Student Health Insurance PlanSTUDENT MEDICAL POLICY INFORMATION 2012-2013

2060 East Ninth Street

Cleveland, Ohio 44115-1355

© 2012 Medical Mutual of Ohio X8652-GHP R7/12

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Dear Student,

Thank you for choosing The University of Toledo!

To support the health and academic success of our student body, a

mandatory health insurance requirement exists for all students registered

for six or more on-campus credit hours per term or, for international and

medical students, one or more on-campus credit hours per term.

If you do not already have qualified health insurance, you can choose

from one of two Student Health Insurance plans. Administered by Medical

Mutual, both plans provide healthcare coverage on or off campus and

special cost-saving features to keep coverage as affordable as possible.

It is important you review the following information to learn more about:

� How to waive coverage� How to enroll in a plan� Both plan options� On-campus medical facilities� The SuperMed Plus network

Once again, thank you for choosing The University of Toledo. We wish you

a successful — and healthy — school year!

Sincerely,

The University of Toledo Health Insurance Management OfficeMain Campus Medical CenterPhone: 419.530.3474

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X-ray and Lab (deductible applies to services unless a copay is listed)

At SHC, UTMC, UTP2

Network Provider

Non-Network Provider

100%

80%

60%

100%

100%

70%

Plan Benefits Plan 1 Plan 2Benefit Period Maximum

Pharmacy Maximum

Mental Health Maximum1

Office Visit and Emergency Room (deductible applies to services unless a copay is listed)

At SHC, UTMC, UTP2

Network Provider

Non-Network Provider

Emergency Room

$100

$300

$500 Individual

$1,000 Family

Combined Medical and Prescription

30 visits per benefit period

$100,000 $500,000

none

none

$250 Individual

$500 Family

100%

80% after $10 copay

60%

$100 copay

Annual Deductible

At SHC, UTMC, UTP2

MMO Network Provider

Non-Network Provider

100%

100% after $15 copay

70%

$50 copay

Preventive Service3 (deductible applies to services unless a copay is listed)

At SHC, UTMC, UTP2

Network Provider

Non-Network Provider

100%

80%

60%

100%

100%

70%

Inpatient Hospitalization (deductible applies to services unless a copay is listed)

At SHC, UTMC, UTP2

Network Provider

Non-Network Provider

100%

80%

60%

100%

100%

70%

Prescription Drug4 (deductible applies to services unless a copay is listed)

UT Pharmacy (100% after copay)

Generic

Brand

NF Brand

Participating Retail Pharmacy

Generic

Brand

NF Brand

$5

$25

$60

$10

$25 + 20%

$60 + 20%

$5

$25

$60

$10

$25 + 20%

$60 + 20%

Note: The Plan pays benefits in accordance with applicable Ohio insurance law. The University of Toledo Student HealthInsurance plan may not cover all of your healthcare expenses; the plan excludes coverage for certain services andcontains limitations on the amounts it will pay.

1 Mental Health Maximum reflects outpatient expense, see brochure for inpatient expense.2 Student Health Center, UT Main Campus and UT Physicians.3 Preventive Services are provided in accordance with state and federal law. Certain preventive services are not subject to deductible.4 Prescription Drug reflects a 30-day supply.

Benefits At A Glance

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Plan 1 AnnualStudent Only

Student + Spouse

Student + Child(ren)

Student + Spouse & Child(ren)

$2,016

$4,157

$2,368

$6,521

Fall$818

$1,686

$960

$2,645

Summer$481

$991

$564

$1,554

Spring/Summer$1,198

$2,471

$1,407

$3,876

Plan 2 AnnualStudent Only

Student + Spouse

Student + Child(ren)

Student + Spouse & Child(ren)

$2,344

$4,833

$2,753

$7,582

Fall$951

$1,960

$1,117

$3,075

Summer$559

$1,152

$656

$1,807

Spring/Summer$1,393

$2,873

$1,636

$4,507

What It Costs

Note: Dependents must be enrolled in the same plan as the student. Coverage selection cannot be changed after the enrollment process.

What You Need to DoThe University of Toledo requires all students registered for six or more on-campus

credit hours to have health insurance. International and medical students registered

for one or more on-campus credit hours are also required to have health insurance.

To waive coverage or enroll as a student in either Plan 1 or 2 go to myut.utoledo.edu.

To ensure compliance with the University’s insurance requirement, you will be

automatically enrolled in the Plan 1 Student Health Insurance Plan and the fee

will be added to your Student Account. The charge will remain on your account

if you do not complete the waiver process or if your other coverage is not

considered comparable.

Any student who is not required to have health insurance in any given semester,

but is registered for at least one on-campus credit hour at The University of

Toledo, has the option of voluntarily enrolling in one of the two Student Health

Insurance Plans by visiting Student.MedMutual.com. The premium is paid

directly to Medical Mutual at the beginning of each semester.

You may add an eligible dependent by completing the online application on

Student.MedMutual.com. The dependent must be enrolled in the same plan

as the student. The premium for the dependent is the responsibility of the student

and is paid directly to Medical Mutual at the beginning of each semester.

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Fall: September 30, 2012Spring/Summer: January 31, 2013

Waiver submissions may be audited by The University of Toledo, and/or its

contractors or representatives. You may be required to provide, upon request,

any coverage documents and/or other records demonstrating that you meet

the school’s requirements for waiving the Student Health Insurance Plan. By

submitting the waiver request, you agree that your current insurance carrier may

be contacted for confirmation of your in-force coverage for the applicable policy

year and that it meets the University’s waiver requirements.

Where to Go for ServiceThe Student Medical Center, University of Toledo Medical Center and University

of Toledo physicians are included in the Level 1 benefits for both Student Health

Insurance plans offered.

Services provided at these locations offer the highest level of benefits, meaning

the greatest cost savings to you.

Main CampusWhen you need care on the Main Campus, make the Main Campus Medical

Center (MCMC) your first stop. Our highly trained and experienced staff offers

a variety of services including primary and urgent medical care, women’s healthcare,

counseling and psychiatric services, laboratory testing, and prescription and

over-the-counter medications.

For specific hours, phone numbers and available services at MCMC, please visit

http://utoledo.edu/healthservices/student/index.html or call 419.530.3451.

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Enroll/Waive Deadlines

Health Science CampusWhen you need care on the Health Science Campus, make the Student Health

and Wellness Center your first stop. The Student Health and Wellness Center is

located in the Ruppert Health Center lower level, Suite 003.

To schedule an appointment please call 419.383.3777 or visit the Health Services

website at www.utoledo.edu/healthservices/hsc/index.html.

Confidential Mental Health ServicesTo schedule an appointment for Mental Health Services please call 419.383.3777.

These services are located in the Student Health and Wellness Center in the

Ruppert Health Center lower level, Suite 003.

Other OptionsVisit Student.MedMutual.com to choose from an extensive list of SuperMed Plus

network providers available to Student Health Insurance plan members.

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Notes

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