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Student Health Insurance Designed for the International Students of the. University of South Carolina International Accelerator Program

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Student Health Insurance

Designed for the International Students of the

University of South Carolina

International Accelerator

Program

2015-2016

Underwritten by:

Companion Life Insurance Company

Columbia, SC

As Policy form #BSHP-POL et al

Policy Number: 2015I5B04

Group Number: S213015

Effective: August 1, 2015 to July 31, 2016

OR

January 1, 2016 to December 31, 2016

OR

May 1, 2016 to April 30, 2017

IMPORTANT NOTICE

This brochure provides a brief description of the important features of the Policy. It is not a Policy. Terms and conditions of the coverage are set forth in the Policy. Please keep this material with your important papers.

NONDISCRIMINATORY

Health care services and any other benefits to which a Covered Person is entitled are provided on a nondiscriminatory basis, including benefits

TABLE OF CONTENTS

Where to find help?...3

Am I eligible?...3

Coverage for dependents ...3

Effective dates and cost...3

Termination of benefits ...4

Premium refund policy ...4

Extension of benefits ...4

Definitions...4-8 Preferred provider information ...8

Pre-certification policy...9

Basic Accident and Sickness Benefits...9-11 Mandated Benefits ...11

Medical Evacuation Benefit ...12

Repatriation of Remains Benefit...12

Right of Reimbursement...12

Exclusions...12-14 Claim Procedures ...14

Claim Appeal Process ...15

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WHERE TO FIND HELP

For questions about claims status, eligibility, enrollment and benefits please contact:

CONSOLIDATED HEALTH PLANS

2077 Roosevelt Avenue Springfield, MA 01104

(413) 733-4540 Toll Free (800) 633-7867

AM I ELIGIBLE?

All University of South Carolina International Accelerator Program Students are automatically enrolled in this this health insurance plan.

Students must actively attend class for at least 25 of the first 31 days after the date for which coverage is purchased. Home study, correspondence, on-line, and television (TV) courses do not fulfill the eligibility requirements. We maintain the right to investigate student status and attendance records to verify eligibility requirements have been met. If We discover the eligibility requirements have not been met, Our only obligation is to refund any premium, less any claims paid for that person.

COVERAGE FOR DEPENDENTS

Insured Students who are enrolled in the Student Health Insurance Plan may also enroll their eligible Dependents. An eligible Dependent is a spouse or a child up to age 26. Dependent eligibility expires concurrently with that of the Insured Student.

Students may also enroll their Dependents within thirty one (31) days of an eligible qualifying event. Eligible qualifying events for a Dependent are defined as birth or marriage (to the Insured Student). Students interested in enrolling their Dependents because of a qualifying event should contact Consolidated Health Plans for an enrollment form and premium information. Coverage will be effective as of the date of the qualifying event. Enrollment requests (including payments) received after the thirty one (31) days following the qualifying event will not be accepted.

EFFECTIVE DATES AND COSTS

The University of South Carolina International Accelerator Program Student Health Insurance Plan provides coverage to students for a twelve (12) month period – from 12:01 a.m. August 1, 2015, through 11:59 PM July 31, 2016.

Premium Student $2,000*

*The above student rates include an administrative fee.

TERMINATION OF BENEFITS

An Insured's coverage will end on the earliest of the date: 1. the Policy terminates;

2. the Insured is no longer eligible; or

3. the period ends for which premium is paid. A Dependent's coverage will end on the earliest of the date:

1. he or she is no longer a Dependent; 2. the Insured's coverage ends; or

3. the period ends for which premium is paid; or 4. the Policy terminates.

PREMIUM REFUND POLICY

In the event the insured student withdraws from school or reduces his/her semester hours to less than 6, within the first 30 days of the semester. We will refund any premiums paid for the student and any covered Dependents, less any claims paid.

A pro-rata refund of premium will be made only in the event:

1. the Covered Person enters full-time active duty in any Armed Forces; and

2. We receive proof of such active duty service.

EXTENSION OF BENEFITS

If a Covered Person is confined in a Hospital for a medical condition on the date his insurance ends, expenses Incurred during the continuation of that Hospital stay will be considered a Covered Expense, but only while such expenses are incurred during the 90 day period following the termination of insurance. We will not continue to pay these Covered Expenses if:

1. the Covered Person's medical condition no longer continues; 2. the Covered Person obtains other coverage; or

3. the Covered Expenses are incurred more than 3 months following termination of insurance.

DEFINITIONS

Accidentmeans a, unexpected and unintended event, which is the direct cause of an Injury. The Accident must occur while the Covered Person is insured under the Policy.

Allowable Chargemeans the charge which is the lesser of: 1) The actual charge, 2) the negotiated charge that a Preferred Provider has agreed to accept for service, or 3) the Usual and Customary Charge for a covered service.

Benefit Periodmeans a period commencing on the first date of treatment for a covered Accident or covered Sickness and continuing for a maximum period shown in the Schedule of Benefits. The term, Benefit Period; includes any Extension of Benefits shown in the Policy.

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Complications of Pregnancy means conditions which require medical treatment before pregnancy ends, and whose diagnosis is distinct from, but are caused or affected by pregnancy. Such conditions are; acute nephritis or nephrosis, cardiac decompensation; missed abortion; hyperemesis gravidarum; pre-eclampsia; non-elective cesarean section; termination of ectopic pregnancy; and spontaneous termination when a live birth is not possible. Complications of Pregnancy does not include: false labor; occasional spotting; voluntary abortion; Doctor prescribed rest during pregnancy; morning sickness; and similar conditions not medically distinct from a difficult pregnancy.

Co-payment means a fixed dollar amount that the Covered Person must pay before benefits are payable under the Policy.

Covered Accidentmeans an Accident that occurs while coverage is in force for a Covered Person and results in a loss or Injury covered by the Policy for which benefits are payable.

Covered Expenses means expenses actually incurred by or on behalf of a Covered Person for treatment, services and supplies not excluded or limited by the Policy. Coverage under the Policy must remain continuously in force from the date the Accident or Sickness occurs until the date treatment, services or supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the date such treatment, service or supply, that gave rise to the expense or the charge, was rendered or obtained.

Covered Person means any eligible person or an eligible Dependent who applies for coverage, and for whom the required premium is paid to Us.

Covered Sickness means sickness, disease or trauma related disorder due to Injury which:

1. Causes a loss while the Policy is in force; and 2. Which results in covered medical expenses.

Covered Sickness includes Mental Health Disorders and Substance Use Disorders.

Deductible means the dollar amount of Covered Expenses that must be incurred as an out-of-pocket expense by each Covered Person on a Policy Term basis before benefits are payable under the Policy.

Doctormeans a Doctor licensed to practice medicine. It also means any other practitioner of the healing arts who is licensed or certified by the state in which his or her services are rendered and acting within the scope of that license or certificate.

It will not include a Covered Person or a member of the Covered Person's Immediate Family or household.

Elective Surgery or Elective Treatment: means those health care services or supplies that do not meet the health care need for a Sickness or Injury. Elective surgery or elective treatment includes any service, treatment or supplies that:

1. are deemed by the Insurer to be research, investigative, or experimental; 2. are not generally recognized and accepted medical practices in the United

States.

Emergency Hospitalization and Emergency Medical Caremeans hospitalization or medical care: That is provided for an Injury or a Sickness caused by the unexpected onset of a medical condition with acute symptoms of sufficient severity and pain that would cause a prudent layperson with an average knowledge of health and medicine to expect that the absence of immediate medical care to result in:

1. The Covered Person's health or in the case of a pregnant woman, the health of the woman and her unborn child, being placed in serious jeopardy.

2. Serious impairment of the Covered Person's bodily functions.

3. Serious dysfunction of any of the Covered Person's bodily organs or parts.

Emergency Servicesmeans, with respect to an emergency medical condition: 1) A medical screening examination (as required under Section 1867 of the

Social Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and

2) Such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under Section 1867 of the Social Security Act (42 U.S.C. 1395dd(e)(3)).

Essential health benefits has the meaning found in Section 1302(b) of the Patient Protection and Affordable Care Act and as further defined by the Secretary of the United States Department of Health and Human Services and includes ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.

Home Countrymeans the Covered Person's country of domicile or citizenship named on the enrollment form or the roster, as applicable. However, the Home Country of an eligible Dependent who is a child is the same as that of the eligible participant.

Home Health Caremeans nursing care and treatment and Daily Living Services provided to a Covered Person in His home as part of an overall extended treatment plan. To qualify for Home Health Care Benefits:

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2. the attending Doctor that confinement in a Hospital or extended care facility would be required in the absence of Home Health Care;nursing care and treatment must be provided by a Hospital certified to provide Home Health Care services or by a certified Home Health Care agency; and 3. Daily Living Services must be approved in writing by the attending Doctor

or by the provider of the nursing care services.

"Daily Living Services" means cooking, feeding, bathing, dressing and personal hygiene services performed by a Home Health Aide, and which are necessary to the care and health of the Covered Person.

Hospice: means a public or private agency or facility which:

1. administers medically supervised written plans of physical, psychological, social and spiritual care for terminally ill individuals and their immediate family;

2. has its own staff doctors, nurses and medical and social counseling services on call 24 hours a day, 7 days a week or contracts and monitors this staff if not furnished by the hospice itself;

3. is supervised on a full-time basis by a doctor or registered nurse (RN); 4. keeps a written record of all hospice services furnished to its patients and

families;

5. makes use of trained volunteers and keeps written records of their use and cost savings;

6. is licensed or certified according to the laws of the state in which it is located; and

7. provides bereavement and medical social services.

Hospitalmeans an institution that:

1. operates as a Hospital pursuant to law for the care, treatment, and providing of in-patient services for sick or injured persons;

2. provides 24-hour nursing service by Registered Nurses on duty or call; 3. has a staff of one or more licensed Doctors available at all times; 4. provides organized facilities for diagnosis, treatment and surgery, either:

a. on its premises; or

b. in facilities available to it, on a pre-arranged basis;

5. is not primarily a nursing care facility, rest home, convalescent home, or similar establishment, or any separate ward, wing or section of a Hospital used as such.

Hospital also means a licensed alcohol and drug abuse rehabilitation facility or a mental hospital. Alcohol and drug abuse rehabilitation facilities and mental hospitals are not required to provide organized facilities for major surgery on the premises on a prearranged basis.

Hospital Confinedmeans a stay of 18 or more consecutive hours as a registered resident bed-patient in a Hospital.

Immediate Familymeans a Covered Person's parent, spouse, child, brother or sister.

Injurymeans accidental bodily harm sustained by a Covered Person that results directly and independently of disease and any bodily infirmity from a Covered Accident. All injuries sustained by one person in any one Accident, including all related conditions and recurrent symptoms of these injuries, are considered a single Injury.

Insuredmeans a person in a Class of Eligible Persons who enrolls for coverage and for whom the required premium is paid making insurance in effect for that person. An Insured is not a Dependent covered under the Policy.

International Studentis a student classified as a Non-Immigrant. For example, students holding visa types: "F" (Student), "J" (Exchange Visitor), "B" (Tourist), or "A" (Diplomat).

Medically Necessarymeans a service, drug or supply which is necessary and appropriate for the diagnosis and treatment of a Covered Injury and Covered Sickness in accordance with generally accepted standards of medical practice in the United States at the time the service, drug or supply is provided. A service, drug or supply will not be considered as Medically Necessary if, it:

1. is investigational, experimental or for research purposes;

2. is provided solely for the convenience of the patient, the patient's family Doctor, Hospital or any other provider:

3. exceeds in scope, duration or intensity the level of care that is needed to provide safe, adequate and appropriate diagnosis or treatment;

4. could have been omitted without adversely affecting the person's condition or the quality of medical care; or

5. involves the use of a medical device, drug or substance not formally approved by the United States Food and Drug Administration.

Out-of-Networkmeans a provider who has not agreed to any prearranged fee schedules. We will not pay charges in excess of the Usual and Customary Charges.

Preferred Allowance means the amount a Preferred Provider will accept as payment in full for covered medical expenses.

Preferred Provider means the Doctors, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices.

Prescription Drugs mean 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs that under the applicable state or federal law may be dispensed only upon written prescription of a Doctor; and 4) injectable insulin.

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Usual and Customary Charge (U&C) means the average amount charged by most providers for treatment, service or supplies in the geographic area where the treatment, service or supply is provided.

We, Our, Usmeans Companion Life Insurance Company, Inc., or its authorized agent.

PRE-CERTIFICATION POLICY

This plan does not require pre-certification of benefits. Please refer to the schedule of benefits section of the policy for covered benefits.

ACCIDENT AND SICKNESS EXPENSE BENEFITS

Covered Expenses are considered incurred on the date the treatment or service is rendered or the supply is furnished. Covered Medical Expenses are:

Aggregate Maximum Benefit Unlimited

Network Provider Non-NetworkProvider Deductible,per Policy Year $300 per Individual$300 Family $600 per Individual$600 Family

Coinsurance 80% of PreferredAllowance (PA) Customary (U&C)60% of Usual and Out-of-Pocket Maximum per Policy

Year $6,350 Individual$12,700 Family $20,000 Individual$40,000 Family

Student Health Center 100% Covered Medical Expenses,No Deductible Out of Country Coverage 60% of Billed Charges

INPATIENT EXPENSE BENEFIT PPO Provider Out-of-NetworkProvider Hospital Room and Board,Daily

semi-private room rate when Hospital Confined and general nursing care provided and charged for by the Hospital.

80% of PA 60% of U&C

Intensive Care We will make this payment in lieu of the semi-private

room expenses. 80% of PA 60% of U&C

Hospital Miscellaneous Expense,

expenses incurred while Hospital Confined or as a precondition for being Hospital Confined, for services and supplies such as the cost of operating room, laboratory tests, X-ray examinations, anesthesia, drugs (excluding take home drugs) or medicines, physical therapy, therapeutic services and supplies. In

80% of PA 60% of U&C

under this benefit, the date of admission will be counted but not the date of discharge.

Surgery – Multiple surgical procedures through a separate incision will be

paid at 50%. 80% of PA 60% of U&C Assistant Surgeon 80% of PA 60% of U&C

Anesthetist 80% of PA 60% of U&C

Doctor’s Visits, Limited to 1 visit per day. Does not apply when related to

surgery. 80% of PA 60% of U&C

Skilled Nursing Facility

– up to 120 days per Policy year 80% of PA 60% of U&C

Mental Health and Substance Use

Disorders Same as any other Covered Sickness OUTPATIENT EXPENSE BENEFIT

Surgery 80% of PA 70% of U&C

Day Surgery Miscellaneous 80% of PA 70% of U&C

Assistant Surgeon 80% of PA 70% of U&C

Anesthetist 80% of PA 70% of U&C

Doctor’s Visit to treat an Injury or Sickness (includes syringes and needles dispensed during a visit), Specialist Visit, Other Practitioner Office Visit, Consultant Physician, Chiropractor, Services when requested by the attending physician.

$30 copay per visit,

then 100% of PA 70% of U&C

Preventive Care and Wellness Services

(no deductible, copay, or coinsurance will apply to in-network services) www.healthcare.gov

100% of PA No Benefit

Emergency Room ExpenseInpatient

deductible applies to out-of-network $100 copay, then80% of PA $100 copay, then80% of U&C

Diagnostic X-ray Services 80% of PA 70% of U&C

Laboratory Procedures 80% of PA 70% of U&C

Rehabilitative therapies – including

Physical and Occupational Therapy 80% of PA 70% of U&C Outpatient Miscellaneous Expense 80% of PA 70% of U&C

Hospice 80% of PA 70% of U&C

Home Health Care –up to 60 visits per

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Urgent Care $50 copay per visit,then 100% of PA $50 copay per visit,then 70% of U&C Mental Health and Substance Use

Disorders Same as any other Covered Sickness

Additional Benefits

Ambulance Service 80% of PA 70% of U&C

Maternity 80% of PA 70% of U&C

Durable Medical Equipment 80% of PA 70% of U&C

Pediatric Dental 100% for Preventive Services 50% for other covered services No Benefit

Pediatric Vision Preventive Services100% for No Benefit

Intercollegiate & Club Sports No Benefit

Abortion Expense (elective) No Benefit

Prescription Drugs - must be filled at participating Cigna pharmacy. Go to

www.cigna.com

$15 copay for a 30-day supply of a generic drug ($0 copay for a 30-day supply of a generic contraceptive) or $30 copay for a 30-day supply of a preferred brand name drug; $50 copay for a 30-day

supply of a non-preferred brand

name drug

No Benefit

Medical Evacuation 100% up to $50,000 Per Policy Year

Repatriation 100% up to $50,000 Per Policy Year

COVERAGE FOR MANDATED BENEFITS

Your Student Health Insurance Plan includes, but is not limited to, benefits for the following coverages as mandated by the state of South Carolina: Dental Anesthesia and Facility; Diabetes; Prostate Cancer Screening; Autism Spectrum Disorders; Off-Label Drug Use; Mastectomy; Breast Reconstructive Surgery; and Cleft Lip and Palate. See the Policy of file at the College for benefit amounts if you need to file a claim under one of these benefits. If any Preventive Services Benefit is subject to the mandated benefit required by state law, they will be administered under the federal or state guideline, whichever is more favorable to the student.

MEDICAL EVACUATION

This benefit, as listed in the schedule of benefits, applies only to International Students and their Dependents. This benefit will pay benefits for the Covered Percentage of the Covered Expenses incurred, if any Injury of Sickness results in the Emergency Medical Evacuation of the Insured Person.

REPATRIATION OF REMAINS COVERAGE

This benefit, as listed in the schedule of benefits, applies only to International Students and their Dependents. In the event of the death of an Insured Person, We will pay the actual charges for the Covered Expenses for the preparation and transportation of the Insured Person’s remain to his or her Home County. This will be done in accord with all legal requirements in effect at the time the body remains are to be returned to his or her Home Country. The death must occur while the person is insured for this benefit.

RIGHT OF REIMBURSEMENT

If a Covered Person incurs expenses for Sickness or Injury that occurred due to the negligence of a third party: (a) We have the right to reimbursement for all benefits We have paid from any and all damages collected from the third party for those same expenses whether by action at law, settlement or compromise by the Covered person, Covered Person's parents, if the Covered Person is a minor, or Covered Person's legal representative as a result of that Sickness or Injury, and (b) We are assigned the right to recover from the third party, or his or her insurer, to the extent of the benefits paid for that Sickness or Injury.

EXCLUSIONS

Any exclusion in conflict with the Patient Protection and Affordable Care Act will be administered to comply with the requirements of the Act. The Policy does not cover nor provide benefits for:

1. Charges that are not Medically Necessary or in excess of the Usual and Customary charge.

2. Expenses in connection with services and prescriptions for eye examinations, eye refractions, eye glasses or contact lenses, or the fitting of eyeglasses or contact lenses, radial keratotomy or laser surgery for vision correction or the treatment of visual defects or problems; except as required by the Pediatric Vision Benefit. 3. Skeletal irregularities of one or both jaws including Temporomandibular Joint

Dysfunction (TMJ), orthognathia and mandibular retrognathia; nasal or sinus surgery;

4. Expenses in connection with cosmetic treatment or cosmetic surgery, except as a result of:

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b. a covered child's congenital defect or anomaly; or c. as specifically provided for in the Policy.

5. Injuries arising out of:

a. playing or participating in an interscholastic, intercollegiate, or professional sport, contest or competition;

b. traveling to or from such sport, contest or competition as a participant; or c. participation in any practice or conditioning program for such sport,

contest, or competition.

6. Drugs and medications for the treatment of impotence and/or sexual dysfunction.

7. Reproductive/Infertility procedures and fertility tests, including but not limited to: family planning, fertility tests, infertility (male or female), including any supplies rendered for the purpose or with the intention of achieving conception; premarital examinations. Examples of fertilization procedures are: ovulation induction; in vitro fertilization; embryo transplant; or similar procedures that augment or enhance the Covered Person's reproductive ability; impotence organic or otherwise.

8. Expenses incurred in connection with voluntary sterilization or sterilization reversal, vasectomy or vasectomy reversal and sexual reassignment;

9. War, or any act of war, whether declared or undeclared; service in the Armed Forces of any country. Loss which occurs during or as a result of committing or attempting to commit an assault, felony, or participation in a riot or insurrection, engaging in an illegal occupation;

10. Expenses incurred for Injury or Sickness for which benefits are paid or payable under any Worker's Compensation or Occupational Disease Law or Act, or similar legislation.

11. Treatment, services, supplies, in a Veteran's Administration or Hospital owned or operated by a national government or its agencies unless there is a legal obligation for the Covered Person to pay for the treatment.

12. Expenses incurred for dental care or treatment of the teeth, gums or structures directly supporting the teeth, including surgical extractions of teeth. This exclusion does not apply to the repair of Injuries to sound natural caused by a covered Injury, and except as specifically provided in the Hospitalization and Anesthesia for Dental Procedures expense benefit; or as required under the Pediatric Dental Benefit.

13. Expenses incurred for acupuncture;

14. Autistic disease of childhood, except as mandated by the State of South

15. Elective Surgery or Elective Treatment as defined by the Policy;

16. Foot care including: flat foot conditions, supportive devices for the foot, subluxations, care of corns, bunions (except capsular or bone surgery), calluses, toenails, fallen arches, week feet, foot strain, and symptomatic complaints of the feet, except those related to diabetic care;

17. Hearing examinations or hearing aids; or other treatment for hearing defects or problems. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process;

18. Hirsutism, alopecia;

19. Weight management, weight reduction, treatment for obesity, surgery for the removal of excess skin or fat, or nutrition programs, except as related to treatment for diabetes.

CLAIM PROCEDURES

1. Itemized medical bills should be mailed promptly to Cigna at the address listed.

SUBMIT ALL CLAIMS TO: Cigna

PO Box 188061 Chattanooga, TN 37422-8061

Electronic Payor ID: 62308

2. Direct all questions regarding benefits available under the Plan, claim procedures, status of a submitted claim or payment of a claim to Consolidated Health Plans.

CLAIMS ADMINISTRATOR:

Consolidated Health Plans

2077 Roosevelt Ave Springfield, MA 01104

Local: (413) 733-4540 or Out of area: (800) 633-7867 www.chpstudent.com

Group: S213015

Medical bills must be submitted within ninety (90) days from the date of treatment. We will pay benefits to you or a parent when a receipted bill is submitted for a covered claim. When benefits are assigned, they will be paid directly to the provider of hospital-medical care. Claim forms may be obtained from the college, if at college,

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CLAIMS APPEAL PROCESS

If a claim is wholly or partially denied, a written notice will be sent to the Insured Person containing the reason for the denial. The notice will include a reference to the provision in the Plan description and a description of any additional information which might be necessary for reconsideration of the claim. The notice will alsodescribe the right to appeal. A written appeal, along with any additional information or comments, may be sent within 6 months after notice of denial. In preparing the appeal, the Insured Person, or his or her representative, may review all documents related to the claim and submit written comments and issues related to the denial. After the written notice is filed and all relevant information is present, the claim will be reviewed and a final decision sent within 60 days after receipt of the notice of the appeal. Under special circumstances, an extension for further review will be granted, but not for longer than 60 additional days.

Claims Administrator: CONSOLIDATED HEALTH PLANS

2077 Roosevelt Avenue Springfield, MA 01104

(413) 733-4540 Toll Free (800) 633-7867

This plan is underwritten by: COMPANION LIFE INSURANCE COMPANY

COLUMBIA, SC As Policy Form No.: BSHP-POL

For a copy of the Company’s privacy notice you may go to:

www.consolidatedhealthplan.com/about/hipaa or

Request one from the Health Office at your School or

Request one from:

Companion Life Insurance Company C/O Privacy Officer

70 Genesee Street Utica, NY 13502

(Please indicate the school you attend with your written request)

Representations of the Plan must be approved by the Company.

Servicing Agent: University Health Plans, Inc.

One Batterymarch Park Quincy, MA 02169

VALUE ADDED SERVICES

The following services are not part of the Plan Underwritten by Companion Life Insurance Company. These value added options are provided by Consolidated Health Plans in partnership with Davis Vision and FrontierMEDEX.

VISION DISCOUNT PROGRAM

For Vision Discount Benefits please go to: www.chpstudent.com

WELLNESS SERVICES

Future Health www.myfuturehealth.com

EMERGENCY MEDICAL AND TRAVEL ASSISTANCE

FrontierMEDEX ACCESS services is a comprehensive program providing You with 24/7 emergency medical and travel assistance services including emergency security or political evacuation, repatriation services and other travel assistance services when you are outside Your home country or 100 or more miles away from your permanent residence. FrontierMEDEX is your key to travel security.

For general inquiries regarding the travel access assistance services coverage, please call Consolidated Health Plans at 1-800-633-7867.

If you have a medical, security, or travel problem, simply call FrontierMEDEX for assistance and provide your name, school name, the group number shown on your ID card, and a description of your situation. If you are in North America, call the Assistance Center toll-free at: 1-800-527-0218orif you are in a foreign country, call collect at: 1-410-453-6330.

If the condition is an emergency, you should go immediately to the nearest physician or hospital without delay and then contact the 24-hour Assistance Center. FrontierMEDEX will then take the appropriate action to assist You and monitor Your care until the situation is resolved.

Your out-of-pocket costs may be lower when you utilize Cigna PPO Providers. For a listing of Cigna PPO Providers, go to www.cigna.com or contact Consolidated Health Plans at (413) 733-4540, toll-free at (800) 633-7867, or www.chpstudent.com for assistance.

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