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A medical care program of the Indian Health Service or of a tribalorganization. A state health Benefits risk pool. A health plan offered under 5 U.S.C.A. Chapter 89 (commencing withSection 8901) (Federal Employees Health Benefits Program (FEHBP)). A public health plan as defined in federal regulations authorized by Section2701(c)(1)(I) of the Public Health Service Act, as amended by Public Law104‐191, the Health Insurance Portability and Accountability Act of 1996. A health Benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C.A.Sec. 2504(e)). Any other Creditable Coverage as defined by subsection (c) of Section 2701of Title XXVII of the federal Public Health Services Act (42 U.S.C. Sec.300gg(c)).DOCTOR: A legally qualified person licensed in the healing arts and practicingwithin the scope of his or her license and is not a Family Member, including,but not limited to: any Doctor of Medicine, “MD”, or any Doctor of Osteopath,“D.O.”, who is licensed and qualified under the laws of the jurisdiction in whichtreatment is received.ELECTIVE SURGERY OR ELECTIVE TREATMENT: Means those health careservices or supplies that do not meet the health care need for a Sickness orInjury. Elective surgery or elective treatment includes any service; treatment,or supplies that 1) are deemed by the Company to be research orexperimental; or 2) are not recognized and generally accepted medicalpractices in the United States. This does not include services that are medicallynecessary.EMERGENCY: A Sickness or Injury for which immediate medical treatment issought at the nearest available facility. The Condition must be one whichmanifests itself by acute symptoms which are sufficiently severe (includingsevere pain) that a prudent layperson with average knowledge of health andmedicine could reasonably expect the absence of immediate medical attentionto result in any of the following: Placing the health of the individual or, with respect to a pregnant woman,the health of the woman or her unborn child in serious jeopardy; Serious impairment to bodily functions; or Serious dysfunction of any bodily organ or part.INJURY: Bodily Injury due to a sudden, unforeseeable, external event which: Results solely, directly, and independently of disease, bodily infirmity, orany other causes; Occurs after the Covered Person’s Effective Date of Coverage; Occurs while Coverage is in force.7All injuries sustained in any one Accident, including all related Conditions andrecurrent symptoms of these injuries, are considered a single Injury.INSURED: The Covered Person who is enrolled at and meets the eligibilityrequirements of the Policyholder’s school or Dependents of the CoveredPerson.LOSS: Medical expense that is caused by a Covered Injury or Sickness and coveredby the Policy.MENTAL ILLNESS: Any mental disorder and substance abuse disorder that islisted in the most recent revised publication or the most updated volume ofeither the Diagnostic and Statistical Manual of Mental Disorders (DSM)published by the American Psychiatric Association or the InternationalClassification of Disease Manual (ICD) published by the World HealthOrganization and that substantially limits the life activities of the person withthe illness, tobacco and caffeine are excluded from the definition of"substance". "Mental illness" does not include: (i) mental retardation, (ii)learning disorders, (iii) motor skills disorders, (iv) communication disorders,and (v) mental disorders classified as "V" codes.PRE‐EXISTING CONDITION: A Sickness or Injury for which medical care,treatment, diagnosis, or advice was received or recommended within the six(6), consecutive months prior to the Covered Person’s Effective Date ofCoverage under the Policy.PREFERRED PROVIDERS: Th e Physicians, Hospitals, and ot h er healt h careproviders who have contracted to provide specific medical care at negotiatedprices.REASONABLE AND CUSTOMARY EXPENSE (R&C): The most common charge forsimilar professional services, drugs, procedures, devices, supplies, or treatmentwithin the area in which the charge is incurred, so long as those charges arereasonable. The most common charge means the lesser of: The actual amount charged by the Provider;The negotiated rate, if any; orThe charge which would have been made by the Provider of medicalservices for a comparable service or supply made by other Providers in thesame geographic area, as reasonably determined by Ingenix for the sameservice or supply.Geographic area means the first three digits of the zip code in which theservice, treatment, procedure, drugs, or supplies are provided or a greaterarea, if necessary, to obtain a representative cross‐section of charge for a liketreatment, service, procedure, device, drug, or supply.Reasonable charges, fees, or expenses as used herein to describe expense, willbe considered to mean the percentile of the payment system in effect on theEffective Date of this Plan.8

SICKNESS: Illness, disease, pregnancy, and Complications of Pregnancy. Allrelated Conditions and recurrent symptoms of the same or a similar Conditionwill be considered the same Sickness.WE, OUR, AND US: Nationwide Life Insurance Company.YOU, YOUR, YOURS: The covered person.PRE-EXISTING CONDITIONS LIMITATIONThere is no Coverage for Pre‐existing Conditions unless the Covered Person hashad six (6) months of Continuous Coverage. The Covered Person must provideUs proof of prior Creditable Coverage.This limitation will not apply if, during the period immediately preceding theCovered Person’s Effective Date of Coverage under this Policy, the CoveredPerson was covered under prior Creditable Coverage for six (6) consecutivemonths. Prior Creditable Coverage of less than six (6) months will be creditedtoward satisfying the Pre‐existing Condition limitation. This waiver of Pre‐existing Conditions will apply only if the Covered Person becomes eligible andapplies for Coverage within sixty‐three (63) days of termination of his or herprior Coverage.Pregnancy, including Complications of Pregnancy maternity care and geneticdisorders, shall not be considered a Pre‐existing Condition under the Policy.PREFERRED PROVIDER INFORMATIONThe URI Student Healt h Insurance Plan provides access to hospitals and healt hcare providers who participate in Preferred Provider Networks bot h locally andacross t h e country. The advantage of using Preferred Providers is t h at t h eseproviders have agreed to accept a predetermined fee or Preferred Allowanceas payment in full for t h eir services. Consequently, when Insured Persons usePreferred Providers, out‐of‐pocket expenses will be lower because anyapplicable coinsurance will be based on a Preferred Allowance.The Insured Person should be aware t h at Preferred Provider Hospitals mightbe staffed wit h Out‐of‐Network Providers. As a result, receiving services orcare from an Out‐of‐Network Provider at a Preferred Provider Hospital doesnot guarantee t h at all charges will be paid at t h e Preferred Provider level ofbenefits. The participation of specific providers in t h e Preferred ProviderNetworks is subject to change wit h out notice. Insured Persons should alwaysconfirm when making an appointment t h at t h e provider participates in aPreferred Provider Network.First Health Network is t h e Preferred Provider Network and provides access toproviders located across t h e United States. To determine if a providerparticipates in First Healt h , students can call (800) 226‐5116 or visitwww.firsthealth.com. It is important t h at Insured Persons verify t h at t h eirproviders are Preferred Providers each time t h ey call for an appointment or att h e time of service.9“Preferred Providers” are t h e Physicians, Hospitals and ot h er healt h careproviders who have contracted to provide specific medical care at negotiatedprices.“Preferred Allowance” (PA) means t h e amount a Preferred Provider willaccept as payment in full for covered medical expenses.“Network Area” means t h e 40‐mile radius around t h e local school campust h e Named Insured is attending.“Out‐of‐Network” providers have not agreed to any prearranged feeschedules. Insureds may incur significant out‐of‐pocket expenses wit h t h eseproviders. Charges in excess of t h e insurance payment are the Insured’sresponsibility.Regardless of t h e provider, each Insured is responsible for t h e payment oft h eir Deductible. The Deductible must be satisfied before benefits are paid.The Company will pay according to t h e benefit limits in t h e Schedule ofBenefits.MATERNITY TESTINGThis Policy does not cover routine, preventive or screening examinations ortesting unless Medical Necessity is established based on medical records. Thefollowing maternity routine tests and screening exams will be considered, if allother policy provisions have been met; a pregnancy test, CBC, Hepatitis BSurface Antigen, Rubella Screen, Syphilis Screen, Chlamydia, HIV, Gonorrhea,Toxoplasmosis, Blood Typing ABO, RH Blood Antibody Screen, Urinalysis, UrineBacterial Culture, Microbial Nucleic Acid Probe, AFP Blood Screening, PapSmear, and Glucose Challenge Test (at 24‐28 weeks gestation). One Ultrasoundwill be considered in every pregnancy, without additional diagnosis. Anysubsequent ultrasounds can be considered if a claim is submitted with thePregnancy Record and Ultrasound report that establishes Medical Necessity.Additionally, the following tests will be considered for women over 35 years ofage: Amniocentesis/AFP Screening; and Chromosome Testing. FetalStress/Non‐Stress tests are payable. Pre‐natal vitamins are not covered. Foradditional information regarding Maternity Testing, please call ConsolidatedHealth Plans (CHP) at 1‐800‐633‐7867.PRE-CERTIFICATION POLICYThis plan does not require pre‐certification of benefits. Please refer to theschedule of benefits section of the policy for covered benefits.EXTENSION OF BENEFITSThe coverage provided under this policy ceases on the Termination Date.However, if an Insured is hospital confined on the termination date from acovered Injury or Sickness for which Benefits were paid before the terminationdate, covered medical expenses for such Injury or Sickness will continue to be10

paid for a period of twelve (12) months or until the date of discharge,whichever occurs first.The total payments made in respect to the Insured for such condition bothbefore and after the termination date will never exceed the Maximum Benefit.After this “Extension of Benefits” provision has been exhausted, all benefitscease to exist, and under no circumstances will further payments be made.SCHEDULE OF MEDICAL EXPENSE BENEFITSINJURY & SICKNESSPer Injury & Sickness Lifetime Maximum Benefit - 150,000The Policy provides benefits for the Reasonable and Customary (R&C) Charges incurredby an Insured Person for loss due to a covered Injury or Sickness up to a MaximumBenefit of 150,000 for each Injury or Sickness. In no event will the total combinedbenefits for any one Injury or Sickness (either in a single policy term or throughcontinuing policy term coverage) exceed the Policy Maximum Benefit of 150,000.If care is received from an In‐Network Provider, any Covered Medical Expenses will bepaid at the Preferred Provider level of benefits. If the Covered Medical Expense isincurred due to a Medical Emergency or a Preferred Provider is not located within the40‐mile range or the hospital or health care facility is a PPO but its emergency staff isnot, benefits will be paid at the Preferred Provider level of benefits. In all othersituations, reduced or lower benefits will be provided when an Out‐of‐Networkprovider is used.Covered Medical Expenses at URI Health Services are paid at 100% (deductible doesnot apply).Benefits will be paid up to the Maximum Benefit for each service as shown in theschedule below. All benefit maximums are combined Preferred Provider and Out‐of‐Network, unless otherwise noted below. Covered Medical Expenses vidersPer Injury & Sickness Maximum Benefit 150,000Deductible (Per Insured Person, Per Policy 0 200Year)Hospital Expense BenefitHospital Room and Board, daily semi‐privateroom rate, general nursing care provided by theHospital, or Intensive Care Unit (ICU)Hospital Miscellaneous Expense, including t h ecost of t h e operating room, laboratory tests, x‐ray examinations, anest h esia, drugs (excludingtake‐home drugs) or medicines, t h erapeuticservices, and supplies. Including Skilled Nursingand Sub‐Acute CareRoutine Newborn Care, as part of PostpartumCare within the 48/96 hour maximum. IncludingPKU Testing and Treatment.1190% of PA90% of PA60% of R&C60% of R&CIn‐Hospital Doctor’s Fees and Medical Expense,Limited to 1 visit per day. Does not apply whenrelated to surgery.Registered Nurse, private duty nursing care.Pre‐Admission TestingPhysiotherapyMental Illness, limited to 90 consecutive daysSubstance Abuse- Limited to 30 days of Community ResidentialCare services within a policy year (orpartial/day treatment program not to exceedabove benefit).- Detoxification benefits will be paid for up tofive (5) detoxification occurrences or thirty(30) days in any policy year, whichever comesfirst.Surgical Expense Benefits (Inpatientor Outpatient)Surgeon’s Fees, in accordance with dataprovided by Fair Health, Inc. If two or moreprocedures are performed through the sameincision or in immediate succession at the sameoperative session, the maximum amount paidwill not exceed 50% of the second procedureand 50% of all subsequent proceduresAssistant SurgeonAnesthetistOutpatient BenefitsDay Surgery Miscellaneous, services related toscheduled surgery performed in a Hospital,including the cost of the operating room;laboratory tests and x‐ray examinations,including professional fees; anesthesia; drugs ormedicines; and supplies.Outpatient Miscellaneous, including UrgentCare services.Physician Visits, includes annual routinephysicals, hearing tests, speech tests, GYN visits,allergists, and dermatology. Benefits forPhysician Visits do not apply when related tosurgery or Physiotherapy. (The out‐ of‐ networkper visit deductible is in addition to the PolicyDeductible).Paid as any ot h er Sickness1290% of PA60% of R&C80% of PA60% of R&CPaid under Hospital Miscellaneous90% of PA60% of R&C90% of PA60% of R&C90% of PA60% of s90% of PA60% of R&C20% of Surgeon’s Fee75% of Charges75% of iders90% of PA60% of R&C90% of PA60% of R&C 20 co‐pay pervisit, then90% of PA100% atUniversityHealth Services(no co‐pay/deductible) 30 deductibleper visit, then60% of R&C

Outpatient Benefits (cont’d)Eye Exam, limited to one (1) annual routine eyeexam. (The out‐of‐network deductible is inaddition to the Policy Deductible).Chiropractic Care, limited to twelve (12)treatments per Policy Year. (The out‐of‐networkper visit deductible is in addition to the Policydeductible).Physiotherapy/Occupational Therapy, limitedto one (1) visit per day.In‐NetworkProviders 20 co‐pay,then 90% of PAOut‐of‐NetworkProviders 30 deductible,then 60% ofR&C 20 co‐pay pervisit, then90% of PA 30 deductibleper visit, then60% of R&C90% of PA60% of R&C90% of PAImmunizations and/or titersSTI ScreeningMedical Emergency Expenses, use of theEmergency Room and supplies. Treatment mustbe rendered within 72 hours from the time ofInjury or first onset of Sickness. (The out‐of‐network per visit/deductible is in addition to thePolicy Deductible. Co‐pay/per visit deductiblewill be waived if admitted within 24 hours).Diagnostic X‐ray & Laboratory Services,includes Radiation Therapy and Chemotherapy,CAT Scans, MRIs and PET Scans.Injections, when administered in the Physician’soffice and charged on the Physician’sstatement.Tests & Procedures, Diagnostic services andmedical procedures performed by a Physician,other than Physician’s visits, Physiotherapy, x‐rays and laboratory procedures. IncludingDialysis and Filtration Procedures.Mental Illness, Outpatient Services, exceptoutpatient Medication Visits, up to thirty (30)visits per policy year. (The out‐of‐network pervisit deductible is in addition to the Policydeductible).Outpatient Substance Abuse Treatment, paidup to thirty (30) hours per Policy Year. (The out‐of‐network per visit deductible is in addition tothe Policy deductible).100% atUniversityHealth Services90% of PA60% of R&C100% atUniversityHealth Services60% of R&C 50 co‐pay pervisit, then90% of PA 50 deductibleper visit, then60% of R&C90% of PA60% of R&CPaid under OutpatientMiscellaneousPaid under OutpatientMiscellaneous 20 co‐pay pervisit, then 90%of PA 30 deductibleper visit, then60% of R&C 20 co‐pay pervisits, then 90%of PA 30 per visitdeductible then60% of R&C13Prescription DrugsAdditional BenefitsAmbulance ServicesDurable Medical Equipment, Braces, andAppliances, a written prescription must besubmitted with the claim. Replacementequipment is not covered.Physician Consultant Fees, when requested andapproved by the attending Physician.Dental Treatment, Benefits paid for Injury toSound, Natural Teeth and removal of impactedwisdom teeth only. 150 per tooth for simple extraction; 250 per tooth for complication extraction;or 300 per tooth for repair due to a coveredInjury.Maternity, 48 hours vaginal/96 hours cesareanHospital confinement expense maximum.Complications of PregnancyVolun

University of Rhode Island 2011‐2012 Underwritten by: Nationwide Life Insurance Company Columbus, OH Policy Number: 302‐040‐3809 International: August 15, 2011 to August 14, 2012 Domestic: September 1, 2011 to August 31, 2012 IMPORTANT NOTICE This brochure provides a brief description of the important features of the Policy.