Tacoma Student Health Insurance 2012 2013 - University of by huanglianjiang1

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									             Tacoma Student Health Insurance 2012 | 2013

              Tacoma Student Health Insurance 2012 | 2013                                                                                                         1


                                                                                                                                                                  1


What’s Inside


Section 1: Getting Started ......................................................................................................................... 2
         Your UW Student Health Insurance Plan: SHIP .............................................................................. 2
         About this Booklet ........................................................................................................................... 3
         What’s New for 2012-2013 ............................................................................................................... 4
         SHIP - Plan at a Glance .................................................................................................................... 4
         Who’s Eligible .................................................................................................................................. 7
         How to Enroll .................................................................................................................................... 8
         Making Changes .............................................................................................................................. 8
         Premiums ......................................................................................................................................... 9
         When Coverage Begins and Ends................................................................................................... 9
         Important Plan Limitations ............................................................................................................ 10


Section 2: Your Student Health Insurance............................................................................................ 12
         Your Medical Benefits .................................................................................................................... 12
         Medical Plan Highlights ................................................................................................................. 12
         Save Money By Using Network Providers .................................................................................... 13
         Network Providers ......................................................................................................................... 13
         Understanding Your Health Insurance Plan ................................................................................. 13
         Preventive Care Highlights ............................................................................................................ 15
         Mental Health Highlights................................................................................................................ 16
         Prescription Drug Highlights ......................................................................................................... 17
         What’s Covered .............................................................................................................................. 18
         What’s Not Covered—Exclusions and Limitations....................................................................... 25
         Your Dental Benefit ........................................................................................................................ 27
         What’s Not Covered—Dental Exclusions...................................................................................... 29
         Your Vision Benefit ........................................................................................................................ 29


Section 3: More Information ................................................................................................................... 30
         Claims............................................................................................................................................. 30
         Plan and Policy Information .......................................................................................................... 33
         Definitions ...................................................................................................................................... 33


Section 4: Directory ................................................................................................................................. 39
         Useful Links ................................................................................................................................... 40
           Tacoma Student Health Insurance 2012 | 2013
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Section 1: Getting Started



Your student health insurance coverage, offered by LifeWise Assurance Company may not meet
the minimum standards required by the health care reform law for the restrictions on annual dollar
limits. The annual dollar limits ensure that consumers have sufficient access to medical benefits
throughout the annual term of the policy. Restrictions for annual dollar limits for group and
individual health insurance coverage are $1.25 million for policy years before September 23, 2012;
and $2 million for policy years beginning on or after September 23, 2012 but before January 1,
2014. Restrictions for annual dollar limits for student health insurance coverage are $100,000 for
policy years before September 23, 2012, and $500,000 for policy years beginning on or after
September 23, 2012, but before January 1, 2014.
Your 2012-2013 student health insurance coverage has a limit of $200,000 per condition per plan
year. If you have any questions or concerns about this notice, contact LifeWise Assurance
Company at (800) 971-1491. Be advised that you may be eligible for coverage under a group
health plan of a parent's employer or under a parent's individual health insurance policy if you are
under the age of 26. Contact the plan administrator of the parent's employer plan or the parent's
individual health insurance issuer for more information.

Your UW Student Health Insurance Plan: SHIP
If you’re a UW student and you’re not covered by your           too for an additional fee. Some restrictions apply to
parents’ or other medical insurance, it’s a good idea to        dependent coverage, though, so read the details before you
enroll in a Student Health Insurance Plan—even if you’re        enroll. (see the Family Members You May Cover and
pretty healthy right now.                                       Important Information: Deadlines for Adding a New
                                                                Child to Your Coverage sections)
According to the National Department of Health and Human
Services, the average cost of an emergency room visit is        International Students Must Enroll
close to $2,000, and a hospitalization of even a couple of      Please note if you are an international student, you must
days can cost thousands more. A lot of prescription drugs       enroll in SHIP. Limited waivers are available from the
are also very expensive to pay for without insurance (just go   International Student Services office and must be requested
to a pharmacy website like Walgreens.com and look up the        no later than the 5th calendar day of the quarter. Please
costs if you’re curious). And if you don’t have insurance,      contact the International Student Services Office with
doctors and hospitals may require you to pay them before        questions.
they will treat you, unless your injury or illness is life-
threatening.

SHIP is an accident and sickness insurance plans that
covers things like doctors’ visits, hospitalization,
prescriptions and preventive care that meets the federal
guidelines. If you have eligible dependents—a registered
domestic partner, spouse, or children, you may cover them
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About this Booklet
This online booklet will help you understand important       This document provides a description of your plan in clear
details of the UW Student Health Insurance Plan. It’s        language. However, the master contract) contains all of the
intended to be easy to use and to describe things in clear   technical, legally-worded provisions, limitations, exclusions
language, so you can find the answers you’re looking for     and qualifications of your insurance benefits, some of which
easily.                                                      may not be contained in this document. Although every
                                                             attempt has been made to ensure the accuracy and
If you can’t find answers to your student health insurance
                                                             completeness of the information within this online booklet, if
questions here, contact the Student Health & Wellness by
                                                             there are any discrepancies, the master contract is the
email at ssalleans@uw.edu, by phone at (253) 692-4522,
                                                             actual contract and will govern and control payment of
or in person at MAT 354. You can also contact LifeWise
                                                             benefits. If you can’t find the answers to your student health
Assurance Company (LifeWise) at (800) 971-1491 or
                                                             insurance questions here, please review your master
TDD for the Hearing-Impaired at (800) 842-5357.
                                                             contract).
            Tacoma Student Health Insurance 2012 | 2013
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What’s New for 2012-2013
Here are some changes that take effect in the 2012-                  Preventive Care
2013 plan year (Autumn quarter 2012 through Summer                   Preventive care services have been expanded and include
quarter 2013):                                                       all services that meet the federal guidelines (details under
Cost Decrease                                                        “What’s Covered”). Coverage is provided in full if services
                                                                     are received at, or coordinated through, Franciscan Medical
The SHIP quarterly cost for a single student who signs up
                                                                     Clinic - St. Joseph.
for the quarterly plan in any quarter for 2012-2013 will be
$628. It was $729 last year.                                         Prescription Drugs
Franciscan Medical Clinic – St. Joseph                               The maximum copay/coinsurance per prescription will be
                                                                     $100 (was $200).
The deductible is waived for services received at
Franciscan Medical Clinic – St. Joseph. (If lab work                 The network cost share has changed, The cost impact will
performed at Franciscan Medical Clinic – St. Joseph is               vary based upon the type of medication dispensed (see the
referred to and/or billed outside of Franciscan Medical              Prescription Drug benefit).
Clinic – St. Joseph, the deductible will apply.)
                                                                     Dental
Transgender Benefit                                                  The dental benefit maximum will be $500 per plan year
Transgender services are now covered up to a $35,000                 (was $300). Coverage added for restorative services
annual limit. Amount of coinsurance that you pay for non-            (extractions, fillings, root canals, extractions and non-
network services will apply towards the network                      surgical periodontal (gum) treatment).
coinsurance maximum.
                                                                     Neurodevelopmental Therapy
Infusion Therapy                                                     $1,000 plan year benefit limit has been removed.
$25,000 plan year benefit limit has been removed.



SHIP - Plan at a Glance
This chart shows highlights of some of the key features of SHIP. Before you enroll, however, you should read the additional
benefit information included in other parts of this booklet.


                                                 SHIP Plan
                                                 Policy no. SHIP UW (03-2012)
                                                 Plan no. SHIP UW T (03-2012)

Quarterly cost (“premium”)
(other than Summer Qtr)
Student only                                     $618
Student + spouse or domestic partner             $1,536
Student + child(ren)                             $1,395
Student + spouse/domestic partner + child(ren)   $2,313
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                                                          SHIP Plan
                                                          Policy no. SHIP UW (03-2012)
                                                          Plan no. SHIP UW T (03-2012)

Medical                                                   SHIP Plan

Maximum Benefit                                           $200,000 per condition aggregate maximum
The highest amount the plan will pay for any individual
sickness or injury


Deductible                                                $75 per quarter up to a $300 maximum deductible per plan year
                                                          Does not apply to office visits, prescriptions, or procedures at Franciscan Medical
An amount you have to pay for covered medical             Clinic - St. Joseph (diagnostic lab work referred to and/or billed by a lab outside of
expenses before the plan pays any benefits.               Franciscan Medical Clinic - St. Joseph is subject to the deductible)


Coinsurance                                               Network:
Percentages you and the plan pay for many covered             •   Plan pays 80%**
medical expenses. The plan covers more when you               •   You pay the other 20%**
see “network” doctors and other providers.
                                                          Non-network:
                                                              •   Plan pays 60%*
                                                              •   You pay the other 40%*

Preventive Care                                           Franciscan Medical Clinic - St. Joseph (deductible is waived):
Preventive care that meets the federal guidelines is          •Plan pays 100%**
covered.                                                      •You pay the other 0%**
                                                          Network:
                                                              •Plan pays 80%**
                                                              •You pay the other 20%**
                                                          Non-network:
                                                              •Plan pays 60%**
                                                              •You pay the other 40%**

Prescription drugs, LifeWise network                      You pay the higher of:
pharmacies
                                                              •   Generic: 20% or $15 copay
Your costs are always lowest for generic drugs, and           •   Brand formulary: 30% or $25 copay
brand-name drugs on the “formulary” (preferred drug           •   Non-formulary: 40% or $30 copay
list) cost you less than brand-name drugs that are not
on the formulary (up to a 30-day supply per month)
                                                          Maximum copay/coinsurance that a member will pay is $100/prescription
If you don’t show your LifeWise ID card, you pay the
entire cost of the prescription to the pharmacy and
then submit a receipt and claim form to LifeWise for
reimbursement.
Services that meet the federal guidelines are not
subject to any deductible, copay or coinsurance when
you use a network pharmacy. See the Preventive
Care benefit.

Prescription drugs, Non-network                           You pay:
(up to a 30-day supply per month)                             •   Generic: 50%
You pay the entire cost of the prescription to the            •   Brand formulary: 50%
pharmacy and then submit a receipt and claim form to          •   Non-formulary: 50%
LifeWise for reimbursement. Non-network pharmacy
claims are paid based on billed charges.                  Maximum copay/coinsurance that a member will pay is $100/prescription
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                                                               SHIP Plan
                                                               Policy no. SHIP UW (03-2012)
                                                               Plan no. SHIP UW T (03-2012)

 Mental Health                                                 Inpatient:
 Your benefits have different limits depending on                  •   Network, You pay a $300 copay per admission; then the plan pays 80%**; you pay
 whether you receive services on an inpatient basis (in                the other 20%** after deductible
 the hospital) or on an outpatient basis (visits). Benefits        •   Non-network, the plan pays 60%* after you pay a $400 copay per admission after
 are also higher when you see network mental health                    deductible; you pay the other 40%*
 providers.
                                                               Outpatient:
 (There are no fees at the Counseling Center for
 student participants.)                                            •   Network, the plan pays 80%** after deductible (deductible is waived at Franciscan
                                                                       Medical Clinic - St. Joseph)
                                                                   •   Non-network, the plan pays 60%* after deductible

 Alcoholism/Chemical Dependency                                Inpatient:
                                                                   •   Network, you pay a $300 copay per admission; then the plan pays 100%** after
                                                                       deductible
                                                                   •   Non-network, you pay a $400 copay per admission; then the plan pays 100%* after
                                                                       deductible
                                                               Outpatient:
                                                                   •   Network, the plan pays 100%** after deductible
                                                                   •   Non-network, the plan pays 100% after deductible

 Dental and Vision                                             SHIP Plan

 Dental                                                        Plan pays 100% of allowable charges to a $500 maximum benefit per plan year for
                                                               preventive and restorative services, subject to a$25 deductible for individuals or $75
                                                               deductible for family per plan year

 Vision                                                            •   Eye exam: the plan pays 100% up to a $150 maximum per plan year
                                                                   •   Hardware: the plan pays 100% up to a $200 maximum per plan year
                                                                   •   You pay any amounts above the maximums


*Non-network benefits are limited to allowable charges. In addition to your percentage of the coinsurance, you are responsible for all amounts that exceed the
allowable charge.
**Of the allowable charge.
These are just the highlights and are not to be viewed as a comprehensive list of benefits and exclusions. For details, read the rest of
this online booklet.
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Who’s Eligible
The SHIP insurance plan is designed for you if you are a          •   Your spouse or registered domestic partner (see
University of Washington student at the Tacoma campus.                below).
International students are required to enroll in SHIP or
                                                                For a domestic partner to be eligible for coverage, you and
receive a waiver from International Student Services.
                                                                your domestic partner must meet the definition of an
Graduate students with a TA/SA/RA appointment have a            eligible domestic partner and be registered with the
separate insurance plan: GAIP. They may not be covered          Washington State registry or jurisdiction where domestic
under both GAIP and SHIP.                                       partner registration is offered.

Students studying outside the US may enroll in this plan,       Important Information: Deadlines for Adding a New
but are also offered a plan tailored to their needs abroad.     Spouse or Domestic Partner to Your Coverage
You are eligible to enroll SHIP if:                             You must enroll a newly acquired spouse or registered
                                                                domestic partner within 30 days of the marriage or
  •   You’ve been formally admitted as a matriculating          registration.
      student by the Graduate or Undergraduate
      Admissions Office, or the professional schools of         Coverage is effective the first of the month following the
      Law, Medicine, Dentistry or Pharmacy                      event.

  •   You are registered as a matriculating student for         Important Information: Deadlines for Adding a New
      classes through MyUW or the Office of the Registrar       Child to Your Coverage
                                                                A child born to or adopted by you, your enrolled spouse or
  •   You remain enrolled in classes through the 14th
                                                                domestic partner, while you are enrolled in SHIP will
      calendar day of the quarter in which you enroll for
                                                                receive the same benefits as you for the first three weeks
      coverage.
                                                                after birth. If you want continuing coverage for your child
Who’s Not Eligible                                              after this, you must enroll your child in the timeframes listed
                                                                below:
Some students are not eligible to enroll in SHIP:
                                                                  •   You must enroll a newborn child and pay any
      •   Students enrolled in programs administered by UW
                                                                      additional premium to the Student Insurance office
          Educational Outreach including, but not limited to:
                                                                      within 60 days of birth
          the Graduate Nonmatriculated Program, Distance
          Learning, English as a Second Language, Noncredit       •   For adoptions, notify the Student Insurance Office of
          classes, conferences and institutes, or the Access          adoptions in writing, and pay any additional premium
          program                                                     within 60 days of adoption
      •   Individuals enrolled in self-sustaining programs,       •   You must enroll children acquired through marriage
          unless their programs assess the Services &                 or domestic partner registration within 30 days of
          Activities (S&A) Fee                                        marriage or registration.
      •   UW and other state employees attending classes        For newborn and adopted children, coverage is effective
          under the Employee Tuition Exemption Program.         retroactive to the date of birth or adoption/placement for
                                                                adoption.
Family Members You May Cover
                                                                For children acquired through marriage or domestic partner
If you are eligible and enroll for coverage, you may also
                                                                registration, coverage is effective the first of the month
enroll your eligible dependents in the same plan:
                                                                following the event.
  •   Your children under age 26
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How to Enroll
Enroll online by visiting the LifeWise website at                         through the third Friday of the Autumn quarter (the
https://student.lifewiseac.com/UW/BT/ and accessing their                 same as the tuition due date). The “annual” option is
enrollment tool. Premium must be submitted at the time of                 also offered at the beginning of each subsequent
enrollment.                                                               quarter for the rest of the plan year. For example, if you
                                                                          sign up for annual coverage beginning in Winter quarter,
Enrollment begins with the pre-registration period and ends on
                                                                          you’ll be enrolling for the remaining three quarters of that
the third Friday of each quarter (the same as the tuition due
                                                                          academic year: winter, spring and summer.
date). You will not be enrolled in the plan just by submitting
premium payment.                                                      •   Quarterly option—you may enroll on a quarterly basis.
                                                                          You must be registered for school during the quarter in
Your Enrollment Decisions
                                                                          which you enroll. To be covered during a quarter when
1.    Choose to enroll or decline coverage (note:                         you will not be registered, sign up and pay for the annual
      international students must enroll in SHIP or receive               option at the beginning of a quarter when you are
      waiver from International Student Services).                        registered. If you enroll on a quarterly basis, benefits are
                                                                          paid during that quarter term only. You must renew the
2.    If you decide to enroll, choose who you want to cover:
                                                                          plan for coverage to continue in the next quarter.
      just you, or you and your eligible family members.
                                                                    If you enrolled for annual coverage, you may remain covered
3.    Choose to sign up for a whole academic year (also
                                                                    during Summer quarter even if you are not registered for
      called the “plan year”) or for one quarter.
                                                                    classes. If you enrolled for quarterly coverage and were
  •   Whole year (annual) option—you may enroll for a full          covered during Spring quarter, you may sign up for Summer
      plan year of coverage beginning with pre-registration         quarter coverage even if you are not taking classes.


Making Changes
If You Withdraw From Classes                                        Adding a New Child
If you withdraw from all your classes during the first 7            A child born to or adopted by you, or your spouse or
calendar days of the quarter, your insurance will be                domestic partner, while you are enrolled in SHIP will
cancelled. If you withdraw after the 7th calendar day, your         receive the same benefits as you for the first three weeks
insurance coverage will not be affected.                            after birth or adoption only. If you want continuing coverage
You do not have to be enrolled in Summer quarter in order           for your child after this, you must enroll your child in the
to be covered, as long as you signed up for annual                  timeframes (30 days or 60 days, depending on the
coverage (or Spring and Summer coverage).                           situation) listed in the section called Important Information:
                                                                    Deadlines for Adding a New Child to Your Coverage.
Cancellation
                                                                    Adding a New Spouse or Domestic Partner to Your
Unless you cancel by the third Friday of the quarter (the           Coverage
same as the tuition due date), you may not cancel coverage
unless you, your spouse, or your domestic partner enters            You must enroll a newly acquired spouse or registered
                                                                    domestic partner within 30 days of the marriage or
the military service on full-time active duty.
                                                                    registration.
Annual enrollment in the plan cannot be cancelled in
subsequent quarters except if you become eligible for the
GAIP plan or enter full-time military duty. Otherwise, it can
only be cancelled up to the third Friday of the quarter (the
same as the tuition due date) in which it is initially purchased.
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Premiums


                                                          SHIP Premiums for 2012/2013

                                Student Only                   Student and Child(ren)           Student & Spouse or       Student, Spouse or Domestic
                                                                                                Domestic Partner*         Partner* and Child(ren)


 Single Qtr                     $618                           $1,395                           $1,536                    $2,313
 (other than Summer Qtr)


 Annual at Autumn Qtr           $2,472                         $5,580                           $6,144                    $9,252
 (4 quarters)

 Annual at Winter Qtr           $1,854                         $4,185                           $4,608                    $6,939
 (3 quarters)


 Annual at Spring Qtr           $1,236                         $2,790                           $3,072                    $4,626
 (2 quarters)



* For a domestic partner to be eligible for coverage, you and your domestic partner must meet the definition of an eligible domestic partner and be
registered with the Washington State registry or jurisdiction where domestic partner registration is offered.
*** In order to have Summer quarter insurance, you must meet one of the following:
1) have signed up for annual coverage, or
2) be registered for classes in Summer quarter, or
3) be enrolled in SHIP for Spring quarter.




When Coverage Begins and Ends
SHIP coverage is a one-year policy that begins on                  If You’re In the Hospital When Coverage Would
SeptemberTacoma Student Health Insurance
            20, 2012 and ends on September 19, 2013. The         2012 | 2013
                                                                   Otherwise Begin
benefits described in the brochure are applicable during this       If you or your covered family member is in the
term only.                                                          hospital or other facility at the time coverage    10
                                                                    would otherwise begin, coverage will not begin
 2012-2013 Dates of Coverage
                                                                    until after discharge, except for newborn and adoptive
 Autumn Quarter        September 20, 2012–January 6, 2013           children as described in the Who’s Eligible section.

                                                                    When Coverage Ends
 Winter Quarter        January 7, 2013–March 31, 2013
                                                                    The benefits under SHIP expire at the end of the plan year
                                                                    or quarter for which you purchased it, whichever is earlier.
 Spring Quarter        April 1, 2013–June 23, 2013
                                                                    There is no extension of coverage beyond the date for
 Summer Quarter        June 24, 2013–September 19, 2013             which you purchased coverage, unless you continue to
                                                                    qualify as a student, in which case you would need to re-
                                                                    enroll in a timely manner. See the Who’s Eligible and How
                                                                    to Enroll sections.
When Coverage Begins
If you purchase quarterly coverage, you are covered for the         If You’re In the Hospital When Coverage Would
dates in the quarters in which you purchase coverage, as            Otherwise End (Extension of Benefits After
shown in the chart.                                                 Termination)
                                                                    The coverage provided under this plan ends on the
If you purchase annual coverage, you will be covered from
                                                                    termination date (the end of the quarter or plan year for
the date listed above for the quarter in which you purchase
                                                                    which you bought coverage). However, if you or your
the annual coverage and continuing until September 19,
                                                                    covered family member is in the hospital on the termination
2013.
                                                                    date due to a covered injury for which benefits were paid
                                                                    before the termination date, covered medical expenses
                                                                    for that injury will continue to be paid as long as the
                                                                    condition continues, for up to a maximum of one year (365
                                                                    days) after the termination date, subject to the maximum
                                                                    benefit.




Important Plan Limitations
Like all insurance plans, SHIP places limits on benefits to           •   The existence of symptoms within the 3 months
prevent abuse and help contain costs for all participants.                immediately prior to your effective date under the
                                                                          plan, or
There are two types of limitations:
                                                                      •   Any condition that is diagnosed, treated or
  •   The pre-existing condition limitation
                                                                          recommended for treatment within the three months
  •   Specific benefit limitations and exclusions, or services            immediately prior to your effective date under the
      that are not covered at all. See the What’s Covered                 plan.
      section for specific benefits, limits and exclusions.
                                                                    Pre-existing conditions will not be covered for the first three
                                                                    months of coverage under SHIP, unless you were insured
                                                                    under another similar health plan for at least three months
Pre-existing Condition Limitation
                                                                    immediately before becoming insured under SHIP.
A pre-existing condition waiting period applies for members
who are age 19 and older. A pre-existing condition is a             Credit will be given for the period of time you were covered
medical condition that existed prior to the beginning of your       under the immediately preceding health plan if it was less
coverage. It is defined as:                                         than three months.
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The pre-existing condition limitation may not apply in full or   • State high risk pool
in part if you had “creditable coverage” (coverage under         • Federal or any public health care plan, including state
another, similar health plan) in the three months prior to         children’s health care plans
your effective date of coverage in SHIP.                         • Peace Corps Plan
                                                                 • Government health coverage provided for citizens or
Any lapse in coverage means you will have to satisfy the
                                                                   residents of a foreign country
pre-existing condition waiting period again. For example, if
                                                                 • Any other health insurance coverage
you do not enroll in SHIP for a quarter, then re-enroll the
following quarter, the pre-existing condition waiting period     Creditable coverage doesn’t include coverage under a
will have to be satisfied again.                                 limited policy such as an accident only coverage; disability
                                                                 income insurance; workers’ compensation; limited scope
If a claim was paid that was related to a pre-existing
                                                                 dental or vision plans; liability insurance; automobile
condition, payment will not constitute a waiver of this
                                                                 medical insurance; specified disease coverage; Medicare
exclusion for that claim or for any subsequent claim if it is
                                                                 supplemental policy; or long-term care policy.
later determined that the condition was pre-existing.
                                                                 Exceptions
How Waiting Periods Can Be Shortened Or Waived
                                                                 The pre-existing condition exclusion does not apply to any
This plan’s waiting periods for pre-existing conditions may
                                                                 of the following:
be reduced by periods of creditable coverage accrued
under other health care plans prior to the Effective Date for      •   Abortion
this plan. Most medical health care coverage is considered         •   Pregnancy, including complications, if the condition is
creditable (see list below).                                           covered under SHIP
                                                                   •   Prescription drugs
Credit will be given for prior creditable coverage that
                                                                 Genetic information will not be treated as a pre-existing
occurred without a break in coverage of more than 3
                                                                 condition in the absence of a diagnosis of the condition
months. Any coverage before a break in coverage which
                                                                 related to such information. (Genetic testing is not covered
exceeds 3 months won't be credited toward the waiting
                                                                 under SHIP.)
periods. Eligibility waiting periods won’t be considered
creditable coverage or a break in coverage.

Your prior employer or health insurance carrier will provide
a certificate of health coverage that includes information
about the prior health coverage. If you haven’t received a
certificate, or have misplaced it, you have the right to
request one from a prior employer or health carrier within
24 months of the date your coverage under that plan
terminated. If you can't get a certificate, please call
LifeWise Customer Service, because other kinds of proof of
prior coverage are also acceptable.

Creditable coverage shall mean coverage under one or
more of the following types of health care coverage:
• Group health coverage (including self-funded plans and
  COBRA)
• Individual health coverage
• Part A or B of Medicare
• Medicaid
• Military health coverage
• Indian Health Service or tribal coverage
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Section 2: Your Student Health Insurance

Your Medical Benefits
                                                                               •   Emergency room visits
SHIP is an accident and sickness plan that covers the                          •   Hospitalization
basics:
  • Doctors’ visits                                                          While using this section to learn more about your benefits,
  • Preventive care that meets the federal guidelines                        be sure to pay attention to whether benefits being
      (see Preventive Care Highlights)                                       described are for network or non-network providers, so
  • Prescription Drugs                                                       that you know which benefit level to expect when you use
                                                                             the services.
SHIP provides coverage for illness and injuries:



Medical Plan Highlights
Here are some highlights of your medical plan benefits. For details about preventive care, mental health and prescriptions,
see those sections. There’s also a lot more detail about particular services in the What’s Covered section.

 Benefits                                          SHIP Plan
                                                   Policy no. SHIP UW (03-2012)
                                                   Form no. SHIP UW T (03-2012)

                                                   Network Provider                              Non-Network Provider

 Maximum benefit per condition                                                     $200,000 per plan year

 Deductible                                        $75 per quarter; $300 per plan year maximum
 (per participant)                                 The deductible is waived for services received at Franciscan Medical Clinic - St.
                                                   Joseph


 Coinsurance                                       Plan pays 80%**                            Plan pays 60%*
                                                   You pay the other 20%**                    You pay the other 40%*

 Coinsurance maximum                               $2,500                                     $5,000
 (per participant per plan year)

 Inpatient Hospital/Surgical                       You pay a $300 copay per admission, then   You pay a $400 copay per admission, then
 (All covered medical expenses associated with     the plan pays 80%** after deductible       the plan pays 60%* after deductible
 inpatient hospitalization and surgery)

 Outpatient Expenses                               Network Provider                              Non-Network Provider

 Outpatient/Surgical                               Plan pays 80%**                            Plan pays 60%*
 (Services like office visits, diagnostic x-ray,   after deductible                           after deductible
 laboratory tests and rehabilitation therapy)

 Emergency Services

 Emergency Room                                    You pay a $25 copay, then the plan pays    You pay a $25 copay, then the plan pays
 (Copay is waived if admitted)                     80%** after deductible                     80%** after deductible
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                                                                                                                                           13


 Benefits                                            SHIP Plan
                                                     Policy no. SHIP UW (03-2012)
                                                     Form no. SHIP UW T (03-2012)

                                                     Network Provider                             Non-Network Provider

 Ambulance                                           Plan pays 80%** after deductible             Plan pays 80%** after deductible


 Preventive Care, Mental Health and Prescriptions—see the applicable sections


*Non-network benefits (non-network providers and non-preferred pharmacies) are limited to allowable charges. In addition to your percentage of the
coinsurance, you are responsible for all amounts that exceed the allowable charge.
**Of the allowable charge.




Save Money By Using Network Providers
To help you manage the cost of health care, LifeWise has                        SHIP benefits are designed to provide lower out-of-pocket
contracted with local providers and providers throughout the                    expenses when you receive care from network providers.
country to furnish covered services to you. These networks                      The provider networks are different depending upon where
consist of hospitals and other health care facilities,                          you receive care.
physicians and professionals.



Network Providers
Franciscan Medical Clinic - St. Joseph provides outpatient                      If You Are Traveling Outside of Washington, Alaska
health and medical care for all currently enrolled students                     and Oregon
and their dependents. Franciscan Medical Clinic - St.                           If you are traveling outside Washington, Alaska and Oregon
Joseph services are provided by highly trained and                              and need care, you are covered. Before seeking care,
experienced professional staff. Franciscan Medical Clinic -                     contact LifeWise for a contracted provider in your location.
St. Joseph is committed to providing you with the best                          If you use a LifeWise contracted provider, the services
outpatient health care service available.                                       provided will be paid at the network level.
Outside of Franciscan Medical Clinic - St. Joseph, the                          In some cases, you may need to submit your bill or invoice
LifeWise network in Washington, Alaska and Oregon is the                        with a claim form after service.
preferred network. You can locate a network provider
online at student.lifewiseac.com/uw/bt or by contacting
LifeWise’s customer service department at (800) 971-1491.


Understanding Your Health Insurance Plan
Coinsurance                                                                     allowable charge for network provider charges, and you pay
Coinsurance is the percentage you and the plan pay for                          the other 20%. Since both you and the plan each pay a
many covered services, like visits to your doctor when                          portion of the cost, this is called “coinsurance.” Please note
you’re sick. For example, the plan pays 80% of the                              that you’ll pay a lower coinsurance percentage and the plan
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                                                                                                                 14


will pay more when you use network doctors, hospitals, labs   expenses for prescription drugs, outpatient rehabilitation
and other providers.                                          and neurodevelopmental therapy do not count towards the
                                                              coinsurance maximum.
When you use non-contracted providers (providers that
don’t have agreements with LifeWise), you’ll also pay any     Copayments
amount above the allowable charge.                            Copayments (hereafter referred to as “copays”) are fixed
Coinsurance Maximum                                           up-front dollar amounts that you‘re required to pay.

An important feature is the “coinsurance maximum.”            Deductible

If the amount of money you have to pay out of your own        A deductible is the amount of covered medical expenses
pocket (your 20% or 40% “coinsurance”) reaches the            you have to pay before the plan pays any benefits. It’s a
annual coinsurance maximum limit ($2,500 for network          common feature of many types of insurance.
providers) , you don’t have to pay any more coinsurance for   The deductible is calculated on a quarterly basis, per plan
most covered medical expenses for the rest of the plan        year. Only one deductible will be charged per quarter, per
year. The plan takes over in this case and pays the rest of   participant, regardless of whether services are received
your eligible medical expenses for that plan year at 100%.    from UWMC, Harborview, or any other physicians or
Only coinsurance counts toward the coinsurance maximum.       hospitals.
The deductible or copayments do not count toward the          See the Definitions section for additional terms to know.
coinsurance maximum, nor do any penalties or balances
remaining after maximums have been met, like amounts
above the allowable charge. Also, covered medical
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                                                                                                                                             15



Preventive Care Highlights
Benefits for preventive care that meet the federal guidelines are not subject to any deductible, copay or coinsurance when care
is received at, or coordinated through, Franciscan Medical Clinic - St. Joseph. If you are out of the area or Franciscan Medical
Clinic - St. Joseph can’t provide a preventive service, then referred services provided at other network locations are covered at
100% of allowable charges. See the What’s Covered section for more information.

Benefits

                                                      Network Provider                             Non-Network Provider

Preventive Care                                       Plan pays 80%**                              Plan pays 60%*
Benefits for preventive care that meet the federal    after deductible                             after deductible
guidelines are not subject to any deductible, copay   You pay the other 20%**                      You pay the other 40%*
or coinsurance when care is received at, or
coordinated through, Franciscan Medical Clinic -
St. Joseph. Please see the “What’s Covered”           When care is received at, or coordinated
section for more information.                         through, Franciscan Medical Clinic - St.
                                                      Joseph, plan pays 100% (deductible is
                                                      waived).


*Non-network benefits are limited to allowable charges. In addition to your percentage of the coinsurance, you are responsible for all amounts that
exceed the allowable charge.
**Of the allowable charge.
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                                                                                                                                              16



Mental Health Highlights
This chart provides an overview of the plan’s mental health benefits. See the What’s Covered section for more information.


Benefits

                                                     Network Provider                              Non-Network Provider


Inpatient Mental Health Conditions                   $300 copay per admission; then the plan       $400 copay per admission; then the plan
                                                     pays 80%** after deductible                   pays 60%* after deductible

Outpatient Mental Health Conditions                  Plan pays 80%**                               Plan pays 60%*
There are no fees at the Counseling Center for       after deductible (deductible waived at        after deductible
student participants.                                Franciscan Medical Clinic - St. Joseph)



*Non-network benefits are limited to allowable charges. In addition to your percentage of the coinsurance, you are responsible for all amounts that
exceed the allowed amount.
**Of the allowable charge.


How to Find a Mental Health Provider                                             Important: Marital and family counseling is not covered
You can locate a network provider online at                                      under SHIP.
student.lifewiseac.com/uw/bt.
             Tacoma Student Health Insurance 2012 | 2013
                                                                                                                                             17




Prescription Drug Highlights
This chart provides an overview of the plan’s prescription drug benefits. The quarterly deductible is waived for covered drugs
under the Prescription Drug benefit. See the What’s Covered section for details.


 Prescription Drug Highlights

 LifeWise network pharmacies                           You pay the higher of:
 (up to a 30-day supply per month)                          •   Generic: 20% or $15 copay
 Your costs are always lowest for generic drugs,            •   Brand formulary: 30% or $25 copay
 and brand-name drugs on the “formulary”
                                                            •   Non-formulary: 40% or $30 copay
 (preferred drug list) cost you less than brand-name
 drugs that are not on the formulary                   Maximum copay/coinsurance that a member will pay is $100/prescription
 If you don’t show your LifeWise ID card, you pay      Medications that meet the federal guidelines are not subject to any copay or coinsurance
 the entire cost of the prescription to the pharmacy   (see the Preventive Care benefit).
 and then submit a receipt and claim form to
 LifeWise for reimbursement.

 Other (non-network) pharmacies*                       The plan will pay 50%* up to a $100 out-of-pocket maximum per prescription.
 (up to a 30-day supply per month)
 You pay the entire cost of the prescription to the
 pharmacy and then submit a receipt and claim
 form to LifeWise for reimbursement.



*Non-network pharmacy claims are paid based on billed charge

Your costs are always lowest for generic drugs and brand-                        How to Find a Pharmacy
name drugs on the “formulary.” You pay the most for drugs                        Franciscan Medical Clinic - St. Joseph has a full service
not on the formulary.                                                            pharmacy available to you.
Note: Drugs that are not covered include: drugs used for                         To find a preferred pharmacy off-campus, visit
cosmetic purposes, investigational or experimental drugs, diet                   student.lifewiseac.com/uw/bt, then click on Pharmacy.
drugs, fertility drugs, anabolic steroids used for body building,
or growth hormones. See What’s Not Covered for details.

Birth control pills are covered. When you get birth control
from Franciscan Medical Clinic - St. Joseph’s pharmacy or
a Preferred pharmacy, you don’t pay a copay or
coinsurance.
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                                                                                                                      18



What’s Covered
Below is a more detailed list of specific services covered       The plan pays the covered percentage of your covered
under SHIP.                                                      medical expenses for the rental of braces, appliances and
                                                                 durable medical equipment at 60% of allowable charges for
Abortion
                                                                 non-network providers, subject to the quarterly deductible,
After the quarterly deductible has been met, the plan covers     up to an amount equivalent to purchase price. Replacement
these charges at 80% for network providers and 80% of            of braces, appliances or durable medical equipment or for
allowable charges for non-network providers.                     batteries is not covered. (Examples of covered items:
Alcoholism/Chemical Dependency                                   wheelchair, breathing machine, brace, crutch, and splints.
                                                                 Examples of non-covered items include but are not limited
Benefits will be paid at 100% of allowable charges for           to: air conditioners, humidifiers, spas or whirlpool baths,
network providers, and 100% of the allowable charges for         orthopedic shoes, adjustable beds, orthopedic chairs,
the treatment of alcoholism/chemical dependency. Benefits        communication devices, heating pads, bed wetting devices,
will include medically necessary treatment and supporting        deluxe items or personal hygiene items.)
services provided by a state approved treatment program in
an approved treatment facility. Medically necessary              Diabetes Treatment
detoxification must also be covered as a medical                 The plan covers charges for the following appropriate and
emergency as long as you are not yet enrolled in a               medically necessary equipment and supplies for the care
chemical dependency treatment program. Detoxification            and treatment of diabetes, if recommended or prescribed by
benefits are in addition to the alcoholism/chemical              a physician. Coverage includes, but is not limited to: insulin,
dependency benefits and are paid as any other sickness.          syringes, injection aids, blood glucose monitors, test strips
                                                                 for blood glucose monitors, visual reading and urine test
Benefits are subject to all deductibles, copayment,
                                                                 strips, insulin pumps and accessories to the pumps, insulin
coinsurance, limitations, or any other provisions of the plan.
                                                                 infusion devices, prescription oral agents for controlling
Braces, Appliances and Durable Medical Equipment                 blood sugar levels, foot care appliances for prevention of
If, by reason of injury or sickness, you require the use of      complications associated with diabetes and glucagon
durable medical equipment or braces and appliances, the          emergency kits. The plan also covers charges for covered
plan will pay you the covered percentage of covered              medical expenses incurred for outpatient diabetes self-
medical expenses incurred, subject to the deductible             management training and education the same as for any
shown in the medical plan highlights; if all of the following    other sickness, including medical nutrition therapy, as
are true:                                                        ordered by a physician and provided by an approved
                                                                 provider with expertise in diabetes.
  •   Ordered by a physician;
                                                                 The plan treats charges for equipment the same way
  •   Is designed for repeated use;                              covered medical expenses are treated for any other
      Is mainly and customarily used for medical purposes;       sickness. Charges for supplies are treated the same as
  •
                                                                 covered medical expenses for prescriptions if acquired at a
  •   Is not generally of use to a person in the absence of a    pharmacy as shown in the pharmacy highlights. Benefits
      disease or injury;                                         are subject to all deductible, coinsurance, limitations and
                                                                 any provisions of the plan.
  •   Is usable only by the patient;
                                                                 Emergency Medical Evacuation and Repatriation
  •   Is not primarily for the comfort or hygiene of the
                                                                 of Remains
      patient; and
                                                                 Benefits will be provided for you and your eligible
  •   Not for prevention purposes or exercise.                   dependents and insured international students on non-
                                                                 immigrant visas and their eligible insured dependents, as
                                                                 required by the U.S. Information Agency.
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                                                                                                                        19


Emergency Medical Evacuation                                     approved infusion therapy provider. The plan covers
The plan will pay 100% of the actual expense up to a             charges at 80% for network providers and 60% of allowable
lifetime maximum of $10,000 to transport you to your home        charges for non-network providers. Drugs and supplies
country or country of regular domicile. Evacuation must be       used in conjunction with infusion therapy will be provided
recommended and approved by the attending physician.             only under this infusion therapy benefit. No other benefits
Emergency medical evacuation means after being treated           for infusion therapy will be provided under these plans. The
at a local hospital, your medical condition warrants             plan covers these charges the same way covered medical
transportation to your home country to obtain further            expenses are treated for any other sickness.
medical treatment to recover. Covered expenses are               Benefits are subject to all deductible, coinsurance,
expenses up to the maximum for transportation, medical           limitations and any provisions of the plan.
services and medical supplies necessarily incurred in
connection with your emergency medical evacuation. All           Inpatient Expenses
transportation arrangements made for your evacuation               After the quarterly deductible has been met and a $300
must be:                                                           copay per admission for network hospitals or a $400
                                                                   copay for non-network hospitals, these charges are
  •   By the most direct and economical conveyance
                                                                   covered at 80% for network providers and 60% of
  •   Approved in advance by the plan.                             allowable charges for non-network providers.

Repatriation of Remains                                            Benefits include:
In the event of your death, the plan will pay the actual
                                                                       - Hospital room and board
charges for preparing and transporting your remains to your
home country up to a maximum of $7,500. This will be                   - Consultant physician fees
done in accord with all legal requirements in effect at the
time your remains are to be returned to your home.                     - Miscellaneous hospital expense

Home Health Care and Hospice Care                                      - In-hospital doctor visit and medical expense

Benefits will be provided on the same basis as any other               - Pre-admission test
sickness or injury for home health care and hospice care for
                                                                       - Surgery
you if you were homebound and would otherwise require
hospitalization. Benefits will consist of services rendered by         - Anesthetist
home health and hospice agencies licensed by the
                                                                       - Assistant surgeon
department of social and health services when
recommended by a physician.                                            - Multiple surgical procedure expense
Home health care coverage will provide benefits for a            Mammography
maximum of 130 health care visits per plan year.
                                                                 The plan covers charges for screening and diagnostic
Hospice care coverage will provide benefits for terminally ill   mammography services when recommended by your
patients for a period of care of not more than six months.       physician or advanced registered nurse practitioner or
Limited extensions will be granted if you are facing             physician assistant. These charges are covered the same
imminent death as certified in writing by the attending          way covered medical expenses are treated for any other
physician.                                                       sickness. Benefits are subject to all deductibles,
                                                                 coinsurance, benefit maximums, limitations and all other
Benefits are subject to all deductible, coinsurance,             provisions of the plan, except as required by law. See the
limitations and any provisions of the plan.                      Preventive Care benefit.
Infusion Therapy
The plan will cover charges for services and supplies
provided for infusion therapy when furnished by an
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                                                                                                                     20


Maternity
The plan will pay benefits for the student participant and      Mental Health
their spouse or domestic partner’s covered medical              Benefits will be paid as specified in the mental health
expenses for maternity care, including hospital, surgical and   highlights section for mental health services.
medical care. Benefits are also provided for complications
of pregnancy on the same basis as any other condition for       Mental health services means medically necessary
all insured persons. The plan will cover the first two          inpatient and outpatient services provided to treat mental
ultrasounds per pregnancy. Additional ultrasounds will be       disorders covered by the diagnostic categories listed in the
covered if medically necessary. The plan covers charges         most current version of the Diagnostic and Statistical
for a minimum of 48 hours of inpatient care following an        Manual of Mental Disorders (DSM), published by the
uncomplicated vaginal delivery and a minimum of 96 hours        American Psychiatric Association, with the exception of the
of inpatient care following an uncomplicated cesarean           following categories, codes and services:
section for a mother and her newborn child in a health care
                                                                  •   Substance related disorders;
facility, unless the attending physician in consultation with
the mother, makes an alternative decision on the length of        •   Life transition problems, currently referred to as “v”
inpatient stay. The decisions must be based on accepted               codes, and diagnostic codes 302 through 302.9 as
medical practice. For a mother and newborn child who                  found in the Diagnostic and Statistical Manual of
remain in the hospital for the minimum length of time stated          Mental Disorders (DSM), 4th edition, published by the
above, the plan will pay for post-delivery care as ordered by         American Psychiatric Association; and
the attending physician in consultation with the mother. For
                                                                  •   Skilled nursing facility services, home health care,
a mother and newborn child at time of discharge, the
                                                                      residential treatment, and custodial care.
attending physician in consultation with the mother will
make a determination of the type and location of follow-up      Prescription drugs to treat mental disorders will be treated
care based on accepted medical practice, including in-          the same as other prescription drugs under the plan.
person care, services of a midwife and home health care.
                                                                Benefits are subject to all deductibles, copayment,
The plan also covers routine nursery care furnished to a        coinsurance, limitations, or any other provisions of the plan.
baby after its birth and routine well-baby examination by a
                                                                The following limitations apply:
physician furnished to the baby before the participant
mother is discharged from the hospital. In addition, the        Treatment must be provided by a properly licensed
newborn child will have the same coverage as the                physician, psychologist, psychiatrist, certified social worker
participant for the first three weeks after birth.              and counselor and credentialed nurse practitioner or other
                                                                provider as required by state law.
These charges are treated the same way covered medical
expenses for any other injury or sickness are treated.          Inpatient Mental Health
Out-of-network birth centers and midwifery are covered at         After the quarterly deductible has been met and a $300
the in-network cost share.                                        copay per admission for network facilities or a $400
                                                                  copay for non-network facilities, these charges are
Preventive prenatal testing is covered at 100%, deductible
                                                                  covered at 80% for network providers and 60% of
waived when care is received at, or coordinated through,
                                                                  allowable charges for non-network providers up to the
Franciscan Medical Clinic - St. Joseph. Care coordinated
                                                                  maximum benefit of $200,000 per condition.
through Franciscan Medical Clinic - St. Joseph must be to a
network provider for services to be covered at 100%,            Outpatient Mental Health
deductible waived. If care is not coordinated by Franciscan
                                                                  After the quarterly deductible has been met, the plan will
Medical Clinic - St. Joseph, services provided by network
                                                                  pay 80% for network providers and 60% of allowable
providers are covered at 80% of the allowable charge after
                                                                  charges for non-network providers. Outpatient mental
the deductible and 60% of the allowable charge after the
                                                                  health services provided outside the Western
deductible for non-network providers.
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                         21


  Washington area will be paid at network provider levels if            a bodily or cognitive function that was previously
  a provider contracted with LifeWise is used. There is no              normal but was lost as a result of an injury, illness or
  visit limit up to the maximum benefit of $200,000 per                 surgery; or 2) treat disorders caused by physical
  condition.                                                            congenital anomalies. Services must be furnished
                                                                        and billed by a hospital, rehabilitation facility,
Note: Only students are seen at the Counseling Center,
                                                                        physician, physical, occupational, or speech therapist,
and there is no charge for services. Additionally, the
                                                                        chiropractor, or massage therapist. Services must be
deductible does not apply for services received at
                                                                        referred by the attending physician. After 12 visits a
Franciscan Medical Clinic - St. Joseph.
                                                                        medical review will be performed to ensure additional
Midwifery                                                               sessions are medically necessary.
The plan covers charges for midwifery as specified in the           •   Diagnostic X-ray and laboratory tests (when X-rays or
maternity benefit.                                                      laboratory tests are performed at Franciscan Medical
                                                                        Clinic - St. Joseph but referred to and/or billed from
  After the quarterly deductible has been met, the plan
                                                                        non-Franciscan Medical Clinic - St. Joseph providers,
  covers these charges at 80% for network providers, and
                                                                        the applicable coinsurance and deductible will apply)
  80% of allowable charges for non-network providers.

Neurodevelopmental Therapy Services                                 •   Hospital outpatient department and other services

The plan covers charges for medically necessary                     •   Anesthetist
neurodevelopmental therapy treatment to restore and
                                                                    •   Assistant surgeon
improve function for children age 6 and under. This benefit
includes maintenance services where significant                     •   Consultant physician fees
deterioration of the child’s condition would result without the
                                                                    •   Surgery
service. Benefits will be provided as follows:
                                                                    •   Multiple surgical procedure expense
  •   Physical therapy, speech therapy and occupational
      therapy will be covered on an outpatient basis, and           •   Radiation therapy

  •   Inpatient Hospital and skilled nursing facility benefits      •   Chemotherapy
      will be covered for a neurodevelopmental therapy
      admission when care cannot be safely provided on an           •   Blood-borne pathogen protocol
      outpatient basis.                                             •   After the quarterly deductible has been met, these
The child’s physician must submit, for advance approval                 charges are covered at 80% for network providers
and periodic review, a written treatment plan, that                     and 60% of allowable charges for non-network
specifically describes the services to be provided. No                  providers.
benefits will be provided for custodial care, maintenance         Phenylketonuria Treatment
(except as specified), non-medical self-help, recreational,
                                                                  Benefits shall be provided on the same basis as any other
educational or vocational therapy, gym, or swim therapy.
                                                                  sickness for the mineral and vitamin-enriched formulas
After the quarterly deductible has been met, the plan covers
                                                                  necessary for the treatment of phenylketonuria. Benefits are
these charges at 80% for network providers and 60% of
                                                                  subject to all deductible, coinsurance, limitations and any
allowable charges for non-network providers.
                                                                  provisions of the plan.
Outpatient Expenses
                                                                  Pre-Admission Testing
Benefits include:
                                                                  The plan will pay benefits for covered medical expenses
  •   Doctor’s office visit (while not confined in a hospital)    made by a hospital for use of its outpatient facilities for tests
                                                                  ordered by a physician. The tests must be performed as a
  • Rehabilitation Therapy - Means medically necessary
      treatments provided to either 1) restore and improve
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                      22


planned preliminary to your admission as an inpatient for         However, covered medical expenses do not include
surgery in that same hospital.                                    experimental or investigational drugs or any drug that the
                                                                  Food and Drug Administration has determined to be
However:
                                                                  contraindicated for the specific treatment for which the drug
  •   The test must be necessary for, and consistent with,        has been prescribed.
      the diagnosis and treatment of the condition for which
                                                                  Prescriptions at LifeWise Network Pharmacies
      surgery is to be performed
                                                                    •   If you don’t show your LifeWise ID card, you must pay
  •   Reservations for a hospital bed and for an operating              the entire cost of the prescription to the pharmacy
      room must be made prior to the date the tests are                 and then submit an itemized prescription receipt and
      done                                                              claim form to LifeWise for reimbursement. The
      The surgery actually takes place within seven days of             address of where to send the form is located on the
  •
                                                                        LifeWise claim form.
      pre-surgical tests, and
                                                                  Prescriptions at Other Locations
  •   You are physically present at the hospital for the
      tests.                                                        •   The participant must pay the entire cost of the
                                                                        prescription to the pharmacy and then submit an
The plan covers these charges the same as covered                       itemized prescription receipt and claim form to
medical expenses for any other sickness.                                LifeWise for reimbursement. The address of where to
Prescription Drugs                                                      send the form is located on the LifeWise claims form.

Prescription drugs are covered as described in the                Prenatal Testing
prescription drugs highlights. They are only covered when         The plan covers charges for prenatal diagnosis of
prescribed by a physician. Prescriptions are filled or refilled   congenital disorders of a fetus by means of screening and
up to a 35-day supply for each medication, once per month.        diagnostic procedures during pregnancy when such
The following limitations apply:                                  services are determined to be medically necessary as
                                                                  determined by Washington State Board of Health
The plan only covers drugs that are approved for the              Standards. The plan covers these charges the same as
treatment of the participant’s injury or sickness by the Food     covered medical expenses for any other sickness.
and Drug Administration. A drug is covered if prescribed for
a treatment of a covered injury or sickness for which it has      Preventive Care
not been approved by the Food and Drug Administration if          Preventive services are defined as follows:
the drug is recognized as being medically appropriate for               Evidence-based items or services with a rating of “A”
                                                                    •
the specific treatment for which the drug has been                      or “B” in the current recommendations of the U.S.
prescribed in one of the following established reference                Preventive Task Force (USPSTF). Also included are
compendia:                                                              additional preventive care and screenings for women
  •   American Medical Association Drug Evaluations                     not described above in this paragraph as provided for
                                                                        in comprehensive guidelines supported by the Health
  •   American Hospital Formulary Service Drug                          Resources and Services Administration.
      Information
                                                                    •   Immunizations as recommended by the Advisory
  •   United States Pharmacopoeia Drug Information, or                  Committee on Immunization Practices of the Centers
  •   It is recommended by a clinical study or review article           for Disease Control (CDC) and Prevention.
      in two major peer-reviewed professional journals that         •   Evidence-informed infant, child and adolescent
      present data supporting the use or uses to be                     preventive care and screenings provided for in the
      generally safe and effective.                                     comprehensive guidelines supported by the Health
                                                                        Resources and Services Administration.
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                                                                                                                        23


    •   Women’s preventive care as defined by regulation for    reconstructive breast surgery are covered the same as
        women’s health.                                         hospital and surgical benefits otherwise provided by this
                                                                plan. Benefits will be limited by any maximum benefit
Benefits include, but are not limited to:
                                                                amounts, any deductible, copayment, coinsurance,
• Routine physical exams
                                                                limitations or other provisions of the plan.
• Well-baby and well-child exams
                                                                Skilled Nursing Facility
• Physical exams related to school, sports and
  employment                                                    If you require continuing treatment in a skilled nursing
•   Preventive diagnostic services                              facility or a rehabilitation center following hospitalization, the
•   Screening mammograms                                        plan will pay the covered percentage of your covered
                                                                medical expenses for treatment in a skilled nursing facility
•   Immunizations
                                                                or rehabilitation center. The plan covers room and board,
•   Healthy eating assessments and nutritional                  routine nursing care and other services and supplies during
    counseling.
                                                                the confinement including physical therapy, speech therapy
                                                                and occupational therapy. The services must be medically
A full list of covered preventive services is available by
                                                                necessary as a continuation of treatment for the condition
calling LifeWise’s Customer Service at (800) 971-1491.
                                                                for which you were previously hospitalized. You must be
The list also provides the guidelines on how often the
                                                                admitted to the skilled nursing facility or rehabilitation center
services should be provided and who should receive
                                                                within 24 hours following a medically necessary hospital
them. Not all services recommended or billed by your
                                                                stay.
doctor as part of your routine physical may comply with
these guidelines. The list and guidelines are subject to        After the quarterly deductible has been met and a $300
change as required by law and regulation.                       copay per admission for network facilities or a $400 copay
                                                                for non-network hospitals, these charges are covered at
Benefits for preventive care that meet the federal
                                                                80% for network providers and 60% of allowable charges
guidelines aren't subject to any deductible, copay or
                                                                for non-network providers up to a combined maximum of 90
coinsurance when services are received at, or care is
                                                                days per plan year for network and non-network services.
coordinated through, Franciscan Medical Clinic - St.
Joseph. If you are out of the area or Franciscan Medical        Sterilization
Clinic - St. Joseph can't provide a preventive service,         The plan covers charges for sterilization procedures. But,
then referred services provided at other network                the plan does not cover charges for the reversal of a
locations are covered at 100% of allowable charges.             sterilization procedure. Services that meet the federal
Please see the Preventive Care Highlights for how non-          guidelines are not subject to any deductible, copay or
referred preventive care provided at other locations is         coinsurance when care is received at, or coordinated
covered. Non-preventive services are covered the same           through, Franciscan Medical Clinic - St. Joseph. See the
as any other service. Please see the Preventive Care            Preventive Care benefit.
Highlights.
                                                                Transgender Medical Treatment
Reconstructive Breast Surgery
                                                                The plan covers charges for transgender medical treatment
Benefits will be paid for reconstructive breast surgery
                                                                including but not limited to medically necessary laboratory
(including prosthesis) resulting from a mastectomy that         tests and gender reassignment surgeries. The plan covers
resulted from disease, illness, or injury; regardless of when
                                                                these charges the same as covered medical expenses for
the mastectomy or the condition that made the mastectomy        any other sickness, up to a maximum $35,000 per plan
necessary was covered by this plan. Benefits will be paid
                                                                year. However, any non-network coinsurance related to
for all stages of one reconstructive breast reduction on the
                                                                transgender medical treatment accrues toward the $2,500
non-diseased breast to make it equal in size to the
                                                                network coinsurance maximum.
diseased breast after definitive reconstructive surgery on
the diseased breast has been performed. Benefits for
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                 24


Transgender Surgical Services Criteria                          Transplants
Surgical gender reassignment services will be considered        The plan covers charges the same as for any other
medically necessary if the criteria listed under Surgical       sickness for medically necessary services and supplies
Procedures, Breast Surgery or Genital Surgery are met.          after meeting the pre-existing condition requirements
Surgical Procedures                                             relating to the following eligible organ transplants:
For all surgical procedures approved in the most current          •   Heart
Standards of Care published by the World Professional             •   Heart/lung combined
Association for Transgender Health (WPATH), transgender
                                                                  •   Kidney
benefits are available if you are at least 18 years old and
diagnosed as having gender identify disorder (ICD code            •   Kidney/pancreas
302.5).                                                           •   Lungs—single/bilateral
Breast Surgery                                                    •   Liver
For breast surgery (mastectomy, breast reduction, chest           •   Cornea
reconstruction or augmentation mammoplasty) you must be           •   Bone marrow or other form of stem cell rescue.
at least 18 years old and diagnosed as having gender            The plan does not cover any donor expenses.
identify disorder (ICD code 302.5). You must also have one
letter of recommendation for surgery from a mental health
professional.
Genital Surgery

For genital surgery (orchiectomy, penectomy, vaginoplasty,
clitoroplasty, labiaplasty, hysterectomy, salpingo-
oophorectomy, vaginectomy, metoidioplasty, scrotoplasty,
urethroplasty, testicular prosthesis placement, and
phalloplasty) all the following criteria must be met:

  •   You are at least 18 years old and diagnosed as
      having gender identify disorder (ICD code 302.5)

  •   You have successfully lived and worked within the
      desired gender role full time for at least 12 months

  •   You have received recommendations for surgery from
      two separate mental health professionals, at least
      one of which includes an extensive report. One
      Master’s degree level professional is acceptable if the
      second letter is from a psychiatrist or PhD clinical
      psychologist.

  •   The surgery is recognized as medically necessary
      within the most current Standards of Care published
      by the World Professional Association for
      Transgender Health WPATH).
            Tacoma Student Health Insurance 2012 | 2013
                                                                                                                         25



What’s Not Covered—Exclusions and Limitations
Here is a list of services the plan does not cover. No                      neurodevelopmental disabilities in children age 6
Benefits will be paid for services or supplies for treatment                and under as stated under the
for or related to, contributed to, or resulting from the                    Neurodevelopmental Therapy rider.
following:
                                                                        •   Nonmedical services, such as spiritual,
  •   Acupuncture—services, supplies and/or treatment                       bereavement, legal or financial counseling

  •   Bungee jumping or flight in any kind of aircraft, except          •   Recreational, vocational, or educational therapy;
      while riding as a passenger on a regularly scheduled                  exercise or maintenance-level programs
      flight of a commercial airline
                                                                        •   Social or cultural therapy
  •   Cosmetic procedures, except cosmetic surgery
                                                                        •   Gym or swim therapy
      required to correct an injury for which benefits are
      otherwise payable under this plan or for newborn or           •   Custodial care: care provided in rest homes, health
      adopted children                                                  resorts, homes for the aged, halfway houses or
                                                                        places mainly for domiciliary or custodial care;
  •   Counseling, educational or training services
                                                                        extended care in treatment or substance abuse
      •   Community wellness classes and programs that                  facilities for domiciliary or custodial care
          promote positive health and lifestyle choices.
                                                                    •   Experimental or Investigational Services. Any service
          Examples of these classes and programs are adult,
                                                                        or supply that LifeWise Assurance Company
          child, and infant CPR, safety, babysitting skills,
                                                                        determines is experimental or investigational on the
          back pain prevention, stress management, bicycle
                                                                        date it’s furnished, and any direct or indirect
          safety and parenting skills, except for services that
                                                                        complications and aftereffects thereof. LifeWise
          meet the standard for preventive medical services
                                                                        determination is based on the criteria stated in the
          in the Preventive Care benefit.
                                                                        definition of Experimental Services Or Supplies
      •   Counseling, education or training services, except            (please see the “Definitions” section in this booklet).
          as stated under the Alcoholism/Chemical                       This exclusion does not apply to certain experimental
          Dependency Treatment rider, Diabetes Treatment                or investigational services provided as part of
          benefit, Mental Health rider or for services that             oncology clinical trials. Benefit determination is
          meet the standards for preventive medical services            based on the criteria specified in the definition of
          in the Preventive Care benefit. This includes                 “Oncology Clinical Trials” in the Definitions section.
          vocational assistance and outreach; social, sexual
                                                                    •   Genetic testing
          and fitness counseling; and caffeine dependency.
          Also not covered is family and marital                    •   Hearing examinations or hearing aids; or other
          psychotherapy, except when medically necessary                treatment for hearing defects and problems. “Hearing
          to treat the diagnosed mental or substance use                defects” means any physical defect of the ear that
          disorder or disorders of a member.                            does or can impair normal hearing, apart from the
                                                                        disease process
      •   Habilitative, education, or training services or
          supplies for dyslexia, for attention deficit disorders,   •   Human growth hormone
          and for disorders or delays in the development of a
          child’s language, cognitive, motor or social skills,      •   Preventive medicines, except as required by law
          including evaluations thereof. However, this
          exclusion doesn’t apply to treatment of
          Tacoma Student Health Insurance 2012 | 2013
                                                                                                                  26


•   Injury or sickness for which benefits are paid or          •   Prosthetic appliances and orthotic devices, except as
    payable under any Workers’ Compensation or                     specifically provided in the plan
    Occupational Disease Law or Act, or similar
                                                               •   Reproductive/infertility services including but not
    legislation
                                                                   limited to: fertility tests; infertility for male/female
•   Injury sustained while participating in any                    including any services or supplies rendered for the
    intercollegiate sport, contest or competition; traveling       purpose or with the intent of inducing conception.
    to or from such sport, contest or competition as a             Examples of fertilization procedures are: ovulation
    participant; or while participating in any practice or         induction procedures, in vitro fertilization, embryo
    conditioning program for such sport, contest or                transfer or similar procedures that augment or
    competition                                                    enhance your reproductive ability; impotence, organic
                                                                   or otherwise; reversal of sterilization procedures
•   Learning disabilities (excluding ADD/ADHD) and
    behavioral problems including services and supplies        •   Research or examinations relating to research
                                                                   studies, or any treatment for which the patient or the
•   Marital and family counseling
                                                                   patient’s representative must sign an informed
•   Naturopathic services                                          consent document identifying the treatment in which
                                                                   the patient is to participate as a research study or
•   On-Line or Telephone Consultations. Electronic, on-            clinical research study
    line, internet or telephone medical consultations or
    evaluations                                                •   Routine or preventive care that doesn’t meet the
                                                                   federal guidelines for preventive services described in
•   Orthotics (except for diabetic treatment)                      the Preventive Care benefit. This includes services
•   Over-the-counter drugs and take-home medications,              or items provided more often than stated in the
    except as required by law                                      guidelines.

•   Participation in a riot or civil disorder; commission of   •   Routine or palliative foot care, including hygienic
    or attempt to commit a felony; or fighting                     care; impression casting for foot prosthetics or
                                                                   appliances and prescriptions thereof; fallen arches,
•   Prescription drugs, services or supplies as follows:           flat feet, care of corns, bunions (except for bone
    •   Products used for cosmetic purposes                        surgery), calluses, toenails (except for ingrown toenail
                                                                   surgery) and other symptomatic foot problems.
    •   Drugs labeled “Caution – limited by federal law for        However, foot-support supplies, devices and shoes
        investigational use” or experimental drugs                 are covered for the treatment of diabetes.
    •   Drugs used to treat or cure baldness                   •   Sexual dysfunction—services, surgery or related
                                                                   expenses or supplies
    •   Anabolic steroids used for body building
                                                               •   Services and/or Supplies that are not medically
    •   Anorectics – drugs used for the purpose of weight
                                                                   necessary
        control
                                                               •   Services or supplies that you furnish to yourself or
    •   Fertility agents or sexual enhancement drugs, such
                                                                   that are furnished to you by a provider who is an
        as Parlodel, Pergonal, Clomid, Profasi, Metrodin,
                                                                   immediate relative. Immediate relative is defined as
        Serophene or Viagra
                                                                   spouse, natural or adoptive parent, child, sibling,
    •   Growth hormones                                            stepparent, stepchild, stepsibling, father-in-law,
                                                                   mother-in-law, son-in-law, daughter-in-law, brother-in-
    •   Refills in excess of the number specified or
                                                                   law, sister-in-law, grandparent, grandchild, spouse of
        dispensed after one (1) year of the date of the
                                                                   grandparent or spouse of grandchild.
        prescription.
            Tacoma Student Health Insurance 2012 | 2013
                                                                                                                                      27


  •   Services provided normally without charge by the                          •   War or any act of war, declared or undeclared; or
      health service of the policyholder or services covered                        while in the armed forces of any country (a pro-rata
      or provided by the student health fee                                         premium will be refunded upon request for such
                                                                                    period not covered)
  •   Skeletal irregularities of one or both jaws, including
      orthognathia and mandibular retrognathia;                                 •   Weight management services and supplies related to
      temporomandibular joint dysfunction                                           weight reduction programs, weight management
                                                                                    programs, related nutritional supplies, surgery or
  •   Treatment in a governmental hospital unless there is
                                                                                    treatment for obesity, surgery for removal of excess
      a legal obligation for the participant to pay for such
                                                                                    skin or fat.
      treatment



Your Dental Benefit
Dental Highlights

This chart provides an overview of the SHIP dental benefits. You may see any licensed dentist. Benefits are paid at 100% of
allowable charges after dental deductible is met up to the plan year maximum benefit.

 Benefits                                        SHIP

 Annual maximum benefit                          $500 per plan year


 Deductible                                         •   $25 per plan year per participant
                                                    •   $75 per plan year per family

 Eligible Services (these are things that are eligible to be covered under your annual maximum benefit)

 Dental X-rays                                   Yes
                                                 Once every three-year period for complete series (4 bitewing X-rays and up to 10
                                                 periapical X-rays) or panoramic film X-rays. Supplementary bitewing X-rays are covered
                                                 twice per year.

 Oral routine examinations                       Yes
                                                 Two exams per plan year

 Oral hygiene instruction                        Yes
                                                 Three sessions per lifetime

 Fissure Sealants for permanent maxillary        Yes
 (upper) or mandibular (lower) molars with       Once every three-year period per tooth
 incipient or no caries (decay) on an intact
 occlusal surface
 (children to age 13 only)

 Prophylaxis (cleaning, scaling and polishing)   Yes
                                                 Two treatments per plan year

 Space maintainers when used to maintain         Yes
 space for eruption of permanent teeth
 (children under age 12 only)
            Tacoma Student Health Insurance 2012 | 2013
                                                                                                                                        28



 Benefits                                      SHIP

 Topical application of fluoride               Yes
 (children to age 18 only)                     Two treatments per plan year

 Fillings                                      Yes
                                               Covered once in any 24 consecutive months on any given tooth surface.
                                               Resin based composite fillings on second and third molars will be reduced to the
                                               amalgam allowance.

 Crowns                                        Yes
                                               Stainless steel crowns are limited to one per tooth every two plan years.

 Non-surgical periodontal treatment            Yes
                                               Periodontal scaling and root planning and subgingival curettage are limited to a total of 2
                                               full-mouth treatments in any 12 consecutive months.
                                               Periodontal maintenance, as a follow-up to active periodontal treatment, is limited to four
                                               visits per plan year.

 Root canals                                   Yes
                                               Limited to two per arch if performed in conjunction with overdentures.

 Orthodontia                                   Not covered




Injury to Teeth
The plan will pay, after a $100 deductible per injury, 70% of             condition for details). An accidental bodily injury does not
allowable charges incurred, up to a $3,000 dental maximum                 include teeth broken or damaged during the act of chewing
per injury, arising as a direct result of an accidental bodily            or biting on foreign objects. Coverage includes necessary
injury to sound, natural teeth. The accidental bodily injury              procedures for dental diagnosis and treatment rendered
must occur while you are eligible (see pre-existing                       within 12 months of the date of the accident.
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                   29



What’s Not Covered—Dental Exclusions
No benefits will be paid for the following:                      •    Oral hygiene instruction (except as listed above),
                                                                      dietary instruction and home fluoride kits
  •   All other services not specifically included in the
      dental benefits section as covered dental benefits         •    Orthodontia

  •   Behavior management                                        •    Orthognathic and/or maxillofacial surgery. Jaw
                                                                      augmentation or reduction regardless of origin of the
  •   Caries susceptibility tests
                                                                      condition, including any direct or indirect
  •   Charges by any person other than a licensed dentist             complications and after effects thereof.
      or licensed denturist, except for a licensed hygienist
                                                                 •    Plaque control program
  •   Charges for any services in excess of the
                                                                 •    Prescription drugs, medications, or supplies not
      percentages and maximums listed
                                                                      related to covered dental care. For prescriptions
  •   Charges incurred to comply with Occupational Safety             dispensed by a pharmacy, please see the medical
      and Health Administration (OSHA) requirements                   prescription drug benefit.

  •   Charges that would not have been made or that the          •    Replacement of a space maintainer previously paid
      participant would have had no obligation to pay in the          for by the plan
      absence of these plans
                                                                 •    Services for temporomandibular joint disorder (TMJ),
  •   Cleaning of a prosthetic appliance                              including diagnostic services and x-rays related to
                                                                      temporomandibular joints (jaw joints)
  •   Consultations
                                                                 •    Services to the extent that they are not
  •   Local anesthesia, sterilization, and supplies billed as         recommended and approved by the licensed dentist
      separate charges (these services and items are                  attending the participant, charges above the
      included in allowance for procedure)                            allowable charge as determined by the plan; charges
  •   Materials not approved by the American Dental                   for failure to keep scheduled appointments, or for
      Association                                                     filling out claim forms

                                                                 •    Study and diagnostic models




Your Vision Benefit
Vision Highlights
SHIP includes a vision benefit. You can see any licensed        Vision
vision services provider. You are responsible for any
                                                                Service                      Benefit
charges above the maximums. These services are not
subject to the quarterly deductible.                            Routine eye exam             100% up to a maximum of $150
                                                                                             per plan year

                                                                Vision hardware (includes    100% up to a maximum of $200
                                                                frames, lenses, contacts)    per plan year
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                        30


Section 3: More Information

Claims
When You Need to File a Claim                                     request that we review that adverse benefit
                                                                  determination through a formal, internal appeals
Many providers will submit their bills to us directly.
                                                                  process.
However, if you ever need to submit a claim to us yourself,
follow these simple steps.                                        This plan's appeals process will comply with any
                                                                  requirements as necessary under state and federal laws
How to File a Claim                                               and regulations.
1. Print a claim form from the LifeWise website at                What is an adverse benefit determination?
   http://student.LifeWiseac.com/uw/bt/forms.aspx .
                                                                  Adverse benefit determination means a denial,
2. Complete the claim form using the information on the           reduction, or termination of, or a failure to provide or
   itemized bill from the provider.                               make payment for a benefit, in whole or in part for
3. Send the claim form and the itemized bill to LifeWise          services based on:
   Assurance Company. (LifeWise). (Keep copies of the             •   An individual's eligibility to participate in a plan or
   itemized bills for your records.)                                  health insurance coverage, or rescission of
4. You should receive reimbursement for the covered                   coverage;
   percentage of the services you received.                       •   A determination that a benefit is not a covered
Claims must be submitted within 120 days. Failure to give             benefit;
sufficient proof of your claim (for instance, itemized receipts   •   A preexisting condition exclusion, or other limitation
with claim details) within the time required shall not                on otherwise covered benefits;
invalidate nor reduce any claim if it was not reasonably
                                                                  • A determination that a benefit is experimental,
possible to give proof within such time. However, proof
                                                                    investigational, or not medically necessary or
must be given as soon as reasonably possible and in no
                                                                    appropriate.
event later than one year.
                                                                  When You Have An Appeal
When You Have A Complaint
                                                                  After you are notified of an adverse benefit
You can call or write to us when you have a complaint
                                                                  determination, you can request an internal appeal. Your
about a benefit or coverage decision, customer service,
                                                                  internal appeal will be reviewed by individuals who were
or the quality or availability of a health care service. We
                                                                  not involved in the initial adverse benefit determination.
recommend, but don't require, that you take advantage
                                                                  If the adverse benefit determination involved medical
of this process when you have a concern about a benefit
                                                                  judgment, the review will be provided by a health care
or coverage decision. There may be times when
                                                                  provider. They will review all of the information relevant
Customer Service will ask you to submit your complaint
                                                                  to your appeal and will provide a written determination.
for review through the formal internal appeals process
outlined below.                                                   Who may file an internal appeal?
We will review your complaint and notify you of the               You or your authorized representative, someone you
outcome and the reasons for our decision as soon as               have named to act on your behalf, may file an appeal.
possible, but no later than 30 days from the date we              To appoint an authorized representative, you must sign
received your complaint.                                          an authorization form and mail or fax the signed form to
When You Disagree With a Benefit Decision                         the address or phone number listed below. This release
                                                                  provides us with the authorization for this person to
If we declined to provide benefits in whole or in part, and       appeal on your behalf and allows our release of
you disagree with that decision, you have the right to
                                                                  information, if any, to them.
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                  31


Please call us for an Authorization For Appeals form.          mailing or faxing to the address and fax number listed
You can also print a copy of the form by going to our          above. Please provide us with this information as soon
web site at student.lifewiseac.com.                            possible.
How do I file an internal appeal?                              Can I request copies of information relevant to my
                                                               claim?
You or your authorized representative may file an appeal
by calling Customer Service or by writing to us at the         You can request copies of information relevant to the
address listed below. We must receive your appeal              adverse benefit determination. We will provide this
request within 180 calendar days of the date you were          information, as well as any new or additional information
notified of the adverse benefit determination.                 we considered, relied upon or generated in connection to
                                                               your appeal as soon as possible and free of charge.
You can mail your written appeal request to:
                                                               You will have the opportunity to review this information
    LifeWise Assurance Company                                 and respond to us before we make our decision.
    Attn: Appeals Department, MS 123                           What happens next?
    P.O. Box 91102                                             We will review your appeal and provide you with a
    Seattle, WA 98111-9202                                     written decision as stated below:
Or, you may fax your request to:                               • Expedited appeals, as soon as possible, but no later
                                                                 than 72 hours after we received your request. We will
    Appeals Department                                           call, fax or email and will follow up with a decision in
    (425) 918-5592                                               writing.
If you need help with filing an appeal, or would like a        • All other appeals, within 14 days of the date we
copy of the appeals process, please call Customer                received your request. If we need additional time to
Service at the number listed on the front of this booklet.       review your request, we may extend the review to no
You can also get a description of the appeals process by         more than 30 days.
visiting our web page at student.lifewiseac.com.               If we uphold the initial decision, you will be provided
We will acknowledge our receipt of your request in             information about your right to an external review.
writing.                                                       Appeals Regarding Ongoing Care
What if my situation is clinically urgent?                     If you do not agree with our decision to change, reduce
If your provider believes that your situation is clinically    or end coverage of ongoing care for a previously
urgent under law, your appeal will be conducted on an          approved course of treatment because the service or
expedited basis. A clinically urgent situation means one       level of service is no longer medically necessary or
in which your health may be in serious jeopardy or, in         appropriate, you may appeal this decision. After receipt
the opinion of your physician, you may experience pain         of your appeal, we will suspend our denial of benefits
that cannot be adequately controlled while you wait for a      during the appeal period. Our provision of benefits for
decision on your appeal. You may request an expedited          services received during the appeal period does not, and
internal appeal by calling Customer Service at the             should not be construed to, reverse our denial. If our
number listed on the front of this booklet.                    initial decision is upheld, you must repay us all amounts
                                                               that we paid for such services. You may also be
If your situation is clinically urgent, you may also request   responsible for any difference between our allowable
an expedited external review at the same time you              charge and the provider's billed charge.
request an expedited internal appeal.
                                                               When Am I Eligible for External Review?
Can I provide additional information for my appeal?
                                                               If you are not satisfied with the final internal adverse
You may supply additional information to support your          benefit determination based on medical necessity,
appeal at the time you file an appeal or at a later date by    experimental or investigational care, appropriateness,
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                  32


health care setting, level of care or effectiveness of a      What happens next?
covered benefit, you have the right to have our decision      LifeWise is bound by the decision made by the IRO. If
reviewed by an Independent Review Organization (IRO).         the IRO overturned our final internal adverse benefit
An IRO is an independent organization of qualified            determination, we will implement their decision in a
medical reviewers who are certified by the state of           timely manner.
Washington Department of Health to review medical and
other relevant information. There is no cost to you for an    If the IRO upheld our decision, there is no further review
external review.                                              available under this plan's internal appeals or external
                                                              review process. However, you may have other remedies
We will send you an External Review Request form at           available under state or federal law, such as filing a
the end of the internal appeal process notifying you of       lawsuit.
your right to an external review. We must receive your
written request for an external review no later than 4        Other resources for help
months from the date you received the final internal          If you have questions about a claim or your appeal
adverse benefit determination. Your request must              rights, you can contact LifeWise customer service for
include a signed waiver granting the IRO access to            assistance at the number listed on the front of this
medical records and other materials that are relevant to      booklet. If you are not satisfied with our decisions and
your request.                                                 wish to make a complaint or need help filing an appeal
You can request an expedited external review when your        or external review, you can also contact the Washington
provider believes that your situation is clinically urgent    Consumer Assistance Program at any time during this
under law. Please call Customer Service at the number         process.
listed on the front of this booklet to request an expedited   Washington Consumer Assistance Program
external review.                                              5000 Capitol Blvd
We will notify the IRO of your request for an external        Tumwater, WA 98501
review. The IRO will let you, your authorized                 Call: 1-800-562-6900
                                                              Email: cap@oic.wa.gov
representative and/or your attending physician know
where additional information may be submitted directly
to the IRO and when the information must be provided.         Subrogation and Recovery Rights
We will forward your medical records and other relevant       The plan shall be subrogated to all rights of recovery which
materials for your external review to the IRO. We will        any participant has against any person, firm or corporation
also provide the IRO with any additional information they     to the extent of payments for benefits made by the plan to
request that is reasonably available to us.                   or for benefits of a participant. The participant (you) shall
How will I know when the IRO has completed the                execute and deliver such instruments and papers as may
external review?                                              be required and do whatever else is necessary to secure
                                                              such rights to the plan. The plan shall recover only that
Once the external review is completed, the IRO will           portion paid by the plan which is in excess of the amount
notify you and us in writing of their decision as stated      necessary to fully compensate the participant (you) for all
below:                                                        expenses incurred as a result of your loss. The participant
• Expedited external review, as soon as possible but no       (you) shall be permitted to recoup his/her general damages
  later than 72 hours after receiving the request. The        which is not limited to medical expenses, from the tort-
  IRO will notify you and us immediately by phone, e-         feasor before subrogation provided that in so doing, the
  mail or fax and will follow up with a written decision by   participant (you) does not prejudice the rights of the plan.
  mail.
                                                              Right of Recovery
• All other external reviews, within 15 days after
  receiving all necessary information, or 20 days after       Payments made by the plan which exceed the covered
                                                              medical expenses (after allowance for deductible and
  receiving the referral, whichever is earlier.
                                                              coinsurance clauses, if any) payable hereunder shall be
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                        33


recoverable by the plan from or among any persons, firms            •   School accident and similar coverages that cover
or corporations to or for whom such payments were made                  students for accidents only, including athletic injuries,
or from any insurance organizations who are obligated in                either on a twenty-four hour basis or on a “to and
respect of any covered injury or sickness as their liability            from school” basis
may appear.
                                                                    •   Benefits provided in long term care insurance policies
Excess Provision                                                        for non-medical services, for example, personal care,
No benefit under this plan is payable for any expense                   adult day care, homemaker services, assistance with
incurred for injury or sickness which is paid or payable by             activities of daily living, respite care, and custodial
other valid and collectible insurance. Covered medical                  care or for contracts that pay a fixed daily benefit
expenses exclude amounts not covered by the primary                     without regard to expenses incurred or the receipt of
carrier due to penalties imposed on the participant for failing         services
to comply with plan provisions or requirements.                     •   Medicare supplement policies
Other valid and collectible insurance includes:                     •   A state plan under Medicaid

  •   Group, individual, or blanket insurance contracts and         •   A governmental plan, which, by law, provides benefits
      subscriber contracts, and                                         that are in excess of those of any private insurance
                                                                        plan or other nongovernmental plan
  •   Group and individual coverage through closed panel
      plans.                                                        •   Automobile insurance policies required by statute to
                                                                        provide medical benefits; or
Other valid and collectible insurance does not include:
                                                                    •   Benefits provided as part of a direct agreement with a
  •   Hospital indemnity coverage benefits or other fixed
                                                                        patient-provider primary care practice as defined by
      indemnity coverage
                                                                        state law (section 3, chapter 267, Laws of 2007).
  •   Accident-only coverage
  •   Specified disease or specified accident coverage
  •   Limited benefit health coverage


Plan and Policy Information
The benefits are underwritten and administered by LifeWise        Policy Number
Assurance Company (LifeWise). A copy of the master                  •   SHIP UW (03-2012)
contract is available online through the Student Health
Insurance Office website.                                         Plan Numbers
                                                                    •   SHIP UW T (03-2012)
Note: This plan is a blanket disability policy. Coverage
provided is “excess” only and does not contain a
“coordination of benefits” provision.




Definitions
Affordable Care Act -The Patient Protection and                   Alcoholism/chemical dependency—a sickness
Affordable Care Act of 2010 (Public Law 111-148) as               characterized by a physiological or psychological
amended by the Health Care and Education Reconciliation           dependency, or both, on a controlled substance and/or
Act of 2010 (Public Law 111-152)                                  alcoholic beverages. It is further characterized by a frequent
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                      34


or intense pattern of pathological use to the extent the user     Services From Ambulatory Surgical Centers: The
exhibits a loss of self-control over the amount and               allowable charge will be based on the weighted
circumstances of use; develops symptoms of tolerance or           average of rates that we have negotiated with our
physiological and/or psychological withdrawal if use of the       network ambulatory surgical centers.
controlled substance or alcoholic beverage is reduced or          Services From Hospitals (Acute Facilities): The
discontinued; and the user’s health is substantially impaired     allowable charge will be equivalent, on a weighted
or endangered or his or her societal or economic function is      average basis, to similar services received from
substantially disrupted.                                          contracted hospitals. In making this determination, we
Allowable Charge/Allowable Charges—means one of the               review claims experience from our network hospitals.
following:                                                        As charges, services and patients' severities vary from
   • Network Providers                                            hospital to hospital, we apply a “case mix and severity”
                                                                  adjustment to neutralize these differences, using
      The allowable charge is the amount that these               weights which have been developed for this purpose.
      providers have agreed to accept as payment in full          These weights are from external independent sources.
      for medically necessary covered services under
      the terms of their network contracts.                       Services From Skilled Nursing Facilities, Extended
                                                                  Care Facilities, Birthing Centers, Kidney Dialysis
      Network providers agree not to bill you for any             Centers, Rehabilitation Facilities, And Others Sub-
      charges above the amount agreed upon by the                 Acute Facilities: The allowable charge will either be
      provider, except for any cost-shares, amounts in            based on our standard fee schedule for network
      excess of stated benefit maximums, and charges              facilities of that type, a percentage of the billed charge
      for noncovered services for which you are                   or on the weighted average of rates we have
      responsible.                                                negotiated with network providers of the same type.
      Your cost-shares and amounts applied toward               • For services received outside Washington, Alaska
      benefit maximums will be calculated on the basis            and Oregon
      of the allowable charge.                                    The allowable charge will be the lesser of the
  •   Non-network Providers                                       provider’s billed charge or what Medicare would have
                                                                  allowed for the same services.
      When you receive services from non-network
      providers, the allowable charge shall be the                When you receive services from non-network
      lesser of the provider’s billed charge, or one of the       providers, you're responsible for any amount above
      following:                                                  the allowable charge, and for any cost-shares,
                                                                  amounts in excess of stated maximums, and charges
                                                                  for non-covered services.
• For covered services received in Washington,
  Alaska or Oregon:                                               LifeWise reserves the right to determine the amount
  Services From Professional Providers: The                       allowed for any given service or supply.
  allowable charge is derived from LifeWise’s standard          Children—your children, step-children, children for whom
  fee schedule used for negotiations with network               responsibility was assumed through domestic partner
  physicians. This standard fee schedule is developed           registration, foster children, adopted children from the date
  using Medicare Relative Value Units (RVUs)                    of placement in your home and who depend on the
  multiplied by a conversion factor. For some services,         participant for their support, children which you have been
  our allowable charge is a percentage of Medicare’s            granted legal custody, and children which you have legal
  allowable or the Solvay Average Wholesale Price.              obligation to provide coverage due to a court order.
  The conversion factor and the percentage of Medicare
  incorporate information including, but not limited to,        When a court ordered guardianship or foster care
  trends in Medicare RVUs, geographic differences in            terminates or expires, the child is no longer an eligible child.
  provider costs, and overall medical price inflation.
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                     35


Court ordered guardianship and foster care expires at the       expenses before payment of any benefit is made. The
child’s age of majority.                                        deductible will apply per quarter as specified in the plan.

The attainment of the limiting age of 26 will not operate to    Dentist—any dental or medical practitioner, who is properly
terminate the coverage of such child while the child is and     licensed or certified under the laws of the state and is acting
continues to be both:                                           within the scope of his or her license, to:

  •   Incapable of self-sustaining employment by reason of        •   Render dental services
      developmental disability or physical handicap; and,
                                                                  •   Perform dental surgery, or
  •   Chiefly dependent upon you for support and
      maintenance.                                                •   Administer anesthetics for dental surgery.

Coinsurance—see Understanding Your Health                       Dentist also includes a licensed denturist who is acting
Insurance Plan.                                                 within the scope of his or her license.

Copayment—the specified dollar amount you must pay for          Doctor—see Physician.
specified charges. The copayment is separate from and not       Domestic partner—the partner of the student participant
a part of the deductible or coinsurance.                        who:
Covered charge or covered medical expense—are                     •   For registered same-sex and transgender
reasonable charges that are:                                          partners:
  •   Not in excess of allowable charges                              - Has a close personal relationship with the
  •   Not in excess of the maximum benefit amount                     participant in lieu of a lawful marriage
      payable per service as specified                                - Is not married to anyone
  •   Made for services and supplies not excluded under               - Is considered the participant’s “sole domestic
      the plan                                                        partner”
  •   Made for services and supplies that are a medical               - Is, along with the participant, responsible for each
      necessity                                                       other’s common welfare
  •   Made for services included in the plan, and                     - Is not related by blood to the participant as close as
  •   In excess of the amount stated as a deductible, if any.         would bar marriage

Covered medical expenses will be considered “incurred”                - Is barred from a lawful marriage with the student
only:                                                                 participant. (This includes a partner of the same sex,
                                                                      or if one or both partners are transgender.)
  •   When the covered services are provided; and
                                                                  •   For registered opposite sex partners not eligible
  •   When a charge is made to you for such services.                 unless they are 62 years of age or older, and:
Coinsurance/Covered percentage—the part of a covered                  - Has a close personal relationship with the
charge that is payable by the plan after the deductible or            participant in lieu of a lawful marriage
copayment has been met.
                                                                      - Is not married to anyone
Copayment—the specified dollar amount you must pay for
                                                                      - Is considered the participant’s “sole domestic
specified charges. The copayment is separate from and
                                                                      partner”
not a part of the deductible or coinsurance.
                                                                      - Is, along with the participant, responsible for each
Deductible—an amount to be subtracted from the amount
                                                                      other’s common welfare
or amounts otherwise payable as covered medical
             Tacoma Student Health Insurance 2012 | 2013
                                                                                                                             36


        - Is not related by blood to the participant as close as         •     No reliable evidence demonstrates that the service
        would bar marriage.                                                    is effective, in clinical diagnosis, evaluation,
                                                                               management or treatment of the condition
Emergency care - A medical screening examination to
evaluate a medical emergency that is within the capability               •     The service is the subject of ongoing clinical trials
of the emergency department of a hospital, including                           to determine its maximum tolerated dose, toxicity,
ancillary service routinely available to the emergency                         safety or efficacy. However, services that meet the
department.                                                                    standards set in the definition of "Oncology Clinical
                                                                               Trials" below in this section will not be deemed
Further medical examination and treatment to stabilize the
                                                                               experimental or investigational.
member to the extent the services are within the capabilities
of the hospital staff and facilities or, if necessary, to make           •     Evaluation of reliable evidence indicates that
an appropriate transfer to another medical facility.                           additional research is necessary before the service
"Stabilize" means to provide such medical treatment of the                     can be classified as equally or more effective than
medical emergency as may be necessary to assure, within                        conventional therapies
reasonable medical probability that no material deterioration
of the condition is likely to result from or occur during the            •     Reliable evidence includes but is not limited to
transfer of the member from a medical facility.                                reports and articles published in authoritative peer
                                                                               reviewed medical and scientific literature as
Essential Health Benefits - Benefits defined by the                            determined by LifeWise Assurance Company.
Secretary of Health and Human Services that shall
include at least the following general categories:                 Formulary/nonformulary—a formulary prescription is
ambulatory patient services, emergency care,                       included on the approved list of drugs most commonly
hospitalization, maternity and newborn care, mental                utilized by Rubenstein Pharmacy and the UWMC. A
health and chemical dependency services, including                 nonformulary prescription is not included on this list, and
behavioral health treatment, prescription drugs,                   would need to be special-ordered.
rehabilitative and habilitative services and devices,              Hospital—a licensed or properly accredited general
laboratory services, preventive and wellness services              hospital which:
and chronic disease management and pediatric
services, including oral and vision care. The designation            •       Is open at all times
of benefits as essential shall be consistent with the                •       Is operated primarily and continuously for the
requirements and limitations set forth under the                             treatment of and surgery for sick and injured persons
Affordable Care Act and applicable regulations as                            as inpatients
determined by the Secretary of Health and Human
Services.                                                            •       Is under the supervision of a staff of one or more
                                                                             legally qualified physicians available at all times
Experimental Services or Supplies— Experimental or
                                                                     •       Continuously provides on the premises 24-hour
investigational services include a treatment, procedure,
                                                                             nursing service by Registered Nurses
equipment, drug, drug usage, medical device or supply that
meets one or more of the following criteria as determined            •       Provides organized facilities for diagnosis and major
by us:                                                                       surgery on the premises, and

    •     A drug or device that can’t be lawfully marketed           •       Is not primarily a clinic, nursing, rest or convalescent
          without the approval of the U.S. Food and Drug                     home, or an institution specializing in or primarily
          Administration, and hasn’t been granted such                       treating mental disorders.
          approval on the date the service is provided
                                                                   Injury—a bodily injury that is:
    •     The service is subject to oversight by an
                                                                     •       Directly and independently caused by specific
          Institutional Review Board
                                                                             accidental contact with another body or object
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                     37


  •   Unrelated to any pathological, functional, or structural      the patient’s illness, injury or disease; and
      disorder                                                    • Not primarily for the convenience of the patient,
  •   A source of loss                                              physician, or other health care provider, and not more
                                                                    costly than an alternative service or sequence of
  •   Treated by a physician within one year after the date         services at least as likely to produce equivalent
      of accident; and                                              therapeutic or diagnostic results as to the diagnosis or
  •   Sustained while you are covered under this plan.              treatment of that patient’s illness, injury or disease.
                                                                  For these purposes, “generally accepted standards of
All injuries sustained in one accident, including all related
                                                                  medical practice” means standards that are based on
conditions and recurrent symptoms of these injuries will be
                                                                  credible scientific evidence published in peer reviewed
considered one injury. Injury does not include loss that
                                                                  medical literature generally recognized by the relevant
results wholly or in part, directly or indirectly, from disease
                                                                  medical community, physician specialty society
or other bodily infirmity. Covered medical expenses
                                                                  recommendations and the views of physicians practicing in
incurred as a result of an injury that occurred prior to this
                                                                  relevant clinical areas and any other relevant factors.
plan’s effective date will be considered a sickness under
this plan.                                                        Network providers— Healthcare providers that have a
                                                                  contractual arrangement with LifeWise Assurance
International student—a student classified as a non-
                                                                  Company.
immigrant. For example, students holding visa types: “F”
(Student), “J” (Exchange Visitor), “B” (Tourist), or “A”          Non-network providers—Healthcare providers that do not
(Diplomat).                                                       have a contractual arrangement with LifeWise Assurance
                                                                  Company.
Loss—a medical expense covered by SHIP as a result of
injury or sickness as defined in these plans.                     Oncology Clinical Trials – Treatment that is part of a
                                                                  scientific study of therapy or intervention in the treatment
Medical emergency— A medical condition which
                                                                  of cancer being conducted at the phase 2 or phase 3
manifests itself by acute symptoms of sufficient severity
                                                                  level in a national clinical trial sponsored by the National
(including severe pain) such that a prudent layperson, who
                                                                  Cancer Institute or institution of similar stature, or trials
possesses an average knowledge of health and medicine,
                                                                  conducted by established research institutions funded or
could reasonably expect the absence of immediate
                                                                  sanctioned by private or public sources of similar stature.
attention to result in 1) placing the health of the individual
                                                                  All approvable trials must have Institutional Review
(or with respect to a pregnant woman, the health of the
                                                                  Board (IRB) approval by a qualified IRB.
woman or her unborn child) in serious jeopardy; 2) serious
impairment to bodily functions; or 3) serious dysfunction of      The clinical trial must also be to treat cancer that is
any bodily organ or part.                                         either life-threatening or severely and chronically
                                                                  disabling, has a poor chance of a positive outcome using
Examples of a medical emergency are severe pain,
                                                                  current treatment, and the treatment subject to the
suspected heart attacks and fractures. Examples of a non-
                                                                  clinical trial has shown promise of being effective.
medical emergency are minor cuts and scrapes.
                                                                  An “oncology clinical trial” does not include expenses for:
Medically necessary—Those covered services and
supplies that a physician, exercising prudent clinical            • Costs for treatment that are not primarily for the care
judgment, would provide to a patient for the purpose of             of the patient (such as lab services performed solely
preventing, evaluating, diagnosing or treating an illness,          to collect data for the trial).
injury, disease or its symptoms, and that are:                    • Any drug or device provided as part of a phase I
• In accordance with generally accepted standards of                oncology clinical trial
  medical practice;                                               • Services, supplies or pharmaceuticals that would not
• Clinically appropriate, in terms of type, frequency,              be charged to the member, were there no coverage.
  extent, site and duration, and considered effective for         • Services provided in a clinical trial that are fully funded
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                     38


   by another source                                             •   Any condition that is diagnosed, treated or
The member for whom benefits are requested must be                   recommended for treatment within the three months
enrolled in the trial at the time of treatment for which             immediately prior to your effective date under the plan.
coverage is being requested. We encourage you, your            Sickness—a sickness, illness or disease that causes loss,
provider, or the medical facility to ask us for a benefit      and originates while the insured person is covered under
advisory to determine coverage before you enroll in the        this plan. All related conditions and recurrent symptoms of
clinical trial.                                                the same or similar condition will be considered one
                                                               sickness. Covered medical expenses incurred as a result
Participants—an insured student and his or her covered
                                                               of an injury that occurred prior to this plan’s effective date
dependent(s) eligible for and enrolled in SHIP or SHIP Plus.
                                                               will be considered a sickness under this plan.
Per condition aggregate maximum—the total amount of
benefits payable for each injury or sickness under the plan.   Student participant—a student of the Tacoma campus of
                                                               the University of Washington who is eligible and insured for
Physician—a legally qualified licensed practitioner of the     coverage under SHIP.
healing arts who provides care within the scope of his/her
                                                               The plan, us, our—means LifeWise Assurance Company.
license, other than a member of the person’s immediate
family. The term “member of the immediate family” means        You, your or yours—means the insured student
any person related to you within the third degree by the       participant.
laws of consanguinity or affinity.

Plan year—the 12-month period beginning and ending on
the effective dates of the plan.

Pre-existing condition—

  •   The existence of symptoms within the 3 months
      immediately prior to your effective date under the
      plan, or
          Tacoma Student Health Insurance 2012 | 2013
                                                                                                                                39


Section 4: Directory

Organization                                                                        Contact Information

Plan Contacts

Student Health & Wellness                                                           MAT 354
                                                                                    (253) 692-4522
                                                                                    ssallean@uw.edu
www.tacoma.washington.edu/studentaffairs/SHW/shw_insurance.cfm

LifeWise Assurance Company                                                          LifeWise Assurance Company
                                                                                    PO Box 91059
https://student.lifewiseac.com/uw/bt                                                Seattle, WA 98111
                                                                                    Toll Free (800) 971-1491
                                                                                    TDD for Hearing-Impaired (800) 842-5357


University of Washington associated providers

Franciscan Medical Clinic - St. Joseph                                              1708 S. Yakima Avenue, Suite 100
                                                                                    Tacoma, WA 98405
http://www.fhshealth.org/Doctors-and-Clinics/Clinics-by-city/                       (253) 627-9151


UW Physicians                                                                       Located all over the Puget Sound area
                                                                                    (206) 543-6420
http://uwmedicine.washington.edu/Patient-Care/Our-Services/UWP/Pages/default.aspx


UW Medical Center                                                                   1959 NE Pacific
                                                                                    Seattle, WA
http://uwmedicine.washington.edu/Patient-Care/Locations/uwmc/Pages/default.aspx     (206) 598-3300


Harborview Hospital                                                                 325 Ninth Avenue
                                                                                    Seattle, WA
http://uwmedicine.washington.edu/Patient-Care/Locations/HMC/Pages/default.aspx      (206) 744-3000


Children’s Hospital                                                                 4800 Sand Point Way NE
                                                                                    Seattle, WA 98105
http://www.seattlechildrens.org/                                                    (206) 987-2000


Seattle Cancer Care Alliance                                                        825 Eastlake Avenue East
                                                                                    Seattle, WA 98109
http://www.seattlecca.org/                                                          (206) 288-7222

Other Providers

LifeWise Assurance Company                                                          LifeWise Assurance Company
                                                                                    PO Box 91059,
https://student.LifeWiseac.com/uw/bt                                                Seattle, WA 98111
                                                                                    Toll Free (800) 971-1491
                                                                                    TDD for Hearing-Impaired (800) 842-5357

Additional Plans for UW Students

GAIP                                                                                Mailing Address:
                                                                                    Benefits Office, University of Washington
http://www.washington.edu/admin/hr/benefits/insure/gaip/index.html                  Box 359556
                                                                                    Seattle, WA 98195-9556
                                                                                    (206) 543-2800
           Tacoma Student Health Insurance 2012 | 2013
                                                                                                                           40



 Organization                                                                         Contact Information

 Students studying abroad—Study Abroad program                                        International Programs & Exchanges
                                                                                      University of Washington
 http://studyabroad.washington.edu/                                                   1410 NE Campus Parkway
                                                                                      459 Schmitz Hall Box 355815
                                                                                      Seattle, WA 98195-5815
                                                                                      (206) 221-4404



Useful Links
Here are quick links to forms, information, providers:

 Plan Contacts                                 Links

 Student Health & Wellness                     http://www.tacoma.washington.edu/studentaffairs/SHW/shw_insurance.cfm


 LifeWise Assurance Company                    https://student.LifeWiseac.com/uw/bt

 Forms and Additional Info

 Medical/Dental/Vision Claim Form              http://student.LifeWiseac.com/uw/bt/forms.aspx
                                               (click on Medical Claim Form)


 Prescription Drug Claim Form                  http://student.LifeWiseac.com/uw/bt/forms.aspx
                                               (click on Prescription Drug Reimbursement)


 Financial Aid                                 http://www.washington.edu/students/osfa/currentug/forms.html

 Master Contracts                              SHIP

								
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