Fees for 2008 ~ 2009
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Student only
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$1,654
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Additional fee for:
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One dependent
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$2,753
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Two or more dependents
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$3,862
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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
- Medco Health Pharmacy Network
- 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, 2008 ~ August 31, 2009
- 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
- Todd Hutchinson, 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 & Co. - Claim Administration and DSGHP identification cards
Care Allies - Health Care Management
- Toll-free telephone: 1-800-348-1313
- 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
Medex Plus Travel Assistance
- Toll free within the United States of America 1-800-527-0218
- Outside of the United States of America call collect 1-410-453-6330
- On the web at www.MedexAssist.com
(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.)
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