Westfield State University

STUDENT HEALTH INSURANCE PLAN
2024-2025 ACADEMIC YEAR
ANNUAL WAIVER FORM

Eligible students who have other health insurance coverage (i.e. under a parent’s or employer’s plan) and do not want to be enrolled in the Student Health Insurance Plan must submit an online waiver form documenting their other coverage prior to the posted deadline each academic year. Please allow approximately 7 business days for the insurance charge to be removed from your student account.

DEADLINE: SEPTEMBER 30, 2024.

TO CONTINUE THE WAIVER PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Asterisk (*) denotes required field

date of birth:*Required

(MM/DD/YYYY)

student ID:*Required

Introduction
Contact Information
BCBSMA COVID-19 Updates
FAQs

Student Health Plan

Waiver Form
Enrollment Form
Qualifying Event
Enrollment Form
- Day Division
- CGCE
Benefit Information
Blue Cross Blue Shield Info
Provider Search
Worldwide Providers &
Travel Assistance
Prescription Info
- Medication Look Up
- Prescription Claim Form
Insurance ID Card

Optional Plans

Massachusetts Delta Dental Plans
VSP Vision Care Plan
Renters Insurance
Dorm Insurance

Additional Information

Health Services
Health Connector Participant Info
Insurance Info for Graduating Students and Dependents

Please note, with the rising costs of healthcare, and increase in utilization of the Plan, the following plan changes have been imposed for the 2024-2025 academic year to help keep the insurance premium and the plan a viable option for all students.

Deductible will be $500
Out-of-pocket maximum will be $9,100
In-network preventive care - deductible will not apply.
In-network office visit copay will be $30 for primary and mental health visits and $65 for specialist visits (deductible will not apply in-network).
Emergency room copay will be $200 (deductible will not apply).
Ambulance services - new deductible will not apply.
Diagnostic Tests & X-rays - In-network copays will be $50 for lab and $100 for x-ray (deductible does not apply). Out-of-network will be a 20% coinsurance.
Imaging (CT/PET scans, MRIs will be a 20% coinsurance in-network/40% coinsurance out-of-network
The 5-Tier Plan prescription drug copays: deductible does not apply
- Tier 1: $20 copay (generic)
- Tier 2: $40 copay (preferred brand)
- Tier 3: $60 copay (non-preferred brand)
- Tier 4: 50% coinsurance (preferred specialty)
- Tier 5: 50% coinsurance (non-preferred specialty)

To look-up your prescription medication in the 5-Tier Plan, choose Prescription Info → Medication Look Up in the navigation menu on the left.

We encourage students anticipating high out-of-pocket costs to compare other insurance options to the SHIP. The Massachusetts Health Connector offers information about their online insurance marketplace where you can compare and purchase insurance plans. You may be eligible for a Subsidized Health Plan (a low or no cost insurance program for qualifying uninsured adults).

I have read and acknowledge the above statements

Deductible will be $500
Out-of-pocket maximum will be $9,100
In-network preventive care - deductible will not apply.
In-network office visit copay will be $30 for primary and mental health visits and $65 for specialist visits (deductible will not apply in-network).
Emergency room copay will be $200 (deductible will not apply).
Ambulance services - new deductible will not apply.
Diagnostic Tests & X-rays - In-network copays will be $50 for lab and $100 for x-ray (deductible does not apply). Out-of-network will be a 20% coinsurance.
Imaging (CT/PET scans, MRIs will be a 20% coinsurance in-network/40% coinsurance out-of-network
The 5-Tier Plan prescription drug copays: deductible does not apply
- Tier 1: $20 copay (generic)
- Tier 2: $40 copay (preferred brand)
- Tier 3: $60 copay (non-preferred brand)
- Tier 4: 50% coinsurance (preferred specialty)
- Tier 5: 50% coinsurance (non-preferred specialty)

To look-up your prescription medication in the 5-Tier Plan, choose Prescription Info → Medication Look Up in the navigation menu on the left.

Continue to the Summary of Benefits and Coverage

Deductible will be $500
Out-of-pocket maximum will be $9,100
In-network preventive care - deductible will not apply.
In-network office visit copay will be $30 for primary and mental health visits and $65 for specialist visits (deductible will not apply in-network).
Emergency room copay will be $200 (deductible will not apply).
Ambulance services - new deductible will not apply.
Diagnostic Tests & X-rays - In-network copays will be $50 for lab and $100 for x-ray (deductible does not apply). Out-of-network will be a 20% coinsurance.
Imaging (CT/PET scans, MRIs will be a 20% coinsurance in-network/40% coinsurance out-of-network
The 5-Tier Plan prescription drug copays: deductible does not apply
- Tier 1: $20 copay (generic)
- Tier 2: $40 copay (preferred brand)
- Tier 3: $60 copay (non-preferred brand)
- Tier 4: 50% coinsurance (preferred specialty)
- Tier 5: 50% coinsurance (non-preferred specialty)

To look-up your prescription medication in the 5-Tier Plan, choose Prescription Info → Medication Look Up in the navigation menu on the left.

Continue to the Plan Highlights

Deductible will be $500
Out-of-pocket maximum will be $9,100
In-network preventive care - deductible will not apply.
In-network office visit copay will be $30 for primary and mental health visits and $65 for specialist visits (deductible will not apply in-network).
Emergency room copay will be $200 (deductible will not apply).
Ambulance services - new deductible will not apply.
Diagnostic Tests & X-rays - In-network copays will be $50 for lab and $100 for x-ray (deductible does not apply). Out-of-network will be a 20% coinsurance.
Imaging (CT/PET scans, MRIs will be a 20% coinsurance in-network/40% coinsurance out-of-network
The 5-Tier Plan prescription drug copays: deductible does not apply
- Tier 1: $20 copay (generic)
- Tier 2: $40 copay (preferred brand)
- Tier 3: $60 copay (non-preferred brand)
- Tier 4: 50% coinsurance (preferred specialty)
- Tier 5: 50% coinsurance (non-preferred specialty)

To look-up your prescription medication in the 5-Tier Plan, choose Prescription Info → Medication Look Up in the navigation menu on the left.

I have read and acknowledge the above statements

Contact Information

For waiver, enrollment, eligibility, general benefit questions or plan issues
contact University Health Plans at 833-251-1115.

For specific benefit or claims questions
contact Blue Cross Blue Shield of Massachusetts at 888-753-6615.

Dental Insurance
(For Massachusetts Students Only)

Vision Insurance

Renters Insurance

Westfield State University

STUDENT HEALTH INSURANCE PLAN
2024-2025 ACADEMIC YEAR
ANNUAL WAIVER FORM

Student Health Plan

Qualifying Event
Enrollment Form

Benefit Information

Blue Cross Blue Shield Info

Prescription Info

Optional Plans

Additional Information

Contact Information

Westfield State University

STUDENT HEALTH INSURANCE PLAN 2024-2025 ACADEMIC YEAR ANNUAL WAIVER FORM

Student Health Plan

Qualifying Event Enrollment Form

Benefit Information

Blue Cross Blue Shield Info

Prescription Info

Optional Plans

Additional Information

Contact Information

STUDENT HEALTH INSURANCE PLAN
2024-2025 ACADEMIC YEAR
ANNUAL WAIVER FORM

Qualifying Event
Enrollment Form