PLAN BROCHURE ADDENDUM

Transcription

1 Touro University Nevada Campus Only Student Health Insurance Plan (SHIP) PLATINUM Level Plan Please Note: This Brochure addendum is being provided for Touro University Students enrolled in programs at the Nevada Campus. Insurance regulations differ by state, and this addendum, which includes changes to the Schedule of Benefits as well as Exclusions, serves to highlight the differences between Nevada and California insurance requirements. For all students attending classes in Nevada, the provisions included herein will supercede the plan Brochure provisions previously published in the Touro University SHIP Brochure. This plan will also cover any additional benefit mandated by the State of Nevada not currently listed here. PLAN BROCHURE ADDENDUM For all additional provisions related to this plan, please continue to refer to the Touro University SHIP Brochure. Policy Number: To download an ID card or for further information on this plan, visit: Underwritten by: Nationwide Life Insurance Company

2 SCHEDULE OF BENEFITS Maximum Benefit: PPO (In-Network) unlimited (except where noted) NON-PPO (Out-of-Network) Deductible: $250 per policy year $500 per policy year Benefits are subject to Deductible unless otherwise indicated. The Deductible shall not apply to: Preventive/wellness exams and immunizations Routine Antibody Titers testing Outpatient Prescription Drugs Copayments do not apply to Deductibles. Insured Percent: 100% of the Preferred Allowance (PA) 60% of Reasonable and Customary Charges (R&C) Office Visit Copay: $20 per visit $40 per visit Urgent Care Copay: $20 per visit $40 per visit Emergency Room Copay: Out-of Pocket Maximum: $150 per visit (waived if admitted to Hospital) $4,000 per policy year (combined total for PPO or non-ppo) Includes Coinsurance, Copayments and Deductibles Excludes Pre-Certification Penalty, and non-covered medical expenses Any Coinsurance paid by You is applied to the Out-of-Pocket Limit per Policy Year Once the Out-of-Pocket Maximum is reached by the Covered Person, the Insured Percent paid by the Company will increase to 100% In-Network and Out-of-Network up to the Policy Year Maximum Benefit as specified herein Covered Charges are paid at 100% of Preferred Allowance (PA) for PPO and 60% of Reasonable & Customary (R&C) for non-ppo, unless otherwise indicated, and include the following, subject to the limitations indicated above or below. The Covered Person is responsible for paying the Deductible amount listed before the Company will begin paying benefits, except as indicated below. PREVENTIVE CARE PPO NON-PPO Well Adult Care includes screening for certain conditions such as: cancer, high cholesterol, depression, diabetes, obesity, and sexually transmitted diseases; only as recommended by the U.S. Department of Health and Human Services (see Preventive/Wellness definition for further detail) Immunizations includes but not limited to: flu shot, tetanus, diphtheria, pertussis, Tdap, hepatitis A, hepatitis B, HPV, measles-mumps-rubella, pneumonia, varicella, meningococcal; only as recommended by the U.S. Centers for Disease Control and Prevention DEDUCTIBLE & COPAY WAIVED DEDUCTIBLE & COPAY WAIVED INPATIENT PPO NON-PPO Hospital Confinement/Room and Board and Hospital Miscellaneous daily average semi-private room rate and general nursing care provided by a Hospital; Hospital miscellaneous expenses, such as the cost of the operating room, laboratory tests, X-ray examinations including professional fees, anesthesia, physical therapy, drugs (excluding take-home drugs) or medicines, therapeutic services and supplies. Includes intensive care. Maternity and Newborn Care while Hospital Confined, and routine nursery care provided immediately after birth, up to 48 hours after birth (96 hours for cesarean delivery) Registered Nurse Expense private-duty nursing care Surgeon s Fees if multiple procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 25% of all subsequent procedures Assistant Surgeon Pre-certification is required for all inpatient services. If the Covered Person does not secure Pre-Certification for non-emergency admissions or provide notification of an Emergency admission, the Company will reduce payment for such claims by $750 of the Covered Charges. See full Plan Brochure for more details. Page 2

3 SCHEDULE OF BENEFITS (continued) INPATIENT (continued) PPO NON-PPO Anesthetist professional services in connection with inpatient surgery Pre-Admission Testing if testing occurs within 3 working days prior to admission Doctor Visits Treatment of Mental Conditions / Substance Use Disorder OUTPATIENT PPO NON-PPO Office Visits including Evaluation and Management and diagnostic services performed and billed by a Physician s office, including Family or General Practice, Pediatrician, Internal Medicine or OB/GYN when acting as a primary care Physician; does not apply when related to surgery or Physical Therapy Specialists (other than Family or General Practice, Pediatrician, Internal Medicine or OB/GYN when acting as a primary care Physician); does not apply when related to surgery or Physical Therapy Consulting Physician Emergency Expense use of emergency room and supplies Urgent Care Surgeon s Fees if multiple procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed 50% of the second procedure and 25% of all subsequent procedures after $150 Copay per visit (waived if admitted) 100% of R&C* after $150 Copay per visit (waived if admitted) Assistant Surgeon Anesthetist professional services in connection with outpatient surgery Day Surgery Miscellaneous Rehabilitative and Habilitative Therapy when prescribed by attending Doctor Chiropractic Treatment or Osteopathic Manipulative Medicine (OMM) when prescribed by attending Doctor; limited to 20 visits per policy year Treatment of Mental Conditions / Substance Use Disorder after $20 copay per visit after $40 copay per visit Diagnostic X-Ray and Laboratory Services Radiation Therapy and Chemotherapy Allergy Testing and Treatment Tests and Procedures diagnostic services and medical procedures performed by a Doctor other than Doctor s visits, physical therapy, X-rays, and lab procedures Pre-certification is required for all inpatient services. If the Covered Person does not secure Pre-Certification for non-emergency admissions or provide notification of an Emergency admission, the Company will reduce payment for such claims by $750 of the Covered Charges. See full Plan Brochure for more details. * Emergency Care received by non-ppo providers and/or facilities will be paid at 100% of R&C. However, charges in excess of R&C are still the responsibility of the Covered Person. Page 3

4 SCHEDULE OF BENEFITS (continued) OTHER PPO NON-PPO Routine Antibody Titers Testing Ambulance Services Durable Medical Equipment/Braces and Appliances/ Prosthetic Devices DEDUCTIBLE & COPAY WAIVED 100% of R&C 100% of R&C Podiatry TMJ Treatment treatment for the dysfunction of the temporomandibular joints, including surgery of the jaw to correct or treat TMJ Pediatric Dental Care limited to Covered Persons under the age of 19; includes coverage for preventive and diagnostic, basic restorative, major, and medically necessary orthodontia services; waiting periods and other limitations may apply; pre-authorization is required for major and orthodontic care; benefits are subject to the medical Deductible and Out-of-Pocket Maximum; see definition for further information Pediatric Vision Care limited to Covered Persons under the age of 19; includes one exam/fitting per policy year, including prescription eyeglasses (lenses and frames, limited to one per year) or contact lenses (in lieu of eyeglasses) Hearing Aids limited to one (1) hearing aid per hearing impaired ear per plan year; repairs and replacements are limited to once every three (3) years Pregnancy including complications of pregnancy Infertility Services includes limited laboratory studies, diagnostic procedures, and infertility office visit evaluation; fertility treatments are limited to six (6) artificial insemination cycles per lifetime Approved Clinical Trials for life-threatening disease or condition 100% of R&C for preventive & diagnostic services 70% of R&C for restorative services 50% of R&C for major services and medically necessary orthodontia 100% of actual charges up to $150 then 60% thereafter Paid as any other Sickness Paid as any other Sickness ELECTIVE SERVICES PPO NON-PPO Elective Termination of Pregnancy Acupuncture Dental Treatment for Injury to Sound Natural Teeth only Repair or Replacement of Eyeglasses, Contact Lenses, or Hearing Aids when required as a direct result of an Injury 100% of R&C Voluntary Sterilization (Vasectomy) Diagnosis and Treatment of Sleep Disorders Repatriation of Remains $50,000 DEDUCTIBLE WAIVED Emergency Medical Evacuation $50,000 DEDUCTIBLE WAIVED Out-of-Country Coverage non-emergency medical treatment, if not covered by any other coverage Subject to 12-month waiting period for services and requires pre-authorization. Page 4

5 SCHEDULE OF BENEFITS (continued) OUTPATIENT PRESCRIPTION DRUGS Only a thirty (30) day supply can be dispensed at any time (certain exceptions apply as specified by the retail pharmacy). One (1) Copayment per thirty (30) day supply. No cost sharing applies to Generic Contraceptives or other Preventive Services drugs. Includes prescription contraceptives which have been approved by the FDA, prescribed pre-natal vitamins, and smoking deterrent prescription medications. Includes medications, equipment and supplies for the management and treatment of diabetes. The Deductible does not apply. The Covered Person will be responsible for the cost difference between Brand and Generic, in addition to the Tier 2 Copayment for a Brand drug when there is a Generic equivalent available unless Do Not Substitute or Dispense as Written is indicated on the prescription. The cost sharing for orally administered chemotherapy will not exceed $100 per prescription. You must show your insurance ID Card to the pharmacist. Normally there are no claims to file. If you forget your ID Card, you may be asked to file a claim form for reimbursement. Save your receipts and go to for a claim form. EXPRESS SCRIPTS PHARMACIES ONLY Generic: $20 Copay Preferred Brand Name: $35 Copay Non-preferred Brand Name: $60 Copay DEDUCTIBLE WAIVED ONLY PRESCRIPTIONS FILLED AT AN EXPRESS SCRIPTS PHARMACY ARE COVERED To locate an Express Scripts pharmacy, call or visit GENERAL EXCLUSIONS Unless otherwise specifically included, no benefits will be paid for loss or expense caused by, contributed to, or resulting from, or treatment, services, or supplies for, at, or related to: 1. Eyeglasses, contact lenses, routine eye refractions, eye examinations, or radial keratotomy or similar surgical procedures to correct vision; except when required as a direct result of an Injury. This exclusion does not pertain to the Pediatric Vision Services provided herein. 2. Hearing Screenings or hearing examinations or hearing aids and the fitting or repairing of hearing aids, except in the case of Accident or Injury or as specifically provided in the Policy. 3. Cosmetic treatment, cosmetic surgery, plastic surgery, resulting complications, consequences, and aftereffects or other services and supplies that the Company determines to be furnished primarily to improve appearance rather than a physical function or control of organic disease, except as provided herein or for treatment of an Injury that is covered under the Policy. Improvements of physical function does not include improvement of self-esteem, personal concept of body image, or relief of social, emotional, or psychological distress. Procedures not covered include but are not limited to: face-lifts; sagging eyelids; prominent ears; skin scars; warts, nonmalignant moles and lesions, unless Medically Necessary; hair growth; hair removal; correction of breast size, asymmetry, or shape by means of reduction, augmentation, or breast implants (except for correction of deformity resulting from mastectomies or lymph node dissections); and deviated nasal septum, including submucous resection, except Medically Necessary treatment of acute purulent sinusitis. This exclusion does not include reconstructive surgery when the service is incidental to or follows surgery resulting from trauma, Injury, infection, or other diseases of the involved part. 4. Treatment, service, or supply that is not Medically Necessary for the diagnosis, care, or treatment of the Sickness or Injury involved, except as specified herein. 5. Treatments that are considered to be unsafe, Experimental, or Investigational by the American Medical Association (AMA) and resulting complications, except in connection with an Approved Clinical Trial. 6. Custodial care; care provided in a rest home or home for the aged. 7. Dental care or treatment of the teeth, gums, or structures directly supporting the teeth, including surgical extractions of the teeth, except as specified herein. 8. Injury sustained while (a) participating in any intercollegiate, professional or club sport, 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 for such sport, contest, or competition, unless no other coverage exists. 9. Reproductive/Infertility services beyond what is provided under the Policy; including treatment for sexual dysfunction; sterilization reversal; vasectomy reversal, except as specifically provided in this Policy. 10. Hospital Confinement or any other services or treatment that are received without charge or legal obligation to pay. 11. Services provided normally without charge by the health service of the Policyholder. 12. Treatment in a government Hospital, unless there is a legal obligation for the Covered Person to pay for such treatment. 13. Any services of a Doctor or nurse who is the Covered Person s Family Member. 14. Services received after the Covered Person s coverage ends, except as specifically provided under the Extension of Benefits provision. Page 5

6 GENERAL EXCLUSIONS (continued) 15. Under the Outpatient Prescription Drug benefit, shown in the Schedule of Benefits, any drug or medicine: a) Obtainable over the counter (OTC) except as specifically provided under Preventive Services; b) For the treatment of alopecia (hair loss) or hirsutism (hair removal); c) For the purpose of weight control; d) Anabolic steroids used for bodybuilding; e) For the treatment of infertility; f) Sexual enhancement drugs; g) Cosmetic, including but not limited to the removal of wrinkles or other natural skin blemishes due to aging or physical maturation, or treatment of acne; h) Drugs labeled Caution limited by federal law to Investigational use or Experimental Drugs; i) Purchased after coverage under the Policy terminates; j) If the FDA determines that the drug is: Contraindicated for the treatment of the condition for which the drug was prescribed; or Experimental for any reason, except in connection with an Approved Clinical Trial. 16. Vitamins, minerals, food supplements. 17. Services for the treatment of any Injury or Sickness incurred while committing or attempting to commit a felony; or while taking part in an insurrection or riot. 18. Injury or Sickness for which Benefits are paid or payable under any workers compensation or occupational disease law or act, or similar legislation. 19. War or any act of war, declared or undeclared; or while on active duty in the armed forces of any country. 20. General fitness, exercise programs, health club memberships, and weight management programs. 21. Treatment received in the Covered Person s Home Country, outside of the United States of America, except when Medically Necessary for an Emergency Confinement in a Hospital. 22. Non-cystic acne. Page 6