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2012-201337-2 preliminary benefit summary-v2_benefit summary

Student Injury and Sickness
Insurance Plan for Connecticut Community-
Technical Colleges

2012-2013
Connecticut Community-Technical Colleges is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company. All enrolled students are eligible to enroll in the Optional 24-Hour Injury and Sickness Plan on a voluntary basis. Eligible Dependents of students enrolled in the Optional plan may also enroll on a voluntary basis.
2012-201337-2. *Policy terms andconditions subject to regulatoryapproval.
Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
● Up to $100,000 Per Insured Person, Per Policy Year Maximum Benefit for Covered Medical Expenses.
● $1,000 Deductible for Preferred Providers Per Insured Person, Per Policy Year, $2,000 Deductible for you enroll. The certificate of Out of Network Providers Per Insured Person, Per Policy Year.
● Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and coverage including costs, Out of Network benefits are payable at 60% of Usual and Customary charges (all benefits are subject to satisfaction of the Deductible, specific benefit limitations, maximums and copays as described in the ● Preferred Provider Out-of-Pocket Maximum of $10,000 Per Insured Person, Per Policy Year. Out-of- may be continued in force. Copies Network Out-of-Pocket maximum of $15,000 Per Insured Person, Per Policy Year. After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses will be paid at 100% up to the policy Maximum Benefit subject to any applicable benefit maximums. Refer to the plan certificate for details about how the ● Prescription Drug Benefits: $15 copay for Tier 1 / $35 copay for Tier 2 / $70 copay for Tier 3 up to a 31-day supply per prescription filled at a UnitedHealthcare Network Pharmacy (UHPS).
Prescriptions must be filled at a UHPS network pharmacy. Mail order through UHPS at 2.5 times the ● Coverage available for eligible Dependents.
● The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can The Policy is a Non-Renewable http://www.uhcsr.com/lookupredirect.aspx?delsys=52.
● Scholastic Emergency Services – Domestic Students are covered when 100 miles or more away from their campus or home address. International Students are covered worldwide except in their homecountry.
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 $100,000 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 1-800-767-0700. 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
Each Child
Pre-existing Condition means any condition which is diagnosed, treated or
employment and was continuous to a date not more than 150 days prior to their recommended for treatment within the 12 months immediately prior to the effective date under this policy. This Pre-existing Condition Limitation will not Insured's effective Date under the policy. Routine follow-up care to determine apply to (a) newly Insured Persons who were covered for such Pre-existing whether a breast cancer has reoccurred in a person who has been previously Conditions, under previous Qualifying Coverage when (a) the preceding determined to be breast cancer free shall not be considered as medical advice, diagnosis, care or treatment unless evidence of breast cancer is found during or Qualifying Coverage was continuous to a date not less than 120 days prior to as a result of such follow-up. Genetic information shall not be treated as a their effective date under this policy; or (b) newly Insured Persons who apply condition in the absence of a diagnosis of the condition related to such within 30 days of initial eligibility under this policy and whose previous Qualifying information. Pregnancy shall not be considered a pre-existing condition.
Coverage was terminated due to the involuntary loss of employment and was Exclusions and Limitations
continuous to a date not more than 150 days prior to their effective date under No benefits will be paid for: a) loss or expense caused by, contributed to, or this policy; (This exclusion will not be applied to an Insured Person who is under resulting from; or b) treatment, services or supplies for, at, or related to: Acne; acupuncture; allergy, including allergy testing; except as specifically 28. Prescription Drugs, services or supplies as follows: a) Therapeutic devices or appliances, including: hypodermic needles and Milieu therapy, learning disabilities, behavioral problems, parent-child problems, syringes, except for hypodermic needles or syringes prescribed by a conceptual handicap, developmental delay or mental retardation, except as Physician for the purpose of administering medications for medical specifically provided in the policy; except as specifically provided in the Benefits conditions, provided such medications are covered under the policy, support garments and other non-medical substances; b) Immunization agents, biological sera, blood or blood products Congenital conditions, except as specifically provided for Newborn or adopted c) Drugs labeled, “Caution - limited by federal law to investigational use” or experimental drugs except for drugs for the treatment of cancer that Cosmetic procedures, except cosmetic surgery required to correct an Injury for have not been approved by the Federal Food and Drug Administration, which benefits are otherwise payable under this policy, or for newborn or provided the drug is recognized for treatment of the specific type of adopted children; removal of warts, non-malignant moles and lesions; cancer for which the drug has been prescribed in one of the following Custodial care; care provided in: rest homes, health resorts, homes for the aged, established reference compendia: (1) The U.S. Pharmacopeia Drug halfway houses, college infirmaries or places mainly for domiciliary or custodial Information Guide for the Health Care Professional (USP DI); (2) The care; extended care in treatment or substance abuse facilities for domiciliary or American Medical Association’s Drug Evaluations (AMA DE); or (3) The American Society of Hospital Pharmacist’s American Hospital Dental treatment, except as specifically provided in the Policy; Formulary Service Drug Information (AHFS-DI); e) Drugs used to treat or cure baldness; anabolic steroids used for body 11. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other f) Anorectics - drugs used for the purpose of weight control; treatment for visual defects and problems; except when due to a disease g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; except as 12. Foot care including: flat foot conditions, supportive devices for the foot, care of specifically provided in the Benefits for Infertility Treatment; corns, bunions (except capsular or bone surgery), calluses, toenails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet; i) Refills in excess of the number specified or dispensed after one (1) year 13. Health spa or similar facilities; strengthening programs; 14. Hearing examinations or hearing aids, except as specifically provided in the 29. Reproductive/Infertility services including but not limited to: family planning; Benefits for Hearing Aids for Children; or other treatment for hearing defects and fertility tests; infertility (male or female), including any services or supplies problems. “Hearing defects” means any physical defect of the ear which does rendered for the purpose or with the intent of inducing conception, except as or can impair normal hearing, apart from the disease process; specifically provided in the Benefits for Infertility Treatment; premarital examinations; impotence, organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal of sterilization procedures; Immunizations, except as specifically provided in the policy or Benefits for 30. Research or examinations relating to research studies, or any treatment for which Preventive Pediatric Care; preventive medicines or vaccines, except where the patient or the patient’s representative must sign an informed consent required for treatment of a covered Injury or as specifically provided in the policy; document identifying the treatment in which the patient is to participate as a 18. For Accidental Death and Dismemberment Benefit only, no indemnity will be paid research study or clinical research study, except for a procedure, treatment or for loss caused by the voluntary use of any controlled substance as defined in Title the use of any drug as experimental if such procedure, treatment or drug, for the II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now Sickness or condition being treated, or for the diagnosis for which it is being or hereafter amended, unless as prescribed by his Physician for the Insured; prescribed, has successfully completed a Phase III clinical trial of the Federal 19. Injury or Sickness for which benefits are paid or payable under any Workers' Food and Drug Administration; except as specifically provided in the policy; Compensation or Occupational Disease Law or Act, or similar legislation; 31. Routine Newborn Infant Care, well-baby nursery and related Physician charges; 20. Injury or Sickness outside the United States and its possessions, Canada or except as specifically provided in the policy; Mexico, except for a Medical Emergency when traveling for academic study 32. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; 21. Injury sustained by reason of a motor vehicle accident to the extent that benefits except as specifically provided in the policy; are paid or payable by any other valid and collectible insurance; 33. Services provided without charge by the Health Service of the Policyholder; or 22. Injury sustained while (a) participating in any intercollegiate or professional sport, services covered or provided by the student health fee for which the Insured is contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participating in any practice or conditioning program 34. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia, except as specifically provided in the Benefits for Treatment of Craniofacial Disorders; temporomandibular joint dysfunction; deviated nasal septum, including submucous resection and/or other surgical correction thereof; 25. Outpatient Physiotherapy; except for a condition that required surgery or nasal and sinus surgery; except for treatment of chronic purulent sinusitis; Hospital Confinement: 1) within the 30 days immediately preceding such 35. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, Physiotherapy; or 2) within the 30 days immediately following the attending bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 26. Participation in a riot, civil disorder or a felony, except when Injury occurs when the Insured Person has an elevated blood alcohol content or when under the influence of intoxicating liquor or any drug or both. Participation means to 38. Injury resulting from suicide or attempted suicide while sane or insane (including voluntarily take a part or share with others assembled together in some activity.
intentional drug overdose); or intentionally self-inflicted Injury; Riot means a violent public disturbance of the peace by a number of persons 39. Supplies, except as specifically provided in the policy; 40. Surgical breast reduction, breast augmentation, breast implants or breast Pre-existing Conditions for a period of 12 months except for congenital prosthetic devices, or gynecomastia; except as specifically provided in the anomalies of a Newborn Infant or, except for individuals who have been Benefits for Reconstructive Breast Surgery and Benefits for Treatment of Tumors continuously insured under the school's student insurance policy for at least 12 consecutive months. Credit will be given for Pre-existing Conditions for newly 41. Treatment in a Government hospital for which the Insured is not charged, unless Insured Persons who were covered under previous Qualifying Coverage, but not there is a legal obligation for the Insured Person to pay for such treatment; covered for such Pre-existing Conditions under the Qualifying Coverage when 42. War or any act of war, declared or undeclared; or while in the armed forces of (a) the preceding Qualifying Coverage was continuous to a date not less than any country (a pro-rata premium will be refunded upon request for such period 120 days prior to their effective date under this policy; and for (b) newly Insured Persons who apply within 30 days of initial eligibility under this policy and whose 43. Weight management, weight reduction, nutrition programs, treatment for obesity, previous Qualifying Coverage was terminated due to the involuntary loss of except surgery for morbid obesity, surgery for removal of excess skin or fat.

Source: http://www.hcc.commnet.edu/resources/insurance/2012-201337-2%20Preliminary%20Benefit_Summary-v2.pdf

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