STUDENT ACCIDENT INSURANCE PLAN POLICY NO T STUDENT SPORTS ACCIDENT INSURANCE PLAN POLICY NO T

Transcription

1 POLICY NO T STUDENT SPORTS ACCIDENT INSURANCE PLAN POLICY NO T Pre-Certification is not required Underwritten by: Guarantee Trust Life Insurance Company Servicing Agent: Associated Insurance Plans International 609 N. Pine Street, Suite 202 Burlington, WI (800) Fax (262) Student Insurance Website: Please contact between the hours of 9:00 a.m. to 4:30 p.m. Central Standard Time. SCAN for a direct link to your student insurance website.

2 TABLE OF CONTENTS ACCIDENT INSURANCE PLAN FOR ALL FULL-TIME STUDENTS ELIGIBILITY....3 EFFECTIVE AND EXPIRATION DATES...3 REFUND POLICY...3 ACCIDENTAL DEATH AND DISMEMBERMENT PLAN SUMMARY...3 SCHEDULE OF BENEFITS ACCIDENT POLICY... 4 DEFINITIONS FOR ACCIDENT POLICY...5 STUDENT ACCIDENT EXCLUSIONS...7 INTERCOLLEGIATE SPORTS EXCLUSIONS...7 HOW DO I OBTAIN MY IDENTIFICATION CARD?....8 HOW DO I FILE A CLAIM UNDER MY STUDENT INSURANCE PLAN?...8 HOW DO I CHECK THE STATUS OF A CLAIM I HAVE ALREADY FILED? HOW CAN I RECEIVE ASSISTANCE WITH A QUESTION OR PROBLEM?...8 OPTIONAL, ADDITIONAL PREMIUM REQUIRED DENTAL/VISION/PHARMACY DISCOUNT PLAN... 9 OPTIONAL, ADDITIONAL PREMIUM DENTAL AND VISION INSURANCE PLAN HOW DO I RECEIVE ASSISTANCE WITH A QUESTION OR PROBLEM? Please call the Administrator, at (800) , Monday through Friday, between the hours of 9:00 a.m. to 4:30 p.m. Central Standard Time, or us through the Student Insurance website: We appreciate hearing from you with your comments, questions, and concerns. 2

3 ACCIDENT INSURANCE PLAN FOR ALL REGISTERED FULL-TIME STUDENTS Detach and keep in your possession. University of Saint Francis Accident Insurance Plan Identification Card Guarantee Trust Life Insurance Company NOTE: In a life threatening emergency, go to the nearest emergency room for treatment. Print name and school ID number This ID card is for identification only. Possession of the card does not guarantee the right to services or other benefits unless the holder is complying with all provisions of the Member Policy and is currently insured on the date of service. Contact the Company to verify coverage. Notification of Injury must be provided to the Company within 30 days after the date of accident. Bills for which benefit is to be paid must be submitted within 90 days of the date of treatment. Pre-certification is not required. Policy Number: Student Accident T Sports Accident T Direct all claim inquiries and correspondence to: Administrative Concepts, Inc. Payor #: Old Eagle School Road, Suite 1005 Wayne, PA (888) am - 7 pm CST Note: The attached is a temporary ID card. You may also print an ID card online at. ELIGIBILITY All registered students of University of Saint Francis are covered for accidents. Benefits are in force while attending class, internships or practicum programs, and while attending any University of Saint Francis sponsored event or activity. Coverage is also provided for travel directly to and directly from such events. EFFECTIVE AND EXPIRATION DATES Benefits will become effective at 12:00 am on August 1, 2015 and expire at 11:59 pm on July 31, REFUND POLICY There is no provision for cancellation other than upon entry into the Armed Forces. Any student withdrawing from school during the first 31 days of the period for which coverage is purchased (annual, fall, spring, or summer) shall not be covered under the Policy and a full refund of the payment will be made. Such a student will not be entitled to any benefits during the days preceding withdrawal, and no claims received will be honored. Students withdrawing after such 31 days will remain covered under the Policy for the full period for which the payment has been paid and no refund will be available unless the student does not attend classes for the next semester, and no claim has been made. In this instance the student may apply for a refund of the unearned premium. Pro-rata refunds will be made upon the entry of any insured person into the Armed Forces of any country. NO OTHER REFUNDS WILL BE PERMITTED. UNIVERSITY OF SAINT FRANCIS ACCIDENT INSURANCE PLAN FOR ALL FULL-TIME STUDENTS The following is a brief description of the benefits of the Student Accident Insurance Plan which has been designed especially for all students attending class at University of Saint Francis. This program provides coverage for 52 weeks from the date of an accident occurring during the policy period for accident occurring anywhere in the world. Accidents occurring as the result of the play and practice of intercollegiate athletics are also covered by this Plan for 104 weeks from the date of accident. The exact provisions governing this insurance are contained in the Master Policy issued to University of Saint Francis for 1 by Guarantee Trust Life Insurance Company and may be viewed online at. ACCIDENTAL DEATH AND DISMEMBERMENT PLAN SUMMARY Loss occurs 365 days from the date of the Accident Loss of Life...$10,000 Loss of Both Hands...$10,000 Loss of Both Feet...$10,000 Loss of the Entire Sight of Both Eyes...$10,000 Loss of One Hand or One Foot...$5,000 Loss of One Hand and Entire Sight of One Eye...$10,000 Loss of One Foot and Entire Sight of One Eye...$10,000 Loss of Speech or Hearing (both ears)...$10,000 Loss of Entire Sight of One Eye or Hearing One Ear..$5,000 Loss of Thumb and Index Finger of the Same Hand..$2,500 Policy Year Aggregate Loss of Life Maximum...N/A 3

4 UNIVERSITY OF SAINT FRANCIS SCHEDULE OF BENEFITS ACCIDENT POLICY Eligibility/Terms of Coverage Policy Provisions Benefit Maximum for Accidental Injury per Condition Benefit Maximum for Accidental Injury Intercollegiate Sports per Condition Deductible Benefit Period Coverage/Benefits Hospital Room & Board & general nursing care, up to the semi-private room charge Hospital Miscellaneous Expense Intensive Care Outpatient Services Physiotherapy (in or outpatient), Benefits are limited to one visit per day. Surgeon s and Assistant Surgeon s Fees (in or outpatient) Anesthesia Services Physician s Visits (in or outpatient), Benefits are limited to one visit per day. Pre-Admission Testing Day Surgery Miscellaneous Medical Emergency Expenses (Hospital or Urgent Care) Diagnotic X-ray and Laboratory Services Test & Procedures Injections Prescription Drugs Ambulance Services Durable Medical Equipment Casts (non-surgical) Dental Treatment for Accidental Injury to Sound Natural Teeth Benefits for Expanded Medical Coverage, HMO/PPO Limitation Waiver, Heart/Circulatory Coverage, and Off-Season Physical (supervised/sponsored) Conditioning - Intercollegiate Sports only Accidental Death and Dismemberment All registered full-time students will be covered for accident//injury occuring while insured under this program, 24 hours a day, anywhere in the world. This program includes coverage for the practice, play, and off-season physical conditioning for Intercollegiate Sports. Excess to any other valid or collectible insurance $15,000 per condition $5,000 per condition None 52 Weeks Accidental Injury 104 Weeks Intercollegiate Accidental Injury 100% of Semi-Private Room Rate Paid under Room & Board Included to $5,000 per Accidental Injury (Intercollegiate Sports Only) $10,000 Principal Sum 4

5 DEFINITIONS FOR ACCIDENT POLICY Accident: An unforeseeable event which results in an Injury. Ambulance: A vehicle which is licensed solely as an ambulance by the local regulatory body to provide transportation to a Hospital or transportation from one Hospital to another for those individuals who are unable to travel to receive medical care by any other means. Air ambulance charges are only eligible for transportation from the site of an Emergency to the nearest appropriate facility or from facility to facility. Benefit Period: The number of days following the date of an Injury during which Covered Charges must be incurred, subject to the Initial Treatment Period. The Benefit Period begins on the date of Injury and ends on the last day of the Benefit Period. The Benefit Period is shown on the Schedule of Benefits. Company: Guarantee Trust Life Insurance Company, a mutual company. Also hereinafter referred to as We, Us and Our. Covered Activity: Any activity which the Policyholder requires the Insured to attend, or any activity of the Policyholder s school, including field trips, which is under the sole control and supervision of the Policyholder, but not including activities which are under the sponsorship or supervision arrangement with any non-policyholder group. Covered Person: A person: Who is eligible for coverage as the Insured; Who has been accepted for coverage or has been automatically added; Who has paid the required premium; and Whose coverage has become effective and has not terminated. Covered Charge: A service or supply listed in this Policy and which is performed or given for the treatment of an Injury. Deductible: A dollar amount of Covered Charges the insured must pay before We pay any benefits under this Policy The Deductible is shown on the Schedule of Benefits. Designated Vehicle: A vehicle designated by and under the direct supervision of the Policyholder and operated by a properly licensed adult driver which transports Insureds to and from Covered Activities. Doctor: A legally qualified person licensed in the healing arts and practicing within the scope of his or her license and is not a Family Member. Durable Medical Equipment: A device which: is primarily and customarily used for medical purposes and is specially equipped with features and functions that are generally not required in the absence of Injury; is used exclusively by the Insured; is routinely used in a Hospital but can be used effectively in a non-medical facility; can be expected to make a meaningful contribution to the lnsured s Injury; and is prescribed by a Doctor and the device is Medically Necessary for the Insured s rehabilitation. Durable Medical Equipment does not include: comfort and convenience items; equipment that can be used by Family Members other than the Insured; health exercise equipment; and equipment that may increase the value of the Insured s Residence. DEFINITIONS FOR ACCIDENT POLICY (CONTINUED) Such items that do not qualify as Durable Medical Equipment include, but are not limited to: modifications to the lnsured s residence, property or automobiles, such as ramps, elevators, spas, air conditioners and vehicle hand controls; or corrective shoes, exercise and sports equipment. Eligible Person: An Eligible Person, as defined by the Policyholder, is shown on the Schedule. Hospital: An institution licensed, accredited or certified by the State which: is accredited by the Joint Commission on Accreditation of Healthcare Organizations; provides 24-hour nursing service by registered nurses (RN.); mainly provides diagnostic and therapeutic care under the supervision of Doctors on an inpatient basis; and maintains permanent surgical facilities or has an arrangement with another surgical facility supervised by a staff of one or more Doctors. Hospital also includes tax-supported institutions, which are not required to maintain surgical facilities. Hospital does not include a place, special ward, floor or other accommodation used for: custodial or educational care; rest, the aged; a nursing home or an institution mainly rendering treatment or services for mental illness or substance abuse. Hospital Confined/Hospital Confinement: Confinement in a Hospital for at least 18 consecutive hours by reason of an Injury for which benefits are payable. Initial Treatment Period: The number of days following an Injury during which the Insured must seek initial treatment for an Injury. The Initial Treatment Period is shown on the Schedule of Benefits. Injury: Bodily injury due to an Accident which: results directly and independently of disease, or bodily infirmity; occurs after the effective date of an lnsured s coverage under this Policy; and occurs while this Policy is in force. All injuries sustained in any one Accident, including all related conditions and recurrent symptoms of these Injuries, are considered a single Injury. Insured: An Eligible Person who has satisfied all of the following requirements: he or she is eligible for coverage under the Policy; he or she has been accepted for coverage under the Policy or has been automatically added; premium has been paid for him or her; and his or her coverage has become effective and has not terminated. 5

6 DEFINITIONS FOR ACCIDENT POLICY (CONTINUED) Insured Percent: The percentage of Covered Charges We pay for each Injury. The Insured Percent is shown in the Schedule of Benefits. Intensive Care Unit: A specifically designed facility of the Hospital that provides the highest level of medical care; and which is restricted to those patients who are critically ill or injured Such facility must be separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement. They must be permanently equipped with special life-saving equipment for the care of the critically iii or injured; and under constant and continuous observation by nursing staff assigned on a full-time basis, exclusively to the Intensive Care Unit. Intensive Care Unit does not mean any of these step-down units: progressive care; sub-acute intensive care; intermediate care units; private monitored rooms; observation units; or other facilities which do not meet the standards for Intensive Care. Medically Necessary: A treatment, drug, device, procedure, supply or service that is necessary and appropriate for the diagnosis or treatment of Sickness or Injury in accordance with generally accepted standards of medical practice in the U11iied States at the time it is provided. When specifically applied to Hospital confinement, it means that the diagnosis or treatment of symptoms or a condition cannot be safely provided on an outpatient basis. A treatment, drug, device, procedure, supply or service shall not be considered as Medically Necessary if it: is Experimental/lnvestigational or for research purposes; is provided solely for education purposes or the convenience of the Insured, the lnsured s family, Doctor, Hospital or any other provider; exceeds in scope, duration, or intensity that level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment and where ongoing treatment is merely for maintenance or preventive care; could have been omitted without adversely affecting the person s condition or the quality of medical care; involves the use of a medical device, drug or substance not formally approved by the United States Food and Drug Administration; involves a service, supply or drug not considered reasonable and necessary by the Healthcare Financing Administration Medicare Coverage Issues Manual; or can be safely provided to the patient on a less costeffective basis such as outpatient, by a different medical professional, or pursuant to a more conservative form of treatment. Off-Season Physical Conditioning: Student athletes are covered during all school/team sanctioned and supervised events during off-season workouts and training. Orthopedic Appliances: Any supportive device or appliance used in treating the lnsured s Injury. Other Valid and Collectible Insurance or Plan: Any reimbursement for or recovery of any element of Covered Charges incurred available from any other source whatsoever, except gifts and donations, but including without limitation: DEFINITIONS FOR ACCIDENT POLICY (CONTINUED) any individual, group, blanket, or franchise policy of accident, disability or health insurance; any arrangement of benefits for members of a group, whether insured or uninsured; any prepaid service arrangement such as Blue Cross or Blue Shield; individual or group practice plans, or health maintenance organizations; any amount payable for Hospital, medical or other health services. Injury arising out of a motor vehicle accident to the extent such benefits are payable under any medical expense payment provision (by whatever terminology used including such benefits mandated by law) of any motor vehicle insurance policy; any amount payable for services or injuries or diseases related to the lnsured s job to the extent that he actually received benefits under a Worker s Compensation Law. If the Insured enters into a settlement to give up his or her rights to recover future medical expenses that would have been payable except for that settlement; Social Security Disability Benefits, except that Other Valid and Collectible Insurance or Plan shall not include any increase in Social Security Disability Benefits payable to the Insured after he or she becomes disabled while insured hereunder; or any benefits payable under any program provided or sponsored solely or primarily by any governmental agency or subdivision or through operation of law or regulation. Physical Therapy: Non-surgical physical or mechanical therapy, diathermy, ultrasonic therapy, heat treatment in any form, manipulation or massage. Policyholder: The entity to which this Policy is issued. Policy Year: The period of 12 months following the Policy s Effective Date. Pre-existing Condition: A condition for which medical care, treatment, diagnosis or advice was received or recommended within the 12 months prior to the lnsured s Effective Date of coverage under this Policy. Prescription Drugs: Drugs which may only be dispensed by written prescription under Federal law, and approved for general use by the Food and Drug Administration. The drugs must be dispensed by a licensed pharmacy provider for the lnsured s outpatient use. Reasonable and Customary Charges, Fees or Expenses: The most common charge for similar professional services, drugs, procedures, devices, supplies or treatment within the area in which the charge is incurred, so long as those charges are reasonable. The most common charge means the lesser of: the actual amount charged by the provider; or the charge which would have been made by the provider (Doctor, Hospital, etc) for a comparable service or supply made by other providers in the same Geographic Area as reasonably determined by us for the same service or supply. 6

7 DEFINITIONS FOR ACCIDENT POLICY (CONTINUED) Geographic Area means the three digit zip code in which the service, treatment, procedure, drugs or supplies are provided; or a greater area if necessary to obtain a representative crosssection of charge for a like treatment, service, procedure, device drug or supply. Reasonable and Customary Charges, Fees or Expenses as used in this Policy to describe expense, will be considered to mean the payment system in effect at Policy issue as shown in the Schedule of Benefits. Residence: The home and land or property on which the lnsured s dwelling or home is located. Sound Natural Teeth: Natural teeth, the major portion of the individual tooth which is present, regardless of fillings and caps; and is not carious, abscessed, or defective. Urgent Care Center: A healthcare facility, separate and distinct from a Hospital, providing immediate short term medical care for minor conditions without an appointment but where immediate medical care is necessary. STUDENT ACCIDENTAL INJURY EXCLUSIONS (NON-INTERCOLLEGIATE SPORTS RELATED) Treatment, services or supplies which: Are not Medically Necessary; Are not prescribed by a Doctor as necessary to treat an Injury; Are determined lo he Experimental/lnvestigational in nature; Are received without charge or legal obligation to pay; Are received from persons employed or retained by the School or any Family Member, unless otherwise specified; or Are not specifically listed as Covered Charges in the Policy. Intentionally self-inflicted Injury, violating or attempting to violate any duly enacted law. Injury by acts of war, whether declared or not. Injury received while traveling or flying by air, except as a farepaying passenger on a regularly scheduled commercial airline. Injury covered by Worker s Compensation or the Occupational Disease Law. Injury caused by or contributed to by aggravation or reinjury of a Pre-existing Condition. Heart and/or circulatory malfunction resulting from participation in a Covered Activity. Repetitive motion Injuries, strains, hernia, tendinitis, bursitis and health exhaustion not related to a specific Injury. Any penalty imposed by Other Valid and Collectible Insurance or Plan for failure to follow plan procedures. Eyeglasses, contact lenses, routine eye exams or prescriptions. Suicide or attempted suicide. Treatment of sickness or disease in any form. Cosmetic surgery, except for reconstructive surgery on an injured part of the body. Injury sustained while committing or attempting to commit a felony. STUDENT ACCIDENT EXCLUSIONS (CONTINUED) Injury sustained while voluntarily participating in a riot or civil commotion or disturbance of any kind. Treatment in any Veteran s Administration or federal Hospital, except if there is a legal obligation lo pay. Treatment of temporomandibular joint dysfunction and associated myofacial pain. Off Season Physical Conditioning for intercollegiate sports. The official season for each specific covered sport is the period within the dates determined by the appropriate Athletic/ Activities Association for the practice and play of that sport. Injury sustained while participating in or practicing for any professional, intercollegiate or club sports activity, except as specifically provided. INTERCOLLEGIATE SPORTS INJURY EXCLUSIONS Treatment, services or supplies which: Are not Medically Necessary; Are not prescribed by a Doctor as necessa1y to treat an lnjury; Are determined to be Experimental/lnvestigational in nature; Are received without charge or legal obligation to pay; Are received from persons employed or retained by the School or any Family Member, unless otherwise specified; or Are not specifically listed as Covered Charges in the Policy. Intentionally self-inflicted Injury, violating or attempting to violate any duly enacted law. Injury by acts of war, whether declared or not. Injury received while traveling or flying by air, except as a farepaying passenger on a regularly scheduled commercial airline. Injury covered by Worker s Compensation or the Occupational Disease Law. Any penalty imposed by Other Valid and Collectible lnsurance or Plan for failure to follow plan procedures. Eyeglasses, contact lenses, routine eye exams or prescriptions. Suicide or attempted suicide. Treatment of sickness or disease in any form. Cosmetic surgery, except for reconstructive surgery on an injured part of the body. Injury resulting from participation in or practice for any activity which is not supervised and sponsored by the Policyholder or school. Injury sustained while committing or attempting to commit a felony. Injury sustained while voluntarily participating in a riot or civil commotion or disturbance of any kind. Treatment in any Veteran s Administration or federal Hospital, except if there is a legal obligation to pay. Treatment of temporomandibular joint dysfunction and associated myofacial pain. 7

8 HOW DO I OBTAIN MY IDENTIFICATION CARD? 1. You may detach and retain the temporary Identification Card provided on the brochure. 2. You may obtain your permanent Identification Card on the internet at: Click on Print ID Card. You will need to provide your name, student identification number, and birth date. If you experience any difficulty, please call us at (800) You may call (800) and request that your permanent Identification Card be mailed to you. HOW DO I FILE A CLAIM UNDER MY? Should an Injury occur, the following steps should be taken: 1. Secure the necessary medical treatment. A listing of Preferred Providers is available at: 2. Obtain itemized bills from your physician or provider. 3. You must complete a claim form. Claim forms may be obtained on the Student Insurance website: 4. Please make certain all additional medical bills submitted show your name, school ID number, school, and description of medical condition. Only one claim form, per condition, needs to be mailed. 5. Mail the completed claim form and medical bills as soon as possible to: Administrative Concepts, Inc. 994 Old Eagle School Road, Suite 1005 Wayne, PA Please contact between 7:00 a.m. to 7:00 p.m. CST 6. You may check the status of a claim you have already filed at and click on Check Claims Online. HOW DO I CHECK THE STATUS OF A CLAIM I HAVE ALREADY FILED? 1. Online Inquiry: a) go to: obtain your permanent Identification Card. b) After obtaining your Identification Card, click on Check Claims Online. c) You will need to set up an account by providing your first and last name, your birthdate, your student identification number and the Policy number. This information should be on taken directly from your per manent Identification Card. 2. Telephone Inquiry: Call Administrative Concepts, Inc. at (888) between the hours of 7:00 a.m. to 7:00 p.m. CST. HOW CAN I RECEIVE ASSISTANCE WITH A QUESTION OR PROBLEM? Please call the Servicing Agent, at (800) , Monday through Friday, between the hours of 9:00 a.m. to 4:30 p.m. Central Standard Time, or us through the Student website,. We appreciate hearing from you with your comments, questions, and concerns. 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. Please keep this brochure as a general summary of the insurance. The Master Policy contains all of the provisions, limitations, exclusions and qualifications of your insurance benefits, some of which may not be included in this brochure. If any discrepancy exists between the brochure and the Policy, the Master Policy will govern and control the payment of benefits. This brochure is based on Student Accicent Insurance Plan Policy No T and Student Sports Accident Insurance Plan Policy No T. Medical Benefits Underwritten by: Guarantee Trust Life Insurance Company Student Accicent Insurance Plan Policy No T Student Sports Accident Insurance Plan Policy No T Claims should be mailed to: Administrative Concepts, Inc. 994 Old Eagle School Road, Suite 1005 Wayne, PA Your Local Agent: 609 N. Pine Street, Suite 202, Burlington, WI (800) FAX (262) ( ) office@aipstudentinsurance.com Visit us and enroll on the Web at: This brochure is a brief description of the Plan Benefits. The exact provisions governing the insurance are contained in the Master Policy issued to University of Saint Francis, on file at the Business Office. 8

9 OPTIONAL, ADDITIONAL PREMIUM REQUIRED DENTAL/VISION/PHARMACY DISCOUNT PLAN Additional premium required (see rates listed below). No Claim forms No Waiting Periods No Pre-existing Conditions No Deductibles or Maximums No Age Restriction Discount is immediate at time of service Over 100,000 participating providers nationwide The Co-Health Group Collegiate plan has been specifically designed to meet the needs of today s College and University students, whether they are incoming freshmen, graduate, evening students, international or domestic students attending University of Saint Francis. The Co-Health Benefit Plan provides discounts in certain health care areas not normally reimbursed by insurance. In the Collegiate Plan we are offering the Vision, Dental and Pharmacy Discount Program as a single package of Benefits, or you may purchase discounts for pharmacy or vision separately. Here s how the plan works. Each of the benefit programs (Vision, Dental, and Prescription Pharmacy) has a network of Providers (for example, the participating dentists in the Dental Plan.) As a member of the Plan you can go to any of the providers listed and purchase their products or services on a negotiated discount basis. You receive your discount/savings on the spot. There are no exclusions for pre-existing conditions. There are no claim forms to fill out and no paperwork to be filed. Simply show your Co-Health membership card at the time of your scheduled appointment or at a participating pharmacy. The discounts you will receive are substantial and these savings can be very important to you. The services that make up the Collegiate Plan (Vision, Dental and Pharmacy) are also the three most common areas where you will have unexpected expenses. With our Benefits, you can substantially reduce your out of pocket expenses, and as an added bonus, you can use our plan benefits anywhere in the United States, except the State of Washington. You simply show your Co-Health ID Card and get your discount on the spot. This is not an Insurance Plan. The Co-Health Group Collegiate Plan is a Discount Care Plan offering discounts and savings for Vision, Dental and Prescription Pharmacy expenses. Annual Coverage Premiums Enroll anytime throughout the year at Credit Card or Check ANNUAL PREMIUMS Internet Payment by mail Dental/Vision/Pharmacy Student Only $72.00 $62.00 Family $88.00 $78.00 Dental & Vision Student $62.00 $52.00 Family $79.00 $69.00 Dental & Pharmacy Student $62.00 $52.00 Family $79.00 $69.00 Vision & Pharmacy Student Only $40.00 $30.00 Family $50.00 $40.00 Dental Student $50.00 $40.00 Family $70.00 $60.00 Vision Student Only $25.00 $15.00 Family $30.00 $20.00 Pharmacy Student Only $25.00 $15.00 Family $30.00 $

10 OPTIONAL, ADDITIONAL PREMIUM DENTAL AND VISION INSURANCE PLAN (Additional premium required) Underwritten by Security Life Insurance Company of America Freedom to Use Dentist of Your Choice Up to $2,000 Annual Maximum Coverage for Adult Sealants Three Plan Design Options No Waiting Periods for Most Services Optional Vision Coverage for Additional Premium QUESTIONS? PLEASE CALL You do not need to purchase health insurance to enroll in the optional dental and vision insurance plan. Enroll online at. 10