EligibilityAll registered students taking 12 or more credit hours, including off campus students taking Internet courses, are automatically enrolled in this Insurance Plan at registration. All other undergraduate students taking 6 or more credit hours and all graduate students taking credit hours are eligible to enroll in this Insurance Plan on a voluntary basis.

Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the spouse and unmarried children under 19 years of age who are not self-supporting. Dependent Eligibility expires concurrently with that of the Insured student.

To enroll or waive coverage, go to www.mycoppinstudentinsurance.com.

CareFirst® BlueCross® BlueShield® Student Educational Benefit Trust has arranged for you to access the CareFirst® BlueCross® BlueShield® Preferred Network in your local campus community. Using our Participating Provider Network you may access In-network savings for services rendered nationally if you require treatment or hospitalization outside the immediate area of the Coppin State University campus. You can obtain information regarding In-Network providers by accessing the “Health Ticket” at www.mycoppinstudentinsurance.com.

Premium Rates and Coverage Periods

Effective Dates of Coverage

Academic Year

9/1/2013

Fall Semester 9/1/2013

Spring/Summer Semester 1/25/2014

Waiver/Enrollment Deadline 10/1/2013 10/1/2013 3/1/2014

Students $345 $172.50 $172.50

Spouse $1,053 $526.50 $526.50

Each Child $623 $311.50 $311.50

The above rates include a School Administrative fee. This plan has an early effective date of June 30, 2013 for new incoming 2013-2014 students taking summer classes. Please contact Student Educational Benefit Trust about this early enrollment period.

Waiver ProcessStudents covered by other comparable health insurance, may decline the Coppin State University student health insurance by completing the online waiver form. For your waiver request to be considered, you must complete this form by the waiver deadline of October 1, 2013. Once the waiver request is reviewed, students will be notified via email whether their waiver request has been approved or denied.

Self-funded student health plans, such as those offered through the Student Educational Benefit Trust, are not presently subject to regulations under Health Care Reform (HCR), inclusive of the Patient Protection & Affordable Care Act (PPACA) and Health Care & Education Reconciliation Act of 2010 (HCERA), the Employee Restoration Act of 1987 (ERISA) and/or the Consolidated Restoration Act of 1986 (COBRA). Although it may not meet all the minimum standards for individual and group policies required by HCR, it is designated per se by the United States Department of Health and Human Services (HHS) as minimum essential coverage for the purpose of the complying with the individual minimum essential coverage requirements under Health Care Reform. Although many of the program benefits meet or exceed requirements that would otherwise apply to group or individual plans, you may be eligible up to the age of twenty-six (26) for coverage under a group health plan through your parent’s employer, or under an individual policy through an independent carrier or State Exchange. Contact the plan administrator for your parent’s employer, an individual health insurance issuer, or a State Exchange for more information.

This Plan is Issued by: Student Educational Benefit Trust (hereinafter “Trust”)

33479 Lake Road Avon Lake, Ohio 44012

Group Plan # 403119

Coverage/Claim Questions: 1-877-233-5159

Network Providers:

2013-2014Student Health Insurance Plan Benefit SummaryPlease Read Carefully. Go to www.mycoppinstudentinsurance.com

The Health TicketTo maximize benefits students should seek treatment at the Student Health Service or from a participating preferred provider. The SHS may utilize the Health Ticket as part of the Online Referral process.

The Health Ticket works similar to an airline e-ticket and is easy to obtain by going to www.mycoppinstudentinsurance.com.

Benefits at a Glance

Basic Maximum Benefit: $100,000 per Accident and Sickness

Coinsurance: 100% In-Network / 80% Out-of-Network (except as noted below)

Deductible: $150 per Insured per Academic Year (The $150 Deductible will be waived for treatment provided at the CHC.)

INPATIENT

Hospital Expense: 100% In-Network / 80% Out-of-Network up to $1,200 maximum per day

Surgical Expense: 100% In-Network / 80% Out-of-Network up to $1,500 maximum per Accident and Sickness

OUTPATIENT

Student Health Services: The CSU Community Health Center (CHC) will be utilized as the on-campus health facility. Covered medical expenses are paid at 100% and include one annual Physical exam and STD testing.

Surgical Expense: 100% In-Network / 80% Out-of-Network up to $1,500 maximum per Accident and Sickness.

Day Surgery Miscellaneous: 100% In-Network / 80% Out-of-Network up to $600 maximum per Accident and Sickness

Physician Visits: 100% In-Network / 80% Out-of-Network up to $35 per day, $175 maximum

Outpatient Miscellaneous Benefits (OMB): 100% In-Network / 80% Out-of-Network up to $1,000 maximum per Accident and Sickness. Includes: • X-Ray and Laboratory Expenses • Cat Scan, MRI • Chemotherapy and Radiation Therapy • Tests & Procedures: • Physiotherapy • Injections

Prescription Drugs: $10 Generic drug co-pay / $25 Brand Name drug co-pay / $50 Preferred drug co-pay up to $500 maximum per Academic Year when dispensed by a participating WellDyne network pharmacy, up to 31 day supply per prescription.

Psychotherapy: State Mandated benefit for Treatment of Mental Illness, Emotional Disorders, Drug and Alcohol Abuse.

Dental: 100% In-Network / 100% Out-of-Network to treat an injury to a sound, natural tooth only up to $100 per tooth.

Optional Dental and Vision CoverageCareFirst Dental and Davis Vision is available to all Students and Dependents at www.mycoppinstudentinsurance.com (be sure to register on this site to access the Enrollment options).

CSU Community Health Center (CHC) Referral Required Residential (Students Only)The student must use the resources of the Community Health Center first where treatment will be administered or referral issued. Expenses incurred for medical treatment rendered outside of the Community Health Center for which no prior approval or referral is obtained are excluded from coverage. A CHC referral for outside care is not necessary only under the certain conditions (see brochure for details).

24/7 Nurseline

Students can contact the Nurseline at any time and are encouraged to do so when the Student Health Center is closed or not accessible to the student. The Nurseline can provide students with information about participating providers, answer general medical questions and advise students if they should seek immediate medical attention. The Nurseline is a national hotline and is available toll-free at 1-877-233-5159.

24/7 Telephonic PhysicianYour University sponsored Student Health Insurance Plan offers a quick, integrated, inexpensive, round–the-clock solution to provide access to primary physician care when your University Health Center is not available to you or your dependents due to limited hours of operation, time of day, or the nature of your medical necessity. Access to this cross coverage service is available in all fifty states and Puerto Rico and is accessible at 1-877-233-5159.

Emergency Travel AssistanceThese services are designed to protect Coppin State University students and/or eligible dependents anywhere in the world. If you experience a medical emergency, you have access to a comprehen-sive package of emergency services. Eligible participants have immediate access to doctors, hospitals, pharmacies, and other services by simply calling the Global Assistance team 24 hours a day, 365 days a year. Global Assistance’s worldwide services include medical consultations and referrals, domestic and international hospital admission guarantees, emergency medical transportation, prescription assistance, lost luggage assistance, legal and interpreter assistance, and travel information such as visa and passport requirements, travel advisories.

Where to Find HelpContact Student Educational Benefit Trust at 1-877-233-5159 or use the “Live Chat” option at www.mycoppinstudentinsurance.com for information about:

• Student Insurance Plan Benefits • ID Cards • Claims Processing • WellDyneRx Prescription

Benefits • To Locate a

Preferred Provider • Optional Vision and Dental

Visit us today at www.mycoppinstudentinsurance.com

Important: This is a general Summary only. A complete description of the benefits and full terms and conditions may be found in the Brochure and Plan document. If any discrepancy exists between this Summary and the Brochure, the Plan document will govern and control the payment of benefits.