2012-202374-92 preliminary benefit summary flyer v4_benefit summary

Student Injury and Sickness Insurance This plan is underwritten by
Plan for International Student/Scholar Company and is based on policy
Care Plan Plus
International Student/Scholar Care Plan Plus is pleased to offer an Injury and Sickness Insurance Plan underwritten by UnitedHealthcare Insurance Company. Eligibility Statement: All regular, full time and part time eligible students, scholars or other persons with a current passport who: 1) are engaged in international educational activities; and 2) are temporarily located outside his/her home country as a non-resident alien; and 3) have not obtainedpermanent residency status are eligible to enroll in this Plan on a voluntary basis. Those enrolled in an Optional Practical Training program (with a F-1 or J-1 visa) who were previously enrolled in this Plan are eligible. Eligible Dependents of insured student may enroll concurrently on a voluntary basis. The Named Insured must actively attend classes for at least the first 31 days after the date for which coverage is purchased, with the exception of those with a J Visa or those in an Optional Practical Training program.
Highlights of the Coverage and Services
offered by UnitedHealthcare StudentResources are:
Up to $1,250,000 Per Insured Person, Per Policy Year Maximum Benefit for Covered Medical Expenses.
$50 Deductible Per Insured Person Per Policy Year for Preferred Providers, $250 Deductible Per Insured Person, Per Policy Year for Out of Network Providers.
Covered Medical Expenses for Preferred Providers are payable at 90% of Preferred Allowance and Out of Network benefits are payable at 70% of Usual and Customary charges (all benefits are subject tosatisfaction of the Deductible, specific benefit limitations, maximums and copays as described in the Preferred Provider Out-of-Pocket Maximum of $5,000 Per Insured Person, Per Policy Year. After the Out-of- Pocket Maximum has been satisfied, Covered Medical Expenses will be paid at 100% up to the policy Maximum Benefit subject to any applicable benefit maximums. Refer to the plan brochure for details about how Prescription Drug Benefits: prescription drug benefits are paid at 80% of Usual and Customary Charges.
The Preferred Provider Network for this plan is UnitedHealthcare Choice Plus. Preferred Providers can be found using the following link, www.insuranceforstudents.com.
Scholastic Emergency Services – International Students are covered worldwide except in their homecountry.
MyAccount, available through www.insuranceforstudents.com, allows insured students access 24/7 tocheck their claim status, search for network providers, print ID cards, enter accident details, view EOBs and enter additional insurance information online.
Included with every policy, the UnitedHealth Allies® 5% to 50% savings on dental and vision services, fitness clothing and equipment, and textbooks from McGraw-Hill Professional. The UnitedHealth Allies program is not insurance and is offered byUnitedHealth Allies, a UnitedHealth Group company.
Each Child
UnitedHealthcare StudentResources
PRE-EXISTING CONDITION means any condition which is 18. Prescription Drugs, services or supplies as follows: diagnosed, treated or recommended for treatment within the 6 Therapeutic devices or appliances, including: hypodermic months immediately prior to the Insured's Effective Date under the needles, syringes, support garments and other non-medical substances, regardless of intended use except as specifically Exclusions and Limitations
Immunization agents, biological sera, blood or blood products No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies Drugs labeled, “Caution – limited by federal law to investigational use” or experimental drugs; except as specifically Addiction, such as: nicotine addiction and caffeine addiction; non- Products used for unapproved cosmetic indications; chemical addiction, such as: gambling, sexual, spending, shopping, Drugs used to treat or cure baldness; anabolic steroids used for Anorectics - drugs used for the purpose of weight control; Congenital conditions, except as specifically provided for Newborn Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or Refills in excess of the number specified or dispensed after one for newborn or adopted children; removal of warts, non-malignant 19. Reproductive/Infertility services including but not limited to: family Custodial care; care provided in: rest homes, health resorts, homes planning; fertility tests; infertility (male or female), including any for the aged, halfway houses, college infirmaries or places mainly for services or supplies rendered for the purpose or with the intent of domiciliary or custodial care; extended care in treatment or inducing conception; premarital examinations; impotence, organic or substance abuse facilities for domiciliary or custodial care; otherwise; tubal ligation; vasectomy; sexual reassignment surgery; Dental treatment, except for accidental Injury to Teeth; 20. Research or examinations relating to research studies, or any Eye examinations, eye refractions, eyeglasses, contact lenses, treatment for which the patient or the patient’s representative must prescriptions or fitting of eyeglasses or contact lenses, vision sign an informed consent document identifying the treatment in correction surgery, or other treatment for visual defects and which the patient is to participate as a research study or clinical problems; except when due to a disease process; 10. Foot care including: care of corns, bunions (except capsular or bone 21. Routine Newborn Infant Care, well-baby nursery and related Physician charges except as specifically provided in the policy; 11. Immunizations, except as specifically provided in the policy; 22. Routine physical examinations and routine testing; preventive testing preventive medicines or vaccines, except where required for or treatment; screening exams or testing in the absence of Injury or treatment of a covered Injury or as specifically provided in the policy; Sickness; except as specifically provided in the policy; 12. Injury or Sickness for which benefits are paid under any Workers' 23. Services provided normally without charge by the Health Service of Compensation or Occupational Disease Law or Act, or similar the Policyholder; or services covered or provided by the student 13. Injury sustained while (a) participating in any interscholastic, 24. Deviated nasal septum, including submucous resection and/or other intercollegiate, club or professional sport, contest or competition; (b) surgical correction thereof; nasal and sinus surgery, except for traveling to or from such sport, contest or competition as a participant; or (c) while participating in any practice or conditioning 25. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail program for such sport, contest or competition; planing, bungee jumping, or flight in any kind of aircraft, except while 14. Organ transplants, including organ donation; riding as a passenger on a regularly scheduled flight of a commercial 15. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately 26. Suicide or attempted suicide while sane or insane (including drug preceding such Physiotherapy; or 2) within the 30 days immediately overdose); or intentionally self-inflicted Injury; following the attending Physician's release for rehabilitation; 27. Supplies, except as specifically provided in the policy; 16. Participation in a riot or civil disorder; commission of or attempt to 28. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically 17. Pre-existing Conditions, for a period of 6 months, except for individuals who have been continuously insured under the 29. Treatment in a Government hospital, unless there is a legal obligation International Community Service insurance policy for at least 6 for the Insured Person to pay for such treatment; consecutive months; Credit will be given for the time the Insured was 30. War or any act of war, declared or undeclared; or while in the armed covered under previous Creditable Coverage if the Creditable forces of any country (a pro-rata premium will be refunded upon Coverage was continuous to a date not more than sixty-three (63) request for such period not covered); and prior to the Insured’s Effective Date under this Policy; or 2) a 31. Weight management, weight reduction, nutrition programs, Newborn Infant or Adopted Child who has been continuously treatment for obesity, surgery for removal of excess skin or fat.
insured under previous Creditable Coverage since birth or adoptionif the Creditable Coverage was continuous to a date not more than63 days prior to the Insured Newborn or Adopted Child Effectivedate under this policy.

Source: http://www.insuranceforstudents.com/_pages/care/int/cpi_2012_fly.pdf

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