Referrals

Students and covered dependents over the age of 18 (covered adults) should seek treatment at Student Health Services for all medical conditions, even if the student is on a medical leave of absence. If Student Health Services is unable to provide the care needed and the care is a covered service, you must obtain a referral or pre-approval from Student Health Services for a visit to a WUSM participating physician (the “in-network providers”) to be covered by the plan. If both Student Health Services and the in-network provider are unable to provide the care needed and the care is a covered service, Student Health Services will provide a referral to receive treatment outside of Student Health Services’ network (the “out-of-network providers”). A separate referral is required for each individual condition, and at the beginning of each year prior to receiving care for ongoing conditions.

Unless otherwise stated in this policy, the student will be responsible for a co-payment of $20 for each visit to a specialist, collected at the time of visit. Second opinion consultation is not covered. Students must return to the Student Health Services with all medication prescriptions and diagnostic testing orders for such prescriptions or orders to be covered by the Plan. Except as otherwise per-approved by Student Health Services, all prescriptions and diagnostic testing must be obtained through the Student Health Services for coverage. Please see the Benefits Summary SBC for a summary of expenses for in-network and out-of-network fees.

Expenses incurred for medical treatment rendered outside of the Student Health Service for which no prior approval or referral is obtained are excluded from coverage. Only one referral is required for each injury or sickness per policy year.

If a covered adult is unable to access Student Health Services (for example, while away from WUSM) then pre-approved is required before SHS will cover any medical expenses, except as provided below. Upon returning to WUSM, the covered adult must return to Student Health Services for any necessary follow-up care or referrals. When the Student Health Service is closed, those with urgent medical needs should contact the after-hours phone service for approval; for non-urgent medical needs, contact the office the next business day.

Except as otherwise provided below, the plan will not pay benefits to an in-network or out-network provider without a referral or pre-approval from Student Health Services. Without a referral or pre-approval, the student will will be responsible for 100% of the costs.

A referral from SHS is not required for services from the following providers in order to be covered according to the terms in the Student Health Plan:

  • Emergency services treatment as required to stabilize the patient. Once stabilized, covered adults are required to obtain a referral or pre-approval from Student Health Services for any necessary follow-up care the following business day;
  • Care for covered children at Forest Park Pediatrics or with a referral from Forest Park Pediatrics;
  • Care from the WU Division of Dermatology;
  • Counseling services from an in-network psychologist; and
  • Care from the Barnes-Jewish Vision Center

A covered child is not eligible to utilize Student Health Services and instead should obtain a referral from Forest Park Pediatrics, P.C. A covered child should return to Forest Park Pediatrics for all medication prescriptions and diagnostic testing orders.

Forest Park Pediatrics will serve as the Pediatric Primary Care Physicians for the covered child. Forest Park Pediatrics will provide routine preventive and primary care services rendered to a covered child on an outpatient basis.

To the extent Forest Park Pediatrics is unable to provide the medical care required and the service is a covered service, a referral must be obtained from Forest Park Pediatrics for the service to be covered under the plan.