BENEFITS AT A GLANCE

BENEFITS AT A

GLANCE

STUDENT HEALTH INSURANCE PLAN | PLAN YEAR 2020/2021

DESIGNED EXCLUSIVELY FOR THE GRADUATE, INTERNATIONAL, AND NURSING STUDENTS OF:

UNIVERSITY OF NEVADA LAS VEGAS

("the Policyholder")

UNDERWRITTEN BY:

Wellfleet Insurance Company | Fort Wayne, IN ("the Company")

Policy Number: WI2021NVSHIP35 Group Number: ST1039SH Graduate & Professional Students and International-- Effective: 8/16/2020 - 8/15/2021 Nursing--Effective: 9/1/2020 - 8/31/2021

ADMINISTERED BY:

Wellfleet Group, LLC

NVSHIP35 rev 9.17.20

UNIVERSITY OF NEVADA LAS VEGAS 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

Table of Contents (Click on section title below to go to section in "Benefits at a Glance.")

Welcome Students.........................................................................................................................................................2 Where to Find Help........................................................................................................................................................3 UNLV Student Health Center .........................................................................................................................................3 Withdrawal from School................................................................................................................................................4 Eligibility and Waiver of Coverage .................................................................................................................................4 Coverage for Dependents..............................................................................................................................................5 Effective Dates & Costs..................................................................................................................................................5 Preferred Provider Organization (PPO) Network ..........................................................................................................7 Graduate & Professional, International, and Nursing Students Schedule of Benefits ..................................................7

Pre-Certification................................................................................................................................................... 18 Exclusions and Limitations...........................................................................................................................................18 Value Added Services ..................................................................................................................................................21

Welcome Students...

We are pleased to provide you with this summary of the 2020 ? 2021 Student Health Insurance Plan ("Plan"), which is fully compliant with the Affordable Care Act. "Benefits at a Glance" includes effective dates and costs of coverage, as well as other helpful information. For additional details about the Plan, please consult the Plan Certificate and other materials at unlv.. For questions about medical benefits or claims, please call Wellfleet Student at (877) 657-5033, TTY 711.

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Wellfleet Student PO Box 15369 Springfield, MA 01115-5369

UNIVERSITY OF NEVADA LAS VEGAS 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

Where to Find Help

For Questions About:

Servicing Agent Enrollment Waivers Insurance Benefits Claims Processing ID Cards Preferred Provider Listings

Preferred PPO Provider Listings

Cigna Claims

Prescription Drug Provider

Please Contact:

Academic HealthPlans unlv.

Wellfleet Group, LLC PO Box 15369 Springfield, Massachusetts 01115-5369 (877) 657-5033, TTY 711

Academic HealthPlans unlv. or Cigna

Send Cigna claims to: CIGNA PO Box 188061 Chattanooga, TN 37422 ? 8061 Electronic Payor ID: 62308

For information about the Wellfleet Rx/ESI Prescription Drug Program, please visit

Your plan includes Wellfleet Rx ? offering over 40 generics at a $0 copay. Please ask your health care provider to review our formulary to see if these medications are right for you. Click here for more information.

UNLV Student Health Center

When you need care, consider the UNLV Student Health Center (SHC) on campus as your first stop. They can provide many of the routine health services you need. Services obtained at the SHC are covered at no cost to the member with all applicable deductibles, copays and coinsurance waived for medical services. The UNLV SHC is open Monday through Thursday from 8:00 a.m. to 6:00 p.m. and Friday 9:00 a.m. to 5:00 p.m.

For more information, call the Student Health Center at (702) 895-3370. In the event of an emergency, call 911 or the Campus Police at (702) 895-3668.

A SHC referral is not required, and it does not guarantee services received will be considered eligible expenses under the plan, nor is it a guarantee of payment.

The Student Health Center Pharmacy has a $20 Copay per prescription.

Insured dependents are not eligible to use the UNLV SHC. The benefits listed in the Schedule of Benefits are available to the insured dependents.

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Wellfleet Student PO Box 15369 Springfield, MA 01115-5369

UNIVERSITY OF NEVADA LAS VEGAS 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

Withdrawal from School

If you leave the University of Nevada, Las Vegas for reason of a covered accident or sickness, you will be eligible for continued coverage under this Plan for only the first term immediately following your leave, provided you have approval by your school and any applicable regulatory authority, and were enrolled in this Plan for the term previous to your leave. Enrollment must be initiated by the student and is not automatic. All applicable enrollment deadline dates apply. You must pay the applicable insurance premium.

Please make sure you understand your school's credit hour and other requirements for enrolling in this plan. We reserve the right to review, at any time, your eligibility to enroll in this plan. If it is determined that you did not meet the school's eligibility requirements for enrollment, your participation in the plan may be terminated or rescinded in accordance with its terms and applicable law.

If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy and the full premium will be refunded. After 31 days, you will be covered for the full period that you have paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to a covered Accident or Sickness*). *Please refer to your Certificate for full information regarding premium reimbursement if withdrawing and refund of premium.

Eligibility and Waiver of Coverage

An eligible student must attend classes at the Policyholder's school for the first 31 days of the period for which he or she is enrolled.

Except in the case of withdrawal from school due to Sickness or Injury, any student who withdraws from the Policyholder's school during the first 31 days of the period for which he or she is enrolled shall not be covered under the insurance plan. A full refund of Premium will be made, minus the cost of any claim benefits paid by the Certificate. A student who graduates or withdraws after such 31 days of the period for which he or she is enrolled will remain covered under the Certificate for the term purchased and no refund will be allowed.

All International Students are required to have a F-1 Visa, and dependents have a F-2 Visa to be eligible for this insurance plan.

We maintain the right to investigate eligibility status and attendance records to verify that the Certificate eligibility requirements have been met. If We discover that the Certificate eligibility requirements have not been met, Our only obligation is refund of premium less any claims paid.

Eligibility requirements must be met each time Premium is paid to renew Coverage.

Who is Eligible

International Students

All registered International students, with F-1 visa status on a UNLV I-20, taking credits are required to have health insurance coverage, either through this Student Health Insurance Plan or through another individual or family plan. Students are automatically enrolled in the Student Health Insurance Plan unless proof of comparable coverage is provided by completing the waiver. Waivers must be submitted each term. International student accounts will be charged the Student Health Insurance Fee for the Fall and Spring/Summer term.

Graduate & Professional Students

All registered, degree-seeking Graduate & Professional students taking 1-8 credit hours and all registered, degreeseeking Law students taking 1-11 credit hours are eligible to enroll in this Student Health Insurance Plan. All registered, degree-seeking Graduate & Professional students taking 9 or more credits and all Graduate Assistantship (GA) students enrolled in 6 or more credit hours are required to have health insurance coverage, either through this Student Health Insurance Plan or through another individual or family plan. Students are automatically enrolled in the Student Health Insurance Plan unless proof of comparable coverage is provided by completing the waiver.

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Wellfleet Student PO Box 15369 Springfield, MA 01115-5369

UNIVERSITY OF NEVADA LAS VEGAS 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

Students need to submit a waiver once per academic year. Graduate student accounts will be charged the Student Health Insurance Fee for the Fall and Spring/Summer term.

Nursing Students

All registered, degree-seeking School of Nursing students taking 1-8 credits are eligible to enroll in this Student Health Insurance Plan on a voluntary basis. However, if you do not already have adequate medical insurance coverage, you must enroll online at unlv.. All registered degree-seeking School of Nursing students taking 9 or more credits are required to have health insurance coverage, either through this Student Health Insurance Plan or through another individual or family plan. Students are automatically enrolled in the Student Health Insurance Plan unless proof of comparable coverage is provided by completing the waiver.

Waivers must be submitted once per academic year. Nursing student accounts will be charged the Student Health Insurance Fee for the Fall and Summer/Summer term.

Insured Students who are enrolled in the Student Health Insurance Plan may also enroll their eligible dependents.

Who is not Eligible

Non-degree seeking students are not eligible to enroll in the student health insurance program.

Coverage for Dependents

Eligible individuals may also insure, on a Voluntary Participation Basis, their eligible Dependents. Eligible Dependents are the spouse (or lawful domestic partner), and unmarried children under 26 years of age. Individuals who enroll their dependents must enroll them within 31 days of the Insured Student's enrollment in the plan with the exception of adopted children or newborn children (see the Certificate provision entitled Dependent Child Coverage).

Newly Born Children - A newly born child of Yours will be covered from the moment of birth. Such newborn child will be covered for Covered Injury or Covered Sickness for an initial period of 31 days. This includes the necessary care and Treatment of medically diagnosed congenital defects and birth abnormalities from the moment of birth. If additional premium is required, to continue coverage beyond this initial 31-day period, You must notify Us of the birth so We can generate an updated premium bill so a timely premium payment is made. If an additional premium is not required, We request that the Insured Student notify Us of the birth to ensure proper claims adjudication.

Effective Dates & Costs

All time periods begin at 12:00 A.M. local time and end at 11:59 P.M. local time at the Policyholder's address.

Coverage Dates for Graduate & Professional, International Students and their Eligible Dependents.

Coverage Period

Coverage Start Date

Coverage End Date Enrollment/Waiver Deadline

Fall

8/16/2020

1/11/2021

10/5/2020

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Spring/Summer

1/12/2021

8/15/2021

2/26/2021

(New Students Only)

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Wellfleet Student PO Box 15369 Springfield, MA 01115-5369

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