St dent Gol Health Insurance Plan, 2014-15
PLAN OVERVIEW
The Student Gold Health Insurance
Plan offers quality health insurance
coverage for CU-Boulder students
(and their spouses/ same sex domestic
partners and dependents). It provides
primary care coverage at Wardenburg
Health Center on campus as well as
coverage for specialists and major
medical care outside of Wardenburg
Health Center.
PL
E I IBILI Y
CU-Boulder degree-seeking students
must be enrolled in 6 or more credit
hours or 1 credit hour for graduate
students to be eligible for the Student
Gold Health Insurance Plan. Spouses/
same sex domestic partners and
dependents of an eligible student may
also purchase the plan.
WARDENBURG
LTH C
T R
Wardenburg Health Center (WHC) is
located centrally on the CU-Boulder
campus and has a medical staff
specializing in the unique health and
wellness needs of college students.
Patients must obtain a referral from
WHC for outside care except in an
emergency.
X-Ray
•
Prescription benefit
•
•
National and international coverage
• Out-of-pocket maximum of $5,000
for in-network and $10 ,000 for outof-network per plan year
•
Unlimited policy maximum
•
Referrals to specialists in the
community (required for most
services outside of WHC)
• Optional additional coverage
available
SERVICES INSIDE
WARDENBU G EALTH
CE
ER
No deductible or coinsurance for the
following covered services:
•
Wardenburg Health Center is the
Primary Care Provider with no
deductible or coinsurance for
covered services inside WHC.
$40 copay per visit for specialists
outside of WHC (copays do not
apply to the deductible)
• $500 deductible per person per
policy year for services outside
WHC using an in-network provider;
once deductible is met, 20 percent
coinsurance applies.
•
•
Primary care for illnesses and
injuries
•
Routine immunizations
• Travel Clinic services (excluding
specialty travel immunizations)
Men 's health services including one
annual exam per policy year
Coverage for laboratory services
initiated by a WHC provider
100 percent coverage for X-ray
services
Psychological Health and
Psychiatry
•
Initial assessment
•
Individual, couples and group
therapy
• Substance abuse evaluation and
treatment
•
Eating disorders evaluation and
treatment
•
Medical evaluation and medication
management
•
Stress management services
•
Crisis care
•
No copay for the first 20 visits;
$20 copay per visit thereafter (group
therapy excluded)
Medical Clinic
•
•
Laboratory
• $1 ,000 deductible per person per
policy year for services outside
WHC using an out-of-network
provider; once deductible is met,
50 percent coinsurance applies.
Sports Medicine
•
25 physical therapy visits per policy
year
•
1O chiropractic visits per policy year
• Orthopedic surgeon consultations
•
No copay for the first 20 visits;
$20 copay per visit thereafter
• Sexually transmitted infection
testing and education
Women's Health Services
• Allergy injections
•
One annual exam per policy year
•
•
Gynecology services and
consultations
•
Birth control consultations
•
Human Papillomavirus (HPV)
vaccinations
•
Sexually transmitted infection
testing and education
•
No copay for the first 20 visits;
$20 copay per visit thereafter
No copay for the first 20 visits; $20
copay per visit thereafter (allergy
injections excluded)
Nutrition Services
•
•
Counseling for a variety of nutritionrelated concerns
No copay for the first 20 visits;
$20 copay per visit thereafter
SERVICES OUTSIDE
WARDENS
T
Eye Exam (no copay or deductible)
• One routine eye exam per plan year
through a Wardenburg-contracted
optometrist. Glasses, contacts and
contact lens fittings are not covered .
Specialist Visits
•
•
Patients requiring a specialist must
first be seen by a WHC provider to
obtain a referral to an in-network
specialist.
For a complete list of in-network
providers visit:
-www.cofinity.net (inside
Colorado)
-myfirsthealth.com (outside
Colorado)
•
In-Network Providers:
-$40 copay per visit for specialists
outside of WHC (copays do not
apply to the deductible).
-A $500 deductible per person
per policy year will apply for
some office visit procedures;
surgeries; imaging such as MRls,
ultrasounds and CTs; and lab
services.
-Coinsurance appl ies after the
dedu.ctible is met. The Gold
Plan pays 80 percent and the
policyholder is responsible for 20
percent up to the out-of-pocket
maximum.
• Out-of-Network Providers:
•
100 percent coverage for
contraceptives
•
Unlimited maximum benefit per year
URGENT CARE/EMERGENCY I
I
C"
~
• $75 copay per urgent care visit
• $150 copay per emergency room
visit
- A $1 ,000 deductible per person
per policy year will apply.
• $200 copay for hospitalization per
admission
-Coinsurance applies once the
deductible is met. The Gold Plan
will pay 50 percent of reasonable
customary charges and the
policyholder is responsible for the
remaining 50 percent up to the
out-of-pocket maximum.
•
c
10
FT
• A $50 deductible per person per
policy year will apply.
• Once the deductible is met, copays
will apply: $15 for generic, $30 for
formulary and $60 for nonformulary
prescriptions.
Procedures and lab tests may
be subject to the deductible and
coinsurance
OPTIONAL ADDITIONAL
VE
• Spouse/ same sex domestic partner
and dependent coverage
•
Dental plan
•
Vision plan
Dates of Coverage and Costs
Semester
Dates of Coverage
Student
Spouse/
Domestic Partner
Fall 201 4
8/ 18/2014- 12/ 31 / 201 4
$1 ,695
$4, 197
$2 ,340
Spring 2015
1/ 1/ 2015-8/1 7/ 2015
$1 ,695
$4, 197
$2 ,340
Summer 2015 On.ly
6/ 1/ 2015-8/1 7/ 2015
$848
$2 ,099
$1 ,170
Dependent
NOTE: Enrolling in the Student Gold Health Insurance Plan for fall and spring semesters provides a full year of coverage.
Spring coverage extends through August 17, 2015, regardless of whether the student graduates in May or takes summer
classes.
For a detailed plan description including limitations, visit www.colorado.edu/studentinsurance.
S:
Fall 2014: September 3, 2014
Spring 2015: January 21 , 2015
Summer 2015: June 5, 2015
STUDENT HEALTH
U
<'
FFICE
HOW TO ENROLL IN THE
STUDENT GOLD HEALTH
lN U
NC P
303-492-5107
[email protected]
www.colorado.edu/
studentinsurance
Enroll in the Student Gold Plan online.
For detailed information visit www.
colorado.edu/studentinsurance.
-
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