The University of Texas System Student Health Insurance Plan 2017

TheUniversityofTexasSystem

SWXGHQW+HDOWKInsurancePlan

2017-2018

Underwritten by:

Blue Cross and Blue Shield of Texas

(BCBSTX)

Please read the brochure to understand your coverage.

Please see “Important Notice” on the final page of this document.

AccountNumber:

Medical: 101464

Table of Contents

Introduction 1

Privacy Notice 2

Eligibility 2

Qualifying Events 4

Effective Dates & Termination 4

How to Enroll 6

Extension of Benefits After Termination 6

Coordination of Benefits 7

Continuation of Coverage 7

Additional Covered Expenses 7

Student Health Center 7

Schedule of Benefits 8

Pre-Authorization Notification 15

Definitions 15

Exclusions and Limitations 19

Academic Emergency Services 23

BlueCard

Summary of Benefits and Coverage 24

BCBSTX Online Resources 24

Claims Procedure 25

Important Notice 26

Introduction

The University of Texas System is pleased to offer AcademicBlue, its Student Health Insurance Plan, underwritten by Blue

Cross and Blue Shield of Texas (BCBSTX) and administered by Academic HealthPlans. This brochure explains your health care

benefits, including which health care services are covered and how to use the benefits. This insurance plan protects Insured

students and their covered Dependents on or off campus for weekends, holidays, summer vacations, at home or while

traveling, 24 hours per day, for the Contract year. This Plan meets the requirements of the Affordable Care Act. The actuarial

value of this plan meets or exceeds a Gold metal level of coverage. This policy will always pay benefits in accordance with

any applicable Federal and Texas state insurance law(s).

Please keep these three fundamental plan features in mind as you learn about this policy:

• The Student Health Insurance Plan is a Preferred Provider Organization (PPO) plan. You should seek treatment

from the BCBSTX Blue Choice® Preferred Provider Organization (PPO) Network, which consists of hospitals, doctors,

and ancillary and other health care providers who have contracted with BCBSTX for the purpose of delivering

covered health care services at negotiated prices, so you can maximize your benefits under this plan. A list of

Network Providers can be found online at utsystem.myahpcare.com by clicking on the “Find a Doctor or Hospital”

link under “Benefits,” or by calling (855) 267-0214. Using BCBSTX providers may save you money.

• If your plan includes benefits covered at your Student Health Center, many of them may be provided at low or

no cost to you. Review this brochure for details.

• Participating in an insurance plan does not mean all of your health care costs are paid in full by the insurance

company. There are several areas for which you could be responsible for payment, including, but not limited to,

a Deductible, a Copayment or Coinsurance (patient percentage of Covered Expenses), and medical costs for services

excluded by the plan.

• It is your responsibility to familiarize yourself with this plan. Exclusions and limitations are applied to the coverage

as a means of cost containment (please see page 19 for more details). To make this coverage work for you, it is

helpful to be informed and proactive. Check the covered benefits in this brochure before your procedure whenever

possible. Know the specifics and communicate them to your health care provider. Review the User Guide for a step-by-step

overview of how to use your benefits.

We are here to help.

Representatives from Academic HealthPlans and BCBSTX are available to answer your questions. You may contact AHP at (855)

247-7587 for enrollment and eligibility questions and BCBSTX at (855) 267-0214 for benefit and claim questions.

AcademicBlue

is offered by Blue Cross and Blue Shield of Texas, a Division of Health Care Service

Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield

Association.

Academic HealthPlans, Inc. (AHP) is a separate company that provides program management and administrative services

for the student health insurance plans of Blue Cross and Blue Shield of Texas.

Please Note: We have capitalized certain terms that have specific, detailed meanings, which are important to help

you understand your policy. Please review the meaning of the capitalized terms in the “Definitions” section on page 15.

Privacy Notice

We know that your privacy is important to you and we strive to protect the confidentiality of your personal health

information. Under the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA), we are required

to provide you with notice of our legal duties and privacy practices with respect to personal health information. You will

receive a copy of the HIPAA Notice of Privacy Practices upon request. Please write to Academic HealthPlans, Inc., P.O.

Box 1605, Colleyville, TX 76034-1605, or call (855) 247-7587, or you may view and download a copy from the website at

utsystem.myahpcare.com.

Eligibility

The policy issued to the university is a non-renewable, one-year-term policy. However, if you still maintain the

required eligibility, you may purchase the plan the next year. It is the Covered Person’s responsibility to enroll for

coverage each year in order to maintain continuity of coverage, unless you are automatically enrolled. If you no

longer meet the eligibility requirements, contact Academic HealthPlans at (855) 247-7587 prior to your termination date.

Eligibility Requirements

Health Institution Students (Hard Waiver) - It is a requirement that all Health Science Center and medical students

are automatically enrolled in the Student Health Insurance Plan at registration unless proof of comparable coverage is

furnished.

International Students (Mandatory) - All international students holding non-immigrant visas are eligible and are

required to purchase this Student Health Insurance Plan in order to complete registration, except for those students

who certify in writing that comparable coverage is in effect under another plan as approved by The University of Texas

(UT) System Board of Regents.

The Board of Regents has authorized the assessment of a health insurance fee to each such international student

who cannot provide evidence of continuing coverage under another approved plan. This fee will be the amount of

the premium approved for the UT System Student Health Insurance Plan. Required Student Health Insurance coverage for

international students includes repatriation and Medical Evacuation benefits.

All Other Students (Voluntary) - All other fee paying students at an institution of the UT System who are taking

credit hours, graduate students working on research/dissertation or thesis, post doctorate students, scholars, fellows

and visiting scholars are eligible to enroll in this Student Health Insurance Plan.

A student must remain enrolled and paying fees through the census date, unless he or she withdraws from school due

to an Injury or Sickness and the absence is an approved medical leave. The Company maintains its right to investigate

student status and attendance records to verify that the eligibility requirements have been met. If the Company

discovers the eligibility requirements have not been met, its only obligation is refund of premium.

Enroll Eligible Dependents - Eligible students who enroll may also insure their Dependents. Dependent enrollment must

take place at the initial time of student enrollment; exceptions to this rule are made for newborn or adopted

children, or for dependents who become eligible for coverage as the result of a qualifying event. (Please see “Qualifying

Events,” see page 4, for more details.) “Dependent” means an Insured’s lawful spouse; or an Insured’s child, stepchild,

foster child, dependent grandchild or spouse’s dependent grandchild; or a child who is adopted by the Insured or

placed for adoption with the Insured, or for whom the Insured is a party in a suit for the adoption of the child; or

a child whom the Insured is required to insure under a medical support order issued or enforceable by the courts. Any

such child must be under age 26.

Coverage will continue for a child who is 26 or more years old, chiefly supported by the Insured and incapable of self-

sustaining employment by reason of mental or physical handicap. Proof of the child’s condition and dependence must be

submitted to the Company within 31 days after the date the child ceases to qualify as a dependent, under this policy,

for the reasons listed above. During the next two years, the Company may, from time to time, require proof of the

continuation of such condition and dependence. After that, the Company may require proof no more than once a year.

Dependent coverage is available only if the student is also insured. Dependent coverage must take place within the

exact same coverage period as the Insured’s; therefore, it will expire concurrently with the Insured’s policy.

A newborn child will automatically be covered for the first 31 days following the child’s birth. To extend coverage for a

newborn child past the 31-day period, the covered student must:

1) Enroll the child within 31 days of birth, and

2) Pay any required additional premium

If you’re not eligible for the Student Health Insurance Plan and would like coverage, please visit

ahpcare.com.

If you’re enrolled in Medicare due to age or disability, you are not eligible for the Student Health Insurance Plan.

Qualifying Events

Eligible students who have a change in status and lose coverage under another health care plan are eligible to enroll

for coverage under the policy, provided, within 31 days of the qualifying event, such students send to Academic

HealthPlans:

• A copy of the Certificate of Creditable Coverage, or a letter of ineligibility (lost coverage), from their previous

health insurer

• A “Qualifying Events” form, which they can download from utsystem.myahpcare.com

A change in status due to a qualifying event includes but is not limited to:

• Birth or adoption of a child

• Loss of a spouse, whether by death, divorce, annulment or legal separation

• If you are no longer covered on a family member's policy because you turned 26

Students can pay a prorated monthly rate to enroll after the enrollment period due to a qualified event if enrollment

is done within 31 days of the qualified event. The effective date will be the later of the following: the date the

student enrolls for coverage under the Policy and pays the required premium, or the day after the prior coverage

ends. To apply for coverage that is needed because of a qualifying event, you may download the “Qualifying Events

Form” from utsystem.myahpcare.com.

Effective Dates and Termination

The policy on file at the school becomes effective at 12 a.m. Central time at the university’s address on the later of the

following dates:

The effective date of the policy; or

The date after premium is received by the Company or its authorized representative.

The coverage provided with respect to the Covered Person shall terminate at 11:59 p.m. Central time on the

earliest of the following dates:

1) The last day of the period through which the premium is paid;

2) The date the eligibility requirements are not met.

You must meet the eligibility requirements listed herein each time you pay a premium to continue insurance coverage.

To avoid a lapse in coverage, your premium must be received within 31 days after the coverage expiration date.

Refunds of premium are allowed only upon entry into the Armed Forces, and the Company receives proof of

active duty. Otherwise all premiums received by the Company will be considered fully earned and nonrefundable.

Annual Effective and Termination Dates

Please visit utsystem.myahpcare.com to view your specific campus coverage periods.

Effective Date

From

Through

Annual

07/01/2017

06/30/2018

Annual

08/01/2017

07/31/2018

Annual

08/15/2017

08/14/2018

Annual

09/01/2017

08/31/2018

Open Enrollment Periods

The open enrollment periods during which students may apply for coverage for themselves, and/or their spouse

and/or dependents, is as follows:

From

Through

Fall

06/01/2017

10/01/2017

Spring

11/01/2017

02/28/2018

Summer

04/01/2018

06/15/2018

Note: Voluntary Students and/or Dependents

Students and/or dependents enrolling during the Open Enrollment Period, prior to the effective date of the plan, will

be effective on the 1st day of the selected coverage period. Enrollment after the effective date of the selected

coverage period, during the Open Enrollment Period, will be effective the day the company receives the premium.

Renewal Notice

It is the student’s responsibility to make a timely renewal payment to avoid a lapse in coverage. Please refer to your

enrollment form to review the payment options you selected as a reminder of the enrollment periods and effective

dates for your campus. Mark your calendar now to avoid any lapse in coverage. All Insureds who enroll for periods

of less than one year will be mailed a renewal notice, to the Insured’s last known address, to submit their next

premium payment; however, it is the Insured’s responsibility to make a timely renewal payment.

PLEASE NOTE: Renewal notices will not be mailed from one policy year to the next. If you maintain your student

status, you will be eligible to enroll in the following year’s policy. If you do not maintain your student status, you

may be eligible for continuation of coverage (please see page 7 for more information). Contact your campus office

that is responsible for student insurance before the policy termination date for information on continuation of

coverage.

Coverage period notice: Coverage Periods are established by the University and subject to change from one Policy

year to the next. In the event that a coverage period overlaps another coverage period, the prior coverage period will

terminate as of the effective date of the new coverage period. In no case will an eligible member be covered under

two coverage periods within the same group.

How to Enroll

Enroll in the Student Health Insurance Plan today!

Students who have purchased the Student Health Insurance can access their insurance information any time day or

night at utsystem.myahpcare.com.

The secure site provides online access to coverage information, print-friendly replacement ID cards and benefit

information. Visit utsystem.myahpcare.com and:

1) Find your Campus

2) Click on Student Log in

3) Enter a User Name and Password

4) Follow the onscreen prompts

After creating your account, you may log into the system and check your coverage at your convenience. You can

update your personal status, review effective dates, cost and plan coverage.

You can access these online services without having to log in:

• Email us with a question or comments

• Look up a Network Provider

• Review plan coverage

• Contact us at (855) 247-7587

Extension of Benefits After Termination

The coverage provided under the plan ceases on the termination date. However, if a Covered Person is hospital-

confined on the termination date for a covered Injury or Sickness for which benefits were paid before the

termination date, the Covered Expenses for such covered Injury or Sickness will continue to be paid provided the

condition continues. However, payments will not continue after the earlier of the following dates: 90 days after the

termination date of coverage, or the date of the Insured’s discharge from the hospital. The total payments made for

the Covered Person for such condition, both before and after the termination date, will never exceed the maximum

benefit. After this “Extension of Benefits” provision has been exhausted, all benefits cease to exist, and under no

circumstances will further payments be made.

Coordination of Benefits

Under a Coordination of Benefits (COB) provision, the plan that pays first is called the primary plan. The secondary

plan typically makes up the difference between the primary plan’s benefit and the Covered Expenses. When one plan

does not have a COB provision, that plan is always considered the primary plan, and always pays first. You may still

be responsible for applicable Deductible amounts, Copayments and Coinsurance.

Continuation of Coverage

All Insureds who have graduated or are otherwise ineligible for coverage under this policy, and have been continuously

insured under the policy offered by the policyholder for six (6) months, are eligible to continue their existing medical

coverage for a period of not more than six (6) months under the school’s policy in effect at the time of such

continuation.

Premium rates for continuation of coverage are higher than rates for students at The University of Texas System.

Enrollment must be made and applicable premium must be paid directly to Academic HealthPlans and must be

received within 30 days after the expiration date of your student coverage. For more information on continuation of

coverage, please contact Academic HealthPlans at (855) 247-7587.

Additional Covered Expenses

The policy will always pay benefits in accordance with any applicable federal and state insurance law(s).

Student Health Center (SHC)

If the institution has a Student Health Center, the Deductible will be waived and benefits paid at 100% of the

Allowable Amount of Covered Expenses incurred at the Student Health Center.

Please go to utsystem.myahpcare.com and select your campus for specific details about your Student Health Center benefits.

NOTE: Non-student Dependents are not eligible for services provided at a Student Health Center. If you receive medical

care on campus from your respective institution’s Student Health Center, your claim is filed for you.

Schedule of Benefits

The provider network for this plan is the BCBSTX BlueChoice® PPO Network. After the Deductible is satisfied, benefits

will be paid based on the selected provider. Benefits will be paid at 80% of the Allowable Amount for services

rendered by Network Providers in the BCBSTX BlueChoice® PPO Network, unless otherwise specified in the policy.

Services obtained from Out-of-Network Providers (any provider outside the BCBSTX BlueChoice® PPO Network) will be

paid at 60% of the Allowable Amount, unless otherwise specified in the policy. Benefits will be paid up to the

maximum for each service, as specified below, regardless of the provider selected.

AT PHARMACIES CONTRACTING WITH THE PRIME THERAPEUTICS NETWORK: You must go to a pharmacy

contracting with the Prime Therapeutics Network in order to access this program. Present your insurance ID card to

the pharmacy to identify yourself as a participant in this Plan. Eligibility status will be online at the pharmacy. You

can locate a participating pharmacy by calling (800) 423-1973 or online at utsystem.myahpcare.com by selecting your

campus and then clicking on the “Find a Pharmacy” link under Benefits.

Maximum Benefit

Unlimited

Deductible

(Per Covered Person, Per Policy Year)

Network Provider

Out-of-Network Provider

$500 Student

$1,500 Family

$1,000 Student

$3,000 Family

Out-Of-Pocket Maximum

(Per Covered Person, Per Policy Year)

$6,600 Student

$12,700 Family

$13,200 Student

$37,500 Family

OUT-OF-POCKET MAXIMUM means the maximum liability that may be incurred by a Covered Person in a benefit

period for covered services, under the terms of a coverage plan. Once the Out-of-Pocket Maximum has been

satisfied, Covered Expenses will be payable at 100% for the remainder of the policy year, up to any maximum

that may apply. Coinsurance applies to the Out-of-Pocket Maximum.

The relationship between Blue Cross and BlueShield of Texas (BCBSTX) and contracting pharmacies is that of independent contractors,

contracted through a related company, Prime Therapeutics, LLC. Prime Therapeutics also administers the pharmacy benefit program.

BCBSTX, as well as several other independent BlueCross plans, has an ownership interest in Prime Therapeutics.

The Network Out-of-Pocket Maximum may be reached by:

• The network Deductible

• Charges for outpatient prescription drugs

• The hospital emergency room Copayment

• The Copayment for Doctor office visits

• The Copayment for Specialist’s office visits

• The payments for which a Covered Person is responsible after benefits have been provided (except for the cost

difference between the hospital's rate for a private room and a semi-private room, or any expenses incurred for

Covered Expenses rendered by an Out-of-Network Provider other than Emergency Care and Inpatient treatment

during the period of time when a Covered Person’s condition is serious)

The following expenses cannot be applied to the Network Out-of-Pocket Maximum and will not be paid at 100% of the

Allowable Amount when a Covered Person’s Network Out-of-Pocket Maximum is reached:

• charges that exceed the Allowable Amount

• the Coinsurance resulting from Covered Services rendered by an Out-of-Network Provider

• services, supplies, or charges limited or excluded in this Policy

• expenses not covered because a benefit maximum has been reached

• any Covered Expenses paid by the Primary Plan when BCBSTX is the secondary plan for purposes of

coordination of benefits

The Out-of-Network Out-of-Pocket Maximum may be reached by:

• The Out-of-Network Deductible

• The hospital emergency room Copayment

• The payments for Covered Services rendered by an Out-of-Network Provider for which a Covered Person is

responsible after benefits have been provided (except for the cost difference between the hospital's rate for a

private room and a semi-private room)

The following expenses cannot be applied to the Out-of-Network Out-of-Pocket Maximum and will not be paid at 100% of the

Allowable Amount when a Covered Person’s Out-of-Network Out-of-Pocket Maximum is reached:

•

charges that exceed the Allowable Amount

•

the Coinsurance resulting from Covered Services a Covered Person may receive from a Network Provider

•

services, supplies, or charges limited or excluded in this Policy

•

expenses not covered because a benefit maximum has been reached

•

any Covered Expenses paid by the Primary Plan when BCBSTX is the secondary plan for purposes of

coordination of benefits

Deductible Applies unless otherwise noted

Inpatient Network Provider Out-of-Network Provider

Hospital Expenses: Include the daily semi-private

room rate; intensive care; general nursing care

provided by the hospital; and hospital

miscellaneous expenses such as the cost of the

operating room, laboratory tests, X-ray

examinations, pre-admission testing, anesthesia,

drugs (excluding take-home drugs) or medicines,

physical therapy, therapeutic services and

supplies.

80%

of Allowable Amount

60%

of Allowable Amount

Surgical Expenses: When multiple surgical

procedures are performed during the same

operative session, the primary or major

procedure is eligible for full Allowable Amount

for that procedure.

80%

of Allowable Amount

60%

of Allowable Amount

Assistant Surgeon

80%

of Allowable Amount

60%

of Allowable Amount

Anesthetist

80%

of Allowable Amount

60%

of Allowable Amount

Doctor’s Visits

80%

of Allowable Amount

60%

of Allowable Amount

Routine Well-Baby Care

80%

of Allowable Amount

60%

of Allowable Amount

Mental Illness/Chemical Dependency

Paid as any other

covered Sickness

Paid as any other

covered Sickness

Outpatient

Network Provider

Out-of-Network Provider

Surgical Expenses: When multiple surgical

procedures are performed during the same

operative session, the primary or major

procedure is eligible for full allowance for that

procedure.

80%

of Allowable Amount

60%

of Allowable Amount

Day Surgery Miscellaneous: Related to

scheduled surgery performed in a hospital,

including the cost of the operating room,

laboratory tests, X-ray examinations,

professional fees, anesthesia, drugs or

medicines and supplies.

80%

of Allowable Amount

60%

of Allowable Amount

Assistant Surgeon

80%

of Allowable Amount

60%

of Allowable Amount

Anesthetist

80%

of Allowable Amount

60%

of Allowable Amount

Outpatient Network Provider Out-of-Network Provider

Doctor Office Visit/Consultation

Doctor Copayment Amount: For office visit/

consultation when services rendered by a Family

Practitioner, OB/GYN, Pediatrician, Behavioral

Health Practitioner, or Internist and Physician

Assistant or Advanced Practice Nurse who works

under the supervision of one of these listed

physicians

Specialty Care Copayment Amount: For office

visit/consultation when services rendered by a

Specialty Care Provider refer to Medical/Surgical

Expenses section for more information.

100%

of Allowable Amount

after

$20

Copayment per visit

(Deductible waived)

$40

Copayment per visit

(Deductible waived)

60%

of Allowable Amount

Physical Medicine Services:

Physical therapy or chiropractic care – office

services. Physical medicine services include, but are

not limited to, physical, occupational and

manipulative therapy.

Benefit Period Visit Maximum

80%

of Allowable Amount

60%

of Allowable Amount

Benefits for physical medicine services will be limited

to 35-visits per Benefit Period.

Radiation Therapy and Chemotherapy: Including

dialysis and respiratory therapy.

80%

of Allowable Amount

60%

of Allowable Amount

Emergency Care and Accidental Injury

Facility Services: (Copayment is waived if the

Insured is admitted; Inpatient hospital expenses

will apply).

80% of Allowable Amount after $150 Copayment.

(Deductible waived)

Physician Services

80% of Allowable Amount

Non-Emergency Care

Facility Services: (Copayment is waived if the

Insured Facility is admitted; Inpatient hospital

expenses will apply).

80%

of Allowable Amount

after $150 Copayment

60%

of Allowable Amount after

$150 Copayment

Physician Services

80%

of Allowable Amount

60%

of Allowable Amount

Urgent Care

100%

of Allowable Amount

after $75 Copayment

60%

of Allowable Amount

Outpatient

Network Provider

Out-of-Network Provider

Diagnostic X-rays and Laboratory Procedures

80%

of Allowable Amount

60%

of Allowable Amount

Tests and Procedures: Diagnostic services and

medical procedures performed by a Doctor,

other than Doctor’s visits

80%

of Allowable Amount

60%

of Allowable Amount

Mental Illness/Chemical Dependency

Paid as any other covered

Sickness

Paid as any other covered

Sickness

Allergy Injections and Allergy Testing

80%

of Allowable Amount

60%

of Allowable Amount

Extended Care Expenses Network Provider Out-of-Network Provider

Extended Care Expenses:

All services must be pre-authorized

80%

of Allowable Amount

60%

of Allowable Amount

Home HealthCare

Limited to 60 visit maximum each Benefit Period

Skilled Nursing

Limited to 25 days maximum each Benefit Period

Hospice Care

No Benefit Period Visit Maximum

Private Duty Nursing

Not Covered

Other Network Provider Out-of-Network Provider

Virtual Visits (through MD live)

$20

Copayment per visit

60%

of Allowable Amount

Ground and Air Ambulance Services

80%

of Allowable Amount

60%

of Allowable Amount

Durable Medical Equipment: When prescribed by

a Doctor and a written prescription accompanies

the claim when submitted.

80%

of Allowable Amount

60%

of Allowable Amount

Maternity/Complications of Pregnancy

80%

of Allowable Amount

60%

of Allowable Amount

Speech and Hearing Services:

Services to restore loss of hearing/speech, or

correct an impaired speech or hearing function.

Hearing Aids

Hearing Aid Maximum

80%

of Allowable Amount

60%

of Allowable Amount

Hearing aids are limited to one hearing aid per

ear, per36-monthperiod.

Dental: Made necessary by Injury to sound,

natural teeth only.

80%

of Allowable Amount

80%

of Allowable Amount

Needle Stick: Only for students doing course

work or Hospital training.

100%

of Allowable Amount

60%

of Allowable Amount

Pediatric Vision, up to age 19: See benefit flier

for details.

100% of Allowable

Amount

See Fee Schedule

Pediatric Routine Dental Care, up to age19:

See benefit flier for details.

80% of Allowable Amount 80% of Allowable Amount

Pediatric Basic & Major Dental, up to age 19:

See benefit flier for details.

50% of Allowable Amount 50% of Allowable Amount

Pediatric Medically Necessary Orthodontia, up

to age 19: See benefit flier for details.

50% of Allowable Amount 50% of Allowable Amount

Other

Network Provider Out-of-Network Provider

Organ and Tissue Transplant Services: The

transplant must meet the criteria established

by BCBSTX for assessing and performing organ

or tissue transplants as set forth in BCBSTX’s

written medical policies.

80%

of Allowable Amount

60%

of Allowable Amount

Preventive Care Services: Includes but are not

limited to:

a. Evidence-based items or services that

have in effect a rating of “A” or “B” in

the current recommendations of the

United States Preventive Services Task

Force (“USPSTF”);

b. Immunizations recommended by the

Advisory Committee on Immunization

Practices of the Centers for Disease

Control and Prevention(“CDC”);

c. Evidenced-informed preventive care and

screenings provided for in the

comprehensive guidelines supported by

the Health Resources and Services

Administration(“HRSA”) for infants,

child(ren), and adolescents; and

d. With respect to women, such additional

preventive care and screenings, not

described in item “a” above, as provided

for in comprehensive guidelines

supported by the HRSA.

Preventive care services as mandated by

state and federal law are covered. Please

refer to the Policy or call Blue Cross and

Blue Shield of Texas for more information

at (855) 267-0214.

100%

of Allowable Amount

(Deductible Waived)

60%

of Allowable Amount

Pharmacy Benefits Network Provider Out-of-Network Provider

Retail Pharmacy (Deductible Waived)

Benefits include diabetic supplies.

Copayment amounts are based on a 30-day supply.

With appropriate prescription order, up to a 90-day

supply is available at three (3) times the

Copayment. Copayment amounts will apply to Out-

of-Pocket maximum.

Prescriptions filled at the SHC: 100% of

Allowable Amount after a

$15 Copayment for each Generic Drug

$30 Copayment for each Preferred Brand- name

Drug

$50 Copayment for each Non- Preferred Brand-

name Drug

Generic acne medications are now

available.

90 day supply may be purchased through the

Prime Therapeutics Network Mail Program at a

$40 Copayment for each generic, $75 for each

preferred brand and

$125 for each non-preferred brand

At pharmacies contracting

with Prime Therapeutics

Network: 100% of

Allowable Amount after a:

When a Covered Person

obtains prescription drugs

from an Out-of-Network

pharmacy, benefits will be

provided at 60% of the

allowable amount a Covered

Person would have received

had he/she obtained drugs

from a network pharmacy,

minus the Copayment amount

or Coinsurance amount.

Generic Drug

$15

Copayment

$15

Copayment

Preferred Brand-name Drug*

$30

Copayment

$30

Copayment

Non-Preferred Brand-name Drug*

$50

Copayment

$50

Copayment

Specialty Drug

80%

of Allowable Amount

60%

of Allowable Amount

*Copayment plus the cost difference between the Brand Name Drug or supplies per prescription for which there is

Generic Drug or supply available.

The relationship between Blue Cross and BlueShield of Texas (BCBSTX) and Contracting Pharmacies is that of Independent Contractors,

contracted through a related company, Prime Therapeutics, LLC. Prime Therapeutics also administers the pharmacy benefit program.

BCBSTX, as well as several other independent Blue Cross Plans, has an ownership interest in Prime Therapeutics.

Pre-Authorization Notification

BCBSTX should be notified of all hospital confinements prior to admission.

1) Pre-authorization Notification of Medical Non-emergency Hospitalizations: The patient, Doctor or hospital should

telephone (800) 441-9188 at least one (1) business day prior to the planned admission.

2) Pre-authorization Notification of Medical Emergency Hospitalizations: The patient, patient’s representative,

Doctor or hospital should telephone (800) 441-9188 within two (2) business days of the admission or as

soon as reasonably possible to provide the notification of any admission due to medical emergency.

BCBSTX is open for Pre-authorization notification calls from 8 a.m. to 6 p.m. Central time, Monday through Friday.

IMPORTANT: Failure to follow the notification procedures will not affect benefits otherwise payable under the Policy; in

addition, pre-authorization notification is not a guarantee that benefits will be paid.

Definitions

Allowable Amount means the maximum amount determined by Us to be eligible for consideration of payment for a

particular service, supply or procedure.

For hospitals, Doctors and other providers contracting with BCBSTX in Texas or any other Blue Cross and Blue

Shield Plan – The Allowable Amount is based on the terms of the Network Provider contract and the payment

methodology in effect on the date of service. The payment methodology used may include diagnosis-related

groups (DRGs), fee schedule, package pricing, global pricing, per diems, case- rates, discounts, or other payment

methodologies.

For hospitals, Doctors and other providers not contracting with BCBSTX in Texas or any other Blue Cross

and Blue Shield Plan outside of Texas (non-contracting Allowable Amount) – The Allowable Amount will be the

lesser of:

(i) The provider’s billed charges, or;

(ii) The BCBSTX non-contracting Allowable Amount. Except as otherwise provided in this section, the non-

contracting Allowable Amount is developed from base Medicare participating reimbursements adjusted by a

predetermined factor established by BCBSTX. Such factor shall be not less than 75 percent and will exclude

any Medicare adjustment(s) which is/are based on information on the claim.

Notwithstanding the preceding sentence, the non-contracting Allowable Amount for home health care

is developed from base Medicare national per-visit amounts for low utilization payment adjustment, or

LUPA, episodes by home health discipline type adjusted for duration and adjusted by a predetermined

factor established by Us. Such factor shall be not less than 75 percent and shall be updated on a

periodic basis. When a Medicare reimbursement rate is not available or is unable to be determined

based on the information submitted on the claim, the Allowable Amount for non- contracting

providers will represent an average contract rate in aggregate for network providers adjusted by a

predetermined factor established by Us. Such factor shall be not less than 75 percent and shall be

updated not less than every two years.

We will utilize the same claim processing rules and/or edits that We utilize in processing Network

Provider claims for processing claims submitted by non-contracted providers, which may also alter the

Allowable Amount for a particular service. In the event we do not have any claim edits or rules,

We may utilize the Medicare claim rules or edits that are used by Medicare in processing the claims.

The Allowable Amount will not include any additional payments that may be permitted under the

Medicare laws or regulations which are not directly attributable to a specific claim, including, but not

limited to, disproportionate share and graduate medical education payments.

Any change to the Medicare reimbursement amount will be implemented by Us within ninety (90) days

after the effective date that such change is implemented by the Centers for Medicare and Medicaid

Services, or its successor.

For multiple surgeries - The Allowable Amount for all surgical procedures performed on the same

patient on the same day will be the amount for the single procedure with the highest Allowable

Amount plus a determined percentage of the Allowable Amount for each of the other covered

procedures performed.

For prescription drugs as applied to Network Provider and Out-of-Network Provider pharmacies - The

Allowable Amount for pharmacies that are Network Providers will be based on the provisions of the

contract between BCBSTX and the pharmacy in effect on the date of service. The Allowable Amount for

pharmacies that are not Network Providers will be based on the Average Wholesale Price.

Benefit Period means the period of time starting with the effective date of this policy through the

termination date as shown on the face page of the policy. The Benefit Period is as agreed to by the

policyholder and the Insurer.

Coinsurance means a percentage of an eligible expense that the Covered Person is required to pay toward a

Covered Expense.

Company means Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual

Legal Reserve Company (also referred to herein as “BCBSTX”).

Copayment means a fixed dollar amount that the Covered Person must pay before benefits are payable under

the policy.

Covered Expenses means expenses actually incurred by or on behalf of a Covered Person for treatment,

services and supplies not excluded or limited by the policy. Coverage under the policy must remain

continuously in force from the date of the accident or Sickness until the date treatment, services or

supplies are received for them to be a Covered Expense. A Covered Expense is deemed to be incurred on the

date such treatment, service or supply that gave rise to the expense or the charge was rendered or obtained.

Covered Person means any eligible student or an eligible dependent who applies for coverage, and for

whom the required premium is paid to the Company.

Deductible means the dollar amount of Covered Expenses that must be incurred as an out-of-pocket

expense by each Covered Person on a policy term basis before benefits are payable under the policy.

Dependent means an Insured’s lawful spouse; or an Insured’s child, stepchild, foster child, dependent

grandchild or spouse’s dependent grandchild; or a child who is adopted by the Insured or placed for

adoption with the Insured, or for whom the Insured is a party in a suit for the adoption of the child; or a child

whom the Insured is required to insure under a medical support order issued or enforceable by the courts. Any

such child must be under age 26.

Doctor means a Doctor licensed to practice medicine. It also means any other practitioner of the healing arts

who is licensed or certified by the state in which his or her services are rendered and acting within the

scope of that license or certificate. It will not include a Covered Person or a member of the Covered

Person’s immediate family or household.

Emergency Care means health care services provided in a hospital emergency facility (emergency room) or

comparable facility to evaluate and stabilize medical conditions of recent onset and severity, including, but

not limited to, severe pain, that would lead a prudent layperson, possessing an average knowledge of

medicine and health, to believe that the person’s condition, Sickness, or Injury is of such a nature that failure

to get immediate care could result in:

• Placing the patient’s health in serious jeopardy;

• Serious impairment of bodily functions;

• Serious dysfunction of any bodily organ or part;

• Serious disfigurement; or

• In the case of a pregnant woman, serious jeopardy to the health of the fetus.

Emergency Services means, with respect to an emergency medical condition, a medical screening examination

that is within the capability of the emergency department of a hospital, including ancillary services routinely

available to the emergency department to evaluate such emergency medical condition, and, within the

capabilities of the staff and facilities available at the hospital, such further medical examination and treatment

as are required to stabilize the patient.

Injury means accidental bodily harm sustained by a Covered Person that results directly and independently

from all other causes from a covered accident. The Injury must be caused solely through external, violent and

accidental means. All injuries sustained by one person in any one accident, including all related conditions and

recurrent symptoms of these injuries, are considered a single Injury.

Inpatient means that a Covered Person is a registered bed patient and is treated as such in a health care facility.

Insured means a person in a Class of Eligible Persons who enrolls for coverage and for whom the required

premium is paid, making insurance in effect for that person. An Insured is not a dependent covered

under the policy.

Interscholastic Activities means playing, participating and/or traveling to or from an interscholastic,

intercollegiate, club sports, professional, or semi-professional sport, contest or competition, including practice

or conditioning for such activity.

Medically Necessary means those services or supplies covered under the plan that are:

• Essential to, consistent with, and provided for in the diagnosis or in the direct care and treatment

of the condition, Sickness, disease, Injury, or bodily malfunction; and

• Provided in accordance with, and are consistent with, generally accepted standards of

medical practice in the United States; and

• Not primarily for the convenience of the Insured, his physician, behavioral health

practitioner, the hospital, or other provider; and

• The most economical supplies or levels of service that are appropriate for the safe and effective

treatment of the Insured. When applied to hospitalization, this further means that the Insured

requires acute care as a bed patient due to the nature of the services provided or the Insured’s

condition and the Insured cannot receive safe or adequate care as an outpatient.

The medical staff of BCBSTX shall determine whether a service or supply is Medically Necessary under the

Plan and will consider the views of the state and national medical communities; the guidelines and practices

of Medicare, Medicaid, or other government-financed programs; and peer-reviewed literature. Although

a physician, behavioral health practitioner or professional other provider may have prescribed treatment,

such treatment may not be Medically Necessary within this definition.

Network Provider means a hospital, Doctor or other provider who has entered into an agreement with

BCBSTX (and, in some instances, with other participating Blue Cross and/or Blue Shield Plans) to participate

as a managed care provider.

Out-of-Network Provider means a hospital, Doctor or other provider who has not entered into an agreement

with BCBSTX (or other participating Blue Cross and/or Blue Shield Plan) as a managed care provider.

Outpatient means that a Covered Person is receiving treatment while not an Inpatient. Services considered

Outpatient include, but are not limited to, services in an emergency room regardless of whether a

Covered Person is subsequently registered as an Inpatient in a health care facility.

Out-of-Pocket Maximum means the maximum liability that may be incurred by a Covered Person in a

Benefit Period before benefits are payable at 100 percent of the Allowable Amount.

Pre-authorization means the process that determines in advance the Medical Necessity or experimental,

investigational and/or unproven nature of certain care and services under this Policy.

Qualifying Intercollegiate Sport means a sport: a.) which has been accorded varsity status by the

Institution as an NCAA sport; and (b.) which is administered by such Institution’s department of

intercollegiate athletics; and (c.) for which the eligibility of the participating student athlete is reviewed

and certified in accordance with NCAA legislation, rules, or regulations; and (d.) which entitles qualified

participants to receive the Institution’s official awards.

Sickness means an illness, disease or condition causing a Covered Person to incur medical expenses while

covered under the Policy. All related conditions and recurrent symptoms of the same or similar condition

will be considered one Sickness.

Virtual Visits means services provided for the treatment of non-emergency medical and behavioral

health conditions as described under the Policy.

We, Our, Us means Blue Cross and Blue Shield of Texas or its authorized agent.

Exclusions and Limitations

Except as specified in this policy, coverage is not provided for loss or charges incurred by or resulting from:

1. Charges that are not Medically Necessary or are in excess of the Allowable Amount;

2. Services that are provided, normally without charge, by the Student Health Center, infirmary or

hospital, or by any person employed by the University;

3. Acne, including acne prescription drugs covered under Outpatient prescription drugs;

4. Acupuncture procedures;

5. Biofeedback procedures, except as needed to treat acquired brain injuries;

6. Breast augmentation or reduction;

Routine circumcision, unless the procedure is Medically Necessary for treatment of a sickness, disease

functional congenital disorder not excluded hereunder, or may be necessitated due to an Accident,

or except for covered infants within 28 days of birth;

8. Testing or treatment for sleep disorders;

9. Any charges for surgery, procedures, treatment, facilities, supplies, devices, or drugs that We

determine are experimental or investigational;

10. Expenses incurred for Injury or Sickness arising out of, or in the course of, a Covered Person’s

employment, regardless of whether the benefits are, or could be, paid or payable under any worker’s

compensation or occupational disease law or act, or similar legislation;

11. Treatment, services or supplies in a Veteran’s Administration facility or a hospital owned or operated

by a national government or its agencies, unless there is a legal obligation for the Covered Person

to pay for the treatment;

12. Expenses in connection with services and prescriptions for eyeglasses or contact lenses, or the fitting

of eyeglasses or contact lenses; radial keratotomy; or laser surgery for vision correction or the

treatment of visual defects or problems, except for pediatric vision;

13. Sinus or other nasal surgery, including correction of a deviated septum by submucous resection

and/or other surgical correction, except for a covered Injury;

14. Expenses in connection with cosmetic treatment or cosmetic surgery, except as a result of:

• A covered Injury that occurred while the Covered Person was insured;

• An infection or other diseases of the involved part; or

• A covered child’s congenital defect or anomaly;

15. Injuries arising from Interscholastic Activities and Qualifying Intercollegiate Sports;

16. Riding as a passenger or otherwise in any vehicle or device for aerial navigation, except as a fare-

paying passenger in an aircraft operated by a commercial scheduled airline;

17. Injury resulting from sky diving, parachuting, hang gliding, glider flying, parasailing, sail planning,

bungee jumping;

18. War, or any act of war, whether declared or undeclared or while in service in the active or

reserve Armed Forces of any country or international authority;

19. Elective abortion, including related services and supplies, except when the life of the mother would be

endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or

incest;

20. Any expenses incurred in connection with sexual dysfunction, sterilization reversal, vasectomy

reversal ;

21. In-vitro fertilization;

22. Promotion of fertility through extra-coital reproductive technologies including, but not limited to,

artificial insemination, intrauterine insemination, super ovulation uterine capacitation enhancement,

direct intra-peritoneal insemination, trans-uterine tubal insemination, gamete intra-fallopian transfer,

pronuclear oocyte stage transfer, zygote intra-fallopian transfer, and tubal embryo transfer;

23. Donor expenses for a Covered Person in connection with an organ and tissue transplant if the

recipient is not covered under this Policy;

24. Expenses incurred for dental care or treatment of the teeth, gums or structures directly supporting the

teeth, including surgical extractions of teeth. This exclusion does not apply to the repair of Injuries

to sound natural teeth caused by a covered Injury;

25. Foot care, including: flat-foot conditions, subluxations, care of corns, bunions (except capsular or bone

surgery), calluses, toenails, fallen arches, weak feet, foot strain, and symptomatic complaints of the

feet, except those related to diabetic care, circulatory disorders of the lower extremities, peripheral

vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency;

26. Hirsutism;

27. Alopecia;

28. Weight management, weight reduction, or treatment for obesity including any condition

resulting therefrom, including hernia of any kind;

29. Surgery for the removal of excess skin or fat;

30. Nutrition programs, except as related to treatment for diabetes;

31. Custodial care;

32. Long-term care service;

33. Bariatric surgery;

34. Private duty nursing services, except for covered extended care expenses;

35. Weight loss programs;

36. Prescription drug coverage is not provided for:

a. Refills in excess of the number specified or dispensed after one (1) year from the date

of the prescription;

b. Administration of insulin, or non-medical substances regardless of their intended use;

for hair growth, anabolic steroids for body building, anorectics for weight control, etc;

c. Drugs labeled “Caution- limited by federal law to investigational use” or experimental

drugs;

d. Immunizing agents, biological sera, blood or blood products administered on an

Outpatient basis, except as specifically provided in this Policy;

e. Any devices, appliances, support garments, hypodermic needles except as used in the

administration of insulin, or non-medical substances regardless of their intended use;

f. Drugs used for cosmetic purposes, including but not limited to Retin-A for wrinkles,

Rogaine for hair growth, anabolic steroids for body building, anorectics for weight

control; etc;

g. Fertility agents or sexual enhancement drugs, medications or supplies for the treatment

of impotence and/or sexual dysfunction, including but not limited to: Parlodel,

Pergonal, Clomid, Profasi, Metrodin, Serophene, Viagra, Cialis, or Levitra;

h. Lost or stolen prescriptions;

i. Drugs prescribed and dispensed for the treatment of obesity or for use in any program

of weight reduction, weight loss, or dietary control;

j. Non-sedating antihistamines drugs and combination medications containing a non-

sedating antihistamine decongestant;

k. Non-commercially available compounded medications, regardless of whether or not

one or more ingredients in the compound requires a Prescription Order. (Non-

commercially available compounded medications are those made by mixing or

reconstituting ingredients in a manner or ratio that is inconsistent with the United

States Food and Drug Administration-approved indications provided by the ingredients'

manufacturers;

l. Brand Name proton pump inhibitors;

m. Drugs which are not approved by the U.S. Food and Drug Administration (FDA) for a

particular use or purpose or when used for a purpose other than the purpose for which

the FDA approval is given, except as required by law or regulation.

Academic Emergency Services*

To ensure immediate access to assistance if you experience a crisis while traveling over 100 miles from home, or outside

your home country, Academic HealthPlans has included Academic Emergency Services (AES) benefits in your student health

plan coverage. AES offers a wide range of services and benefits to provide everything you need to prepare for your

international experience, as well as get the help or information you need in a crisis, no matter how large or small.

The following services and benefits are available to you 24 hours a day, 7 days a week:

Medical Assistance: Pre-travel information; physician referrals; medical monitoring to ensure adequate care; 24/7 Nurse

Help Line; prescription assistance or medicine dispatch.

Emergency Medical Evacuation and Repatriation: Unlimited benefit for evacuation from inadequate facility to a higher

level of care facility, repatriation home for continued care if medically necessary, or recovery and repatriation of deceased

remains.

Accidental Death and Dismemberment: $25,000 benefit

Emergency Family Assistance: Benefits for visit of a family member or friend if hospitalized for 3 or more days, return of

children if left unattended, bereavement reunion, emergency return home in the event a participant’s family member

suffers life threatening illness or death and return of participant’s personal belongings in the event of evacuation or

death.

Travel, Legal and Security Assistance: Pre-travel destination information or security advice; assistance locating lost

luggage; passport replacement assistance; emergency travel arrangements; translation assistance; interpreter referral; legal

consultation and referral; emergency message forwarding.

Preparing for your time away from home is easy; simply visit the

Academic Emergency Services portal: aes.myahpcare.com

To obtain additional pre-travel information or advice, or in the event of a medical, travel or security crisis, call

Academic Emergency Services immediately.

(855) 873-3555 call toll free from the US

+ 1 (410) 453-6354 call collect from anywhere

Email: assistance@ahpcare.com

This provides you with a brief outline of the services available to you. Terms, conditions, limitations and exclusions apply.

All services must be arranged and paid for through the AES service provider. There is no claim process for reimbursement

of self-paid expenses unless specifically described in the service plan.

*Academic Emergency Services (AES) is a global emergency services product. These services are provided by a separate and independent company from AES

or Academic HealthPlans. AES provides medical, security and natural disaster evacuation services, repatriation of remains, emergency medical and

travel assistance, travel information and other services for Academic HealthPlans.

BlueCard®

Like all Blue Cross and Blue Shield Licensees, We participate in a program called “BlueCard.” Whenever the Covered Person

accesses health care services outside Our service area, the claims for those services may be processed through BlueCard and

presented to Us for payment in conformity with network access rules of the BlueCard Policies then in effect (“Policies”). Under

BlueCard, when Covered Persons incur Covered Expenses within the geographic area served by an onsite Blue Cross and/or

Blue Shield Licensee (“Host Blue”), We will remain responsible to the Covered Person for fulfilling the Policy’s contract

obligations. The Host Blue will only be responsible, in accordance with applicable BlueCard Policies, if any, for providing such

services as contracting with its participating Providers and handling all interactions with its participating Providers.

Summary of Benefits and Coverage

The Affordable Care Act requires all health insurers to provide consumers with a Summary of Benefits and Coverage (SBC). The

SBC is a description of the benefits and health coverage offered by a particular health plan. The SBC is intended to provide

clear, consistent descriptions that may make it easier for people to understand their health insurance coverage.

The items in the SBC just represent an overview of coverage; they are not an exhaustive list of what is covered or excluded.

The full terms of coverage are located in your insurance Policy. To obtain an SBC for your Policy, please go to

utsystem.myahpcare.com.

BCBSTX Online Resources

BCBSTX members have online access to claims status, Explanations of Benefits, ID cards, Network Providers, correspondence and

coverage information by logging in to Blue Access for Members

(BAM). Visit BCBSTX.com and click on the “Log in” tab. Follow

the simple, onscreen directions to establish an online account in minutes.

BAM has been enhanced to include BAM Mobile, a self-service tool that provides a quick and easy way to view any email

notifications We may have sent. In Message Center, notifications are securely sent directly to the Insured student’s email

address. If the Insured student prefers to receive paper copies, he or she may opt out of electronic delivery by going into “My

Email Preferences” and making the change there.

Please go to utsystem.myahpcare.com for additional premium and benefit information.

Claims Procedure

In the event of Injury or Sickness, the student should:

1. Report to the Student Health Center for treatment, or, when not in school, to his/her Doctor or hospital. Insureds should

go to a Network Doctor or hospital for treatment, if possible.

IN AN EMERGENCY, REPORT DIRECTLY TO THE NEAREST EMERGENCYROOM FOR TREATMENT.

2. Mail to the address below all prescription drug receipts (for providers outside of the Student Health Center and for

providers outside of those contracting with Prime Therapeutics), medical and hospital bills, along with patient’s name and

Insured student’s name, address, Social Security Number, BCBSTX member ID number, and name of the University under

which the student is Insured.

3. File claims within 30 days of Injury or first treatment for a Sickness. Bills should be received by the Company within 90

days of service. Bills submitted after one year will not be considered for payment except in the absence of legal capacity.

The Plan is underwritten by:

Blue Cross and Blue Shield of Texas

Submit all claims or inquiries to:

Blue Cross and Blue Shield of Texas

P.O. Box 660044

Dallas, TX 75266-0044

BCBSTX Customer Service: (855) 267-0214

Medical Providers: Call (800) 451-0287

All Others: Call AHP (855) 247-7587

Plan is administered by:

Academic HealthPlans, Inc.

P. O. Box 1605

Colleyville, TX 76034-1605

Fax (855) 858-1964

For more information

utsystem.myahpcare.com

Important Notice

The information in this brochure provided a brief description of the important features of the insurance plan. It is not a

contract of insurance. The Master Policy on file at the University contains all of the provisions, limitations, exclusions and

qualifications of your insurance benefits, some of which may not be included in this brochure. The Master Policy is the

contract and will govern and control the payment of benefits. The terms and conditions of coverage are set forth in the

Policy issued in the state in which the Policy was delivered. Complete details may be found in the Policy on file at your

school’s office. The Policy is subject to the laws of the state in which it was issued. Please keep this information as a

reference.

See the Policy on file with your school for more information.

bcbstx.com

Health care coverage is important for everyone.

We provide free communication aids and services for anyone with a disability or who needs language assistance.

We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.

To receive language or communication assistance free of charge, please call us at 855-710-6984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.

Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)

300 E. Randolph St. TTY/TDD: 855-661-6965

35th Floor Fax: 855-661-6960

Chicago, Illinois 60601 Email: [email protected]

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:

U.S. Dept. of Health & Human Services Phone: 800-368-1019

200 Independence Avenue SW TTY/TDD: 800-537-7697

Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html