STUDENT GOLD HEALTH INSURANCE

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STUDENT GOLD HEALTH INSURANCE
Boulder, Colorado 80309
                                        “the Policyholder”

                2013-2014
      STUDENT GOLD HEALTH INSURANCE
               PLAN GUIDE
                  Designed for University of Colorado Boulder
                         Students & their Dependents

Administrator Policy Number: CHH8017734
Underwriter Reference Number: CAS9493060

                      Insurance Underwritten by
                      National Union Fire Insurance Company of Pittsburgh, Pa.
                      with its principal place of business in New York, NY
                      the “Company”

                                         1
STUDENT GOLD HEALTH INSURANCE
AT A GLANCE
                                               24-Hour Emergency Hotline................................................... page 22
                                               Accidental Death & Dismemberment........................................ page 15
                                               Basic Plan Dates and Cost......................................................... page 5
                                               Bone Density Testing............................................................... page 12
                                               Claims Procedures.................................................................. page 21
                                               Continuation of Coverage......................................................... page 5
                                               Coordination of Benefits.......................................................... page 17
                                               Definitions....................................................................... pages 17-18
                                               Eligibility................................................................................... page 3
                                               Enrollment Deadlines................................................................ page 5
                                               Exclusions........................................................................ pages 16-17
                                               How To Select or Waive Coverage.............................................. page 4
                                               Inpatient Pre-Admission Notification Requirement.........................page 22
                                               Maternity Expense............................................................pages 13, 15
                                               Prescription Drugs............................................................pages 14, 17
                                               Optional Dental Benefits......................................................... page 20
                                               Optional Vision Benefits.......................................................... page 19
                                               Preferred Provider Organization (PPO)....................................... page 6
                                               WHC Referral Requirement........................................................ page 7
                                               Repatriation & Medical Evacuation Benefits.............................. page 23
                                               Routine Services for Dependent Children.................................. page 13
                                               Schedule of Benefits........................................................... pages 9-14
                                               Temporary Student Gold Health Insurance Plan ID Card........... page 21

This is only a brief description of the coverage available under policy S30749NUFIC-CO-UCB. The Policy may
contain definitions, reductions, limitations, exclusions and termination provisions. Full details of the coverage
are contained in the Policy. If there is any conflict between the contents of this document and the Policy, or
if any point is not covered in this document, the terms and conditions of the Policy will govern in all cases.
Travel assistance services provided by Travel Guard. Insurance and services provided by member companies
of American International Group, Inc. Coverage may not be available in all jurisdictions and is subject to actual
policy language. For additional information, please visit our website at www.AIG.com.

                                                            2
STUDENT GOLD HEALTH INSURANCE
Who Needs Medical Coverage and Why?
In the United States, health insurance coverage isn’t just a good idea — it is considered a necessity by most people. Medical
care can be extremely expensive. A medical emergency, sudden illness, or serious accident could end the educational dreams
of an uninsured person and cause financial devastation for the student and his or her family.
Unless you have coverage through an employer’s group health plan, one of the best ways to obtain health insurance coverage
is to enroll in the “Student Gold Health Insurance Plan” (Plan) which is the University of Colorado Boulder’s endorsed Health
Plan described in this Guide.
The Plan covers certain routine medical care, lab work, prescription drugs, and care for a sickness, injury, surgery, or a
hospital stay. In addition to coverage for eligible medical care at the on-campus Wardenburg Health Center (Wardenburg),
Covered Persons can be referred to other healthcare providers when care is needed that is not available at Wardenburg.

CU-Boulder’s mandatory health insurance policy
CU-Boulder’s goal is to provide students with the best educational experience possible. Because health and wellness can
directly affect the quality of this experience, CU-Boulder requires all students to be covered by a health insurance plan and
makes optional coverage available for eligible dependents.
Please keep in mind that most degree-seeking CU-Boulder students will be automatically enrolled and billed each semester for
the Student Gold Health Insurance Basic Plan, unless a waiver of Plan Coverage is completed and approved (See “Eligibility”,
“ How to Select or Waive Coverage” and “Enrollment Deadlines” on page 4).

    Eligibility
Students
Eligible students must actively attend classes for at least the first 31 days after the date for
which coverage is purchased.
• Degree-seeking undergraduate students enrolled in six or more credit hours and
     graduate students enrolled in one credit hour are eligible and are automatically enrolled
     in the Plan.
• Continuing Education, ACCESS and Study Abroad students enrolled in six or more credit
     hours, and paying the base student and Wardenburg Health Center fees, are eligible to
     enroll in the Plan and must do so by visiting Wardenburg Health Clinic.
• Students approved for the Time Off or Stay Connected programs for medical reasons
     are eligible to enroll in the Plan and must do so by visiting Wardenburg Health Center.
NOTE: Home study, correspondence and television (TV) courses do not fulfill the eligibility
requirements that the student actively attend classes. The Company maintains its right
to investigate student status and attendance records to verify that the policy eligibility
requirements have been met. If the Company discovers the eligibility requirements have not
been met, its only obligation is to refund premium.

Dependents
•    The Covered Student’s legally married spouse or registered domestic partner; and
     children under age 26 are eligible.
•    Newborn children are covered for Injury or Sickness from birth until 31 days old (includes
     Eligible Expenses for inpatient or outpatient care). Coverage may be continued for that
     child when the Company is notified in writing within 31 days from the date of birth and
     the required premium is received.
•    Covered Students may purchase dependent coverage at the time of student’s enrollment
     in the plan; or within 31 days of date of marriage, birth or adoption only. Dependent
     eligibility expires concurrently with that of the Covered Student, except as specifically
     provided under the Extension of Benefits.
•    Covered Students desiring to enroll eligible dependents may do so by completing the
     enrollment process and remitting full applicable premium payment to the University. See
     page 5 for Plan Cost and Enrollment Deadlines.
NOTE: Dependent Children are not able to seek treatment at Wardenburg Health Center (WHC).

                                                                3
STUDENT GOLD HEALTH INSURANCE
Enrollment                                                              How to Enroll in Optional Club
Automatic enrollment                                                      Sports Coverage
Due to the University’s mandatory policy for health insurance,
all undergraduate students enrolled for 6 or more credit hours
(1 hour for graduate students) are automatically enrolled
                                                                                 Optional Club Sports Coverage
in the Student Gold Health Insurance Plan and billed each               Injuries    arising     out     of
semester (see page 3 for Exceptions to automatic and online             participation in club sports
enrollment). In order to opt out of the insurance please                are specifically excluded from
follow the directions below:                                            coverage under the Student
Refer to: www.colorado.edu/studentinsurance                             Gold Health Insurance Plan. If
Voluntary enrollment:   Continuing Education, ACCESS                    you wish to receive coverage
and Study Abroad students enrolled in six (6) or more                   and benefits for an injury
credit hours, and paying the base student and WHC fees;                 resulting from membership
and students approved for the Time Off or Stay Connected                and participation in club
programs for medical reasons may enroll for coverage                    sports, the optional club sports
only under the following conditions: (a) during an initial or           coverage must be selected
subsequent open enrollment period; or (b) within 31 days                during open enrollment and
of a marriage, birth or adoption; or (c) within 31 days of
                                                                        the appropriate premium
ineligibility under another creditable plan.
                                                                        must be paid. Optional
                                                                        coverage may be purchased
  How to Select or Waive                                                by visiting www.colorado.edu/
                                                                        studentinsurance.
  Coverage                                                              Only those students enrolled
                                                                        in the Basic Plan are eligible and
Students must select or waive the University insurance                  may select the additional sports
through the online student portal at https://portal.                    coverage.
prod.cu.edu/FedAuthLogin.html

Students Continuing from Fall into Spring                                 How to Enroll in the
If you enrolled in the plan for Fall 2013, you will automatically
be enrolled in Spring 2014 unless you actively waive coverage.            Optional Dental Coverage
If you waived the plan in the Fall, you may still enroll for
Spring/Summer 2014 within the enrollment period. All main                 and/or Optional Vision
campus students must make an insurance choice every year.
                                                                          Coverage
New Spring 2014 Students
If you are a new student starting in Spring 2014 the final
deadline for selecting the plan or waiving coverage for Spring          The Optional Dental Coverage and Optional Vision
semester is January 19, 2014. If you are a Spring 2014                  Coverage enrollment are available to Covered Persons at
student, the insurance plan you choose for that semester                initial enrollment under the Basic Plan each Policy Year by
continues into the summer, whether you are taking classes               completing the online enrollment and payment process at:
or not. Students must select or waive the University insurance          www.colorado.edu/studentinsurance
through the online student portal at https://portal.prod.
cu.edu/FedAuthLogin.html                                                Plan details on pages 19 and 20.

     DID YOU KNOW?                                                          The Policy is a non-renewable one-year term
   You can use your                                                         insurance policy. Similar coverage may be
   Smart Phone                                                              purchased for the following academic year. It is
   QRCode Application                                                       the Covered Student’s responsibility to maintain
   to scan and store                                                        continuity of coverage by inquiring about such
   Student Gold                                                             coverage if he or she has not received the
   Health Insurance
   Plan Information.                                                        information for the new policy year.

                                                                    4
STUDENT GOLD HEALTH INSURANCE
Late Enrollment—what do you do if
BASIC PLAN DATES & COST                                           you miss the enrollment deadline or
                                     SPRING/ SUMMER               lose coverage after the deadline?
                         FALL                     ONLY
                                     SUMMER
                      Semester Semester            (New           A student who initially waived coverage under the University’s
                      (billed Fall (billed Spring Partici-        Student Gold Health Insurance Plan but subsequently experi-
                       Semester)                  pants)
                                     Semester)                    ences ineligibility under another coverage may elect to enroll
COVERAGE              8/18/13 -      1/1/14 -     6/1/14 -        for coverage under the University’s policy within 31 days of
                                                                  ineligibility under another Creditable Coverage plan.
PERIOD                12/31/13       8/17/14      8/17/14
Student                                                           A student eligible to enroll on a voluntary basis who does not
                        $1,515        $1,515        $758          enroll himself or herself during an open enrollment period
Spouse/domestic                                                   may not apply for coverage until the next subsequent open
                        $3,598        $3,598       $1,800         enrollment period unless application for coverage is made
partner
                                                                  within 31 days of a marriage, birth or adoption; or (c) within
Each Child              $2,092        $2,092       $1,046         31 days of ineligibility under another creditable plan.
       Plan Costs include an administrative fee.
                                                                  What to do if you miss the waiver
      OPTIONAL CLUB SPORTS COST                                   deadline?
                           FALL         SPRING/SUMMER             If you meet the criteria to drop the Student Gold Health
                                                                  Insurance Plan after the fall or spring semester deadlines,
Student Only              $126                  $126              you may petition to waive the health plan, for one month past
                                                                  the deadline. A $25 processing fee will be charged.
  ENROLLMENT DEADLINE DATES FOR
         BASIC PLAN AND                                           Information for teaching, research,
       OPTIONAL COVERAGE:                                         or graduate assistants, or graduate
        Fall 2013 - September 5, 2013                             part-time instructors
       Spring 2014 - January 23, 2014                             If you are a teaching, research, or graduate assistant or a
         Summer 2014 - June 5, 2014                               graduate part-time instructor and hold at least a 20 percent
 The Master Policy on file at the University becomes              appointment, the University will contribute a portion of the
 effective at 12:01 a.m. August 18, 2013. The coverage            cost toward the Student Gold Health Insurance Plan. Call the
 of an eligible student who enrolls for coverage under            Graduate School for details and eligibility.
 the Policy shall take effect at 12:01 a.m. on the latest
 of the following dates: (1) the Policy Effective Date; (2)       Continuation of Coverage
 the date for which the first premium for the Covered
 Student’s coverage is received by the Company; or (3)            Covered Persons enrolled in the Continuation Plan are not
 the date the Policyholder’s term of coverage begins; (4)         eligible to receive services at Wardenburg Health Center. A
 the date the student becomes a member of an eligible             referral is not required for outside providers.
 class of persons as described in the Description of Class
 section of the Schedule of Benefits in the Policy on file        If a Covered Student is no longer an eligible person under
 with the Policyholder. The Master Policy terminates at           the Policy, he or she has the right to exercise the option to
 11:59 p.m. August 17, 2014. Insurance for a Covered              continue coverage up to 3 months beginning on the date
 Student will end at 11:59 p.m. on the first of these to          coverage would otherwise terminate. When a Covered Student
 occur: (a) the date the Policy terminates; (b) the last          chooses to exercise this right, his or her written request and
 day for which any required premium has been paid; (c)
 the date on which the Covered Student withdraws from             the appropriate premium must be received by the Company
 the school because of: (1) entering the armed forces             within 31 days following the date coverage under the Policy
 of any country (Premiums will be refunded on a pro-              terminates. In no event will this option to continue coverage
 rata basis (less any claims paid) when written request           be extended beyond the number of months initially requested.
 is made; or (2) withdrawal from school during the first          Continuation of coverage will be subject to the terms and
 31 days of the period for which enrollment was made.
 If withdrawal from the Policyholder’s school is for other        conditions of the Policy in effect on the date the Covered
 than (1) or (2) above, no premium refund will be made.           Student becomes eligible under this option. Call 1-888-
 Students will be covered for the Policy term for which           622-6001 to obtain information regarding enrollment in the
 they are enrolled and for which premium has been paid.           Continuation Plan. Enroll by visiting www.studentinsurance.
 Coverage for dependents will not be effective prior to           com/Schools/CO/CUB.
 that of the Covered Student or extend beyond that of the
 Covered Student. Refunds of pro-rated premiums are
 allowed only upon entry into the armed forces.

                                                              5
STUDENT GOLD HEALTH INSURANCE
Extension of Benefits                                                         house Doctor-ordered lab and/or X-ray, mental health
                                                                              visits are available at WHC (see the following pages
If the Covered Person is confined to a Hospital on the date
                                                                              for details). Eligible Expenses incurred at WHC are not
his or her coverage terminates as a result of a Sickness or
                                                                              subject to deductibles, pre-existing or co-pays (other
Injury for which benefits were payable prior to the date his
                                                                              than pharmacy). Benefits for covered hospitalization,
or her coverage terminated, benefits will be payable for
                                                                              emergency room charges, obstetrical care, specialized
Eligible Expenses incurred until the earliest of: (1) the date the
                                                                              care and testing outside Wardenburg Health Center are
Hospital confinement ends; (2) the end of the 90 day period
                                                                              outlined in the Schedule of Benefits.
following the date his or her coverage terminated; or (3) the
date the applicable Maximum Amount is reached.                           2.   Preferred Provider Organization (PPO): Cofinity
The Extension of Benefits will apply only to the extent the                   (inside Colorado) and First Health (outside Colorado)
Covered Person will not be covered under the Policy or any                    provide 24-hour helplines and web support at www.
other health insurance policy in the ensuing term of coverage.                myameriben.com. These organizations are groups of
                                                                              Doctors, Hospitals and medical care providers who have
                                                                              agreed to provide medical services at reduced costs
  Overview of the Student                                                     for CU-Boulder insured students and their dependents
                                                                              requiring care outside of Wardenburg. PPO discounts
  Gold Health Insurance Plan                                                  can significantly reduce out-of-pocket expenses by
                                                                              reducing the cost of the Covered Person’s deductible
  for Students & Dependents                                                   and co-insurance payments.
                                                                         3.   Pharmacy Benefit Manager: Express Scripts is
The Student Gold Health Insurance Plan has been developed                     a nationwide pharmacy benefit manager providing
for CU-Boulder students and their eligible dependent spouse/                  a 24-hour helpline staffed by qualified customer
domestic partner and children. The Plan provides certain                      service staff and pharmacy technicians. Express Scripts
benefits for medical, orthopedic, women’s health, pharmacy,                   provides prescription drug support services and discount
psychological health and psychiatry coverage at Wardenburg                    pharmacy benefits to insured CU-Boulder students and
Health Center and from preferred providers for Eligible                       covered dependent/domestic partner.
Expenses not available at Wardenburg.                                    4.   Dental and Vision: Covered Persons are also entitled
The Plan includes special design features in an effort to keep                to enroll in the optional dental coverage and an optional
coverage and medical services affordable. Examples include:                   vision coverage. Details and enrollment are available
1. Primary Medical Provider: Wardenburg Health                                at: www.studentinsurance.com.
    Center (WHC) is the primary medical provider for                     5.   Optional Club Sports Coverage:                   Covered
    covered students and spouses/domestic partners (not                       Persons are also entitled to enroll in the Optional Club
    children) for services such as acute care visits.                         Sports Coverage. Enrollment is available at www.
    Chronic illness management, routine healthcare, in-                       studentinsurance.com.

                                                                     6
STUDENT GOLD HEALTH INSURANCE
Wardenburg Health Center (WHC) Referral
                               You must receive the referral from WHC before you receive Covered Medical
                               Care. If you need urgent care when WHC is closed or you need emergency
                               care, you must return to WHC for necessary follow-up care, except as stated
                               below.

Wardenburg Health Center (WHC) Referral Requirement
The student and spouse/domestic partner must first utilize              4.     Medical care obtained when the Covered Student
the resources of Wardenburg Health Center where treatment                      or spouse/domestic partner is no longer able to use
will be administered or a referral issued. No benefits will be                 the WHC; due to a change in student status;
paid for expenses incurred for medical treatment rendered               5.     Services provided for Dermatology, Maternity, OB/
outside WHC for which no prior approval or referral is                         GYN Care, Home Health Care, Dental Treatment
obtained. A referral from WHC must accompany the claim                         or Eye Care;
when submitted. Exceptions to the Referral Requirement are              6.     No services are available for dependent children at
as follows:                                                                    WHC and therefore, are exempt from the Referral
   1.    Medical Emergency. The Covered Student or spouse/                     Requirements; or
         domestic partner must return to WHC for necessary              7.     Preventive Services not covered at Wardenburg
         follow-up care, except when referred to a specialist                  Health Center.
         as a result of an emergency room visit. See definition       Call Student Insurance at 303-492-5107 to determine
         of Emergency Medical Condition on page 18;                   whether a preventive care service is available at WHC.
   2.    When Wardenburg Health Center is closed.
         Wardenburg is not a 24-hour facility;                        Visit website at www.colorado.edu/studentinsurance to find a
    3.    Medical care received more than 15 miles from               provider in the Cofinity PPO Network if being treated within
          campus;                                                     the State of Colorado or First Health.

  Services and Benefits Inside Wardenburg Health Center
Wardenburg Health Center is the Primary Care Provider                 Psychological Health and Psychiatry
for Students and spouse/domestic partners enrolled in the                 • Initial assessment/urgent care
Student Gold Health Insurance Plan. The benefits provided at              • Individual, couples, and group therapy
Wardenburg Health Center are not part of the Student Gold                 • Substance abuse evaluation and treatment
Health Insurance Plan.                                                    • Eating disorders evaluation and treatment
No co-insurance, co-pay or deductible.                                    • Medical evaluation and medication management
Medical Clinic                                                            • Stress management services
   • Primary care for Sickness and Injuries that do not               Sports Medicine
       require the services of a specialist                               • 25 physical therapy visits per policy year
   • Routine immunizations                                                • 10 chiropractic visits per policy year at WHC with
   • Travel Clinic services (excluding specialty travel                       a valid referral from an appropriate health care
       immunizations)                                                         provider
   • Men’s health services including one annual exam per                  • Orthopedic surgeon consultations
       policy year; including HPV (Human Papilloma virus)             Women’s Health Services
       vaccines                                                           • One annual exam per policy year
   • Sexually Transmitted Infection testing and education                 • Gynecology services and consultations that do not
   • Allergy injections                                                       require the services of a specialist outside of WHC
   • Nutrition services                                                   • Birth control consultations
   • Preventive Services                                                  • Human Papillomavirus (HPV) vaccination
Laboratory and X-Ray                                                      • Sexually Transmitted Infection testing and education
   • Coverage for x-ray services                                      Eye Exam
   • Coverage for laboratory services when ordered by                     • One routine eye exam per plan year through WHC’s
       WHC provider only                                                      contracted optical provider. Glasses, contacts and
                                                                              contact lens fittings are not covered.

                                                                  7
STUDENT GOLD HEALTH INSURANCE
Services and Benefits Inside Wardenburg Health Center, (Continued)

Outpatient mental health and
substance abuse services
The Department of Psychological Health and Psychiatry
(PHP) will provide assessment and treatment services. The
type of treatment offered, the frequency of treatment, and
the duration of treatment will be determined by the health
care provider’s assessment, the needs of the Covered Person,
and the availability of services. PHP utilizes brief, focused
individual and couples therapy, along with a wide range of
longer-term group therapy options.

Specialists at Wardenburg Health                                    Wardenburg Health Center
Center (WHC)                                                        services provided at WHC, but
Wardenburg Health Center contracts for the services of
specialty Doctors from the Boulder community and the                not covered by Student Gold
Anschutz Medical Campus of the University of Colorado               Health Insurance Plan include,
Denver. Specialty clinic visits at Wardenburg are subject to
appointment availability, and may be limited during the             but are not limited to:
summer session and breaks.                                           •    Acupuncture
Orthopedic Services in Sports Medicine                               •    ADHD/ADD testing
 •   100 percent coverage for orthopedic visits at WHC               •    Bike fits
     with a valid referral from an appropriate health care           •    Copies of X-rays and medical records
     provider.                                                       •    Custom knee braces
 •   All relevant records are shared with the specialist, who        •    Immunizations for Japanese encephalitis, rabies,
     reports back to WHC with results, thereby setting up                 yellow fever, and typhoid
     a system for continuity of care between WHC and the             •    Loaned equipment
     specialist.                                                     •    Massage therapy
Chiropractic Services in Sports Medicine                             •    Missed appointments
                                                                     •    Patient-requested lab tests (not Medically Necessary)
 •    100 percent as shown on page 7.
                                                                     •    Replacement of medical supplies

Gynecology        Services     in    Women’s       Health
Services
 •   100 percent coverage for gynecologist consults and
     specialty procedures including but not limited to:
                                                                         If you are no longer a CU-Boulder
     colposcopy, L.E.E.P., biopsy, and cryosurgery at WHC.               student, you may not receive any
IMPORTANT: Your deductible, coinsurance, and copay                       services at WHC unless you:
WILL apply to the following:
 • If you require specialist care outside of Wardenburg                  • Completed the spring semester but
    Health Center, even if a Wardenburg Health Center                      are not enrolled for the summer or
    health care provider refers you.
 •   If you require specialist care, and no appointments are             • Withdrew after the 31st day of the
     available at Wardenburg Health Center, and you are
     referred outside of Wardenburg Health Center.
                                                                           semester in which case you will be
 •   You are always responsible for the deductible,                        eligible for treatment at WHC until
     coinsurance, and copay for services you receive outside               the end of the semester.
     of Wardenburg Health Center, even if a WHC referral
     is issued.

                                                                8
Basic Plan Schedule of Benefits
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
Plan Feature
Policy Year Maximum Benefit          Unlimited
Deductible per Covered Person
per Policy Year                            $250 PPO / $500 Non-PPO
(PPO and Non-PPO are applied
separately)
Pharmacy Deductible per Covered                      $50
Person per Policy Year
                                                                            Once the Out-of-Pocket Limit has been
                                                                            satisfied, Eligible Expenses will be payable
                                                                            at 100% for the remainder of the Policy
                                                                            Year, not to exceed any benefit maximum
                                                                            that may apply. The Policy Year Deductible
                                       $5,000 PPO / $10,000 Non-PPO         and coinsurance apply toward meeting
Out-of-Pocket Limit
                                             applied separately             the Out-of-Pocket maximum. Per service
                                                                            copays, non-covered charges, charges
                                                                            above the Reasonable and Customary
                                                                            Charge, and any charges above the
                                                                            service limit will not apply toward the Out-
                                                                            of-Pocket Limit.
                                                                OUT-OF-
                                        PREFERRED
INPATIENT                                                      NETWORK
                                        PROVIDERS
                                                               PROVIDERS
                      PPO = Allowable Charges           R&C = Reasonable and Customary Charges
Anesthetist—Professional Services       80% of PPO             80% of R&C

Assistant Surgeon                       80% of PPO             50% of R&C

Biologically Based Mental Illness         Paid as any other Sickness        See page 15 for more details.
Doctor Visits (non-surgical)            80% of PPO             50% of R&C
                                                                            The per admission copay is in addition
                                                                            to the per Policy Year Deductible. Eligible
                                                                            Expenses include Hospital room and
                                                                            board charges (limited to average semi-
                                                                            private room rate except if ICU or CCU)
                                                                            and general nursing care provided by the
                                       $200 copay per      $200 copay per   Hospital; and Miscellaneous expenses
Hospital Expense                         admission           admission      such as the cost of the operating room,
                                        80% of PPO          50% of R&C      laboratory tests, X-ray examinations,
                                                                            anesthesia, drugs (excluding take home
                                                                            drugs) or medicines, therapeutic services,
                                                                            and supplies. In computing the days
                                                                            payable under this benefit, the date of
                                                                            admission will be counted, but not the date
                                                                            of discharge.
Intensive Care                          80% of PPO             50% of R&C   See Hospital Expense above.
                                                                            See Benefits for Mental Disorders on page
Mental Disorders                          Paid as any other Sickness
                                                                            15.
Physiotherapy/Occupational
                                        80% of PPO             50% of R&C
Therapy

                                                           9
Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
                                                               OUT-OF-
                                        PREFERRED
INPATIENT, Continued                                          NETWORK
                                        PROVIDERS
                                                              PROVIDERS
                    PPO = Allowable Charges          R&C = Reasonable and Customary Charges
                                                                            Payable within 14 Days prior to
Pre-Admission Testing                   80% of PPO            50% of R&C
                                                                            admission.
Private Duty Nursing                    80% of PPO            50% of R&C
                                                                            48 hours vaginal delivery / 96 hours
                                                                            for cesarean. While Hospital Confined;
Routine Newborn Care                       Paid as any other Sickness
                                                                            and routine nursery care provided
                                                                            immediately after birth.
                                                                            If two or more procedures are performed
                                                                            through the same incision or in immediate
                                                                            succession at the same operative session,
Surgeon’s Fees                          80% of PPO            50% of R&C    the maximum amount paid will not exceed
                                                                            the applicable coinsurance levels for the first
                                                                            procedure and second procedures and 25%
                                                                            of the third and subsequent procedures.
                                                               OUT-OF-
                                        PREFERRED
OUTPATIENT                                                    NETWORK
                                        PROVIDERS
                                                              PROVIDERS
Anesthetist                             80% of PPO            80% of R&C
Assistant Surgeon                       80% of PPO            50% of R&C
Chemotherapy & Radiation Therapy        80% of PPO            50% of R&C
                                                                            Related to scheduled surgery performed in
                                                                            a Hospital, or an outpatient surgical facility
                                                                            including the cost of the operating room;
Day Surgery Facility/Miscellaneous
                                        80% of PPO            50% of R&C    laboratory tests and X-ray examinations,
Procedures
                                                                            including professional fees; anesthesia;
                                                                            drugs or medicines (excluding take-home
                                                                            drugs); and supplies
Diagnostic X-ray and Laboratory
                                        80% of PPO            50% of R&C
Services
                                       $40 copay per      $40 copay per
                                             visit              visit
                                        100% of PPO        50% of R&C
Doctor’s Visits (non surgical)
                                         Policy Year        Policy Year
                                       deductible does    deductible does
                                         not apply.         not apply.
                                                                            For use of Hospital Emergency Room,
                                                                            including attending Doctor’s charges,
                                      $150 copay per      $150 copay per    operating room, laboratory and x-ray
                                                                            examinations, supplies. 1) The $150
Emergency Room                             visit               visit
                                                                            copay is waived if admitted. Policy Year
                                       100% of PPO         100% of R&C      Deductible does not apply. 2) Treatment
                                                                            must be rendered within 72 hours from
                                                                            time of Injury or first onset of Sickness.
                                                                            Administered in the Doctor’s office and
Injections                              80% of PPO            50% of R&C
                                                                            charged on the Doctor’s statement.

                                                         10
Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
                                                                     OUT-OF-
                                            PREFERRED
OUTPATIENT, Continued                                               NETWORK
                                            PROVIDERS
                                                                    PROVIDERS
                     PPO = Allowable Charges            R&C = Reasonable and Customary Charges
Mental Disorders                                                                    Refer to Doctor Visit Benefit on page 10.
                                        Paid as any other         Paid as any other
                                            Sickness                  Sickness      Refer to page 15 - “Benefits for Mental
Biologically Based Mental Illness                                                   Disorders”
Physiotherapy/Occupational Therapy          80% of PPO              50% of R&C
                                                              • $15
                                                                copay per            Benefit includes birth control with no
                                                                prescription         copay.
                                                                for Generic          Insulin covered at 100% and are not
                                       •     $15 copay per • $30                     subject to the maximum per Policy Year.
Prescription Drugs                           prescription       copay per            Prescribed pre-natal vitamins are
                                             for Generic        prescription         covered.
$50 deductible per Policy Year,   •          $30 copay per      for Brand            Mail order Prescription Drugs through
Limited to a 31-day supply per               prescription       Name                 Express Scripts at 2.5 times the copay.
prescription                                 for Formulary Out-of-Network
                                             Brand Name    Pharmacy, the             See page 14 for details.
Express Scripts Pharmacy Benefit                                                     If a Covered Person’s Doctor chooses
Manager— Maximum per Policy Year. •          $60 copay per Covered Person
                                             prescription  must pay for the          a brand or non-formulary drug and
                                             for Non-      Prescription Drug         a generic is available, the Covered
                                             formulary     at the pharmacy           Person will pay the difference between
                                             Brand Name    and submit receipt        the brand/non-formulary drug and the
                                                           with a Prescription       generic (low tier) cost and the applicable
                                                           Claim Form for            copay.
                                                           reimbursement.            The Basic Plan Deductible Amount per
                                                                                     Policy Year will be waived.

                                                                                     If two or more procedures are
                                                                                     performed through the same incision
                                                                                     or in immediate succession at the same
                                                                                     operative session, the maximum amount
Surgeon                                     80% of PPO              50% of R&C
                                                                                     paid will not exceed the applicable
                                                                                     coinsurance levels for the first procedure
                                                                                     and second procedures and 25% of the
                                                                                     third and subsequent procedures.

                                                                                     Diagnostic services and medical
                                                                                     procedures by a Doctor, other than
Tests & Procedures                          80% of PPO              50% of R&C
                                                                                     Doctor Visits, Physiotherapy, X-Rays
                                                                                     and Lab Procedures.
                                           $75 copay per          $75 copay per
                                                 visit                  visit
                                            100% of PPO            50% of R&C
Urgent Care
                                             Policy Year            Policy Year
                                           deductible does        deductible does
                                             not apply.             not apply.
                                                                     OUT-OF-
                                            PREFERRED
OTHER                                                               NETWORK
                                            PROVIDERS
                                                                    PROVIDERS
Alcoholism Expense                             Paid as any other Sickness

Ambulance Services                          80% of PPO              80% of PPO

                                                             11
Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
                                                                  OUT-OF-
                                          PREFERRED
OTHER                                                            NETWORK
                                          PROVIDERS
                                                                 PROVIDERS
                     PPO = Allowable Charges           R&C = Reasonable and Customary Charges
Biofeedback Coverage                      80% of PPO             80% of PPO
                                                                                  Not otherwise covered by Preventive
Bone Density Testing                      100% of PPO            100% of PPO
                                                                                  Benefits.

CAT Scan/MRI                              80% of PPO             50% of R&C

                                                                                  Additional Premium/Enrollment
Club Sports                                    Paid as any other Injury
                                                                                  Required

                                                                                  Made necessary due to Injury to sound,
Dental Treatment (Accidental Injury)      80% of PPO             50% of R&C       natural teeth only. $2,000 maximum
                                                                                  per Policy Year.
                                                                                  For diabetic needles/syringes and
                                                                                  testing supplies, insulin pump supplies
Diabetic Expense                          80% of PPO             50% of R&C       and glucose monitor or sensors, the
                                                                                  benefit will be payable at 100%; and is
                                                                                  not subject to the Deductible.
                                       Diagnostic: paid as any other
Colorectal Cancer Screening            Sickness/deductible applies                Not otherwise covered by Preventive
(Diagnostic & Routine Colonoscopy)     Routine: paid as any other Sickness/       Services
                                       deductible waived

                                                                                  Benefits are limited to one visit per day
Dialysis Treatment                        80% of PPO             50% of R&C       and do not apply when related to a
                                                                                  Doctor’s visit.

                                                                                  A written prescription must accompany
Durable Medical Equipment and
                                                                                  the claim when submitted. Replacement
Braces & Appliances                       80% of PPO             80% of R&C
                                                                                  equipment is not covered. Benefits
                                                                                  include Prosthetic Devices.
Fertility Testing                         80% of PPO             50% of R&C       Benefits payable for testing only.
Home Health Care                          80% of PPO             50% of R&C       In lieu of hospitalization.
                                                                                  Not otherwise covered by Preventive
                                                                                  Services. Benefits include charges
                                                                 100% of R&C      incurred for cervical cancer
HPV Vaccine                               100% of PPO             Policy Year     immunization for covered females
                                           Policy Year          deductible does   under age 26. If the initial shot in the
                                         deductible does          not apply.      series is received prior to the Covered
                                           not apply.                             Person turning age 26, subsequent
                                                                                  immunizations are covered according
                                                                                  to standard protocol.(Doctor’s visit
                                                                                  copay will apply.)
Intramural Sports                              Paid as any other Injury
                                          100% of PPO            100% of R&C
                                           Policy Year            Policy Year
Mammography
                                         deductible does        deductible does
                                           not apply.             not apply.
                                                           12
Basic Plan Schedule of Benefits (Continued)
(Refer to Wardenburg Health Center Referral Requirement, page 7.)
                                                                    OUT-OF-
                                           PREFERRED
OTHER, Continued                                                   NETWORK
                                           PROVIDERS
                                                                   PROVIDERS
                      PPO = Allowable Charges            R&C = Reasonable and Customary Charges
Maternity & Complications of
                                                Paid as any other Sickness
Pregnancy
Nutritional Counseling                     100% of PPO             100% of PPO
                                           100% of PPO            100% of R&C
                                                                                    As specified by the Patient Protection and
                                            not subject to         not subject to
                                                                                    Affordable Care Act (PPACA). (To view a
Preventive Services Benefit                  deductible,            deductible,
                                                                                    list of covered preventive services, log
                                           copayment, or          copayment, or
                                                                                    onto www.healthcare.gov)
                                             coinsurance           coinsurance.
                                           100% of PPO             100% of R&C
                                            Policy Year             Policy Year
Prostate Cancer Screening
                                          deductible does         deductible does
                                            not apply.              not apply.

                                                                                    Benefits are payable for Eligible
                                                                                    Expenses for Breast Reconstructive
                                                                                    Surgery after a mastectomy. This
                                                                                    includes coverage for: 1) All stages of
                                                                                    the reconstruction of the breast on which
Reconstructive Breast Surgery                   Paid as any other Sickness          the mastectomy has been performed;
                                                                                    2) surgery and reconstruction of the
                                                                                    other breast to produce symmetrical
                                                                                    appearance; and 3) prostheses and
                                                                                    physical complications at all stages of
                                                                                    mastectomy, including lymphedemas.

Repatriation and Medical Evacuation - Refer to page 23 - Travel Assist/Student Assist
                                                                                    1 visit per day and does not apply
Respiratory Therapy                         80% of PPO             50% of R&C
                                                                                    when related to Doctor Visits.

                                                                                    $40 maximum per exam. Benefit
                                           100% of PPO             100% of R&C
                                                                                    includes one annual eye exam that
                                            Policy Year             Policy Year
Routine Eye Exam                                                                    includes refraction. A routine eye exam
                                          deductible does         deductible does
                                                                                    does not include charges for contact
                                            not apply.              not apply.
                                                                                    lens exam.

Routine Hearing Exam                        80% of PPO             50% of R&C
                                                                                    Not otherwise covered by Preventive
                                                                                    Services Benefit (See page 13). Includes
Preventive Health Services                 100% of PPO             100% of R&C
                                                                                    routine tests and immunizations per
                                                                                    CDC guidelines.
                                           100% of PPO             100% of PPO      Not otherwise covered by Preventive
Routine Services for Dependent              Policy Year             Policy Year     Services Benefit (See page 13).
Children                                  deductible does         deductible does   Includes immunizations per CDC
                                            not apply.              not apply.      guidelines.
                                                                                    1 visit per day and does not apply
Speech Therapy                              80% of PPO             50% of R&C
                                                                                    when related to Doctor Visits.

                                                             13
Basic Plan Schedule of Benefits (Continued)
 (Refer to Wardenburg Health Center Referral Requirement, page 7.)
                                                                      OUT-OF-
                                               PREFERRED
 OTHER, Continued                                                    NETWORK
                                               PROVIDERS
                                                                     PROVIDERS
                      PPO = Allowable Charges               R&C = Reasonable and Customary Charges
                                                                                       Eligible Expenses include:
                                                                                       (a) mental health counseling (subject to
                                                                                          the limitations applicable to inpatient
                                                                                          and outpatient treatment of Mental
                                                                                          and Nervous Disorders);
                                                                                       (b) hormone replacement therapy
                                                                                          (subject to the limitations applicable
                                                                                          to Prescription Drugs);
                                                                                       (c) sexual reassignment surgery, limited
 Transsexualism/Gender Identity                                                           to $10,000 per Policy Year.
                                                   Paid as any other Sickness
 Disorders                                                                                 (1) for female to male:
                                                                                             mastectomy, hysterectomy,
                                                                                             salpingo-oophorectomy,
                                                                                             vaginectomy,metoidioplasty,
                                                                                             scrotoplasty, urethroplasty,
                                                                                             placement of testicular prosthesis,
                                                                                             phalloplasty; or
                                                                                           (2) male to female: orchiectomy,
                                                                                             penectomy, vaginoplasty,
                                                                                             clitoroplasty, labiaplasty.
 Treatment of Temporomandibular Joint
                                               80% of PPO            80% of R&C
 Dysfunction

  Prescription Drugs
The Student Gold Health Insurance Plan provides pharmacy             other medical substances, regardless of intended use;
coverage through a prescription card program administered            except as provided under Benefits for Diabetes;
by Express Scripts. A Covered Person may purchase                 (b) Biological sera, blood or blood products administered on
prescription drugs at over 60,000 network pharmacies                  an outpatient basis;
nationwide. The latest listing of participating pharmacies is
available at: www.colorado.edu/studentinsurance                   (c) Drugs labeled, “Caution—limited by federal law to
                                                                      investigational use” or experimental drugs;
Prescription Benefits are based on a Mandatory Generic
Formulary, which means that participating pharmacies will fill    (d) Products used for cosmetic purposes;
generic prescriptions on all covered formulary medications if     (e) Drugs used to treat or cure baldness; anabolic steroids
there is a generic drug on the market. If a Covered Person’s          used for body building;
Doctor chooses a brand or non-formulary drug and a generic
                                                                  (f) Anorectics—drugs used for the purpose of weight
is available, the Covered Person will pay the difference
                                                                      control;
between the brand/non-formulary drug and the generic (low
tier) cost and the applicable copay.                              (g) Fertility agents or sexual enhancement drugs, such
                                                                      as Parlodel, Pergonal, Clomid, Profasi, Metrodin,
Prescription benefits are subject to all Plan provisions.
                                                                      Serophene, or Viagra;
Please refer to the Schedule of Benefits for your deductible,
coinsurance and maximum benefit information (pages 8-12).         (h) Growth hormones; or
 The following Prescription Drugs, services or supplies are not   (i) Refills in excess of the number specified or dispensed
covered:                                                              after one (1) year of date of the prescription.
(a) Therapeutic devices or appliances, including:
    hypodermic needles, syringes, support garments and

                                                              14
Accidental Death and *
                                                                      Dismemberment Benefit
                                                                   Loss of Life, Limb or Sight
                                                                   If such Injury shall independently of all other causes and
                                                                   within 180 days from the date of Injury solely result in any
                                                                   one of the following specific losses, the Covered Person or
                                                                   beneficiary may request the Company to pay the applicable
                                                                   amount below. Payment under this benefit will not exceed the
                                                                   policy Maximum Benefit.
                                                                   For Loss of:
                                                                          Life....................................................... $10,000
                                                                          Both Hands or Both Feet........................ $10,000
                                                                          Sight of Both Eyes.................................. $10,000
                                                                          One Hand and One Foot....................... $10,000
                                                                          One Hand and Sight of One Eye............ $10,000
   Maternity Testing                                                      One Foot and Sight of One Eye ............. $10,000
                                                                          One Hand or One Foot............................ $5,000
                                                                          The Sight of One Eye .............................. $5,000
The Policy does not cover routine, preventive or screening                Thumb or Index Finger............................. $2,500
examinations unless Medical Necessity is established based         “Loss” of a hand or foot means complete severance through
on medical records. The following maternity routine tests          or above the wrist or ankle joint. “Loss” of sight of an eye
and screening exams will be considered if all other policy         means the total, irrevocable loss of the entire sight in that eye.
provisions have been met: Initial screening at first visit -       “Loss” of thumb and index finger means complete severance
Pregnancy test: Urine human chorionic gonadotropic (HCG)           through or above the metacarpophalangeal joint of both
(first trimester only), Asymptomatic bacteriuria; Urine culture,   digits. “Severance” means the complete separation and
Blood type and Rh antibody, Toxoplasmosis;  Blood Typing           dismemberment of the part from the body.
ABO; Microbial Nucleic Acid Probe; Rubella, Pregnancy-
associated plasma proteie-A (PAPPA)(first trimester only),
Free beta human chorionic gonadotropin (HCG), Hepatitis            MANDATED BENEFITS
B; HBsAg, Pap smear, Gonorrhea, Gc culture, Chlamydia;             Benefits for Prosthetic Devices *
Clamydia culture, Syphilis; RPR, and HIV-ab; Each visit            Benefits will be paid for the Reasonable and Customary
- Urine analysis, Once every trimester - Hematocrit and            Charges for the purchase of Prosthetic Devices.
Hemoglobin; Once during first trimester - Ultrasound; Once         Prosthetic device means an artificial device to replace, in
during second trimester - Ultrasound (anatomy scan); Triple        whole or in part, an arm or leg.
Alpha-fetroprotein (AFP), Estriol, hCG or Quad screen test         Benefits are limited to the most appropriate model that
Alpha fetroprotein (AFP), Estriol, hCG, inhibin-a; Once            adequately meets the medical needs of the Covered
during second trimester if age 35 or over - Amniocentesis or       Person as determined by the attending Doctor. Repairs and
Chorionic cillus sampling (CVS); Once during second or third       replacements of Prosthetic Devices are also covered unless
trimester - 50g Glucola (blood glucose 1 hour post prandial);      necessitated by misuse or loss.
and Once during third trimester - Group B Strep Culture. For       Benefits for Biologically Based Mental Illness *
additional information regarding Maternity Testing, please         Benefits will be paid the same as any other Sickness for the
call AmeriBen at 1-855-639-8676.                                   treatment of Biologically Based Mental Illness and Mental
                                                                   Disorders as defined below. The benefit provided will not
                                                                   duplicate any other benefits provided in this policy.
                                                                   “Biologically Based Mental Illness” means schizophrenia,
                                                                   schizoaffective disorder, bipolar affective disorder, major
                                                                   depressive disorder, specific obsessive-compulsive disorder,
          To receive the network discount                          and panic disorder.
            at a participating pharmacy,                           “Mental Disorder” means post-traumatic stress disorder,
            present your Student Health                            drug and alcoholism disorders, dysthymia, cyclothymia,
                                                                   social phobia, agoraphobia with panic disorder and general
               Insurance ID card when                              anxiety disorder. The term includes anorexia nervosa and
           you purchase the prescription.                          bulimia nervosa to the extent those diagnoses are treated on
       For a list of participating pharmacies,                     an outpatient, day treatment, and inpatient basis, exclusive of
         access the Express Scripts link at                        residential treatment. For purposes of this coverage, Mental
                                                                   Disorder does not include autism.
        www.colorado.edu/studentinsurance
                                                                      * Benefits shall be subject to all Policy Year Deductible,
                                                                        copayment, coinsurance, limitations, and any other
                                                                                       provisions of the policy.

                                                               15
Benefits for Therapies for Congenital Defects and Birth                   or with the intent of inducing conception; hair growth
Abnormalities *                                                           or removal; impotence, organic or otherwise; learning
Benefits will be paid the same as any other Sickness for                  disabilities; premarital examinations; vasectomy; alopecia.
physical, occupational and speech therapy for congenital                  This exclusion does not apply to Preventive Services
                                                                          mandated by the Patient Protection and Affordable Care
defects and birth abnormalities for covered dependent
                                                                          Act.
children beginning after the first 31 days of life to the child’s   2.    For elective abortions.
sixth birthday.                                                     3.    For addiction and co-dependency services and supplies
Benefits will be paid for the greater of the number of such               related to: nicotine addiction; caffeine; and non-chemical
visits provided under the policy or twenty visits per year for            addictions, such as gambling, sex, spending, shopping,
each therapy. Benefits will be provided without regard to                 working and religion; and treatment for co-dependency.
whether the condition is acute or chronic and without regard        4.    As a result of injury sustained or Sickness contracted
to whether the purpose of the therapy is to maintain or to                while in the service of the Armed Forces of any country.
improve functional capacity.                                              Upon the Covered Person entering the Armed Forces of
                                                                          any country, the Company will refund any unearned pro-
Benefits for Hearing Aids for Minor Children *                            rata premium. This does not include Reserve or National
Benefits will be paid the same as any other Sickness for                  Guard Duty for training unless it exceeds 31 days.
Eligible Expenses for Hearing Aids for a minor dependent            5.    As a result of committing or attempting to commit an
child who has a hearing loss that has been verified by a                  assault or felony or participation in a felony, riot or civil
licensed Doctor and a licensed Audiologist. The Hearing Aid               commotion.
shall be medically appropriate to meet the needs of the minor       6.    For breast reconstruction and implantation or removal
dependent child and according to accepted professional                    of breast prostheses unless such care and services are
                                                                          performed solely and directly as a result of a Medically
standards.
                                                                          Necessary mastectomy.
Benefits shall include the purchase of the following:               7.    For any period of care designed to help a Covered Person
1. Initial Hearing Aids and replacement Hearing Aids not                  in the activities of daily living not requiring continuous
    more frequently than every five years;                                attention by trained medical or paramedical personnel.
                                                                          Such care may involve: preparation of special diet;
2. A new Hearing Aid when alterations to the existing                     supervision over medication that can be self-administered;
    Hearing Aid cannot adequately meet the needs of the                   and assisting the person getting in or out of bed, walking,
    minor dependent child; and                                            bathing, dressing, eating and using the toilet.
3. Services and supplies including, but not limited to the          8.    For cosmetic surgery except that “cosmetic surgery” shall
    initial assessment, fitting, adjustments, and auditory                not include reconstructive surgery when such surgery is
    training that is provided according to professional                   incidental to or follows surgery resulting from trauma,
                                                                          infection or other disease of the involved part and
    standards.
                                                                          reconstructive surgery because of a congenital disease
Additional Mandated Benefits                                              or anomaly of a covered dependent newborn child which
Benefits are provided for the items listed below as mandated              has resulted in a functional defect. It also shall not
by the State of Colorado. A detail of these benefits may be               include breast reconstructive surgery after a mastectomy.
found in the Master Policy on file at the University’s Student      9.    For rest cures or custodial care.
Insurance Office. These benefits include Benefits for Cleft         10.   As a result of dental treatment, except for treatment
Lip or Cleft Palate, Benefits for Hospitalization and General             resulting from Injury to sound, natural teeth. This exclusion
Anesthesia for Dental Procedures for Dependent Children,                  does not apply to Preventive Services mandated by the
Benefits for Treatment of Autism Spectrum Disorders, Benefits             Patient Protection and Affordable Care Act.
for Medical Foods, Benefits for Mammography, Diabetes,              11.   For donor expenses in relation to organ transplants.
Child Health Supervision Services, Cervical Cancer Vaccine,         12.   For elective treatment or elective surgery.
Colorectal Cancer Screening, Prostate Cancer Screening,             13.   For treatment, services, drugs, device, procedures or
and any other applicable mandated benefits.                               supplies that are experimental or investigational.
                                                                    14.   For eye examinations (except as specifically provided),
   * Benefits shall be subject to all Policy Year Deductible,             eyeglasses, contact lenses, or prescription for such,
     copayment, coinsurance, limitations, and any other                   or treatment for visual defects and problems. “Visual
                                                                          defects” means any physical defect of the eye which
                    provisions of the policy.
                                                                          does or can impair normal vision apart from the disease
                                                                          process. Vision examinations not related to prescription
                                                                          or fitting of lenses will be covered only when performed
                                                                          in connection with the diagnosis or treatment of Sickness
   EXCLUSIONS                                                             or Injury. Eye refraction is not covered. This exclusion
                                                                          does not apply to Preventive Services mandated by the
                                                                          Patient Protection and Affordable Care Act.
The Policy does not cover nor provide benefits for loss or          15.   For eye surgery such as radial keratotomy when the
expenses incurred:                                                        primary purpose is to correct myopia (nearsightedness),
1. For surgery and/or treatment of: acupuncture;                          hyperopia (farsightedness) or astigmatism (blurring).
    gynecomastia; family planning; infertility (male or female),    16.   For treatment provided in a government Hospital unless
    including any services or supplies rendered for the purpose           there is a legal obligation to pay such charges in the
                                                                16
absence of insurance.
17. For any services rendered by a Covered Person’s
    Immediate Family Member.
                                                                       COORDINATION OF
18. For Injury resulting from: the practicing for, participating
    in, or traveling as a team member to and from
                                                                       BENEFITS
    intercollegiate, or professional sports activity, including
    travel to and from the activity and practice.                  If the Covered Person has other group type, governmental, or
19. For maintenance therapy which is defined as those              automobile no fault medical benefits coverage, the benefits
    therapy services rendered to a Covered Person who is no        payable under the Policy will be coordinated with the other
    longer making documentable progress to maintain the            coverage so that the combined benefits paid or provided by
    level of progress previously attained.                         all plans will not exceed 100% of the allowable expense. The
20. For a treatment, service or supply which is not Medically      plan paying second takes the benefits of the primary plan into
    Necessary, except as specifically provided.                    account when it determines benefits.
21. For mental or nervous disorders except as specifically
    provided.
22. For outpatient prescription drugs except at specifically
    provided.
                                                                       DEFINITIONS
23. For personal items or services such as television,
    telephone or transportation.                                   “Accident” means an occurrence which (a) is unforeseen; (b)
24. For preventive treatment, testing, medicines, serums, or       is not due to or contributed to by Sickness or disease of any
    vaccines except as specifically provided. This exclusion       kind; and (c) causes Injury.
    does not apply to Preventive Services mandated by the          “Act” means the Patient Protection and Affordable Care Act
    Patient Protection and Affordable Care Act.                    of 2010 (Public Law 111-148) as amended by the Health
25. For routine physical examinations, health examinations         Care and Education Reconciliation Act of 2010 (Public Law
    or preschool physical examinations, including routine          111-152).
    care of a newborn infant, well-baby care and related
                                                                   “Allowable Charges” means the charges agreed to by the
    Doctor charges, except as specifically provided for in the
    Policy. This exclusion does not apply to Preventive Services   Preferred Provider Organization for specified covered medical
    mandated by the Patient Protection and Affordable Care         treatment, services and supplies.
    Act.                                                           “Covered Person” means a Covered Student and his or her
26. For elective sterilization or its reversal, unless otherwise   dependent(s) insured under the Policy.
    provided.                                                      “Covered Student” means a student of this Policyholder who
27. For services normally provided without charge by               is insured under the Policy.
    the Policyholder’s Health Service/Center, Infirmary or         “Deductible/Deductible Amount” means the dollar amount
    Hospital, or by health care providers employed by the          of Eligible Expenses a Covered Person must pay before
    Policyholder or services covered by the Student Health         benefits become payable.
    Service/Center fee.                                            “Doctor” means: (a) legally qualified physician licensed by
28. After the date insurance terminates for a Covered Person
                                                                   the state in which he or she practices; and (b) a practitioner
    except as may be specifically provided in the Extension of
    Benefits Provision.                                            of the healing arts performing services within the scope of
29. For chiropractic care or treatment not related to the          his or her license as specified by the laws of the state of such
    treatment of Sickness or Injury.                               practitioner; and (c) certified nurse midwives and licensed
30. For Injury or Sickness resulting from war or act of war,       midwives while acting within the scope of that certification.
    declared or undeclared.                                        The term “Doctor” does not include a Covered Person’s
31. Weight management, services and supplies related               Immediate Family Member.
    to weight reduction programs; weight management                “Elective Treatment” means medical treatment, which is
    programs, related nutritional supplies and treatment for       not necessitated by a pathological change in the function
    obesity, (except for surgery for morbid obesity). Treatment    or structure in any body part, occurring after the Covered
    of morbid obesity is covered. Morbid obesity is defined        Person’s effective date of coverage.
    as follows: Morbid obesity associated with serious and
                                                                   Elective treatment includes, but is not limited to: tubal ligation;
    life-threatening disorders such as diabetes mellitus and
    hypertension. Morbid obesity means a body weight two           vasectomy; breast reduction unless as a result of mastectomy;
    times the normal weight or greater, or 100 pounds in           submucous resection and/or other surgical correction of
    excess of normal body weight based on normal body              deviated nasal septum, other than necessary treatment of
    weight using generally accepted height and weight tables       acute purulent sinusitis; treatment for weight reduction;
    for a person of the same age, sex, height and frame.           learning disabilities; botox injections; treatment of infertility.
    Benefits will be provided only upon written request for        “Eligible Expense” means a charge for any treatment, service
    treatment with a treatment plan written by a Doctor, and       or supply which is performed or given under the direction of
    services and treatment must meet the requirements of           a Doctor for the Medically Necessary treatment of a Sickness
    Medical Necessity. Surgery for removal of skin or fat,         or Injury: (a) not in excess of the Reasonable and Customary
    except as specifically provided in the Policy.                 charges; or (b) not in excess of the charges that would have
32. As a result of an Injury or Sickness for which benefits
                                                                   been made in the absence of this coverage; (c) with respect
    are paid under any Workers’ Compensation or
    Occupational Disease Law.                                      to the Preferred Provider, is the Allowable Charge; (d) is the

                                                               17
negotiated rate, if any and (e) incurred while the Policy is in       “Injury” means bodily injury due to an Accident which: (a)
force as to the Covered Person except with respect to any             results solely, directly and independently of disease, bodily
expenses payable under the Extension of Benefits Provision.           infirmity or any other causes; (b) occurs after the Covered
“Emergency Medical Condition” means the sudden, and at                Person’s effective date of coverage; and (c) occurs while
the time, unexpected onset of a health condition that requires        coverage is in force. All injuries sustained in any one Accident,
immediate medical attention, that a prudent lay person having         including all related conditions and recurrent symptoms of
average knowledge of health services and medicine and                 these injuries, are considered one Injury.
acting reasonably would have believed that an emergency               “Medical Necessity/Medically Necessary” means that a
medical condition or life or limb threatening emergency               drug, device, procedure, service or supply is necessary and
existed and that failure to provide medical attention would           appropriate for the diagnosis or treatment of a Sickness or
result in serious impairment to bodily functions or serious           Injury based on generally accepted current medical practice
dysfunction of a bodily organ or part, or would place the             in the United States at the time it is provided.
person’s health in serious jeopardy.                                  A service shall not be considered as Medically Necessary if:
Emergency does not include the recurring symptoms of a chronic        (a) it is provided only as a convenience to the Covered Person
illness or condition unless the onset of such symptoms could          or provider; or (b) it is not the appropriate treatment for the
reasonably be expected to result in the complications listed above.   Covered Person’s diagnosis or symptoms; or (c) it exceeds
“Emergency Services” means the following:                             (in scope, duration or intensity) that level of care which is
  (a) a medical screening examination, as required by federal         needed to provide safe, adequate and appropriate diagnosis
      law, that is within the capability of the emergency             or treatment; or (d) it is experimental/investigational or for
      department of a Hospital, including ancillary services          research purposes; or (e) could have been omitted without
      routinely available to the emergency department, to             adversely affecting the patient’s condition or the quality
      evaluate an Emergency Medical Condition;                        of medical care; or (f) involves treatment of or the use of
  (b) such further medical examination and treatment that are         a medical device, drug or substance not formally approved
      required by federal law to stabilize an Emergency Medical       by the U.S. Food and Drug Administration (FDA); or (g)
      Condition and are within the capabilities of the staff and      involves a service, supply or drug not considered reasonable
      facilities available at the Hospital, including any trauma      and necessary by the Healthcare Financing Administration
      and burn center of the Hospital.                                Medicare Coverage Issues Manual or Center for Medicare
“Essential Health Benefits” means the essential health                and Medicaid Services Issues Manual; or (h) it can be safely
benefits defined in Section 1302(b) of the Act. This includes         provided to the patient on a more cost-effective basis such as
at least the following general categories and the items and           outpatient, by a different medical professional or pursuant to
services covered within the categories: (a) Ambulatory patient        a more conservative form of treatment.
services; (b) Emergency services; (c) Hospitalization; (d)            The fact that any particular Doctor may prescribe, order,
Maternity and newborn care;(e) Mental health and substance            recommend or approve a service or supply does not, of itself,
use disorder services, including behavioral health treatment;         make the service or supply Medically Necessary.
(f) Prescription drugs; (g) Rehabilitative and habilitative           “Reasonable and Customary” means the charge, fee
services and devices; (h) Laboratory services; (i) Preventive         or expense which is the smallest of: (a) the actual charge;
and wellness services and chronic disease management; (j)             (b) the charge usually made for a covered service by the
Pediatric services, including oral and vision care.                   provider who furnishes it; (c) the negotiated rate, if any; and
“Hospital” means a facility which meets all of these tests:           (d) the prevailing charge made for a covered service in the
(a) provides in-patient services for the care and treatment of        geographic area by those of similar professional standing.
injured and sick people; and (b) it provides room and board           “Geographic area” means the three digit zip code in which
services and nursing services 24 hours a day; and (c) it has          the services, procedure, devices, drugs, treatment or supplies
established facilities for diagnosis and major surgery; and           are provided or a greater area, if necessary, to obtain a
(d) it is supervised by a Doctor; and (e) it is run as a Hospital     representative cross-section of charge for a like treatment,
under the laws of the jurisdiction which it is located; and (f)       service, procedure, device, drug or supply.
it is accredited by the Joint Commission on Accreditation of          “Sickness” means disease or illness including related
Healthcare Organizations.                                             conditions and recurrent symptoms of the Sickness. Sickness
Hospital does not include a place run mainly: (a) as a                also includes pregnancy and Complications of Pregnancy. All
convalescent home; or (b) as a nursing or rest home; (c) as           Sicknesses due to the same or a related cause are considered
a place for custodial or educational care; or as an institution       One Sickness.
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; and (b) 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.
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