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SHI Benefit Summary

	Student Insurance Info

Note:

The Student Health Center is available to registered students only.

Dependents can select a Primary Care Physician of their choice.

1. Please refer to the Referral Requirements in this plan brochure.

2. Out of Network Providers are considered non-participating under the Plan. Benefits will be paid at the reasonable and customary rates. Please be aware that these providers can bill the difference between the reasonable and customary rates and the billed amounts they charge for their services.

3. Physical/Occupational Therapy Benefits are only payable 30 days preceding or following a condition that requires surgery or hospital confinement.

This is only a brief description of the coverage available. The policy on file at the University may contain, reductions, limitations, exclusions, and termination provisions. Full details of the coverage are contained in the Policy. If there is any conflict between the contents of this Brochure and the Policy, the Policy shall govern. This plan also covers Mandated Benefits as required by North Carolina.

BENEFIT SUMMARY
Aug. 10, 2009 - Aug. 9, 2010

	STUDENT HEALTH CENTER	IN-NETWORK (PPO)	OUT OF NETWORK²
Insurance Premiums (per semester)		REFERRAL REQUIRED¹	REFERRAL REQUIRED¹
Student— $344 Add a spouse— $816 Add a child— $499	NO Deductible	$300 Annual Deductible Then You Pay:	$300 Annual Deductible Then You Pay:
OUTPATIENT SERVICES
Physician & Urgent Care Visits	FREE	$10 Co-pay + 20%	$10 Co-pay + 40%
Lab and X-Ray Services	FREE	$10 Co-pay per service + 20%	$10 Co-pay + 40%
Outpatient Surgery Assistant Surgeon Anesthesia	N/A	20% 75% of surgical Allowance 75% of Surgical Allowance	40% 75% of Surgical Allowance 75% of Surgical Allowance
Chemo/Radiation Therapy	N/A	20%	40%
Allergy Injections (Allergy testing is not covered	FREE	20%	40%
Emergency Room Visits	N/A	$150 Co-pay + 20%	$150 Co-pay + 40%
INPATIENT SERVICES		Pre-Notification Required	Pre-Notification Required
Hospitalization	N/A	20% of Semi-Private Room Rate	40% of Semi-Private Room Rate
Inpatient Surgery Assistant Surgeon Anesthesia	N/A	20% 75% of Surgical Allowance 75% of Surgical Allowance	40% 75% of Surgical Allowance 75% of Surgical Allowance
Pre-admission Testing	N/A	20%	40%
MENTAL HEALTH
Outpatient Psychotherapy	N/A	$10 Co-pay + 20% Limited to 1 visit per day	$10 Co-pay + 40% Limited to 1 visit per day
Inpatient Psychotherapy	N/A	20% Limited to 1 visit per day	40% Limited to 1 visit per day
Alcoholism and Substance Abuse	N/A	20%	40%
OTHER SERVICES
Ambulance	N/A	20%	40%
Durable Medical Equipment	N/A	20%	40%
Prescriptions (Limited to $750 Max per benefit year)	$10 Co-pay	$10 Generic + 20% $25 Brand Name + 20%	$10 Generic + 20% $25 Brand Name + 20%
Accidental Dental Coverage	N/A	20%	40%
Maternity	N/A	20%	40%
Physical/Occupational Therapy Services³	FREE	$10 Co-pay per service + 20%	$10 Co-pay per service + 40%

Page Maintained By: Student Health Services