SOMA College Health Insurance Plan

SOMA COLLEGE MEDICAL INSURANCE PROGRAM
2008 - 2009 SCHOOL YEAR
HIGH DEDUCTIBLE PLAN 2

Schedule of Benefits Per Policy Year				High Deductible Health
				Plan 2
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)			$2,000 Policy Year
(9/1/08 - 8/31/09 Policy Year)

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

Maximum Out-Of-Pocket			$8,000*
(Does Not Include Deductible)
* After the Insured has incurred $8,000 out-of-pocket this plan pays for 100%
of Preferred Providers and 80% of Out-of Network for covered medical expenses.


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

1. Room & Board	.....	Preferred allowance			Usual & Customary
Hospital Miscellaneous

2. Intensive Care	.....	Paid Under Room & Board Hosp. Misc.			Paid Under Room & Board Hosp. Misc.

3. Routine Newborn Care	.....	Paid as any other Sickness 4 days max			Paid as any other Sickness 4 days max
(4 days Hospital confinement
expense maximum
4. Physiotherapy	.....	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) at 50% off Primary

7. Anesthetist	.....	25% of Surgery Allowance			25% of Surgery Allowance

8. Registered Nurse	.....	Preferred Allowance			Usual & Customary
9. Physician's Visits	.....	Preferred Allowance			Usual & Customary
10. Pre-admission Testing	.....	Preferred Allowance			Usual & Customary
11. Psychotherapy	.....	Preferred Allowance			Usual & Customary

Covered Charges - Outpatient Benefits
		Preferred Provider			Out of Network

1. Surgery	.....	Preferred Allowance			Usual & Customary
2. Day Surgery Miscellaneous	.....	Preferred Allowance			Usual & Customary
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

5. Physician's Visit (30 visits max)	.....	Preferred Allowance			Usual & Customary
6. Physiotherapy	.....	Preferred Allowance			Usual & Customary
7. Medical Emergency	.....	Preferred Allowance			Usual & Customary
8. X-Rays & Laboratory	.....	Preferred Allowance			Usual & Customary
9. Radiation Therapy	.....	Preferred Allowance			Usual & Customary
10. Tests & Procedures	.....	Preferred Allowance			Usual & Customary
11. Injections	.....	Preferred Allowance			Usual & Customary
12. Chemotherapy	.....	Preferred Allowance			Usual & Customary
13. Psychotherapy	.....	50% of Preferred Allowance			50% of Usual & Customary
14. Prescription Drugs, when	.....	Usual & Customary when utilizing a UHPS® Pharmacy			No benefits - Prescriptions are only covered if filled at a UHPS® Pharmacy
utilizing a UHPS®
Pharmacy only

(Prescription inhalants for persons suffering asthma or other life threatening bronchia
ailments are not limited by restrictions on the number of days before an inhaler
may be obtained or prescribed by the treating physician when utilizing a UHPS® pharmacy.

15. MRI/CAT Scan	.....	Preferred Allowance			Usual & Customary

Covered Charges - Other Benefits
		Preferred Provider			Out of Network

1. Ambulance	.....	80% Usual & Customary			80% Usual & Customary
2. Durable Medical	.....	80% Usual & Customary			80% Usual & Customary
Equipment
3. Dental (Benefits for	.....	80% Usual & Customary			80% Usual & Customary
injury to sound
natural teeth)
4. Alcoholism	.....	Paid as any other Sickness			Paid as any other Sickness

5. Drug Abuse	.....	Paid Under Psychotherapy			Paid under Psychotherapy

6. Maternity	.....	Paid as any other Sickness			Paid as any other Sickness

7. Elective Abortion	.....	No Benefits			No Benefits
8. Complications of	.....	Paid as any other Sickness			Paid as any other Sickness
Pregnancy
9. Repatriation	.....	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.

11. AD&D	.....	$5,000 - $10,000 max			$5,000-$10,000 max
12. Intercollegiate Sports	.....	No Benefits			No Benefits
13. Home Health Coverage	.....	Preferred Allowance			Usual & Customary
14. Other special Coverage's	.....	Preferred Allowance			Usual & Customary

(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 hemoglobin and urine test. For
women, examination includes the office visit charge, pap smear, gonorrhea, Chlamydia test, hemocult for women
over the age of 50, a hemoglobin and urine test.


This is a brief summary of benefits under Policy No. 2008-201305-1.
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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