Payment will be made as allocated herein for Covered Medical Expenses incurred for any one Accident or any one Sickness while insured under the Plan, not to exceed an Aggregate Maximum while continuously insured of $750,000 for any one covered Accident or any one covered Sickness.

The payment of any Copays, Deductibles, the balance above any Coinsurance amount and any medical expenses not covered are the responsibility of the Covered Person.

To maximize savings and reduce out-of-pocket expenses, a Covered Person should select a Preferred Provider. It is to his/her advantage to utilize a Preferred Provider because significant savings can be achieved from the substantially lower rates these providers have agreed to accept as payment for their services. Non-Preferred Care is subject to Reasonable and Customary (R&C) Charge allowance maximums. Any charges in excess of the R&C allowance are not covered under the Plan. Preferred Providers are independent contractors and are neither employees nor agents of the University, Aetna Student Health, or Aetna.

$750,000 per Accident or Sickness per Policy Year

Plan Deductibles

Preferred Care: $0
Non-Preferred Care: $350 annual Deductible ($700 per family)

Prescription Drug per prescription Copay/Deductibles and
coinsurance amounts do not apply towards meeting the Annual
Out-of-Pocket Maximum.

Annual Out-of-Pocket Maximum (includes Deductibles)

Preferred Care: $2,500
Non-Preferred Care: $10,000

Prescription Drug per prescription Copay/Deductibles and
coinsurance amounts do not apply towards meeting the Annual
Out-of-Pocket Maximum.

Hospital Room and Board Expenses

Covered Medical Expenses are payable as follows:
Preferred Care: 100% of the Negotiated Charge for an overnight stay.
Non-Preferred Care: 80% of the Reasonable Charge for the semi­private room rate for an overnight stay.

Inpatient Hospitalization Benefits

Intensive Care Unit Expenses

Covered Medical Expenses are payable as follows:
Preferred Care: 100% of the Negotiated Charge for an overnight stay.
Non-Preferred Care: 80% of the intensive care room rate for an overnight stay.

Covered Medical Expenses include, but are not limited to: laboratory tests, X-rays, anesthesia, use of special equipment, medicines, and use of operating room.

Miscellaneous Hospital Expenses

Covered Medical Expenses are payable as follows:
Preferred Care: 100% of the Negotiated Charge.
Non-Preferred Care: 80% of the Reasonable Charge.

Covered Medical Expenses include, but are not limited to: laboratory tests, X-rays, anesthesia, use of special equipment, medicines, and use of operating room.

Physician Hospital Visit Expenses

Covered Medical Expenses for charges for the non-surgical services of the attending Physician or a consulting Physician are payable as follows:
Preferred Care: 100% of the Negotiated Charge.
Non-Preferred Care: 80% of the Reasonable Charge.

Surgical Benefits (Inpatient and Outpatient)

Surgical Expenses

Covered Medical Expenses for charges for surgical services performed by a Physician are payable as follows:
Outpatient:
Preferred Care: 100% of the Negotiated Charge after a $10 copay.
Non-Preferred Care: 80% of the Reasonable Charge.
Inpatient:
Preferred Care: 100% of the Negotiated Charge.
Non-Preferred Care: 80% of the Reasonable Charge.

Anesthetist Expenses & Assistant Surgeon Expenses

Covered Medical Expenses for the charges of an anesthetist and an assistant surgeon during a surgical procedure for surgical services performed during a surgical operation are payable as follows: Preferred Care: 100% of the Negotiated Charge.
Non-Preferred Care: 80% of the Reasonable Charge.

Outpatient Benefits Covered Medical Expenses include, but are not limited to: Physician’s office visits, hospital or outpatient department or emergency room visits, durable medical equipment, physical therapy, clinical lab, radiological facility or other similar facility licensed by the state.

Physician’s Office Visits Expenses (including routine care, specialist visits, well child care and GYN visits)

Covered Medical Expenses are payable as follows:
Preferred Care: 100% of the Negotiated Charge after a $10 copay.
Non-Preferred Care: 80% of the Reasonable Charge

Emergency Care Expenses

Covered Medical Expenses for treatment of an Emergency Medical Condition are payable as follows:
Preferred Care: 100% of the Negotiated Charge after a $50 copay.
Non-Preferred Care: 100% of the Reasonable Charge after a $50 deductible.

Lab and X-Ray Expenses (Non-Hospital)

Covered Medical Expenses are payable as follows:
Preferred Care: 100% of the Negotiated Charge.
Non-Preferred Care: 80% of the Reasonable Charge.

Durable Medical Equipment Expenses

Covered Medical Expenses are payable as follows:
Preferred Care: 100% of the Negotiated Charge.
Non-Preferred Care: 80% of the Reasonable Charge.

Mental Health and Substance Abuse Benefits

Inpatient Expenses – Mental Health

Covered Medical Expenses for the treatment of a mental health condition while confined as an inpatient in a hospital or facility licensed for such treatment are payable on the same basis as for any other Sickness.

Outpatient Expenses – Mental Health

Covered on the same basis as any other condition.

Inpatient Expenses – Substance Abuse

Covered Medical Expenses for the treatment of substance abuse while confined as an inpatient in a hospital or facility licensed for such treatment are payable on the same basis as for any other Sickness.

Outpatient Expenses – Substance Abuse

Covered Medical Expenses for the care or treatment of substance abuse by a licensed or accredited health service organization, or hospital, or by a fully licensed practitioner are payable as any other condition.

Maternity Benefits

Maternity Expenses

Covered Medical Expenses for pregnancy, childbirth, and complications of pregnancy are payable on the same basis as any other Sickness. In the event of an inpatient confinement, such benefits would be payable for inpatient care of the Covered Person and any newborn child, for a minimum of 48 hours after a vaginal delivery and for a minimum of 96 hours after a cesarean delivery. A $10 copay applies to the first visit.

Voluntary Termination of Pregnancy Expenses

Covered Medical Expenses for voluntary termination of pregnancy are payable on the same basis as any other Sickness.

Additional Benefits

Women’s Health Benefit Expenses

Covered Medical Expenses will include one baseline mammogram for women between the ages of 35 and 40. Women age 40 and older have coverage for an annual mammogram per Policy Year. And in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider. Covered Medical Expenses are payable on the same basis as any X-ray expense. Covered Medical Expenses include an annual routine Pap smear screening. Covered Medical Expenses are payable on the same basis as any outpatient expense.

Ambulance Expenses

Covered Medical Expenses are payable at 100% of the Reasonable Charge for the services of a professional ambulance to or from a hospital when required due to the emergency nature of a covered Accident or Sickness.

Prescription Drug Benefit

Covered Medical Expenses for outpatient Prescription Drugs associated with a covered Sickness or covered Accident occurring during the Policy Year, are payable as follows:
Preferred Care: 100% after a $10 Copay for each Brand Name Prescription Drug or for each Generic Prescription Drug.
Non-Preferred Care: 70% of Reasonable Charge after a $10 Deductible for each Brand Name Prescription Drug or for each Generic Prescription Drug dispensed at a Non-Participating Pharmacy.

Please note: You are required to pay in full at the time of service for all Prescriptions dispensed at a Non-Participating Pharmacy. Medications not covered by this benefit include, but are not limited to: allergy sera, drugs whose sole purpose is to promote or to stimulate hair growth, appetite suppressants, smoking deterrents, immunization agents and vaccines, and non-self injectables. Prior authorization is required for growth hormones, prescriptions in excess of 30 day supply and drugs which are used in the treatment of malaria. For assistance, or for a complete list of excluded medications or drugs available with prior authorization, please contact (800) 238-6279.

Hospice Care Expenses

Covered Medical Expenses are payable as follows:
Preferred Care: 100% of the Negotiated Rate.
Non-Preferred Care: 80% of the Reasonable Rate.

Home Health Care Expenses

Covered Medical Expenses are payable as follows:
Preferred Care: 100% of the Negotiated Rate.
Non-Preferred Care: 80% of the Reasonable Rate.