Schedule of Benefits Summary. Health Plan. Out-of-network Provider

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1 Schedule of Benefits Summary University Name: University of Nebraska - Student Plan Health Plan : 2014/2015 Academic Year (see attached) Payment for Services Covered Services are reimbursed based on the Allowable Charge. Blue Cross and Blue Shield of Nebraska s have agreed to accept the benefit payment as payment in full, not including Deductible, Coinsurance and/or Copayment amounts and any charges for non-covered services, which are the Covered Person s responsibility. That means providers, under the terms of their contract with Blue Cross and Blue Shield, can t bill for amounts over the Contracted Amount. s can bill for amounts over the Allowance. Covered Services provided by the University Student Health Clinics at UNK, UNL, UNO and UNMC will be covered with no cost-share to members, except as shown under the Prescription Drugs section. Deductible (Embedded*) Individual $500 $1,000 Family $1,000 $2,000 Coinsurance Covered Person Pays 20% 50% Plan Pays 80% 50% Out-of-pocket Limit (Embedded*) (includes Deductible, Coinsurance and Copays) Individual $2,500 $ 5,000 Family $5,000 $10,000 Once the annual Out-of-pocket Limit is reached, most Covered Services are payable by the plan at 100% for the rest of the. and Deductible and Out-of-pocket Limits cross accumulate. All other limits (days, visits, sessions, dollar amounts, etc.) do cross accumulate between and, unless noted differently. *Embedded If you have single coverage, you only need to satisfy the individual Deductible and Out-of-pocket Limit amounts. If you have family coverage, no one family member contributes more than the individual amount. Family members may combine their covered expenses to satisfy the required family Deductible and Out-of-pocket amounts.

2 Covered Services Illness or Injury Physician Office Primary Care Physician Office Services $20 Copay Specialist Physician Office Services $30 Copay Primary Care Physician benefits include the office visit provided by a physician who has a majority of his or her practice in internal or general medicine, obstetrics/gynecology, general pediatrics or family practice. A Certified physician assistant and a Certified nurse practitioner are covered in the same manner as a Primary Care Physician. Specialist Physician benefits include the office visits provided by a physician who is not a Primary Care Physician. Physician Professional Services (Outpatient and Inpatient Services) Urgent Care Facility Services (a single Copay applies to each urgent care visit) Emergency Care Services (Services received in a Hospital emergency room setting) Facility $75 Copay $300 Copay then Deductible and Coinsurance Professional Services (Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis) Outpatient Hospital or Facility Services Inpatient Hospital or Facility Services Preventive Services Preventive Services Affordable Care Act (ACA) required preventive services (may be subject to limits that include, but are not limited to, age, gender, and frequency) Plan Pays 100% Other covered preventive services not required by ACA Plan Pays 100% Immunizations Pediatric (up to age 7) Plan Pays 100% Coinsurance Age 7 and older Plan Pays 100% Related to an illness Same as any other illness Same as any other illness Pre-classroom Enrollment Immunizations and Testing (Services required by University prior to admission) Plan Pays 100% Plan Pays 100%

3 Mental Illness and/or Substance Dependence and Abuse Covered Services Inpatient Services Outpatient Services Office Services $20 Copay All Other Outpatient Items & Services Emergency Care Services (Services received in a Hospital emergency room setting) Facility $300 Copay then Deductible and Coinsurance Professional Services (Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis) Transgender Assignment/Reassignment Inpatient Services Outpatient Services Office Services $20 Copay All Other Outpatient Items & Services Emergency Care Services (Services received in a Hospital emergency room setting) Facility $300 Copay then Deductible and Coinsurance Professional Services (Copayment is waived if admitted to the hospital within 24 hours for the same diagnosis) Note: Surgery and related Covered Services limited to $75,000 while covered

4 Other Covered Services Illness or Injury Accident Related Care (Supplemental Benefit) (limited to $2,000 per person per, for charges in excess of this amount see the applicable service Plan Pays 100% category) Ambulance (to the nearest facility for appropriate care) Ground Ambulance Air Ambulance ( if due to an emergency) Durable Medical Equipment Home Health Care Skilled Nursing Care (limited to 8 hours per day Home Health Aide (limited to 60 days per ) Respiratory Care (limited to 60 days per ) Hospice Services Independent Laboratory Diagnostic Plan Pays 100% Preventive Intercollegiate Sports Injuries (limited to UNK and UNO students and subject to $20,000 per person per Benefit Year) Pediatric Dental (up to age 19) Same as Preventive Services Same as any other illness Same as Preventive Services Same as any other illness Preventive and Diagnostic Maintenance and Simple Restorative Complex Restorative Orthodontic Services (24 month wait applies) NOTE: Age and frequency limits apply Dental Network Dental GRID Pregnancy and Maternity Services (prenatal/postnatal care and delivery) Skilled Nursing Facility (limited to 60 days per ) Person pays 70% Person pays 70%

5 Other Covered Services Illness or Injury Temporomandibular and Craniomandibular Joint Disorder Therapy & Manipulations Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per ) Chiropractic or osteopathic manipulative treatments or adjustments (combined limit to 20 sessions per ) Vision Exams Diagnostic (to diagnose an illness) See Physician Office Services Preventive (routine exam including refraction) - Pediatric (up to age 19) See Pediatric Vision Services Section See Physician Office Services See Pediatric Vision Services Section Plan Pays 100% up to $50 Plan Pays 100% up to $50 - Adult (age 19 and over) limited to per then Not per then Not $50 per Covered Covered All Other Covered Services Pediatric Vision Services Pediatric Vision Services are limited to Covered Persons up to age 19 Vision Examination (including refraction and dilation, limited to one exam per ) Eyeglass Frames/Lenses or Contacts (limited to one set of frames and eyeglass lenses per or one purchase of Contact lenses per Benefit Year) Lenses Frames Contact Lenses (including evaluation and fitting, when in lieu of eyeglasses) Medically Necessary Contact Lenses (in lieu of eyeglasses, for specific conditions) NOTE Certification required in excess of $600 Low Vision Services and Aids Comprehensive low vision evaluation (limited to one every ( 5 ) s) Follow-up low vision care (limited to four visits in any (5) period) Low vision aids NOTE: Certification required for low vision Services and aids

6 Prescription Drugs University of Nebraska Lincoln Health Center Pharmacy Out-of network Retail and Mail order per 30-day supply Generic drugs $5 Copay $10 Copay level of Formulary Brand Name Drugs $30 Copay $40 Copay Non-formulary Brand Name Drugs $80 Copay $80 Copay level of level of NOTE: A 90-day supply is available at a retail Extended Supply Network pharmacy subject to 3 copays. Specialty drugs (specialty drugs must be purchased through a designated specialty pharmacy after two fills) $100 Copay $100 Copay Not Covered Contraceptives Formulary - Generic Plan Pays 100% Plan Pays 100% 25% - Brand Plan Pays 100% Plan Pays 100% 25% Non-formulary - Generic Same as any other Generic Drug - Brand Same as any other Non-formulary Brand Name - Ogestrel 0.5/50 $30 Copay $40 Copay level of - Nuvaring Plan Pays 100% Plan Pays 100% 25% Please note: This Schedule of Benefits Summary is intended to provide you with a brief overview of your benefits. It is not a contract and should not be regarded as one. For more complete information about your plan, including benefits, exclusions and contract limitations, please refer to the master group contract. In the event there are discrepancies between this document and the contract, the terms and conditions of the contract will govern.

7 University of Nebraska Medical Center for the 2014/2015 Academic Year Allied Health, PA1, PT1, PT2, PT3, Medical Nutrition August 25, 2014 through August 24, 2015 Perfusion 5 & 6, Cytotechnology, Medicine 1 & 2, Pharmacy 1, 2 & 3, Radiology, Oncology, Nursing, Post MS, graduate, RSTE Medical Family Therapy Accelerated Nursing May 12, 2014 through May 11,2015 Clinical Lab Science May 29, 2014 through May 28, 2015 New 4 th Year Pharmacy (4 th Year Student enrolling in plan May 12, 2014 through May 11,2015 for first time) PA 2 & 3 September 2, 2014 through September 1, 2015 Post Graduate Dental Certificate July 1, 2014 through June 30, 2015 Post Graduate July 1, 2014 through June 30, 2015 New 3 rd & 4 th Year Medical Student July 7, 2014 through July 6, 2015 University of Nebraska - Kearney for the 2014/2015 Academic Year Enrolled Students August 1, 2014 through July 31, 2015 University of Nebraska - Lincoln for the 2014/2015 Academic Year Enrolled Students August 14, 2014 through August 13, 2015 University of Nebraska - Omaha for the 2014/2015 Academic Year Enrolled Students August 14, 2014 through August 13, 2015

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