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1 STUDENT OSTEOPATHIC MEDICAL ASSOCIATION SCHOOL YEAR PLAN SUMMARIES COLLEGE HEALTH INSURANCE PROGRAM 2 Medical Health Insurance Plans Dental Plan Option Vision Plan Option The complete SOMA Brochures, Insurance Policies containing benefits, terms, conditions, limitations, and exclusions comply with the provisions of the Affordable Care Act applicable to Student Health Insurance Coverage. These items along with Administrative Forms, Enrollment Forms, and Claim Instruction/Form can be found on the SOMA Insurance Website The SOMA Health Insurance is compliant with the final rule requirements for Student Health Insurance Coverage under the Public Health Service (PHS) and the Patient Protection and Affordable Care Act (ACA). On Line Enrollment Available SOMA

2 STUDENT HEALTH INSURANCE PLAN 1 HIGHLIGHTS This table is for informational purposes only, and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits and programs and does not constitute a contract. Covered expenses are subject to plan maximums, limitations, and exclusions as described in the policy. The Preferred Provider (PPO) Network is PHCS (www.multiplan.com). Plan administered by Summit America Insurance. The SOMA plan is compliant with the requirements of Student Health Insurance Coverage under the Affordable Care Act (ACA) Eligibility - 1) Osteopathic Medical Students 2) Associate Members (Any student of an allied health care profession associated with one of the American Osteopathic Association recognized College of Osteopathic Medicine Benefit Category In-Network Preferred Allowance Out-of-Network Usual, Reasonable & Customary Aggregate Lifetime Maximum Unlimited Unlimited Policy Year Aggregate Maximum Amount per Sickness/Injury $500,000 $500,000 Deductible Per Insured Person (09/01/13 08/31/14) $500 Policy Year $800 Policy Year Maximum Out-of-Pocket (Does Not Include Deductible) After the Insured has incurred $9,750 out-of-pocket, this plan pays 100% of Preferred Providers and 100% of Outof-Network for covered medical expenses. $9,750 $9,750 Co-Insurance 75% 50% Hospital In-Patient Benefits 75% 50% Surgical Expense 75% 50% 75% 50% Doctor s Office Visit $25 Primary Care/$50 Specialist $25 Primary Care/$50 Specialist per visit per visit Emergency Room ($100 copay) 75% 50% Diagnostic Services 75% 50% Psychotherapy 50% 50% Prescription Drugs Rx deductible of $100 for Brand Name (Tier 2 & 3) drugs Copay -$15 tier 1/$25 tier 2/$50 Tier 3 when utilizing the Script Care, Ltd. Network Pharmacy No Benefits Prescriptions are only covered if filled at a Network Pharmacy Needle Stick 75% 50% Maternity 75% 50% Repatriation Medical Evacuation Preventive /Wellness Care Benefit (Plan deductible does not apply) 100% No benefit Additional Benefits mandate benefits vary by state. You may be eligible for additional benefits depending on your state or residence. Please contact to see if you qualify for other benefits not shown on this schedule. 2

3 STUDENT HEALTH INSURANCE PLAN 2 HIGHLIGHTS This table is for informational purposes only, and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits and programs and does not constitute a contract. Covered expenses are subject to plan maximums, limitations, and exclusions as described in the policy. The Preferred Provider (PPO) Network is PHCS (www.multiplan.com). Plan administered by Summit America Insurance. The SOMA plan is compliant with the requirements of Student Health Insurance Coverage under the Affordable Care Act (ACA) Eligibility - 1) Osteopathic Medical Students 2) Associate Members (Any student of an allied health care profession associated with one of the American Osteopathic Association recognized College of Osteopathic Medicine Benefit Category In-Network Preferred Allowance Out-of-Network Usual, Reasonable & Customary Aggregate Lifetime Maximum Unlimited Unlimited Policy Year Aggregate Maximum Amount per Sickness/Injury $500,000 $500,000 Deductible Per Insured Person (09/01/13 08/31/14) $2,250 Policy Year $4,500 Policy Year Maximum Out-of-Pocket (Does Not Include Deductible) After the Insured has incurred $8,000 out-of-pocket, this plan pays 100% of Preferred Providers and 100% of Out-of- Network for covered medical expenses. $8,000 $8,000 Co-Insurance 75% 50% Hospital In-Patient Benefits 75% 50% Surgical Expense 75% 50% Doctor s Office Visit 75% 50% Emergency Room 75% 50% Diagnostic Services 75% 50% Psychotherapy 50% 50% Prescription Drugs (the policy deductible does apply) 75% No Benefits Prescriptions are only covered if filled at a Network Pharmacy Needle Stick 75% 50% Maternity 75% 50% Repatriation Medical Evacuation Preventive /Wellness Care Benefit (Plan deductible does not apply) 100% No benefit Additional Benefits mandate benefits vary by state. You may be eligible for additional benefits depending on your state or residence. Please contact to see if you qualify for other benefits not shown on this schedule. 3

4 OPTIONAL DENTAL PROGRAM Dental benefits are provided through a stand-alone group dental insurance policy. Contract Year Maximum per Covered Person Contract Year Deductible per Covered Person/Family Class I exempt In-Network $1,500 $25/$75 *Out-of-Network $1,500 $25/$75 Class I Dental Plan Payment (no waiting period or deductible) Exams All X-rays Cleanings Fluoride Treatments Sealants Palliative Treatment Class II Dental Plan Payment (no waiting period, deductible applies) Space Maintainers Basic Restorative Non-surgical Periodontics Repairs of Crowns, Inlays, Onlays, Bridges and Dentures Simple Extractions 100% 100% 90% 90% Class III Dental Plan Payment (six-month waiting period, deductible applies) Endodontics Surgical Periodontics Complex Oral Surgery General Anesthesia Inlays, Onlays, Crowns Prosthetics 50% 50% Orthodontics Not Covered Not Covered * Plan payment percentages are based on the insurance company's Maximum Allowable charge. Network dentists accept their contracted Maximum Allowable Charge as payment in full for covered services OPTIONAL VISION PROGRAM Vision Benefits are provided through a stand-alonevision program Benefit Frequency (based on service year) Copayment Coverage from a Network Doctor Out-of-Network Reimbursement Eye Care Wellness - Regular exams are essential for protecting your visual wellness Exam 12 Months $20 Covered in full Up to $25 Allowance Prescription Eyewear - You may choose between glasses or contacts. Remember if you choose contacts, you will not be eligible to receive glasses (lenses and frame) in the same service period. Lenses 12 Months $20 (applied to lenses & frame) Single vision, lined bifocal lenses, lined trifocal lenses and tints are covered in full Single vision up to $30 allowance Lined bifocal up to $35 allowance Lined trifocal up to $45 allowance Tints up to $5 allowance Frame 12 Months Covered up to $150 allowance Contact Lenses 12 Months None Covered up to $150 allowance Up to $45 allowance Up to $105 allowance Your allowance applies to the cost of your contact lens exam and your contact lenses. You will receive a 15 percent savings off the cost of your contact lens exam from a VSP doctor. Your contact lens exam is performed in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. 4

5 PREMIUM RATES MONTHLY PREMIUM Medical Plan Student Only Under Age 30 Age 30 & Over Spouse Only Under Age 30 Age 30 & Over (Based on Student s Age) Child(ren) Under Age 30 Age 30 & Over Plan 1 Plan 2 Co-Pay Plan High Deductible (HDHP) $233 $274 $469 $562 $147 $169 $278 $322 Vision Plan Dental Plan $17 $38 $10 $32 $348 $222 $18 $43 How to Enroll On-Line for the Guaranteed Group SOMA Health Insurance Plan (no health questions) 1) Go to 2) Click on Health Insurance 3) Click on On-Line Enrollment, Complete Information 4) Click Submit Premium will be charged to your MasterCard or Visa Credit/Debit Card 5 Custom Low Cost Individual Health Insurance Options Now Available (Subject to medical underwriting. Rates are based on age and zip code. Coverage is not guaranteed.) 1) Go to 2) Click on Health Insurance 3) Click on Individual Health Insurance Options 4) Click on Proposal Request for Individuals and Families (1 st red bar) 5) Complete Information 6) Click submit button (you will receive a proposal within 24 hours) Questions? Call Toll-Free

6 STUDENT OSTEOPATHIC MEDICAL ASSOCIATION COLLEGE HEALTH INSURANCE PROGRAM SCHOOL YEAR Endorsed By: Student Osteopathic Medical Association 142 East Ontario Street Chicago, IL , x 8193 Arranged By: Mass Marketing Insurance Consultants, Inc John Humphrey Drive Orland Park, IL Claims/ Eligibility Administration: Summit America Insurance Services, Inc. P.O. Box Overland Park, KS Underwritten By: Medical United States Fire Insurance Company by Fairmont Specialty, a part of Crum & Forster 5 Christopher Way Eatontown, NJ Dental United Concordia Life And Health Insurance Company 4401 Deer Path Road Harrisburg, PA Vision VSP 3333 Quality Drive Rancho Cordova, CA DISCLAIMER Your student health insurance coverage, offered by United States Fire Insurance Company meets the requirements for Student Health Insurance Coverage under the Public Health Service (PHS) and the Patient Protection and Affordable Care Act (ACA), but may not meet the minimum standards required by the health care reform law for the 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 student health insurance coverage are $500,000 for policy years beginning on or after September 23, 2012, but before January 1, Your student health insurance coverage has an annual limit of $500,000. If you have any questions or concerns about this notice, contact Mass Marketing Insurance Consultants ( ). 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. 6

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