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Schedule of Benefits

These benefits are only a preview and do not give verification of coverage.

Student Only Schedule of Benefits 2017-2018

Wheaton College Accident and Illness 
COVERAGE PERIOD August 1, 2017 through July 31, 2018
Claims and Coverage ASRM - 844.898.8944 - iees@asrmllc.com
Insurance Company BCS Insurance Company
Preferred Medical Provider Network (within USA only) www.multiplan.com  (not required, but best discount)
Pharmacy Network - Express Scripts (required to use) To locate network pharmacy, visit www.express-scripts.com
Enrollment, Coverage and Premium Agent First Agency/Bryan Cronen - bcronen@1stagency.com
MONTHLY PREMIUM 
$129/month  Billed August 1-December 31st and January 1st-July 31st 
DEDUCTIBLES PER COVERAGE PERIOD
At Student Health Services (SHS) No deductibles, coinsurance or co-pays (except prescription co-pays)
Non-SHS services $100 per person/coverage period
PRE-EXISTING CONDITION 
Limitation or exclusion None
ANNUAL MAXIMUMS
Out-of-pocket maximum cost for participating providers $5,000/person; $12,500/family per year
Policy Maximum Benefit $100,000 for medical treatment; $2,000 for prescriptions 
HOSPITAL SERVICES
Inpatient medical care 80% covered after deductible
Hospice care 80% covered after deductible
Home health care 80% covered after deductible; must follow confinement of 3 days 
PHYSICIAN MEDICAL SERVICES
Hospital and skilled nursing facility visits 80% covered after deductible
Surgeon and surgeon assistant; anesthesiologist or anesthetist 80% covered after deductible
Office visits in Student Health Service No copay or deductible
Office visits at other primary care, specialists and consultants $25 co-pay then 80% covered
Physical therapy, physical medicine, occupational therapy, speech therapy $25 co-pay then 80% covered
Chiropractic, osteopathic manipulation $25 co-pay then 80% covered
GENERAL MEDICAL SERVICES
Radiology & diagnostics (as covered by the plan) 80% covered after deductible; some labs covered 100% at SHS 
Durable medical equipment 80% covered after deductible; covered 100% at SHS 
PREVENTIVE CARE
Travel vaccines  100% at SHS  pursuant to SHS protocols
Specified immunizations for college entrance (Tdap/Td series; MMR series, meningococcal vaccine)  100% at SHS
Not covered outside of SHS 
Tuberculosis Screening (Skin test or blood test) 100% at SHS  pursuant to SHS protocols
College entrance physical exams  100% at SHS  pursuant to SHS protocols
Routine gynecological exams, including Pap Smears and mammograms 80% covered after deductible; at SHS 100%, within frequency guidelines
Colorectal cancer screening 80% covered after deductible
EMERGENCY CARE, AMBULANCE AND URGENT CARE
Emergency services and supplies  $150 co-pay then 80% covered, waived if admitted
Urgent care center $25 co-pay then 80% covered
Ambulance Services 80% covered after deductible 
Emergency Health Evacuation (via United Health Care) 100% covered
PREGNANCY and MATERNITY CARE
Physician office visits (pre-natal) $25 co-pay then 80% covered
Inpatient services 80% covered after deductible
BEHAVIORAL HEALTH/SUBSTANCE USE DISORDER
Outpatient services $25 co-pay then 80% covered after deductible
Inpatient services 80% covered after deductible
Psychotherapy $25 co-pay then 80% covered after deductible
PRESCRIPTION DRUGS
At SHS Pharmacy $10 co-pay for generic; $50 co-pay for brand-name Rx
At Retail Pharmacy (in Express Scripts network) $20 co-pay for generic; $50 co-pay for brand-name Rx
Plan year maximum Capped at $2,000 
ROLE OF STUDENT HEALTH SERVICE (SHS) Primary source of care - In-network and eligible for reimbursement