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 meet Life Threatening Emergency Care Guidelines or 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 Benefits

$500,000

Deductible

$0

Inpatient Hospital

Hospital Room and Board Expenses

100%

Inpatient Hospital Miscellaneous Expenses

100%

Mental Health Expense

100% with a $100 per day copayment

Substance Abuse

100% with a $100 per day copayment

Outpatient Hospital

Emergency Expenses (within 48 hours)

100% with a $35 copayment

Non Emergency Expenses **

100%

Mental Health

100% with a $20 per visit copayment

Substance Abuse

100% with a $20 per visit copayment

Physician Expenses

Physician Visits

100% with a $10 per office visit copayment

Consultant Expenses **

100% with a $10 per office visit copayment

Surgical Expense **

100%

Assistant Surgeon Expense

100%

Anesthetist Expense

100%

Outpatient Physician Expenses **

100%

Ancillary Service Expenses

Ambulance Expense

80%

Prescription Drugs

100% with a $10 Generic, $20 Brand &
$40 Non-formulary copayment
Maximum Benefit $2500 per year

Physical Therapy Expenses **

100%

Home Health Expenses **

90%

Durable Medical Equipment Expenses **
(including Diabetic Supplies)

90%

UHP Discounted Dental Program

Free Annual Exam & X-ray at Network Provider

UHP Discounted Vision Program

Free Annual Exam at Network Provider with purchase of eye glasses or contact lenses.

Life Coverage

$2,500

Accidental Death & Dismemberment Coverage

$2,500

** Referral from CampusCare Health Center Physician required

Refer to Certification of Coverage for complete listing of covered services, definitions, limitations & exclusions