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Dartmouth Student Group Health Plan Fact Sheet
Plan Year:  2013 - 2014

Fees for 2013 - 2014

Student only: $2,187.00
Additional fee for
One dependent: $3,708.00
Two or more dependents: $5,298.00

Note:  The cost of the plan for dependent coverage is in addition to the cost of the plan for student coverage.  Spouses and domestic partners enrolled into the plan are subject to an annual spouse/domestic partner health access fee of $270.00 and a new dependent enrollment application needs to be submitted to the DSGHP Office by the start of each plan year.

Plan Features

Worldwide Coverage

  • Lifetime Maximum = Unlimited

Medical Benefits

  • Annual Deductibles:
    • In Network: $200 per individual, $400 per family
    • Out of Network: $400 per individual, $800 per family (usual & customary charges apply)
  • Co-insurance in the Hanover Area = 20% PPO, 30% non-PPO
  • PPO offers lower fees for in-network providers. See Preferred Provider Networks below.
  • Out of Pocket Maximums
    • In Network: $1,000 per individual, $2,000 per family
    • Out of Network: $2,000 per individual, $4,000 per family (usual & customary charges apply)
  • First Dollar Coverage for Dick's House services and mental health visits
  • Health Service referral required for Hanover area services

Prescription Drug Benefits

  • Dick's House Pharmacy
    • Generic Medication - 100% covered
    • Name Brand Medication (no generic available) 100% covered
    • Name Brand Medication (generic available) 80% covered (deductible applies)
  • All Other Pharmacies
    • PPO Network Pharmacy - 80% covered
    • Non-PPO Network Pharmacy - 80% covered (usual & customary fees apply)
  • Deductibles & Out-Of-Pocket Maximums
    • Rx Annual Deductible - $50 per individual; $100 per Family
    • Rx Maximum out of pocket = $750 per individual; $1,000 per Family

Coverage Year

  • New Students:  August 1, 2013 - August 31, 2014
  • Returning Students:  September 1, 2013 - August 31, 2014

NOTE:  Coverage for current plan year terminates August 31, unless student submits a written application to cancel December or March. No exceptions.

On-campus Services

DSGHP Office - Enrollments, Waivers, General Assistance

  • 5 Rope Ferry Road, Hanover NH 03755
  • Ginger Farewell Lawrence, DSGHP Supervisor
  • Brenda Wilson, DSGHP Administrative Assistant
  • Michelle Murray, DSGHP Administrative Assistant
  • Deborah Heath, Summer DSGHP Administrative Assistant
  • ***, Summer DSGHP Administrative Assistant
  • E-mail address: Dartmouth.Student.Health.Plan@dartmouth.edu
  • Phone: 603/646-9438
  • Fax: 603/646-9410

Referrals for Services in the Hanover, NH Area

  • Medical Services: Primary Care and Women's Health 603/646-9401
  • Mental Health: Counseling Department 603/646-9442

Other Services

HealthSmart (Formerly Klais & Company, Inc.) - Claim Administration and DSGHP Identification Cards

AdvoCare - Health Care Management

  • Toll-free telephone: 800/525-8548
  • Pre-certification for inpatient and emergency hospital admissions
  • Maternity Notification
  • Special case management

Preferred Provider Network (PPO)

Express Scripts Pharmacy Network

  • Dick's House Pharmacy is an Express Scripts Network Pharmacy
  • On the web at www.Express-Script.com
  • Member toll free telephone: 800/711-0917
  • Pharmacy toll free telephone: 800/922-1557

International SOS Travel Assistance

As an added benefit the College provides a comprehensive program that provides emergency medical assistance with International SOS (I/SOS). Services range from telephone advice, medical referrals, legal aide, to full-scale evacuation by private air ambulance. The I/SOS network of 5,000 employees, including multilingual critical care and aero-medical specialists, operate 24 hours a day, 365 days a year from over 26 I/SOS Alarm Call-In Centers around the world.

Dental Savings Program

  • Members of the DSGHP have access to the Basix Dental Savings Program which is a network of dentists who have agreed to accept reduced charges for dental services.

(This brief summary does not constitute a promise of benefits on behalf of the Plan or Dartmouth College. Please see the Plan Document for a complete description of benefits, limitations, exclusions and special provisions.)

Last Updated: 7/22/13