Benefits

All services must be medically necessary, authorized by a CampusCare Primary Care Provider (PCP) and provided at a Contracted Network Provider unless they are authorized by the CampusCare Medical Director in order to be covered under the rates listed below. All members must establish a provider relationship prior to any referrals or treatment. This can currently be done remotely via a telehealth visit. Call your PCP for an appointment.

**All members must make an appointment with one of the CampusCare Primary Care Provider to receive authorization or a referral before seeking care with a specialty physician in order to be covered under the benefits listed below.

There are no exclusions for pre-existing medical conditions. There are no deductibles and minimal co-payments for services. For additional information about benefits, limitations, and exclusions refer to the CampusCare Certificate of Coverage.

Covered medical services will be paid up to maximum and at the rates listed below:

Benefits Summary 
Hospital In Network
Inpatient100% minus a $50 per day co-payment
Outpatient100%
Emergency Care
In Network100% minus a $50 co-payment
Out of Network70% minus a $50 co-payment.
(100% Usual and Customary*)
Member liability: 30% + $50 co-payment
Physician Services
Physician Visits In Network100% minus a $15 co-payment
Occupational Therapy100% minus a $15 co-payment (max 20 sessions/AY)
Physical Therapy 100% minus a $15 co-payment (max 40 sessions/ AY)
Speech Therapy100% minus a $15 co-payment (max 20 sessions/AY)
Respiratory Therapy100% minus a $15 co-pay
Preventative Services
(Excludes services covered by Student Health Service Fee)
Plan year preventative services covered at first dollar
Routine Vision ExamOne per plan year. Covered at first dollar when provided by select providers
Ancillary Services
Ambulance80%
Pharmacy Formulary100% for prescriptions with:
$10 Generic co-payment
$20 Brand co-payment
$40 Non-formulary co-payment with 10% co-insurance
Diabetic Supplies and DME90%
Home Health Care90%
Medical Supplies
(in hospital or physician's office)
100%
Mental Health Care &
Substance Abuse Care
Inpatient100% minus a $50 per day co-payment
Outpatient100% minus a $15 co-payment

*Usual and Customary means 70% of billed charges, which is based on the negotiated rate that would have been paid to a participating provider.