Request Insurance Waiver
How to Use the Insurance Waiver Request Form
Insurance waiver requests must be submitted no later than the 6th day of the term.
Students requesting a waiver must provide evidence that they have or will have insurance that is equal to or better than the EWU International Insurance.
If you are a SACM sponsored student, submit the following:
- Current and valid financial guarantee
- scanned copy of SACM insurance card
- F-2 Dependents should also submit their F-1 spouses financial guarantee
*Note: SACM students must be on the SACM list that SACM provides the Office of Global Initiatives at the start of each academic quarter. If you are not on the list, you will not receive an insurance waiver.
Minimum Insurance Requirements for Waiver Requests
To be considered “comparable” and eligible for insurance fee reversal, international student and scholar health insurance plan must offer coverage for the following health services according to 22 C.F.R. § 62.14 and the Patient
Protection & Affordability Act https://www.healthcare.gov/glossary/patient-protection-and-affordable-care-act/ and meet the minimum standards listed below:
- Unlimited yearly benefit
- Deductible amount less than or equal to $250USD
- No maximum daily benefit for In-Hospital Room and Board
- Maximum out-of-pocket costs $4,500 per benefit year
- Insurance carrier must have a claims office in USA
- Preventative services provided with no deductible or co-pay
- Outpatient emotional and mental disorders
- Inpatient emotional and mental disorders
- Outpatient alcoholism and substance abuse
- Pregnancy/maternity costs
- Prescription drugs
- X-rays and lab work
- Ambulance charges
- Annual exams, Immunizations and Contraceptives covered with NO co-pay
- Doctor’s visits
- Durable medical equipment
- Medical evacuation and repatriation coverage
- Repatriation of deceased remains
Additional requirements for the insurance provider as follows:
- Underwritten by an insurance corporation having an A.M. Best rating of “A¥” or above; a McGraw Hill Financial/Standard & Poor’s Claims-paying Ability rating of “A¥” or above; a Weiss Research, Inc. rating of “B+” or above; a Fitch Ratings, Inc. rating of “A¥” or above; a Moody’s Investor Services rating of “A3” or above; or such other rating as the Department of State may from time to time specify; or
- Backed by the full faith and credit of the government of the exchange visitor’s home country; or
- Part of a health benefits program offered on a group basis to employees or enrolled students by a designated sponsor; or
- Offered through or underwritten by a federally qualified Health Maintenance Organization or eligible Competitive Medical Plan as determined by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services.
EWU International Student Insurance Policy
|Highlights of the Student Injury and Sickness Insurance Plan Benefits|
|Preferred Providers: The Provider Network for this plan is Choice. Preferred Providers can be found using the following link: http://www.uhcsr.com/lookupredirect.aspx?delsys=52|
|Student Health Center Benefits: The Deductible and Copays will be waived and benefits will be paid at 100% for Covered Medical Expenses incurred when treatment is rendered at or referred by the Student Health Center.|
|Preferred Providers||Out-of-Network Providers|
|Overall Plan Maximum||There is no overall maximum dollar limit on the policy|
|Plan Deductible||$250 Per Insured Person, per Policy Year||$500 Per Insured Person, per Policy Year|
After the Out-of-Pocket Maximum has been satisfied, Covered Medical Expenses will be paid at 100% for the remainder of the Policy Year subject to any applicable benefit maximums. Refer to the plan certificate for details about how the Out-of-Pocket Maximum applies.
|$4,500 Per Insured Person, Per Policy Year
$9,000 For all Insureds in a Family, Per Policy Year
|$9,000 Per Insured Person, Per Policy Year
$18,000 For all Insureds in a Family, Per Policy Year
All benefits are subject to satisfaction of the Deductible, specific benefit limitations, maximums and Copays as described in the plan certificate.
|80% of Preferred Allowance for Covered Medical Expenses||60% of Usual and Customary Charges for Covered Medical Expenses|
Mail order through UHCP at 2.5 times the retail Copay up to a 90 day supply.
|$15 Copay for Tier 1
$35 Copay for Tier 2
$70 Copay for Tier 3
Up to a 31-day supply per prescription filled at a United Healthcare Pharmacy (UHCP)
|$15 Copay for generic drugs
$35 Copay for brand name drugs
Up to a 31-day supply per prescription
50% of Usual and Customary Charges
|Preventive Care Services
Including but not limited to: annual physicals, GYN exams, routine screenings and immunizations. No Deductible, Copays, or Coinsurance will be applied when the services are received from a Preferred Provider. Please visit www.healthcare.gov/preventive-care-benefits/ for a complete list of the services provided for specific age and risk groups.
|100% of Preferred Allowance||60% of Usual and Customary Charges|
|The following services have per Service
This list is not all inclusive. Please read the plan certificate for complete listing of Copays.
|Medical Emergency: $100 Copay per visit||Medical Emergency: $ $100 Copay per visit|
|Pediatric Dental and Vision Benefits||Refer to the plan certificate for details (age limits apply).|