The Massachusetts College of Pharmacy & Health Sciences Student Health Insurance Plan

The Massachusetts College of Pharmacy and Health Sciences Student Health Insurance Plan has been developed especially for Massachusetts College of Pharmacy and Health Sciences students. The Plan provides coverage for Sicknesses and Injuries that occur on and off campus, and includes special cost-saving features to keep the coverage as affordable as possible. Massachusetts College of Pharmacy and Health Sciences is pleased to offer the Plan as described in this Brochure.

Where to find help
For Questions About:

• Claims
• Insurance Benefits

Please Contact:

Bollinger, Inc.
P.O. Box 727
Short Hills, NJ 07078-0727
(866) 267-0092 (Toll-free)

For Questions About:

• Enrollment Forms
• Waiver Process

Please contact:

Massachusetts College of Pharmacy and
Health Sciences
Student Financial Services
179 Longwood Ave., Boston, MA 02215
(617) 732-2864

For Questions About:

• On Campus Counseling Services

Please contact:

MCPHS Counseling Services
(617) 732-2837

Health Services

Massachusetts College of Pharmacy and Health Sciences students on the Boston campus have full access to the Simmons College Health Center, 94 Pilgram Road, Boston, MA. 02115,which offers a walk in clinic and primary care services by appointment. To make an appointment, students may call(617) 521-1002.

Hours of Operation:

Monday - Thursday 9 a.m. - 8 p.m. Friday 9 a.m. - 5 p.m.
Saturday, Sunday, and Holidays 12 p.m. - 4 p.m.

The MCPHS Counseling Services offers confidential counseling to address a wide range of personal and professional issues and is available at no charge to students. For more information and hours of operation, visit Counseling Services or check them PHS Counseling Services web page at: www.mcphs.edu

The Massachusetts College of Pharmacy & Health Sciences Student Health Insurance Plan

This is a brief description of the Injury and Sickness Medical Expense benefits available for Massachusetts College of Pharmacy and Health Sciences students and their eligible dependents. The exact provisions governing this insurance are contained in the Master Policy issued to the College, and maybe viewed at the MCPHS Counseling Services or the Simmon’s College Health Center during business hours.

Policy Period

1. Students: Coverage for all insured students enrolled for the Policy Year will become effective at 12:01 a.m. on September 1, 2007, and will terminate at 12:01 a.m. on September 1, 2008.

2. Fall Students ONLY: Coverage for all insured students enrolled for the Fall Semester ONLY will become effective at 12:01 a.m. on September 1, 2007, and will terminate at 12:01 a.m. on January 16, 2008.

3. Spring Students ONLY: Coverage for all insured students enrolled for the Spring Semester ONLY will become effective at 12:01 a.m. on January 16, 2008, and will terminate at 12:01 a.m. on September 1, 2008.

4. Summer Students ONLY: Coverage for all insured students enrolled for the Summer Semester ONLY will become effective at 12:01 a.m. on May 21, 2008, and will terminate at 12:01 a.m. on September 1, 2008.

5. Insured Dependents: Coverage will become effective on the same date the insured student's coverage becomes effective, or the day after the postmarked date when the completed application and premium are sent, if later. Coverage for insured dependents terminates in accordance with the Termination provisions described in the Master Policy.

Basic Student Health Insurance Premium Rates

JV Visa Enrollees

Supplemental Medical Plan Coverage

A Supplemental Medical Plan is available to eligible domestic, international students, and to their eligible dependents who elect coverage under the Basic Student Health Insurance Plan. The Aggregate Maximum benefit under the Basic Student Health Insurance Plan described later in this Brochure is$50,000. If you have purchased the Student Health Insurance Plan at Massachusetts College of Pharmacy and Health Sciences, you are eligible to purchase the Supplemental Medical Plan to extend the combined maximum to $200,000 for students and to $100,000 for dependents. Please contact Bollinger, Inc. for additional information.

Supplemental Plan Enrollment Forms are available by contacting: Bollinger, Inc. at (800) 526-1379

Premium Refund Policy

Except for medical withdrawal due to a covered Injury or Sickness, any student withdrawing from school during the first31 days of the period for which coverage is purchased shall note covered under the Policy and a full refund of the premium will be made. Students withdrawing after such 31 days will remain covered under the Policy for the full period for which premium has been paid, and no refund will be allowed. A Covered Person entering the armed forces of any country will not be covered under the Policy as of the date of such entry. A pro-rata refund of premium will be made for such person, and any covered dependents, upon written request received by Bollinger, Inc. within 90 days of withdrawal from school.

Student Coverage
Eligibility/Enrollment
All registered undergraduate and graduate students taking three-quarters of full-time credit hours or more, and participants in the English Language Program are required to purchase the Plan and will be automatically enrolled in the Plan unless proof of comparable coverage is furnished and the Enrollment/Waiver form has been received by the office of Student Financial Services by the specified deadline dates set forth below.

All J1 Visa students and their dependents who are covered under the Student Health Insurance Plan are required to purchase additional coverage to comply with United States Information J1Visa regulations. Details regarding this addition-al coverage are available in this Brochure.

Dependent Coverage

Eligibility
Covered students may also enroll their lawful spouse and unmarried dependent children under age 19 who reside with, and are fully supported by, the covered student for the same coverage.

Enrollment
To enroll the dependent(s) of a covered student, please complete the Enrollment Form and return it to Bollinger, Inc. together with your check, money order, or Master Card/Visa payment. If the application is received before August 31,2007, there will be no break in coverage. If the application is received after August 31, 2007, the coverage becomes effective the day after the postmarked date of the completed application. The Fall enrollment deadline for dependents is August 31, 2007. Dependent Enrollment Forms will not be accepted after August 31, 2007. The Spring enrollment deadline is January 16, 2008. Dependent Enrollment Forms will not be accepted after January 16, 2008. The Summer enrollment deadline is May 21, 2008. Dependent Enrollment Forms will not be accepted after May 21, 2008.

Dependent Enrollment Forms are available: download

Newborn Infant Coverage and Adopted Child Coverage
A child born to a Covered Person shall be covered for Injury, Sickness, and congenital defects for 31 days from the date of birth. At the end of this 31-day period, coverage will cease under the Massachusetts College of Pharmacy and Health Sciences Student Health Insurance Plan. To extend coverage for a newborn past the 31 days, the Covered Person must (1)enroll the child within 31days of birth and (2) pay the additional premium starting from the date of birth.

Coverage is provided for a child legally placed for adoption with a Covered Person for 31 days from the moment of placement, provided the child lives in the household of the Covered Person and is dependent upon the Covered Person for support. To extend coverage for an adopted child past the 31 days, the Covered Person must (1) enroll the child within 31 days of placement of such child and (2) pay any additional premium, if necessary, starting from the date of placement.
 

Pre-existing Condition Limitation

No benefits will be payable in excess of $3,000 for the Covered Person's Pre-existing Conditions. They are defined as an Injury sustained or a Sickness for which the Covered Person was medically treated or advised by a Physician within the six months immediately prior to his Effective Date of Coverage under the Policy. Routine follow-up care to determine whether a breast cancer has re-occurred in a person who has been previously determined to be breast cancer free shall not be considered as medical advice or treatment for purposes of this section unless evidence of breast cancer is found during or as a result of such follow-up. Genetic information shall not be treated as a condition in the absence of a diagnosis of the condition related touch information. Pregnancy shall not be considered a pre-existing condition. Covered Medical Expenses resulting from a Pre-existing condition will not be covered unless:

1. six consecutive months have elapsed during which no medical treatment or advice is given by a Physician for such condition; or

2. the Covered Person has been insured under the Policy and the School’s prior policies for one year; or

3. the Covered Person has been receiving benefits under the School’s prior policies and has been continuously insured since the date of accident, Injury or Sickness, whichever occurs first; or

4. the Covered Person was insured under a prior plan that this Plan replaces and replacement is effective within 120 days of the termination date of the prior plan (150 days if prior coverage was terminated due to an involuntary loss of employment), then credit will be given for each day of coverage under the prior plan towards the satisfaction of the 180 day limitation on pre- existing conditions.

Continuously Insured
Previously Covered Persons must re-enroll for coverage, including dependent coverage, by August 31, 2007, for the Fall Semester, by January 16, 2008, for the Spring Semester and by May 21, 2008, for the Summer Semester in order to avoid a break in coverage for conditions that existed in the prior Policy Year. Once a break in continuous coverage occurs, the definition of Pre-Existing Conditions will apply.

Preferred Provider Organization

The Plan Administrator contracts with a Preferred Provider Organization (“PPO”), First Health Network, for access to providers in the Commonwealth of Massachusetts and elsewhere in the United States.

The most favorable reimbursement rates for benefits outlined in the Policy are based upon medical treatment being received from one of the preferred providers. The PPO gives the Covered Person access to a network of Physicians, Hospitals and other health care providers, who have agreed to accept lower rates for their services.

For updated information on the preferred provider in your area visit the website at www.firsthealth.com/ccnUsa/ed/index.html or call toll free 1-800-633-8033. A directory of preferred providers is avail-able on the website.

Covered Health Services may be obtained from any health care practitioner, however the Covered Person should be aware that outside the coverage of this Plan, he/she can use the resources of the Simmons College Health Center or MCPHS Counseling Services when first seeking non-emergency treatment.

Participation of individual preferred providers is subject to change without prior notice. It is the responsibility of the Covered Person to verify preferred provider status at the time services are rendered. Deductibles, co-payments or coinsurance are the responsibility of the Covered Person. If a Covered Person seeks treatment from a non-participating provider due to Medical Emergency or in the event the nearest provider cannot be reached, the benefit payable under the Policy will not be reduced.

Description of Benefits

Payment will be made as allocated herein for Covered Medical Expenses incurred for any one Injury or any one Sickness while insured under the Plan, not to exceed an Aggregate Maximum while continuously insured of $50,000 for any one covered Injury or any one covered Sickness.

A complete listing of Preferred Providers is available at the MCPHS Student Health Services or you can see www.firsthealth.com/ccnUsa/ed/index.html or call(800) 633-8033for a list of preferred providers practicing in your area.

Summary of Benefits Chart
The following benefits are subject to the imposition of Policy limits and exclusions. All coverage is based on the Usual and Customary Charge allowance unless otherwise specified. This Plan always pays benefits in accordance with any applicable Commonwealth of Massachusetts Insurance Law(s).

Inpatient Hospitalization Benefits
Hospital Room Board Expenses	Preferred Care: 80% of the PPO Allowance for an overnight stay. Non-Preferred Care:80% of the Usual and Customary Charge for the average semi-private room rate for an overnight stay.
Intensive Care: Unit Expenses	Covered Medical Expenses are payable as follows: Preferred Care: 80% of the PPO Allowance for an overnight stay. Non-Preferred Care: 80% of the Usual and Customary Charge for the intensive care room rate for an overnight stay.
Miscellaneous Expenses	Covered Medical Expenses are payable as follows: Preferred Care: 80% of the PPO Allowance. Non-Preferred Care:80% of the Usual and Customary Charge. Covered Medical Expenses include, but aren't limited to: laboratory tests, X-rays, nurses, anesthesia, supplies and equipment use, and medicines.
Physician Hospital Visit Expenses	Covered Medical Expenses for charges for the non-surgical services of the attending Physician or a consulting Physician are payable as follows: Preferred Care: 80% of the PPO Allowance. Non-Preferred Care:80% of the Usual and Customary Charge.
Surgical Benefits (Inpatient and Outpatient)
All Covered Medical Expenses in this section (excluding Anesthesia and Assistant Surgical Expenses) are subject to a maximum of $5,000 per surgery.
Surgical Expenses/Physician’s Charge	Covered Medical Expenses for charges for surgical services performed by physician are payable as follows: Preferred Care: 80% of the PPO Allowance. Non-Preferred Care: 80% of the Usual and Customary Charge.
Surgical Expenses/Facility Charge	Covered Medical Expenses for charges incurred for surgical services are payable as follows: Preferred Care: 80% of the PPO Allowance. Non-Preferred Care: 80% of the Usual and Customary Charge.
Anesthetist Assistant Surgeon Expenses	Covered Medical Expenses for the charges of an anesthetist and an assistant surgeon during a surgical procedure are payable as follows: Preferred Care: 30% of the actual payment made to the surgeon. Non-Preferred Care: 30% of the actual payment made to the surgeon.
Outpatient Surgical Hospital Miscellaneous Services Expenses	Covered Medical Expenses are payable as follows for examinations, laboratory tests, X-rays, anesthesia, use of operating room, medicines, and any other necessary hospital treatment (except personal services) incurred while an outpatient for surgical services. Preferred Care: 80% of the PPO Allowance. Non-Preferred Care: 80% of the Usual and Customary Charge.
>Outpatient Benefit Expense (Other Than Surgical)
Covered Medical Expenses are payable up to a combined maximum of $1,500 per Injury or Sickness per Policy Year. (Please note that some benefits have individual Copays/Deductibles and maximums separate from the Aggregate Maximum.) Covered Medical Expenses include, but are not limited to: non-surgical services of a Physician, hospital outpatient department or emergency room, durable medical equipment, allergy testing and treatment expenses, clinical lab-oratory, and radiological facility.
Physician’s Office Visit Expenses	Covered Medical Expenses are payable as follows: Preferred Care: 80% of the PPO Allowance. Non-Preferred Care: 80% of the Usual and Customary Charge.
Outpatient Expenses	Covered Medical Expenses for the treatment of an accidental Injury or Sickness are payable as follows: Preferred Care: 80% of the PPO Allowance. Non-Preferred Care:80% of the Usual and Customary Charge.
Hospital Emergency Room Expenses	Covered Medical Expenses for the treatment of an Emergency Medical Condition are payable as follows: Preferred Care: 80% of the PPO Allowance after a $50 Copay per visit. Non Preferred Care: 80% of the Usual and Customary Charge after a $50 Deductible per visit.
Durable Medical Expenses	$100 maximum per condition. Covered Medical Expenses also includes scalp hair prosthesis worn for hair loss suffered as a result of any form of cancer or leukemia.
Testing Required after Needlestick Injury (Student Only), Including the Testing of the Student's Patient if Prescribed by the Student's Physician	Covered Medical expenses for Needlestick Testing are payable on the same basis as any outpatient expense.
Chest X-Ray to Screen for Tuberculosis	Covered Medical Expenses for Tuberculosis Screening are payable on the same basis as any outpatient expense.
Mental Health and Substance Abuse Benefits
Inpatient Expenses	Covered Medical Expenses for inpatient treatment of a mental health condition or for substance abuse are payable as follows: Treatment of biologically based mental health conditions, or rape related mental or emotional disorders, while confined as an inpatient in a hospital or facility licensed for such treatment are payable on the same basis as any other inpatient expense. Treatment of non-biologically based mental health conditions, or for substance abuse, including alcohol, while confined as an inpatient in a hospital or facility licensed for such treatment, are payable on the same basis as any other inpatient expense subject to a maximum of 60 days per Policy Year.
Outpatient Expenses	Covered Medical Expenses for a mental health condition or for substance abuse are payable as follows: Treatment for biologically based conditions or rape related mental or emotional disorders are covered on the same basis as any other out patient expense. Treatment for non-biologically based mental health conditions (including substance abuse) are covered on the same basis as any other out patient expense, subject to a maxi-mum of 24 visits per Policy Year.
Maternity Benefits
Maternity Expenses	Covered Medical Expenses for pregnancy, childbirth, and complications of pregnancy are payable on the same basis as any other Sickness. In the event of an inpatient confinement, such benefits would be payable for inpatient care of the Covered Person and any new-born child, for a minimum of 48 hours after a vaginal delivery and for a minimum of 96 hours after a cesarean delivery. Any decision to shorten such minimum coverages shall be made by the attending Physician in consultation with the mother and done in accordance with the rules and regulations promulgated by the Department of Public Health. In such cases, Covered Medical Expenses may include home visits, parent education, and assistance and training in breast or bottle-feeding.
Additional Benefits
Voluntary Termination of Pregnancy Expenses	Covered Medical Expenses for voluntary termination of pregnancy are payable on the same basis as any other Sickness.
Prescription Drug Benefit Expenses	Covered Medical Expenses for outpatient Prescription Drugs associated with a covered Sickness or covered Injury which occurs during the Policy Year are payable as follows with a $500 Policy Year Maximum.100% after a $10 Copay for each generic prescription drug and a $15 Copay for each brand-name prescription drug. Please note that you are required to pay in full at the time of service for all Prescriptions dispensed at a Non-Participating Pharmacy. Medications not covered by this benefit include, but are not limited to: allergy sera; drugs whose sole purpose is to promote or to stimulate hair growth; appetite suppressants; smoking deterrents; immunization agents and vaccines; and non-self injectables. Covered medications include off-label drugs to treat cancer or HIV/AIDS, oral contraceptives, Lunelle, Depo-Provera, Patch, and Ring. Expenses incurred for office visits in conjunction with the administration of a covered prescription contraceptive. Please use your Caremark ID card when obtaining your Prescriptions.
High Cost Procedure	Covered Medical Expenses for high cost procedures in excess of $200, such as, but not limited to: outpatient diagnostic C.A.T. Scans, Magnetic Resonance Imaging, and Laser treatments are payable as follows: Preferred Care: 80% of the PPO Allowance. Non-Preferred Care: 80% of the Usual &Customary Charge. Covered Medical Expenses are payable up to a maximum of$2,000 per Injury or Sickness.
Ambulance Expenses	Covered Medical Expenses are payable at100% of the actual charge to a maximum of$250 per trip for the services of a professional ambulance to or from a hospital when required due to the emergency nature of a covered Injury or Sickness.
Consultation Expenses	Covered Medical Expenses are payable for the services of a consulting Physician when deemed Medically Necessary and ordered by the attending Physician for the purpose of treatment up to a $250 maximum.
Dental Expenses	Covered Medical Expenses are payable at100% of the actual charge to a maximum of $500 per tooth for the treatment of an Injury to sound, natural teeth. Covered Medical Expenses are payable at 100% of the actual charge up to a maximum of $50per tooth for the removal of impacted wisdom teeth.
Allergy Testing/Treatment Expenses	Covered Medical Expenses are payable for allergy testing and treatment services on the same basis as any outpatient expense.
Pediatric Preventive Care Expenses	Covered Medical Expenses for insured, dependent children from birth to age 6 are payable at 80% of the actual charge. Covered Medical Expenses include the following services: physical examination;history; measurements; sensory screening; neuropsychiatric evaluation; and, development screening, and assessment at the following age intervals: Birth to under age 1 (6 exams per year) Age 1 to under age 2 (3 exams per year) Age 2 to under age 6 (1 exam per year) Services shall include hereditary and metabolic screening at birth, appropriate immunizations and tuberculin tests, hematocrit, hemoglobin, or other appropriate blood tests and urinalysis as recommended by the Physician.
Hearing Screening Expenses for Newborns	Hearing screenings for newborns means services rendered to a dependent child of a Covered Person for hearing tests performed before the newborn infant is discharged from the hospital or birthing center. Covered Medical Expenses are payable at 80% of the actual charge.
Early Intervention Service Expenses	Covered Medical Expenses will be payable at 80% of the actual charge up to a maxi-mum of $3,200 per Policy Year and to a maximum of $9,600 per lifetime. Covered Medical Expenses includes Medically Necessary services, which must be provided by a “certified early intervention specialist” working in early intervention programs certified by the Department of Public Health. Coverage is available to insured, dependent children from birth until three months after their 3rd birthday (or until September 1st of the year of the child’s 3rdbirthday if the child was born after April1st).
Cardiac Rehabilitation Expenses	Covered Medical Expenses are payable on the same basis as any other Sickness for covered expenses incurred for cardiac rehabilitation treatment rendered in connection with documented cardiovascular disease. Treatment includes, but is not limited to, outpatient treatment which is initiated within 26 weeks after diagnosis of cardiovascular disease.
Women’s Health Benefit Expenses	Covered Medical Expenses include expenses for an annual Pap smear screening for women age 18 and older. Covered Medical Expenses are payable on the same basis as any outpatient expense. If follow-up diagnostic Pap smears are Medically Necessary, they will be covered on the same basis as any outpatient expense. Covered Medical Expenses include one baseline mammogram for women between the ages of 35 and 40. Women age 40 and older have coverage for an annual mammogram per Policy Year. Covered Medical Expenses are payable on the same basis as any other X-ray expense.
Home Health Care Expenses	Covered Medical Expenses are payable at80% of the actual charge.
Hospice Care Expenses	Covered Medical Expenses for inpatient care will be covered on the same basis as any inpatient expense. Covered Medical Expenses for outpatient care will be covered on the same basis as any outpatient expense.
Diabetic Equipment and Self-Management Education Program (Please note: Insulin, syringes, and diabetic testing supplies are covered under the Prescription Drug portion of the Plan)	Covered Medical Expenses for diabetic equipment, other than those provided under the Prescription Drug portion of the Plan, and self-management education pro-grams, are payable on the same basis as any expense.
Bone Marrow Transplant Expenses for Breast Cancer	Covered Medical Expenses are payable on the same basis as any expense in accordance with State Law. Refer to the Master Policy for details.
Infertility Expense Benefit	Covered Medical Expenses are payable on the same basis as any expense for Medically Necessary expenses for the diagnosis and treatment of infertility. Covered Medical Expenses include expenses incurred for non-experimental infertility procedures including artificial insemination (AI; in vitro fertilization and embryo placement (IVF); gamete intra-fallopian transfer(GIFT); sperm, egg and/or inseminated egg procurement, processing, and banking to the extent such costs are not covered by the donor’s insurer, if any; intracytoplasmic sperm injection (ICSI) for treatment of male factor fertility; and zygote intra-fallopian transfer (ZIFT). Benefits payable under this provision are not subject to any Pre-Existing Conditions exclusion (if applicable under the Plan).
Speech or Hearing Therapy Benefit	Covered Medical Expenses are payable on the same basis as any other expense. Covered Medical Expenses include expenses incurred for the diagnosis or treatment by a Physician for acute speech, hearing, and language disorders; but only if the charges are made for: Diagnostic services rendered to find out if and to what extent the Covered Person’s ability to speak or hear is lost or impaired. Rehabilitative services rendered that are expected to restore or improve a Covered Person's ability to speak or hear.

Additional Services and Discounts

As a participant in the Student Health Insurance Plan, you can also take advantage of the following services, discounts, and programs. These services, discounts, and programs are not underwritten by Peoples Benefit Life Insurance Company.

General Provisions
State Mandated Benefits

The Plan will pay benefits for the following Mandated Benefits and any other applicable Mandate in accordance with any other applicable Commonwealth of Massachusetts Insurance Law(s): Alcoholism Treatment; Bone Marrow Transplants for Treatment of Breast Cancer; Cardiac Rehabilitation; Clinical Trials Benefit; Cytologic Screening and Mammographic Examinations; Dietary Products; Diabetes Treatment; Home Health Care; Hormone Replacement Therapy; Hospice Care; Human Leukocyte Antigen or Histocompatibility Locus Antigen Testing; Infertility Treatment; Initial Prosthetic Device and Reconstructive Surgery; Lead Poisoning; Maternity, Childbirth, Well-Baby and Post Partum Care; Mental Disorders Treatment; Off-Label Drug Use; Psychiatric Care Benefit; Scalp Hair Prothesis; Speech, Hearing and Language Disorders.

Non-Duplication of Benefits

The Policy provides benefits in accordance with all of its provisions only to the extent that benefits are not provided by any other valid and collectible insurance. If the Covered Person is covered by other valid and collectible insurance, all benefits payable by such insurance will be determined before benefits will be paid by the Policy. The Policy is the second payor to any other insurance having primary status or no coordination or non-duplication of benefits provision.

If the Covered Person is insured under group or blanket insurance, which is also excess to other coverage, the Policy pays a maximum of 50% of the benefits otherwise payable.

Definitions
CO-INSURANCE means the out-of-pocket expenses to be paid by the Covered Person as a percentage of the Covered Medical Expenses.

Covered Medical Expenses are usual, customary, and Medically Necessary charges that are:

1. not in excess of the maximum amount payable for services as specified in the policy schedule;
2. in excess of any deductible amount; and
3. incurred while the Covered Person’s coverage under the Policy is in force.

ELECTIVE SURGERY means any surgery or treatment that is not Medically Necessary, including any service, treatment, or supply that is deemed by us to be research or experimental; or is not recognized as generally accepted medical practice in the United States.

Elective Surgery and Elective Treatment do not include any procedures deemed a Medical Necessity. Elective Surgery does not mean a Cosmetic Procedure required to correct an Injury for which benefits are otherwise payable under the Policy. Elective Surgery and Elective Treatment includes but is not limited to surgery and/or treatment for acne; acupuncture; allergy and allergy vials, including allergy testing; bio-feedback type services; birth control; breast implants, unless provided for under Mandated Benefits; breast reduction, unless provided for under Mandated Benefits; circumcision; corns, calluses and bunions; cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under the Policy, and except for cosmetic surgery required to correct a covered Injury or infection or other diseases of the involved part and reconstructive surgery because of congenital disease or anomaly of a covered newborn child for which benefits are otherwise payable under the Policy; deviated nasal septum, including submucous resection and/or other surgical correction; family planning; hair growth or removal; learning disabilities; nonmalignant warts, moles and lesions; obesity and any condition resulting therefrom (including hernia or any kind), except for the treatment of an under-lying covered Sickness; premarital examinations; preventive medicines or vaccines, except where required for the treatment of a covered Injury or under the Mandated Benefits section; sexual reassignment surgery; skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; sleep disorders, including testing; smoking cessation; temporomandibular joint dysfunction (TMJ); tubal ligation; vasectomy; and weight loss or reduction.

EMERGENCY MEDICAL CONDITION means a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of a Covered Person or another person in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any body organ or part or with respect to pregnant women, as further defined in §1867(e)(1) (B) of the Social Security Act, 42 U.S.C. §1395(e) (1)(B).

HOSPITAL means an institution which meets all of the following requirements:

1. It must be operated according to law;
2. It must give 24-hour medical care, diagnosis and treatment to sick or injured on an in-patient basis for which a charge is made;
3. It must provide diagnostic and surgical facilities supervised by Physicians;
4. Registered Nurses must be on 24-hour call or duty;
5. The care must be given either on the Hospital’s premises or in facilities available to the Hospital on a prearranged basis.

A Hospital is not a rest, convalescent, extended care, rehabilitation or skilled nursing facility. It is not a facility for the aged. It is not a place which primarily treats alcoholism or drug addiction; nor does it include any ward, wing or other section of the Hospital that is used for such purposes.

INJURY means bodily injury caused by an accident. The accident must occur while the Covered Person’s insurance is in force under the Policy. A Covered Person must begin receiving services, supplies or treatment within 90 days from the time of accident in order for it to be considered a covered Injury. All Injuries sustained by one person in any one accident, including all related conditions and recurrent symptoms of these Injuries, are considered a single covered Injury. The Injury must be the direct cause of loss and must be independent of all other causes. The Injury must not be caused by or contributed to by Sickness.

COVERED PERSON means an eligible student as outlined in this brochure who has paid the required premium. The words he, his and him refer to the Covered Person, regardless of gender.

MEDICALLY NECESSARY means health care services that are consistent with generally accepted principles of professional medical practice as determined by whether: (a) the service is the most appropriate available supply or level of services for the insured in question considering potential benefits and harms to the individual; (b) is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or (c) for services and interventions not in widespread use, is based on scientific evidence.

MAXIMUM BENEFIT means the maximum amount payable for expenses incurred by a Covered Person for any on Injury or Sickness.

OUTPATIENT EXPENSE means those expenses incurred for Medically Necessary services received while not confined as abed patient in a Hospital.

PHYSICIAN means a person licensed by the state in which he is resident to practice the healing arts including Chiropractor, Optometrist, Certified Registered Nurse, Anesthetist, Nurse Practitioner and Certified Nurse Midwife. He must be practicing within the scope of his license for the service or treatment given. He may not be the Covered Person or a member of his immediate family.

PREFERRED PROVIDER ORGANIZATION means a diversified group of medical providers who have entered into agreements with the Plan Administrator or the Company to provide medical benefits and services to the Covered Persons.

SICKNESS means an illness or disease which first causes loss while the coverage is in effect and which results in Covered Medical Expenses. All related conditions and recurrent symptoms of the same or a similar condition will be considered the same Sickness. It also includes pregnancy, and complications of pregnancy.

USUAL AND CUSTOMARY CHARGE means those charges for necessary treatment and services that are reasonable for the treatment of cases of comparable severity and nature. This will be derived from the mean charge based on the experience in a related area of the service delivered.

Exclusions

Benefits will not be paid under the Policy and any attached Rider for any expenses, which result from:

1. Expenses incurred as the result of dental treatment, except as specifically provided for treatment resulting from Injury to natural teeth;
2. Services that are provided normally without charge by the University's health center, infirmary or Hospital; or by any person employed by the University;
3. Eyeglasses, radial keratotomy, contact lenses, hearing aids or prescriptions or examinations except as required for repair caused by a covered Injury;
4. Declared or undeclared war, riot, civil disorder, civil commotion or acts of terrorism;
5. Riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as fare-paying passenger in an aircraft operated by a commercial scheduled airline. This exclusion does not apply to insured students while taking flight instructions for University credit;
6. Injury or Sickness for which benefits are payable under any Worker's Compensation or Occupational Disease Law;
7. Injury sustained or Sickness contracted while in the service of the armed forces of any country. When a Covered Person enters the armed forces, we will refund any unearned pro-rata premium with respect to such person;
8. Treatment provided in a government hospital unless there is a legal obligation to pay such charges in the absence of other insurance;
9. Routine screenings or test which are not Medically Necessary for the diagnosis or treatment of your condition or which are not specifically ordered by the admitting Physician (except as stated in the Mandated Benefits section of the Policy);
10. Hospital care (admission tests, supplies or continued care), medical care, rehabilitation, or any other treatment, procedure, facility, equipment, drug, device, supply or service which we determine is not Medically Necessary. We have the right to deny payments if a Physician or Hospital does not supply medical records required to determine Medical Necessity. We also have the right to deny or reduce payment if the records supplied do not provide adequate justification for per forming the service;
11. Cosmetic surgery, except for the correction of birth defects, correction of deformities resulting from cancer surgery, or surgery that is required as a result of an Injury which necessitates medical treatment within 24 hours of the accident. Correction of deviated nasal septum shall be considered as Cosmetic surgery for the purpose of the Policy;
12. Expenses resulting from a motor vehicle accident for which benefits are payable from other valid insurance;
13. Expenses for preventative medicines, vaccines except anti-toxins administered within twenty-four (24) hours after an accident, or injections administered during an out patient visit, except an injection given by a Physician in private practice who will certify that a Medical Emergency was required for the condition;
14. Homemaking, companion or chronic (custodial) care services. Charges of a home health aide who is a member of your household. Charges of any care provided by relatives (by blood, marriage or adoption);
15. Blood or blood plasma that is replaced by or for the patient;
16. Services or supplies which are experimental or investigative in nature: including the treatment, procedure, facility, equipment, drugs, drug usage, devices, or supplies not recognized as accepted medical practice and any such items requiring federal or other governmental agency approval not received at the time services were rendered;
17. Expenses or supplies related to sex changes, sexual dysfunctions or inadequacies with the exception of penile prosthesis required for physiological impotence;
18. Orthopedic appliances or devices, including orthopedic shoes, for treatment of the foot or conditions relating tot he foot (except under Mandated Benefits);
19. Expenses incurred for the treatment of and supplies for weight reduction, hair growth or removal, or smoking cessation;
20. Alopecia, Biofeedback-type services, Gynecomastia, Hirsutism, Nicotine Addiction, Patient Controlled Analgesia (PCA);
21. Psychoanalysis or psychotherapy services you receive which are credited towards a degree or to further your education or training, regardless of symptoms that you may have;
22. Expenses incurred outside the United States by a Covered Person whose home country is outside the United States and who has received a Medical Evacuation Benefit:;
23. Educational or learning disabilities;
24. Treatment of temporomandibular joint dysfunction (TMJ) and associated myofacial pain;
25. Injury resulting from the playing, practice, participating, or conditioning in any intercollegiate, or inter-scholastic contest or competition sponsored by the University, any professional or semi-professional sport, or Injury sustained while traveling to or from such sport, contest or competition as a participant; and
26. Elective Surgery or Elective Treatment.
     

Extensions of Benefits after Termination

The coverage provided under this Plan ceases on the termination date. However, if a Covered Person is Hospital Confined on the termination date from a covered Injury or Sickness for which benefits were paid before the termination date, Covered Medical Expenses for such Injury or Sickness will continue to be paid until the completion of his Hospital Confinement but not to exceed 31 days from the expiration date of coverage.

After the “Extension of Benefits’ provision has been exhausted, all benefits cease to exist, and under no circumstances will further payments be made.

The total payments made in respect of the Covered Person for each condition both before and after the termination date will never exceed the Maximum Benefit.

Claim Procedure

All claims must be submitted to Bollinger, Inc. within 30 days from the date of loss. Attach all available bills at that time. If they are not available send them in at a later date, properly identifying them with the name of the student and school.

Bollinger, Inc.
P.O. Box 727
Short Hills, NJ 07078
(866) 267-0092 (Claims/Coverage Questions)
(800) 526-1379 (Other Questions)

Customer Service Representatives are available Mondaythrough Friday, 8:00 a.m. to 5:00 p.m. (ET).

1. Bills must be submitted within 90 days from the date of treatment.
2. Payment for Covered Medical Expenses will be made directly to the Hospital or Physician concerned unless bill receipts and proof of payment are submitted.
3. No claim forms are required. In the event that additional information is needed to determine benefits, Bollinger, Inc. will request the necessary information from you or your medical provider.
4. In the event of a disagreement over the payment of a claim, a written request to review the claim must be mailed to Bollinger, Inc., within 60 days from the date appearing on the Explanation of Benefits (EOB).

Utilization Review Program

If a claim is denied payment due to lack of Medical Necessity, the Covered Person may appeal the decision. Send a written appeal to the Plan Administrator at Bollinger, Inc., P. O. Box727, Short Hills, NJ 07078-0727. Include in the written appeal any additional information or evidence the Covered Person may have regarding the claim.

The appeal will be sent to an independent utilization review organization for review. Written notification of the decision by the independent utilization review organization will be sent to the Covered Person within 30 days of the appeal receipt date.

If the first appeal is denied, a second appeal may be submitted to the Office of Patient Protection within 45 days of the Covered Person’s receipt of the written decision. Procedures for filing a grievance with the Office of Patient Protection, as well as interpreter and translation services. The procedures for filing the appeal are the same as the first appeal. All new information or evidence regarding the Medical Necessity of the claim should be submitted for review.

You may contact Bollinger, Inc. at 1-866-267-0092 to deter-mine the status or outcome of the utilization review decision.

Emergency Services

In the event of an Emergency Medical Condition, a Covered Person has the option of calling a local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever a Covered Person is confronted with an Emergency Medical Condition which in the judgment of a prudent layperson would require pre-hospital emergency services.

All claims must be submitted to Bollinger, Inc. within 30 days from the date of loss. Attach all available bills at that time. If they are not available send them in at a later date, properly identifying them with the name of the student and school.

Medical Evacuation and Repatriation Benefits

Medical Evacuation. Upon receipt of due proof that a Covered Person incurred expenses for Physician ordered Emergency Medical Evacuation, including medically appropriate transportation and Medically Necessary Care en route to the nearest suitable Hospital or to the Covered Person’s home country, when the Covered Person is critically ill or injured and has been Hospital confined for at least 5 days, and appropriate local care is not available, we will pay the allowable charges incurred not to exceed $10,000, subject to prior approval of the Plan Administrator for this Plan and the attending Physician.

Payment of a benefit under the terms of this provision is in lieu of all benefits otherwise payable under the plan and any riders. Insurance for the Covered Person ends upon the evacuation.

Repatriation. Upon receipt of due proof of a Covered Person’s death, we will pay the allowable charges for the preparation and transportation of the deceased’s body for burial or cremation in his home country or country of regular domicile subject to the approval of the Plan Administrator of the Policy. If applicable, such action will be in accordance with any inter-national standards. The benefit payable is not to exceed$10,000, and death must occur at least 100 miles away from the Covered Person’s city of residence. Benefits provided by this provision are paid in addition to any other benefits payable under the Policy.

Travel Assistance Program
(Provided by On-Call International)

Each Insured Student and his/her enrolled Dependents are eligible for travel assistance services when traveling 100 miles or more away from their home and campus address. Travel Services are only available for medical claims that are covered under the Student Injury and Sickness Insurance Plan. Services provided include:

Medical Consultation and Evaluation
Hospital Admission Guarantee
Critical Care Monitoring
Prescription Medication Dispatching
Emergency Message Transmission
Family/Friend Transportation

Within North America Call 1-800-407-7307
Outside North America Call 1-603-898-9159

Note: The Travel Assistance program is not insurance. It is not connected with or provided by Peoples Benefit Life Insurance Company. On-Call International Benefits are available 24 hours a day, 7 days a week, 365 days a year.

For Information contact the Plan Administrator

P. O. Box 727
Short Hills, NJ 07078-0727
866-267-0092 (Claims/Coverage Questions)
800-526-1379 (All Other Questions)

This Plan is Underwritten by:
PEOPLES BENEFIT LIFE
INSURANCE COMPANY
Cedar Rapids, Iowa

Preferred Provider Network

Policy Number: NHG-MP-400.MA(Rev.4/05)                     1189187