14 Benefit Brochure SJSU_Intl

8/9/2019 14 Benefit Brochure SJSU_Intl

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2014-2015

studentinsurance.wellsfargo.co

You can view the standard Summary of Benefits & Coverage (SBC) which is requiredby Health Care Reform. It summarizes your coverage in a format that all insurancecompanies now use. To view your plan SBC, go to:studentinsurance.wellsfargo.com or call(800) 853-5899 to request a paper copy free of charge. Underw

Aetna Life InsuraPolicy #

The Plan BrWells Fargo Insurance S

Student Insura

The California State University International student health insurance plan is underwritten by Aetna Life InsurCompany (Aetna) and administered by Chickering Claims Administrators, Inc. (CCA). Aetna Student HealthSM isthe brand name for products and services provided by Aetna and CCA and their applicable afliated companie

15.02.310.1 D

INTERNATIONAL

SAN JOS STATE UNIVERSI


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2 San JoS S tate UniverSity - international

IMPORTANT NOTICEThis is just a brief description of your benets. For information regarding the full Master Policy (which incmation about refund requests, how to le a claim, mandated benets and other important information) plea(866) 378-8

send an email through your Aetna Navigator Account or athttp://www.aetnastudenthealth.com/customer-service/customYou will be able to obtain a copy of the full Master Policy as soon as it is availab

WHEN COVERAGE BEGINS

Insurance under the Master Policy will become effective at 12:01 a.m. onthe

later of: The Master Policy effective date; The beginning date of the term for which premium has been paid; The day after the Enrollment Form (if applicable) and premium payment

are received by Wells Fargo Insurance, Authorized Agent or University; or The day after the date of postmark if the Enrollment Form is mailed.

IMPORTANT NOTICE - Premiums will not be pro-rated if the Insured enrollspast the first date of coverage for which he or she is applying. Final decisionsregarding coverage effective dates are made by Aetna Student Health.

The below enrollments will be allowed a30 daygrace period from the termstart date to enroll whereby the effective date will be backdated a maximum

of30 days. No policy shall ever start prior to the term start date:1. All hard-waiver and mandatory (insurance is required as a condition ofenrollment on campus) insurance programs.

2. All re-enrollments into the same exact policy if re-enrollment occurswithin30 days of the prior policy termination date.

TERMS OF COVERAGE ANNUAL8/1/14 - 7/31/15FALL

8/1/14 -12/31/14SPRING/SUMMER1/1/15 - 7/31/15

Student only $1,105.26 $465.95 $638.62NOTE: Costs below are in addition to the student premium. Dependents must be enrolled for the same term

Spouse only $3,455.74 $1,447.78 $1,999.04Per Child (Age 0-25) only $1,731.09 $722.49 $1,007.48

Rates include premium payable to Aetna Life Insurance Company, as well as administrative fees payable to CEvacuation and Repatriation and Worldwide Emergency Travel Assistance benefits/services provided through

WHEN COVERAGE ENDS

Insurance of all Insured Persons terminates at 11:5the earliDate the Master Policy terminates for all Insu

End of the period of coverage for which prem Date the Insured Person ceases to be eligible f Date the Insured Person enters military servic In the event there is overlapping coverage und

number, the policy with the earliest effectivthrough its termination date and the subsequenimmediately afterward with no gap in coverag

Dependent coverage will not be effective prior to textend beyond that of the Insured Student.COVERAGE IS NOT AUTOMATICALLY RENenroll when coverage terminates to maintain coveplan expiration or renewal will be sent.

PLAN COST


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San JoS S tate UniverSity - international

All international students, visiting faculty, scholars or other persons possessingand maintaining a current passport and valid visa status (F-1, J-1 or M-1,etc.), engaged in educational activities at San Jos State University who aretemporarily located outside their home country and have not been grantedpermanent residency status, are required to be insured under the Policy.Waiver may only be granted to people already insured under equivalent plans.Coverage is available for students engaged in Practical Training. Enrollmentmust be accompanied by confirmation of Practical Training from the insuredstudent in the form of a copy of your EAD (OPT coverage is available for the first12 months of OPT only). Contact Wells Fargo Insurances Customer Service formore details. (A person who is an immigrant or permanent resident alien is noteligible for coverage under the international plan.)To be an Insured Person under the Policy, the student must have paid the requiredpremium and his/her name, student number and date of birth must have beenincluded in the declaration made by the School or the Administrative Agent to theInsurer. All students must actively attend classes on campus for45 consecutivedays following their effective date for the term purchased and/or pursuant totheir visa requirements for the period for which coverage is purchased, except inthe case of medical withdrawal or during school authorized breaks.

ALIC & Wells Fargo maintains its right to investigate student status andattendance records to verify that the Policy eligibility requirements have beenmet. If and whenever ALIC & Wells Fargo discovers that the Policy eligibilityrequirements have not been met, its only obligation is a pro-rata refund ofpremium.Eligible students who involuntarily lose coverage under another group insuranceplan are also eligible to purchase the Student Health Insurance Plan within30days of loss of coverage. These students must provide Wells Fargo with proofthat they have lost insurance through another group (certificate and letter ofineligibility) within30 days of the qualifying event. The effective date wouldbe the later of: a) term effective date, or b) the day after prior coverage ends

if enrollment request is received by Wells Fargo within30 days from loss ofprior coverage.COVERAGE FOR DEPENDENTS

Eligible Insured Students may also purchase Dependent coverage at the timeof students enrollment in the plan; or within31 days of one of the followingqualified events: marriage, addition of domestic partner, birth, adoption orarrival in the U.S. Eligible dependents are the spouse or legally registered andvalid domestic partner who resides with the Insured Student and the students,the spouses, or the domestic partners natural child, stepchild or legally adoptedchild under 26 years of age. Dependents of an Eligible International studentor visiting faculty member must possess a valid passport and a proper visa

(F-2, J-2, or M-2). A Newborn will automatically be covered for Injury orSickness from birth until 31 days old, providing that the student is coveredunder this plan. Coverage may be continued for that child when Wells Fargois notified in writing within31 daysfrom the date of birth and by payment ofany additional premium.Dependents must be enrolled for the same termof coverage for which the Insured Student enrolls. Dependent coverageexpires concurrently with that of the Insured Student, and Dependentsmust re-enroll when coverage terminates to maintain coverage.

WHO IS ELIGIBLE TO ENROLL? PREMIUM REFUND/CANCELLATION

Refund requests should be directed to Well(800) 853-5899 or via email [email protected] refund of premium will be granted for the reasorefunds will be granted.1. If you withdraw from school within the rst45 days of the c

period, you and your insured dependents will insurance premium provided that you and yourle a medical claim during this period. Written school must be provided. If you withdraw afte45 days of the cperiod, your and your insured dependents covuntil the end of the term for which you have pa

2. If you or your insured dependents enter the aryou and your insured dependents will not be Policy as of the date of such entry. If you enter will be cancelled. If your dependent enters threfund of premium will be made for such perreceived by Wells Fargo Insurance Services w45 days of enservice.

3. Refunds will be granted for insured dependentssuch as legal separation, divorce or death with31 days of the oevent, provided that your insured dependents dduring the insured period. Written proof of sucsubmitted. Refunds will not be prorated.

INSURANCE PAYMENTS WITH PERSON(Note: personal checks are not always a payment oschools enrollment form for available payment opt If you makyour dependents insurance payment via personal Insurance and we are unable to process the checkclosure of account, etc.), your and your dependentterminated retroactive to the effective date of the e


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WHERE DO I GO FOR SERVICE?

When you need care, consider Student Health Services (SHS) on your campusas your rst stop. They can provide many of the routine health services youneed. Services obtained at the SHS are reimbursed at the Preferred Care rate.A SHS referral is not required, and it does not guarantee services receivedwill be considered eligible expenses under the plan, nor is it a guarantee ofpayment. You may visit any licensed health care provider directly for coveredservices, except for specic Plan restrictions on certain services. However, whenyou visit a Preferred Care Provider, youll generally have less out of pocketexpense for your care. To learn more about Preferred Care Providers, visitwww.aetnastudenthealth.com .Insured dependents are not eligible to use the SHS. The benets listed inthe Schedule of Benets are available to the insured dependents.*Providers are independent contractors and are not agents of Aetna. Providerparticipation may change without notice. Aetna does not provide care orguarantee access to health services.

PREFERRED CARE PROVIDER NETWORK

Aetna Student Health has arranged for you to access the Aetna Preferred Care

Provider network. It is to your advantage to utilize a Preferred Care Providerbecause savings can be achieved from the Negotiated Charges these providershave agreed to accept as payment for their services. Students are responsiblefor informing their Physicians of potential out-of-pocket expenses for a referral toboth a Preferred Care Provider and a Non-Preferred Care Provider. Preferred CareProviders are independent contractors and are neither employees nor agents ofthe California State University system nor Aetna Student Health. To find aPreferred Care Provider, you can use Aetnas online DocFind service located atwww.aetnastudenthealth.com . Click on Find Your School and enter yourschool name. You can use DocFind to find out whether a specific providerbelongs to Aetnas network or to find Preferred Care Providers practicing inyour area.

PRESCRIPTION DRUGCLAIM PROCEDURE

When obtaining a covered prescription, please present your ID card to a Pre-ferred Pharmacy, along with your applicable copay. The pharmacy will bill Aetnafor the cost of the drug, plus a dispensing fee, less the copay amount.When you need to fill a prescription, and do not have your ID card with you,you may obtain your prescription from an Aetna Preferred Pharmacy, and bereimbursed by submitting a completed Aetna Prescription Drug claim form. Youwill be reimbursed for covered medications, less your copay.For an Aetna Prescription claim form go towww.aetnastudenthealth.com .

Find your school, then click Prescription to obtain an RX claim form. Or call(866) 378-8885 .Prescriptions from a Non-Preferred Pharmacy, or a health center pharmacy inca-pable of billing, must be paid for in full at the time of service and submittedfor reimbursement.

ID CARDS

Medical ID cards may be shipped before or witheffective date. Providers need your Member ID# you, verify your coverage and bill Aetna Life Innot need an ID card to be eligible to receive benattention before receiving your ID card, benefits the Policy. Once you have received your ID card,facilitate prompt payment of your claim. You canwww.aetnastudenthealth.com .

INFORMED HEALTH LINE

The Informed Health Line is a 24-hours-a-day, for insured students and dependents to access coor get assistance with locating nearby preferred n(800) 556-1555 to talk to a registered nurse who can pa range of topics. Callers must be enrolled in the Sin order to be eligible to utilize the Informed Heal

MEMBER WEB: AETNA NAVIGATOR

Got Questions? Get Answers with Aetna Nav

As an Aetna Student Health insurance member, Navigator, your secure member website, packed wiand health information. You can take full advantagto complete a variety of self-service transactions oBy logging into Aetna Navigator, you can:

Review who is covered under your plan. Request member ID cards. View Claim Explanation of Benefits (EOB) st Estimate the cost of common healthcare servic

plan your expenses. Research the price of a drug and learn if there Find healthcare professionals and facilities tha

Send an e-mail to Aetna Student Health Cuconvenience. View the latest health information and news, a

How do I register? Go towww.aetnastudenthealth.com Click onFind Your School. Enter your school name and then click on Se Click on Aetna Navigator and then the Access Navig Follow the instructions for First Time User b

Now link. Select a user name, password and security phr

Need help with registering onto Aetna Navig

Technical assistance is available toll free, Mondayto 9 p.m. Eastern Time at (800) 225-3375.


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WAIVER OF ANNUAL DEDUCTIBLEIn compliance with Federal Health Care Reform legislation, the Annual Deductible is waived for Preferred Carebenet types: Routine Physical Exam Expense (Ofce Visits), Pap Smear Screening Expense, Mammogram ExExpense, Routine Colorectal Cancer Screening, Routine Prostate Cancer Screening Expense, Preventive Care ImmVisits (Ofce Visits), Screening & Counseling Services (Ofce Visits) as illustrated under the Routine Physical Prenatal Care (Ofce Visits), Comprehensive Lactation Support and Counseling Services (Facility or Ofce VisitServices (Ofce Visits), Female Voluntary Sterilization (Inpatient and Outpatient), Pediatric Preventive Vision anDrugs, Brand Prescription Drugs if no Generic equivalent. FDA-Approved Female Generic Emergency Contrace

SCHEDULE OF BENEFITS

Deductibles*The following Deductibles are applied before Covered Medical Expenses are payable:Student/Spouse/Child: $150 per Insured per*Per visit or admission deductibles do not apply towards satisfying the plan Deductible.CoinsuranceCovered Medical Expenses are payable at the coinsurance percentage specied below, after any applicableOut of Pocket MaximumsPreferred Care Individual Out-of-Pocket: $2,500 per insured per Policy Year; Preferred Care FamOnce the Individual or Family Out-of-Pocket Limit for Preferred Care has been satised, Covered Medical Policy Year, up to any benet maximum that may apply. Coinsurance, Deductibles, Copays and Prescriptionthat do not apply towards satisfying the Out-Of-Pocket Limit: expenses that are not Covered Medical Expenpenalties,and other expenses not covered by this Plan.INPATIENT HOSPITALIZATION EXPENSES PREFERRERoom and Board Expense,semi-private room. 100% of the Negotiated Charge 75Intensive Care Room and Board Expense, overnight stay. 100% of the Negotiated Charge 75% of thMiscellaneous Hospital Expense, includes; among others; expenses incurred during ahospital connement for: anesthesia and operating room; laboratory tests and x rays;oxygen tent; and drugs; medicines; and dressings.

100% of the Negotiated Charge 75% of th

SURGICAL EXPENSE (INPATIENT & OUTPATIENT) PREFESurgical Expense 100% of the Negotiated Charge 75% of thAnesthesia Expense 100% of the Negotiated Charge 75% of thOUTPATIENT BENEFITS PREFERRED CAREWalk-In Clinic Expense.Copay is due at the time of visit and is in addition to the plandeductible.

100% of the Negotiated Chargeafter a $15 Co-pay per visit

75% of the Recognafter a $30 Co-pay

Emergency Room Visit Expense. Important note: Please note that as Non-Preferred Care Pro- viders do not have a contract with Aetna, the provider may not accept payment of your cost share(your deductible and coinsurance) as payment in full. You may receive a bill for the differencebetween the amount billed by the provider and the amount paid by this Plan. If the provider billsyou for an amount above your cost share, you are not responsible for paying that amount. Pleasesend Aetna the bill at the address listed on the back of your member ID card and Aetna will resolveany payment dispute with the provider over that amount. Make sure your member ID number is onthe bill. The copay is in addition to the plan deductible.

100% of the Negotiated Chargeafter $200 Co-pay per visit (Co-pay waived if admitted)

100% of the Recognafter $200 Deductib(Deductible waived

Continued on next page

IMPORTANT NOTICEThis is just a brief description of your benets. For information regarding the full Master Policy (which incmation about refund requests, how to le a claim, mandated benets and other important information) plea(866) 378-8

send an email through your Aetna Navigator Account or athttp://www.aetnastudenthealth.com/customer-service/customYou will be able to obtain a copy of the full Master Policy as soon as it is availab

The Plan will pay benets in accordance with any applicable California S


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SCHEDULE OF BENEFITS (CONTINUED)

OUTPATIENT BENEFITS PREFERRED CAREUrgent Care Expense.Please note: A covered person should not seek medical care ortreatment from an urgent care provider if their illness, injury, or condition, is an emergencycondition. The covered person should go directly to the emergency room of a hospital or call 911for ambulance and medical assistance. The copay is in addition to the plan deductible.

100% of the Negotiated Chargeafter a $15 Co-pay per visit

75% of the Recognafter a $30 Co-pay

Ambulance Expense 90% of the Negotiated Charge 90% of th

Physicians Ofce Visit Expense.Copay is due at time of visit and is in addition to theplan deductible. 100% of the Negotiated Chargeafter a $15 Co-pay per visit 75% of the Recognafter a $30 Co-payLaboratory and X-Ray Expense 100% of the Negotiated Charge 75% of th Therapy Expense,for the following types of therapy provided on an outpatient basis:Physical Therapy, Chiropractic Care, Speech Therapy, Inhalation Therapy, CardiacRehabilitation, or Occupational Therapy. Benets for Chiropractic Care are limited to50visits per Policy Year.


Breast Feeding Durable Medical Equipment Expense,includes the rental or purchaseof breast feeding durable medical equipment for the purpose of lactation support.100% of the Negotiated Charge 75% of th

Allergy Testing and Treatment Expense,includes laboratory tests, physician ofce visitsto administer injections, prescribed medications for testing and treatment of the allergy,and other medically necessary supplies and services.

Payable on the same basis as any othe

Routine Physical Exam Expense 100% of the Negotiated Charge 75% of thPediatric Preventive Care Expense,for the comprehensive preventive care of children16 years of age or younger, including periodic health evaluations, immunizations, andlab services.


Pediatric Preventive Care Expense,for the comprehensive preventive care of children17 and 18 years of age, including periodic health evaluations, immunizations, and labservices.


MENTAL HEALTH BENEFITS PREFERRED CASevere Mental Illness Expense - Inpatient,for the diagnosis and medically necessarytreatment of severe mental illnesses of a person of any age, and of serious emotionaldisturbances of a child.

Payable as any other Sickness

Severe Mental Illness Expense - Outpatient 100% of the Negotiated Charge 75% of thMental and Nervous Disorders Expense, inpatient and outpatient. 100% of the Negotiated Charge 7ALCOHOLISM AND DRUG ADDICTION TREATMENT PREFInpatient Expense,for the treatment of alcohol and drug addiction. 100% of the Negotiated Charge 75% of th

Outpatient Expense,for the treatment of alcohol and drug addiction. 100% of the Negotiated Charge 75% of th

Continued on next page


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SCHEDULE OF BENEFITS (CONTINUED)

MATERNITY BENEFITS PREFERRED CAREMaternity Expense,for the care of the covered person and any newborn child.Payable on the same basis as any othe

Well Newborn Nursery Care Expense,for the routine care of a covered personsnewborn child. 100% of the Negotiated Charge 75% of th

ADDITIONAL BENEFITS PREFERRED CARE

Prescribed Medicine ExpenseNote: Contraceptive Drugs and Device benets are illustrated under the Family PlanningBenet, as noted in the Benets Description on page 8.

Preferred Care Pharmacy:100% of the Negotiated Charge, following Brand Name Prescription Drug or $15 Co

Prescription Drug.Non-Preferred Care Pharmac:

100% of the Recognized Charge, followingBrand Name Prescription Drug or $15 Co

Prescription Drug.Pap Smear Screening Expense 100% of the Negotiated Charge 75% of thMammogram Expense 100% of the Negotiated Charge 75% of th

Family Planning Expense, includes charges incurred for services and supplies that areprovided to prevent pregnancy. 100% of the Negotiated Charge 75% of th

Routine Screening Expense, includes charges for Chlamydia, Sexually TransmittedDisease, and Colorectal Cancer screenings. 100% of the Negotiated Charge 75% of th

Rehabilitation Facility Expense 100% of the Negotiated Charge 75% of th

Cochlear Implant Expense, internally implanted devices. 100% of the Negotiated Charge 75% of th

Adult Routine Eye Exam, eye exams for refraction. 100% of the Negotiated Charge 75% of th

Elective Abortion Expense 100% of the Negotiated Charge 75% of th

Bariatric Surgery Expense,expenses include services rendered as part of medicallynecessary bariatric surgery treatment for morbid obesity. Payable on the same basis as any othe

Human Organ Transplant Expense Payable on the same basis as any othe

Pediatric Vision Care Services and Supplies 100% of the Negotiated Charge 75% of th

Pediatric Vision Care Exam Expense 100% of the Negotiated Charge 75% of th

Pediatric Dental Diagnostic and Preventive Care 100% of the Negotiated Charge 75% of th

Pediatric Dental Basic Restorative Care 70% of the Negotiated Charge 50% of th

Pediatric Dental Major Restorative Care 50% of the Negotiated Charge 50% of th

For more details about these benets, please see the Benet Descriptions section on p


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BENEFIT DESCRIPTIONS

Routine Physical Exam Expense:Benets include expenses for a routine physi-cal exam performed by a physician. If charges for a routine physical exam givento a child who is a covered dependent are covered under any other benet sec-tion, those charges will not be covered under this section.A routine physical exam is a medical exam given by a physician, for a reasonother than to diagnose or treat a suspected or identied injury or sickness. In-cluded as a part of the exam are:

Routine vision and hearing screenings given as part of the routine physicalexam.X-rays, lab, and other tests given in connection with the exam, and

Materials for the administration of immunizations for infectious diseaseand testing for tuberculosis.

In addition to any state regulations or guidelines regarding mandated RoutinePhysical Exam services, Covered Medical Expenses include services rendered inconjunction with,

Evidence-based items that have in effect a rating of A or B in the currentrecommendations of the United States Preventive Services Task Force.

For females, screenings and counseling services as provided for in thecomprehensive guidelines recommended by the Health Resources andServices Administration. These services may include but are not limited to:

Screening and counseling services, such as:o Interpersonal and domestic violence;o Sexually transmitted diseases*; ando Human Immune Deciency Virus (HIV) infections.

Screening for gestational diabetes. High risk Human Papillomavirus (HPV) DNA testing for women age 18 and

older and limited to once every three years.*Sexually transmitted disease screening expense is limited to two screeningsper Policy Year.

X-rays, lab and other tests given in connection with the exam. Immunizations for infectious diseases and the materials for administration

of immunizations that have been recommended by the AdvisoryCommittee on Immunization Practices of the Centers for Disease Controland Prevention. If the plan includes dependent coverage, for covered newborns, an initialhospital check up.

Important Note:For details on the frequency and age limits that apply to Routine Physi-cal Exams and Routine Cancer Screenings, a covered person may contacthis or her physician or Member Services by logging onto the Aetna websitewww.aetna.com or calling the toll-free number on the back of the ID card.Screening and Counseling Services: Covered Medical Expenses include chargesmade by a physician in an individual or group setting for the following:Depression Screening: This service is limited to once per year.Obesity: Screening and counseling services to aid in weight reduction due toobesity. Coverage includes:

Preventive counseling visits and/or risk factor reduction intervention; Medical nutrition therapy; Nutritional counseling; and

Healthy diet counseling visits provided in connection with Hyperlipidemia(high cholesterol) and other known risk factors for cardiovascular anddiet-related chronic disease.

Services in this category are subject to a combigroup visits by any recognized provider per Po

The 10 Healthy Diet Counseling visits will bnumber of visits allowed for Obesity counselin

Misuse of Alcohol and/or Drugs: Screening and counseling sprevention or reduction of the use of an alcohol agCoverage includes preventive counseling visits, risand a structured assessment.

Services in this category are subject to a combgroup visits by any recognized provider per PoUse of Tobacco Products: Screening and counseling servicperson to stop the use of tobacco products.Coverage includes:

Preventive counseling visits; Treatment visits; and Class visits;

To aid a covered person to stop the use of tobacco pTobacco product means a substance containing tob

cigarettes; cigars; smoking tobacco; snuff; smokeless tobacco; and candy-like products that contain tobacco.

Limitations: Unless specied above, not covered unCounseling Services benet are charges incurred fo

Services which are covered to any extent unde Services in this category are subject to a comb

group visits by an recognized provider per PoliFamily Planning Expense: For females with reproductiveMedical Expenses include those charges incurred are provided to prevent pregnancy. All services anbenet must be approved by the Food and Drug Ad

Coverage includes counseling services on contracephysician, obstetrician or gynecologist. Such couMedical Expenses when provided in either a groupThe following contraceptive methods are covered eVoluntary Sterilization: Covered expenses include charges provider for female voluntary sterilization procedurplies including, but not limited to, tubal ligation and Covered expenses under this Preventive Care benetvoluntary sterilization procedure to the extent that thrately by the provider or because it was not the primLimitations:Unless specified above, not covered under this ben

Services which are covered to any extent under Services and supplies incurred for an abortion; Services provided as a result of complications

sterilization procedure and related follow-up ca Services which are for the treatment of an iden Services that are not given by a physician or un Psychiatric, psychological, personality or emot

Continued on


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San JoS S tate UniverSity - international Continued on

BENEFIT DESCRIPTIONS (CONTINUED)

Any contraceptive methods that are only reviewed by the FDA and notapproved by the FDA;

Male contraceptive methods, sterilization procedures or devices; The reversal of voluntary sterilization procedures, including any related

follow-up care.Important note: Brand-Name Prescription Drug or Devices will be covered at100% of the Negotiated Charge, including waiver of Annual Deductible if a Ge-neric Prescription Drug or Device is not available in the same therapeutic drugclass or the prescriber species Dispense as Written.Pediatric Preventive Care Expense: Covered Medical Expenses include chargesfor the comprehensive preventive care of children 16 years of age or younger,consistent with the Recommendations for Preventive Pediatric health Care, asadopted by the American Academy of Pediatrics. Covered Medical Expenses willinclude periodic health evaluations, immunizations and lab services.Pediatric Preventive Care Expense: Covered Medical Expenses include chargesfor the comprehensive preventive care of children 17 and 18 years of age, consis-tent with the Recommendations for Preventive Pediatric health Care, as adoptedby the American Academy of Pediatrics. Covered Medical Expenses will includeperiodic health evaluations, immunizations and lab servicesTherapy Expense: Covered Medical Expenses include charges incurred by a cov-ered person for the following types of therapy provided on an outpatient basis:

Physical Therapy,Chiropractic Care,

Speech Therapy, Inhalation Therapy,

Cardiac Rehabilitation, or Occupational Therapy.

Expenses for Chiropractic Care are Covered Medical Expenses, if such care isrelated to neuromusculoskeletal conditions and conditions arising from: the lackof normal nerve, muscle, and/or joint function.Expenses for Speech and Occupational Therapies are Covered Medical Expenses,only if such therapies are a result of injury or sickness.Covered Medical Expenses for chemotherapy, including anti-nausea drugs used

in conjunction with the chemotherapy, radiation therapy, tests and procedures,physiotherapy (for rehabilitation only after a surgery), and expenses incurredat a radiological facility. Covered Medical Expenses also include expenses forthe administration of chemotherapy and visits by a health care professional toadminister the chemotherapy.Benets for these types of therapies are payable for Covered Medical Expenses,on the same basis as any other sickness.Allergy Testing and Treatment Expense: Benets include charges incurred fordiagnostic testing and treatment of allergies and immunology services.Covered Medical Expenses include, but are not limited to, charges for the fol-lowing:

laboratory tests, physician office visits, including visits to administer injections, prescribed

medications for testing and treatment of the allergy, including anyequipment used in the administration of prescribed medication, andother medically necessary supplies and services.

Severe Mental Illness of persons of any age and Serious Emotional Dis-turbances of a Child Inpatient Expense: Covered Medical Expenses for thediagnosis and medically necessary inpatient treatment of severe mental illnessesof a person of any age, and of serious emotional disturbances of a child are pay-

able on the same basis as any other Sickness.Covered Medical Expenses also include the chargeduring partial hospitalization in a hospital or treatmeproval must be obtained on a case-by-case basis by cClinical Review Services for Minors - If clinical review servicthe California Welfare and Institution Code, are pwho is a minor and who is conned in as a full-timhealth facility on the consent of his parent or guard

be included as Covered Medical Expenses: Charges for the clinical review services to threquired by the California Welfare and Instituti

Charges, if any, for services of an interpreter, a Charges, if any, for services of a patients right

Severe Mental Illness of persons of any age turbances of a Child Outpatient Expense: Covered Medical Ediagnosis and medically necessary outpatient treatdrugs, of severe mental illnesses of a person of any disturbances of a child are payable on the same basMental and Nervous Disorders Inpatient Expe: Covered Mediother than those for severe mental illness and/or serof a child, include charges incurred by a covered ptime inpatient in a hospital or residential treatmentmental and nervous disorders.Covered Medical Expenses also include the chargeduring partial hospitalization in a hospital or treatmapproval must be obtained on a case-by-case basisHealth.Clinical Review Services for Minors: If clinical review servicthe California Welfare and Institution Code, are pwho is a minor and who is conned in as a full-timhealth facility on the consent of his parent or guardbe included as Covered Medical Expenses:

Charges for the clinical review services to th

required by the California Welfare and Instituti Charges, if any, for services of an interpreter, a Charges, if any, for services of patients rights

Mental and Nervous Disorders Outpatient Ex: Covered Medes, other than those for severe mental illness and/obances of a child, include charges for treatment of mwhile the covered person is not conned as a full-tiMaternity Expense: Covered Medical Expenses include iered person and any newborn child for a minimumdelivery and for a minimum of 96 hours after a cesAny decision to shorten such minimum coverage ing Physician, in consultation with the mother. In Expenses may include home visits, parent educatioin breast or bottle-feeding.Prenatal diagnosis of genetic disorders of the fetus dures of a high-risk pregnancy, Maternity Expensenancy are payable on the same basis as any other SPrenatal Care: Prenatal care will be covered for service


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female in a physicians, obstetricians, or gynecologists ofce but only to theextent described below. Coverage for prenatal care under this benet is limitedto pregnancy-related physician ofce visits including the initial and subsequenthistory and physical exams of the pregnant woman (maternal weight, bloodpressure and fetal heart rate check).Comprehensive Lactation Support and Counseling Services: Covered MedicalExpenses will include comprehensive lactation support (assistance and trainingin breast feeding) and counseling services provided to females during pregnancy

and in the post-partum period by a certied lactation support provider. The post-partum period means the 60 day period directly following the childs date ofbirth. Covered expenses incurred during the post-partum period also include therental or purchase of breast feeding equipment.Lactation support and lactation counseling services are covered expenses whenprovided in either a group or individual setting.Well Newborn Nursery Care Expense: Benets include charges for routine careof a covered persons newborn child as follows:

Hospital charges for routine nursery care during the mothers confinement,but for not more thanfour days,

Physicians charges for circumcision, and Physicians charges for visits to the newborn child in the hospital and

consultations, but for not more than 1 visit per day.Pap Smear Screening Expense: Covered Medical Expenses include one routineannual Pap smear screening (or an alternative cervical cancer screening test whenrecommended by a physician or a health care provider), and an FDA approvedhuman papillomavirus screening test for women age 18 and older.Mammogram Expense: Covered Medical Expenses include coverage for mam-mograms for screening or diagnostic purposes upon referral of a nurse practitio-ner, certied nurse-midwife, physician assistant, or physician.

BENEFIT DESCRIPTIONS (CONTINUED)

Pediatric Vision Care Services and Supplies: Covered expenses ifor the following vision care services and supplies:

Office visits to an ophthalmologist, optometrifitting of prescription contact lenses.

Eyeglass frames, prescription lenses or prescriCoverage includes charges incurred for:

Non-conventional prescription contact lenses visual acuity to 20/40 or better in the better e

cannot be obtained with conventional lenses. Aprescribed after cataract surgery has been perfoLow vision services.A listing of the locations of the vision network proaccessed atwww.aetna.com website. Be sure to look at thenetwork provider listing that applies to your planuse different networks of providers. You must presnetwork provider at the time of service. This beneshown on the Schedule of Benets. As to coveragcalendar year, this benet will cover either prescripor prescription contact lenses, but not both.Limitations: Unless specied above, not covered undeincurred for services and supplies:

Eyeglass frames, non-prescription lenses andlenses that are for cosmetic purposes.Human Organ Transplant Expense: Transplants of organs, tissuWe provide or pay for donation-related Services for aor not they are Members) in accord with our guideline


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EXCLUSIONS & LIMITATIONS

IMPORTANT NOTICE:This is just a brief description of your benets. For infor-mation regarding the full Master Policy (which includes plan benets, exclusionsand limitations, and information about refund requests, how to le a claim, man-dated benets and other important information) please call Aetna Student Healthat(866) 378-8885 orsend an email through your Aetna Navigator Account or atwww.aetnastudenthealth.com/customer-service/customer-service.aspx You will be able to obtain a copy of the full Master Policy as soon as it is available.Plan benets are subject to all applicable state and federal laws and regulations,which are subject to change. The plan neither covers nor provides benets forthe following:1. Expense incurred for services normally provided without charge by the Poli-

cyholders Health Service; Inrmary or Hospital; or by health care providersemployed by the Policyholder.

2. Expense incurred for eye refractions; vision therapy; radial keratotomy;eyeglasses; contact lenses (except when required after cataract surgery);or other vision or hearing aids; or prescriptions or examinations except asrequired for repair caused by a covered injury.

3. Expense incurred as a result of injury due to participation in a riot. Partici-pation in a riot means taking part in a riot in any way; including incitingthe riot or conspiring to incite it. It does not include actions taken in self-defense; so long as they are not taken against persons who are trying torestore law and order.

4. Expense incurred as a result of an accident occurring in consequenceof riding as a passenger or otherwise in any vehicle or device for aerialnavigation; except as a fare-paying passenger in an aircraft operated bya scheduled airline maintaining regular published schedules on a regularlyestablished route.

5. Expense incurred as a result of an injury or sickness due to working forwage or prot or for which benets are payable under any Workers Com-pensation or Occupational Disease Law.

6. Expense incurred as a result of an injury sustained or sickness contractedwhile in the service of the Armed Forces of any country. Upon the covered

person entering the Armed Forces of any country; the unearned pro-ratapremium will be refunded to the Policyholder.7. Expense incurred for treatment provided in a governmental hospital unless

there is a legal obligation to pay such charges in the absence of insurance.8. Expense incurred for elective treatment or elective surgery except as spe-

cically provided elsewhere in this Policy and performed while this Policyis in effect.

9. Expense incurred for cosmetic surgery, reconstructive surgery, or other ser-vices and supplies which improve, alter, or enhance appearance whether ornot for psychological or emotional reasons. This exclusion will not apply to theextent needed to: (a) Improve the function or create a normal appearanceto the extent possible of a part of the body that is not a tooth or structurethat supports the teeth and is malformed as a result of a congenital defect,including harelip, webbed ngers or toes, or as a direct result of disease orsurgery performed to treat a disease or injury; (b) Repair an injury (includingreconstructive surgery for prosthetic device for a covered person who hasundergone a mastectomy) which occurs while the covered person is coveredunder this Policy. Surgery must be performed in the calendar year of the ac-cident which causes the injury or in the next calendar year.

10. Expense covered by any other valid and collectible medical; health or ac-cident insurance to the extent that benets are payable under other validand collectible insurance whether or not a claim is made for such benets.

11. Expense incurred as a result of commission of12. Expense incurred after the date insurance term

except as may be specically provided in the Ex13. Expense incurred for services normally prov

school and covered by the school fee for servic14. Expense incurred for any services rendered b

persons immediate family or a person who livhome.

15. Expense incurred for injury resulting from theor intercollegiate sports; including collegiate oand intramurals.

16. Expense for the contraceptive methods; devicor related to articial insemination; in-vitro ferprocedures; elective sterilization or its reversalspecically provided for in this Policy.

17. Expenses for treatment of injury or sickness tomade; as a judgment or settlement; by any persthe injury or sickness (or their insurers).

18. Expense incurred for which no member of thefamily has any legal obligation for payment.

19. Expense incurred for custodial care. Custodisupplies furnished to a person mainly to help hof daily life. This includes room and board anThe person does not have to be disabled. Suchcustodial care without regard to: by whom theythey are recommended; or by whom or by whic

20. Expense incurred for the removal of an organ fpurpose of donating or selling the organ to any limitation does not apply to a donation by a cochild; brother; sister; or parent.

21. Expenses incurred for or in connection with pplies that are, as determined by Aetna, to be etional. A drug, a device, a procedure, or treatmeexperimental or investigational if: (a) There areavailable from controlled clinical trials publisherature to substantiate its safety and effectiveneinvolved; or (b) If required by the FDA, approvmarketing or a recognized national medical or agency has determined in writing that it is expor for research purposes; or (c) The written pby the treating facility, or the protocol or protstudying substantially the same drug, device, pthe written informed consent used by the treatfacility studying the same drug, device, procethat it is experimental, investigational, or for rethis exclusion will not apply with respect to ser

drugs) received in connection with a disease (a) The disease can be expected to cause deathabsence of effective treatment; and (b) The carfor that disease or shows promise of being effdemonstrated by scientic data. In making thistake into account the results of a review by a pcal professionals. They will be selected by Ae

Continued on


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professionals who treat the type of disease involved; or (c) The coveredperson has been accepted into a phase I, II, III, or IV approved cancerclinical trial and the attending physician recommended the program. Also,this exclusion will not apply with respect to drugs that: (a) Have beengranted treatment investigational new drug (IND) or Group c/treatmentIND status; or (b) Are being studied at the Phase III level in a nationalclinical trial; sponsored by the National Cancer Institute if Aetna determinesthat available, scientic evidence demonstrates that the drug is effective orshows promise of being effective for the disease.22. Expense incurred as a result of dental treatment; except for medically nec-essary dental or orthodontic services that are an integral part of reconstruc-tive surgery for cleft palate procedures as provided elsewhere in this Policy.

23. Expense incurred by a covered person; not a United States citizen; for ser-vices performed within the covered persons home country; if the coveredpersons home country has a socialized medicine program.

24. Expense incurred for alternative; holistic medicine; and/or therapy; includ-ing but not limited to; yoga and hypnotherapy.

25. Expense for: (a) care of at feet; (b) supportive devices for the foot; (c)care of corns; bunions; or calluses; (d) care of toenails; and (e) care offallen arches; weak feet; or chronic foot strain; except that (c) and (d) arenot excluded when medically necessary; because the covered person isdiabetic; or suffers from circulatory problems.26. Expense for injuries sustained as the result of a motor vehicle accident; tothe extent that benets are payable under other valid and collectible insur-ance; whether or not claim is made for such benets. The Policy will onlypay for those losses; which are not payable under the automobile medicalpayment insurance Policy.

27. Expense incurred when the person or individual is acting beyond the scopeof his/her/its legal authority.

28. Expense incurred for hearing aids; the tting; or prescription of hearingaids.

29. Expense for care or services to the extent the charge would have beencovered under Medicare Part A or Part B; even though the covered personis eligible; but did not enroll in Part B.

30. Expense for telephone consultations; charges for failure to keep a sched-uled visit; or charges for completion of a claim form.

31. Expense for the cost of supplies used in the performance of any occupa-tional therapy.

32. Expense for personal hygiene and convenience items; such as air condition-ers; humidiers; hot tubs; whirlpools; or physical exercise equipment; evenif such items are prescribed by a physician.

33. Expense for services or supplies provided for the treatment of obesity and/ or weight control, unless otherwise provided in this plan.

34. Expense for incidental surgeries; and standby charges of a physician.35. Expense for treatment and supplies for programs involving cessation of

tobacco use, except as otherwise provided in this Plan.

36. Expense incurred for the use of orthotics; unless used exclusively to pro-mote healing.37. Expenses incurred for; or in connection with; speech therapy. This exclusion

does not apply for charges for speech therapy that is expected to restorespeech to a person who has lost existing function (the ability to expressthoughts; speak words; and form sentences); as a result of an accidentor sickness.

38. Expense for charges that are not recognized cAetna; except that this will not apply if the chadoes not exceed the recognized charge for that than the amount or percentage; specied as the

39. Expense for treatment of covered students whhealth care eld; and who receive treatment asthat eld.

40. Expenses for routine physical exams; includinwell newborn care; routine vision exams; routhearing exams; immunizations; or other prevenexcept to the extent coverage of such exams; imsupplies is specically provided in the Policy.

41. Expense incurred for a treatment, service, or snecessary as determined by Aetna for the diagthe sickness or injury involved. This applies erecommended, or approved by the persons atteIn order for a treatment, service, or supply tonecessary, the service or supply must: (a) be is likely to produce a signicant positive outcoto produce a negative outcome than, any alterboth as to the sickness or injury involved and condition; (b) be a diagnostic procedure whichstatus of the person and be as likely to result affect the course of treatment as, and no more lioutcome than, any alternative service or supplor injury involved and the persons overall headiagnosis, care, and treatment, be no more coall health expenses incurred in connection withsupply) than any alternative service or supply tdetermining if a service or supply is appropriaAetna will take into consideration: (a) informapersons health status; (b) reports in peer reviewreports and guidelines published by nationally nizations that include supporting scientic datprofessional standards of safety and effectivefor diagnosis, care, or treatment; (e) the opinioin the generally recognized health specialty inrelevant information brought to Aetnas attenfollowing services or supplies be considered (a) those that do not require the technical skillhealth, or a dental professional; or (b) those personal comfort or convenience of the personhim or her, or any persons who is part of his orprovider, or healthcare facility; or (c) those fuperson is an inpatient on any day on which thecould safely and adequately be diagnosed or tre

those furnished solely because of the setting if safely and adequately be furnished in a physicother less costly setting.

42. Expenses incurred for the treatment of acne.Any exclusion above will not apply to the extent threquired under any law that applies to the coverag

EXCLUSIONS & LIMITATIONS (CONTINUED)


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COORDINATION OF BENEFITS

If the Covered Person is insured under more than one group health plan, thebenefits of the plan that covers the insured student will be used before those ofa plan that provides coverage as a dependent. When both parents have grouphealth plans that provide coverage as a dependent, the benefits of the plan ofthe parent whose birth date falls earlier in the year will be used first. The benefitsavailable under this Plan may be coordinated with other benefits available to theCovered Person under any auto insurance, Workers Compensation, Medicare,or other coverage. The Plan pays in accordance with the rules set forth in theMaster Policy.

EXTENSION OF BENEFITS

If a Covered Person is conned to a hospital on the date his or her insuranceterminates, expenses incurred after the termination date and during the con-tinuance of that hospital connement, shall be payable in accordance with thepolicy, but only while they are incurred during the 30 day period, following suchtermination of insurance.

HOW DO I FILE A CLAIM?

On occasion, the claims investigation process will require additional informationin order to properly adjudicate the claim. This investigation will be handleddirectly by:

Aetna Student HealthP.O. Box 981106, El Paso, TX 79998

(866) 378-8885 (toll-free)Customer Service Representatives are available 8:30 a.m. to 5:30 p.m. (PST),Monday through Friday, for any questions. Claim forms can be obtained bycalling the number above or by visitingwww.aetnastudenthealth.com .1. Bills must be submitted within90 days from the date of treatment.2. Payment for Covered Medical Expenses will be made directly to the

hospital or Physician concerned unless bill receipts and proof of paymentare submitted.

3. If itemized medical bills are available at the time the claim form issubmitted, attach them to the claim form. Subsequent medical billsshould be mailed promptly to the above address.

4. In the event of a disagreement over the payment of a claim, a writtenrequest to review the claim must be mailed to Aetna Student Healthwithin180 days from the date appearing on the Explanation of Benefits(EOB).

5. You will receive an Explanation of Benefits when your claims areprocessed. The Explanation of Benefits will explain how your claimwas processed; according to the benefits of your Student Accident andSickness Insurance Plan.

ADDITIONAL DISCOUNTS AND SERVICES

As a member of the Plan, you can also take advantage of additional discounts,and programs such as tness discounts and weight management programs.These are not underwritten by Aetna and are NOT insurance. The member isresponsible for the full cost of the discounted services. Please note that theseprograms are subject to change without notice. To learn more about these ad-ditional services and search for providers visit,www.aetnastudenthealth.com .

HOW TO APPEAL A CLAIM

In the event a Covered Person disagrees with howshe may request a review of the decision. The Covbe made in writing withinone hundred eighty (180) da of receiExplanation of Benets (EOB). The Covered Pershe/she disagrees with the way the claim was proalso include any additional information that supporecords, Physicians ofce notes, operative reportsnecessity, etc.). Please submit all requests to:

AetnaP.O. Box 14464Lexington, KY 40512

NOTICE

Aetna considers non-public personal member informhas policies and procedures in place to protect the use and disclosure. When necessary for your careof your health Plan, or other related activities, wewith our affiliates, and disclose it to healthcare ppharmacies, hospitals, and other caregivers), vendauthorities, and their respective agents. These partconfidential as provided by applicable law. ParticipProviders are also required to give you access to yreasonable amount of time after you make a requenotice describing in greater detail our practices conNPI, please call the toll-free Customer Services nAetna Student Health on the internet at:www.aetnastudenthealt


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Accident: An occurrence which (a) is unforeseen, (b) is not due to orcontributed to by sickness or disease of any kind, and (c) causes injury.Actual Charge: The charge made for a covered service by the provider whofurnishes it.Coinsurance: The percentage of Covered Medical Expenses payable by Aetnaunder this Accident and Sickness Insurance Plan.Copay : This is a fee charged to a person for Covered Medical Expenses. ForPrescribed Medicines Expense, the copay is payable directly to the pharmacyfor each: prescription, kit, or refill, at the time it is dispensed. In no event willthe copay be greater than the pharmacys charge per: prescription, kit, or refill.Covered Medical Expense: Those charges for any treatment, service orsupplies covered by this Policy which are:

not in excess of the recognized and customary charges, ornot in excess of the charges that would have been made in the absenceof this coverage, andincurred while this Policy is in force as to the covered person exceptwith respect to any expenses payable under the Extension of BenefitProvisions.

Covered person: A covered student and any covered dependent while coverageunder this Policy is in effect.Deductible: The amount of Covered Medical Expenses that are paid by eachcovered person during the policy year before benefits are paid.Designated Care: Care provided by a Designated Care Provider upon referralfrom the School Health Services.Designated Care Provider: A health care provider (or pharmacy;) that isaffiliated; and has an agreement with the School Health Services to furnishservices and supplies at a negotiated charge.Emergency Medical Condition: This means a recent and severe medicalcondition, including, but not limited to, severe pain, which would lead aprudent layperson possessing an average knowledge of medicine and health,to believe that his or her condition, sickness, or injury, is of such a nature thatfailure to get immediate medical care could result in:

Placing the persons health in serious jeopardy, or Serious impairment to bodily function, or Serious dysfunction of a body part or organ, or In the case of a pregnant woman, serious jeopardy to the health of the

fetus.Generic Prescription Drug or Medicine:A prescription drug which is not pro-tected by trademark registration, but is produced and sold under the chemicalformulation name.Hospice : 1. Hospice care means a centrally administered program ofpalliative services and supportive services provided by an interdisciplinaryteam directed by a physician. The program includes the provision of physical,psychological, custodial and spiritual care for persons who are terminally ill andtheir families. The care may be provided in the home, at a residential facilityor at a medical facility at any time of the day or night. The term includes thesupportive care and services provided to the family after the patient dies.2. As used in this section: (a) Family includes the immediate family, theperson who primarily cared for the patient and other persons with significantpersonal ties to the patient, whether or not related by blood.

(b) Interdisciplinary team means a group of persmeet the special needs of terminally ill patients ansuch persons as a physician, registered nurse, soctrained volunteer.Injury:Bodily injury caused by an accident. This iand recurrent symptoms of such injury.Medically Necessary:A service or supply that is: necessfor the diagnosis or treatment of a sickness, or iaccepted current medical practice.In order for a treatment, service, or supply to necessary, the service or supply must:

Be care or treatment which is likely to produoutcome as any alternative service or supply, injury involved and the persons overall healtmore likely to produce a negative outcome thor supply, both as to the sickness or injury inoverall health condition

Be a diagnostic procedure which is indicated person. It must be as likely to result in inforthe course of treatment as any alternative servthe sickness or injury involved and the personIt must be no more likely to produce a negaalternative service or supply, both as to the sand the persons overall health condition, and

As to diagnosis, care, and treatment, be no maccount all health expenses incurred in conneservice, or supply,) than any alternative serviabove tests.

In determining if a service or supply is appropriaAetna will take into consideration:

information relating to the affected persons h reports in peer reviewed medical literature,

reports and guidelines published by nationalorganizations that include supporting scientif generally recognized professional standards o

in the United States for diagnosis, care, or tre the opinion of health professionals in the gen

specialty involved, andany other relevant information brought to Aet

In no event will the following services or supplies necessary:

Those that do not require the technical skillhealth, or a dental professional, or

Those furnished mainly for: the personal comperson, any person who cares for him or her, of his or her family, any healthcare provider, Those furnished solely because the person ison which the persons sickness or injury coulddiagnosed or treated while not confined, or

Those furnished solely because of the settincould safely and adequately be furnished, in aoffice, or other less costly setting.

DEFINITIONS

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Negotiated Charge:The maximum charge a Preferred Care Provider orDesignated Provider has agreed to make as to any service or supply for thepurpose of the benefits under this Policy.Non-Preferred Care:A health care service or supply furnished by a health careprovider that is not a Designated Care Provider, or that is not a Preferred CareProvider, if, as determined by Aetna:

the service or supply could have been provided by a Preferred CareProvider, and

the provider is of a type that falls into one or more of the categories ofproviders listed in the directory.

Non-Preferred Care Provider: a health care provider that has not contracted to furnish services or

supplies at a negotiated charge, orPharmacy:An establishment where prescription drugs are legally dispensed.Physician:(a) legally qualified physician licensed by the state in which he orshe practices, and (b) any other practitioner that must by law be recognizedas a doctor legally qualified to render treatment.Preferred Care: Care provided by

a covered persons primary care physician, or a preferred care providerof the primary carephysician, or

a health care provider that is not a Preferred Care Provider for anemergency medical condition when travel to a Preferred Care Provider,is not feasible, or

a Non-Preferred Urgent Care Provider when travel to a Preferred UrgentCare Provider for treatment is not feasible, and if authorized by Aetna.

Preferred Care Provider: A health care provider that has contracted to furnishservices or supplies for a negotiated charge, but only if the provider is, withAetnas consent, included in the directory as a Preferred Care Provider for:

the service or supply involved, and the class of covered persons of which you are member.

Preferred Pharmacy:A pharmacy, including a mail order pharmacy, which isparty to a contract with Aetna to dispense drugs to persons covered under thisPolicy, but only:

while the contract remains in effect, and while such a pharmacy dispenses a prescription drug, under the terms

of its contract with Aetna.Prescription:An order of a prescriber for a prescription drug. If it is an oralorder, it must be promptly put in writing by the pharmacy.Recognized Charge:Only that part of a charge which is recognized is covered.The recognized charge for a service or supply is the lowest of:

The providers usual charge for furnishing it, and The charge Aetna determines to be appropriate, based on factors such

as the cost of providing the same or a similar service or supply and themanner in which charges for the service or supply are made, and The charge Aetna determines to be the prevailing charge level made forit in the geographic area where it is furnished.

In some circumstances, Aetna may have an agreement, either directly orindirectly through a third party, with a provider which sets the rate that Aetnawill pay for a service or supply. In these instances, in spite of the methodologydescribed above, the recognized charge is the rate established in suchagreement.

In determining the recognized charge for a service Unusual, or Not often provided in the area, or Provided by only a small number of provider

Aetna may take into account factors, such as: The complexity, The degree of skill needed, The type of specialty of the provider, The range of services or supplies provided by The prevailing charge in other areas.

DEFINITIONS (CONTINUED)


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On Call International does not replace your medical insurance. All medical costsincurred should be submitted to your health plan and are subject to the policylimits of your health coverage. All assistance services must be arranged and pro-vided by On Call International. Claims for reimbursement will not be accepted.

PROGRAM GUIDELINESU.S. students studying in a U.S. location are eligible for services when travelingmore than 100 miles away from their permanent residence or campus locationfor up to one year. Medical transportation services and repatriation of deceasedremains services are available at campus location.*

U.S. students studying abroad are eligible for services both at and away fromtheir new campus location for up to one year.*Foreign national students studying in the U.S. are eligible for On Call Interna-tionals services, both on or away from campus or while traveling in a countrythat is not their country of origin.**Member shall be eligible for services during the term of his/her dened Pro- gram as long as his/her program is still effective and the membership fee hasbeen paid prior to departure.

KEY SERVICESMedical Monitoring:On Calls medical staff will communicate with the mem-bers attending physician and obtain a full understanding of the situation. Medi-cal professionals will stay in regular communication with local medical personneland relay necessary information to the Member and Family.Emergency Medical Evacuation:If adequate medical facilities are not avail-able locally, On Call will make arrangements to use whatever mode of transport,equipment and medical personnel necessary to evacuate a member to the near-est facility capable of providing a high standard of care.Medical Repatriation:If after seeking medical attention, it is medically advis-able for the member to seek further care at home, On Call will transport themember home or to a medical facility closer to home with a medical or non-medical escort, as necessary.Compassionate Visit:If a member is traveling alone and will be hospitalizedfor more thanseven days, On Call will provide economy, round-trip, commoncarrier transportation to the place of hospitalization and arrange lodging for a

designated family member or friend.Care of Minor Children:If a member is traveling with dependent children andis hospitalized as a result of a medical emergency for more thanseven days,On Call will arrange for the transportation of the unattended children to theirhome, with an attendant if necessary.Return of Deceased Remains:On Call will assist with the logistics of returninga members remains home in the event of his or her death. This service includes

EMERGENCY ASSISTANCE SERVICES

Continued on

Provided by On Call InternationalGLOBAL RESPONSE CENTER:

(877) 318-6901 (Toll-free within the U.S.)(603) 328-1909 (Outside the U.S.)

One Delaware Drive Salem, NH 03079E-mail: [email protected]

www.oncallinternational.com arranging the preparation of the remains for transpmentation, providing the necessary shipping conttransport.Medical, Dental and Pharmacy Referrals: On Call will provimedical, dental professionals and pharmacies in thof western style medical facilities and English spserved by On Call to the extent possibleHospital Admission Guarantee:On Call will guarantee hosvalidating a members health coverage or by adva(Any advance of funds shall be charged to the mem

of service).Prescription Assistance:If a member needs a replacementraveling, On Call will assist in lling that prescripwith prescription replacement are the members reEmergency Message Transmission:On Call will receive andrized emergency messages for members.Legal Consultation and Referral:If a member is away fromquires the services of an attorney, On Call shall arconsultation with an attorney without charge to thmember will be referred to a local attorney.Lost Luggage Assistance:On Call will assist the member luggage lost or delayed in transit.Lost/Stolen Travel Document Assistance:On Call will providarranging for the replacement of passports, visas, ticates and other travel-related documents. Any elost travel documents are the members responsibiInterpreter & Legal Referrals:On Call will refer members and interpreters if communication problems cannoPre-trip Information:On Call offers members reports vimail including visa, passport and inoculation requweather conditions, embassy and consulate referrand travel advisories for any destination.As a member, you can call upon doctors, hospitalvices whenever traveling 100 miles or more fromcampus location or abroad, 24 hours a day, 365

call connects you to a state-of-the art Global Respthe-clock with trained multilingual professionals cies quickly and efciently. As the U.S. member oGroup, a 36-partner global network of independincluding more than 53 alarm centers, On Call Iresponse capabilities worldwide with a global netwproviders, including air and ground ambulance ser


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Any treatment or expense related to childbirthexcept for any abnormal pregnancy or vital cwhich endangers the life of the mother and/orfirst twenty-four weeks of pregnancy.

A member on an organ transplant list prior tentitled to a transport for that transplant.

On Call cannot be held responsible for failure to pcaused by conditions beyond its control includingweather conditions, strikes, unforeseen changes totions, failure to comply with On Calls recommendservice is prohibited by local laws or regulatory agMember may be required to release On Call or aliability during emergency evacuation and/or repaWithout limiting the foregoing, On Calls actionAgreement are ministerial in nature, and all medicprofessionals ultimately selected by a Member. Omalpractice performed by a local doctor, healthcarOn Call, at its sole discretion, will assist Membersinterventions falling under the Limitations and Unserves the right, at its sole discretion, to request ad

or pre-payment or indemnication from the Memservice on a fee-for-service basis.

CONDITIONS & EXCLUSIONSOn Call International will not pay for services in the following instances:

Services rendered without the coordination and approval of On Call Intentionally self-inflicted injuries, suicide or any attempted threat except

when hospitalized as an inpatient. Expenses incurred if the original or ancillary purpose of the members trip

is to obtain medical treatment. Participation in a declared or undeclared act of war, civil disturbance or

insurrection or an accident occurring while the member is serving onfull-time or active duty in the Armed Forces of any country. *Participationin an international authority flight in aircraft being used for experimentalpurpose, or in military aircraft (except the Military Aircraft Command ofthe United States or similar air transport Services Account of other) orwhile serving as a member of the crew of any aircraft.

Use of any alcohol or drug unless prescribed by a physician or exceptif hospitalized as an inpatient. *Any services provided to an injuredperson where the member is entitled to receive reimbursement forsuch expenses under any group insurance program maintained by themembers insurance company or employer.

Routine or non-disabling medical problems, such as simple fractures, or

sickness, which can be treated by local doctors and do not prevent theinjured person from continuing the trip or returning home.

EMERGENCY ASSISTANCE SERVICES (CONTINUED)


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WELLS FARGO INSURANCE PRIVACY INFORMATIONWe know that your privacy is important to you and we strive to protect the condentiality of your personal information. We do not customers to anyone, except as permitted or required by law (e.g., information you provide to us may be shared with your school tinformation from unauthorized access and use, we use security measures that comply with federal law. These measures include compdetailed copy of our privacy policy through your school or by calling us at(800) 853-5899 or by visiting us atstudentinsurance.wellsfargo.com .

CLAIMS ADMINISTERED BY:Claims and Coverage Questions

Aetna Student HealthP.O. Box 981106El Paso, TX 79998

(866) 378-8885 (toll-free)www.aetnastudenthealth.com

PREFERRED CARE PROVIDER:To Find a Doctor or Provider in the

Aetna Preferred Care Provider Network

Aetna Preferred Care Provider Network (866) 381-1529 (toll-free)http://www.aetna.com/docfind/custom/studenthealth

24-HOUR NURSE ADVICE: Aetna Informed Health Line(800) 556-1555

PRESCRIPTIONS: Aetna Pharmacy Management

(888) 792-3862http://www.aetna.com/docfind/custom/studenthealth

EMERGENCY TRAVEL ASSISTANCE:

(Provide this information to yourEmergency Contact)

On Call InternationalOne Delaware DriveSalem, NH 03079(877) 318-6901 (Toll-free within the U.S.)(603) 328-1909 (Outside the U.S.)www.oncallinternational.com

THE PLAN BROKERED BY:

Eligibility, Enrollment andGeneral Questions

Wells Fargo Insurance

Student Insurance DivisionCA License No. 0D0840810940 White Rock Road, 2nd FloorRancho Cordova, CA 95670(800) 853-5899Fax: (877) 612-7966studentinsurance.wellsfargo.com

IMPORTANT NOTEThe California State University International Student Health Insurance Plan is underwritten by Aetna Life Insurance ComInc. Aetna Student Health is the brand name for products and services provided by these companies and their applicable

This material is for information only and is not an offer or invitation to contract. Health insurance plans contain exclusiocontractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide careto be accurate as of the production date; however, it is subject to change. Policy forms issued in OK include: GR-9613

NOTICE: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other perscontaining any materially false information or who conceals for the purpose of misleading, information concerning anyis a crime and subjects such person to criminal and civil penalties.

15.02.310.1 D


19/21

Underwritten by Aetna Life Insurance Company (ALIC)SAN JOS STATE UNIVERSITY INTERNATIONAL - HEALTH IN

2014-2015 ENROLLMENT FORM

STUDENTS NAMELAST / SURNAME| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | FIRST NAME

| | | | | | | | | | | | | | | | | | | | | | | | | | |

MIDDLE IN

STUDENT SJSU I.D. # DATE OF BIRTH(Month, Day, Year)

U.S. MAILING ADDRESS(Use school address if none)

STREET| | | | | | | | | | | | | | | | | | | | | | | | |

APART

CITY

STATE ZIP

PHONE # EMAIL ADDRESS (REQUIRED)

Please check appropriate box: FEMALE MALE

Please check appropriate box: SINGLE MARRIED

Please check appropriate box(es):

UNDERGRADUATE GRADUATE PRACTICAL TRAINING VISITING FACULT SCVISA TYPE (if applicable: F-1, J-1, etc.) HOME COUNTRY: (if applicable)

PLEASE LIST DEPENDENTS TO BE INSURED BELOW. DEPENDENT COVERAGE IS AVAILABL(Dependents must be enrolled on the date the student is enrolled or within 31 days of date of birth, marriage, or arrival in U.S.)SPOUSELAST / SURNAME FIRST NAME MIDDLE INITIAL GEN (Month, Day, Y

CHILD LAST / SURNAME FIRST NAME MIDDLE INITIAL G (Month, Day, Y



EMERGENCY

CONTACT PERSON

NAME RELATIONSHIP PHONE #

EMAIL ADDRESS

NEW RENEWING

Wells Fargo Insurance Medical ID#8 0

PLEASE SEE OTHER SIDE FOR RATES AND PAYMENT INFORMATION YOU MUST COMPLETE BOTH SIDES OF THIS EUnderwritten by Aetna Life Insurance Company (ALIC)

WELLS FARGO INSURANCE PRIVACY INFORMATIONWe know that your privacy is important to you and we strive to protect the condentiality of your personal information. We do not disclose any personal informby law (e.g., information you provide to us may be shared with your school to process your insurance transaction). To protect your personal information from umeasures include computer safeguards and secured les and buildings. You may obtain a detailed copy of our privacy policy through your school or by callin(800) 853-5899 or by visiting us atstudentinsurance.wellsfarg.

ID CARDSMedical ID cards may be shipped before or within 3 weeks of your policy effective date. Providers need your Memcoverage and bill Aetna Life Insurance Company. You do not need an ID card to be eligible to receive benefits, if yobenefits will be payable according to the Policy. Once you have received your ID card, present it to the provider to facyour ID cards atwww.aetnastudenthealth.com .

You can view the standard Summary of Benefits & Coverage (SBC) which is required by Health Care Reform. It summaricompanies now use. To view your plan SBC, go to:studentinsurance.wellsfargo.com or call800-853-5899 to request a paper copy free of charge.


20/21


21/21

Plan Update

The following changes ha ve been made to your plan:Please note that, unless otherwise indicated, all changes listed below are retroactiveto your plans effective date.

Issue Date:State: California

1. Restating the Coverage for Dependents section as follows:

COVERAGE FOR DEPENDENTS

Eligible Insured Students may also purchase Dependent coverage at the time ofstudents enrollment in the plan; or within 31 days of one of the following qualifiedevents: marriage, addition of domestic partner, birth, adoption or arrival in the U.S.Eligible dependents are the spouse or legally registered and valid domestic partnerwho resides with the Insured Student and the students, the spouses, or the domestic

partners natural child, stepchild or legally adopted child under 26 years of age.

Dependents of an Eligible International student or visiting faculty member must possess a valid passport and a proper visa (F-2, J-2, or M-2). A Newborn willautomatically be covered for preventive care; injury; sickness; premature birth;medically diagnosed congenital defects; and birth abnormalities from birth until 31days old, providing that the student is covered under this plan. Coverage may becontinued for that child when Wells Fargo Insurance is notified in writing within31 days from the date of birth and by payment of any additional premium.

Dependents must be enrolled for the same term of coverage for which the InsuredStudent enrolls. Dependent coverage expires concurrently with that of the InsuredStudent, and Dependents must re-enroll when coverage terminates to maintain

coverage.

2. Restating the Extension of Benefits section as follows:

EXTENSION OF BENEFITS

If a Covered Person is confined to a hospital on the date his or her insuranceterminates, expenses incurred after the termination date and during the continuanceof that hospital confinement, shall be payable in accordance with the policy, but onlywhile they are incurred during the 30 day period, following such termination ofinsurance.

If a covered person is totally disabled on the termination date of the Policy, benefitswill be extended to provide covered benefits that are necessary to treat medicalconditions causing or directly related to the disability as determined by Aetna.

3. Restating Exclusions & Limitations #2 and #30 as follows:

2. Expense incurred for eye refractions; vision therapy; radial keratotomy; eyeglasses;contact lenses (except when required after cataract surgery); or other vision or hearingaids; or prescriptions or examinations except as required for repair caused by acovered injury, unless otherwise provided in the Policy.
https://www.aetnastudenthealth.com/default.aspxhttps://www.aetnastudenthealth.com/default.aspxhttps://www.aetnastudenthealth.com/default.aspxhttps://www.aetnastudenthealth.com/default.aspx

Documents

14 Benefit Brochure SJSU_Intl