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:
Date prescription filled
Name and address of pharmacy
Doctor name or ID number
NDC number (drug number)
Name of drug and strength
Quantity and days’ supply
Prescription number (Rx number)
DAW (Dispense As Written)
Amount paid
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.
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 1-888-251-6253 and/or by asking the provider.
The Preferred Provider for your plan is UnitedHealthcare Options PPO. If care is received from a Preferred Provider, any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. Reduced or lower benefits will be provided when an Out-of-Network provider is used. By using a Preferred Provider you can also save yourself some out of pocket expenses. Use this link to search for participating physicians, hospitals, facilities, medical equipment, or supplies in your local area.
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:
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:
Emergency Medical Evacuation
Dispatch of Doctors/Specialists
Medical Repatriation
Transportation after Stabilization
Transportation to Join a Hospital Insured Person
Return of Minor Children
Repatriation of Remains
May also include additional assistance services to support your medical needs, including worldwide medical referrals and medication/vaccine transfers.
Contact information is on the back of your SR ID card or in My Account
For more information on Global Emergency Services, please review the Assistance and Evacuation Benefits section in your Brochure-Certificate.
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.
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.
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:
Clip, do not staple, all bills to the completed form.
Make sure all bills or itemized receipts indicate a diagnosis code, procedure code, date of service, cost, and the provider’s tax ID number.
Mail claim to: UnitedHealthcare StudentResources P. O. Box 809025 Dallas, TX 75380
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
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:
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.
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.
Welcome to the Student & Dependent Enrollment Center! Here you will find all the necessary tools to enroll in your school sponsored policy.
We suggest you review the brochure for your rates, effective dates before starting the enrollment process. The plan’s benefits can be found in the brochure within the Schedule of Benefits section with the exclusions towards the back.
International students or other persons with a current passport who: 1) are engaged in educational activities; 2) are temporarily located outside his/her home country as a non-resident alien; 3) have not obtained permanent residency status in the U.S.; and 4) are enrolled in an associate, bachelor, master or Ph.D. degree program at a university or other educational institution, with no less than 6 credit hours (unless such school’s full-time status requires less); Visiting Scholars, Optional Practical Training Students and formal English as a Second Language program students with an F-1 or J1 visa are required to purchase this Plan unless proof of comparable coverage is furnished.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s legal spouse and dependent children under 26 years of age.
U.S. citizens are not eligible for coverage as a student or a Dependent.
Begin the enrollment process by following the instructions below
IMPORTANT INFORMATION FOR ALL DEGREE SEEKING STUDENTS & EXCHANGE 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 and eligible to purchase coverage and you choose not to enroll for coverage before the Annual/Fall Enrollment Deadline your Dependents or you, 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
TO ENROLL PLEASE CLICK ON THE FOLLOWING LINK:
Please be sure to select I AGREE when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.Â
English as Second Language , Optional Practical Training and Visiting Faculty Scholar/Dependent Enrollment Instructions
TO ENROLL PLEASE CLICK ON THE FOLLOWING LINK:
Please be sure to select I AGREE when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.Â
IMPORTANT INFORMATION FOR ALL ATHLETES 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 and eligible to purchase coverage and you choose not to enroll for coverage before the Annual/Fall Enrollment Deadline your Dependents or you, 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
TO ENROLL PLEASE CLICK ON THE FOLLOWING LINK:
Please be sure to select I AGREE when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.Â
Qualifying Life Event
Students who did not enroll themselves or their dependent(s) during the open enrollment period may be able to enroll in the policy if they experience a Qualifying Life Event.
Qualifying Life Events include:
Acquiring a new family member
Marriage/Civil Union
Divorce
Loss or change of Job
Expiration of Benefits
If you and/or your dependents meet the requirements for a Qualifying Life Event, you will need to provide the following:
Proof of qualifying life event/proof of involuntary loss of coverage
Enrollment Form
Payment
All documents and payment must be received within 30 days of the qualifying life event. After 30 days, the student or dependents 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.
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If you have any questions about the enrollment process, please call 1-877-738-5787 or CONTACT US
Welcome to the Student & Dependent Enrollment Center! Here you will find all the necessary tools to enroll in your school sponsored policy.
We suggest you review the brochure for your rates, effective dates and optional coverages before starting the enrollment process. The plan’s benefits can be found in the certificate within the Schedule of Benefits section with the exclusions towards the back.
All English Language Institute (ELI) students are required to purchase this plan unless proof of comparable coverage is furnished.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s legal spouse and dependent children under 26 years of age.
U.S. citizens are not eligible for coverage as a student or a Dependent.
Begin the enrollment process by following the instructions below.
If you have eligible Dependents in the Fall or are a student in the Fall semester and are eligible to purchase coverage and you choose not to enroll for coverage before the Annual/Fall 1/Fall 1 & 2 Enrollment Deadline, your Dependents or you will not be eligible to enroll again until the start of the next fall unless you experience a Qualifying Life Event during the year.
*Fall 2, Spring 1, Spring 1 & 2, Spring 2, and Summer enrollment periods are for new incoming and renewing students and their dependents only.
Please be sure to select YES when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.
Qualifying Life Event
Students who did not enroll themselves or their dependent(s) during the open enrollment period may be able to enroll in the policy if they experience a Qualifying Life Event.
Qualifying Life Events include:
Acquiring　a new family member
Marriage/Civil Union
Divorce
Loss or change of Job
Expiration of Benefits
If you and/or your dependents meet the requirements for a Qualifying Life Event, you will need to provide the following:
Proof of qualifying life event/proof of involuntary loss of coverage
Enrollment Form
Payment
All documents and payment must be received within 30 days of the qualifying life event. After 30 days, the student or dependents 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.
All English Language Institute (ELI) students are required to purchase this plan unless proof of comparable coverage is furnished.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s legal spouse and dependent children under 26 years of age.
U.S. citizens are not eligible for coverage as a student or a Dependent.
Begin the enrollment process by following the instructions below.
ELI Student/Dependent Enrollment Instructions
Summer: 6/22/18
TO ENROLL PLEASE CLICK ON THE FOLLOWING LINK:
Please be sure to select YES when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.
If you have any questions about the enrollment process, please call 1-888-251-6253 or CONTACT US
Welcome to the Student & Dependent Enrollment Center! Here you will find all the necessary tools to enroll in your school sponsored policy.
We suggest you review the brochure for your rates, effective dates and optional coverages before starting the enrollment process. The plan’s benefits can be found in the certificate within the Schedule of Benefits section with the exclusions towards the back.
All F1 international students are required to purchase this plan unless proof of comparable coverage is furnished.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s legal spouse and dependent children under 26 years of age.
U.S. citizens are not eligible for coverage as a student or a Dependent.
Begin the enrollment process by following the instructions below.
F1 Student/Dependent Enrollment Instructions
Annual/Fall Enrollment Deadline: 9/7/18
*Spring/Summer Enrollment Deadline: 1/25/19
OPEN ENROLLMENT PERIODS
If you have eligible Dependents in the Fall or are a student in the Fall semester and are eligible to purchase coverage and you choose not to enroll for coverage before the Annual/Fall Enrollment Deadline, your Dependents or you 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/Summer enrollment period is for new incoming and renewing students and their dependents only.
Please be sure to select YES when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.Â
Qualifying Life Event
Students who did not enroll themselves or their dependent(s) during the open enrollment period may be able to enroll in the policy if they experience a Qualifying Life Event.
Qualifying Life Events include:
Acquiring a new family member
Marriage/Civil Union
Divorce
Loss or change of Job
Expiration of Benefits
If you and/or your dependents meet the requirements for a Qualifying Life Event, you will need to provide the following:
Proof of qualifying life event/proof of involuntary loss of coverage
Enrollment Form
Payment
All documents and payment must be received within 30 days of the qualifying life event. After 30 days, the student or dependents 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.
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If you have any questions about the enrollment process, please call 1-888-251-6253 or CONTACT US
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.
International Graduate Students Enrolled in 9 or More Credit Hours
Are required to purchase this plan unless proof of comparable coverage is furnished.
Please Note:Â If you waive the insurance you will not be eligible to enroll until the following school year unless you experience a Qualifying Life Event.
Student Waiver Instructions
Annual Waiver Deadline: 9/15/17
Spring/Summer Waiver Deadline (New Incoming Students Only): 1/31/18
After you verify that you are required to waive and have other insurance you will need:
Your current health insurance plan ID card,
Your health insurance brochure or plan description (or you might want mom & dad’s phone number handy to help answer some of the waiver questions). There might be a few questions about your current plan.
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:
Approval e-mail– Your waiver was approved. You should print this e-mail and save it with your records.
Denial e-mail– Your waiver was denied. If you would like us to look this over or if you answered a question incorrectly, please contact us.
Qualifying Life Event
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
Welcome to the Student & Dependent Enrollment Center! Here you will find all the necessary tools to enroll in your school sponsored policy.
We suggest you review the brochure for your rates, effective dates before starting the enrollment process. The plan’s benefits can be found in the brochure within the Schedule of Benefits section with the exclusions towards the back.
International Graduate Students enrolled in 9 credit hours or more are required to purchase this plan unless proof of comparable coverage is furnished.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s legal spouse and dependent children under 26 years of age.
U.S. citizens are not eligible for coverage as a student or a Dependent.
Begin the enrollment process by following the instructions below.
Student/Dependent Enrollment Instructions
Annual Enrollment Deadline: 9/15/17
*Spring/Summer Enrollment Deadline (New Incoming Students Only): 1/31/18
 IMPORTANT INFORMATION FOR STUDENTS & DEPENDENTS
Open Enrollment Periods for all Dependents and Students: If you have eligible Dependents in the Fall or, are a student in the fall and eligible to purchase coverage and you choose not to enroll for coverage before the Annual Enrollment Deadline your Dependents or you, will not be eligible to enroll again until the start of the next fall unless you experience a Qualifying Life Event during the year
*The Spring/Summer enrollment period is for new incoming students and their dependents only.
TO ENROLL PLEASE CLICK ON THE FOLLOWING LINK:
Â
Please be sure to select I AGREE when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.Â
Qualifying Life Event
Students who did not enroll themselves or their dependent(s) during the open enrollment period may be able to enroll in the policy if they experience a Qualifying Life Event.
Qualifying Life Events include:
Acquiring a new family member
Marriage/Civil Union
Divorce
Loss or change of Job
Expiration of Benefits
If you and/or your dependents meet the requirements for a Qualifying Life Event, you will need to provide the following:
Proof of qualifying life event/proof of involuntary loss of coverage
Enrollment Form
Payment
All documents and payment must be received within 30 days of the qualifying life event. After 30 days, the student or dependents 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.
Â
If you have any questions about the enrollment process, please call 1-888-251-6253 or CONTACT US
Welcome to the Student & Dependent Enrollment Center! Here you will find all the necessary tools to enroll in your school sponsored policy.
We suggest you review the brochure for your rates, effective dates before starting the enrollment process. The plan’s benefits can be found in the brochure within the Schedule of Benefits section with the exclusions towards the back.
International students or other persons with a current passport who: 1) are engaged in educational activities; 2) are temporarily located outside his/her home country as a non-resident alien; 3) have not obtained permanent residency status in the U.S.; and 4) are enrolled in an associate, bachelor, master or Ph.D. degree program at a university or other educational institution, with no less than 6 credit hours (unless such school’s full-time status requires less); Visiting Scholars, Optional Practical Training Students and formal English as a Second Language program students with an F-1 or J1 visa are required to purchase this Plan unless proof of comparable coverage is furnished.
Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the student’s legal spouse and dependent children under 26 years of age.
U.S. citizens are not eligible for coverage as a student or a Dependent.
Begin the enrollment process by following the instructions below.
Athlete Student/Dependent Enrollment Instructions
Annual/Fall Dependent Enrollment Deadline: 9/6/17
*Spring Dependent Enrollment Deadline: 1/31/18
*Summer Dependent Enrollment Deadline: 6/30/18
IMPORTANT INFORMATION FOR ALL ATHLETES 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 and eligible to purchase coverage and you choose not to enroll for coverage before the Annual/Fall Enrollment Deadline your Dependents or you, 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
TO ENROLL PLEASE CLICK ON THE FOLLOWING LINK:
Please be sure to select I AGREE when you are asked if you wish to share your Insurance Information with your school in order for your school to verify if you are in compliance with their Insurance Requirements.Â
Qualifying Life Event
Students who did not enroll themselves or their dependent(s) during the open enrollment period may be able to enroll in the policy if they experience a Qualifying Life Event.
Qualifying Life Events include:
Acquiring a new family member
Marriage/Civil Union
Divorce
Loss or change of Job
Expiration of Benefits
If you and/or your dependents meet the requirements for a Qualifying Life Event, you will need to provide the following:
Proof of qualifying life event/proof of involuntary loss of coverage
Enrollment Form
Payment
All documents and payment must be received within 30 days of the qualifying life event. After 30 days, the student or dependents 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.
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If you have any questions about the enrollment process, please call 1-877-738-5787 or CONTACT US
