Benefits At A Glance

All services must be medically necessary, authorized by a CampusCare Health Center Physician and provided at a Contracted Network Provider unless they are authorized by the CampusCare Medical Director in order to be covered under the rates listed below.

**All members must make an appointment with one of the CampusCare Health Center Physician to recieve authorization or a referral before seeking care with a speciality physician in order to be covered under the benefits listed below.

 

There are no exclusions for pre-existing medical conditions. For additional information about benefits, limitations, and exclusions refer to the CampusCare Certificate of Coverage.

 

Covered medical services will be paid up to maximum and at the rates listed below:

 

Benefits Summary

                 Lifetime Maximum Benefit is $500,000

Benefit

Coverage*

Hospital In Network

Inpatient

Outpatient

100% minus a $50 per day co-payment Link to In Network Hospitals

100% minus a $50 co-payment

 

 

Emergency Care

In Network

100% minus a $50 co-payment Link to In Network Hospitals

Out of Network

70% minus a $50 co-payment. (100% of U/C is Usual and Customary)

Member liability 30% and $50 co-payment
(For an explanation of the U/C Usual and Customary please click here.)

Physician Services

Physician Visits In Network

100% with a $15 per office visit co-payment

Physical Therapy

100%

Preventative Health Care Service (Excludes preventative services covered by Student Health Services)

Plan Year Preventative Services Covered at First Dollar

Routine Vision Exam

No out of pocket expense when provided by select network providers;
click here to make an appointment

Ancillary Services

Ambulance

80%

Pharmacy Formulary

100% for prescriptions with:

$10 Generic co-payment

$20 Brand co-payment

$40 Non-formulary co-payment
Pharmacy Maximum benefit per year is $2,500

Diabetic Supplies and DME

90%

Home Health Care

90%

Medical Supplies (used in hospital or physician's office)

100%

Mental Health Care & Substance Abuse Care In Network

Inpatient

100% with a $50 per day co-payment Link to In Network Hospitals

Outpatient

100% with a $15 per visit co-payment