Wake Forest University School of Medicine 2015 2016

Wake Forest University School of Medicine 2015– 2016 Student Injury and Sickness Insurance Plan 15 COL 3322 Slide 1 of 15 Student. Resources

Rates 2015– 2016 Monthly Rates Student $272 Spouse $272 One Child $272 Two or More Children $544 Spouse + Two or More Children $816 This plan is underwritten by United. Healthcare Insurance Company and is based on Policy #2015 -200275 -1. For a full description of coverage, including costs, benefits, exclusions, any reductions or limitations and terms under which the policy may be continued in force, log on to www. uhcsr. com/wfsom. Slide 2 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Plan Changes Out-of-Network Coinsurance has increased from 60% of Usual and Customary to 70% of Usual and Customary for Outpatient Physician’s Visits and Preventive Care Services. Slide 3 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Plan Highlights • No Overall Maximum Benefit for Covered Medical Expenses (per Insured Person, per Policy Year). • Covered Medical Expenses for Preferred Providers are payable at 80% of Preferred Allowance and Out-of. Network benefits are payable at 60% of Usual and Customary Charges (all benefits are subject to satisfaction of any deductible, specific benefit limitations, maximums, and copays as described in the policy). • Coverage is available for eligible Dependents of students who participate in the plan. Slide 4 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Plan/Benefit Highlights Benefits Preferred Providers Out-of-Network Hospitalization 80% of PA 60% of U&C Surgery 80% of PA 60% of U&C Outpatient Services 80% of PA 60% of U&C Medical Emergency Expenses $150 Copay per visit, 80% of PA $150 deductible per visit, 80% of U&C Physician’s Office Visit $35 copay, 100% of PA $35 deductible, 70% of U&C Preventive Care and Immunizations 100%, no cost sharing 70% of U&C PA=Preferred Allowance Slide 5 of 15 U&C=Usual and Customary Charges Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Plan/Benefit Highlights Benefits Preferred Providers Out-of-Network 100% of PA 100% of U&C Mental Illness (Inpatient and Outpatient) Paid as any other sickness Substance Use Disorder (Inpatient and Outpatient) Paid as any other sickness 80% of PA 80% of U&C $30 copay, 80% of PA $30 deductible, 60% of U&C Dental Injury (to sound, natural teeth only) Ambulance Expense X-ray/Laboratory/ Tests & Procedures PA=Preferred Allowance Slide 6 of 15 U&C=Usual and Customary Charges Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Prescription Drug Highlights • United. Healthcare Pharmacy (UHCP) Prescription Drug Benefits: ► $10 copay for Tier 1, $25 copay for Tier 2, $50 copay for Tier 3; up to a 31 -day supply per prescription. (Mail order Prescription Drugs through UHCP at 2. 5 times the retail Copay up to a 90 -day supply. ) (If a retail United. Healthcare Network Pharmacy agrees to the same rates, terms and requirements associated with dispensing a 90 -day supply, then up to a consecutive 90 -day supply of a Prescription Drug Product at 2. 5 times the Copay that applies to a 31 -day supply per prescription. ) • $10 Deductible per prescription for generic, $25 Deductible per prescription for brand name; up to a 31 -day supply per prescription at an Out-of-Network pharmacy. Slide 7 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Provider Network • The Preferred Provider Network for this plan is United. Healthcare Choice Plus. Preferred Providers can be found using the following link: www. uhcsr. com/wfsom. Region Providers Hospitals Central 242, 317 2, 156 Northeast 211, 180 1, 004 Southeast 146, 055 1, 241 West 153, 456 930 Leased 44, 988 366 Total 798, 087 5, 701 Provider counts as of May 2015. Slide 8 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Global Emergency Services United. Healthcare Global • Domestic students are covered when they’re 100 miles or more away from their campus or home address. International students are covered worldwide except in their home country. • Provides medical evacuation and repatriation benefits. • Must be contacted prior to receiving services and information is on the medical ID card. Slide 9 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

My Account With My Account, available through www. uhcsr. com/wfsom, insured students can securely: • Review plan coverage details online • Print an ID card and/or request a replacement ID card • Check claim status and review EOB (Explanation of Benefits) • Find a Preferred Provider • Update personal information • Contact UHCSR with a question/comment • Access helpful resources and forms Slide 10 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

UHCSR Mobile App With the free UHCSR Mobile App, available at Google. Play and Apple’s App. Store, you’ll have access to the most popular self-service features like: • Viewing and sharing your ID card. You can even email or fax it to your provider. • Viewing claims received within the prior 60 days. • Searching for a Preferred Provider. • Accessing your custom My Account page. Slide 11 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

United. Health Allies® • Included with every policy, the United. Health Allies discount program typically saves members 5– 50% on many health and wellness products and services. • Members save on dental and vision care, fitness club memberships, weight management programs, smoking cessation, massage therapy, and much more. The United. Health Allies Discount Program is administered by Health. Allies, Inc. , a discount medical plan organization. This discount program is not a qualified health plan under the Affordable Care Act. United. Health Allies discount plan is NOT insurance. Slide 12 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Understanding your ID Card Download your electronic ID Card with either My Account or the UHCSR Mobile App. SR ID# This is the Member Identification number your provider will need to confirm your benefits. Group Name This is the Group Identifier your provider will need to confirm your benefits. Plan Name This is the plan name you need to provide to physicians or when online. Slide 13 of 15 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Plan/Benefit Highlights Submitting a Claim • Providers will typically file claims on your behalf. • You don’t need a company claim form to file a claim. • If you receive services from a provider who would like payment upfront, simply send (within 90 days of sickness or injury) all medical and hospital Send claims to: bills, along with the patient’s name, United. Healthcare address, and SR ID number Student. Resources to this address. PO Box 809025 • If you prefer to fax your claim, the number is 469 -229 -5510. Slide 14 of 15 Dallas, TX 75380 -9025 Confidential Property of United. Health Group. Do not distribute or reproduce without express permission of United. Health Group

Questions? Please contact UHCSR Customer Service at: 888 -251 -6259 or email at: customerservice@uhcsr. com United. Healthcare Student. Resources Slide 15 of 15