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2016–2017 Student Injury and Sickness Insurance Plan for University of Maine - Farmington
Who is eligible to enroll?
Al domestic registered ful -time undergraduate students taking 9 or more credit hours and al domestic graduate students
taking 6 or more credit hours and al international students with F-1 visas are automatical y enrolled in this insurance Plan at
registration, unless proof of comparable coverage is furnished. Students living outside of Maine enrol ed in only online courses
are not eligible.

Where can I get more information about the benefits available?
Please read the plan brochure to determine whether this plan is right for you before you enroll. The plan brochure provides
details of the coverage including costs, benefits, exclusions, and reductions or limitations and the terms under which the
coverage may be continued in force. Copies of the plan brochure are available from the University and may be viewed at
www.crossagency.com/um.

Who can answer questions I have about the plan?
If you have questions please contact Customer Service at 1-800-977-4698 or [email protected] or Cross
Insurance Agency at 1-800-537-6444 or Col [email protected].

What important dates or deadlines should I be aware of?
Online waivers must be submitted by October 1, 2016 for Annual coverage and February 20, 2017 for Spring/Summer
coverage.
How much does the plan cost?
8/1/16 – 7/31/17
1/1/17 – 7/31/17
This plan is underwritten by HPHC Insurance Company, an affiliate of Harvard Pilgrim Health Care Inc. and administered by UnitedHealthcare StudentResources and serviced by Cross Insurance Agency and is based on policy number 2016-200202-1. The Policy is a Non-Renewable One-Year Term Policy. 15PPOSBME-1322-1 HPHC Insurance Company Highlights of the Coverage and Services offered by UnitedHealthcare StudentResources
METALLIC LEVEL – GOLD WITH ACTUARIAL VALUE OF 78.006%
Preferred Providers
Out-of-Network Providers
Overall Plan Maximum
There is no overal maximum dollar limit on the policy Plan Deductible
$4,500 Per Insured Person, Per $6,500 Per Insured Person, Per Policy (The Deductible will not be applied (The Deductible will not be applied until the Company has paid $2,500 until the Company has paid $2,500 in in Covered Medical Expenses.) Covered Medical Expenses.) Out-of-Pocket Maximum
$6,350 Per Insured Person, Per There is no Out-of-Pocket Maximum After the Out-of-Pocket Maximum has been for Out-of-Network benefits satisfied, Covered Medical Expenses will be paid at 100% for the remainder of the Policy Year subject to any applicable benefit maximums. Refer to the plan brochure for details about how the Out-of-Pocket Maximum applies.
Coinsurance
80% of Preferred Al owance to 60% of Usual and Customary Charges All benefits are subject to satisfaction of the $2,500, Deductible applies after to $2,500, Deductible applies after Deductible, specific benefit limitations, $2,500, then 100% thereafter for $2,500, then 80% thereafter for maximums and Copays as described in the Covered Medical Expenses Covered Medical Expenses plan brochure.
Prescription Drugs
$20 Copay for Tier 1 Prescriptions must be filled at a UHCP $30 Copay for Tier 2 network pharmacy. Mail order through UHCP $60 Copay for Tier 3 at 2.5 times the retail copay up to a 90 day Up to a 31-day supply per prescription fil ed at a UnitedHealthcare Pharmacy (UHCP) Preventive Care Services
100% of Preferred Al owance Including but not limited to: annual physicals, GYN exams, routine screenings and immunizations. No Copay or Deductible when the services are received from a Preferred Provider. Please see for complete details of the services provided for specific age and risk groups.
The following services have per Service
Medical Emergency: $100 Copay, in Medical Emergency: $100 Deductible, addition to the Policy Deductible. The in addition to the Policy Deductible. This list is not all inclusive. Please read the Copay wil be waived if admitted to The per visit Deductible wil be waived plan brochure for complete listing of if admitted to the Hospital. Copays/Deductibles.
Pediatric Dental and Vision Benefits
Refer to the plan brochure for details (age limits apply). UnitedHealthcare Global:
Domestic Students are eligible for UnitedHealthcare Global services when Global Emergency Services
100 miles or more away from your campus address and 100 miles or more away from your permanent home address.
Preferred Providers
The Preferred Provider Network for this plan is HPHC Insurance Company Network. Preferred Providers can be found using
the following link: https://www.uhcsr.com/lookupredirect.aspx?delsys=67.
Healthiest You: National Telehealth Service
Starting on the effective date of your policy, you have 24/7 access to medical advice through HealthiestYou, a national
telehealth service. By cal ing the toll-free number listed on the front of your medical ID card or visiting
www.telehealth4students.com, you have access to board-certified physicians via phone and/or video, where permitted. This
service is especial y helpful for minor il nesses, such as al ergies, sore throat, earache, pink eye, etc. Based on the condition
15PPOSBME-1322-1 HPHC Insurance Company being treated, the doctor can also prescribe certain medications, saving you a trip to the doctor's office. Using HealthiestYou can save you money and time, while avoiding costly trips to a doctor's office, urgent care facility, or emergency room. As an insured with StudentResources, there is no consultation fee for this service.* Every cal with a HealthiestYou doctor is covered 100% during your policy period. This service is meant to compliment your Student Health Center. If possible, we encourage you to visit your SHC first before using this service. Depending on your school's set-up, your cal may be routed to the Student Health Center during their business hours for further assistance. HealthiestYou is not health insurance. HealthiestYou is designed to complement, and not replace, the care you receive from your primary care physician. HealthiestYou physicians are an independent network of doctors who advise, diagnose, and prescribe at their own discretion. HealthiestYou physicians provide cross coverage and operate subject to state regulations. Physicians in the independent network do not prescribe DEA control ed substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. HealthiestYou does not guarantee that a prescription wil be written. Not available in Arkansas; limited services in California, Idaho, Iowa, Louisiana, and Texas. *If you are an Insured under this insurance Plan, and you cal prior to the plan effective date, you wil be charged a $40 service fee before being connected to a board-certified physician. Student Assistance Insureds have immediate access to the Student Assistance Program, a service that coordinates care using a network of resources. Services available include counseling, financial and legal advice, as wel as mediation. Counseling services are offered by Licensed Clinicians who can provide insureds with someone to talk to when everyday issues become overwhelming. Financial services, provided by licensed CPA's and Certified Financial Planners offer consultations on issues such as financial planning, credit and col ection issues, home buying and renting and more. Legal Services are provided by fully credentialed attorneys with at least 5 years of experience practicing law. Mediation services are available to help resolve family-related disputes. Translation services are available in over 170 languages for most services. Insureds also have access to LiveAndWorkWell.com where they can take health risk assessments, use health estimators to calculate things like their target heart rate and BMI, and participate in personalized self-help programs. More information about these services is available by logging into My Account at www.uhcsr.com/MyAccount.
Exclusions and Limitations:
No benefits wil be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies
for, at, or related to any of the following:
Learning disabilities. Cosmetic procedures, except reconstructive procedures to:  Correct an Injury or treat a Sickness for which benefits are otherwise payable under this policy. The primary result of the procedure is not a changed or improved physical appearance.  Treat or correct Congenital Conditions of a Newborn Infant.  Correct port wine stains. Dental treatment, except:  For accidental Injury to Sound, Natural Teeth.  As described under Dental Treatment in the policy. This exclusion does not apply to benefits specifical y provided in Pediatric Dental Services. Elective Surgery or Elective Treatment. Elective abortion. Flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline. Foot care for the following:  Routine foot care including the care, cutting and removal of corns, cal uses, toenails, and bunions (except capsular or bone surgery). This exclusion does not apply to preventive foot care for Insured Persons with diabetes. Hearing examinations. Hearing aids, except as specifical y provided under the Benefits for Hearing Aids. Other treatment for hearing defects and hearing loss. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process. This exclusion does not apply to:  Hearing defects or hearing loss as a result of an infection or Injury. Hirsutism. Alopecia. 15PPOSBME-1322-1 HPHC Insurance Company Immunizations, except as specifical y provided in the policy. Preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifical y provided in the policy. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation. Injury sustained while:  Participating in any intercollegiate or professional sport, contest or competition.  Traveling to or from such sport, contest or competition as a participant.  Participating in any practice or conditioning program for such sport, contest or competition. Investigational services. Participation in a riot or civil disorder. Commission of or attempt to commit a felony. Fighting. Prescription Drugs, services or supplies as fol ows:  Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non- medical substances, regardless of intended use, except as specifical y provided in the Benefits for Diabetes  Immunization agents, except as specifical y provided in the policy. Biological sera.  Drugs labeled, "Caution - limited by federal law to investigational use" or experimental drugs, except as specifical y provided in the Benefits for Off-Label Drug Use.  Products used for cosmetic purposes.  Drugs used to treat or cure baldness. Anabolic steroids used for body building.  Anorectics - drugs used for the purpose of weight control.  Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or  Growth hormones.  Refil s in excess of the number specified or dispensed after one (1) year of date of the prescription. Reproductive/Infertility services including but not limited to the fol owing:  Procreative counseling.  Genetic counseling and genetic testing.  Cryopreservation of reproductive materials. Storage of reproductive materials.  Fertility tests.  Infertility treatment (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception.  Premarital examinations.  Impotence, organic or otherwise.  Female sterilization procedures, except as specifical y provided in the policy.  Reversal of sterilization procedures.  Sexual reassignment surgery. Research or examinations relating to research studies, or any treatment for which the patient or the patient's representative must sign an informed consent document identifying the treatment in which the patient is to participate as a research study or clinical research study, except as specifical y provided in the policy. Routine eye examinations. Eye refractions. Eyeglasses. Contact lenses. Prescriptions or fitting of eyeglasses or contact lenses. Vision correction surgery. Treatment for visual defects and problems. This exclusion does not apply as follows:  When due to a covered Injury or disease process.  To benefits specifical y provided in Pediatric Vision Services.  To one pair of eyeglasses or contact lenses to treat accommodative strabismus, cataracts, or aphakia. Routine Newborn Infant Care and well-baby nursery and related Physician charge, except as specifical y provided in Preventive care services, except as specifical y provided in the policy, including:  Routine physical examinations and routine testing.  Preventive testing or treatment.  Screening exams or testing in the absence of Injury or Sickness. Services provided normal y without charge by the Health Service of the Policyholder. Services covered or provided by the student health fee. Nasal and sinus surgery, except for treatment of a covered Injury. Skydiving. Parachuting. Hang gliding. Glider flying. Parasailing. Sail planing. Bungee jumping. Sleep disorders. Speech therapy, except as specifical y provided in the policy. Stand-alone multi-disciplinary smoking cessation programs. These are programs that usual y include health care providers specializing in smoking cessation and may include a psychologist, social worker or other licensed or certified Supplies, except as specifical y provided in the policy. 15PPOSBME-1322-1 HPHC Insurance Company Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia, except:  As specifical y provided in the Benefits for Breast Cancer Treatment and Reconstructive Breast Surgery.  Medical y Necessary surgery for gynecomastia.  As specifical y provided in the policy. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium wil be refunded upon request for such period not covered). Weight management. Weight reduction. Nutrition programs. Treatment for obesity (except morbid obesity for an Insured diagnosed as morbidly obese). Surgery for removal of excess skin or fat. This exclusion does not apply to benefits specifical y provided in the policy. NOTE: The information contained herein is a summary of certain benefits which are offered under a student health insurance policy issued by UnitedHealthcare. This document is a summary only and may not contain a full or complete recitation of the benefits and restrictions/exclusions associated with the relevant policy of insurance. This document is not an insurance policy document and your receipt of this document does not constitute the issuance or delivery of a policy of insurance. Neither you nor UnitedHealthcare has any rights or responsibilities associated with your receipt of this document. Changes in federal, state or other applicable legislation or regulation or changes in Plan design required by the applicable state regulatory authority may result in differences between this summary and the actual policy of insurance. 15PPOSBME-1322-1 HPHC Insurance Company

Source: http://www2.crossagency.com/2016-2017/pdf/sbc_umf.pdf