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HEALTH SERVICES (DHS)

P e r s o n s i n s u r e d u n d e r t h i s P l a n m a y c h o o s e t o b e t r e a t e d w i t h i n o r o u t s i d e o f t h e D e v o n H e a l t h S e r v i c e s ( D H S ) N e t w o r k . D H S c o n s i s t s o f h o s p i t a l s , D o c t o r s , a n d o t h e r h e a l t h c a r e p r o v i d e r s o r g a n i z e d i n t o a n e t w o r k f o r t h e p u r p o s e o f d e l i v e r i n g q u a l i t y h e a l t h c a r e a t a f f o r d a b l e r a t e s . R e i m b u r s e m e n t r a t e s w i l l v a r y a c c o r d i n g t o t h e s o u r c e o f c a r e a s d e s c r i b e d u n d e r t h e P l a n S u m m a r y . I n o r d e r t o u s e t h e s e r v i c e s o f a N e t w o r k P r o v i d e r , y o u m u s t p r e s e n t a n i d e n t i f i c a t i o n c a r d w h i c h i s m a i l e d t o a l l s t u d e n t s i n s u r e d u n d e r t h e N o r t h a m p t o n C o m m u n i t y C o l l e g e S t u d e n t A c c i d e n t a n d S i c k n e s s I n s u r a n c e P l a n .

A s s i g n m e n t o f a n e t w o r k p h y s i c i a n d o e s n o t g u a r a n t e e e l i g i b i l i t y o r r i g h t t o I n j u r y o r S i c k n e s s b e n e f i t s u n d e r t h i s P l a n . P r o v i d e r s m a y b e p e r i o d i c a l l y a d d e d o r d e l e t e d a s p a r t i c i p a n t s i n t h e D H S N e t w o r k . N o t a l l p h y s i c i a n s p r a c t i c i n g a t a h o s p i t a l e l e c t t o p a r t i c i p a t e i n t h e D H S N e t w o r k . I n s u r e d ' s a r e r e s p o n s i b l e t o v e r i f y t h a t a p r o v i d e r i s a p a r t i c i p a n t p r i o r t o s e r v i c e s b e i n g r e n d e r e d .

P e r s o n s i n s u r e d u n d e r t h i s P l a n m a y c h o o s e t o b e t r e a t e d w i t h i n o r o u t s i d e o f t h e V a l l e y P r e f e r r e d N e t w o r k . V a l l e y P r e f e r r e d c o n s i s t s o f h o s p i t a l s , D o c t o r s , a n d o t h e r h e a l t h c a r e p r o v i d e r s o r g a n i z e d i n t o a n e t w o r k f o r t h e p u r p o s e o f d e l i v e r i n g q u a l i t y h e a l t h c a r e a t a f f o r d a b l e r a t e s . R e i m b u r s e m e n t r a t e s w i l l v a r y a c c o r d i n g t o t h e s o u r c e o f c a r e a s d e s c r i b e d u n d e r t h e P l a n S u m m a r y . I n o r d e r t o u s e t h e s e r v i c e s o f a N e t w o r k P r o v i d e r , y o u m u s t p r e s e n t a n i d e n t i f i c a t i o n c a r d w h i c h i s m a i l e d t o a l l s t u d e n t s i n s u r e d u n d e r t h e N o r t h a m p t o n C o m m u n i t y C o l l e g e S t u d e n t A c c i d e n t a n d S i c k n e s s I n s u r a n c e P l a n .

A s s i g n m e n t o f a n e t w o r k p h y s i c i a n d o e s n o t g u a r a n t e e e l i g i b i l i t y o r r i g h t t o I n j u r y o r S i c k n e s s b e n e f i t s u n d e r t h i s P l a n . P r o v i d e r s m a y b e p e r i o d i c a l l y a d d e d o r d e l e t e d a s p a r t i c i p a n t s i n t h e V a l l e y P r e f e r r e d N e t w o r k . N o t a l l p h y s i c i a n s p r a c t i c i n g a t a h o s p i t a l e l e c t t o p a r t i c i p a t e i n t h e N e t w o r k . I n s u r e d ' s a r e r e s p o n s i b l e t o v e r i f y t h a t a p r o v i d e r i s a p a r t i c i p a n t p r i o r t o s e r v i c e s b e i n g r e n d e r e d .

Benefit In Devon Health or Valley Preferred Network

Benefit Out of Devon Health or Valley Preferred Network

Per Condition Aggregate Maximum Benefit

80%

50%

$12,000

$50

$150

50% $10 copay

50%

50% $20 copay

PLAN SUMMARY

Related lab work.......................................................................................................

80%

OUTPATIENT MENTAL HEALTH VISITS (15 visits/year).............................................................................................................

100% $20 copay

COVERAGE

When hospital or medical care is required for either an Injury or a Sickness, payment will be made according to the following schedule.

STUDENT ACCIDENT AND SICKNESS INSURANCE PLAN..........................

ANNUAL DEDUCTIBLE ......................................................................................... (the annual deductible must be met before the plan will cover eligible expenses)

OUTPATIENT PHYSICIAN VISIT BENEFIT......................................................

100% $10 copay

W h e n a n i n s u r e d P e r s o n u s e s t h e s e r v i c e s o f a D e v o n H e a l t h S e r v i c e s o r V a l l e y P r e f e r r e d p r o v i d e r , t h e C o v e r e d M e d i c a l E x p e n s e s i n c u r r e d w i l l b e p a y a b l e a t 8 0 % o f t h e P r e f e r r e d A l l o w a n c e , u n l e s s o t h e r w i s e n o t e d .

W h e n t r e a t m e n t i s r e n d e r e d b y p r o v i d e r s o u t s i d e t h e D e v o n H e a l t h S e r v i c e s o r V a l l e y P r e f e r r e d N e t w o r k t h e C o v e r e d M e d i c a l E x p e n s e s w i l l b e p a y a b l e a t 5 0 % o f t h e R e a s o n a b l e a n d C u s t o m a r y E x p e n s e s i n c u r r e d .

Payment will be made for Covered Medical Expense incurred for covered accident or sickness up to a per condition maximum of $12,000. 8

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