Ohio State
Student Life
Student Health
Benets Plan
Member
Overview
2024 – 25
Be equipped to use your coverage to
protect your well-being and your wallet.
24COL4904
Welcome to the Student
Health Benets Plan!
Read these highlights to learn your coverage basics.
NAMES TO KNOW
UnitedHealthcare Student Resources
UnitedHealthcare Student Resources issues your
medical member ID card, coordinates covered
services and administers claims for all benets
but adult dental.
UnitedHealthcare Insurance company
underwrites Tiers 2, 3 and 4 of your benets.
They might contact you by mail - please always
reply if requested.
OptumRx coordinates your
prescription benet.
Delta Dental of Ohio underwrites, issues
and coordinates your adult dental benets
and claims.
OSU Health Plan, as well as UHCSR and Delta
Dental, manage networks of preferred providers
that you can see at lower out-of-pocket costs.
UnitedHealthcare Global provides global
emergency services if you are traveling.
REMEMBER
Always carry your
Member ID card or have it
electronically accessible.
Read your email and postal
mail and keep your local
address up to date in
Buckeye Link.
Make sure you follow
through on your nancial
obligations. Even though
sometimes your cost for
covered services may be
zero, other times you may
owe a copay, co-insurance
or deductible.
If you have questions
about a bill you receive,
contact your resources
and ask for assistance.
SHI is here to help.
2
Where to go for care
To keep costs low:
• Student Health Services at Wilce
Student Health Center
• Counseling and Consultation Service
• Ohio State College of Optometry Clinic
• Ohio State College of Dentistry Student Clinic
Next try:
• OSU Health Plan Network providers
in Franklin County
• UHC Choice Plus Network providers
outside Franklin County
• United Behavioral Health Network providers
outside Franklin County
• Delta Dental PPO/Premier Network providers
Your provider choices can help you
save money. Seeing providers
outside of these locations and
networks may result in much higher
out-of-pocket costs.
3
Medical Benets
UnitedHealthcare Insurance Company underwrites
Tiers 2, 3 and 4.
You can reduce your cost responsibility if you choose providers in Tier One or Tier Two.
TIER ONE
Student Health
Services at Wilce
Student Health Center
TIER TWO
In Franklin County:
OSU Health Plan
Network
Outside Franklin
County: UHC Choice
Plus Network
TIER THREE
In Franklin County:
UHC Choice Plus
Network but not OSU
Health Plan Network
TIER FOUR
All other providers
4
Your out-of-pocket costs increase at providers in Tiers Three and Four.
Search options at shi.osu.edu > Find a Provider/Pharmacy.
Contact OSU Health Plan 614-292-4700 or UnitedHealthcare Student Resources
1-833-789-9300
If it’s a life-threatening emergency, always go to the nearest hospital or call 9-1-1.
Notes!
• For Tiers 2, 3 and 4, plan pays % of Allowed Amount.
• Benets for covered services incurred while traveling outside the USA will
be applied at Tier 2.
CAUTION
This is not a complete list of benets or limitations and exclusions.
Visit uhcsr.com/osu or shi.osu.edu to access your Summary Brochure and Certicate
of Coverage.
This service is subject
to Tier 2 deductible.
Students Only Students and Dependents
This service is
subject to Tier 3 and
Tier 4 deductibles.
TIER ONE
Plan Pays
TIER TWO TIER THREE TIER FOUR
Plan Pays Plan Pays Plan Pays
Office Visits 100% 100% after $20 copay 60% 60%
Diagnostic Lab
test and X-ray
100% 90% 60% 60%
Rehabilitative and Habilitative
Therapies
100%
1
up to policy
year visit limit
90% up to policy 60% up to policy 60% up to policy
year visit limit year visit limit year visit limit
Allergy Testing,
Treatment and Injections
100% excluding serum
Based on setting where Based on setting where Based on setting where
service is performed service is performed service is performed
Surgery and Outpatient
procedures
100% 90% 60% 60%
Urgent Care Office Visits
2
N/A 100% after $25 copay 60% 60%
Emergency Care N/A 90% after $100 copay. Copay will be waived if admitted.
Ambulance N/A 90% 90% 90%
Inpatient and Outpatient
Hospital care
N/A 90% 60% 60%
Durable Medical Equipment,
Prosthetic 100%
3
90% 60% 60%
and Orthotic Devices
Applicable Limitations to Benets Above
Policy Year Maximum Benefits N/A Unlimited
Policy Year Deductible N/A
$150 per Individual;
$350 per family
$500 per individual; $1,500 per family
Policy Year
Out-of-Pocket Maximum
N/A
$3,000 individual;
$6,000 family
$6,000 individual; $12,000 family
1
Not all covered services are available at Student Health Services.
2
Additional services rendered during an urgent care ofce visit will be paid per category schedule after you’ve
met your deductible. For example: An X-Ray will be paid at 90% at Tier Two providers and 60% at Tiers Three and Four.
3
Covered when in stock and ordered by a Student Health Services provider.
5
Preventive Benets
Preventive care is routine care given to help you avoid illness and improve your health.
Benets highlighted on this page are for adults age 19 years or older. For members
18 years or younger, refer to the full Summary Brochure and Certicate of Coverage
available on shi.osu.edu or uhcsr.com/osu.
IMPORTANT
Your age, gender, history and risk status determine what preventive care services
are covered for you. Make sure to talk with your doctor about what’s recommended.
Preventive care guidelines are shaped by the Patient Protection and Aordable Care
Act (PPACA), United States Preventive Service Task Force (USPSTF) and the Advisory
Committee on Immunization Practices (ACIP), as well as the Health Resources and
Services Administration (HRSA), Department of Health and Human Services (HHS),
and the Centers for Disease Control and Prevention (CDC).
You can reduce your cost responsibility if you choose providers in Tier One or Tier Two.
TIER ONE
Student Health
Services at Wilce
Student Health Center
TIER TWO
In Franklin County:
OSU Health Plan
Network
Outside Franklin
County: UHC Choice
Plus Network
TIER THREE
In Franklin County:
UHC Choice Plus
Network but not OSU
Health Plan Network
TIER FOUR
All other providers
6
Your out-of-pocket costs increase at providers in Tiers Three and Four.
Search options at shi.osu.edu > Find a Provider/Pharmacy.
Contact OSU Health Plan 614-292-4700 or UnitedHealthcare Student Resources
1-833-789-9300.
If it’s a life-threatening emergency, always go to the nearest hospital or call 9-1-1.
Notes!
• UnitedHealthcare Insurance Company underwrites
•
Benets for covered services incurred while
Tiers 2, 3 and 4. For Tiers 2, 3 and 4, plan pays % of
traveling outside the USA will be applied at Tier 2.
Allowed Amount.
•
Pre-travel assessments are not covered.
7
Students Only Students and Dependents
After you meet the
Tier 4 deductible.
TIER ONE TIER TWO TIER THREE TIER FOUR
Plan Pays Plan Pays Plan Pays Plan Pays
Adult Immunizations
1
100% 100% 100% 60%
Annual well visit
2
100% 100% 100% 60%
Annual well woman visit
3
100% 100% 100% 60%
Breast Cancer Screening
4
100% 100% 100% 60%
Colorectal Cancer Screening
2
100% 100% 100% 60%
Testicular and Prostate
N/A 100% 100% 60%
Cancer Screening
2
Immunizations and screening
laboratory tests required by 50% Not Covered
Ohio State academic programs
Applicable Limitations to Benets Above
Policy Year Maximum Benefits N/A Unlimited
$500 per individual;
Policy Year Deductible N/A
$1,500 per family
Policy Year $3,000 individual;
N/A $6,000 individual; $12,000 family
Out-of-Pocket Maximum $6,000 family
1
As required or recommended by PPACA/USPSTF/ACIP or the
3
Covered well woman services are per PPACA/USPSTF guidelines,
State of Ohio, including: inuenza, hepatitis A, hepatitis B, Td/Tdap, including screenings for cervical cancer, chlamydia, gonorrhea,
varicella, meningococcal, MMR, pneuomococcal, zoster and HPV. syphilis, HIV and HPV.
2
Covered services are those rated A or B by the USPSTF.
4
As required or recommended by PPACA or the State of Ohio.
Prescription Benets
The prescription benet uses the OptumRx Prescription Drug List (PDL), which is a
list of covered medications (generic and brand) organized by how they’ll be paid. You
can access the PDL at shi.osu.edu and uhcsr.com/osu.
When you ll a prescription at the Wilce Student Health Center Pharmacy or
any UnitedHealthcare Pharmacy (UHCP) Network Pharmacy, you pay only the
co-insurance and applicable minimum cost. At a Non-Network pharmacy, you pay
in full rst and then submit a claim form for reimbursement of the plan portion.
WILCE STUDENT HEALTH CENTER PHARMACY
1875 Millikin Rd | 614-292-0125
Notes!
• Minimum cost per prescription does not apply to generic and brand
(no generic available) contraceptive drugs.
•
Specialty drugs must be lled through UHCP cannot be lled at the
Student Health Center or other pharmacy locations. Sign into your UHCSR
MyAccount, go to prescriptions to manage your prescriptions or call
OptumRx Specialty at 1-855-427-4682.
CAUTION This is not a complete list of benets or limitations and exclusions. Visit
uhcsr.com/osu or shi.osu.edu to access your Summary Brochure and Certicate
of Coverage.
8
Students and Dependents
Wilce Student Health
Center Pharmacy
Plan Pays
UHCP Network
Pharmacy
Plan Pays
Tier 1 90% 90%
Tier 2 80% 80%
Tier 3 50% 50%
Women’s Contraceptive Drugs
Generic and Brand
100%
(no Generic Available)
100%
Brand (Generic Available) 50% 50%
Non-Network Pharmacy
Generic - 90% of billed charge
Brand Name - 50% of billed charge
Policy Year Out-of-Pocket Maximum $6,000 individual; $12,000 family
Additional Limitations to Benets Above
Fill Supply Most medications up to 31-day supply
Minimum Cost Per Prescription $10, not to exceed the drug cost
Policy Year Maximum Benefit N/A Unlimited
Policy Year
Out-of-Pocket Maximum
$3,000 individual; $6,000 family
9
Mental Health Benets
UnitedHealthcare Insurance Company underwrites
Tiers 2, 3 and 4.
Students and covered dependents age 14 and older can utilize Counseling and
Consultation Service (CCS). For children under age 14, seek an OSU Health Plan
provider inside Franklin County or a United Behavioral Health provider outside
Franklin County.
You can reduce your cost responsibility if you choose providers in Tier One or Tier Two.
TIER ONE
Counseling and
Consultation Service
TIER TWO
In Franklin County:
OSU Health Plan
Network
Outside Franklin
County: UHC Choice
Plus Network
TIER THREE
In Franklin County:
UHC Choice Plus
Network but not OSU
Health Plan Network
TIER FOUR
All other providers
Your out-of-pocket costs increase at providers in Tiers Three and Four.
Search options at shi.osu.edu > Find a Provider/Pharmacy.
Contact OSU Health Plan 614-292-4700 or UnitedHealthcare Student Resources
1-833-789-9300.
If it’s a life-threatening emergency, always go to the nearest hospital or call 9-1-1.
CCS AT YOUNKIN SUCCESS CENTER
Fourth Floor, 1640 Neil Ave
CCS AT LINCOLN TOWER
Tenth Floor, 1800 Cannon Drive
614-292-5766
css.osu.edu
10
Counseling and Consultation Service oers individual and group psychotherapy, couples counseling, urgent care
during normal business hours and limited psychiatry services.
Notes!
• For Tiers 2, 3 and 4, plan pays % of Allowed Amount.
• Benets for covered services incurred while traveling outside the USA will be applied at Tier 2.
11
CAUTION
This is not a complete list of benets or limitations and exclusions. Visit uhcsr.com/osu or shi.osu.edu to
access your Summary Brochure and Certicate of Coverage.
This service is subject
to Tier 2 deductible.
Students Only Students and Dependents
This service is subject
to Tier 3 and Tier 4
deductibles.
TIER ONE
Plan Pays
TIER TWO
Plan Pays
TIER THREE
Plan Pays
TIER FOUR
Plan Pays
Outpatient Psychotherapy 100% 100% after $20 copay 60% 60%
Outpatient Psychotherapy for
Alcohol or Drug Abuse
100% 100% after $20 copay 60% 60%
Outpatient Psychiatry 100% 100% after $20 copay 60% 60%
Outpatient Child
1
Psychotherapy or Psychiatry
N/A 100% after $20 copay 60% 60%
Inpatient Psychotherapy
or Psychiatry
N/A 90% 60% 60%
Testing for Learning
Disabilities/ADHD
N/A 90% 60% 60%
Applicable Limitations to Benets Above
Policy Year Maximum Benefits Unlimited
Policy Year Deductible N/A
$150 per individual;
$350 per family
$500 per individual; $1,500 per family
Policy Year
Out-of-Pocket Maximum
N/A
$3,000 individual;
$6,000 family
$6,000 individual; $12,000 family
1
Under age 14 and including alcohol or drug abuse
Vision Benets
You can reduce your out of pocket cost by choosing a provider in Tier One.
UnitedHealthcare Insurance Company underwrites
Tiers 2, 3 and 4.
TIER ONE
Ohio State College of
Optometry Clinics
TIER TWO
In Franklin County:
OSU Health Plan
Network
Outside Franklin
County: UHC Choice
Plus Network
TIER THREE
In Franklin County:
UHC Choice Plus
Network but not OSU
Health Plan Network
TIER FOUR
All other providers
OHIO STATE COLLEGE OF
OPTOMETRY CLINICS
1664 Neil Ave
614-292-2020
12
Search options at shi.osu.edu > Find a Provider/Pharmacy.
Contact OSU Health Plan 614-292-4700 or UnitedHealthcare Student Resources
1-833-789-9300.
If it’s a life-threatening emergency, always go to the nearest hospital or call 9-1-1.
Notes!
• At Tier 1, students receive an allowance of $100 towards eyewear or contact lenses. They also receive
a 20% discount on frames and eyeglass lenses.
•
Non-routine vision services provided at Ohio State College of Optometry Clinics are payable under
the medical benet at the Tier 2 level. Deductible, co-pay and co-insurance amounts may apply.
•
Benets for covered services incurred while traveling outside the USA will be applied at Tier 2.
• The $100 eyewear or contact lenses allowance is not available to dependents.
CAUTION
This is not a complete list of benets or limitations and exclusions. Visit uhcsr.com/osu or shi.osu.edu to
access your Summary Brochure and Certicate of Coverage.
13
Students Only Students and Dependents 19 Years or Older
TIER ONE
Plan Pays
TIER TWO
Plan Pays
TIER THREE
Plan Pays
TIER FOUR
Plan Pays
Annual Vision Exam 100% after $15 copay 100% up to $50 after $20 copay
Annual Vision Exam with
Contact Lens Evaluation
100% after $15 copay
and $25 copay for CL
evaluation
100% up to $50 after $20 copay
Eyewear Allowance $100 None
Pediatric vision benets for members under age 19 can be found in the full Summary Brochure and Certicate of
Coverage available at shi.osu.edu or uhcsr.com/osu. Remember to take your UHCSR Member ID card with you to
provider visits.
Adult Dental Benets
Dental benets are underwritten by Delta Dental.
Primary pediatric dental benets for members under 19 years of age are covered
under the medical benet and underwritten by UnitedHealthcare Insurance
Company with a separate $500 deductible. There is also secondary pediatric dental
coverage underwritten by Delta Dental of Ohio. Details are available at shi.osu.edu
and uhcsr.com/osu.
OHIO STATE
COLLEGE OF DENTISTRY
STUDENT CLINICS
Postle Hall
305 W. 12th Ave.
614-688-3763
OHIO STATE DENTAL
FACULTY PRACTICE
305 W. 12th Ave.
614-292-1472
WILCE STUDENT
HEALTH CENTER
DENTAL SERVICES
Second Floor
1875 Millikin Rd.
614-292-4321
CAUTION
This is not a complete list of benets or limitations and exclusions.
Visit uhcsr.com/osu or shi.osu.edu to access your Summary Brochure and Certicate
of Coverage.
14
Students and Dependents 19 Years or Older
College of Dentistry
Student Health
Faculty Practice or
Services or College of Non-Network
Delta Dental PPO/Delta
Dentistry Student Clinic
Plan Pays
Premier Network
Plan Pays
Plan Pays
Diagnostic and Preventive Services
Exams and cleanings twice per benefit
100% after $17 copay 70% 50%
year; fluoride treatment for dependent
children once per benefit year.
Emergency Exam and Pallative
Treatment Used to temporarily 100% after $17 copay 70% 50%
relieve pain.
Radiographs (X-rays) Bitewing
X-rays are payable once per benefit
100% 70% 50%
year. Full-Mouth X-rays are payable
once per five benefit years.
Simple Extractions 70% 50% 50%
Oral Surgery Services
Surgical extractions. Coverage for the
70% 50% Not Covered
removal of asymptomatic third molars
is excluded.
Minor Restorative Services
Used to repair teeth damaged
by disease or injury (for example, 70% 50% 50%
amalgam [silver] and resin [white]
fillings).
Single Crown 50% 50% 50%
Periodontic Services
Used to treat diseases of the gums and 70% 50% 50%
supporting structures of the teeth.
Endodontic Services
50% 50% 50%
Limited to root canals only.
Anesthesia IV sedation. 50% 50% Not Covered
Applicable Limitations to Benets Above
Policy Year Maximum Benefits $750 per Individual
Policy Year Deductible N/A $50
15
Additional Benets
Medical and Mental Health Online resources
available to you:
The medical policy partner, UHCSR oers online resources for non-emergency medical
and mental health care through HealthiestYou, a Teladoc company. These services
are available as an additional resource to the care you have available on campus at the
Wilce Student Health Center and/or Counseling and Consultation Service.
24/7 Doctor Access
HealthiestYou provides round-the-clock access to board-certied physicians. When
you are unable to visit the Wilce Student Health Center during open hours, they can
connect you with a board-certied physician using this nationwide telehealth service.
This service is especially helpful for minor illnesses such as allergies, sore throat,
earache, pink eye, etc.
Virtual Counseling Services
Virtual counseling services are available to you for free through HealthiestYou.
They provide access to Psychiatrists (MD), Psychologists (PhD), Counselors,
Clinical Social Workers and Therapists (Masters) through phone and video at your
convenience. When registering for these mental health services, you’ll be able to
choose your counselor and appointment time based on your preferences and needs.
Visits are secure, discreet and condential and you have ongoing support with the
same provider.
You can learn more about these services at uhcsr.com/hycounseling.
16
Emergency Travel Assistance Benets
As part of your Student Health Benets Plan, you,
your insured spouse/domestic partner and your
insured minor child(ren) are eligible for Global
Emergency Services.*
International students are eligible to receive
services worldwide, except in your home country.
Domestic students are eligible to receive services
when 100 miles or more away from your campus
address or 100 miles or more away from your
permanent home address or while participating in
a study abroad program.
Key Medical Evacuation and Repatriation
benets include:
•
Emergency Medical Evacuation
• Dispatch of Doctors/Specialists
• Medical Repatriation
• Transportation aer Stabilization
• Transportation to Join a Hospitalized
Insured Person
• Return of Minor Children
• Repatriation of Mortal Remains
• Additional Assistance Services to support
you while away from home
To access services, please refer to the contact
information on the back of your ID card or access
My Account at www.uhcsr.com/MyAccount and
select My Benets/Additional Benets/UHC Global
Emergency Services.
All services must be arranged and provided by the
Emergency Response provider; any services not
arranged by the Emergency Response provider
will not be considered for payment. The Assistance
and Evacuation Benets and related services are not
meant to be used in lieu of or replace local emergency
services. If the condition is an emergency, you should go
immediately to the nearest physician or hospital without
delay and then contact the 24-hour Emergency Response
Center. Appropriate action to assist you and monitor
your care will be taken at that time.
*Underwritten by UnitedHealthcare
Insurance Company. Check your Certicate
of Coverage for a description of the benets,
services, exclusions and limitations.
Your student health insurance program also gives
you access to evacuation services in the event of a
political emergency situation or natural disaster.
Contact Assist America at 1-855-289-2616 (inside
USA) or +1-609-986-1212 (outside USA) if you need
assistance on these services.
Lastly, as a student of The Ohio State University, you
also have access to special Emergency Travel Assistance
benets. These benets include Emergency Return
Home, Return of Personal Belongings, Bereavement
Reunion and Return of Traveling Companion. To learn
more about these benets, or to request these services,
please visit the Student Health Insurance oce.
17
Campus Area Resources
WILCE STUDENT HEALTH CENTER
1875 Millikin Road 614-292-4321, shs.osu.edu
COUNSELING AND CONSULTATION SERVICE
Younkin Success Center 4th Floor and Lincoln Tower 10th Floor
614-292-5766, ccs.osu.edu
STUDENT LIFE STUDENT WELLNESS CENTER
B130 RPAC, 614-292-4527, swc.osu.edu
CENTER FOR INTEGRATIVE MEDICINE
2000 Kenny Rd., 614-293-9777
OSU SPORTS MEDICINE CENTER
2835 Fred Taylor Drive, 614-293-3600
CENTER FOR WOMEN’S HEALTH AT THE OHIO STATE UNIVERSITY
WEXNER MEDICAL CENTER
1800 Zollinger Road, 614-293-2076
MARTHA MOREHOUSE MEDICAL PLAZA
2050 Kenny Rd (Accessible by Campus Transport)
Aer Hours Advanced Urgent Care
Ohio State Internal Medicine
614-293-3200
614-293-8054
OHIO STATE PRIMARY CARE THOMAS RARDIN
2231 N. High St., 614-293-2700
Contact information
OFFICE OF STUDENT LIFE STUDENT HEALTH INSURANCE
830 Lincoln Tower, 1800 Cannon Drive, Columbus, OH 43210
Visit: shi.osu.edu Call: 614-688-7979
Email: shi_info@osu.edu Hours: Mon–Fri, 8 a.m.–4:30 p.m.
Please call ahead to conrm hours and operations.
18
Tools
uhcsr.com/osu: view information and access your Member ID card for all benets but adult dental
uhcsr.com/myaccount: access your medical claims to understand what’s being paid
osuhealthplan.com: search preferred provider lists online
deltadentaloh.com: search providers, access a dental ID card and view adult dental claims
Summary Brochures and Certicate of Coverage: read full details of what’s covered and what’s not, available
online at shi.osu.edu, uhcsr.com/osu and deltadentaloh.com
Healthiestyou: 24/7 access to a licensed medical and mental health doctors regarding diagnosis and treatment of
many illnesses.
Terms
Copay: at fee owed at the time you use a covered service.
Co-insurance: percentage you pay of the covered service cost.
Deductible: dollar amount you pay up front before the plan starts to pay for most covered services.
Out-of-pocket maximum: most you’ll pay each year for covered services, excluding your Student Health
Benets Plan fee
Regional or commuter student looking for providers
outside Franklin County?
The UHC Choice Plus Network has extensive listings. Visit shi.osu.edu’s Find a Provider/Pharmacy page
or uhcsr.com/osu or call UnitedHealthcare Student Resources 1-833-789-9300.
Call: 614-688-7979
Hours: Mon–Fri, 8 a.m.–4:30 p.m.
19
STUDENT HEALTH INSURANCE
Note: The student health insurance information contained herein is a summary of certain benets which are offered under a
student health insurance policy issued by UnitedHealthcare and based on policy numbers 2024-1098-1 and 2024 -1098-4. This
document is a summary only and may not contain a full or complete recitation of the benets and restrictions/exclusions associated
with the relevant policy of insurance. This document is not an insurance policy document and your receipt of this document does
not constitute the issuance or delivery of a policy of insurance. Neither you nor UnitedHealthcare has any rights or responsibilities
associated with your receipt of this document. Changes in federal, state or other applicable legislation or regulation or changes in
Plan design required by the applicable state regulatory authority may result in differences between this summary and the actual
policy of insurance. The policies provide one year term insurance coverage.
