(Includes: Undergraduate Students and Non-Supported
The American College Student Association (ACSA) Student Health Insurance Plan underwritten
by UnitedHealthcare Insurance Company and serviced by Gallagher Koster is available to all
Undergraduate students taking a minimum of 6 credit hours and non-supported Graduate
Students taking 3 credit hours are eligible to enrol in this insurance plan.
Highlights of the Coverage and Services offered by UnitedHealthcare StudentResources are:
Company and serviced by
Maximum benefit of to $2,000,000 per Insured Person per Policy Year.
$250 deductible for Preferred Providers, $500 deductible for Out of Network Providers,
$7,500 Out-of-Pocket maximum per Insured Person per Policy Year.
A Preferred Provider is a member of the United HealthCare Choice Plus PPO network.
Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred nd click on the UCF logo.
Al owance and Out of Network benefits are payable at 60% of Usual and Customary
charges (all benefits are subject to satisfaction of the deductible, specific benefit
limitations, maximums and co-pays as described in the policy).
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Students under the age of 19 are immediately covered for pre-existing conditions. For
students who are 19 and over, pre-existing conditions wil apply for the first 6 months
Gal agher Koster
except for individuals who have been continuously insured under the school’s student
insurance policy for at least 6 consecutive months.
Network Prescription Drug Benefit at UnitedHealthcare Network Pharmacies: $15 copay
per prescription for Tier 1, $40 copay per prescription for Tier 2, $70 copay for Tier 3 up
to a 31-day supply per prescription. Specific Contraceptive Drugs and Devices covered at
100%, no copays. Prescriptions are covered up to the policy maximum.
Preventive Services benefit which includes annual physicals, GYN exams, routine
screenings and immunizations, covered at 100%, no copayments or deductibles to
Preferred Providers only. Please sfor complete details of the
services provided for specific age and risk groups.
Coverage available for eligible dependents. Dependent coverage must be purchased for
the same time period as the student’s period of coverage.
FrontierMEDEX – Domestic Students are covered when 100 miles or more away from
their campus or home address. International Students are covered worldwide except in
This Student health insurance coverage, offered by UnitedHealthcare Insurance Company, may not
meet the minimum standards required by the health care reform law for restrictions on annual dollar
limits. The annual dollar limits ensure that consumers have sufficient access to medical benefits
throughout the annual term of the policy. Restrictions for annual dollar limits for group and individual
health insurance coverage are $1.25 million for policy years before September 23, 2012; and $2
million for policy years beginning on or after September 23, 2012 but before January 1, 2014.
Restrictions on annual dollar limits for student health insurance coverage are $100,000 for policy
years before September 23, 2012 and $500,000 for Each Injury or Sickness policy years beginning on
or after September 23, 2012 but before January 1, 2014. This student health plan puts a policy year
limit of $500,000 for each Injury or Sickness that applies to the essential benefits provided in the
schedule of Benefits unless otherwise specified. If you have any questions or concerns about this
notice, contact Customer Service at 1-866-948-8472. Be advised that an Insured Person may be
eligible for coverage under a group health plan of a parent's employer or under a parent’s individual
health insurance policy if you are under the age of 26. Contact the plan administrator of the
parent’s employer plan or the parent’s individual health insurance issuer for more information.
Exclusions & Limitations:
No benefits wil be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies for, at, or related to:
3. Nicotine addiction, except as specifically provided in the policy
4. Milieu therapy, learning disabilities, behavioral problems, parent-child problems, attention deficit disorder, conceptual handicap, developmental delay or disorder or mental
8. Congenital conditions, except as specifically provided under Benefits for Newborn Infant, Adopted or Foster Child or Benefits for Cleft Lip and Cleft Palate;
9. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children;
10. Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or custodial care; extended care in
treatment or substance abuse facilities for domiciliary or custodial care;
11. Dental treatment, except for Injury to Sound, Natural Teeth;
12. Elective Surgery or Elective Treatment, except cosmetic surgery made necessary as the result of a covered Injury or to correct a disorder of a normal bodily function;
14. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and
problems; except when due to a Covered Injury or disease process; except as specifical y provided in the policy or under Benefits for Newborn Infant, Adopted or Foster Child or Benefits for
15. Flat foot conditions, supportive devices for the foot, subluxations of the foot, fallen arches, weak feet, chronic foot strain, symptomatic complaints of the feet and routine foot care including
the care, cutting and removal of corns, cal uses, toenails, and bunions (except capsular or bone surgery);
16. Health spa or similar facilities; strengthening programs;
17. Hearing examinations; hearing aids; or other treatment for hearing defects and problems except as specifically provided under Benefits for Cleft Lip and Cleft Palate or Benefits for Newborn Infant,
Adopted or Foster Child, or Benefits for Child Health Assurance. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process;
20. Immunizations, except as specifically provided in the policy, preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifically provided in the policy;
21. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation.
22. Injury or Sickness outside the United States and its possessions, Canada or Mexico, except for a Medical Emergency when traveling for academic study abroad programs business or pleasure;
22. Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by any other valid and collectible insurance;
23. Injury sustained while (a) participating in any intercollegiate or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant;
or (c) while participating in any practice or conditioning program for such sport, contest or competition;
26. Nuclear, chemical or biological Contamination, whether direct or indirect. “Contamination” means the contamination or poisoning of people by nuclear and/or chemical and/or biological
substances which cause Sickness and/or death;
27. Outpatient Physiotherapy; except for a condition that required surgery or Hospital Confinement: 1) within the 30 days immediately preceding such Physiotherapy; or 2) within the 30
days immediately fol owing the attending Physician's release for rehabilitation; or except as specifically provided under Benefits For Habilitative Services For The Treatment of Congenital
28. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting, except in self-defense;
29. Pre-existing Conditions except for individuals who have been continuously insured under the school’s student insurance policy for at least 6 consecutive months. Credit will be given
for the time the Insured was covered under a previous similar plan if the pervious coverage was continuous to a date not more than 63 days prior to the Insured’s Effective Date under this
policy. This exclusion wil not apply to an Insured Person who is under age 19;
30. Prescription Drugs, services or supplies as follows:
a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use; except as specifically provided
b) Immunization agents, biological sera, blood or blood products administered on an outpatient basis;
c) Drugs labeled, “Caution - limited by federal law to investigational use” or experimental drugs;
e) Drugs used to treat or cure baldness; anabolic steroids used for body building;
f) Anorectics - drugs used for the purpose of weight control;
g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra;
i) Refills in excess of the number specified or dispensed after one (1) year of date of the prescription.
31. Reproductive/Infertility services including but not limited to: family planning; fertility tests; infertility (male or female), including any services or supplies rendered for the purpose or with the
intent of inducing conception; premarital examinations; impotence, organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal of sterilization procedures;
32. Research or examinations relating to research studies, or any treatment for which the patient or the patient’s representative must sign an informed consent document identifying the
treatment in which the patient is to participate as a research study or clinical research study, except as specifical y provided in the policy;
33. Routine Newborn Infant Care, wel -baby nursery and related Physician charges; except as specifically provided in the policy
34. Preventive Care services; routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness;
except as specifically provided in the policy;
35. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee;
36. Deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for treatment of chronic purulent sinusitis;
37. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly
scheduled flight of a commercial airline;
39. Speech therapy except as specifically provided in Benefits for Cleft Lip and Cleft Palate; naturopathic services;
40. Supplies, except as specifically provided in the policy;
41. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia;
42. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment;
43. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium wil be refunded upon request for such period not covered); and
44. Weight management, weight reduction, nutrition programs, treatment for obesity, surgery for removal of excess skin or fat
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