Student Health Plan - UPMC Health Plan [PDF]

2010 - 2011

Student Health Plan brought to you by

University of Pittsburgh

Table of Contents

University of Pittsburgh and UPMC Health Plan

2

University of Pittsburgh Student Health and Counseling

2

UPMC Health Plan

3

Travel Assistance Program Pharmacy

4

MyHealth OnLine

5

Commonly Used Terms

6

Frequently Asked Questions

7

Covered Services

If you have any questions about UPMC Health Plan, contact us at

1-888-499-6885. Attention:

You can print an ID card online. Please see page 5 for complete instructions.

10

How to Enroll in UPMC Health Plan Coverage

14

Enrollment Form

15

Timelines, Premiums, and Refunds

17

Questions? Call us!

3

Tips for Students Policies and Notices

18 19

1

Campus Information and Business Hours OAKLAND: Student Health Service Medical Arts Building, Suite 500 3708 Fifth Avenue, Pittsburgh, PA 15213 Phone: 412-383-1800 Fax: 412-383-1846 www.studhlth.pitt.edu Clinic Hours: Fall & Spring Semesters M, T, H 8:30 a.m. – 7 p.m. W, F 8:30 a.m. – 5 p.m. Sat 10 a.m. – 3 p.m.

Young adults between the ages of 19 and 29 represent one of the largest and fastest growing segments of the U.S. population without health insurance. The absence of affordable health insurance coverage creates potential health and financial risks to students who pursue higher education. With so much to think about, wouldn’t it be nice to be free from worry about how to find and pay for health care if you or a dependent becomes sick or injured? UPMC Health Plan and the University of Pittsburgh have coverage available for you.

University Counseling Center 334 William Pitt Union Pittsburgh, PA 15260

With UPMC Health Plan, you get world-class physicians when you are sick and health promotion programs to keep you well. These programs are specifically designed to meet the physical and emotional needs of college students — and they are delivered and managed right here in western Pennsylvania, by people who know the region’s health care resources and systems.

Phone: 412-648-7930 Fax: 412-648-7933 www.counseling.pitt.edu

That means you’re free to concentrate on your education. And, after all, isn’t that why you’re in college?

Clinic Hours: Fall & Spring Semesters M,W 8:30 a.m. – 9 p.m. T, H, F 8:30 a.m. – 5 p.m.

University of Pittsburgh

Summer Semester M-F 8:30 a.m. – 5 p.m.

Summer Semester M-F 8:30 a.m. – 5 p.m.

2

University of Pittsburgh and UPMC Health Plan

REGIONAL: Bradford Campus Frame-Westerberg Commons, Room 226 Phone: 814-362-5272 Clinic Hours: Fall & Spring Semesters M-F 8:30 a.m. – 12 p.m. and 1 p.m. – 5 p.m. Summer Semester: M, T, TH 10 a.m. – 2 p.m. Greensburg Campus Chambers Hall, Room 216 Phone: 724-836-9947 Clinic Hours: Fall & Spring Semesters M-F 8:30 a.m. – 4:30 p.m. Summer Semester: Closed Johnstown Campus Student Union, Room G-10 Phone: 814-269-7110 Clinic Hours: Fall & Spring Semesters M-F 8:30 a.m. – 5 p.m. Titusville Campus McKinney Student Union, Room 219 Phone: 814-827-4467 Clinic Hours: Fall & Spring Semesters M-F 8:30 a.m. – 5 p.m. Summer Semester: Closed

Student Health and Counseling Student Health Service and University Counseling Center in Oakland As a student, you have access to the following valuable services from the University of Pittsburgh Student Health Service. These services are supported by your student health fee as indicated on your eBill (i.e., University of Pittsburgh billing statement/ invoice for tuition and other costs): • Routine physical examinations • Primary care physician services • Routine gynecological services and counseling • Commonly required blood tests and lab work • Orthopaedics • Health education resource materials Additionally, the University Counseling Center provides personal and academic counseling to students at no charge. The Center is staffed by psychologists, counselors, social workers, and a psychiatrist. All counseling is confidential.

Regional Student Health Services Regional campuses also offer student health services through offices staffed by health care professionals. Students may use these offices for initial assessment and treatment of routine illnesses and injuries.

Your Health Is Our #1 Priority UPMC Health Plan’s Student Health Plan is designed to complement your University of Pittsburgh Student Health Service and University Counseling Center. UPMC Health Plan can cover the more extensive medical treatment or emergency care that you may require during your student years that is not covered by your student health fee as indicated on your eBill. See pages 10 through 13 for the full range of UPMC Health Plan covered services.

Selecting a physician online Go to: www.upmchealthplan.com Select: Find a Doctor

Begin your search.

As part of an integrated health care delivery system, UPMC Health Plan includes more than 80 hospitals and more than 7,600 physicians in a 29-county region. We make it our responsibility to help each of our student members enjoy the best quality of life and health possible. Through the many primary care physicians and specialists in our outstanding provider network, we help our members to remain healthy as well as to detect any medical problems at an early stage when treatment is more effective and may prevent such problems from escalating into serious illness. If your doctor does not participate in the UPMC Health Plan network, you are still covered. Your student health insurance plan gives you the freedom to see out-ofnetwork providers at a reduced benefit level after the annual deductible is met. Additionally, student members may be responsible to pay the difference between the provider’s charge and the UPMC Health Plan payment. Out-of-area students who go home for extended visits and students who travel within the U.S. can use the physicians and facilities of UPMC Health Plan’s national network, which includes more than 550,000 providers and 4,500 facilities.

Within the United States: 1-800-872-1414

Outside the United States: 1-609-986-1234 www.assistamerica.com

Travel Assistance Program Peace of mind wherever you roam UPMC Health Plan includes travel assistance services through Assist America at no additional charge. Assist America provides emergency medical services for students studying abroad or students traveling more than 100 miles from their campus address or from their permanent home address. If you need help away from home, Assist America can locate qualified doctors and hospitals, replace forgotten prescriptions, provide emergency medical evacuation, or arrange transportation so that family members can be with injured relatives.

3

Pharmacy Pitt Student Health Service Pharmacy Contact Information and Business Hours

4

hone: 412-383-1850 P Fax: 412-383-1855 Hours: Fall & Spring Semesters M, T, H 8:30 a.m. 7 p.m. W, F 8:30 a.m. - 5 p.m. Sat 10 a.m. - 3 p.m. Summer Semester M-F 8:30 a.m. - 5 p.m.

Prescription drug coverage you need, where you need it Your student health benefits through UPMC Health Plan include prescription drug coverage that allows you and your doctors to choose the most effective pharmaceutical regimen — one that helps you manage your prescription drug costs and also allows freedom of choice. Pitt Student Health Service Pharmacy in Oakland provides you with first-class pharmacy services and a convenient way to fill your prescriptions. Your student health insurance also allows you to fill prescriptions at any of the hundreds of facilities throughout western Pennsylvania that participate in UPMC Health Plan’s retail pharmacy network. You may also call the UPMC Health Plan Member Services Department at 1-888-499-6885 or go to www.upmchealthplan.com to find a pharmacy near you. And when you’re traveling outside your neighborhood, you can take advantage of nearly 30,000 pharmacies nationwide. The UPMC Health Plan pharmacy network includes:

• • • • • • • • •

CVS Giant Eagle Kmart Rite Aid Sam’s Club Target Walgreens Wal-Mart Hundreds of independent pharmacies

Our pharmacy program offers you a variety of high-quality, effective generic and brand-name drugs. You can also take advantage of mail-order prescriptions that will arrive at your door and can be ordered in 90-day supplies. UPMC Health Plan will pay up to a maximum of $750 per Benefit Period under the Standard Student Health Plan and $1000 per Benefit Period under the Enhanced Student Health Plan in combination with mail-order, retail, and specialty drugs per enrolled member. Please refer to the benefit summary on pages 10 through 13 for actual deductible, coinsurance, and copayment amounts.

MyHealth OnLine 24/7 access to health information and health improvement tools All University of Pittsburgh students enrolled in UPMC Health Plan have access to MyHealth OnLine, an easy-to-use Internet-based member service center. When you log in to MyHealth OnLine, you unlock a free, confidential resource that can be personalized just for you. Here you can investigate health symptoms and read the latest news in the extensive library of health-oriented information. Interactive features help you devise personal action plans for getting in shape, eating better, losing weight, or quitting tobacco, and Web-based health trackers are available for you to log what you eat each day, your activity level, and your weight. MyHealth OnLine lets you: • View detailed information about your health insurance benefits and covered services • Access your Explanation of Benefits (EOB) • Search for physicians and other health care providers • Request new ID cards • Estimate cost of care • Order and refill prescriptions • Access MyHealth tools and information Additionally, members have access to the MyHealth Record, a confidential personal health record (PHR) that helps members keep health information current. Every claim submitted in a member’s name for tests, procedures, office visits, prescriptions, and other covered benefits is automatically incorporated into the MyHealth Record. Members can also fill in the rest of their health history, including family history, new symptoms, over-the-counter medications, and other health-related information that may not be captured in our claims database. The MyHealth Record is held to the same security standards as customer information in the banking and finance industries. Members are the only ones who can retrieve, edit, or print their record.

To access MyHealth OnLine: • Go to www.upmchealthplan.com.

• Enter your username and password at the Member Login box.

• Click on desired topics. Firsttime users may register for a username on the site.

To print a temporary or replacement ID card: • Go to www.upmchealthplan.com.

• First-time users must register for a username on the site. You will need your member ID number to log in. If you do not have your member ID number, call Member Services at 1-888-499-6885.

• From the homepage, click on “order new ID card” under “Online Services.”

5

Commonly Used Terms Coinsurance – The percentage of expenses for covered benefits that you are responsible to pay after your deductible is met.

Copayment – A specific, agreed-upon dollar amount that a patient pays to the provider when receiving services or supplies.

Deductible – The initial amount that you must pay each Benefit Period for covered benefits before UPMC Health Plan begins to pay for covered benefits.

Dependent – A spouse, or an unmarried child under 19 years of age or up to 25 years of age if the child is a full-time student at an accredited institution of higher learning and is not self-supporting.

Enrollment Form – Form that a student uses to officially enroll himself or herself and eligible dependents in the Student Health Plan.

In-Network Services – Services performed by participating providers who have a contract or agreement with UPMC Health Plan to provide specific services for a specific fee.

Mail-Order Prescription Drugs – Medications that can be ordered in a 3-month or 90-day supply for a reduced out-of-pocket cost.

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Non-Participating Provider – A provider that has not contracted with UPMC Health Plan to provide services at a reduced fee.

Out-of-Network Services – Health care services received outside of the designated PPO network by non-participating providers. Benefits are paid at a lower level after the annual deductible is met. Members may also have to pay the difference between the provider’s charge and the UPMC Health Plan payment.

Participating Provider – A provider that has contracted with UPMC Health Plan to provide medical services to covered persons. The provider may be a hospital or other facility, a physician, or a pharmacy that has contractually accepted the terms and conditions as set forth by UPMC Health Plan.

Preferred Provider Organization (PPO) – An arrangement between a group of doctors or providers and another entity, such as an employer or other group. This arrangement makes it possible for price discounts on services in exchange for a higher volume of patients.

Specialty Prescription Drugs – Specialty medications are used to treat complex clinical conditions and are limited to a 30-day supply. Most specialty medications must be obtained through our designated specialty provider, which provides convenient and expedited delivery through the mail.

Frequently Asked Questions General Information When will my coverage become effective? Coverage will be effective on September 1, 2010, if UPMC Health Plan has received the correct premium payment and enrollment information. Premium payment and application forms will be accepted through September 30, 2010.

What is the period of coverage? The UPMC Health Plan Student Health Plan defines its benefit year as September 1, 2010, to August 31, 2011. An opportunity to enroll in the middle of the benefit year occurs with the spring semester and covers the period from January 1 to August 31, 2011.

What is open enrollment and when does it occur? Open enrollment is the period during which a student may enroll for coverage. Students enrolling for the fall semester have until September 30, 2010, to enroll for health care coverage. Students who are not eligible for the fall semester but who become eligible for the spring semester may enroll during the period December 1, 2010, to January 31, 2011.

What if a student lives in another state but attends one of University of Pittsburgh campuses? Is this student covered while he or she is outside of western Pennsylvania? Students are covered for out-of-network care through a nationwide network of participating providers. In addition, if a student travels outside of the plan area and needs medical care, he or she can call Assist America at 1-800-872-1414 (in the United States) or 1-609-986-1234 (for travel outside of the United States). This benefit helps members locate providers.

Eligibility Who is considered an eligible student? All registered full-time students are eligible for coverage under UPMC Health Plan. The number of credits an individual must carry to be considered a full-time student varies depending on the degree program. Please check with your Home Department Academic Advisor if you have any questions regarding your status as a full- or part-time student. Students must be actively registered for at least the first 31 days of the school term for which coverage is established. Eligible students who enroll may also insure their dependents. Eligible dependents include the spouse and any unmarried children under 19 years of age or up to 25 years of age if the children are full-time students at an accredited institution of higher learning and are not self-supporting.

What if I am not eligible by September 1, 2010, but become eligible for the spring semester? A student who becomes eligible for the spring semester can enroll any time during the open enrollment period between December 1, 2010, and January 31, 2011. The effective date of coverage for this open enrollment period will be January 1, 2011.

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What if I register as full-time but later decide to drop a class? If after 31 days of the school term a student is listed as an eligible full-time student by the University of Pittsburgh, he or she will be covered for the remainder of the school health plan coverage year (September 1, 2010, through August 31, 2011).

As a member, do I have to do anything in order to continue my coverage for spring 2011? Students who pay an annual premium are not required to do anything for the spring semester and are covered through August 31, 2011. Students who choose the installment plan (paying half the premium by September 30, 2010, and the other half by February 15, 2011) are responsible for making a timely renewal payment.

Dependent Coverage Is there a “family deductible” in this student benefit plan? No. All student and eligible dependents (spouse and children) are required to satisfy an individual deductible each plan year. There is no family deductible for this student benefit plan.

Can I add a newborn child to my coverage?

8

Yes. Your newborn will automatically be covered by UPMC Health Plan for 31 days from the date of birth. Unless you call the Health Plan at 1-888-499-6885 to enroll your son or daughter within this 31-day period, your child will lose coverage on the 32nd day following birth. Likewise, a child legally placed with a covered student for adoption or a legally adopted child of a covered student will automatically be covered for 31 days from the date of placement. The covered student must call the Health Plan within 31 days of placement for the coverage to continue. In all of these instances, your premium may be adjusted.

Payment Options What if UPMC Health Plan receives my payment and enrollment form after September 30, 2010? If UPMC Health Plan receives an enrollment form and premium after September 30, 2010, the payment and form will not be accepted and will be returned to the student.

What if I cannot pay the annual premium in one payment? An alternative payment option allows students to pay for their medical coverage in two installments. Provided the first half of the premium payment and the enrollment application are postmarked by September 30, 2010, the second half of the premium must be paid by February 15, 2011. Premium bills for the second half of the year will be mailed in December. This statement constitutes warning of cancellation. If you haven’t received your premium bill by January 31, 2011, please contact the student payment line at 1-800-889-2193 to make the payment. Payments after this date will not be accepted and coverage will be terminated February 28, 2011.

What method of payment can I use to pay the premium for the student health plan coverage? The student may pay for the student health plan coverage with a credit/debit card, check, or money order. If payment is made with a debit/credit card, the payer must call the student payment line at 1-800-889-2193 to make the payment. The completed enrollment form should be mailed back in the enclosed postage-paid envelope. If payment is made with a check or money order, it should be mailed with the completed enrollment form in the enclosed postage-paid envelope.

Under what circumstances can premiums be refunded? If you drop below full-time student status and notify UPMC Health Plan at 1-888-499-6885 by September 30, 2010 (annual term), or January 31, 2011 (spring term), and no claims have been filed for you or your covered dependents, then you will receive a full refund. If you enter the armed forces, your premium will be refunded from your effective date in the armed forces.

9

Coverage What are some of the non-covered services? In addition to items that are considered standard exclusions, the following is a list of non-covered services:

• • • • • • • •

Allergy Services Speech Therapy Skilled Nursing Facility Private Duty Nursing Durable Medical Equipment (corrective appliances) Prosthetic Devices Podiatry Services Chiropractic Services

Where can I get a directory or list of participating providers? Visit the UPMC Health Plan website at www.upmchealthplan.com.

What if I have been seen by a non-participating physician? Visits to non-participating providers are covered at 60 percent of reasonable and customary charges after the student meets his or her deductible. Additionally, student members may be responsible to pay the difference between the provider’s charge and the UPMC Health Plan payment.

There are two plans you can choose from: the standard plan and the enhanced plan. Review both plans carefully before you make your decision.

UPMC Health Plan

University of Pittsburgh Standard Student Health Plan

Preferred Provider Organization Rx Copay - 10/20/40 The Preferred Provider Organization (PPO) plan offers you the choice of two levels of health care benefits each time you need medical services. Members will have reduced cost-sharing if care is received from a participating provider. Coordination of service is not required. Covered Services

Participating Provider

Non-Participating Provider

$100

$200

Individual

$5,000

$10,000

Family

Annual deductible Individual Annual out-of-pocket limit $10,000

$20,000

Plan payment level

80% after deductible

60% after deductible1

Lifetime benefit level

$250,000

$50,000

Primary care provider (PCP) required

No

No

Pre-existing condition limitations

None

None

Precertification requirements

Provider responsibility

Member responsibility: $500 penalty per incident for failure to pre-certify non-emergency inpatient admissions

Routine physical exam

100% after $25 copayment per visit

Not covered

Adult immunizations



Flu vaccine

100% (deductible does not apply)




Not covered

Pediatric immunizations

100% (deductible does not apply)

60% (deductible does not apply)1

Well-baby visits


Not covered





Preventive Care Adult

Pediatric

10

Physician Services Physician office visit (for illness or injury) Medical/surgical services (inpatient medical and surgical care, outpatient surgeon’s fees, anesthesia)

These dollar limits apply to outpatient surgical services: 1) Covered up to $12,000 per Benefit Period for surgeon fees; 2) Covered up to $2,400 per Benefit Period for assistant surgeon fees; 3) Covered up to $2,400 per Benefit Period for anesthetist No dollar limits on medical services per Benefit Period

Women’s Care Routine gynecological exam, Pap test, mammogram, prenatal visit, diagnostic tests, and surgical services

100% after $25 copayment (applies to routine gynecologic exam only) 80% after deductible for all other care; Pap test and mammogram are not subject to deductible

60% after deductible1 Routine gynecological exam, Pap test, and mammogram not subject to deductible

Abortion services covered up to $250 per Benefit Period Hospital Services Inpatient care, medical/ancillary services, diagnostic tests, and supplies

100% after $500 copayment per inpatient stay

Outpatient care

80% after deductible for outpatient care


Emergency Services Emergency care coverage

100% after $50 copayment per visit (copayment waived if admitted)


Covered up to $6,000 per Benefit Period (includes both physician and facility charges) Diagnostic Services Advanced imaging (e.g., PET, MRI, etc.)



Other imaging (e.g., x-ray, sonogram, etc.)





Lab and other diagnostic services

Outpatient lab and radiology services limited to $1,500 per Benefit Period

Covered Services







Medical Therapy Services Chemotherapy, radiation, infusion therapy, dialysis treatment Rehabilitation Therapy Services Physical and occupational therapy

Covered up to 60 visits per Benefit Period for all three therapies combined Other Medical Services Home health care



Hospice care



Behavioral Health — Contact UPMC Health Plan Behavioral Health Services at 1-877-461-8610 Behavioral Health Inpatient2



Limit of 30 days per Benefit Period; lifetime maximum of 90 days Outpatient2


Substance abuse services



Up to 20 visits per Benefit Period; group visits and 15-minute medication visits count as ½ visit 50% after deductible1

80% after deductible for outpatient care Inpatient detoxification

Limit of 7 days per admission; lifetime maximum of 4 admissions

Inpatient rehabilitation

Limit of 30 days per Benefit Period; lifetime maximum of 90 days

Outpatient rehabilitation

Limit of 60 visits per Benefit Period; lifetime maximum of 120 visits

Prescription Drug Coverage — The Your Choice pharmacy program will apply (Mandatory Generic) Retail prescription drug3 • Prescriptions must be dispensed by a participating pharmacy

$10 copayment for generic drugs $20 copayment for preferred brand drugs $40 copayment for non-preferred brand drugs 90-day maximum retail supply available for 3 copayments Up to a maximum of $750 per Benefit Period in combination with mail-order and specialty drugs

drug3

Specialty prescription • Specialty medications are limited to a 30-day supply • Most specialty medications must be filled at our contracted specialty pharmacy provider (List available upon request)

$40 copayment for specialty drugs 30-day maximum specialty supply Up to a maximum of $750 per Benefit Period in combination with mail-order and retail drugs

Mail-order prescription drug3 • A three-month supply (up to 90 days) of medication may be dispensed through the contracted mail service pharmacy

$20 copayment for generic drugs $40 copayment for preferred brand drugs $80 copayment for non-preferred brand drugs 90-day maximum mail-order supply Up to a maximum of $750 per Benefit Period in combination with retail and specialty drugs

In this document, the term “UPMC Health Plan” refers to benefit plans offered by UPMC Health Network, Inc., as well as plans offered by UPMC Health Plan, Inc. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. UPMC Health Plan Member Services: 1-888-499-6885. TTY Services: 1-800-361-2629.

1 If care is out-of-network, benefits are paid at a lower level after your annual deductible is met. If you go to an out-ofnetwork provider, you also may have to pay the difference between the provider’s charge and the UPMC Health Plan payment (reasonable and customary amount). 2 Pennsylvania Act 1998-150 mandates 30 inpatient days per Benefit Period (no lifetime maximum) and 60 outpatient visits per Benefit Period for certain diagnoses based on medical necessity and appropriateness. For additional information concerning coverage and diagnosis requirements, call UPMC Health Plan Behavioral Health Services at 1-877-461-8610. 3 If the brand-name drug is dispensed instead of the generic equivalent, you must pay the copayment associated with the brand-name drug as well as the retail price difference between the brand-name drug and the generic drug. This summary is meant to assist in comparing the benefit plans. It is not a contract. If differences exist between this summary and a group’s contract or a member’s certificate of coverage, the contract or certificate of coverage prevails.

One Chatham Center 112 Washington Place Pittsburgh, Pennsylvania 15219 www.upmchealthplan.com (EW8) University of Pitt Student Health Plan 2010

11

UPMC Health Plan

University of Pittsburgh Enhanced Student Health Plan

Preferred Provider Organization Rx Copay - 10/20/40 The Preferred Provider Organization (PPO) plan offers you the choice of two levels of health care benefits each time you need medical services. Members will have reduced cost-sharing if care is received from a participating provider. Coordination of service is not required. Covered Services



None

$200

Individual

None

$10,000

Family

None

$20,000

Plan payment level

100%


Lifetime benefit level

$250,000

$50,000

Primary care provider (PCP) required

No

No

Pre-existing condition limitations

None

None

Precertification requirements

Provider responsibility

Member responsibility: $500 penalty per incident for failure to pre-certify non-emergency inpatient admissions



Not covered

Adult immunizations

100%




Not covered

Pediatric immunizations

100%

80% (deductible does not apply)1

Well-baby visits


Not covered

Physician office visit (for illness or injury)



Specialist office visit



100%


Annual deductible Individual Annual out-of-pocket limit

Preventive Care Adult

Pediatric

12

Physician Services

Medical/surgical services (inpatient medical and surgical care, outpatient surgeon’s fees, anesthesia)

These dollar limits apply to outpatient surgical services: 1) Covered up to $12,000 per Benefit Period for surgeon fees; 2) Covered up to $2,400 per Benefit Period for assistant surgeon fees; 3) Covered up to $2,400 per Benefit Period for anesthetist No dollar limits on medical services per Benefit Period

Women’s Care Routine gynecological exam, Pap test, mammogram, prenatal visit, diagnostic tests, and surgical services

100% after $25 copayment (applies to routine gynecologic exam only) 100% for all other care

80% after deductible1 Routine gynecological exam, Pap test, and mammogram not subject to deductible

Abortion services covered up to $250 per Benefit Period

Hospital Services Inpatient care, medical/ancillary services, diagnostic tests, and supplies


Outpatient care

100%


Emergency Services Emergency care coverage



Covered up to $6,000 per Benefit Period (includes both physician and facility charges) Diagnostic Services Advanced imaging (e.g., PET, MRI, etc.)

100%


Other imaging (e.g., x-ray, sonogram, etc.)

100%


Lab and other diagnostic services

100%

80% after deductible1 Outpatient lab and radiology services limited to $1,500 per Benefit Period

Covered Services



100%




Medical Therapy Services Chemotherapy, radiation, infusion therapy, dialysis treatment Rehabilitation Therapy Services Physical and occupational therapy

Covered up to 60 visits per Benefit Period for all three therapies combined Other Medical Services Home health care

100%


Hospice care

100%


Behavioral Health — Contact UPMC Health Plan Behavioral Health Services at 1-877-461-8610 Behavioral Health Inpatient2



Limit of 30 days per Benefit Period; lifetime maximum of 90 days Outpatient2


Substance abuse services



Up to 20 visits per Benefit Period; group visits and 15-minute medication visits count as ½ visit 50% after deductible1

100% Inpatient detoxification

Limit of 7 days per admission; lifetime maximum of 4 admissions

Inpatient rehabilitation

Limit of 30 days per Benefit Period; lifetime maximum of 90 days

Outpatient rehabilitation

Limit of 60 visits per Benefit Period; lifetime maximum of 120 visits

Prescription Drug Coverage — The Your Choice pharmacy program will apply (Mandatory Generic) $10 copayment for generic drugs $20 copayment for preferred brand drugs $40 copayment for non-preferred brand drugs 90-day maximum retail supply available for 3 copayments

Retail prescription drug3 • Prescriptions must be dispensed by a participating pharmacy

Up to a maximum of $1,000 per Benefit Period in combination with mail-order and specialty drugs drug3

Specialty prescription • Specialty medications are limited to a 30-day supply • Most specialty medications must be filled at our contracted specialty pharmacy provider (List available upon request)

$40 copayment for specialty drugs 30-day maximum specialty supply Up to a maximum of $1,000 per Benefit Period in combination with mail-order and retail drugs

drug3

Mail-order prescription • A three-month supply (up to 90 days) of medication may be dispensed through the contracted mail service pharmacy

$20 copayment for generic drugs $40 copayment for preferred brand drugs $80 copayment for non-preferred brand drugs 90-day maximum mail-order supply Up to a maximum of $1,000 per Benefit Period in combination with retail and specialty drugs

In this document, the term “UPMC Health Plan” refers to benefit plans offered by UPMC Health Network, Inc., as well as plans offered by UPMC Health Plan, Inc. This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. UPMC Health Plan Member Services: 1-888-499-6885. TTY Services: 1-800-361-2629.

1 If care is out-of-network, benefits are paid at a lower level after your annual deductible is met. If you go to an out-ofnetwork provider, you also may have to pay the difference between the provider’s charge and the UPMC Health Plan payment (reasonable and customary amount). 2 Pennsylvania Act 1998-150 mandates 30 inpatient days per Benefit Period (no lifetime maximum) and 60 outpatient visits per Benefit Period for certain diagnoses based on medical necessity and appropriateness. For additional information concerning coverage and diagnosis requirements, call UPMC Health Plan Behavioral Health Services at 1-877-461-8610. 3 If the brand-name drug is dispensed instead of the generic equivalent, you must pay the copayment associated with the brand-name drug as well as the retail price difference between the brand-name drug and the generic drug. This summary is meant to assist in comparing the benefit plans. It is not a contract. If differences exist between this summary and a group’s contract or a member’s certificate of coverage, the contract or certificate of coverage prevails.

One Chatham Center 112 Washington Place Pittsburgh, Pennsylvania 15219 www.upmchealthplan.com (EW9) University of Pitt Student Health Plan 2010

13

How to Enroll in UPMC Health Plan Coverage All full-time registered students are eligible for coverage with UPMC Health Plan. If you would like to take advantage of this opportunity, simply complete the Student Health Insurance Plan Enrollment Form, which follows, by September 30, 2010. The completed form should be mailed in the enclosed postage-paid envelope to: UPMC Health Plan One Chatham Center 112 Washington Place Pittsburgh, PA 15219

14



If UPMC Health Plan receives an enrollment form and payment after September 30, 2010, the payment and form will not be accepted and will be returned to the student.

Student Health Insurance Plan Enrollment Form Application information

Term and payment options

Last

First

Middle Initial

Social Security #

Date of Birth

I am enrolling for: q Annual benefit period (9/1/10 to 8/31/11) q Spring benefit period (1/1/11 to 8/31/11) I am enrolling in: q Standard Plan q Enhanced Plan

Mailing address Permanent Street Address / Apt. # City / State

I am enclosing premium payment for: q the entire annual benefit period q the first half of the annual benefit period. I understand that I must remit my premium payment for the second half of the annual benefit period by 2/15/11 to avoid a lapse in coverage. q the entire spring benefit period

Zip

Permanent Telephone

Permanent E-mail

Billing address, if different from above

Credit/Debit Payment Please call the student payment line at 1-800-889-2193 to make the payment.

College Street Address / Apt. # City / State

NOTICE TO STUDENTS: If the University of Pittsburgh determines that you do not qualify as an eligible full-time student, your coverage will be terminated retroactive to the effective date, and no premium will be refunded.

Zip

College Telephone

College E-mail

Covered family members Name (First, MI, Last)

Sex M F

Self Spouse Dependent Dependent

q

Date of Birth

/

/

Social Security Number -

-

M

F

/

/

-

-

M

F

/

/

-

-

/

-

-

M

F

/

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For more than 2 dependents, check this box, then sign and attach an additional enrollment form.

If you or any family members are covered by other group health insurance, including Medicare, please complete below Name of Member

Name of other group health insurance

Policy Number

To enroll, please return this application with payment to: UPMC Health Plan One Chatham Center 112 Washington Place Pittsburgh, PA 15219 For more information please call: 1-888-499-6885

I have read and agree with the terms as stated on this application. By acceptance of coverage upon signing this application for so long as I am enrolled in UPMC Health Network, Inc., I authorize, on the behalf of myself and my eligible dependents and spouse if any, all of my/our health care providers to release to UPMC Health Plan/Health Network, Inc., or its authorized agents all information related to my/our medical history and treatment, including mental health; substance abuse treatment conditions and AIDS-related information if any; for all lawful purposes relating to the administration of my health benefits, including determining or reviewing coverage claims, quality assurance, clinical resource management and utilization review for services that I/we request or receive. I further authorize UPMC Health Plan/UPMC Health Network, Inc., to release such information to health care providers and entities for such purposes. My right to revoke this consent in writing at any time will not apply to the extent that UPMC Health Plan/ UPMC Health Network, Inc., or any other provider already has acted in reliance on this statement. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading any information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I understand that providing false information or omission of relevant information in this application may result in the denial of claim(s) or cancellation of coverage.

Student Signature

Date Signed

X

Mo/Day/Yr

Copyright 2010 UPMC Health Plan, Inc. All rights reserved. Pitt Enrollment Form C20100702-06 (MFS) 07/02/10 xxM xx

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UPMC Health Plan Student Health Plan 2010-2011 Timelines Term

Effective dates of coverage Enrollment forms must Payment must be be postmarked by postmarked by

Annual term

9/1/2010 - 8/31/2011

Sept. 30, 2010

Sept. 30, 2010

Annual term (installment payment option)

9/1/2010 - 2/28/2011

Sept. 30, 2010

Sept. 30, 2010

3/1/2011 - 8/31/2011

N/A

Feb. 15, 2011

Spring term ONLY

1/1/2011 - 8/31/2011

Jan. 31, 2011

Jan. 31, 2011

2010-2011 Premiums Standard Plan Annual (entire payment)

Annual (first half)

Annual (second half)

Spring term ONLY

Student

$1,365.36

$682.68

$682.68

$910.24

Student and child(ren)

$3,808.32

$1,904.16

$1,904.16

$2,538.88

Student and spouse

$9,010.56

$4,505.28

$4,505.28

$6,007.04

$11,453.40

$5,726.70

$5,726.70

$7,635.60

Annual (entire payment)

Annual (first half)

Annual (second half)

Spring term ONLY

$1,563.00

$781.50

$781.50

$1,042.00

Student, spouse, and child(ren)

Enhanced Plan

Student Student and child(ren)

$4,359.24

$2,179.62

$2,179.62

$2,906.16

Student and spouse

$10,314.00

$5,157.00

$5,157.00

$6,876.00

Student, spouse, and child(ren)

$13,110.24

$6,555.12

$6,555.12

$8,740.16

2010-2011 Refunds Term

Effective dates of coverage UPMC must be notified by

Effective date of refund

Annual term

9/1/2010 - 8/31/2011

Sept. 30, 2010

Sept. 1, 2010

Spring term

1/1/2011 - 8/31/2011

Jan. 31, 2011

Jan. 1, 2011

Notice to Student: If the University of Pittsburgh determines that you do not qualify as an eligible full-time student, your coverage will be terminated retroactive to the effective date, and no premium will be refunded. Refunds will only be given if you drop below full-time student status and notify UPMC Health Plan by September 30, 2010 (annual term), or January 31, 2011 (spring term), and no claims have been filed for you or your covered dependents, or if you enter the armed forces.

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Tips for Students You won’t use what you don’t understand, and we want to make sure that you are clear on your benefits. The following are some tips to make things easier for you.

Familiarize yourself with the Student Health Service and University Counseling Center. For care involving the treatment of routine illnesses and injuries, the University maintains the Student Health Service at 3708 Fifth Avenue and the University Couseling Center at 334 William Pitt Union for all students in Oakland. More serious medical situations may require care beyond the capabilities of a campus health facility, and you will be directed by the Student Health Service on campus or by UPMC Health Plan.

Know your coverage. Some services – like speech therapy, podiatry services, and chiropractic services – are not covered under UPMC Health Plan. Refer to pages 10 through 13 for coverage information or contact the Health Plan at 1-888-499-6885 to find out what is covered under your benefit plan before you make an appointment. If you are using insurance other than UPMC Health Plan, make sure you know where to call for information about your benefits.

Be prepared.

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When you visit a provider, make sure you know what medications you are taking and any medical conditions or allergies you may have.

Always carry your insurance card. Make sure you always have your insurance card with you when you see a provider. If you have applied for UPMC Health Plan and have not received your card, contact us at 1-888-499-6885.

Be assured that your privacy is our priority. Unless you give permission, nothing that takes place at a visit with a provider will be shared with anyone else, including your parents. The one exception would be a life-threatening situation.

Questions? Call us! If you have any questions about UPMC Health Plan, contact us at

1-888-499-6885.

Policies and Notices Utilization Management Our role as financial and medical steward of your health care requires that UPMC Health Plan review and approve certain procedures prior to those services being completed. The Health Plan’s clinical staff will communicate with your physicians for these review processes. UPMC Health Plan’s key utilization management procedures include prior authorization, concurrent review, retrospective review, and discharge planning.

Privacy & Confidentiality Whether you are a prospective or current member of UPMC Health Plan, we respect and protect your personal information. That is one of your rights as a UPMC Health Plan member. You retain this right even when you are no longer a member of UPMC Health Plan. Your name, address, Social Security number, and birth date are confidential – along with any data we have about the services that you have received or the premium that you pay. We use your personal health and financial information only internally and with our contracted providers or agents for the purposes of your health care treatment and the health care operations required to provide that treatment. We do not share your personal information with the University of Pittsburgh. UPMC Health Plan complies with all aspects of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and monitors related issues. For questions concerning the confidentiality of behavioral health information, please contact UPMC Health Plan Behavioral Health Services at 1-877-461-8610. In this document, the term “UPMC Health Plan” refers to benefit plans offered by UPMC Health Network, Inc., as well as to those plans offered by UPMC Health Plan, Inc. This managed care plan may not cover all of your health care expenses. Read your contract carefully to determine which health care services are covered. UPMC Health Plan Member Services Department: 1-888-499-6885 TTY Services: 1-800-361-2629

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One Chatham Center 112 Washington Place Pitttsburgh, PA 15219 www.upmchealthplan.com

Copyright 2010 UPMC Health Plan, Inc. All rights reserved. PITT PLAN BR C20100708-05 (MFS) 07/07/10 xxM xx