PART VI
SCHEDULE OF BENEFITS
MEDICAL EXPENSE BENEFITS-INJURY
COLORADO SCHOOL OF MINES - INTERCOLLEGIATE SPORTS PLAN
2016-4059-8
INJURY ONLY BENEFITS



Maximum Benefit
$90,000 (For Each Injury)

Deductible Out-of-Network
$1,000 (Per Insured Person) (Per Policy Year)

Coinsurance Preferred Providers
90% except as noted below

Coinsurance Out-of-Network
70% except as noted below


This policy provides benefits for Injury sustained by an Insured Person while: 1) actually engaged, as an official representative of the
Policyholder, in the play or practice of an intercollegiate sport under the direct supervision of a regularly employed coach or trainer of
the Policyholder; or 2) actually being transported as a member of a group under the direct supervision of a duly delegated
representative of the Policyholder for the purpose of participating in the play or practice of a scheduled intercollegiate sport.

The Preferred Provider for this plan is Multiplan.

If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. If
the Covered Medical Expense is incurred due to a Medical Emergency, benefits will be paid at the Preferred Provider level of benefits.
In all other situations, reduced or lower benefits will be provided when an Out-of-Network provider is used.

Copays and Per Service Deductibles: All Copays and per service Deductibles specified in the Schedule of Benefits are in addition to
the policy Deductible.

The benefits payable are as defined in and subject to all provisions of this policy and any endorsements thereto. Benefits are subject to
the policy Maximum Benefit unless otherwise specifically stated. Benefits will be paid up to the maximum benefit for each service as
scheduled below. All benefit maximums are combined Preferred Provider and Out-of-Network unless otherwise specifically stated.



Inpatient
Preferred Provider
Out-of-Network Provider
Room & Board:
Preferred Allowance
Usual and Customary Charges
$250 Copay per visit
$750 Deductible per visit
Intensive Care:
Preferred Allowance
Usual and Customary Charges
Hospital Miscellaneous:
Paid under Room & Board
Paid under Room & Board
Physiotherapy:
Preferred Allowance
Usual and Customary Charges
Surgery:
Preferred Allowance
Usual and Customary Charges
Assistant Surgeon:
Preferred Allowance
Usual and Customary Charges
Anesthetist:
Preferred Allowance
Usual and Customary Charges
Registered Nurse's Services:
Preferred Allowance
Usual and Customary Charges
Physician's Visits:
Preferred Allowance
Usual and Customary Charges
Pre-admission Testing:
Preferred Allowance
Usual and Customary Charges



COL-06-CO STU (Rev 07-08)
- (1) PPO -
INJ


SCHEDULE OF BENEFITS (Continued)
MEDICAL EXPENSE BENEFITS-INJURY
COLORADO SCHOOL OF MINES - INTERCOLLEGIATE SPORTS PLAN
2016-4059-8
INJURY ONLY BENEFITS

Outpatient
Preferred Provider
Out-of-Network Provider
Surgery:
Preferred Allowance
Usual and Customary Charges
Day Surgery Miscellaneous:
Preferred Allowance
Usual and Customary Charges
$250 Copay per visit
$750 Deductible per visit
(Day Surgery Miscellaneous charges are based on the Outpatient Surgical Facility Charge Index.)
Assistant Surgeon:
Preferred Allowance
Usual and Customary Charges
Anesthetist:
Preferred Allowance
Usual and Customary Charges
Physician's Visits:
100% of Preferred Allowance
Usual and Customary Charges
$25 Copay per visit
$25 Deductible per visit
Physiotherapy:
Preferred Allowance
Usual and Customary Charges
$25 Copay per visit
(40 visits maximum Per Policy Year)
Medical Emergency:
Preferred Allowance
Usual and Customary Charges
$100 Copay per visit
$100 Deductible per visit
(The Copay/per visit Deductible will be waived if admitted to the Hospital.)
X-rays:
Preferred Allowance
Usual and Customary Charges
Laboratory:
Preferred Allowance
Usual and Customary Charges
Tests & Procedures:
Preferred Allowance
Usual and Customary Charges
Injections:
Preferred Allowance
Usual and Customary Charges
Prescription Drugs:
No Benefits
No Benefits

Other


Ambulance:
100% of Preferred Allowance
100% of Usual and Customary Charges
$200 Copay per trip
$200 Deductible per trip
(Benefit includes air ambulance payable at 90% of Preferred Allowance in-network / 70% of Usual and Customary
Charges out-of-network. Limited to $5,000 maximum Per Policy Year.)
Durable Medical Equipment:
Preferred Allowance
Usual and Customary Charges
($5,000 maximum (Per Policy Year) (Exception: See Benefits for Prosthetic Devices)
Consultant:
100% of Preferred Allowance
Usual and Customary Charges
$25 Copay per visit
$25 Deductible per visit
Dental:
Preferred Allowance
90% of Usual and Customary Charges
(Injury to Sound, Natural Teeth only.)
Urgent Care Center:
Preferred Allowance
Usual and Customary Charges
$35 Copay per visit
$35 Deductible per visit


SHC Referral Required: Yes ( ) No (X)
Conversion Permitted: Yes ( ) No (X)

Pre Admission Notification: Yes ( ) No (X)

( ) 52 Week Benefit Period or (X) Extension of Benefits

Other Insurance: (X) *Coordination of Benefits (X) Excess Motor Vehicle ( ) Primary Insurance

*If benefit is designated, see endorsement attached.

COL-06-CO STU (Rev 07-08)
- (2) PPO -
INJ