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BENEFITS AT AGLANCESTUDENT HEALTH INSURANCE PLAN PLAN YEAR 2021/2022DESIGNED EXCLUSIVELY FOR THE STUDENTSOF:CHAMPLAIN COLLEGEBurlington, VTPolicy Number: WI2122VTSHIP146Group Number: ST0824SHEffective: 8/20/2021 - 8/19/2022(“the Policyholder”)UNDERWRITTEN BY:Wellfleet Insurance Company Fort Wayne, INADMINISTERED BY:Wellfleet Group, LLC.(“the Company”)VTSHIP146 6.10.21
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANTable of Contents (Click on section title below to go to section in “Benefits at a Glance.”)Welcome Students .2Where to Find Help.3Am I Eligible? .4How Do I Waive/Enroll?.4Effective Dates & Costs .4Preferred Provider Organization (PPO) Network .5Champlain College Schedule of Benefits .5Pre-Certification.17Exclusions and Limitations .17Value Added Services .20Welcome Students We are pleased to provide you with this summary of the 2021 – 2022 Student Health InsurancePlan (“Plan”), which is fully compliant with the Affordable Care Act. “Benefits at a Glance” includeseffective dates and costs of coverage, as well as other helpful information. For additional eandothermaterialsatwww.wellfleetstudent.com. If you have questions about enrollment into the Plan, please callChamplain College at (802) 860-2777. For questions about medical benefits or claims, please callWellfleet Student at (877) 657-5030, TTY 711.2Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANWhere to Find HelpFor Questions About:Please Contact:Insurance BenefitsEnrollmentWaiverChamplain College163 South Willard St.Burlington, VT 05402Phone: (802) 860-2777Claims ProcessingID CardsPreferred Provider ListingsID card RequestsWellfleet Group, LLCPO Box 15369Springfield, Massachusetts 01115-5369(877) 657-5030, TTY 711www.wellfleetstudent.comServicing AgentAmy MerrittHickok & Boardman346 Shelburne St. Box 1064Burlington VT 05402(802) 383-1630amerritt@hbinsurance.comWellfleet mPreferred PPO Provider ListingsSend Cigna claims to:CIGNAPO Box 188061Chattanooga, TN 37422 – 8061Electronic Payor ID: 62308Cigna claimsFor information about the Wellfleet Rx/ESI, please visitwww.wellfleetstudent.comYour plan includes Wellfleet Rx – offering over 40 generics ata 0 copay. Please ask your health care provider to reviewour formulary to see if these medications are right for you.Click here http://wellfleetrx.com/students/formularies/ formore information.Prescription Drug Provider Member’s Rights or Assistance Link to Champlain College CertificateState of Vermont’s Health Care Advocate(800) 917-7787 or (802) 863-3302Vermont Department of Financial Regulations(800) 964-1784 or (802) 828-2900Wellfleet Insurance Company Customer Service (877)657-5030, TTY 711www.wellfleetstudent.com3Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANAm I Eligible?All registered full-time traditional undergraduate students (12 credits or more) will automatically be enrolled andbilled for Student Health Insurance offered by Champlain College through Wellfleet Group unless the studentcompletes an online waiver by August 1, 2021.Students enrolled in the Allied Health Program for at least 1 course, are required to participate in the Student HealthInsurance Plan unless proof of personal coverage equal to or exceeding the school Plan is provided to the College byAugust 1, 2021.How Do I Waive/Enroll?If You are eligible to be covered under this Plan, You are automatically enrolled, unless You waive coverage. Todocument proof of comparable coverage, students need to complete the online Waiver Form and submit it prior tothe start of the school year. The deadline to waive for the annual plan is August 1, 2021. To submit the online WaiverForm: Go to www.wellfleetstudent.com; Start by selecting Champlain College from the drop-down box; Next click on the Waiver tab; Review Champlain College’s Online Waiver Disclosure Acknowledgement; Click “Continue”; and proceed as directed.Effective Dates & CostsAll time periods begin at 12:00 A.M. local time and end at 11:59 P.M. local time at the Policyholder's address.Coverage PeriodCoverage Start DateCoverage End DateWaiver ------------------------------------------Plan Costs for Domestic/International Undergraduate and Graduate Students and Allied Health Program***AnnualStudent* ------*** Please note for any students not withdrawing within the time frames required by your school, coverage willbe provided for the term purchased and no refund will be allowed. This does not apply for full withdrawals dueto a sickness or injury.*The above plan costs include an administrative service fee. For questions aboutterm costs other than the Annual, please contact Champlain Admissions.4Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANPreferred Provider Organization (PPO) Network providing access to quality health care at discounted costs!By enrolling in this Plan, you have the Cigna PPO Network of participating Providers. To find a complete listing of theNetwork’s participating Providers, go to www.cigna.com, or contact Wellfleet Student toll-free at (877) 657-5030,TTY 711, or www.wellfleetstudent.com for assistance.Champlain College Schedule of BenefitsThis is only a brief description of coverage available under Certificate form VT SHIP CERT (2019). The Certificate willcontain full details of coverage, coinsurance, limitations, exclusions, and termination provisions. If there are anyconflicts between this document and the Certificate, the Certificate governs in all cases.UNLESS OTHERWISE SPECIFIED BELOW THE MEDICAL PLAN DEDUCTIBLE (IF APPLICABLE) WILL ALWAYS APPLY.SCHEDULE OF BENEFITSPreventive Services:In-Network Provider: The Deductible, Coinsurance, and any Copayment are not applicable to Preventive Services.Benefits are paid at 100% of the Negotiated Charge when services are provided through an In-Network Provider.Out-of-Network Provider: Deductible, Coinsurance, and any Copayment are applicable to Preventive Servicesprovided through an Out-of-Network Provider. Benefits are paid at 60% of the Usual and Customary Charge.Medical DeductibleIn-Network ProviderOut-of-Network ProviderIndividual:Individual: 400 400Cost sharing You incur for Covered Medical Expenses that is applied to the Out-of-Network Deductible will not beapplied to satisfy the In-Network Deductible. Cost sharing You incur for Covered Medical Expenses that is applied tothe In-Network Deductible will not be applied to satisfy the Out-of-Network Provider Deductible.Out-of-Pocket Maximum:*Combined In-Network Provider and Out-of-Network ProviderIndividual: 5,550Cost sharing You incur for Covered Medical Expenses that is applied to the Out-of-Network Provider Out-of-PocketMaximum will be applied to satisfy the In-Network Provider Out-of-Pocket Maximum and cost sharing You incur forCovered Medical expenses that is applied to the In-Network Provider Out-of-Pocket Maximum will be applied tosatisfy the Out-of-Network Provider Out-of-Pocket Maximum.*The combined amount will never exceed the federal maximum.Prescription Drug Out-of-Pocket Maximum*:In-Network ProviderIndividual: 1,350*The Prescription Drug Out-of-Pocket Maximum counts toward the overall Out-of-Pocket Maximum.5Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANCoinsurance Amounts:In-Network Provider:Out-of-Network Provider:80% of the Negotiated Charge for Covered Medical Expenses unless otherwisestated below.60% of the Usual and Customary Charge (U&C) for Covered Medical Expenses unlessotherwise stated below.Medical Benefit Payments for In-Network Providers and Out-of-Network ProvidersThe Certificate provides benefits based on the type of health care provider You select. The Certificate providesaccess to both In-Network Providers and Out-of-Network Providers. Different benefits may be payable for CoveredMedical Expenses rendered by In-Network Providers versus Out-of-Network Providers, as shown in the Schedule ofBenefits.Dental and Vision Benefit PaymentsFor dental and vision benefits, You may choose any dental or vision provider.For dental, different benefits may be payable based on the type of service, as shown in the Schedule of Benefits.Preferred Provider Organization:To locate an In-Network Provider in Your area, consult Your Provider Directory or call toll free 877-657-5030 or visitOur website at www.wellfleetstudent.com.THE COVERED MEDICAL EXPENSE FOR AN ISSUED CERTIFICATE WILL BE:1. THOSE LISTED IN THE COVERED MEDICAL EXPENSES PROVISION;2. ACCORDING TO THE FOLLOWING SCHEDULE OF BENEFITS; AND3. DETERMINED BY WHETHER THE SERVICE OR TREATMENT IS PROVIDED BY AN IN-NETWORK OR OUT-OFNETWORK PROVIDER.4. UNLESS OTHERWISE SPECIFIED BELOW THE MEDICAL PLAN DEDUCTIBLE WILL ALWAYS APPLY.BENEFITS FOR COVEREDINJURY/SICKNESSIN-NETWORK PROVIDEROUT-OF-NETWORK PROVIDERInpatient Benefits80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesPreadmission Testing80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesPhysician’s Visits whileConfined:Limited to 1 visit per day ofConfinement per provider80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesHospital CareIncludes hospital room &board expenses andmiscellaneous services andsupplies.Subject to Semi-Privateroom rate unless intensivecare unit is required.Room and Board includesintensive care.Pre-Certification Required6Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANInpatient Surgery:Pre-Certification RequiredSurgeon Services80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesAnesthetist80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesAssistant Surgeon80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesRegistered Nurse Servicesfor private duty nursingwhile Confined80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesPhysical Therapy whileConfined (inpatient)80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesSkilled Nursing FacilityBenefitPre-Certification required80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesInpatient RehabilitationFacility Expense BenefitPre-Certification Required80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesINPATIENT MENTAL HEALTH DISORDER AND SUBSTANCE USE DISORDERMental Health Disorder and 80% of the Negotiated Charge after60% of Usual and Customary Charge afterSubstance Use DisorderDeductible for Covered Medical ExpensesDeductible for Covered Medical ExpensesBenefitPre-Certification RequiredIn accordance with thefederal Mental Health Parityand Addiction Equity Act of2008 (MHPAEA), the costsharing requirements, dayor visit limits, and any Precertification requirementsthat apply to a MentalHealth Disorder andSubstance Use Disorder willbe no more restrictive thanthose that apply to medicaland surgical benefits for anyother Covered Sickness.7Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANOutpatient BenefitsOutpatient Surgery:Pre-Certification requiredSurgeon Services80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesAnesthetist80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesAssistant Surgeon80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesOutpatient Surgery Facilityand Miscellaneous expensesfor services & supplies, suchas cost of operating room,therapeutic services,oxygen, oxygen tent, andblood & plasma80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesPhysician’s Office Visits 25 Copayment then the plan pays 80% ofthe Negotiated Charge after Deductible forCovered Medical Expenses 25 Copayment then the plan pays 60% ofUsual and Customary Charge after Deductiblefor Covered Medical ExpensesSpecialist/ConsultantPhysician Services 25 Copayment then the plan pays 80% ofthe Negotiated Charge after Deductible forCovered Medical Expenses 25 Copayment then the plan pays 60% ofUsual and Customary Charge after Deductiblefor Covered Medical ExpensesTelemedicine or TelehealthServices 25 Copayment then the plan pays 80% ofthe Negotiated Charge after Deductible forCovered Medical Expenses 25 Copayment then the plan pays 60% ofUsual and Customary Charge after Deductiblefor Covered Medical ExpensesCardiac Rehabilitation80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesPulmonary Rehabilitation80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesRehabilitation Therapyincluding, Physical Therapy,and Occupational Therapyand Speech TherapyPre-Certification Required80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesHabilitative Servicesincluding, Physical Therapy,and Occupational Therapyand Speech TherapyPre-Certification Required80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical Expenses8Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANEmergency Services in anemergency department(includes Urgent Care forEmergency MedicalConditions). 100 Copayment then the plan pays 80% ofthe Negotiated Charge after Deductible forCovered Medical ExpensesPaid the same as In-Network Provider subjectto Usual and Customary Charge.Urgent Care Centers fornon-life-threateningconditions 25 Copayment then the plan pays 80% ofthe Negotiated Charge after Deductible forCovered Medical Expenses 25 Copayment then the plan pays 60% ofUsual and Customary Charge after Deductiblefor Covered Medical ExpensesDiagnostic Imaging Services80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical Expenses80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesLaboratory Procedures(Outpatient)80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesChemotherapy andRadiation Therapy80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesInfusion TherapyPre-Certification Requiredonly when administered inthe home as part of homehealth care80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesHome Health Care Expenses80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesHospice Care Coverage80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesOutpatient Private DutyNursing80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesPre-Certification RequiredCT Scan, MRI and/or PETScansPre-Certification RequiredPre-Certification RequiredPre-Certification Required9Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANOUTPATIENT MENTAL HEALTH DISORDER AND SUBSTANCE USE DISORDERMental Health Disorder andSubstance Use DisorderBenefitPre-Certification Requiredexcept for office visitsPhysician’s Office Visitsincluding, but not limited to,physician visits; individual andgroup therapy; medicationmanagement 25 Copayment then the plan pays 80% ofthe Negotiated Charge after Deductible forCovered Medical Expenses 25 Copayment then the plan pays 60% ofUsual and Customary Charge after Deductiblefor Covered Medical ExpensesAll Other Outpatient Servicesincluding, but not limited to,Intensive OutpatientPrograms (IOP); partialhospitalization; ElectronicConvulsive Therapy (ECT);Repetitive TranscranialMagnetic Stimulation (rTMS);psychiatric and neuropsychtesting80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesIn accordance with the federalMental Health Parity andAddiction Equity Act of 2008(MHPAEA), the cost sharingrequirements, day or visitlimits, and any PreCertificationrequirements that apply to aMental Health Disorder andSubstance Use Disorder willbe no more restrictive thanthose that apply to medicaland surgical benefits for anyother Covered Sickness.10Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANPrescription Drugs Retail PharmacyNo cost sharing applies to ACA Preventive Care medications filled at a participating network pharmacy.You will be notified of any changes in prescription drug coverage and can access the preferred drug list atwww.wellfleetstudent.com.TIER 1(Including Enteral Formulas)For each fill up to a 30 daysupply filled at a Retailpharmacy 15 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedSee the Enteral Formula andNutritional Supplementssection of this Schedule forsupplements not purchased ata pharmacy.More than a 30 day supplybut less than a 61 day supplyfilled at a Retail pharmacy 30 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedMore than a 60 day supplyfilled at a Retail pharmacy 45 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedTIER 2(Including Enteral Formulas)For each fill up to a 30 daysupply filled at a Retailpharmacy 30 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedSee the Enteral Formula andNutritional Supplementssection of this Schedule forsupplements not purchased ata pharmacy.More than a 30 day supplybut less than a 61 day supplyfilled at a Retail pharmacy 60 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible Waived11Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANMore than a 60 day supplyfilled at a Retail pharmacy 90 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedTIER 3(Including Enteral Formulas)For each fill up to a 30 daysupply filled at a RetailPharmacy 50 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedSee the Enteral Formula andNutritional Supplementssection of this Schedule forsupplements not purchased ata pharmacy.More than a 30 day supplybut less than a 61 day supplyfilled at a Retail pharmacy 100 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedMore than a 60 day supplyfilled at a Retail pharmacy 150 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedZero Cost Generics100% of the Negotiated Charge forCovered Medical ExpensesNot CoveredDeductible WaivedSpecialty Prescription DrugsSpecialty Prescription DrugsFor each fill up to a 30 daysupply 50 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedMore than a 30 day supplybut less than a 61 day supply 100 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible Waived12Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANMore than a 60 day supply 150 Copayment then the plan pays 100%of the Negotiated Charge for CoveredMedical ExpensesNot CoveredDeductible WaivedOrally administered anti-cancer prescription drugs (including specialty drugs)BenefitGreater of: Chemotherapy Benefit; or Infusion Therapy BenefitDiabetic Supplies (for Prescription supplies purchased at a pharmacy)BenefitPaid the same as any other Retail Pharmacy Prescription Drug FillOther Benefits80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesAllergy Injections/Treatment80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesEmergency AmbulanceService ground and/or air,water transportation80% of the Negotiated Charge afterDeductible for Covered Medical ExpensesPaid the same as In-Network Provider subjectto Usual and Customary ChargeNon-Emergency AmbulanceService ground and/or air,water transportation80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesBariatric SurgeryPre-Certification Required80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesCovered Cancer Clinical TrialsSame as any other Covered SicknessDurable Medical EquipmentPre-Certification Required80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesDiabetic services and supplies(including equipment andtraining)80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical Expenses80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesAllergy TestingRefer to the Prescription Drugprovision for diabetic suppliescovered under thePrescription Drug benefit.Dialysis Treatment13Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANHearing AidsMaternity BenefitEnteral Formulas andNutritional SupplementsTreatment shall be atleast 2,500 during anycontinuous period of 12months for any InsuredPerson.80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesSame as any other Covered Sickness80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical Expenses80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical Expenses80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesSee the Prescription Drugsection of this Schedule whenpurchased at a pharmacy.Prosthetic DevicesPre-Certification RequiredReconstructive SurgeryPre-Certification Required14Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANPediatric Dental Care Benefit(to the end of the month inwhich the Insured Personturns age 21)See the Pediatric Dental Care Benefit description in the Certificate for further information.Preventive Dental CareLimited to 2 dental examsevery 12 months100% of Usual and Customary ChargeThe benefit payable amountfor the following services isdifferent from the benefitpayable amount forPreventive Dental Care:Emergency DentalRoutine Dental CareEndodontic ServicesProsthodontic ServicesPeriodontic ServicesMedically NecessaryOrthodontic CareClaim forms must besubmitted to us as soon asreasonably possible. Refer toProof of Loss provisioncontained in the GeneralProvisions.Pediatric Vision Care Benefit(to the end of the month inwhich the Insured Personturns age 21)50% of Usual and Customary Charge50% of Usual and Customary Charge50% of Usual and Customary Charge50% of Usual and Customary Charge50% of Usual and Customary Charge50% of Usual and Customary Charge100% of Usual and Customary Charge after Deductible for Covered Medical Expenses perPolicy YearLimited to 1 visit(s) per PolicyYearand 1 pair of prescribedlenses and frames or contactlenses (in lieu of eyeglasses)per Policy YearClaim forms must besubmitted to us as soon asreasonably possible. Refer toProof of Loss provisioncontained in the GeneralProvisions.Abortion Expense80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesAccidental Injury DentalTreatment80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical Expenses15Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
CHAMPLAIN COLLEGE 2021- 2022 STUDENT HEALTH INSURANCE PLANSickness Dental Expense80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesChiropractic Care BenefitPre-Certification Required 25 Copayment then the plan pays 80% ofthe Negotiated Charge after Deductible forCovered Medical Expenses 25 Copayment then the plan pays 60% ofUsual and Customary Charge after Deductiblefor Covered Medical ExpensesGender Affirmation ServicesBenefit80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical Expenses80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesTreatment forTemporomandibular Joint(TMJ) Disorders80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesTuberculosis screening, Titers,Quantiferon B tests includingshots (other than coveredunder preventive services)80% of the Negotiated Charge afterDeductible for Covered Medical Expenses60% of Usual and Customary Charge afterDeductible for Covered Medical ExpensesSports Accident Expense incurred as the result of theplay or practice ofIntercollegiate or club sportsSame as any other Covered InjurySame as any other Covered InjuryNon-emergency Care WhileTraveling Outside of theUnited States80% of Actual Charge after Deductible for Covered Medical ExpensesSubject to 10,000 maximum per Policy YearMedical Evacuatio
Group Number: ST0824SH Effective: 8/20/2021 - 8/19/2022 GLANCE . Vermont Department of Financial Regulations . Benefits are paid at 100% of the Negotiated Charge when services are provided through an In-Network Provider. Out-of-Network Provider: Deductible, Coinsurance, and any Copayment are applicable to Preventive Services .
