SOMA Insurance Plan

SOMA INSURANCE PLAN
2010 - 2011 SCHOOL YEAR
PLAN 2

Schedule of Benefits Per Policy Year				PLAN 2

SICKNESS AND INJURY BENEFITS
		Preferred Provider			Out of Network

Aggregate Lifetime Maximum			UNLIMITED

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

Deductible (Per Insured Person)		$2,000.00 Policy Year			$4,000.00 Policy Year
(09/01/09 - 8/31/10 Policy Year)

Coinsurance		80%*			60%*
*except as noted below
Maximum Out-Of-Pocket			$8,000
* After the Insured has incurred $8,000 out-of-pocket this plan pays for 100%
of Preferred Providers and 100% 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			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.

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

8. Registered Nurse's Services	.....	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 (Maximum is Per Policy Year)	.....	Paid under Outpatient Misc/$25 copay per visit)			Usual & Customary


6. Physiotherapy	.....	Preferred Allowance			Usual & Customary


7. Outpatient Miscellaneous Benefit	.....	Preferred Allowance			Usual & Customary

8. Medical Emergency	.....	Preferred Allowance			Usual & Customary
9. X-Rays & Laboratory	.....	Preferred Allowance			Usual & Customary

10. Radiation Therapy	.....	Preferred Allowance			Usual & Customary

11. Tests & Procedures	.....	Preferred Allowance			Usual & Customary

12. Injections	.....	Preferred Allowance			Usual & Customary

13. Chemotherapy	.....	Preferred Allowance			Usual & Customary

14. Psychotherapy	.....	50% of Preferred Allowance			50% of Usual & Customary

15. 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 from asthma or other life threatening bronchial 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.

16. 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 Equipment	.....	80% Usual & Customary			80% Usual & Customary

3. Dental (Benefits for injury to	.....	80% Usual & Customary			Usual & Customary
sound natural teeth)
4. Consultant	.....	Preferred Allowance			Usual & Customary

5. Needle Stick	.....	Paid as any other Sickness			Paid as any other Sickness

6. Alcoholism	.....	Paid as any other Sickness			Paid as any other Sickness

7. Drug Abuse	.....	Paid Under Psychotherapy			Paid under Psychotherapy

8. Maternity	.....	Paid as any other Sickness			Paid as any other Sickness

9. Elective Abortion	.....	No Benefits			No Benefits
10. Complications of Pregnancy	.....	Paid as any other Sickness			Paid as any other Sickness

11. Repatriation	.....	Benefits provided by Scholastic Emergency Services, Inc.			Benefits provided by Scholastic Emergency Services, Inc.

12. Medical Evacuation	.....	Benefits provided by Scholastic Emergency Services, Inc			Benefits provided by Scholastic Emergency Services, Inc

13. AD&D	.....	$5,000 - $10,000 maximum			$5,000-$10,000 maximum
14. Intercollegiate Sports	.....	No Benefits			No Benefits
15. Home Health Coverage	.....	Preferred Allowance			Usual & Customary
16. Wellness Benefit	.....	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/Chlamydia 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.

* 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. 2009-201305-1.
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 States Fire Insurance Company.

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