ), exceptas specified herein.

10. Injury sustained while (a) participating in anyprofessional, or semi-professional sports contest orcompetition; (b) traveling to or from such sport,contest, or competition as a participant; or (c) whileparticipating in any practice or conditioning programfor such sport, contest, or competition, except asspecifically provided in the Policy.

11. Injury sustained by reason of a motor vehicle Accidentto the extent that Benefits are paid or payable by anyother valid and collectible insurance whether or notclaim is made for such Benefits or if the Insured is notproperly licensed to operate the motor vehicle withinthe jurisdiction in which the Accident takes place.

12. Injury resulting from parachuting, hang gliding,skydiving, parasailing, scuba diving, skin diving, gliderflying, sailplaning, racing or speed contests or bungeejumping.

13. Injury occurring in consequence of riding as apassenger or otherwise being in any vehicle or deviceof aerial navigation, except as a fare-payingpassenger on a regularly scheduled flight of acommercial airline.

14. Elective termination of pregnancy.15. Impotence, organic or otherwise, vasectomy.16. Hospital Confinement or any other services or

treatment that are received without charge or legalobligation to pay; Inpatient Room & Board charges inconnection with a Hospital stay primarily forenvironmental change; Inpatient room & boardcharges in connection with a Hospital stay primarily fordiagnostic tests which could have been performedsafely on an Outpatient basis.

17. Services provided normally without charge by thehealth service of the Policyholder or services coveredor provided by a student health fee; Services renderedby employees or Physicians or other persons orretained by the University or for the use of theUniversities facilities.

18. Treatment in a government Hospital, unless there is alegal obligation for the Covered Person to pay for suchtreatment.

19. Any services of a Physician or Nurse who lives withYou or Your Dependent(s) or who is related to You orYour Dependent(s) by blood or marriage.

20. Expense covered by any other medical insurance tothe extent that Benefits are payable under any othermedical insurance whether or not a claim is made forsuch Benefits.

21. Services received before the Covered Person’sEffective Date Services received after the CoveredPerson’s Coverage ends, except as specificallyprovided under the Extension of Benefits provision.

22. Under the Prescription Drug Benefit, any drug ormedicine: Obtainable Over the Counter (OTC); for thetreatment of alopecia (hair loss) or hirsutism (hairremoval); for the purpose of weight control; anabolicsteroids used for body building; growth hormones;sexual enhancement drugs; cosmetic, including butnot limited to, the removal of wrinkles or other naturalskin blemishes due to aging or physical maturation, or

treatment of acne except as specifically provided inthis Policy; treatment of nail (toe or finger) fungus;refills in excess of the number specified or dispensedafter one (1) year of date of the prescription; for anamount that exceeds a 30 day supply; drugs labeled,“Caution – limited by federal law to Investigationaluse” or Experimental Drugs; purchased afterCoverage under the Policy terminates; consumed oradministered at the place where it is dispensed; if theFDA determines that the drug is contraindicated forthe treatment of the Condition for which the drug wasprescribed; or Experimental for any reason.

23. Vitamins, minerals, food supplements, herbs, herbalformulas, or home remedies; except as prescribed.

24. Services for the treatment of any Injury or Sicknessincurred while committing or attempting to commit afelony; or while taking part in an insurrection or riot; orfighting, except in self-defense.

25. Injury or Sickness for which Benefits are paid orpayable under any workers’ compensation oroccupation disease law or act, or similar legislation.

26. War or any act of war, declared or undeclared; orwhile in the armed forces of any country.

27. Modifications made to dwellings, property, orautomobiles such as ramps, elevators, stair lifts,swimming pools, spas, air conditioners or air-filteringsystems, equipment that may increase the value ofthe residence, or car hand controls, whether or nottheir installation is for purposes of providing therapy oreasy access, or are portable to other locations.

28. Nutrition counseling services (except as specificallyprovided in the Policy), including services by aPhysician for general nutrition, weight increase orreduction services, except as specifically provided inthe Policy; general fitness, exercise programs, healthclub memberships and weight management programs(except as specifically provided); exercise machineryor equipment, including but not limited to treadmill,stair steps, trampolines, weights, sports equipment,support braces used primarily for use during any sportor in the course of employment, any equipmentobtainable without a Physician’s prescription.

25 26 27

29. Treatment received in the Covered Person’s HomeCountry, outside of the United States of America,except when medically necessary for an EmergencyConfinement in a Hospital or as specified herein.

30. Non-cystic acne.31. Acupuncture, acupressure, aroma therapy, hypnosis,

rolfing, Hyperhidrosis, Psychosurgery biofeedback.32. Diagnosis and treatment of sleep disorders including

but not limited to apnea monitoring, sleep studies, andoral appliances used for snoring, except treatment andappliances for documented obstructive sleep apnea.

33. Elective surgery or treatment except as specificallyprovided.

34. Pregnancy that results under a Surrogate ParentingAgreement.

SUBROGATION AND RECOVERY RIGHTSIf We pay Covered Expenses for an Accident or Injury Youincur as a result of any act or omission of a third party, andYou later obtain recovery from the third party, You areobligated to reimburse Us for the expenses paid. We mayalso take subrogation action directly against the third party.Our reimbursement rights are limited by the amount Yourecover. Our reimbursement and subrogation rights aresubject to deduction for the pro-rata share of Your costs,disbursements and reasonable attorney fees. You mustcooperate with and assist Us in exercising Our rights underthis provision and do nothing to prejudice Our rights.

EXCESS PROVISIONNo benefits are provided by the Policy for expenses whichare reimbursable by any other valid and collectibleinsurance plan, but such charges in excess thereof shall becovered as otherwise provided.

CLAIM PROCEDURESBenefits will be paid as soon as We receive proper proof ofloss unless this Policy provides for periodic payment. Whenthis Policy provides for periodic payment, the benefits willaccrue and will be paid monthly subject to proper proof ofloss.Within the forty-five (45) days following receipt of theappropriate documentation, We will either 1) makepayment for the services provided, 2) notify the provider orclaimant in writing of the reason or reasons fornonpayment, or 3) notify the provider or claimant in writing

of what additional information or documentation isnecessary to complete the claim filing. If We fail to comply,We are required to pay, in addition to any reimbursementfor health care services provided, interest on the benefitsbeginning forty-five (45) days after receipt of the properlydocumented at the rate of 1.5 percent (1.5%) per month,not to exceed eighteen percent (18%) per year. Theseprovisions do not apply to claims that a carrier isinvestigating because of suspected fraud.

There is no utilization review performed on the Policy.

Claims Administrator:CONSOLIDATED HEALTH PLANS

2077 Roosevelt AvenueSpringfield, MA 01104

(413) 733-4540 orToll Free (800) 633-7867www.chpstudent.com

Group Number: S210206

You can access up to date information about your plan,including amendments, Provider directory, privacy notice,and rights and responsibilities at this website address.

COMPLAINT AND APPEAL PROCEDURESTo file a complaint or to appeal a claim, send a letterstating the issue to Consolidated Health Plan’s AppealDepartment at the below address. Include your name,phone number, address, school attended and emailaddress, if available.

Claims Administrator:Consolidated Health Plans

2077 Roosevelt AvenueSpringfield, MA 01104

(413) 733-4540 orToll Free (800) 633-7867www.chpstudent.com

Appeals must be received within 180 days of the date thestudent receives written notification of the claim denial. Youalso have the right to appeal to the Office of PatientProtection at 1-800-436-7757, fax: 1-617-624-5046 or visitwww.state.ma.us/dph/opp.

You may request an Urgent Appeal. This request may beverbal or written. A decision will be made within seventy-

two (72) hours of receipt for an Urgent Appeal. Undercertain circumstances, You also have a right to an externalappeal of a denial of coverage.If You need help filing an internal appeal or external review,Your state’s Consumer Assistance Program (CAP) orDepartment of Insurance may be able to help You. To findhelp in Your state, go towww.HealthCare.gov/consumerhelp and click on Yourstate. The HealthCare.gov website also has informationabout other consumer protections and health carecoverage options created by the Affordable Care Act.

Servicing Broker:UNIVERSITY HEALTH PLANS, INC.

One Batterymarch ParkQuincy, MA 02169-7454Local: (617) 472-5324

Out of area: (800) 437-6448www.universityhealthplans.com

Please visit our website for frequently asked questions andanswers regarding this plan, or email us at

[email protected]

The Plan is underwritten by:NATIONWIDE LIFE INSURANCE COMPANY

Policy Number: 302-111-2013For a copy of the Company’s privacy policy go to:

www.consolidatedhealthplan.com/about/hipaa

28

VALUE ADDED SERVICES

OPTIONAL DENTAL INSURANCE PLANDeltaCare through Delta Dental

Dental Insurance Plan is available to all Eastern NazareneCollege students on an optional basis. DeltaCare works muchlike a dental HMO in which the student receives all care from anetwork of participating dentists.To enroll in this plan or to find out more information, pleasecontact University Health Plans at (800) 437-6448 or on theweb at www.universityhealthplans.com

EMERGENCY MEDICAL AND TRAVEL ASSISTANCEFrontierMEDEX ACCESS services is a comprehensiveprogram providing You with 24/7 emergency medical andtravel assistance services including emergency security orpolitical evacuation, repatriation services and other travelassistance services when you are outside Your homecountry or 100 or more miles away from your permanentresidence. FrontierMEDEX is your key to travel security.For general inquiries regarding the travel accessassistance services coverage, please call ConsolidatedHealth Plans at 1-800-633-7867.If you have a medical, security, or travel problem, simplycall FrontierMEDEX for assistance and provide your name,school name, the group number shown on your ID card,and a description of your situation. If you are in NorthAmerica, call the Assistance Center toll-free at: 1-800-527-0218 or if you are in a foreign country, call collect at: 1-410-453-6330.If the condition is an emergency, you should goimmediately to the nearest physician or hospitalwithout delay and then contact the 24-hour AssistanceCenter. FrontierMEDEX will then take the appropriateaction to assist You and monitor Your care until thesituation is resolved.

VISION DISCOUNT PROGRAMFor Vision Discount Benefits please go to:

www.chpstudent.com

EASTERN NAZARENE COLLEGE - 2015-2016 SCHEDULE OF BENEFITSIn-Network Benefit Out-of-Network Benefit

Policy Year Maximum Benefit (including medical evacuation and repatriation) UnlimitedOut-of-Pocket Maximum (includes Coinsurance, Deductible and Copayment; does not includenon-covered medical expenses or elective treatment) $6,350 Per Individual/ $12,700 per Family N/A

Preventive/Wellness & Immunization Services 100% of Preferred Allowance (PA)(Policy year deductible does not apply) 70% of Reasonable & Customary (R&C)

Outpatient Services (other than Surgery, Maternity, Mental Health/Drug or Alcohol)Physician visits 90 % of PA after $25 per visit co-pay 70% of R&C after $25 per visit co-paySpecialists and Consultants 80% of PA 80% of R&CDiagnostic X-ray and Laboratory Services; including pre-admission testing 90 % of PA 70% of R&CDiagnostic Imaging, including CT Scan, MRI, and/or PET Scans 90 % of PA 70% of R&CInpatient Services – (other than Surgery, Maternity, Mental Health/Drug or Alcohol, except as specified)Miscellaneous Hospital Services 90 % of PA 70% of R&CRoom and Board expense, at the semi-private room, general nursing care, and ICU 90 % of PA 70% of R&CPhysician Visits (includes Specialists/Consultants) 90% of PA 70% of R&CSkilled Nursing and Sub-Acute Care Facilities 90% of PA 70% of R&CSurgical Services (Inpatient & Outpatient)When multiple surgeries are performed through the same incision at the same operative session, We will pay an amount not to exceed 50% of the Benefit otherwise payable for thesubsequent procedure.Surgeon’s Fee 90% of PA 70% of R&C

Assistant Surgeon / Anesthetist Services 30% of the Surgical Allowance,Payable at 90% of PA

30% of the Surgical Allowance,Payable at 70% of PA

Second Surgical Opinion 5% of the Surgical Allowance,Payable at 90% of PA

5% of the Surgical Allowance,Payable at 70% of PA

Day Surgery Miscellaneous 90% of PA 70% of R&CMaternity Care – Includes forty-eight (48) hours of Inpatient care following a normal delivery and ninety-six (96) hours of Inpatient care following a cesarean delivery, unless after conferringwith the mother or a person responsible for the mother or newborn, the Attending Physician or a certified nurse-midwife who consults with a Physician, decides to discharge the mother ornewborn child sooner. In the event of early discharge, Home Health Care visits will be provided.Pre- and Post-Natal Care Paid the same as any other Sickness Paid the same as any other SicknessHospital services Paid the same as any other Sickness Paid the same as any other SicknessBiologically-Based and Non-Biologically Based Mental Conditions, including Alcoholism/Drug AbuseInpatient services 90% of PA 70% of R&COutpatient Office Visits 90% of PA after a $25 per visit co-pay 70% of R&C after a $25 per visit co-payUrgent Care and Emergency ServicesUrgent Care (non-Emergency) Facility Services 90% of PA after a $25 per visit co-pay 70% of R&C after a $25 per visit co-payEmergency services - visits to an Emergency room for stabilization or the initiation oftreatment for an Emergency Condition. 90% of PA after a $100 per visit co-pay 90% of R&C after a $100 per visit co-pay

Emergency Medical Transportation services 100 % of PA 100% of R&COther ServicesAllergy Testing & Treatment 90% of PA after a $25 per visit co-pay 70% of R&C after a $25 per visit co-payHabilitative care–including Physical and occupational therapy 90% of PA 70% of R&CRehabilitative Physical and Occupational Therapy (Outpatient). 90% of PA 70% of R&CChiropractic 90% of PA after a $25 per visit co-pay 70% of R&C after a $25 per visit co-payHome Health Care 90% of PA 70% of R&CHospice 90% of PA 70% of R&CInfertility 90% of PA 70% of R&CDiabetic treatment and Education Paid the same as any other SicknessDurable Medical Equipment (DME) – includes Prosthetic and Orthotic Devices 90% of PA 70% of R&C

Prescription Drug Expense (Policy year deductible does not apply) (per 30-day supply)Prescriptions must be filled at a Catamaran participating pharmacy.

$0 Co-pay for genericcontraceptives and wellnessprescriptions; or

$15 Co-pay for other genericprescriptions; or

$20 Co-pay for any brand nameprescription

Not Covered

Routine Vision Exam for Covered Persons under nineteen (19) – one exam every two (2) years.Eye glasses/contact lenses not covered. 100% of R&C up to $150, 50% thereafter

Weight Loss programs – up to $150 per Policy Year. 100% of actual ChargeScalp Hair Prostheses one (1) per policy year. 100% of Reimbursable ChargeHearing aids for children 21 years of age or younger- up to $2,000 per hearing impaired year every 36 months 90% of PA 70% of R&C

Non-Prescription Enteral Formula for Home use 90% of PA 70% of R&CElective CoverageAccidental Dental Expense (Injury to sound, natural teeth) 90% of PA 70% of R&CSickness Dental Expense ( Removal of impacted wisdom teeth) – up to $150 per tooth 80% of R&CAccidental Death & Dismemberment (Aggregate Limit of Liability)Exclusions and limitations may apply. For definitions of eligibility and complete school lossschedule, detailing the benefits received for accidental death, dismemberment, loss of sight,speech or hearing, please refer to the Master Policy available at your school.

Up to a maximum of $5,000

Intercollegiate Sports, unlimited maximum benefit per policy year. Paid as any other injury

Cambodian(Khmer)/ karRbkas sIþBIkarbMerIEpñkbkERbPasapÞal´'mat´' nigPasasresr

eyIgpþl´'CUn karbMerIEpñkbkERbPasapÞal´'mat´' nigPasasresr

RbsinebIGñkRtUvkar

enAkñúgTMrg´'kar Epñkcat´'Ecg nigTMrg''kareZVIbNþwg. ebIGñkRtUvkar

sUmTak´'TgtamTUrs&BÞ mkkariyal&y

bMerIGtiziCneyIg tamelx 1800-633-7867.

Chinese(Mandarin)/國語

翻譯及傳譯服務通知

如果您提出要求，我們可以為您提供與行政手續和索

賠申請有關的翻譯及傳譯服務。請與我們的客戶服務

部聯絡，電話是1-800-633-7867（1-800-MED-STOP ）。 English/English Notice Regarding Translator and Interpretation Services We provide, upon request, interpreter and translation services related to administrative procedures and claims processing. This service is available to you when you contact our Customer Service Department at 1-800-MED-STOP.

French/Français Avis sur les services de translation et d'interprétation Nous fournissons, sur demande, des services d'interprétation et de translation relatifs aux procédures administratives et au traitement des réclamations. Ce service est à votre disposition quand vous contactez notre service après-vente (Customer Service Department) à 1-800-MED-STOP. Greek/Ελληνικά Ειδοποίηση σχετικά µε τις υπηρεσίες µετάφρασης και διερµηνείας Παρέχουµε, κατ' απαίτηση, υπηρεσίες µετάφρασης και διερµηνείας σχετικά µε τις διοικητικές διαδικασίες και τις διεργασίες αιτήσεων. Η υπηρεσία αυτή είναι διαθέσιµη σε εσάς όταν εσείς επικοινωνείτε µε το τµήµα εξυπηρέτησης πελατών στο τηλεφωνικό αριθµό 1-800-MED-STOP. Haitian Creole/Kreyòl Avi sou sèvis tradiksyon ak entèpretasyon Nou bay, lè ou mande li, sèvis tradiksyon ak entèpretasyon pou keksyon administratif ak reklamasyon. Pou jwen sèvis sa, rele Depatman Kliyan sou nimewo 1-800-MED-STOP. Italian/Italiano Avviso Riguardante Servizi di Traduzione ed Interpretazione. Forniamo, su richiesta, servizi di interpretazione e traduzione relativi a procedure amministrative e procedimenti per reclami. Questo servizio è disponibile contattando il Servizio Assistenza Clienti al 1-800 MED-STOP.

Portuguese/Português Informação sobre serviços de Tradução e Interpretação Nós fornecemos, mediante solicitação, serviços de tradução e interpretação relacionados a procedimentos administrativos e processamento de reclamações. Este serviço encontra-se à sua disposição quando Você contatar o nosso Departamento de Atendimento ao Consumidor: 1-800-MED-STOP. Russian/Русский Объявление: услуги устных и письменных переводчиков По требованию клиентов мы предоставляем услуги устных и письменных переводчиков для оказания помощи в вопросах, связанных с административными процедурами и обработкой заявлений. Для того, чтобы воспользоваться услугами переводчика, обратитесь в Отдел обслуживания клиентов по телефону 1-800-MED-STOP. Spanish/Español Aviso sobre servicios de interpretación y traducción Nosotros podemos ofrecerle, si usted lo solicita, servicios de traducción relacionados con procedimientos administrativos y procesamiento de reclamos. Este servicio se encuentra disponible cuando usted habla con el departamento del servicio al consumidor al 1-800-MED-STOP.