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2015 - 2016 DSGHP Fact Sheet

Fees for 2015 - 2016

Student only: $2,645.00
Additional fee for
One dependent: $4,485.00
Two or more dependents: $6,409.00

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 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: $250 per individual, $500 per family
    • Out of Network: $500 per individual, $1,000 per family (usual & customary charges apply)
  • Co-insurance = 20% PPO, 30% non-PPO
  • PPO offers lower fees for in-network providers. See Preferred Provider Networks below.
  • Out of Pocket Maximums
    • In Network: $2,000 per individual, $4,000 per family
    • Out of Network: $4,000 per individual, $8,000 per family (usual & customary charges apply)
  • First Dollar Coverage for Dick's House services and mental health visits
  • Health Service referral required for Hanover, NH area services

Prescription Drug Benefits

  • Dick's House Pharmacy
    • Generic Medication - $5.00 co-pay for 30 day supply
    • Name Brand Medication (no generic available) $15.00 co-pay for 30 day supply
  • 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 now combined with medical maximum out of pocket

Coverage Year

  • New Students:  August 1, 2015 - August 31, 2016
  • Returning Students:  September 1, 2015 - August 31, 2016

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

  • Mailing Address:  5 Rope Ferry Road, HB# 6143, Hanover, NH 03755-1421
  • Physical Address:  37 Dewey Field Road, 4th Floor, Rooms 403 and 408
  • Ginger Farewell Lawrence, DSGHP Manager
  • Brenda Wilson, DSGHP Administrative Assistant
  • Michelle Murray, DSGHP Administrative Assistant
  • Serena Tucker, DSGHP Administrative Assistant
  • E-mail address:
  • Phone: (603) 646-9438 and (603) 646-9449
  • Fax: (603) 646-8893

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


  • StatusLink to query claims online at
  • Toll-free telephone: (800) 331-1096
  • E-mail address:
  • Claim Administration
  • DSGHP Identification Cards
    • ID Cards will be mailed to student Hinman boxes
  • Pre-certification for inpatient and emergency hospital admissions
  • Special case management

Preferred Provider Network (PPO)

  • Cigna, at
  • Claim Submission To:  Cigna PPO, PO Box 188061, Chattanooga, TN 37422-8061

Claim Filing Information

  • Mail all Claims to: Cigna PPO, PO Box 188061, Chattanooga, TN 37422-8061
  • Mail all completed Benefit Claim Forms to: HealthSmart Benefit Solutions, Inc., 3320 W. Market St., Suite 100, Fairlawn, OH 44333
  • Electronic Claims EDI#: 62308

Express Scripts Pharmacy Network

  • Dick's House Pharmacy is an Express Scripts Network Pharmacy
  • On the web at
  • 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.

          Please Note:  ISOS guarantees medical payment but expects reimbursement from your insurer.

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: 6/26/15