Medical Insurance

This link will take you to Medical Insurance Waivers, Applications, Enrollment, and Claim Forms.

• Privacy Policy
• Boston College Student Injury and Sickness Insurance Plan 2006-2007
• Student Eligibility and Enrollment
• Waiver Procedure
• Dependent Eligibility and Enrollment
• Effective and Termination Dates
• Policy Terms and Plan Cost
• Withdrawals
• EyeMed Vision Care Plan
• Dental Savings Program
• Benefits Payable
• Preferred Provider Network
• Definitions
• Pre-Existing Conditions
• Schedule of Benefits
• Medical Expense Benefits
• Benefits for Treatment of Drug Abuse
• Prescription Drug Program
• Intercollegiate Sports
• Students Going Abroad
• Assist America Global Emergency Medical Services
• Mandated Benefits
• Excess Provision
• Exclusions and Limitations
• Medical Emergency Treatment
• Accidental Death and Dismemberment Benfits
• Extension of Benefits After Termination
• Complaint Resolution
• Claim Procedure
• Certificate of Coverage
• Questions? More Information?

PRIVACY POLICY

From The MEGA Life and Health Insurance Company (MEGA). We know that your privacy is important to you and we strive to protect the confidentiality of your nonpublic personal information. We do not disclose any nonpublic information about our customers or former customers to anyone, except as permitted or required by law. We believe we maintain appropriate
physical, electronic and procedural safeguards to ensure the security of your nonpublic personal information. You may obtain a copy of Our (MEGA?s) Privacy Practices by calling toll-free at 800-767-0700 or visiting their website at http://www.studentresources.com.

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BOSTON COLLEGE STUDENT INJURY AND SICKNESS INSURANCE PLAN

The following is an outline of the insurance which is provided under a blanket policy issued to Boston College. The policy is underwritten by The MEGA Life and Health Insurance Company and is administered by Koster Insurance Agency. The claims administrator is Klais and Company, Inc. This brochure is a brief digest of the coverage of the policy. It is not the policy. Only the actual provisions of the policy which will be in the possession of the College will apply. This brochure should be retained by you when you enroll in the program.

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STUDENT ELIGIBILITY AND ENROLLMENT

Full-Time Students
Students enrolled at least 75% of full-time and all students enrolled in a degree program, regardless of the number of credit hours, are required by state law and Boston College to be covered under this plan, unless the student submits the required Waiver Information. Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased. Home study, correspondence, internet, and television (TV) courses do not fulfill the eligibility requirements that the student actively attend classes. The Company maintains its right to investigate student status and attendance records to verify that the policy eligibility requirements have been met. If the Company discovers that the policy eligibility requirements have not been met, its only obligation is refund of premium.

Students who are not citizens or permanent residents of the U.S. will automatically be enrolled in the Boston College plan regardless of the number of credit hours for which they are enrolled.

Non Degree Part-time Students
Non degree students registered at the credit levels listed below will be automatically enrolled in the plan and charged by BC. Failure to maintain these credit levels will result in the termination of the mandatory Boston College Student Injury and Sickness Insurance Plan. It is the student's responsibility to monitor their eligibility status.

• Graduate Woods College of Advancing Studies?7 or more
• Graduate Arts and Sciences?7 or more
• Graduate Education?7 or more
• Graduate Management?7 or more
• Graduate Nursing?7 or more
• Graduate Social Work?7 or more
• Woods College of Advancing Studies Undergraduate?9 or more

Please note that students who register for Doctoral Continuation only are considered full-time and will be automatically charged for this insurance unless waiver information is submitted by the deadline.

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WAIVER PROCEDURE

Students who do not want to be enrolled in the Student Injury and Sickness Insurance Plan, can waive the student insurance plan by providing proof of comparable coverage electronically through Agora. In order to show proof of comparable coverage, students need to log on to, http://agora.bc.edu and complete the online Waiver Form. Students may begin waiving the insurance for 2006-2007 on April 16, 2006. All Waiver Forms must be submitted by October 4, 2006 for the first semester and for newly enrolled students for the second semester by February 7, 2007. Students who do not complete a Waiver Form by the deadline will be billed the ?Student Only? premium and enrolled in the Plan. If you waive the insurance at the beginning of the first semester it will be waived for the entire year. If you wish to obtain the Boston College Student Injury and Sickness Insurance Plan for the second semester, you must go to Student Services prior to the second semester waiver deadline and request to have the waiver removed by completing a Petition to Add form.

Please Note: If the student is under the age of 18, the student may not use the automated system. A written Waiver Form is required and must be signed by the parent or guardian and student. A written Waiver Form is available at http://www.bc.edu/studentservices/.

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DEPENDENT ELIGIBILITY AND ENROLLMENT

Insured Students may also enroll their eligible dependents. Dependent means the spouse (husband and wife) of the Named Insured and their dependent, unmarried children and any Newborn Infant of a dependent of the Named Insured. Children shall cease to be dependent on the first to occur of: 1) The end of the month in which they marry; or, 2) The end of the month in which they attain the age of 19 years. The attainment of the limiting age will not terminate the coverage of such child while the child is and continues to be both: 1) Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and, 2) Chiefly dependent upon the Insured Person for support and maintenance. Proof of such incapacity and dependency shall be furnished to the Company: 1) by the Named Insured; and, 2) within 31 days of the child?s attainment of the limiting age. Subsequently, such proof must be given to the Company annually following the child?s attainment of the limiting age. If a claim is denied under the policy because the child has attained the limiting age for dependent children, the burden is on the Insured Person to establish that the child is and continues to be handicapped as defined by subsections (1) and (2).

It is the student?s responsibility to ensure timely enrollment of eligible dependents each policy year. Previously insured dependents must be re-enrolled by the deadlines in order to avoid a break in coverage. Dependents are not automatically reenrolled. Students can enroll their eligible dependents by obtaining a Dependent Enrollment Form at the Boston College Health Services Primary Care Center (Cushing Hall 117) or by downloading a Dependent Enrollment Form on the Web at http://www.bc.edu/studentservices/ and submitting it and the applicable premium by the deadline to Koster Insurance Agency, or by submitting an online Dependent Enrollment Form. To submit dependent information online, go to http://www.kosterweb.com, select Boston College from the drop down box and then select the 2006 2007 Dependent Enrollment Form. Students can contact Koster Insurance Agency at 800-457-5599 or by email at BCstudentinsurance@kosterins.com.

The deadlines for dependent enrollment are October 4, 2006 for the first semester and February 7, 2007 for the second semester. Dependent coverage terminates concurrent with that of the Insured Student. Coverage for dependents begins on the later of the following: the beginning date of the semester policy term or the date payment is received at Koster Insurance Agency. Please be aware that Dependent Enrollment Forms and payments not received by the deadlines may result in a break in coverage and Dependents may be subject to the Pre-existing Condition Limitation.

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EFFECTIVE AND TERMINATION DATES

The Master Policy on file at the School becomes effective on August 7, 2006 and terminates on August 6, 2007. Coverage for the first semester under this policy begins on August 7, 2006 and terminates on January 14, 2007. Coverage for the second semester begins on January 15, 2007 and terminates on August 6, 2007.

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POLICY TERMS AND PLAN COST

Students will be billed the ?Student Only? amount and enrolled in the insurance plan unless a Waiver Form has been completed before the semester billing.

This is a Non-Renewable One Year Term Policy.

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WITHDRAWALS

All premiums are payable in advance for each policy term in accordance with the Company?s premium rates. The full premium must be paid even if the correct premium is received after the policy Effective Date. There is no pro-rata or reduced premium payment for late enrollees. If you withdraw from Boston College and receive a 100% refund of tuition, you will receive a full cancellation of this insurance premium. If you withdraw from Boston College, and receive a pro-rated refund of tuition, your coverage will remain in effect until the end of the period for which you have paid a premium. In this instance you will not receive a cancellation of the insurance premium. All full-time student premium cancellations will be generated by the Student Services Office at Boston College. Dependent refunds will be generated by Koster Insurance Agency. There will be no pro-rated refunds to students who cancel coverage under the policy unless the Insured enters the armed forces.

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EYEMED VISION CARE PLAN

The discount vision plan is available through EyeMed Vision Care. EyeMed?s provider network consists of over 20,000 independent providers and retail stores nationwide, including LensCrafters, Target and Pearle Vision. You will receive a separate EyeMed ID card. There is no waiting period; you can take advantage of EyeMed ID card. You can purchase brand name prescription eyeglasses, conventional contact lenses or even non-prescription sunglasses at savings between 15% to 45% off regular retail pricing. In addition, you can receive discounts from 5% to 15% off laser correction surgery at some of the nation?s most highly qualified laser correction surgeons. To locate a 5 participating provider, you can call 1-866-8EYEMED or go online at http://www.enrollwitheyemed.com (and select the Access Plan.) This plan is not underwritten by The MEGA Life and Health Insurance Plan.

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DENTAL SAVINGS PROGRAM

The Dental Savings Program is an exclusive plan for students enrolled in the Student Injury and Sickness Insurance Plan. The program is operated by Basix, LLC to provide students access to general and specialty dental care from a select network of local dentists. The network of providers have met strict credentialing and quality assurance requirements. The network of participating dental providers have agreed to accept negotiated prices for the services they provide. Students will be responsible for paying for services they receive at the time of the visit. Students will generally save from 20% to 50% of charges for a wide range of dental services ? from routine cleanings to root canals. Because the Dental Savings Program is not insurance, there are no claim forms, annual maximums, benefit limitations and conditions or other plan provisions. Students can log onto the website, www.basixstudent.com to locate participating dental providers, download the fee schedule and learn more about the Program. This plan is not underwritten by The MEGA Life and Health Insurance Plan.

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BENEFITS PAYABLE

All benefits are payable without discrimination for all Insured Persons under this Plan. Benefits are currently mandated by state and federal law are contained within these benefit provisions.

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PREFERRED PROVIDER NETWORK

The Boston College Student Injury and Sickness Insurance Plan provides access to hospitals and health care providers locally in New England (MA, CT, RI, ME, VT, and NH) through the Health Care Value Management (HCVM) Preferred Provider Network, and outside of New England and nationally through the CCN Preferred Provider Network. These networks allow students to have greater access to Preferred Providers whether they are on campus or traveling across the United States. The advantage to using a Preferred Provider is that Preferred Providers have agreed to accept a predetermined fee or Preferred Allowance as payment for their services. Consequently, when Insured Persons use Preferred Providers, out-ofpocket expenses will be less because any applicable co-payments will be based on a Preferred Allowance. The Insured Person should be aware that Preferred Provider Hospitals may be staffed with Out-of-Network Providers. Receiving services or care from an Out-of6 Network Provider at a Preferred Hospital does not guarantee that all charges will be paid at the Preferred Provider level of benefits..

?Preferred Providers? are the Physicians, Hospitals and other health care providers who participate in HCVM and CCN. The availability of specific providers is subject to change. Insured?s should always confirm that a Preferred Provider is participating at the time of services and/or by asking the provider when making an appointment for services. HCVM is owned by CCN, and the most efficient and accurate way to determine if a provider participates in either HCVM or CCN, is to call CCN toll-free at 1-888-685-7774 or visit http://www.ccnusa.com.

?Preferred Allowance? means the amount a Preferred Provider will accept as payment in full for Covered Medical Expenses.

?Out of Network? providers have not agreed to any prearranged fee schedules. Insured?s may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are the Insured?s responsibility.

?Network Area? means the geographic service area approved by the Massachusetts Division of Insurance. Regardless of the provider, each Insured is responsible
for the payment of their Deductible. The Deductible must be satisfied before benefits are paid. The Company will pay according to the benefit limits in the Schedule of Benefits.

?Preferred Hospitals? ? Eligible inpatient Hospital expenses at a Preferred Hospital will be paid at 100%, up to any limits specified in the Schedule of Benefits. Call CCN toll-free at 1-888-685-7774 for information about participating Hospitals.

?Out-of-Network Hospitals? ? If care is provided at a Hospital that is not a Preferred Provider, eligible inpatient Hospital expenses will be paid according to the benefits limits in the Schedule of Benefits.

?Outpatient Hospital Expense? ? Preferred Providers may discount your bills for outpatient hospital expenses. Benefits are paid according to the Schedule of Benefits. You pay any amount that exceeds the benefits shown on the Schedule of Benefits, up to the Preferred Allowance.

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DEFINITIONS

ADOPTED OR ADOPTIVE CHILD means 1) a child from the date of the filing of a petition to adopt who has been residing in the home of the Insured as a foster child and the Insured has been receiving foster care payments, provided the person adopting the child is insured under the policy on the date the petition is filed; or 2) a child from the date of placement by a licensed placement agency for purposes of adoption in the home of the Insured provided the person adopting the child is insured under this policy on the date the child is placed with the Insured. Such child will be covered under the policy for the first 31 days after: 1) date of the filing of a petition to adopt a foster child; or 2) date of placement of a child for purposes of adoption. The Insured will have the right to continue such coverage for the child beyond the first 31 days. To continue the coverage the Insured must a) apply to the Company, and b) pay the required additional premium (if any) for the continued coverage within 31 days after: 1) filing of a petition to adopt; or 2) date of placement for purposes of adoption. If the Insured does not use this right as stated here, all coverage as to that child will terminate at the end of the first 31 days after date of 1) filing of a petition to adopt; or 2) date of placement of a child for purposes of
adoption.

COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in excess of Usual and Customary Charges; 2) not in excess of the maximum benefit amount payable per service as specified in the Schedule of Benefits; 3) made for services and supplies not excluded under the policy; 4) made for services and supplies which are a Medical Necessity; 5) made for services included in the Schedule of Benefits; and 6) in excess of the amount stated as a Deductible, if any. Covered Medical Expenses will be deemed ?incurred? only: 1) when the covered services are provided; and 2) when a charge is made to the Insured Person for such services

DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or any endorsement to this policy as a Deductible, it shall mean an amount to be subtracted from the amount or amounts otherwise payable as Covered Medical Expenses before payment of any benefit are made. The Deductible will apply per policy year or per occurrence (for each Injury or Sickness) as specified in the Schedule of Benefits.

ELECTIVE SURGERY AND 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 Company to be research or experimental; or 2) are not recognized and generally accepted medical practices in the United States.

EXPERIMENTAL OR INVESTIGATIVE TREATMENT means a service, supply, procedure, device or medication that meets any of the following:

1. without the approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished or to be furnished; or
2. a treatment, or the ?informed consent? form used with a treatment, that was received and approved by the treating facility?s institutional review board or other body servicing a similar function, or federal law requires such review or approval; or
3. reliable evidence shows that the treatment is the subject of ongoing Phase I or Phase II clinical trails; is the research, experimental, study or investigative arm of ongoing Phase III clinical trail; or is otherwise under study to determine its safety, efficacy, toxicity, maximum tolerated dose, or is efficacy as compared with a standard means of treatment or diagnosis; or ongoing Phase III clinical trail; or is otherwise under study to determine its safety, efficacy, toxicity, maximum tolerated dose, or is efficacy as compared with a standard means of treatment or diagnosis; or
4. reliable evidence shows that prevailing opinion among experts regarding the treatment is that more studies or clinical trails are necessary to determine its safety, efficacy, toxicity, maximum tolerated does, or its efficacy as compared with a standard means of treatment or diagnosis.
   

   Reliable evidence, as used in this definition, means only published reports and articles in the authoritative peer-reviewed medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same treatment; or the written informed consent form used by the treating facility or by another facility studying substantially the same treatment.

HOSPITAL means a licensed or properly accredited general hospital which: 1) is open at all times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured persons as inpatients; 3) is under the supervision of a staff of one or more legally qualified Physicians available at all times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; and 6) is not primarily a clinic, nursing, rest or convalescent home.

HOSPITAL CONFINED/HOSPITAL CONFINEMENT means confined in a Hospital for at least 18 hours by reason of an Injury or Sickness for which benefits are payable.

INJURY means bodily injury which is: 1) directly and independently caused by specific Accidental contact with another body or object; 2) unrelated to any pathological, functional, or structural disorder; 3) a source of loss; 4) treated by a Physician within 30 days after the date of Injury; and 5) sustained while the Insured Person is covered under this policy. All injuries sustained in one Injury, including all related conditions and recurrent symptoms of these injuries will be considered one injury. Injury does not include loss which results wholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered Medical Expense incurred as a result of an injury that occurred prior to this policy?s Effective Date will be considered a Sickness under this policy.

INSURED PERSON means: 1) the Named Insured; and, 2) Dependents of the Named Insured, if: 1) the Dependent is properly enrolled in the program, and 2) the appropriate dependent premium has been paid. The term ?Insured? also means Insured Person.

INTENSIVE CARE means: 1) a specifically designated facility of the Hospital that provides the highest level of medical care; and 2) which is restricted to those patients who are critically ill or injured. Such facility must be separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement. They must be: 1) permanently equipped with special life-saving equipment for the care of the critically ill or injured; and 2) under constant and continuous observation by nursing staff assigned on a full-time basis, exclusively to the intensive care unit. Intensive care does not mean any of these step-down units: 1) Progressive care; 2) Sub-acute intensive care; 3) Intermediate care units; 4) Private monitored rooms; 5) Observation units; or 6) Other facilities which do not meet the standards for intensive care.

MEDICAL EMERGENCY means a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possess an average knowledge of health and medicine, to result in: 1) placing the health of the Insured Person in serious jeopardy; 2) serious impairment to body function or serious dysfunction of any body organ or part; or 3) with respect to a pregnant woman, the health of the woman or her unborn child.

MEDICAL NECESSITY or MEDICALLY NECESSARY means those services or supplies provided or prescribed by a Hospital or Physician which are: 1) Essential for the symptoms and diagnosis or treatment of the Sickness or Injury; 2) Provided for the diagnosis, or the direct care and treatment of the Sickness or Injury; 3) In accordance with the standards of good medical practice; 4) Not primarily for the convenience of the Insured, or the Insured?s Physician; and, 5) The most appropriate supply or level of service which can safely be provided to the Insured. The Medical Necessity of being Hospital Confined means that: 1) the Insured requires acute care as a bed patient; and, 2) the Insured cannot receive safe and adequate care as an outpatient. This policy only provides payment for services, procedures and supplies which are a Medical Necessity. No benefits will be paid for expenses which are determined not to be a Medical Necessity, including any or all days of Hospital Confinement.

MENTAL AND NERVOUS DISORDER means a Sickness that is a mental, emotional or behavioral disorder. If not excluded or defined elsewhere in the policy, all diagnoses classified as a ?Mental Disorder? according to the (International Classification of Diseases) are considered one Sickness.

NAMED INSURED means an eligible, registered student of the Policyholder, if: 1) the student is properly enrolled in the program; and 2) the appropriate premium for coverage has been paid.

NEWBORN INFANT means any child born of an Insured or of the Insured?s Dependent while that person is insured under this policy. Newborn Infants will be covered under the policy for the first 31 days after birth. Coverage for such a child will be for Injury or Sickness, including medically diagnosed congenital defects, birth abnormalities, prematurely and nursery care; benefits will be the same as for the Insured Person who is the child?s parent.

The Insured will have the right to continue such coverage for the child beyond the first 31 days. To continue the coverage the Insured must, within 31 days after the child?s birth: 1) apply to the Company; and 2) pay the required additional premium, if any, for the continued coverage. If the Insured does not use this right as stated here, all coverage as to that child will terminate at the end of the first 31 days after the child?s birth.

PHYSICIAN means a legally qualified licensed practitioner of the healing arts who provides care within the scope of his/her license, other than a member of the Insured person?s immediate family. This includes but is not limited to certified registered nurse anesthetists, nurse practitioners, certified nurse midwives, podiatrists, chiropractors, optometrists or any other legally licensed practitioner of the healing arts who is practicing within the scope of his/her license. Physician?s eligible for reimbursement under the terms of this policy shall include pediatric specialty care Physicians, including mental health care, by Physicians with recognized expertise in specialty pediatrics to eligible Insureds requiring such services. The term ?member of the immediate family? means any person related to an Insured Person?s within the third degree by the laws of consanguinity or affinity.

PHYSIOTHERAPY means any form of the following: physical or mechanical therapy; diathermy; ultra-sonic therapy; heat treatment in any form; manipulation or massage prescribed by a Physician.

PRESCRIPTION DRUGS means: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a Physician; and 4) injectable insulin.

REGISTERED NURSE means a professional nurse (R.N.) who is not a member of the Insured Persons? immediate family.

SICKNESS means sickness or disease of the Insured Person which causes loss while the Insured Person is covered under this policy. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. Covered Medical Expenses uncured as a result of an Injury that occurred prior to this policy?s Effective Date will be considered a sickness under this policy.

SOUND, NATURAL TEETH means natural teeth, the major portion of the individual tooth is present, regardless of fillings or caps; and is not carious, abscessed or defective.

USUAL AND CUSTOMARY CHARGES means a reasonable charge which is: 1) usual and customary when compared with the charges made for similar services and supplies; and 2) made to persons having similar medical conditions in the locality of the Policyholder. No payment will be made under this policy for any expenses incurred which in the judgment of the Company are in excess of Usual and Customary Charges.

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PRE-EXISTING CONDITIONS

A Pre-Existing condition means any condition (1) which manifested itself during the (six) 6 months immediately preceding the Insured?s Effective Date of coverage under this policy and would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or for which medical advice, diagnosis, care or treatment was recommended or received; or (2) pregnancy existing on the Insured?s Effective Date of coverage under this policy.

If the Insured had at least 6 months of prior comparable coverage in effect to a date not more than thirty days prior to the effective date under this policy, then the pre-existing condition will be covered under this policy on the same basis as any other Injury or Sickness. If the Insured had no prior comparable coverage in effect to a date not more than thirty days prior to the effective date of coverage under this policy, then coverage for a pre-existing condition for the first six (6) months of coverage under this policy will be limited to a maximum of $2,500. The six (6) month Pre-existing Condition limitation requirement will be reduced by the period of time the Insured Person was covered under a previous health plan in effect 30 days prior to the effective date of coverage under this Plan. After the Insured has been enrolled under the Student Injury and Sickness Insurance Plan for six (6) months or more, the preexisting condition will be covered the same as any other Injury or sickness.

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SCHEDULE OF BENEFITS

MEDICAL EXPENSE BENEFITS - INJURY AND SICKNESS BENEFITS

Coinsurance for Preferred Providers is 100% of Preferred Allowance and 80% of Usual and Customary (U&C) to Out-of-Network Providers. The Policy provides benefits as shown below for loss incurred by an Insured Person due to a covered Injury or Sickness. If you receive care from a Preferred Provider, any Covered Medical Expenses will be paid at the applicable Preferred Provider level of benefits. If a Preferred Provider is not available in the Network Area, benefits will be paid at the level of benefits shown as Preferred Provider benefits. If the Covered Medical Expense is incurred due to a Medical Emergency Treatment, benefits will be paid at the Preferred Provider level of benefits. (See Medical Emergency Treatment on page 36 for additional information) In all other situations, reduced, or lower benefits will be provided when an Out-of-Network provider is used. The Benefits Payable are as defined in and subject to all provisions of this Policy and any endorsements thereto. Benefits will be paid up to the Maximum Benefit identified for each service below. Although the Maximum Benefit per Injury or Sickness is $100,000, there are some specific benefit limitations as identified on the Schedule.

These benefits may be subject to a Pre-Existing Condition limitation.

OUTPATIENT BENEFITS	PREFERRED PROVIDERS	OUT OF NETWORK PROVIDERS
Surgery. In accordance with data provided by Ingenix, Inc. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum paid will not exceed the benefit for the one of such procedures for which the largest benefit is payable, unless medically necessary.	100% of the Preferred Allowance up to a maximum of $5,000 per procedure	80% of U&C Charges up to a maximum of $5,000 per procedure
Assistant Surgeon	30% of the Surgery Allowance	30% of the Surgery Allowance
Anesthetist. Professional services in connection with outpatient surgery	30% of the Surgery Allowance	30% of the Surgery Allowance
Day Surgery Miscellaneous. Related to scheduled surgery performed in a hospital including the cost of the operating room, laboratory tests and x-ray examinations, professional fees, anesthesia, drugs or medicines, and supplies. Usual and customary charges based on the Outpatient Surgical Facility Charge Index.	100% of the Preferred Allowance up to a maximum of $5,000 per procedure	80% of U&C Charges up to a maximum of $5,000 per procedure
High Cost Procedure Expense. For outpatient procedures costing over $200, included but not limited to CAT Scan, MRI, Laser Treatments, Radiation and Chemotherapy	100% of Preferred Allowance up to $5,000	80% of U&C Charges up to $5,000
Outpatient Miscellaneous Expense. Includes physician office visit, hospital outpatient department or emergency room, diagnostic x-rays, laboratory services, diagnostic tests and procedures, consultant visits and injections (excluding allergy and immunizations ? refer to Wellness Program).Durable Medical Equipment (when requested and approved by attending physician. Written prescription must accompany claim when submitted)	After the following co-payments, covered at 100% of Preferred Allowance up to $1,500 per Injury or Sickness: $20 Office Visit $100 Emergency Room (waived if admitted) $35 Hospital Outpatient Department	After the following co-payments, covered up to 80% U&C Charges up to $1,500 per Injury or Sickness: $20 Office Visit $100 Emergency Room (waived if admitted) $35 Hospital Outpatient Department
Physiotherapy (Physical Therapy), when prescribed by the attending physician and limited to one visit per day	100% of Preferred Allowance up to $500	80% of U&C Charges up to $500
Prescription Drugs. Prescriptions must be filled at a MEDCO participating pharmacy. Contact http://www.medcohealth.com for participating pharmacies. Deductible does not apply	$10 co-payment for a 30-day supply of generic or $25 co-payment for a 30-day supply for preferred brand name drugs or $45 co-payment for a 30-day supply of a non-preferred brand name drug up to $1,000 per policy year	If a Non-MEDCO pharmacy is used, you will need to pay for prescriptions and submit receipts for reimbursement based on MEDCO?s preferred pricing

MENTAL DISORDERS TREATMENT BENEFIT and ALCOHOL TREATMENT BENEFIT (See Benefits for Treatment of Mental Disorders)

Benefits Payable - all benefits are payable without discrimination for all Insured Person under this plan. Benefits currently mandated by state and federal law are contained within the benefit provisions.

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MEDICAL EXPENSE BENEFITS?INJURY AND SICKNESS

Benefits are payable for Covered Medical Expenses (see ?Definitions?) less any Deductible incurred by or for an Insured Person for loss due to Injury or Sickness subject to: a) the Maximum Benefit for all services; b) the maximum amount for specific services; both as set forth in the Schedule of Benefits; and c) any coinsurance amount set forth in the Schedule of Benefits or any endorsement hereto. The total payable for all Covered Medical Expenses shall never exceed the Maximum Benefit stated in the Schedule of Benefits. Read the ?Definitions? section and the ?Exclusions and Limitations? section carefully. No benefits will be paid for services designated as ?No Benefits? in the Schedule of Benefits or for any matter described in ?Exclusions and Limitations.? If a benefit is designated, Covered Medical Expenses include:

INPATIENT EXPENSE BENEFITS

The following benefits are payable when the insured Person is confined as a resident patient in a licensed hospital:

Room and Board: 1) daily semi-private room rate when Hospital Confined; and 2) general nursing care provided and charged by the Hospital.

Hospital Miscellaneous: 1) while Hospital Confined; or 2) as a precondition for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; X-ray examinations; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies. In computing the number of day?s payable under this benefit, the date of admission will be counted, but not the date of discharge. In computing the number of day?s payable under this benefit, the date of admission will be counted but not the date of discharge.

Intensive Care: As provided in the Schedule of Benefits.

Routine Newborn Care: See Benefits for Maternity, Childbirth, Well-Baby and Post Partum Care.

Physiotherapy: Paid under Hospital Miscellaneous.

Surgery: Physician?s fees for inpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed the benefit for the one of such procedures for which the largest benefit is payable unless medically necessary.

Assistant Surgeon Fees: In connection with inpatient surgery as provided in the Schedule of Benefits.

Anesthetist Services: Professional services administered in connection with inpatient surgery as provided in the Schedule of Benefits.

Registered Nurse?s Services: 1) private duty nursing care only; 2) while Hospital Confined; 3) ordered by a licensed Physician; and 4) a Medical Necessity. General nursing care provided by the Hospital is not covered under this benefit.

Physician?s Visits, when Hospital Confined. Benefits do not apply when related to surgery.

Pre-Admission Testing: limited to routine tests such as: complete blood count; urinalysis; and chest X-rays. If otherwise payable under the policy, major diagnostic procedures such as: cat-scans; NMR?s; and blood chemistries will be paid under the ?Hospital Miscellaneous? benefit. This benefit is payable within 7 working days prior to admission.

Skilled Nursing Facility: The Company will pay up to $75 per day for up to ten (10) days for confinement as an in-patient in a nursing home or rehabilitation facility per Injury or sickness following a period of hospitalization. Payment for confinement in the Boston College Health Services Primary Care Center will not require a prior period of hospitalization.

OUTPATIENT EXPENSE BENEFITS

The following benefits are payable on an outpatient basis.

Surgery: Physician?s fees for outpatient surgery. Payment will be made based upon the surgical schedule as specified in the Schedule of Benefits. If two or more procedures are performed through the same incision or in immediate succession at the same operative session, the maximum amount paid will not exceed the benefit for the one of such procedures for which the largest benefit is payable unless medically necessary.

Assistant Surgeon Fees: In connection with outpatient surgery as provided in the Schedule of Benefits.

Anesthetist Services: Professional services administered in connection with outpatient surgery as provided in the Schedule of Benefits.

Day Surgery Miscellaneous (Outpatient): In connection with outpatient day surgery; excluding non-scheduled surgery; and surgery performed in a Hospital emergency room; trauma center; Physician?s office; or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests and X-ray examinations, including professional fees; anesthesia; drugs or medicines; therapeutic services; and supplies..

Outpatient Miscellaneous Expense: The following services will be under the Outpatient Miscellaneous Benefit as designated on the Schedule of Benefits: physician?s visits, hospital outpatient department, hospital emergency room, diagnostic x-rays, laboratory services, diagnostic tests and procedures, medical emergencies, consultant visits.

Medical Emergency (Outpatient): only in connection with a Medical Emergency as defined. Benefits will be paid for the attending Physician?s charges, X-rays, laboratory procedures, injections, the use of the emergency room and supplies. Treatment must be rendered within 72 hours from time of Injury or first onset of Sickness.

Injections (Outpatient): 1) when administered in the Physician?s office; and 2) charged on the Physician?s statement. Injections do not include immunizations or allergy injections ? refer to Wellness benefit.

Consultant Physician Fees: when requested and approved by the attending Physician, paid under Outpatient Miscellaneous.

High Cost Procedures Expense: For specific procedures in excess of $200.00, up to a maximum of $5,000 per Injury or Sickness. Covered Charges include, but are not limited to, charges for: C.A.T. Scan, Magnetic Resonance Imaging, Ultrasound, and Laser Treatment performed on an outpatient basis. This benefit is payable in addition to any benefit payable under the Outpatient Miscellaneous Expense.

Radiation and Chemotherapy: benefits are limited to one visit per day and covered under High Cost Procedures Expense.

Physiotherapy: Benefits are limited to one visit per day.

OTHER EXPENSE BENEFITS

Ambulance Services: Benefits payable for emergency transportation of a medical emergency as provided on the Schedule of Benefits

Wellness Program: Examinations, immunizations, and tests are for the prevention of disease, reimbursement will be made as provided on the Schedule of Benefits.

Second Surgical Opinion: Consultation only for a second written surgical opinion as to necessity of surgery when requested and approved by the attending Physician.

Accidental Dental Treatment: 1) performed by a Physician; and, 2) made necessary by Injury to Sound, Natural Teeth. Breaking a tooth while eating is not covered. Routine dental care and treatment to the gums are not covered.

Sickness Dental Expense: For the extraction of boneimpacted wisdom teeth.

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BENEFITS FOR TREATMENT OF DRUG ABUSE

Benefits will be paid for the treatment of Drug Abuse, subject to all terms and conditions of the policy and the provisions of this endorsement.

1. Benefits will be paid for confinement as an inpatient in an accredited or licensed Hospital, a residential treatment program, or in any other public or private facility thereof providing services especially for the treatment of Drug Abuse and which is licensed by the Department of Public Health for those services. Benefits will not exceed a maximum of 30 days in any policy year.
   
2. Outpatient benefits for treatment of Drug Abuse shall not exceed a maximum of $500.00 over a 12-month period. Services must be furnished by an accredited or licensed Hospital, any public or private facility or portion thereof providing services especially for the treatment of Drug Abuse and which is licensed by the Department of Public Health for those purposes. Consultants or treatment sessions furnished by such a facility in this provision shall be rendered by a Physician who devotes a substantial portion of his/her time treating Drug Abuse.

Benefits shall be subject to all Deductible, copayment, coinsurance, limitations or any other provisions of the policy.

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PRESCRIPTION DRUG PROGRAM

The outpatient prescription drug benefit is available through the MEDCO Pharmacy Network and includes national pharmacy chains such as CVS, Walgreens, and Brooks, and local independent pharmacies, and is based on their national preferred drug formulary as well as a 3-tier co-payment structure. After a per prescription co-payment of $10.00 for a 30-day supply of a generic
drug or a $25.00 co-payment for a 30-day supply of a preferred brand name drug, or a $45 co-payment for a 30-day supply of a non-preferred brand drug, the Expenses incurred for the cost of prescription drugs will be reimbursed at 100% up to the maximum of $1,000.00 per policy year. In order to maximize your benefits under this prescription plan, we encourage you to ask your physician to consult the drug formulary. Insured Students will be given an ID Card to show to the pharmacy as proof of coverage. If a prescription needs to be filled prior to receiving the ID card,
reimbursement will be made upon submitting a completed Rx claim form (claims forms can be obtained from Koster Insurance Agency or online at http://www.bc.edu/studentservices/. Within the first 90 days of the policy year, students seeking reimbursement without having their ID card, will be reimbursed for the full amount paid for the prescription less the copayment. After the first 90 days, students not using their ID card will be reimbursed at the retail price less both the copayment amount and the MEDCO discounted amount that would have been applied had the ID card been used. MEDCO Pharmacies can be located by calling 1-800-711-0917 or by visiting http://www.medcohealth.com. In accordance with the Massachusetts State Mandate, Outpatient hormone replacement therapy for premenopausal and postmenopausal women and outpatient contraceptive drugs and devices are covered. Please refer to Exclusions and Limitations for medications not covered.

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INTERCOLLEGIATE SPORTS

If an Insured Person sustains an accidental injury whileparticipating in the play or practice of an intercollegiate sport sponsored by Boston College, the Company will pay up to a maximum of $1,000 for medical or surgical treatment or hospitalization, except that injury to sound natural teeth is limited to $500 for any one Injury. This plan also provides up to $1,000 for Accidental Death and Dismemberment and Loss of Sight Benefit as a result of injury sustained while participating in the play or practice of an intercollegiate sport sponsored by Boston College. All varsity athletic injuries must be reported immediately to the Boston College Athletic Trainer. The benefits and the maximum amounts are specified in the Schedule of Benefits and endorsement attached hereto, if so noted in the Schedule of Benefits

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STUDENTS GOING ABROAD

Whether studying or traveling abroad, the Student Injury and Sickness Insurance Plan provides the same benefits as if you were on campus at Boston College. When outside of the United States, you will likely be asked to pay for your medical care first and then will need to seek reimbursement. Covered Medical Expenses will be reimbursed on an out-of-network basis. When you submit claims for reimbursement, you will need to have the itemized bill(s) translated into English and include a letter informing the claims administrator that you are seeking reimbursement for charges previously paid. Please insure that your name, ID number, address (to receive your reimbursement check), and the College?s name are on the bill.

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ASSIST AMERICA GLOBAL EMERGENCY MEDICAL SERVICES

If you are a student insured with this insurance plan, you and your insured spouse and minor child(ren) are eligible for Assist America services. The requirements to receive these services are as follows:

International Students, insured spouse and insured minor child(ren): You are eligible to receive Assist America services worldwide, except in your home country.

Domestic Students, insured spouse and insured minor child(ren): You are eligible for Assist America services when 100 miles or more away from your campus address or 100 miles or more away from your permanent home address or while participating in a Study Abroad program.

Assist America services include Emergency Medical Evacuation and Return of Mortal Remains. The Emergency Medical Evacuation services are not meant to be used in lieu of or replace local emergency services such as an ambulance requested through emergency 911 telephone assistance. All Assist America services must be arranged and provided by Assist America prior to receiving services in order for these services to be covered.

Key Services include:

• Medical Consultation, Evaluation and Referral
• Foreign Hospital Admission Guarantee
• Emergency Medical Evacuation
• Critical Care Monitoring
• Medically Supervised Repatriation
• Prescription Assistance
• Transportation to Join Patient
• Care for Minor Children Left Unattended Due to a Medical Incident
• Return of Mortal Remains
• Emergency Counseling Services
• Lost Luggage or Document Assistance
• Interpreter and Legal Referrals

To access services, please call:
(877) 488-9833 Toll-free within the United States
(609) 452-8570 Collect outside of the United State Services are also accessible via e-mail at medservices@assistamerica.com

Please visit http://www.Kosterweb.com for the Assist America Global Emergency Medical Services brochure which includes service descriptions and program exclusions and limitations.

Services are also accessible via e-mail at medservices@assistamerica.com

When calling Assist America?s Operations Center, please be prepared to provide:

1. Caller?s name, telephone and (if possible) fax number, and relationship to the patient
2. Patient?s name, age, sex, and Reference Number (found on student?s ID card)
3. Description of the patient?s condition
4. Name, location, and telephone number of hospital, if applicable
5. Name and telephone number of the attending physician
6. Information of where the physician can be immediately reached

Assist America is not travel or medical insurance but a service provider for emergency medical assistance services. All medical costs incurred should be submitted to your health plan and are subject to the policy limits of your health coverage. All assistance services must be arranged and provided by Assist America. Claims for reimbursement for services not provided by Assist America will not be accepted. Please refer to your Assist America brochure for Program Guidelines as well as limitations and exclusions pertaining to the Assist America program.

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MANDATED BENEFITS

BENEFITS FOR ALCOHOLISM TREATMENT

Benefits will be paid the same as any other Sickness for the treatment of Alcoholism subject to the following:

1. Inpatient benefits will be limited to a maximum of 30 days in any policy year when an Insured is confined in an accredited or licensed Hospital or in any other public or private facility thereof providing services especially for the detoxification or rehabilitation of intoxicated persons or alcoholics and which is licensed by the Department of Public Health for those services, or in a residential alcohol treatment program as referred to in section 24 of chapter 90 of the Massachusetts Insurance Laws.
2. Outpatient benefits will be limited to a maximum of $500.00 over a 12-month period for services furnished by: 1) an accredited or licensed Hospital; or 2) by any public or private facility or portion thereof providing services especially for the rehabilitation of intoxicated persons or alcoholics and which is licensed by the Department of Public Health for those purposes. Consultants or treatment sessions furnished by a facility in this clause shall be rendered by a Physician or psychotherapist fully licensed under the provisions of Chapter 112 of the Massachusetts Insurance Laws who devotes a substantial portion of his time treating intoxicated persons or alcoholics.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR BONE MARROW TRANSPLANTS FOR TREATMENT OF BREAST CANCER

Benefits will be paid the same as any other Sickness for a bone marrow transplant or transplants for Insureds who have been diagnosed with breast cancer that has
progressed to metastatic disease. Insureds must meet the criteria established by the Department of Public Health and which are consistent with medical research protocols reviewed and approved by the National Cancer Institute.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR CARDIAC REHABILITATION

Benefits will be paid the same as any other Sickness for Cardiac Rehabilitation. Cardiac Rehabilitation shall mean multidisciplinary, Medically Necessary treatment of persons with documented cardiovascular disease, which shall be provided in either a Hospital or other setting and which shall meet standards promulgated by
the commissioner of public health. Benefits shall include, but not be limited to, outpatient treatment which is to be initiated within twenty-six (26) weeks after diagnosis of such disease.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR CYTOLOGIC SCREENING AND MAMMOGRAPHIC EXAMINATIONS

Benefits will be paid the same as any other Sickness for: 1) an annual cytologic screening for women eighteen (18) years of age or older; and 2) a baseline mammogram for women between the ages thirty-five (35) and forty (40) and for an annual mammogram for women forty (40) years of age and older.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR DEPENDENT CHILDREN EARLY INTERVENTION SERVICES

Benefits will be paid the same as any other Sickness for early intervention services for Dependent children from birth to their third birthday. Certified early intervention specialists in accordance with an early intervention program approved by the Department of Public Health and in accordance with the applicable certification requirements shall provide early intervention services. Maximum benefit per policy year for such services shall not exceed $5,200 for each Dependent child and a Maximum Lifetime Benefit of $15,600 per child.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR DEPENDENT CHILDREN PREVENTIVE CARE

Benefits will be paid for the Usual and Customary Charges for those preventive and primary services delivered or supervised by a Physician that are rendered to a Dependent child of an Insured from the date of birth through the attainment of six years of age. Benefits include physical examination, history, measurements, sensory screening, neuropsychiatric evaluation and development screening, and assessment at the following intervals: six times during the child?s first year after birth, three times during the next year, annually until age six. Benefits shall also include hereditary and metabolic screening at birth, appropriate immunizations, and tuberculin tests, hematocrit, hemoglobin or other appropriate blood tests, and urinalysis as recommended by the Physician. Benefits
shall include those special medical formulas which are approved by the commissioner of the Department of Public Health, prescribed by a Physician, and are Medically Necessary for treatment of phenylketonuria, tyrosinemia, homocystinuria, maple syrup urine disease, propionic acidemia, or methylmalonic acidemia in infants and children.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR ENTERAL FORMULA

Benefits will be paid the same as any other Sickness for nonprescription enteral formulas for home use when a Physician has issued a written order for such formula and when Medically Necessary for the treatment of malabsorption caused by Crohn?s disease, ulcerative colitis, gastroesophageal reflux, gastrointestinal motility, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids. Benefits for inherited diseases of amino acids and organic acids shall include food products modified to be low protein limited to $2,500 annually for any Insured Person. Benefits are provided for formulas that are taken orally as well as those that are administered by tube. Benefits shall be subject to a co-payment for a 30-day supply of enteral formula that is equal to the co-payment required for outpatient Physician Visits.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR HOME HEALTH CARE SERVICES

Benefits will be paid the same as any other Sickness for Home Health Care Services. Additional services such as occupational therapy, speech therapy, medical social work, nutritional consultation, the services of a home health aid and the use of durable medical equipment and supplies shall be provided to the extent such services are determined to be a Medically Necessary component of said nursing and physical therapy. Benefits for Home Health Care Services are payable only when such services are Medically Necessary and provided in conjunction with a Physician approved Home Health Care Services plan. Durable medical equipment and supplies provided as part of anapproved Home Health Care Services Plan will not be subject to any policy limitations regarding durable medical equipment and supplies. ?Home health care services? means health care services for an Insured Person by a public or private home health agency which
meets the standards of service of the purchaser of service, provided in a patient?s residence; provided, however, that such residence is neither a hospital nor an institution primarily engaged in providing skilled nursing or rehabilitation services. Said services shall include, but not be limited to, nursing and physical therapy.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR HOSPICE CARE

When an Insured Person is diagnosed with a covered Injury or Sickness, and therapeutic intervention directed toward the cure of the Injury or Sickness is no longer appropriate, and the Insured?s medical prognosis is one in which there is a life expectancy of six months or less as a direct result of such Injury or Sickness, benefits will be payable for the Usual and Customary Charges for services and supplies for hospice care prescribed by a Physician and provided by a licensed hospice agency, organization or unit. This benefit does not cover non-terminally ill patients who may be confined in: a convalescent home, rest or nursing facility; a skilled nursing facility; a rehabilitation unit or a facility that provides treatment for persons suffering from mental disease or disorders, or care for the aged, drug addicts, or alcoholics. For this benefit to be payable, a written statement from the attending Physician that the Insured is terminally ill within the terms of this benefit and a written statement from the hospice certifying the days on which services were provided must be furnished to the Company.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR HUMAN LEUKOCYTE ANTIGEN OR HISTOCOMPATIBILITY LOCUS ANTIGEN TESTING

Benefits will be paid the same as any other Sickness for human leukocyte antigen testing or histocompatibility locus antigen testing that is necessary to establish bone marrow transplant donor suitability for potential donors for Insured Persons. Benefits shall include the costs of testing for A, B or DR antigens, or any combination thereof, consistent with rules, regulations and criteria established by the Department of Public Health.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR INFERTILITY TREATMENT

Benefits will be paid the same as any other Sickness for the diagnosis and treatment of infertility for persons residing within the Commonwealth of Massachusetts to the same extent that benefits are provided for other pregnancy-related procedures. Benefits will include, but not be limited to, the following Non-experimental Infertility Procedures:

1) Artificial Insemination (AI); 2) In Vitro Fertilization and Embryo Placement (IVF-EP); 3) Gamete Intra-Fallopian Transfer (GIFT); 4) Sperm, egg and/or inseminated egg procurement, processing and banking, to the extent such costs are not covered by the donor?s insurer, if any; 5) Intracytoplasmic Sperm Injection (ICSI) for the treatment of male factor infertility; and 6) Zygote Intrafallopian Transfer (ZIFT). Benefits are not provided for the following Experimental Infertility Procedures: 1) Any Experimental Infertility Procedure, until the procedure becomes recognized as nonexperimental and is so recognized by the Commissioner; 2) Surrogacy; 3) Reversal of Voluntary Sterilization; and 4) Cryopreservation of eggs.

?Infertility? means the condition of a presumably healthy individual who is unable to conceive or produce
conception during a period of one (1) year.

?Non-experimental Infertility Procedures? means a procedure which is: 1) recognized as such by the American Fertility Society (AFS) or the American College of Obstetrics and Gynecology (ACOG) or another infertility expert recognized as such by the Commission; and 2) incorporated as such in this provision by the Commissioner after a public hearing pursuant to M.G.L. c.30A. ?Experimental Infertility Procedures? means a procedure not yet recognized as non-experimental. Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of thepolicy, except that any pre-existing condition exclusion or waiting period shall not apply to benefits for infertility treatment.

BENEFITS FOR INITIAL PROSTHETIC DEVICE AND RECONSTRUCTIVE SURGERY

Benefits will be paid the same as any other Sickness for a Mastectomy and the initial prosthetic device or reconstructive surgery incident to the Mastectomy. Benefits shall be provided for reconstructive surgery on a nondiseased breast to produce a symmetricalappearance. Reconstructive surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy. When a Mastectomy is performed and there is no evidence of malignancy, benefits will be limited to the cost of the prosthesis or reconstructive surgery to within 2 years after the date of the Mastectomy. ?Mastectomy? means the removal of all or part of the breast for Medically Necessary reasons as determined by a licensed Physician.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR MATERNITY, CHILDBIRTH, WELL-BABY AND POST PARTUM CARE

Benefits will be paid the same as any other Sickness for the expense of prenatal care, childbirth and post partum care. Benefits will be provided for a minimum of forty-eight hours of in-patient care following a vaginal delivery and a minimum of ninety-six hours of in-patient care following a caesarean section for a mother and her newly born child including routine wellbaby care. Any decision to shorten such minimum stay shall be made by the attending Physician in consultation with the mother. Any such decision shall be made in accordance with rules and regulations promulgated by the Department of Public Health. Said regulations shall be relative to early discharge, defined as less than fortyeight hours for a vaginal delivery and ninety-six hours for a caesarean delivery. Post-delivery care shall include, but not be limited to, home visits, parent education, assistance and training in breast or bottle feeding and the performance of any necessary and appropriate clinical tests; provided, however, that the first home visit shall be conducted by a Physician. Additional Medically Necessary home visits shall be provided upon recommendation by a Physician. Benefits will be paid the same as any other Sickness for Medically Necessary special medical formulas which are approved by the commissioner of the Department of Public Health, when prescribed by a Physician to protect the unborn fetuses of pregnant women with phenylketonuria.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR OFF-LABEL DRUG USE

If benefits are payable for Prescription Drugs under this policy (see Schedule of Benefits), then benefits will be paid the same as any other Prescription Drug for any drug prescribed to treat an Insured Person for cancer or HIV/AIDS if the drug is recognized treatment for that indication in one of the Standard Reference Compendia, or in Medical Literature. ?Standard reference compendia? means (a) the United States Pharmacopeia Drug Information; (b) the American Medical Association Drug Evaluations; or (c) the American Hospital Formulary Service Drug Information. ?Medical literature? means scientific studies published in any peer-reviewed national professional journal. For such Prescription Drugs that are payable due to establishment by the commissioner as payable after a review of the panel of medical experts as outlined in Massachusetts Insurance Code, 175:47L, benefits will be paid for such drugs that are not included in any of the standard reference compendia or in the medical literature for the treatment of cancer. Benefits shall include Medically Necessary services associated with the administration of such drugs.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR SCALP HAIR PROSTHESES

Benefits will be paid for expenses for scalp hair prostheses worn for hair loss suffered as a result of the treatment of any form of cancer or leukemia when a written statement by a Physician is furnished stating that the scalp hair prosthesis is Medically Necessary. Benefits are limited to $350.00 per Policy Year.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR TREATMENT OF DIABETES

Benefits will paid the same as any other Sickness for Insured Persons for Medically Necessary services and supplies for the diagnosis or treatment of insulin-dependent, insulin-using, gestational and non-insulin-dependent diabetes when prescribed by a Physician. Benefits will be paid for the following, subject to any applicable Deductibles, co-payments and coinsurance as set forth on the Schedule of Benefits:

1. Prescription Drugs: blood glucose monitoring strips for home use; urine glucose strips; ketone strips; lancets; insulin; insulin syringes; insulin pumps and insulin pump supplies; insulin pens and prescribed oral diabetes medications that influence blood sugar levels;
2. Durable medical equipment: blood glucose monitors; voice-synthesizers for blood glucose monitor for use by the legally blind; visual magnifying aids for use by the legally blind;
3. Laboratory/radiological services: including glycosylated hemoglobin, or HbAlc tests; urinary protein/microalbumin and lipid profiles;
4. Prosthetics: therapeutic/molded shoes and shoe inserts prescribed by a Physician and approved by the Federal Drug Administration for the purposes for which they were prescribed for Insureds who have severe diabetic foot disease; and
5. Outpatient services: diabetes outpatient self management training and education, including medical nutrition therapy, when provided by a Physician certified in diabetes health care.
   

   As used in this section, a “Physician certified in diabetes health care” means a licensed health care professional with expertise in diabetes, a registered dietician or a health care provider certified by the National Certification Board of Diabetes Educators as a certified diabetes educator.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR TREATMENT OF MENTAL DISORDERS

Benefits will be paid the same as any other Sickness for the diagnosis and treatment of the following biologically-based mental disorders, as described in the most recent edition of the Diagnostic and Statistical Manual of the American Psychiatric Association, referred to in this benefit as the ?DSM?:

1. schizophrenia,
2. schizoaffective disorder,
3. major depressive disorder,
4. bipolar disorder,
5. paranoia and other psychotic disorders,
6. obsessive-compulsive disorder,
7. panic disorder,
8. delirium and dementia,
9. affective disorders; and
10. any biologically-based mental disorders appearing in the DSM that are scientifically recognized and approved by the commissioner of the Department of Mental Health in consultation with the commissioner of the Division of Insurance.

Benefits will be paid the same as any other Sickness for the diagnosis and treatment of rape-related mental or emotional disorders to victims of a rape or victims of an assault with intent to commit rape, as defined by sections 22 and 24 of chapter 265, whenever the costsof such diagnosis and treatment exceed the maximum compensation awarded to such victims pursuant to subparagraph (C) of paragraph (2) of subsection (b) of section 3 of chapter 258C.

Benefits will be paid the same as any other Sickness for Dependent children under the age of 19 for the diagnosis and treatment of non-biologically-based mental, behavioral or emotional disorders, as described in the most recent edition of the DSM, which substantially interfere with or substantially limit the functioning and social interactions of such a child provided, that said interference or limitation is documented by and the referral for said diagnosis and treatment is made by a Physician, or is evidenced by conduct, including, but not limited to:

1. an inability to attend school as a result of such disorder,
2. the need to hospitalize such child as a result of such disorder, or
3. a pattern of conduct or behavior caused by such disorder which poses a serious danger to self or others.

Such benefits to a Dependent child who is engaged in an ongoing course of treatment shall continue beyond the Dependent?s nineteenth birthday until said course of treatment, as specified in such child?s treatment plan, is completed and while the policy under which such benefits first became available remains in effect, or subject to a subsequent policy which is in effect.

Benefits will be paid the same as any other Sickness for the diagnosis and treatment of all other mental disorders not otherwise provided for in this benefit section and which are described in the most recent edition of DSM during each 12 month period on the following basis:

1. Up to 60 days of inpatient treatment; and
2. Up to 24 outpatient visits.

Benefits will be paid the same as any other Sickness for treatment of alcoholism or chemical dependency when said treatment is rendered in conjunction with treatment for mental disorders pursuant to this benefit section. Benefits shall include inpatient, intermediate, and outpatient services that are Medically Necessary and provided in the least restrictive clinically appropriate setting.

Inpatient services may be provided in a general Hospital licensed to provide such services, in a facility under the direction and supervision of the Department of Mental Health, in a private mental Hospital licensed by the Department of Mental Health, or in a substance abuse facility licensed by the Department of Public Health.

Intermediate services shall include, but not be limited to, Level III community-based detoxification, acute residential treatment, partial hospitalization, day treatment and crisis stabilization licensed or approved by the Department of Public Health or the Department of Mental Health.

Outpatient services may be provided in a licensed Hospital, a mental health or substance abuse clinic licensed by the Department of public health, a public community mental health center, a professional office, or home-based services, provided, however, services delivered in such offices or settings are rendered by a licensed mental health professional acting within the scope of his license

Benefits will be paid the same as any other Sickness for psychopharmacological services and neuropsychological assessment services.

When necessary for administration of claims under this benefit section, consent to the disclosure of information regarding services for mental disorders will be required on the same basis as disclosure of information for other Sickness or Injury.

Benefits will not be payable for mental health benefits or services: which are provided to a person who is incarcerated, confined or committed to a jail, house of correction or prison, or custodial facility in the department of youth services within the commonwealth or one of its political subdivisions; which constitute educational services required to be provided by a school committee pursuant to section 5 of chapter 71B; or which constitute services provided by the Department of Mental Health.

?Licensed mental health professional? means a Physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed mental health counselor, or a licensed nurse mental health clinical specialist. Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR NEWBORN OR ADOPTED CHILDREN

Benefits will be paid for Newborn Infants, including Newborn Infants of a Dependent, from the moment of birth the same as any other Insured Dependent. Benefits shall also be provided for adopted or adoptive children of the Insured Person immediately from the date of the filing of a petition to adopt under chapter two hundred and ten and thereafter if the child has been residing in the home of the Insured Person as a foster child for whom the Insured Person has been receiving foster care payments, or, in all other cases, immediately from the date of placement by a licensed placement agency of the child for purposes of adoption in the home of the Insured Person. Benefits for Newborn infants and adoptive children shall include treatment of Injury and Sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, or premature birth.

Benefits shall include those special medical formulas which are approved by the commissioner of the Department of Public Health, prescribed by a Physician, and are Medically Necessary for treatment of phenylketonuria, tyrosinemia, homocystinuria, maple syrup urine disease, propionic acidemia, or methylmalonic acidemia in infants and children. Benefits shall include screening for lead poisoning on the basis required by the Department of Public Health. Benefit shall include a newborn hearing screening test to be performed before the Newborn Infant is discharged from the hospital or birthing center to the care of the parent or guardian or as provided by regulations of the Department of Public Health.

Benefits shall be subject to all Deductible, co-payment, coinsurance, limitations or any other provisions of the policy.

BENEFITS FOR QUALIFIED CLINICAL TRIALS FOR TREATMENT OF CANCER

Benefits will be paid the same as any other Sickness for Patient Care Service furnished pursuant to a Qualified Clinical Trial. Patient Care Service means a health care item or service that is furnished to an individual enrolled in a Qualified Clinical Trial which is consistent with the Usual and Customary standard of care for someone with the patient?s diagnosis, is consistent with the study protocol for the clinical trial, and would be covered if the patient did not participate in the clinical trial. Qualified clinical trial means a clinical trial that meets the following conditions: