University of New Mexico ( the Policyholder ) Student Health Insurance Plan ( the Plan )

Transcription

1 University of New Mexico ( the Policyholder ) Student Health Insurance Plan ( the Plan ) Please keep this brochure as a general summary of the insurance coverage provided. This is only a brief description of the coverage available under policy series S30494NUFIC-NM-UNM (Rev ). The Policy on file at the University contains all of the definitions, reductions, limitations, exclusions and termination provisions. If any discrepancy exists between this brochure and the Policy, the Policy will govern. Complete details of the coverage are in the Policy issued to the University of New Mexico. It may be inspected online at Travel Assistance services provided by Travel Guard. Insurance and services provided by member companies of American International Group, Inc. For additional information, please visit our website at Any provision of the Policy or the brochure which is in conflict with the statutes of the state in which the policy is issued will be administered to conform with the requirements of the state statutes. INSURANCE UNDERWRITTEN BY: National Union Fire Insurance Company of Pittsburgh, Pa. ( the Company ) with its principal place of business in New York, NY ADMINISTRATOR POLICY NUMBER: CHH UNDERWRITER REFERENCE NUMBER: CAS Revision Date: 1/16/15

2 FREQUENTLY ASKED QUESTIONS & ANSWERS 1. When can the student insurance be purchased? Eligible students are automatically enrolled in the University of New Mexico Student Health Insurance Plan ( the Plan ). (See the Eligibility section below for details.) 2. What is a Preferred Provider Organization ( PPO ) Network? An organization in which a group of Hospitals and Doctors have agreed to provide medical care services to Covered Persons. The PPO provides these services according to negotiated fee schedules that are considered full payment for services rendered, subject to policy provisions. A Covered Person has the option to use a PPO provider or a non-ppo provider. A non-ppo provider is a Hospital, Doctor, or other health care provider who is not a member of the PPO and who has not agreed to provide services according to a negotiated fee schedule. Designated Preferred Providers (DPP) are a group of select Doctors who have contracted with the Policyholder to provide medical care services to Covered Persons according to a negotiated fee schedule, subject to Policy provisions. Benefit payments are reduced if you see an out of network provider (see page 13). 3.Do I need a primary care physician? A primary care physician is not required. When possible, treatment should be sought from UNM Student Health and Counseling ( SHAC ). 4. What is a deductible? The deductible is the dollar amount of Eligible Expenses a Covered Person must pay before benefits become payable. The deductible is waived for treatment rendered at UNM SHAC. The deductible is applicable for any facility or pharmacy other than UNM SHAC. The Plan has a $250 per Covered Person per Policy Year DPP/PPO deductible and a $500 per Covered Person per Policy Year non-ppo deductible (see page 8). 5. How much is my portion of Eligible Expenses? Unless otherwise stated, inside UNM SHAC the Covered Person is responsible for Coinsurance of the Eligible Expenses incurred. Unless otherwise stated, outside UNM SHAC the Covered Person is responsible for Coinsurance of the Eligible Expenses incurred for services provided by PPO or DPP providers or 4 Coinsurance of the Eligible Expenses incurred for services provided by non-ppo providers, subject to the applicable deductible amount. This Plan has an Out of Pocket Limit per Policy Year. The Out of Pocket Limit is $6,350 per Covered Person per Policy Year for services rendered by UNM SHCA and PPO/DPP providers combined and $6,350 per Covered Person per Policy Year for services rendered by non-ppo providers. (see page 8) 6. Where do I get treatment after hours? After hours treatment can be obtained at a Hospital, urgent care center or Hospital emergency room. Deductibles and coinsurance will apply. (see page 13 for PPO/DPP provider listings) 7. Do I need a claim form? Claim forms are required for Accidents. Online claim form submission is available at 8. Can a Spouse/domestic partner be seen at UNM SHAC (if not a Student)? Yes, as long as the student and the Spouse/domestic partner are both covered by the Plan. 9. Where can my dependent children be seen for medical services? Dependent children may not be seen at UNM SHAC. See question #5 for benefits outside UNM SHAC. 10. If the Covered Student purchases coverage and then drops out of school, can he/she still be seen at UNM SHAC? No, he/she cannot use UNM SHAC. The Covered Student should access an outside preferred provider as shown on page 13. The deductible will be applied as explained in question #4 above. ELIGIBILITY The following types of students will be automatically enrolled in the Plan and the student health insurance premium will be added to their tuition bill unless a waiver and proof of coverage under another plan is submitted and approved by the waiver deadline: (a) Non-Immigrant International Students enrolled in any number of credit hours and (b) Medical Professional Students enrolling (and not receiving a tuition refund), paying fees and actively attending classes each semester for 6 or more credit hours or 3 hours in the summer. Graduate Students holding a Teaching Assistantship (TA), Graduate Assistantship (GA), Research Assistantship (RA), or Project Assistantship (PA), enrolled for six (6) or more graduate credit hours throughout the semester and working 25% FTE or higher (home study, correspondence and television courses 2 of 30

3 do not fulfill credit hour requirements) will be automatically enrolled in the Plan unless a waiver opting out of the Plan is submitted prior to the waiver deadline (Please contact the office of Graduate Studies ( ) for additional information and eligibility criteria regarding Assistantships). Waiver procedures and deadline information are available at and Waiver Deadlines: Fall: September 20, 2014 Spring: February 20, 2015 Summer: July 1, 2015 A student who initially waived coverage under the Plan but subsequently experiences ineligibility under another creditable coverage may elect to enroll for coverage under the Plan within 31 days of the date of ineligibility under another Creditable Coverage. Please contact AIG, Educational Markets for enrollment assistance at *Proof of loss of eligibility under another credible coverage is required at the time of enrollment. The Company maintains the right to investigate student status and attendance records to verify that Policy eligibility requirements have been met. If it is discovered that Policy eligibility requirements have not been met, the Company s only obligation is to refund premium, less any claims paid. COST BY COVERAGE PERIOD TYPE OF COVERAGE DEPENDENTS Eligible students who enroll in the Plan may also enroll their eligible dependents. Eligible dependents are (a) the Covered Student s Spouse* (residing with the Covered Student) and (b) the Covered Student s child under age 26. * See definition of Spouse. Domestic partners qualify if they meet the guidelines set forth in the UNM Business Policy #3790 which is available at HOW TO ENROLL A DEPENDENT ANNUAL Students enrolling for: (a) the Fall coverage period must enroll their eligible dependents by September 18, 2014; (b) for the Spring/Summer coverage period must enroll their eligible dependents by February 11, 2015; or (c) for the Summer coverage period must enroll their eligible dependents by July 2, Dependent enrollment may be made online at: Payment options include: Visa or MasterCard. A dependent may be enrolled for coverage under this Plan only when the student enrolls or within 31 days of marriage, birth or adoption. Newborns: A newborn child shall be insured for Injury or Sickness, including the necessary care and treatment of premature birth, medically diagnosed congenital defects and birth abnormalities, and the circumcision of a newborn male, furnished any infant from the moment of birth, and where necessary to protect the life of the mother, if covered under the Policy, or infant, transportation, including air transport, to the nearest available tertiary care facility for newly born infants, for an initial period of thirty-one days. To continue the insurance beyond this initial 31 day period, the Covered Student must notify the Company of the birth in writing or adoption in writing and pay any additional premium required for the child's insurance within the 31 day period. EFFECTIVE DATE OF INSURANCE The coverage of an eligible student, including the student who initially waived coverage and subsequently enrolls within 31 days of ineligibility under another Creditable Coverage, shall take effect at 12:01 a.m. on the latest of the following dates: A. the Policy Effective Date; B. the day after the date for which the first premium for the Covered Student s coverage is received by the Company; FALL SPRING/SUMMER SUMMER 6/1/15 8/17/15 8/18/14-8/17/15 8/18/14-1/11/15 1/12/15-8/17/15 Student $1,444 8 $851 $327 Spouse/Domestic Partner $4,518 $1,888 $2,647 $1,009 Each Child $1,928 $810 $1,133 $435 3 of 30

4 C. the date the Policyholder s term of coverage begins; or D. the date the student becomes a member of an eligible class of persons as described in the Description of Class section of the Schedule of Benefits in the Policy on file with the Policyholder. A dependent may become eligible for coverage under the Plan only when the student becomes eligible; or within 31 days of marriage, birth or adoption. TERMINATION OF INSURANCE Insurance for a Covered Student will end at 11:59 p.m. on the first of these to occur: A. the date the Policy terminates; B. the last day for which any required premium has been paid; or C. the date on which the Covered Student withdraws from the school because of: (1) entering the armed forces of any country (premiums will be refunded on a pro-rata basis, less any claims paid when written request is made); or (2) withdrawal from school during the first 15 days (4 days for summer semester) of the period for which enrollment was made. (Premiums will be refunded when written request is made within the 15 day (or 4 day) period); or (3) departure from the Policyholder s school for his or her home country. (This applies only during summer break.) Refund will be considered only upon written proof of departure for summer break. If withdrawal from school is for other than (1) (2) or (3) above, no premium refund will be made. Students will be covered for the period of coverage for which they are enrolled and for which premium has been paid. Except as specifically provided in the Policy, insurance for a Covered Student's dependent will end when insurance for the Covered Student ends. DEFINITIONS Accident means an occurrence which: (a) is unforeseen; (b) is not due to or contributed by a Sickness or disease of any kind; and (c) causes Injury. Allowable Charges means the charges agreed to by the Preferred Provider Organization for specified covered medical treatment, services and supplies. Coinsurance means the percentage of the Eligible Expense payable by the Covered Person under the Policy. Covered Person means a Covered Student and his or her dependent(s) insured under the Policy. Covered Student means a student of the Policyholder who is insured under the Policy. This definition also includes scholars, as defined by the Policyholder. Creditable Coverage means coverage under any of the following: (a) Any individual or group policy, contract or program, that is written or administered by a disability insurance company, health care service plan, fraternal benefits society, self-insured employee plan, or any other entity, and that arranges or provides medical, hospital and surgical coverage not designed to supplement other private or governmental plans. The term includes continuation or conversion coverage, but does not include accident only, credit, disability income, Medicare supplement, long-term care insurance, dental, vision, coverage issued as a supplement to liability insurance, insurance arising out of workers' compensation or a similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance; (b) The federal Medicare Program pursuant to Title XVIII of the Social Security Act; (c) The Medicaid Program pursuant to Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928; (d) Chapter 55 of Title 10, United States Code, the Civilian Health and Medical Program of the Uniformed Services; (e) a medical care program of the Indian Health Service or of a tribal organization; (f) a state health benefits risk pool; (g) a health plan offered under chapter 89 of Title 5, United States Code, the Federal Employees Health Benefits Program; (h) a public health plan as defined by federal regulations; or (i) a health benefit plan under section 5(e) of the Peace Corps Act. 4 of 30

5 DEFINITIONS, Continued Designated Providers are a group of select Doctors who have contracted with the Policyholder to provide medical care services to Covered Persons according to a negotiated fee schedule, subject to Policy provisions. Doctor means: (a) legally qualified physician licensed by the state in which he or she practices; and (b) a practitioner of the healing arts performing services within the scope of his or her license as specified by the laws of the state of such practitioner; and (c) certified nurse midwives and licensed midwives while acting within the scope of that certification. The term Doctor does not include a Covered Person s immediate family member. Eligible Expense as used herein means a charge for any treatment, service or supply which is performed or given under the direction of a Doctor for the Medically Necessary treatment of a Sickness or Injury: (a) not in excess of the Reasonable and Customary charges; or (b) not in excess of the charges that would have been made in the absence of this coverage; (c) with respect to the Preferred Provider; is the Allowable Charge; (d) is the negotiated rate, if any and (e) incurred while the Policy is in force as to the Covered Person except with respect to any expenses payable under the Extension of Benefits Provision. Emergency Medical Condition means a medical condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could be reasonably expected by a reasonable layperson to result in: (a) jeopardy to the person s health or pregnancy; (b) serious impairment to such person s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person; or serious jeopardy to the health of the Covered Person s fetus. Emergency does not include the recurring symptoms of a chronic illness or condition unless the onset of such symptoms could reasonably be expected to result in the complications listed above. Emergency Services means, with respect to an Emergency Medical Condition: (a) a medical screening examination (as required under section 1867 of the Social Security Act (42, U.S.C. 1395dd) that is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate such Emergency Medical Condition; and (b) such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital, as are required under section 1867 of the Social Security Act (42, U.S.C.1395dd(e)(3)). Emergency does not include the recurring symptoms of a chronic illness or condition unless the onset of such symptoms could reasonably be expected to result in the complications listed above. Essential Health Benefits has the meaning found in section 1302(b) of the Patient Protection and Affordable Care Act and as further defined by the Secretary of the United States Department of Health and Human Services and includes ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic diseases management; and pediatric services, including oral and vision care. Hospital means a facility which meets all of these tests: (a) it provides in-patient services for the care and treatment of injured and sick people; and (b) it provides room and board services and nursing services 24 hours a day; and (c) it has established facilities for diagnosis and major surgery; and (d) it is supervised by a Doctor; and (e) it is run as a Hospital under the laws of the jurisdiction in which it is located; and (f) it is accredited by the Joint Commission on Accreditation of Healthcare Organizations. Hospital does not include a place run mainly: (a) as a convalescent home; (b) as a nursing or rest home; (c) as a place for custodial or educational care; or (d) as an institution mainly rendering treatment or services for: mental or nervous disorders; or substance abuse. The term Hospital includes: (a) an ambulatory surgical center or ambulatory medical center; (b) tertiary care facility; and (c) a birthing facility certified and licensed as such under the laws where located. It shall also include rehabilitative facilities if such is specifically for treatment of physical disability. Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities. Injury means bodily injury due to an Accident which: (a) results solely and directly from the Accident; (b) results independently of disease, bodily infirmity or any other causes; (c) is initially treated by a Doctor within 30 days after the Accident; (d) occurs after the Covered Person s effective date of coverage; and (e) occurs while coverage is in force. All injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered one Injury. Medical Necessity/Medically Necessary: means that a drug, device, procedure, service or supply is necessary and appropriate for the diagnosis or treatment of a Sickness or Injury based on generally accepted current medical practice in the United States at the time that it is provided. 5 of 30

6 DEFINITIONS, Continued A service or supply will not be considered as Medically Necessary if: (a) it is provided as a convenience to the Covered Person or provider; or (b) it is not the appropriate treatment for the Covered Person s diagnosis or symptoms; or (c) it exceeds (in scope, duration or intensity) that level of care which is needed to provide safe, adequate and appropriate diagnosis or treatment; or (d) it is experimental/investigational or for research purposes; or (e) could have been omitted without adversely affecting the patient s condition or the quality of medical care; or (f) involves treatment of or the use of a medical device, drug or substance not formally approved by the U.S. Food and Drug Administration (FDA); or (g) involves a service, supply or drug not considered reasonable and necessary by the Center for Medicare and Medicaid Service Issues Manual; or (h) it can be safely provided to the patient on a more cost-effective basis such as outpatient, by a different medical professional or pursuant to a more conservative form of treatment. The fact that any particular Doctor may prescribe, order, recommend, or approve a service or supply does not, of itself, make the service or supply Medically Necessary. Preventive Services as mandated by the Patient Protection and Affordable Care Act and, in addition to any other preventive benefits described in the Policy or Certificate, means the following services and without the imposition of any costsharing requirements, such as deductibles, co-payment amounts or coinsurance amounts to any Covered Person receiving any of the following: 1. Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force, except that the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention of breast cancer shall be considered the most current other than those issued in or around November 2009; 2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the Covered Person involved; 3. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and 4. With respect to women, such additional preventive care and screenings, not described in paragraph 1 above, as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. The Company shall update new recommendations to the preventive benefits listed above at the schedule established by the Secretary of Health and Human Services. Reasonable and Customary means the charge, fee or expense which is the smallest of: (a) the actual charge; (b) the charge usually made for a covered service by the provider who furnishes it; (c) the negotiated rate, if any; and (d) the prevailing charge made for a covered service in the geographic area by those of similar professional standing. Geographic area means the three digit zip code in which the services, procedure, devices, drugs, treatment or supplies are provided or a greater area, if necessary, to obtain a representative cross-section of charge for a like treatment, service, procedure, device, drug or supply. Reasonable and Customary charges also means the percentile of the payment system in effect on the Effective Date. Where appropriate, the Reasonable and Customary charge will be determined on the basis of the Fair Health, Inc. survey of prevailing fees valued at the 80th percentile. Sickness: means disease or illness including related conditions and recurrent symptoms of the Sickness which begins after the effective date of a Covered Person s coverage. Sickness also includes pregnancy and complications of pregnancy. All Sicknesses due to the same or a related cause are considered one Sickness. Spouse: means the person to whom the Covered Person is married. The term Spouse shall also mean the Covered Student s domestic partner with whom a domestic partnership has been established attesting to the relationship with another person, providing they are living together and any applicable requirements regarding domestic partnership interdependency have been met. A domestic partnership qualifies if the partners are able to provide a domestic partnership certificate from a city, county or state which offers the ability to register a domestic partnership. 6 of 30

7 DESCRIPTION OF BENEFITS DEDUCTIBLES The deductible is waived for treatment rendered at UNM SHAC. The Covered Person s portion paid at UNM SHAC does NOT apply towards deductible payments. MATERNITY TESTING (NOT OTHERWISE COVERED UNDER PREVENTIVE SERVICES): Benefits are payable for Eligible Expenses incurred by a Covered Person for routine maternity tests and screening exams. The Eligible Expenses must be incurred while the Covered Person is insured for these benefits. The Covered Person will pay the Coinsurance of the Eligible Expenses incurred as shown in the Schedule of Benefits. Benefits will be paid for Eligible Expenses incurred for the following tests: (a) pregnancy tests; (b) CBC; (c) Hepatitis B Surface Antigen; (d) Rubella Screen; (e) Syphilis Screen; (f) Chlamydia; (g) HIV; (h) Gonorrhea; (i) Toxoplasmosis; (j) Blood Typing ABO; (k) RH Blood Antibody Screen; (l) Urinalysis; (m) Urine Bacterial Culture; (n) Microbial Nucleic Acid Probe; (o) Pap Smear; and (p) Alpha-fetoprotein IV Screen (between sixteen and twenty weeks of pregnancy). One ultrasound test may be administered per pregnancy without any additional diagnosis. Eligible Expenses for subsequent ultrasound tests may be payable if such additional tests are determined to be Medically Necessary. MAMMOGRAPHY AND CYTOLOGICAL SCREENING (NOT OTHERWISE COVERED UNDER PREVENTIVE SERVICES) Benefits are payable for Eligible Expenses incurred by a Covered Person for: (a) cytologic and human papillomavirus screening performed by a health care provider for determining the presence of precancerous or cancerous conditions and other health problems; and (b) low-dose mammograms for determining the presence of breast cancer. The charges must be incurred while a Covered Person is insured for these benefits. The Covered Person will pay the Coinsurance of the Eligible Expenses incurred as shown in the Schedule of Benefits. Eligible Expenses include the following: (a) In the case of benefits for cytologic screening, as determined by the Doctor in accordance with national medical standards: (1)for women (18) eighteen years of age and older; and (2) for women who are at risk of cancer or at risk of other health conditions that can be identified through cytologic screening. (b) In the case of benefits for human papillomavirus screening and vaccine: (1) human papillomavirus screening for women once every three years for women age 30 and older; and (2) the administration of the human papillomavirus vaccine, for females 9 to 14 years of age, that is approved by the federal Food and Drug Administration. (c) In the case of mammograms: (1) one baseline mammogram for women age 35 through 39. (2) one mammogram biennially for women age (3) one mammogram annually for women age 50 and over. Benefits shall be available only for screening mammograms obtained on equipment designed specifically to perform lowdose mammography in imaging facilities that have met American College of Radiology accreditation standards for mammography. OUTPATIENT PRESCRIPTION DRUGS The Plan provides pharmacy coverage through UNM SHAC and through a prescription card program administered by Catamaran Rx. The Covered Person may purchase prescription drugs at over 45,000 network pharmacies nationwide. The latest listing of participating pharmacies is available at: Click Pharmacy Information to link to Catamaran Rx or by calling the Catamaran Rx help desk at Outside UNM SHAC, prescription benefits are based on a Mandatory Generic Catamaran Rx Formulary, which means that Catamaran Rx participating pharmacies will fill generic prescriptions on all covered formulary medications if there is a generic drug on the market. If the Covered Person or the Covered Person s Doctor chooses a brand-name drug, the Covered Person will pay the difference between the brand-name drug and the generic. Prescription benefits are subject to all Policy provisions. Please refer to the Schedule of Benefits. When prescriptions are filled prior to processing of enrollment activation, the Covered Person must pay for the prescriptions out of pocket and submit the receipts for reimbursement with a completed Catamaran Rx Direct Reimbursement Claim Form available at 7 of 30

8 SCHEDULE OF BENEFITS ELIGIBLE EXPENSES INCLUDE: UNM SHAC DPP PPO NON-PPO Aggregate Maximum Benefit per Policy Year Unlimited Unlimited Unlimited Unlimited Overall Deductible Amount per Policy Year per Covered Person $250 $250 $500 *Out-of-Pocket Limit per Policy Year: Per Covered Person $6,350 $6,350 $6,350 $6,350 Per Family $12,700 $12,700 $12,700 $12,700 *The UNM SHC, DPP and PPO Out-of-Pocket Limits combined will not exceed $6,350 per Covered Person or $12,700 per Family. The Non- PPO Out-of-Pocket Limits apply separately. The Out-of-Pocket Limit is reached when the amount of Eligible Expenses incurred by the Covered Person during the Policy Year, for which the Covered Person is responsible due to Coinsurance being more than, reach the Out-of Pocket Limit. The Out-of-Pocket limit includes deductibles, co-pays and Coinsurance. The Out-of- Pocket Limit does not include charges in excess of Reasonable and Customary; expenses incurred for prescription drugs; charges in excess of any specified maximum or charges incurred for any services not covered under the Policy. Once a Covered Person has reached the Out of Pocket Limit, Coinsurance is reduced to for all Eligible Expenses incurred by the Covered Person in the remainder of that Policy Year up to any benefit maximum that may apply. If, in any Policy Year, the sum of Eligible Expense used toward the Out-of-Pocket Limit of a Covered Student and his or her covered dependents equals the Family Out-of-Pocket amount, the Out-of- Pocket Limit will be deemed to be met with respect to Eligible medical Expense incurred by such Covered Student and his covered dependents for the rest of that Policy Year. When the Family Out-of- Pocket Limit is reached, the Coinsurance will be reduced to of the Eligible Expenses incurred for the remainder of that year. 8 of 30

9 HOSPITAL EXPENSE: University of New Mexico Student Health Insurance Plan Daily Room and Board (limited to average semi-private rate) SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO Not Covered 4 Intensive Care Not Covered 4 Hospital Miscellaneous Not Covered 4 Pre-Admission Testing (Hospital confinement must occur within 3 days of the testing) Not Covered 4 Private Duty Nursing rendered by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) provided such care is: rendered during Hospital Confinement; (b) Medically Necessary; and (c) no other charge is made for such service. Not Covered 4 Physiotherapy during Hospital confinement Not Covered 4 *SURGICAL EXPENSE (Inpatient or Outpatient) 4 Anesthetist 4 Assistant Surgeon 4 *For Covered Students only, surgery to remove non-malignant warts, moles and lesions will be covered at UNM SHAC only. 9 of 30

10 IN-HOSPITAL DOCTOR S FEES EXPENSE SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO Not Covered 4 OUTPATIENT EXPENSE Day Surgery Facility/Miscellaneous - when scheduled surgery is performed in a Hospital or outpatient facility, including the use of the operating and recovery room, laboratory tests and x-ray examinations (including professional fees), anesthesia, drugs or medicines and supplies. Reasonable and Customary Charges for Day Surgery Miscellaneous are based on the most recent edition of the Outpatient Surgical Facility Charge Index. 4 Hospital Emergency Room and Non-Scheduled Surgery - for use of Hospital Emergency Room, operating room and supplies. Not Covered 4 Laboratory and X-ray Examinations (not otherwise covered under Preventive Services) 4 Radiation Therapy and Chemotherapy 4 CAT Scan/MRI and/or PET Scan 4 Diagnostic services and medical procedures performed by the Doctor (other than Doctor s visits, physiotherapy, x-rays and lab procedures) (not otherwise covered under Preventive Services) 4 *Rehabilitation Services/Habilitation Services: Physical Therapy Occupational Therapy Cardiac/Pulmonary Chiropractic Care Speech and Hearing Therapy *Limited to one visit per day of 30

11 SCHEDULE OF BENEFITS, CONTINUED *Non-Rehabilitation or Non-Habilitation Massage Therapy: UNMC SHAC DPP PPO NON-PPO Co-pay Amount: $ *Benefits are limited to two (2) treatments per semester, six (6) treatments per Policy Year, up to $240 Maximum Amount per Policy Year. *Durable Medical Equipment and Orthopedic Appliances *Benefits are payable only upon Doctor s written prescription. Replacements and dental appliances are not covered. The Company has the right to pay the lesser of the purchase price or rental. *Preventive Services mandated by the Patient Protection and Affordable Care Act 4 4 *This benefit is not subject to the Overall Deductible Amount per Policy Year. *Injections and/or Immunizations (not otherwise covered under Preventive Services) Student Only *Includes allergy injections if administered at UNM SHAC *OUT OF HOSPITAL DOCTOR'S FEES EXPENSE Co-pay Amount: Doctor (other than Specialist) $5 $15 Specialist (Doctor whose practice is limited to a particular branch of medicine) $25 *Limited to one visit per day. 4 * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. *Benefits include acupuncturist care or treatment. 11 of 30

12 SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO CONSULTANT S FEES EXPENSE Co-pay Amount: $25 4 * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. AMBULANCE Coinsurance 4 DENTAL EXPENSE (Injury Only) Maximum Amount per Tooth: $150 $150 $150 $150 *OPTIONAL DENTAL TREATMENT EXPENSE If elected by the Covered Person during initial enrollment and the appropriate premium is paid, the Covered Person will be eligible for the Optional Dental Treatment Expense benefit described below. Maximum Amount per Policy Year (all providers combined) Optional Dental Treatment Deductible Amount per Policy Year (all providers combined) $1,000 $1,000 $1,000 $1,000 $50 $50 $50 $50 For Preventive Services** For Basic Services For Major Services This coverage does not include orthodontic services for which treatment began prior to the effective date, nor will benefits be paid for Gold Foil Restoration, Gold Fillings, Inlays, Crowns, Bridges, and Dentures. *This benefit is not subject to the Overall Deductible Amount per Policy Year. **The Optional Dental Treatment Deductible Amount per Policy Year does not apply. 12 of 30

13 SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO PEDIATRIC DENTAL TREATMENT EXPENSE (for Covered Persons under age 19 only) For Diagnostic Services For Preventive Services For Restorative Services For Endodontic Services For Periodontic Services For Prosthodontic Services For Oral and maxillofacial Surgery For Orthodontic Services For Emergency Services PRESCRIBED MEDICINES EXPENSE (Limited to a 30 day supply per prescription) Co-pay Amount per prescription (or the actual amount per prescription, whichever is less) Generic Formulary Brand Name Non-Formulary Brand Name This benefit applies to all prescribed FDA-approved birth control methods. The Co-pay Amount will be waived for prescribed FDAapproved birth control only. Outside of UNM SHAC, prescription benefits are based on a mandatory generic formulary. If the Covered Person or the Covered Person s Doctor chooses a brand-name drug, the Covered Person will pay the difference between the brandname drug and the generic. Prescribed medicines obtained at UNM SHAC are not subject to the Overall Deductible Amount per Policy Year. ABORTION EXPENSE 4 13 of 30

14 SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO MENTAL AND NERVOUS DISORDERS EXPENSE Inpatient Coinsurance *Outpatient 4 Co-pay Amount: Doctor (other than Specialist) $5 $15 Specialist (Doctor whose practice is limited to a particular branch of medicine) $25 *Limited to one visit per day. * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. 4 ALCOHOLISM AND SUBSTANCE ABUSE EXPENSE Inpatient Coinsurance *Outpatient 4 Co-pay Amount: Doctor (other than Specialist) $5 $15 Specialist (Doctor whose practice is limited to a particular branch of medicine) $25 *Limited to one visit per day. * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. 4 *OPTIONAL VISION CARE EXPENSE If elected by the Covered Person during initial enrollment and the appropriate premium is paid, the Covered Person will be eligible for the Optional Vision Care Expense benefit described below. Optional Vision Care Deductible Amount per Policy Year (all providers combined): $50 $50 $50 $50 Maximum Amount (all providers combined): $250 $250 $250 $250 *This benefit is not subject to the Overall Deductible Amount per Policy Year. 14 of 30

15 SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO PEDIATRIC VISION CARE EXPENSE (for Covered Persons under age 19 only) DIABETES EXPENSE Outpatient Expense *Durable Medical Equipment and Orthopedic Appliances 4 *Benefits are payable only upon Doctor s written prescription. Replacements are not covered. The Company has the right to pay the lesser of the purchase price or rental. *Out Of Hospital Doctor's Fees Expense Co-pay Amount Doctor (other than Specialist) $5 $15 Specialist (Doctor whose practice is limited to a particular branch of medicine) $25 4 *Limited to one visit per day. * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. Prescribed Medicines Expense (Limited to a 30 day supply per prescription) Co-pay Amount per prescription (or the actual amount of the prescription, whichever is less) Generic Formulary Brand Name Non-Formulary Brand Drug Outside of UNM SHAC, prescription benefits are based on a mandatory generic formulary. If the Covered Person or the Covered Person s Doctor chooses a brand-name drug, the Covered Person will pay the difference between the brand-name drug and the generic. 15 of 30

16 SMOKING CESSATION TREATMENT Outpatient Expense SCHEDULE OF BENEFITS, CONTINUED Diagnostic services and medical procedures performed by the Doctor (other than Doctor s visits, physiotherapy, x-rays and lab procedures) (not otherwise covered under Preventive Services). *Out Of Hospital Doctor's Fees Expense Co-pay Amount Doctor (other than Specialist) Specialist (Doctor whose practice is limited to a particular branch of medicine) *Limited to one visit per day. * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. Prescribed Medicines Expense (Limited to a 30 day supply per prescription) Co-pay Amount per prescription (or the actual amount of the prescription, whichever is less) Generic Formulary Brand Name Non-Formulary Brand Drug Outside of UNM SHAC, prescription benefits are based on a mandatory generic formulary. If the Covered Person or the Covered Person s Doctor chooses a brand-name drug, the Covered Person will pay the difference between the brand-name drug and the generic. CHILDHOOD IMMUNIZATION EXPENSE UNMC SHAC DPP PPO NON-PPO 4 MAMMOGRAPHY AND CYTOLOGICAL SCREENING EXPENSE Coinsurance 4 $5 $15 $ of 30

17 SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO COLORECTAL CANCER SCREENING EXPENSE Surgical Expense Coinsurance 4 Anesthetist Coinsurance 4 Outpatient Expense: Day Surgery Facility/Miscellaneous - when scheduled surgery is performed in a Hospital or outpatient facility, including the use of the operating and recovery room, laboratory tests and x-ray examinations (including professional fees), anesthesia, drugs or medicines and supplies. Reasonable and Customary Charges for Day Surgery Miscellaneous are based on the most recent edition of the Outpatient Surgical Facility Charge Index. Coinsurance 4 Laboratory and X-ray Examinations (not otherwise covered under Preventive Services) 4 *Out of Hospital Doctor s Fee Expense Co-pay Amount Doctor (other than Specialist) $5 $15 Specialist (Doctor whose practice is limited to a particular branch of medicine) $25 4 * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. BREAST CANCER TREATMENT 4 17 of 30

18 SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO RECONSTRUCTIVE BREAST SURGERY 4 PROSTATE CANCER SCREENING 4 TMJ EXPENSE 4 HEARING AIDS EXPENSE Outpatient Expense *For Durable Medical Equipment and Orthopedic Appliances 4 *Benefits are payable only upon Doctor s written prescription. Replacements are not covered. The Company has the right to pay the lesser of the purchase price or rental. *Out Of Hospital Doctor's Fees Expense Co-pay Amount Doctor (other than Specialist) $5 $15 Specialist (Doctor whose practice is limited to a particular branch of medicine) $25 4 *Limited to one visit per day. *The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. 18 of 30

19 SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO TREATMENT OF INBORN ERRORS OF METABOLISM EXPENSE Outpatient Expense Coinsurance 4 *Out Of Hospital Doctor's Fees Expense Co-pay Amount Doctor (other than Specialist) $5 $15 Specialist (Doctor whose practice is limited to a particular branch of medicine) $25 4 *Limited to one visit per day. * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. Prescribed Medicines Expense (Limited to a 30 day supply per prescription) Co-pay Amount per prescription (or the actual amount of the prescription, whichever is less) Generic Formulary Brand Name Non-Formulary Brand Drug Outside of UNM SHAC, prescription benefits are based on a mandatory generic formulary. If the Covered Person or the Covered Person s Doctor chooses a brand-name drug, the Covered Person will pay the difference between the brand-name drug and the generic. DENTAL ANESTHESIA EXPENSE 4 MATERNITY TESTING EXPENSE 4 19 of 30

20 SCHEDULE OF BENEFITS, CONTINUED UNMC SHAC DPP PPO NON-PPO CLINICAL TRIALS EXPENSE Inpatient Coinsurance 4 Outpatient Expense Coinsurance 4 *Out Of Hospital Doctor's Fees Expense Co-pay Amount Doctor (other than Specialist) $5 $15 Specialist (Doctor whose practice is limited to a particular branch of medicine) $25 4 *Limited to one visit per day. * The Overall Deductible Amount per Policy Year is waived for UNM SHAC and DPP providers only. Prescribed Medicines Expense (Limited to a 30 day supply per prescription) Co-pay Amount per prescription (or the actual amount of the prescription, whichever is less) Generic Formulary Brand Name Non-Formulary Brand Drug Outside of UNM SHAC, prescription benefits are based on a mandatory generic formulary. If the Covered Person or the Covered Person s Doctor chooses a brand-name drug, the Covered Person will pay the difference between the brand-name drug and the generic. 20 of 30