Dartmouth College Health Service
5-7 Rope Ferry Road, HB 6143
Hanover, NH 03755
Phone: 603/646-9400
Fax: 603/646-9410
Dartmouth Student Group Health Plan Fact Sheet
Plan Year: 2012 - 2013
Fees for 2012 - 2013
| Student only: $2,006.00 |
| Additional fee for |
One dependent: $3,402.00
Two or more dependents: $4,861.00 |
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 $225.00 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
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, 2012 - August 31, 2013
- Returning Students: September 1, 2012 - August 31, 2013
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
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
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)
- Dartmouth-Hitchcock Medical Center, Dartmouth-Hitchcock Psychiatric Association.
- Other National Provider Networks contact PHCS and Multiplan at http://www.multiplan.com, or by phone at 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: 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.
(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.)
