Welcome to the Review Brochures Center! You will find everything you will need to know about your policy in your plan brochure such as eligibility, effective and termination dates, plan benefits, any exclusions or limitations, and instructions on how to file a claim.
2017 – 2018 School Year  Â
2017 – 2018 School Year
Welcome to the Find a Doctor, Hospital, or Lab Center! Whether you’re looking for a doctor, hospital, laboratory, or even medical equipment and supplies, we have the information you need, all located right here.
Preferred Providers are the physicians, hospitals, and other health care providers who have contracted to provide specific medical care at negotiated prices. You should always confirm the Preferred Provider is part of the network, as this can change without notice by calling the Company at 800-505-4160 and/or by asking the provider.
We recognize the increased need for appropriate mental health treatment for college students. We’ve partnered with United Behavioral Health (UBH) to ensure that you have access to UBH’s network of mental health care providers and facilities. UBH partners with more than 80,000 clinicians and more than 3,500 care facilities nationwide. Clinical excellence, innovation, and a relentless commitment to the most scientifically advanced health care solutions distinguish UBH as the national leader in behavioral health. To find a local Behavioral Health provider in your area, please click the link below:
College life is exciting but it can also be stressful if you are balancing class with personal responsibilities. In addition, you may be facing more serious issues like family matters, depression, or substance abuse that you can’t handle by yourself. Don’t let problems keep you from enjoying college and preparing for the future. Get the help you need today!
Health Advocate will provide you with the right tools to help you through some of life’s toughest challenges. Students can call Health Advocate’s toll-free number for confidential, short-term professional assistance, focusing on coping skills for a full range of emotional, family, and other personal issues.
A Licensed Professional Counselor will…Â
Call anytime 24/7 1-866-799-2670.
REMEMBER: Call 911 or go to the ER in an emergency.
OptumRx
As a UnitedHealthcare member, you have access to a comprehensive and quality pharmacy benefit provided through the UnitedHealthcare Pharmacy Benefit Program. UnitedHealthcare uses OptumRx. (www.optumrx.com) for certain pharmacy benefit services including your mail order benefit.
Make Informed Decisions
When selecting a medication, you and your doctor should consult the UnitedHealthcare Prescription Drug List (PDL). The PDL includes most brand and generic medications approved by the FDA. Medications may be placed on different “tiers” based on their overall value, with Tier 1 being the most affordable tier option. Click below to download and review the current Prescription Drug List:
To determine if a medication is covered by your pharmacy benefit, its tier level, and available lower cost alternatives log in to My Account.
After you log into My Account, you can access:
Choose a pharmacy that’s in the network
To get the most from your pharmacy benefit, you should use a participating retail pharmacy. There are over 60,000 retail pharmacies in our network, including both chain and independent stores located across the United States.
Use the Pharmacy Locator to find a participating retail pharmacy.
If you had to pay out of pocket for a prescription and need to receive a reimbursement please download the prescription claim form:
Filling prescriptions at pharmacies outside our network will increase your cost.
To get prescription drug information please call 1-855-828-7716.
Access the OptumRx Member FAQÂ for more information. Mail order benefits included only when applicable in your policy brochure.
To view or print the PDF files, you’ll need a free utility called Adobe Reader. If you already have Adobe Reader and still have trouble opening these forms you might need to download the most recent version of Adobe Reader.
Personal Representative Appointment Form (PRA)/Yearly Authorization Form
If you would like a parent or another specific person to assist you with filing your claim(s) and to be able to discuss details of your claim(s) with our claim department, you will need to complete and sign this form. The Yearly Authorization Form gives us permission to discuss any and all medical conditions with your Personal Representative throughout the school year. This form is filled out once and is good for every injury/sickness for the entire school year.
Specific Case Authorization Form
If you would like a parent or another specific person to assist you with filing your claim and to be able to discuss details of your claim with our claim department, you will need to complete and sign this form. The Specific Case Authorization Form gives us permission to discuss only one specific medical condition with your Personal Representative, as you would specify on the form.
This form can help you get reimbursed for all covered medical benefits which you have already paid out of pocket. Please keep in mind when you are requesting reimbursement:
Please download this form if you’ve received a request from us for more information regarding a claim submitted by your doctor or if you would like to speed up the claim process. By providing the injury/sickness information we are able to process your claim accurately and efficiently.
Mail to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025
Or fax to:Â
469-229-5625
This form is used for reimbursement of prescription drugs. If you did not present your ID card when you purchased your prescription out of pocket, you will need to submit this form for a refund. Along with this form for prescriptions filled at a network pharmacy, please attach the paid prescription receipt and the paid cash receipt to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
This form describes how we will obtain your written authorization prior to use or disclosure of your health information. We are required by law and committed to protecting the privacy of your health information. This form explains how we may use information about you and when we can disclose that information to others. You also have rights regarding your health information that are described in this notice.
Travel Assistance – UHCG Program Guide
Anytime you travel more than 100 miles from your home or to another country and experience a medical emergency, you can make a single phone call to the Operations Center for help! You call will be answered by a medically-certified crisis managers who can put in motion a vast number of emergency resources to solve any problem, 24/7.
UnitedHealth Allies Discount Services
This program provides discounts on a wide variety of health care services from a nationwide network of health care professionals and facilities. This booklet describes the products and services available to you at discounted rates. There is no additional charge to you for the discount program.
This page is for those students who wish to opt-out (waive) out of the coverage under their school’s student insurance plan. The school’s student insurance plan can only be waived if the student has coverage under another acceptable insurance plan.
The first step to waive out of your school’s student insurance coverage is to verify that you are an eligible student.
 2018-2019 Waiver Information
All F-1 and J-1 international students, including those enrolled in the English Language Institute are required to purchase this plan unless proof of comparable coverage is furnished.
Please Note: If you waive the insurance you will not be eligible to enroll until the following school year unless you experience a Qualifying Life Event.
IMPORTANT INFORMATION FOR ALL STUDENTS AND DEPENDENTS
Open Enrollment Periods for all Dependents and Students: If you have eligible Dependents in the fall or are a student in the fall semester and eligible to purchase coverage and you choose not to enroll before the Annual/Fall Enrollment Deadline, you or your Dependents will not be eligible to enroll again until the start of the next fall unless you experience a Qualifying Life Event during the year.
*Spring and Summer enrollment periods are for New Incoming and Renewing Students and their Dependents only.
After you verify that you are required to waive and have other insurance you will need:
Once you have completed the waiver form, an email will automatically be sent to the email address you provided notifying you of the waiver request decision. If you receive a(n):
If you did not enroll during your open enrollment period and have since lost coverage under your original plan, you may qualify for a Qualifying Life Event upon providing proof of involuntary loss of coverage and payment within 30 days of losing coverage.　(example: marriage, divorce, loss of job, etc) The enrollment form, check or money order, and the letter of creditable coverage must be received within 30 days of losing coverage. After 30 days the student will no longer be eligible to enroll in the plan until Fall of the following school year.
Please CONTACT US for cost and enrollment information as a Qualifying Life Event.
If you have any questions about the enrollment process, please call 1-888-251-6253 or CONTACT US
We are always happy to help in any way.
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If you would like to submit a paper claim for reimbursement for a prescription that you paid for out of pocket, please print a copy of the Generic Reimbursement Claim Form located below.
After filling out the necessary information, please read the acknowledgement carefully (located at the bottom of page) and sign and date in the space provided.
To submit a Generic Reimbursement Claim Form, please be sure your receipts are complete. In order for your request to be processed, all receipts must contain the information listed below:
This information can usually be found on the receipt which is stapled on the outside of the packaging or in some cases located inside. Your pharmacist can provide the necessary information as well.
Please mail completed form and receipt(s) to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
To view or print the PDF files, you’ll need a free utility called Adobe Reader. If you already have Adobe Reader and still have trouble opening these forms you might need to download the most recent version of Adobe Reader.
Personal Representative Appointment Form (PRA)/Yearly Authorization Form
If you would like a parent or another specific person to assist you with filing your claim(s) and to be able to discuss details of your claim(s) with our claim department, you will need to complete and sign this form. The Yearly Authorization Form gives us permission to discuss any and all medical conditions with your Personal Representative throughout the school year. This form is filled out once and is good for every injury/sickness for the entire school year.
Specific Case Authorization Form
If you would like a parent or another specific person to assist you with filing your claim and to be able to discuss details of your claim with our claim department, you will need to complete and sign this form. The Specific Case Authorization Form gives us permission to discuss only one specific medical condition with your Personal Representative, as you would specify on the form.
This form can help you get reimbursed for all covered medical benefits which you have already paid out of pocket. Please keep in mind when you are requesting reimbursement:
Please download this form if you’ve received a request from us for more information regarding a claim submitted by your doctor or if you would like to speed up the claim process. By providing the injury/sickness information we are able to process your claim accurately and efficiently.
Mail to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025
Or fax to:Â
469-229-5625
This form is used for reimbursement of prescription drugs. If you did not present your ID card when you purchased your prescription out of pocket, you will need to submit this form for a refund. Along with this form for prescriptions filled at a network pharmacy, please attach the paid prescription receipt and the paid cash receipt to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
This form describes how we will obtain your written authorization prior to use or disclosure of your health information. We are required by law and committed to protecting the privacy of your health information. This form explains how we may use information about you and when we can disclose that information to others. You also have rights regarding your health information that are described in this notice.
UnitedHealth Allies Discount Services
This program provides discounts on a wide variety of health care services from a nationwide network of health care professionals and facilities. This booklet describes the products and services available to you at discounted rates. There is no additional charge to you for the discount program.
Global Emergency Services (GES)
Have some peace of mind while traveling. We’ve heard great stories about GES saving the day for students who are studying or traveling in other states or other countries. When you’re at least 100 miles from home and you’re sick or hurt, GES steps in with immediate assistance and evacuation benefits. They can even help you get home if you need to be medically evacuated.
Some benefits of this service include:
For more information on Global Emergency Services, please review the Assistance and Evacuation Benefits section in your Brochure-Certificate.
Access your ID now by visiting My Account. From your My Account, you can print and download your ID card.
In keeping with our Go Green initiative, permanent ID cards will be available by request only. Should you wish to obtain a permanent ID card, you can request one to be shipped to you by accessing your My Account. Permanent ID cards will be shipped 24 – 48 hours of your request.
Use My Account Mobile to access your ID card from your mobile device. Students must have a set up my account to be able to access mobile site.
It would be our pleasure to assist you with any ID Card need you may have. Please feel free to visit our Customer Service center with any other questions regarding your ID card.
