Student Health Insurance
Bollinger Summary of Benefits 2009 - 2010
To find a PPO provider, go to www.firsthealth.com
PPO Network: Currently with Beechstreet, in process of transitioning to First Health effective 8/1/09 - a national network with access throughout most of the United States
Maximum Benefit per Sickness or Injury: $50,000 per Policy Year
Coverage for injuries due to participation in intercollegiate sports is available for students who have paid the required additional premium at the time of enrollment.
Deductible: $250 deductible per Policy Year
Office Visits at LMU-DCOM Outpatient Services are paid at 100% (the Deductible and Copays are also waived). Lab work will be subject to the Deductible and Coinsurance.
Pre-existing conditions are not covered for the first 6 months of coverage under the plan, unless the insured person has had continuous prior creditable coverage to a date not more than 63 days prior to the effective date of coverage under this plan. A pre-existing condition is a sickness, injury, or related condition for which the insured person received medical treatment or advice, or which was diagnosed by a doctor, during the 6 consecutive months prior to the effective date of the insured person’s coverage under this plan.
Covered Charges are limited to the following:
INPATIENT |
|
Hospital Room and Board (up to the average semi-private room rate) |
80% of PPO charges if PPO is utilized or 60% of R&C |
Hospital Miscellaneous |
80% of PPO charges if PPO is utilized or 60% of R&C |
Surgery, including assistant surgeon and anesthetist |
80% of PPO charges if PPO is utilized or 60% of R&C |
Pre-Admission Testing |
80% of PPO charges if PPO is utilized or 60% of R&C |
Doctor Fees |
80% of PPO charges if PPO is utilized or 60% of R&C |
Registered Nurse’s Services |
80% of PPO charges if PPO is utilized or 60% of R&C |
Mental and Nervous Disorders, including alcohol and drug abuse |
80% of PPO charges if PPO is utilized or 60% of R&C; up to a maximum of 20 days per policy year |
OUTPATIENT |
|
Emergency Room |
After a $125 copay per visit (waived if admitted), 80% of PPO charges if PPO is utilized or 60% of R&C |
Doctor Visits |
After a $20 copay per visit (waived at LMU-DCOM Outpatient Services), 80% of PPO charges if PPO is utilized or 60% of R&C |
Well Office Visits |
After a $20 copay per visit (waived at LMU-DCOM Outpatient Services), 80% of PPO charges if PPO is utilized or 60% of R&C; up to a maximum of $250 per Policy Year |
Physical Therapy |
After a $20 copay per visit (waived at LMU-DCOM Outpatient Services), 80% of PPO charges if PPO is utilized or 60% of R&C; up to a maximum of 30 visits per Policy Year |
Surgery, including assistant surgeon and anesthetist |
80% of PPO charges if PPO is utilized or 60% of R&C |
Laboratory and X-Ray, including radiation therapy and chemotherapy |
80% of PPO charges if PPO is utilized or 60% of R&C |
Tests and Procedures |
80% of PPO charges if PPO is utilized or 60% of R&C |
Mental and Nervous Disorders, including alcohol and drug abuse |
After a $20 copay per visit (waived at LMU-DCOM Outpatient Services), 80% of PPO charges if PPO is utilized or 60% of R&C; up to a maximum of 25 visits per Policy Year |
OTHER |
|
Ambulance |
80% of R&C; up to a $1,000 maximum |
Braces and Appliances |
80% of PPO charges if PPO is utilized or 60% of R&C; up to a $2,500 lifetime aggregate maximum |
Chemotherapy and Radiation Therapy |
80% of PPO charges if PPO is utilized or 60% of R&C |
Consultant |
80% of PPO charges if PPO is utilized or 60% of R&C |
Repair of Injury to sound natural teeth |
80% of R&C; up to a maximum of $250 per tooth |
Immunizations |
100% of R&C; up to a maximum of $250 per Policy Year |
Well Baby Care |
100% of R&C; up to a maximum of $250 per Policy Year |
Pregnancy and Maternity, including complications of pregnancy |
80% of PPO charges if PPO is utilized or 60% of R&C |
Accidental Death and Dismemberment |
$5,000 Maximum |
Emergency Medical Evacuation |
$10,000 Maximum |
Repatriation |
$10,000 Maximum |
Prescription Drugs (self-injectibles are not covered) |
After a $15 copay for generic, a $35 copay for preferred brand name or a $50 copay for non-preferred brand name, 100% up to a $1,500 maximum per Policy Year, only if filled at a Caremark pharmacy |
Please see the Lincoln Memorial University 2009-10 Student Health Insurance Plan brochure for a complete description of the plan, including eligibility, claims, definitions, limitations and exclusions when it becomes available.
