AHP OF (21) Anthem-Mines
Student Health Insurance Plan
Colorado School of Mines 2021-2022
This is for informational purposes only and is neither an oer of coverage nor medical advice. It contains only a partial, general description of plan benefits and programs and does
not constitute a contract. Covered Medical Expenses are subject to plan maximums, limitations, and exclusions as described in the Policy. Your Plan provides you with a higher
level of coverage when you receive covered medical expenses from physicians who are part of Anthem Blue Access Network.
PLAN HIGHLIGHTS
BENEFIT CATEGORY
Deductible applies unless otherwise stated below.
In-Network Provider Out-of-Network Provider
Member payment based on the
Allowed Amount
Member payment based on the
Allowed Amount
Hospital Stay, including Room & Board (Deductible Waived) 20% aer a $250 copay 40% aer a $750 copay
Inpatient/Outpatient Surgery 20% 40%
Primary Care Oce Visit to Treat an Injury or Illness
(Deductible Waived)
$25 copay per visit 40% aer a $25 copay per visit
Diagnostic Services: X-ray & Lab 20% 40%
Emergency Room Facility Services (Deductible Waived) 20% aer a $100 copay per visit 20% aer a $100 copay per visit
Prescription Drugs (Deductible Waived)
Covers up to a 30-day supply (retail only)
Tier 1 - Lower Cost Generic
Tier 2 - Preferred Brand
Tier 3 - Non-Preferred Brand
At pharmacies contracting with Anthem Rx
100% aer a:
Tier 1: $15 copay
Tier 2: $30 copay
Tier 3: $60 copay
Not Covered
Preventive Care
For more information, please visit
healthcare.gov/preventive-care-benefits/
No Charge
(Deductible Waived)
40%
20212022 PREMIUM COSTS AND COVERAGE PERIODS
Coverage Periods
Annual
08/01/21 - 07/31/22
Spring/Summer (New Students)
01/01/22 - 07/31/22
Summer I
05/16/22 - 07/31/22
Student
$2,600 $1,509 $549
To view all enrollment and coverage periods available, please visit csm.myahpcare.com.
Eligibility
• All degree-seeking students, regardless of credit hours (Online only degree
students are NOT eligible.)
• All International Students (F and J visas), regardless of degree-seeking
status, must purchase the Student Health Insurance Plan, unless they meet
specific requirements to waive.
Please view the complete brochure online at csm.myahpcare.com for full details of
participation in the plan.
How to Waive
If you have other adequate health insurance and would like to waive the
Student Health Insurance Plan, you must go online to csm.myahpcare.com and
complete the online waiver by the deadline dates each semester. The Annual/
Fall waiver period begins July 15, 2021 and the waiver deadline is September 8,
2021. The Spring/Summer (new students) waiver period opens December 15,
2021 and the deadline to waive is January 26, 2022.
Academic HealthPlans, Inc. (AHP) is an independent company that provides program management and administrative services for the student health plans of Anthem BlueCross BlueShield.
Please note: the new insurance carrier for the 2020-2021 academic year is Anthem, using the Anthem PPO Network.
*Premium rates are pending Department of Insurance (DOI) review and approval and are subject to change.
BENEFIT MAXIMUMS & DEDUCTIBLES
In-Network Provider
Member Cost
Out-of-Network Provider
Member Cost
Overall Deductible (Not applicable to Preventive Services) $0 student $1,000 student
Out-of-Pocket Limit $2,000 student $4,000 student
This document contains a summary of your school’s student health insurance policy benefits and restrictions as of the date of its publication; the summary document may dier from the benefits in the approved
policy of insurance. The final policy may be pending approval by applicable federal and state regulatory authorities. The final approved policy of insurance is accessible upon approval at csm.myahpcare.com.
