StudentResources Wake Forest University School of Medicine 2015–2016 Student Injury and Sickness Insurance Plan 15COL3322 Slide 1 of 15

StudentResources

Wake Forest UniversitySchool of Medicine2015–2016 Student Injury and Sickness Insurance Plan

15COL3322Slide 1 of 15

Rates

Slide 2 of 15 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group

This plan is underwritten by UnitedHealthcare Insurance Company and is based on Policy #2015-200275-1. For a full description of coverage, including costs, benefits, exclusions, any reductions or limitations and terms under which the policy may be continued in force, log on to www.uhcsr.com/wfsom.

2015–2016 Monthly Rates

Student $272

Spouse $272

One Child $272

Two or More Children $544

Spouse + Two or More Children $816

Plan Changes


Out-of-Network Coinsurance has increased from 60% of Usual and Customary to 70% of Usual and Customary for Outpatient Physician’s Visitsand Preventive Care Services.

Plan Highlights


• No Overall Maximum Benefit for Covered Medical Expenses (per Insured Person, per Policy Year).

• Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and Out-of-Network benefits are payable at 60% of Usual and Customary Charges (all benefits are subject to satisfaction of any deductible, specific benefit limitations, maximums, and copays as described in the policy).

• Coverage is available for eligible Dependents of students who participate in the plan.

Plan/Benefit Highlights


Benefits Preferred Providers Out-of-Network

Hospitalization 80% of PA 60% of U&C

Surgery 80% of PA 60% of U&C

Outpatient Services 80% of PA 60% of U&C

Medical Emergency Expenses

$150 Copay per visit, 80% of PA

$150 deductible per visit, 80% of U&C

Physician’s Office Visit $35 copay, 100% of PA$35 deductible, 70% of

U&C

Preventive Care and Immunizations

100%, no cost sharing 70% of U&C

PA=Preferred Allowance U&C=Usual and Customary Charges



Benefits Preferred Providers Out-of-Network

Dental Injury (to sound, natural teeth only)

100% of PA 100% of U&C

Mental Illness (Inpatient and Outpatient)

Paid as any other sickness


Substance Use Disorder (Inpatient and Outpatient)



Ambulance Expense

80% of PA 80% of U&C

X-ray/Laboratory/Tests & Procedures

$30 copay, 80% of PA$30 deductible, 60% of

U&C

PA=Preferred Allowance U&C=Usual and Customary Charges

Prescription Drug Highlights


• UnitedHealthcare Pharmacy (UHCP) Prescription Drug Benefits:

► $10 copay for Tier 1, $25 copay for Tier 2, $50 copay for Tier 3; up to a 31-day supply per prescription. (Mail order Prescription Drugs through UHCP at 2.5 times the retail Copay up to a 90-day supply.) (If a retail UnitedHealthcare Network Pharmacy agrees to the same rates, terms and requirements associated with dispensing a 90-day supply, then up to a consecutive 90-day supply of a Prescription Drug Product at 2.5 times the Copay that applies to a 31-day supply per prescription.)

• $10 Deductible per prescription for generic, $25 Deductible per prescription for brand name; up to a 31-day supply per prescription at an Out-of-Network pharmacy.

Provider Network


• The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can be found using the following link: www.uhcsr.com/wfsom.

Region Providers Hospitals

Central 242,317 2,156

Northeast 211,180 1,004

Southeast 146,055 1,241

West 153,456 930

Leased 44,988 366

Total 798,087 5,701

Provider counts as of May 2015.

Global Emergency Services


UnitedHealthcare Global• Domestic students are covered when they’re

100 miles or more away from their campus or home address. International students are covered worldwide except in their home country.

• Provides medical evacuation and repatriation benefits.

• Must be contacted prior to receiving services and information is on the medical ID card.

My Account


With My Account, available through www.uhcsr.com/wfsom, insured students can securely:

• Review plan coverage details online

• Print an ID card and/or request a replacement ID card

• Check claim status and review EOB (Explanation of Benefits)

• Find a Preferred Provider

• Update personal information

• Contact UHCSR with a question/comment

• Access helpful resources and forms

UHCSR Mobile App


With the free UHCSR Mobile App, available at GooglePlay and Apple’s AppStore, you’ll have access to the most popular self-service features like:

• Viewing and sharing your ID card. You can even email or fax it to your provider.

• Viewing claims received within the prior 60 days.

• Searching for a Preferred Provider.

• Accessing your custom My Account page.

UnitedHealth Allies®


• Included with every policy, the UnitedHealth Allies discount program typically saves members 5–50% on many health and wellness products and services.

• Members save on dental and vision care, fitness club memberships, weight management programs, smoking cessation, massage therapy, and much more.

The UnitedHealth Allies Discount Program is administered by HealthAllies, Inc., a discount medical plan organization. This discount program is not a qualified health plan under the Affordable Care Act. UnitedHealth Allies discount plan is NOT insurance.

Understanding your ID Card


SR ID#This is the Member

Identification number your provider will need to confirm

your benefits.

Group NameThis is the Group Identifier your provider will need to

confirm your benefits.

Plan NameThis is the plan name you

need to provide to physicians or when online.

Download your electronic ID Card with either My Account or the UHCSR Mobile App.



Submitting a Claim• Providers will typically file claims on your behalf.

• You don’t need a company claim form to file a claim.

• If you receive services from a provider who would like payment upfront, simply send (within 90 days of sickness or injury) all medical and hospital bills, along with the patient’s name,address, and SR ID number to this address.

• If you prefer to fax your claim, the number is 469-229-5510.

Send claims to:

UnitedHealthcareStudentResourcesPO Box 809025Dallas, TX 75380-9025

Questions?Please contact UHCSR Customer Service at:

888-251-6259or email at:

[email protected]

UnitedHealthcare StudentResourcesSlide 15 of 15

Documents

StudentResources Wake Forest University School of Medicine 2015–2016 Student Injury and Sickness Insurance Plan 15COL3322 Slide 1 of 15