| SOMA INSURANCE
PLAN |
| 2011
- 2012 SCHOOL YEAR |
| PLAN
2 |
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| Schedule
of Benefits Per Policy Year |
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PLAN
2 |
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| SICKNESS
AND INJURY BENEFITS |
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Preferred
Provider |
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Out
of Network |
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| Aggregate
Lifetime Maximum |
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UNLIMITED |
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| Policy
Year Aggregate Maximum |
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$100,000 |
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| Amount
Per Sickness/Injury |
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| Deductible
(Per Insured Person)
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$2,000
Policy Year |
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$5,000
Policy Year |
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| (09/01/11
- 8/31/12 Policy Year) |
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| Coinsurance |
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80%*
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60%*
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| *except
as noted below |
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| Maximum
Out-Of-Pocket |
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$8,000
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| *
After the Insured has incurred $8,000 out-of-pocket this plan pays
for 100% |
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Preferred Providers and 100% of Out-of Network for covered medical
expenses. |
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| Covered
Charges - Inpatient Benefits |
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Preferred
Provider |
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Out-Of-Network |
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| 1.
Room & Board |
..... |
80%
of Preferred allowance
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60%
of Usual, Reasonable, & Customary Charges
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Hospital Miscellaneous |
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| 2.
Intensive Care |
..... |
Paid
Under Room &
Board
Hosp. Misc.
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Paid
Under Room &
Board
Hosp. Misc.
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| 3.
Routine Newborn Care |
..... |
Paid
as any
other
Sickness
4
days max
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Paid
as any
other
Sickness
4
days max
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(4 days Hospital
confinement |
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expense maximum) |
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| 4.
Physiotherapy |
..... |
Paid
Under Room &
Board
Hosp. Misc.
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Paid
under Room &
Board/Hosp.
Misc.
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| 5.
Surgery |
..... |
80%
of Preferred
Allowance |
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60%
of URC |
| 6.
Assistant Surgeon |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| (includes
coverage for secondary |
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assistant surgeon fees) |
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| 7.
Anesthetist |
..... |
25%
of Surgery
Allowance
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25%
of Surgery
Allowance
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| 8.
Registered Nurse's Services |
..... |
80%
of Preferred
Allowance |
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60%
of URC |
| 9.
Physician's Visits |
..... |
80%
of Preferred
Allowance |
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60%
of URC |
| 10.
Pre-admission Testing |
..... |
80%
of Preferred Allowance
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60%
of URC
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| 11.
Psychotherapy |
..... |
80%
of Preferred Allowance
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60%
of URC
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| Covered
Charges - Outpatient Benefits |
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Preferred
Provider |
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Out
of Network |
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| 1.
Surgery |
..... |
80%
of Preferred
Allowance |
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60%
of URC |
| 2.
Day Surgery Miscellaneous |
..... |
80%
of Preferred
Allowance/
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60%
of URC
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| 3.
Assistant Surgeon |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| (Secondary
surgeon fees are |
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paid at 50% of U & C) |
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| 4.
Anesthetist |
..... |
25%
of Surgery
Allowance
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25%
of Surgery
Allowance
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5.
Physician's Visit
(Maximum is Per Policy Year) |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| 6.
Physiotherapy |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| 7.
Outpatient Miscellaneous Benefit |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| 8.
Medical Emergency |
..... |
80%
of Preferred
Allowance |
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60%
of URC |
| 9.
X-Rays & Laboratory |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| 10.
Radiation Therapy |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| 11.
Tests & Procedures |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| 12.
Injections |
..... |
80%
of Preferred
Allowance
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60%
of URC
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| 13.
Chemotherapy |
..... |
P80%
of referred
Allowance
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60%
of URC
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| 14.
Psychotherapy |
..... |
50%
of Preferred
Allowance/$1,500
Maximum
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50%
of URC
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| 15.
Prescription Drugs, when |
..... |
80%
of Usual
& Customary/
when
utilizing a ScriptCare LTD Pharmacy
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No
benefits - Prescriptions
are
only covered if filled
at
a ScriptCare LTD.
Pharmacy
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utilizing a UHPS ® |
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Pharmacy only |
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(Prescription Inhalants
for persons suffering from asthma or other life threatening
bronchial ailments are not limited |
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by restrictions on the
number of days before an inhaler may be obtained or
prescribed by the treating |
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Physician when utilizing a UHPS ®
Pharmacy. |
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| 16.
MRI/CAT Scan |
..... |
80%
of Preferred
Allowance |
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60%
of URC |
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| Covered
Charges - Other Benefits |
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Preferred
Provider |
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Out
of Network |
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| 1.
Ambulance |
..... |
80%
of URC
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80%
of URC
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| 2.
Durable Medical Equipment |
..... |
80%
of URC
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80%
of URC
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| 3.
Dental (Benefits for injury to |
..... |
80%
of URC
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80%
of URC
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sound natural teeth) |
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| 4.
Consultant |
..... |
80%
of Preferred
Allowance
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80%
of URC
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| 5.
Needle Stick |
..... |
Paid
as any other
Sickness
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Paid
as any
other
Sickness
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| 6.
Alcoholism |
..... |
Paid
as any other
Sickness
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Paid
as any
other
Sickness
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| 7.
Drug Abuse |
..... |
Paid
Under
Psychotherapy
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Paid
under
Psychotherapy
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| 8.
Maternity |
..... |
Paid
as any other
Sickness
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Paid
as any other
Sickness
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| 9.
Elective Abortion |
..... |
No
Benefits |
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No
Benefits |
| 10.
Complications of Pregnancy |
..... |
Paid
as any other
Sickness
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Paid
as any other
Sickness
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| 11.
Repatriation |
..... |
Benefits
provided by
On
Call International
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Benefits provided by
On
Call International |
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| 12.
Medical Evacuation |
..... |
Benefits
provided by
On
Call International
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Benefits provided by
On
Call International |
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| 13. AD&D |
..... |
$5,000
- $10,000 maximum |
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$5,000-$10,000
maximum |
| 14.
Intercollegiate Sports |
..... |
No
Benefits |
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No
Benefits |
| 15.
Home Health Coverage |
..... |
80%
of Preferred
Allowance |
|
60%
of URC |
| 16.
Wellness Benefit |
..... |
80%
of Preferred Allowance
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60%
of URC
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(Wellness
expense for the Insured and Dependents over the age of 18.
Benefits include one examination/routine |
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physical and one
HIV/syphilis test each Policy Year, includes pre/post test
counseling. For men, routine physical |
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examination includes the
office visit charge and a gonorrhea/Chlaydia test, a hemoglobinand
urine test. For |
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women, examination
includes the office visit charge, pap smear, gonorrhea, Chlymydia
test, hemocult for women |
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over the age of 50, a
hemoglobin and urine test. |
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| *
These maximums and the Deductible apply to both Preferred Providers
and |
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Out-Of-Network. (There are not separate maximums/deductible
for each). |
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| This
is a brief summary of benefits under Policy No. US003891. |
| 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 States Fire Insurance
Company. |
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