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Microsoft word - sr spc-cayman sb table 15pposb-ci-2016-203165-91 v2 7-28-16.docx

2016–2017 TBOR Basic International Student Injury and Sickness Plan Endorsed by Middle Tennessee State University Who is eligible to enroll? How do I Enroll? International students or other persons with a current To enroll visit www.pghintlstudent.com, and follow passport who: 1) are engaged in educational activities; 2) are temporarily located outside his/her home country as a non-resident alien; 3) have not obtained permanent All personal e-mails sent securely from the following residency status in the U.S.; and 4) are enrolled in an associate, bachelor, master or Ph.D. degree program at a university or other educational institution, with no less than 6 credit hours (unless such school's full-time status requires Most Communication will come from less); Visiting Scholars, Optional Practical Training Students and formal English as a Second Language program students with an F-1 or J1 visa are required to purchase this Plan What important dates should I be aware of? unless proof of comparable coverage is furnished. Annual/Fall enrollment deadline: 8/30/16 *Spring enrollment deadline: 1/30/17 Students must actively attend classes for at least the first 31 *Summer enrollment deadline: 6/30/17 days after the date for which coverage is purchased with the exception of International Visiting Scholars or those Open Enrollment Periods for all Degree seeking students & engaged in an Optional Practical Training Program. Home Dependents: If you have eligible Dependents in the fall and study, correspondence and online courses do not fulfill the you choose not to enroll your dependent for coverage before Eligibility requirements that the student actively attend the Annual/Fall Enrollment Deadline, your Dependents will not be eligible to enroll again until the start of the next fall unless they experience a Qualifying Life Event during the Who can answer questions I have about the *Spring, and Summer enrollment periods are for new If you have questions please contact Customer Service at incoming students and renewing students only 888-251-6253 or [email protected] Where can I get more information about the benefits available? Please read the plan brochure to determine whether this plan is right before you enroll. The plan brochure provides details of the coverage including costs, benefits, exclusions, and reductions or limitations and the terms under which the coverage may be continued in force. Copies of the plan brochure may be downloaded at www.pghintlstudent.com. How much does the plan cost? 8/1/16 – 7/31/17 8/1/16 – 12/31/16 1/1/17 – 5/31/17 6/1/17 – 7/31/17 Student $1,184.00 Spouse $5,940.00 $2,490.00 $2,458.00 $992.00 *Refunds of premium are allowed only upon entry into the armed forces or ineligibility. This plan is underwritten by Student Resources (SPC) Ltd., a UnitedHealth Group Company and is based on policy number 2016-203117-91. Available through PGH Global and issued to IHC-SP-TBOR Intl Student Care under policy number 2016-203165-91. The Policy is a Non-Renewable One Year Term Policy. 15PPOSB-CI-2016-203165-91 Page 1 of 4 Student Resources (SPC) Ltd., Highlights of the Coverage and Services offered by StudentResources (SPC) Ltd., a UnitedHealth Group Company Preferred Providers Out-of-Network Providers Overall Plan Maximum Up to a $500,000 Maximum Benefit (For each Injury or Sickness) $100 per Insured Person, per Policy $500 per Insured Person, per Policy Year Out-of-Pocket Maximum $10,000 Per Insured Person, Per There is no Out-of-Pocket Maximum After the Out-of-Pocket Maximum has been for Out-of-Network benefits. satisfied, Covered Medical Expenses will be paid at 100% for the remainder of the Policy Year subject to any applicable benefit maximums. Refer to the plan brochure for details about how the Out-of-Pocket Maximum applies. 80% of Preferred Allowance for 70% of Usual and Customary Charges All benefits are subject to satisfaction of the Covered Medical Expenses for Covered Medical Expenses Deductible, specific benefit limitations, maximums and Copays as described in the plan brochure. Prescription Drugs $20 Copay for Tier 1 Prescriptions must be filled at a UHCP 30% Coinsurance for Tier 2 network pharmacy. Mail order through UHCP 40% Coinsurance for Tier 3 at 2.5 times the retail Copay up to a 90 day Up to a 31-day supply per prescription filled at a UnitedHealthcare Pharmacy (UHCP) Preventive Care Services 100% of Preferred Allowance Including but not limited to: annual physicals, $1,000 maximum, per policy year GYN exams, routine screenings and immunizations. No Copay or Deductible when the services are received from a Preferred Provider. Preventive care limits apply based on age and risk group factors. The following services have per Service Physician's Visits: $30 Medical Emergency: $100 Copays/Deductibles Medical Emergency: $100 This list is not all inclusive. Please read the plan brochure for complete listing of Copays/Deductibles. UnitedHealthcare Global: Global International Students are covered worldwide except in their home country. Emergency Services Preferred Providers The Preferred Provider Network for this plan is UnitedHealthcare Options PPO. Preferred Providers can be found using the following link: www.pghintlstudent.com. Online Services 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.pghintlstudent.com. To create an online account, select the "My Account" link and follow the simple, onscreen directions. All you need is your 7-digit Insurance ID number or the email address on file. Insureds can also download our UHCSR Mobile App available on Google Play and Apple's App Store. 15PPOSB-CI-2016-203165-91 Page 2 of 4 Student Resources (SPC) Ltd., Healthiest You: National Telehealth Service their target heart rate and BMI, and participate in Starting on the effective date of your policy, you have 24/7 personalized self-help programs. More information about access to medical advice through HealthiestYou, a national these services is available by logging into My Account at telehealth service. By calling the toll-free number listed on www.pghintlstudent.com. the front of your medical ID card or visiting www.pghintlstudent.com, you have access to board- PRE-EXISTING CONDITION means: 1) the existence of certified physicians via phone and/or video, where symptoms which would cause an ordinarily prudent person permitted. This service is especially helpful for minor to seek diagnosis, care or treatment within the 6 months illnesses, such as allergies, sore throat, earache, pink eye, immediately prior to the Insured's Effective Date under the etc. Based on the condition being treated, the doctor can policy; or, 2) any condition which is diagnosed, treated or also prescribe certain medications, saving you a trip to the recommended for treatment within the 6 months doctor's office. Using HealthiestYou can save you money immediately prior to the Insured's Effective Date under the and time, while avoiding costly trips to a doctor's office, urgent care facility, or emergency room. As an insured with StudentResources (SPC) Ltd., A UnitedHealth Group Exclusions and Limitations: Company, there is no consultation fee for this service.* Every No benefits will be paid for: a) loss or expense caused by, call with a HealthiestYou doctor is covered 100% during contributed to, or resulting from; or b) treatment, services or your policy period. supplies for, at, or related to any of the following: This service is meant to compliment your Student Health Center. If possible, we encourage you to visit your SHC first Addiction, such as: nicotine addiction, except as before using this service. Depending on your school's set- specifically provided in the policy; and caffeine up, your call may be routed to the Student Health Center addiction; non-chemical addiction, such as: gambling, during their business hours for further assistance. sexual, spending, shopping, working and religious; HealthiestYou is not health insurance. HealthiestYou is designed to complement, and not replace, the care you receive from your primary care physician. HealthiestYou Cosmetic procedures, except cosmetic surgery physicians are an independent network of doctors who required to correct an Injury for which benefits are advise, diagnose, and prescribe at their own discretion. otherwise payable under this policy or for newborn or HealthiestYou physicians provide cross coverage and adopted children; operate subject to state regulations. Physicians in the 7. Custodial Care; care provided in: rest homes, health independent network do not prescribe DEA controlled resorts, homes for the aged, halfway houses, college substances, non-therapeutic drugs and certain other drugs infirmaries or places mainly for domiciliary or Custodial which may be harmful because of their potential for abuse. Care; extended care in treatment or substance abuse HealthiestYou does not guarantee that a prescription will be facilities for domiciliary or Custodial Care; written. Not available in Arkansas; limited services in 8. Dental treatment, except for accidental Injury to Sound, California, Idaho, Iowa, Louisiana, and Texas. 9. Elective Surgery or Elective Treatment; *If you are an Insured under this insurance Plan, and you 10. Eye examinations, eye refractions, eyeglasses, contact call prior to the plan effective date, you will be charged a lenses, prescriptions or fitting of eyeglasses or contact $40 service fee before being connected to a board- lenses, vision correction surgery, or other treatment for certified physician. visual defects and problems; except when due to a covered Injury or disease process; Student Assistance Routine foot care including the care, cutting and Insureds have immediate access to the Student Assistance removal of corns, calluses, and bunions (except Program, a service that coordinates care using a network of capsular or bone surgery); resources. Services available include counseling, financial 12. Health spa or similar facilities; strengthening programs; and legal advice, as well as mediation. Counseling services 13. Immunizations, except as specifically provided in the are offered by Licensed Clinicians who can provide insureds policy; preventive medicines or vaccines, except where with someone to talk to when everyday issues become required for treatment of a covered Injury or as overwhelming. Financial services, provided by licensed specifically provided in the policy. CPA's and Certified Financial Planners offer consultations 14. Injury or Sickness for which benefits are paid or payable on issues such as financial planning, credit and collection under any Workers' Compensation or Occupational issues, home buying and renting and more. Legal Services Disease Law or Act, or similar legislation; are provided by fully credentialed attorneys with at least 5 15. Injury or Sickness inside the Insured's home country; years of experience practicing law. Mediation services are 16. Injury or sickness outside the United States and its available to help resolve family-related disputes. Translation possessions, except when traveling for academic study services are available in over 170 languages for most abroad programs, business or pleasure, or to or from the Insureds also have access to Insured's home country; LiveAndWorkWell.com where they can take health risk assessments, use health estimators to calculate things like 15PPOSB-CI-2016-203165-91 Page 3 of 4 Student Resources (SPC) Ltd.,

Injury or Sickness when claims payment and/or 23. Reproductive/Infertility services including but not limited coverage is prohibited by applicable law; to: family planning; fertility tests; infertility (male or Injury sustained while (a) participating in any female), including any services or supplies rendered for interscholastic, intercollegiate or professional sport, the purpose or with the intent of inducing conception; contest or competition; (b) traveling to or from such premarital examinations; impotence, organic or sport, contest or competition as a participant; or (c) otherwise; female sterilization procedures, except as while participating in any practice or conditioning specifically provided in the policy; vasectomy; sexual program for such sport, contest or competition; reassignment surgery; reversal of sterilization 19. Investigational services; 20. Participation in a riot or civil disorder; commission of or 24. Research or examinations relating to research studies, attempt to commit a felony; or any treatment for which the patient or the patient's 21. Pre-existing Conditions in excess of $1,000, except for representative must sign an informed consent individuals who have been continuously insured under document identifying the treatment in which the patient the student insurance policy for at least 6 consecutive is to participate as a research study or clinical research months. The Pre-existing Condition exclusionary period will be reduced by the total number of months that the 25. Routine Newborn Infant Care, well-baby nursery and Insured provides documentation of continuous related Physician charges; in excess of 48 hours for coverage under a prior health insurance policy which vaginal delivery or 96 hours for cesarean delivery; provided benefits similar to this policy provided the 26. Preventive care services; routine physical examinations coverage was continuous to a date within 63 days prior and routine testing; preventive testing or treatment; to the Insured's effective date under this policy; screening exams or testing in the absence of Injury or 22. Prescription Drugs, services or supplies as follows: Sickness, except as specifically provided in the policy; Therapeutic devices or appliances, including: Services provided normally without charge by the hypodermic needles, syringes, support garments Health Service of the institution attended by the Insured; and other non-medical substances, regardless of or services covered or provided by a student health fee; intended use, except as specifically provided in the 28. Deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus Immunization agents, except as specifically surgery, except for treatment of a covered Injury or provided in the policy, biological sera, blood or treatment of chronic purulent sinusitis; blood products administered on an outpatient 29. Supplies, except as specifically provided in the policy; 30. Surgical breast reduction, breast augmentation, breast c) Drugs labeled, "Caution - limited by federal law to implants or breast prosthetic devices, or gynecomastia; investigational use" or experimental drugs; except as specifically provided in the policy; d) Products used for cosmetic purposes; 31. Treatment in a Government hospital, unless there is a e) Drugs used to treat or cure baldness; anabolic legal obligation for the Insured Person to pay for such steroids used for body building; f) Anorectics - drugs used for the purpose of weight 32. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium g) Fertility agents or sexual enhancement drugs, such will be refunded upon request for such period not as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; Weight management, weight reduction, nutrition h) Growth hormones; or programs, treatment for obesity, surgery for removal of Refills in excess of the number specified or excess skin or fat, except as specifically provided in the dispensed after one (1) year of date of the NOTE: The information contained herein is a summary of certain benefits which are offered under a student health insurance policy issued by Student Resources (SPC) Ltd., a UnitedHealth Group Company. This document is a summary only and may not contain a full or complete recitation of the benefits and restrictions/exclusions associated with the relevant policy of insurance. This document is not an insurance policy document and your receipt of this document does not constitute the issuance or delivery of a policy of insurance. Neither you nor Student Resources (SPC) Ltd., a UnitedHealth Group Company has any rights or responsibilities associated with your receipt of this document. Changes in federal, state or other applicable legislation or regulation or changes in Plan design required by the applicable state regulatory authority may result in differences between this summary and the actual policy of insurance. 15PPOSB-CI-2016-203165-91 Page 4 of 4 Student Resources (SPC) Ltd.,

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