7/30/2019 Behc beefits at a Glance

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BGSUs2013-2014 Student Health Insurance Policy

UnitedHealthcare Student Resources

Compare cost and benefits

Plan Cost for 2013-2014 Policy$665.00 Fall Semester 8/1/2013 12/31/2013

$916.00 Spring Semester 1/1/2014-7/31/2014 OR

$1,581.00 Annual Coverage 8/1/2013 7/31/2014

$500,000 Maximum Per illness/injury per policy year

Annual Deductible$175 per illness/injury, maximum of two

$350 maximum deductible per policy year

Annual out-of-pocket$5,000 (Per Insured Person) (Per Policy Year)Deductibles and Co-pays do not apply towards meeting the out of pocket maximum.

Expenses Preferred Provider Non-Preferred

Physician Office Visit75% of the Negotiated Charge

$20 per visit co-payDeductible Does Not Apply

50% of the Reasonable Charge$40 per visit deductible

Inpatient Hospitalization75% of the Negotiated Chargeafter a $250 per visit co-pay

50% of the Reasonable Chargeafter a $250 per visit deductible

Emergency Room (per

visit co-pay/per visit

deductible waived if

admitted)

80% of the Negotiated Chargeafter a $100 per visit co-pay

80% of the Reasonable Chargeafter a $100 per visit deductible

X-ray and Lab75% of the Negotiated Charge

$20 per visit co-payDeductible Does Not Apply

50% of the Reasonable Charge$40 per visit deductible

Prescription Drug80% of Negotiated Charge if filled at any UHC

Preferred PharmacyDeductible Does Not Apply

50% of Reasonable Charge if filled at anyNon-Preferred Pharmacy

Psychiatry Office Visits75% of the negotiated charge

$20 per visit co-payDeductible Does Not Apply

50% of the Reasonable Charge$40 per visit deductible

Preventive Services

100%

No Deductible Co-pays or Co-insurance will beapplied. UnitedHealthcare follows thePreventive Care Services Guidelines

Please see Preventive Care Benefits Guideline

No Coverage

The plan will pay benefits in accordance with any applicable Ohio Health Insurance Law. Please read the Bowling Green StateUniversity Student Health Insurance Plan brochure carefully for more benefit details. While this document describes importantfeatures of the plan, there may be other specifics of the plan that are important to you and some limits to what the plan will pay. If youwant to look at the full plan description, which is contained in the Master Policy issued to Bowling Green State University, you mayview it at 170 Health Center Building during business hours, or contact us at 419-372-7495. The annual maximum for the BowlingGreen State University is $500,000 per illness or injury. The plan also contains other exclusions, limitations and benefit planmaximums. Some illnesses or injuries may cost more to treat and you may be billed for what the plan does not cover.

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