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OUTPATIENT PRESCRIPTION DRUGS

After a copayment of $15 for generic or $30 for a brand name drug when no generic is available, and $50 for a brand name drug when generic is available (per prescription), the cost of prescription drugs is payable in full, up to $600 for the policy year.

P r e s c r i p t i o n s m u s t b e f i l l e d a t a M e d c o p a r t i c i p a t i n g p h a r m a c y . I n s u r e d P e r s o n s w i l l b e g i v e n a n i n s u r a n c e I D c a r d t o s h o w t o t h e P h a r m a c y a s p r o o f o f c o v e r a g e . A l i s t o f p a r t i c i p a t i n g p h a r m a c i e s i s a v a i l a b l e a t t h e H e a l t h a n d W e l l n e s s C e n t e r o r c a l l C o l l e g i a t e I n s u r a n c e R e s o u r c e s a t 1 - 8 0 0 - 3 2 2 - 9 9 0 1 .

Before the insurance ID card is received, if a prescription needs to be filled, go to a participating pharmacy, pay for the medication in full and save the receipt. The insurance ID card will include instructions on how to file for reimbursement for prescriptions filled before the card was received. Reimbursement will be at the Medco contracted discount rate and will be less than the rate charged by the pharmacy. Not all medications are covered. Before receiving the insurance ID card, contact Collegiate Insurance Resources for a list of covered medications or exclusions.

After the insurance ID card is received, no claim forms need be completed. After the card is received call the toll-free customer service number listed on the card for assistance with pharmacy locations (800-400-0136) or contact Medco online at www.medco.com. This number is effective for enrolled members only. Have the ID card handy because the group number and the member number will be needed.

Home Delivery Pharmacy Service is available for medication taken to treat ongoing health conditions. Instructions on how to order will be included with your insurance ID card.

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COVERED MEDICAL EXPENSES

Consist of the following subject to the benefit limits described in this brochure.

Ambulance Expense - professional ground ambulance service for emergency transportation to or from a hospital. Covered to a maximum of $250.

Diagnostic X-ray and Laboratory Expense - diagnostic x-rays and laboratory tests when referred by the attending Physician or by the Student Health Center for lab tests, cultures or x-rays not otherwise provided free of charge by the Student Health Center.

Emergency Room Expense - treatment of Medical Emergency.

Home Health Care Expense Benefit -When by reason of sickness or injury, a Covered Person incurs expenses for covered home health care services, BCS Insurance Company will pay the Reasonable and Customary charges, subject to the following conditions: the service must be: (a) Medically Necessary; (b) furnished by, or under arrangements made by, a licensed Home Health Agency; (c) covered under a home care plan, (d) this plan must be established pursuant to the written order of a doctor and the doctor must renew that plan monthly; (e) delivered in the patient's place of residence on a part-time, intermittent, visiting basis while the patient is confined as a result of Injury or Sickness. Benefits will be provided for no more than 60 home health care visits in any period of 12 consecutive months. The amount payable will not exceed the Hospital Room and Board Benefit rate for the first three visits or one-half the Hospital Room and Board Benefit rate for subsequent visits. Payment of this benefit is subject to all other terms and conditions of the Policy.

H o s p i t a l M i s c e l l a n e o u s E x p e n s e - E x p e n s e s d u r i n g a h o s p i t a l c o n f i n e m e n t o r d a y s u r g e r y o n a n o u t p a t i e n t b a s i s i n c l u d e : ( a ) a n e s t h e s i a , a n e s t h e s i a s u p p l i e s a n d s e r v i c e s ; ( b ) o p e r a t i n g , d e l i v e r y a n d t r e a t m e n t r o o m s a n d e q u i p m e n t ; ( c ) d i a g n o s t i c x - r a y a n d l a b o r a t o r y t e s t s ; ( d ) l a b s t u d i e s ; ( e ) p r e s c r i b e d d r u g s a n d m e d i c i n e s ; ( f ) m e d i c a l a n d s u r g i c a l d r e s s i n g s , s u p p l i e s , c a s t s a n d s p l i n t s ; ( g ) r a d i a t i o n t h e r a p y , i n t r a v e n o u s c h e m o t h e r a p y , k i d n e y d i a l y s i s , a n d i n h a l a t i o n t h e r a p y ; ( h ) c h e m o t h e r a p y t r e a t m e n t w i t h r a d i o a c t i v e s u b s t a n c e s ; ( i ) i n t r a v e n o u s i n j e c t i o n s a n d s o l u t i o n s , a n d t h e i r a d m i n i s t r a t i o n ; ( j ) p h y s i c a l t h e r a p y ; a n d ( k ) o t h e r n e c e s s a r y a n d p r e s c r i b e d h o s p i t a l e x p e n s e s .

Hospital Room and Board Expense - up to the daily semi-private room rate.

Mental and Nervous Disorders Expense Benefit -

Inpatient

1 0 W e w i l l p a y 8 0 % o f n e t w o r k a l l o w a b l e o r 5 0 % o f U s u a l , C u s t o m a r y a n d R e a s o n a b l e c h a r g e s f o r t h e C o v e r e d E x p e n s e s i n c u r r e d w h e n a C o v e r e d P e r s o n r e q u i r e s

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