SOMA College Health Insurance Plan

SOMA COLLEGE MEDICAL INSURANCE PROGRAM
2008 - 2009 SCHOOL YEAR
PLAN 1

Schedule of Benefits Per Policy Year				PLAN 1

SICKNESS AND INJURY BENEFITS
		Preferred Provider			Out of Network

Aggregate Lifetime Maximum			$1,000,000

Policy Year Aggregate Maximum			$100,000
Amount Per Sickness/Injury

Deductible (Per Insured Person)			$250.00 Policy Year
(09/01/08 - 8/31/09 Policy Year)

Coinsurance		80%*			60%*
*except as noted below

Covered Charges - Inpatient Benefits
		Preferred Provider			Out-Of-Network

1. Room & Board	.....	Preferred allowance/ $1,500 Aggregate Maximum Per Day			Usual & Customary/ $1,500 Aggregate Maximum Per Day
Hospital Miscellaneous

2. Intensive Care	.....	Paid Under Room & Board Hosp. Misc.			Paid Under Room & Board Hosp. Misc.
		Paid Under Room & Board Hosp. Misc.			Paid Under Room & Board Hosp. Misc.
3. Routine Newborn Care	.....	Paid as any other Sickness			Paid as any other Sickness
(4 days Hospital confinement
expense maximum)
4. Physiotherapy	.....	Paid Under Room & Board Hosp. Misc.			Paid under Room & Board/Hosp. Misc.
		Paid Under Room & Board Hosp. Misc.			Paid under Room & Board/Hosp. Misc.
5. Surgery	.....	Preferred Allowance			Usual & Customary
6. Assistant Surgeon	.....	Preferred Allowance			Usual & Customary
(includes coverage for secondary
assistant surgeon fees)

7. Anesthetist	.....	25% of Surgery Allowance			25% of Surgery Allowance
		25% of Surgery Allowance			25% of Surgery Allowance
8. Registered Nurse's Services	.....	Preferred Allowance			Usual & Customary
9. Physician's Visits	.....	Preferred Allowance			Usual & Customary
10. Pre-admission Testing	.....	Preferred Allowance/ $1,500 maximum			Usual & Customary/ $1,500 maximum
		Preferred Allowance/ $1,500 maximum			Usual & Customary/ $1,500 maximum
11. Psychotherapy	.....	Preferred Allowance/ 3 days Maximum/$25 per day			Usual & Customary 3 days Maximum/$25 per day
		Preferred Allowance/ 3 days Maximum/$25 per day			Usual & Customary 3 days Maximum/$25 per day

Covered Charges - Outpatient Benefits
		Preferred Provider			Out of Network

1. Surgery	.....	Preferred Allowance			Usual & Customary
2. Day Surgery Miscellaneous	.....	Preferred Allowance/ $1,500 maximum			Usual & Customary/ $1,500 maximum
		Preferred Allowance/ $1,500 maximum			Usual & Customary/ $1,500 maximum
3. Assistant Surgeon	.....	Preferred Allowance			Usual & Customary
(Secondary surgeon fees are
paid at 50% of U & C)
4. Anesthetist	.....	25% of Surgery Allowance			25% of Surgery Allowance
		25% of Surgery Allowance			25% of Surgery Allowance
5. Physician's Visit (Maximum is Per Policy Year)	.....	Paid under Outpatient Misc/$25 copay per visit/30 visits maximum			Paid under Outpatient Misc/$25 copay per visit/30 visits maximum


6. Physiotherapy	.....	Preferred Allowance/ $50 max per visit/ 10 visits maximum			Usual & Customary/ $50 max per visit/ 10 visits maximum


7. Outpatient Miscellaneous Benefit	.....	Preferred Allowance/ $2,000 maximum			Usual & Customary $2,000 maximum
		Preferred Allowance/ $2,000 maximum			Usual & Customary $2,000 maximum
8. Medical Emergency	.....	Preferred Allowance			80% of Usual & Customary
9. X-Rays & Laboratory	.....	Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous
		Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous
10. Radiation Therapy	.....	Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous
		Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous
11. Tests & Procedures	.....	Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous
		Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous
12. Injections	.....	Preferred Allowance/ $1,500 maximum			Usual & Customary/ $1,500 maximum
		Preferred Allowance/ $1,500 maximum			Usual & Customary/ $1,500 maximum
13. Chemotherapy	.....	Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous
		Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous
14. Psychotherapy	.....	50% of Preferred Allowance/$1,500 Maximum			50% of Usual & Customary/ $1,500 Maximum
		50% of Preferred Allowance/$1,500 Maximum			50% of Usual & Customary/ $1,500 Maximum
15. Prescription Drugs, when	.....	Usual & Customary/ $15 copay/Tier 1 $25 copay/Tier 2 $500 maximum			No benefits - Prescriptions are only covered if filled at a UHPS ® Pharmacy
utilizing a UHPS ®
Pharmacy only

(Prescription Inhalants for persons suffering from asthma or other life threatening bronchial ailments are not limited
by restrictions on the number of days before an inhaler may be obtained when ordered or prescribed by the treating
Physician./ After the per prescription Copay utilizing a UHPS ® Pharmacy, the policy Deductible does not
apply.)
16. MRI/CAT Scan	.....	Paid under Outpatient Miscellaneous			Paid under Outpatient Miscellaneous

Covered Charges - Other Benefits
		Preferred Provider			Out of Network

1. Ambulance	.....	80% Usual & Customary/ $200 maximum			80% Usual & Customary/ $200 maximum
		80% Usual & Customary/ $200 maximum			80% Usual & Customary/ $200 maximum
2. Durable Medical Equipment	.....	80% Usual & Customary/ $1,500 maximum			80% Usual & Customary/ $1,500 maximum
		80% Usual & Customary/ $1,500 maximum			80% Usual & Customary/ $1,500 maximum
3. Dental (Benefits for injury to	.....	80% Usual & Customary/ $500 maximum			Usual & Customary/ $500 maximum
sound natural teeth)		80% Usual & Customary/ $500 maximum			Usual & Customary/ $500 maximum
4. Alcoholism	.....	Paid as any other Sickness			Paid as any other Sickness
		Paid as any other Sickness			Paid as any other Sickness
5. Drug Abuse	.....	Paid Under Psychotherapy			Paid under Psychotherapy
		Paid Under Psychotherapy			Paid under Psychotherapy
6. Maternity	.....	Paid as any other Sickness			Paid as any other Sickness
		Paid as any other Sickness			Paid as any other Sickness
7. Elective Abortion	.....	No Benefits			No Benefits
8. Complications of Pregnancy	.....	Paid as any other Sickness			Paid as any other Sickness
		Paid as any other Sickness			Paid as any other Sickness
9. Repatriation	.....	Benefits provided by Scholastic Emergency Services, Inc.			Benefits provided by Scholastic Emergency Services, Inc.
		Benefits provided by Scholastic Emergency Services, Inc.			Benefits provided by Scholastic Emergency Services, Inc.
10. Medical Evacuation	.....	Benefits provided by Scholastic Emergency Services, Inc			Benefits provided by Scholastic Emergency Services, Inc
		Benefits provided by Scholastic Emergency Services, Inc			Benefits provided by Scholastic Emergency Services, Inc
11. AD&D	.....	$5,000 - $10,000 maximum			$5,000-$10,000 maximum
12. Intercollegiate Sports	.....	No Benefits			No Benefits
13. Home Health Coverage	.....	Preferred Allowance			Usual & Customary
14. Other special Coverage's	.....	Preferred Allowance/ $150 maximum per policy year			Usual & Customary/ $150 maximum per policy year
year - not subject
to the deductible

(Wellness expense for the Insured and Dependents over the age of 18. Benefits include one examination/routine
physical and one HIV/syphilis test each Policy Year, includes pre/post test counseling. For men, routine physical
examination includes the office visit charge and a gonorrhea/Chlaydia test, a hemoglobinand urine test. For
women, examination includes the office visit charge, pap smear, gonorrhea, Chlymydia test, hemocult for women
over the age of 50, a hemoglobin and urine test. (Not subject to Policy Year Deductible)).

* These maximums and the Deductible apply to both Preferred Providers and
Out-Of-Network. (There are not separate maximums/deductible for each).

This is a brief summary of benefits under Policy No. 2008-200408-1.
Complete terms and conditions of coverage benefits are set forth
in the Master Policy issued to Student Osteopathic Medical
Association. This plan is underwritten by United HealthCare Insurance Company.

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