CampusCare
Schedule of Benefits 2007/2008
All services must be medically necessary, authorized by a CampusCare Health Center Physician and provided at a Contracted Network Provider unless they meet emergency guidelines or as authorized by the CampusCare Medical Director. Covered medical services will be paid up to maximum and at the rates listed below.
Lifetime Maximum Benefit	$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 $20 per visit copayment
Outpatient Hospital
Emergency Expenses (within 48 hours)	100%
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 Dental	Free Annual Exam & X-ray at Network Provider
UHP Vision	Free Annual Exam at Network Provider
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