Student Gold Health Insurance Plan

2012–2013

The Student Gold Health Insurance Plan offers quality health insurance coverage for CU-Boulder students (and their spouses/domestic partners and dependents), with primary care at Wardenburg Health Center on campus as well as coverage for services outside of Wardenburg Health Center.

NOTE: The information below is a summary of the plan. Please view the brochure for complete details, exclusions, and a benefits chart.

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Plan Eligibility

Eligible students must actively attend classes for at least the first 31 days after the date for which coverage is purchased.

  • Degree-seeking undergraduate students enrolled in six or more credit hours and graduate students enrolled in one credit hour or more are eligible and are automatically enrolled in the Gold Plan.
  • Continuing Education, ACCESS, and Study Abroad students enrolled in six or more credit hours, and paying the base student fee and Wardenburg Health Center fees, may be eligible to enroll in the Gold Plan and must do so by visiting Wardenburg Health Center.
  • Students approved for the Time Off or Stay Connected programs for medical reasons are eligible to enroll in the Gold Plan and must do so by visiting Wardenburg Health Center.

Plan Summary

  • Wardenburg Health Center (WHC) is the Primary Care Provider with no deductible or co-pay for covered services inside WHC.
  • $40 co-pay per visit for specialists outside of WHC (co-pays do not apply to the deductible)
  • $250 deductible per person per policy year for services outside WHC using an in-network provider; once deductible is met, 20 percent co-insurance applies.
  • $500 deductible per person per policy year for services outside WHC using a out-of-network provider; once deductible is met, 50 percent co-insurance applies.
  • Prescription benefit
  • National and international coverage
  • Out-of-pocket maximum of $5,000 for PPO network and $10,000 for non-PPO network per plan year
  • Annual policy maximum of $1 million
  • Referrals to specialists in the community (required for most services outside of WHC)
  • Optional additional coverage available
  • The plan administrator is AmeriBen

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Dates of Coverage and Costs

Fall: 8/18/2012 – 12/31/2012
Spring & Summer: 1/1/2013 – 8/17/2013
Summer Only: 6/1/2013 – 8/17/2013

Enrolling in the Student Gold Health Insurance Plan for fall and spring semesters provides a full year of coverage. Spring coverage extends through August 17, 2013, regardless of whether the student graduates in May or is not taking summer classes.

 

Gold Plan Costs for 2012-13

The premium will be included on your tuition bill each semester. Summer semester is included in spring semester coverage.

  Student Spouse/Domestic Partner Dependent
Fall 2012 $1,363 $3,169 $1,805
Spring 2013 $1,363 $3,169 $1,805
Summer 2013 Only $682 $1,585 $903

*Spouses/same gender domestic partners must be enrolled in the same plan as the student.

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Covered Services INSIDE Wardenburg Health Center

No co-pay or deductible

Medical Clinic

  • Primary care for illnesses and injuries not requiring services of an outside specialist
  • Routine immunizations
  • Travel Clinic services (excluding specialty travel immunizations)
  • Men’s health services including one annual exam per policy year
  • Sexually Transmitted Infection testing and education
  • Allergy injections
  • Nutrition services

Laboratory and X-Ray

  • Coverage for laboratory services ordered by a WHC provider
  • Coverage for X-ray services

Psychological Health & Psychiatry

  • Initial assessment
  • Individual, couples, and group therapy
  • Substance abuse evaluation and treatment
  • Eating disorders evaluation and treatment
  • Medical evaluation and medication management
  • Stress management services
  • Urgent care

Sports Medicine

  • 25 physical therapy visits per policy year
  • 10 chiropractic visits per policy year
  • Orthopedic surgeon consultations

Women’s Health Services

  • One annual exam per policy year
  • Gynecology services and consultations not requiring the services of a specialist outside of WHC
  • Birth control consultations
  • Human Papillomavirus (HPV) vaccinations
  • Sexually Transmitted Infection testing and education

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Covered Services OUTSIDE Wardenburg Health Center

Eye Exam

  • No co-pay or deductible
  • One routine eye exam per plan year through a Wardenburg-contracted optometrist (College Optical). Glasses, contacts, and contact lens fittings are not covered.

Specialist Visits (REFERRAL REQUIRED)

  • The patient must first be seen by a WHC provider to obtain a referral to an appropriate PPO provider.
  • For a complete list of in-network providers: Inside Colorado: https://www.cofinity.net or Outside of Colorado: myfirsthealth.com

In-Network Providers:

  • $40 co-pay per visit for specialists outside of WHC (co-pays do not apply to the deductible).
  • A $250 deductible per person per policy year will apply for some office visit procedures; surgeries; imaging such as MRIs, ultrasounds, and CTs; and lab services.
  • Co-insurance applies after the deductible is met. The Gold Plan pays 80 percent and the policy holder is responsible for the remaining 20 percent up to the out-of-pocket maximum.

Out-of-Network Providers:

  • A $500 deductible per person per policy year will apply.
  • Co-insurance applies after the deductible is met. The Gold Plan pays 50 percent and the policy holder is responsible for 50 percent up to the out-of-pocket maximum.

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Prescription Benefit

  • A $50 deductible per person per policy year will apply.
  • Once the deductible is met, co-pays will apply: $15 for generic, $30 for brand, and $60 for nonformulary prescriptions.
  • $100,000 maximum benefit per year
  • The prescription drug program is managed by Express Scripts: www.expressscript.com

Urgent Care/Emergency/Hospitalization

  • $75 co-pay per urgent care visit
  • $150 co-pay per emergency room visit
  • $200 charge for hospitalization per admission in addition to the deductible
  • Procedures and lab tests may be subject to the deductible and co-insurance

Optional Additional Coverage

Additional coverage options are available for students and eligible dependents who are enrolled in the Student Gold Plan:

Information on these options coming soon!

  • Spouse/domestic partner and dependent coverage
  • Club sports rider (Gold does not cover club sports injuries)
  • Supplemental Medical (Increase lifetime maximum benefit to $1 million)
  • Dental discount plan
  • Vision discount plan

Plan Brochure

Gold Plan brochure for 2012-13 (PDF)

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