2009 - 2010 Dartmouth Student Group Health Plan Fact Sheet

Fees for 2009 - 2010

Plan Features

Worldwide Coverage

• Lifetime Maximum = $2,000,000

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

• September 1, 2009 - August 31, 2010

• 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
• E-mail address: Dartmouth.Student.Health.Plan@dartmouth.edu
• Phone:  603-646-9438 and 603-646-9439

Referrals for services in the Hanover, NH Area

• Medical Services: Primary Care and Women's Health (646-9401)

• Mental Health: Counseling Department (646-9442)

Other Services

Klais & Company, Inc. - Claim Administration and DSGHP identification cards

• StatusLink to query claims on-line at www.klais.com
• Toll-free telephone: 1-800-331-1096
• E-mail address: klaisclaims@klais.com

Advo Care - Health Care Management

• Toll-free telephone: 1-800-525-8548
• Pre-certification for inpatient and emergency hospital admissions
• Maternity Notification
• Special case management

Preferred Provider Network (PPO)

• Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock Psychiatric Association.

• Other National Provider Networks contact PCHS and Multiplan at http://www.multiplan.com, or by phone at 1-800-672-2140

Medco Health Pharmacy Network

• Dick's House Pharmacy is a Medco Health Network Pharmacy
• On the web at www.Medco.com
• Member toll free telephone:  1-800-711-0917
• Pharmacy toll free telephone:  1-800-922-1557

International SOS Travel Assistance

• Coming Soon

(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.)