Insurance for Domestic Students

Insurance Policy Details

The information below is a synopsis of the Blue Cross Blue Shield policy information, and is subject to change. For the most up-to-date information, view the online brochure at Blue Cross Blue Shield.

Plan 1 $100,000 lifetime maximum per insured person, per policy year
Plan 2 $500,000 lifetime maximum per insured person, per policy year
$300 deductible per insured person per policy year
80/20 payment for PPO Network services (excluding prescriptions)*
60/40 payment for Non-network services (excluding prescriptions)*
100% for preventive services
100% medical evacuation and repatriation costs
Dental insurance is optional please visit the Blue Cross Blue Shield website for more information
There is no maximum on the prescription benefit

* After deductible is met, Blue Cross Blue Shield pays 80% of remaining eligible costs that were accrued using medical staff and/or services listed with theBlue Cross Blue Shield Options PPO network. The student pays 20%. If the student uses staff and/or services not listed on the Blue Cross Blue Shield network, the student pays a higher percentage of the bill, 40% of Usual and Customary charges plus 100% or any charges above Usual and Customary prices. It benefits you financially to stay within the assigned network.

A Primary Care Physician (PCP) can treat most illnesses. If the PCP decides that a specialist needs to be consulted, the PCP can issue a referral to you. In order for the insurance company to cover a consultation fee with a specialist, you must have a referral from your PCP or the Student Health Center (SHC). Without the referral, coverage for a specialist consultation fee will be denied by the insurance company. To obtain a referral from the SHC, call (972) 883-2747 and schedule an appointment.

Prescription Benefits

There is not a maximum on the prescription benefit. You must purchase the prescription in full from a pharmacy of your choice. You may then file a claim for reimbursement through Prime Therapeutics. To get the most of out of your prescription benefit, ask your doctor if generic drugs are available. For more information about filing a claim, see claims page.

Proof of Insurance Card

Blue Cross Blue Shield sends one card per school year to policyholders. In your first semester of coverage you should receive an insurance card 2-4 weeks after Census Day. (Because eligibility for the UT Dallas Student Health Insurance Plan is contingent upon enrollment at UT Dallas, insurance cards cannot be sent until all students are officially registered, which is Census Day.) You may also print a card from the Blue Cross Blues Shield website at that time. If you need to see a doctor between the start of the semester and Census Day, you may obtain an Interim Coverage letter from the insurance office.

Policy Cost and Coverage Dates

2012-2013 Academic Year

Student Health Insurance Coverage
Period name	Coverage dates	Student	Spouse	All children	Student, Spouse & All Children
Fall 2012	8/19/12-1/13/13	$472	$1,374	$742	$2,588
Spring 2012	1/14/13-5/29/13	$445	$1,296	$700	$2,441
Summer 2012	5/30/13-8/18/13	$287	$835	$451	$1,573

Exclusions and Limitations

Inform yourself about the Exclusions and Limitations of this policy at Blue Cross Blue Shield (page 24-25)

Examples of Exclusions:

Assistant surgeon fees
Acne
Dental
Vision
Hearing

Examples of Limitations:

No more than one surgical procedure will be covered when multiple procedures are performed through the same incision or in immediate succession
Outpatient physical therapy except for a condition that required surgery or a hospital confinement

Also, allergy medicines are covered and included in the $1,000 maximum under prescription drugs. Benefits for treatment of sexually transmitted diseases are covered up to $500 maximum per policy year, etc.

Optional Major Medical Coverage

This coverage covers up to $400,000 of additional eligible medical expenses over the basic benefit maximum of $100,000 and is only available for purchase at the time of initial enrollment in the SHI Plan. For more details, view the online brochure at Blue Cross Blue Shield.

Optional Major Medical Coverage
Period name	Coverage dates	Student	Spouse	Each Child	Student, Spouse & One Child
Annual 2012-2013*	8/19/12-8/18/13	$648	$648	$648	$1,944