Benefits at a Glance

BGSU’s2013-2014 Student Health Insurance Policy
UnitedHealthcare Student Resources

Compare cost and benefits:

Estimated Plan Cost for 2013-2014 Policy (The amounts shown are Estimates Only)	$665.00 Fall Semester 8/1/2013 – 12/31/2013 $916.00 Spring Semester 1/1/2014-7/31/2014 $1,581.00 Annual Coverage 8/1/2013 – 7/31/2014
$500,000 Maximum	Per illness/injury per policy year
Pharmacy Maximum	$500,000 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 covered person

Expenses	Preferred Provider (Deductible Applies)	Non-Preferred (Deductible Applies)
Physician Office Visit	75% of the Negotiated Charge $20 per visit co-pay	50% of the Reasonable Charge $20 per visit deductible
Inpatient Hospitalization	75% of the Negotiated Charge after a $250 per visit co-pay	50% of the Reasonable Charge after a $250 per visit deductible
Emergency Room (per visit co-pay/per visit deductible waived if admitted)	80% of the Negotiated Charge after a $100 per visit co-pay	80% of the Reasonable Charge after a $100 per visit deductible
X-ray and Lab	75% of the Negotiated Charge $20 per visit co-pay	50% of the Reasonable Charge $20 per visit deductible
Prescription Drug	80% of Negotiated Charge if filled at any UHC Preferred Pharmacy	50% of Reasonable Charge if filled at any Non-Preferred Pharmacy
Psychiatry Office Visits	75% of the negotiated charge $20 per visit co-pay	50% of the Reasonable Charge $20 per visit deductible
Preventive Services	100% No Deductible Co-pays or Co-insurance will be applied. UnitedHealthcare follows the Preventive Care Services Guidelines	No Coverage

Expenses

Preferred Provider

(Deductible Applies)

Non-Preferred

(Deductible Applies)

Physician
Office Visit

75% of the Negotiated Charge

$20 per visit co-pay

50% of the Reasonable Charge

$20 per visit deductible

Inpatient Hospitalization

75% of the Negotiated Charge

after a $250 per visit co-pay

50% of the Reasonable Charge

after a $250 per visit deductible

Emergency Room (per visit co-pay/per visit deductible waived if admitted)

80% of the Negotiated Charge

after a $100 per visit co-pay

80% of the Reasonable Charge

after a $100 per visit deductible

X-ray and Lab

75% of the Negotiated Charge

$20 per visit co-pay

50% of the Reasonable Charge

$20 per visit deductible

Prescription Drug

80% of Negotiated Charge if filled at any UHC Preferred Pharmacy

50% of Reasonable Charge if filled at any Non-Preferred Pharmacy

Psychiatry
Office Visits

75% of the negotiated charge

$20 per visit co-pay

50% of the Reasonable Charge

$20 per visit deductible

Preventive
Services

100%

No Deductible Co-pays or Co-insurance will be applied. UnitedHealthcare follows the Preventive Care Services Guidelines

No Coverage

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

Student Insurance Office
Room 170 Health Center Building
Bowling Green, OH 43403-0147
Phone: 419-372-7495
Fax: 419-372-4812
studentins@bgsu.edu

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