brochure0910 aetna

8/8/2019 brochure0910 aetna

1/46

2009 - 2010

Student Health Insurance Plan

Underwritten by:Aetna Life Insurance Company(ALIC)

Policy Number 711116

5E V N E X T >


2/46

TABLE OF CONTENTS

Page NumbersDePaul University Student Accident and Sickness Insurance Plan...............................................................................3

Where to Find Help .......................................................................................................................................................3

Important Note...............................................................................................................................................................4

On Call International .....................................................................................................................................................5

Student Coverage...........................................................................................................................................................6

Dependent Coverage .....................................................................................................................................................6

Enrollment Process........................................................................................................................................................7

Continuously Insured.....................................................................................................................................................7

Preferred Provider Network ..........................................................................................................................................7

Pre-Certification Requirements .....................................................................................................................................8

Pre-Existing Conditions/Continuously Insured Provisions ........... ........... .......... ........... .......... ........... .......... ........... ...... 8

Policy Period .................................................................................................................................................................9

Payment Options ...........................................................................................................................................................9

Rates ............................................................................................................................................................................10

Deductibles..................................................................................................................................................................11

Refund Policy ..............................................................................................................................................................11

Description of Benefits................................................................................................................................................11

Summary of Benefits Chart .........................................................................................................................................12

Inpatient Hospitalization Benefits ...............................................................................................................................12

Surgical Benefits .........................................................................................................................................................13

Outpatient Benefits......................................................................................................................................................13

Mental Health Benefits................................................................................................................................................17

Substance Abuse Benefits ...........................................................................................................................................18

Maternity Benefits .......................................................................................................................................................18

Additional Benefits......................................................................................................................................................19

Additional Services and Discounts..............................................................................................................................25

General Provisions.......................................................................................................................................................27

Extension of Benefits ..................................................................................................................................................27

Termination of Insurance ........... .......... ........... ........... .......... ........... ........... .......... ........... ........... .......... .......... ........... .28

Exclusions ...................................................................................................................................................................29

Definitions...................................................................................................................................................................33

Claim Procedure ..........................................................................................................................................................45

Prescription Drug Claim Procedure.............................................................................................................................46

Notice ..........................................................................................................................................................................46

2


3/46

DEPAUL UNIVERSITYSTUDENT ACCIDENT AND SICKNESS INSURANCE PLANThis is a brief description of the Accident and Sickness Medical Expense benefits available for DePaul Universitystudents and their eligible dependents. The Plan is underwritten by Aetna Life Insurance Company (called Aetna).The exact provisions governing this insurance are contained in the Master Policy issued to the University and maybe viewed at the Universitys Office of Student Affairs Dean of Students Office during business hours.

WHERE TO FIND HELP

In case of an emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility.

GOT QUESTIONS? GET ANSWERS WITH AETNAS NAVIGATOR

As an Aetna Student Health insurance member, you have access to Aetna Navigator, your secure member website,packed with personalized claims and health information. You can take full advantage of our interactive website tocomplete a variety of self-service transactions online. By logging into Aetna Navigator, you can:

Review who is covered under your Plan. Request member ID cards. View Claim Explanation of Benefits (EOB) statements. Estimate the cost of common health care services and procedures to better plan your expenses. Research the price of a drug and learn if there are alternatives. Find health care professionals and facilities that participate in your Plan. Send an e-mail to Aetna Student Health Customer Service at your convenience. View the latest health information and news, and more!HOW DO I REGISTER?

Go to www.aetnastudenthealth.com. Click on Find Your School. Enter your school name and then click on Search. Click on Aetna Navigator and then the Access Navigator link. Follow the instructions for First Time User by clicking on the Register Now link. Select a user name, password and security phrase. Your registration is now complete, and you can begin accessing your personalized information!NEED HELP WITH REGISTERING ONTO AETNA NAVIGATOR?

Registration assistance is available toll free, Monday through Friday, from 7 a.m. to 9 p.m.Eastern Time at (800) 225-3375.

For questions about:

Insurance Benefits Enrollment Claims Processing Pre-Certification RequirementsPlease contact:Aetna Student HealthP.O. Box 15708Boston, MA 02215-0014

(800) 878-1938

3


4/46


ID cardsID cards will be issued as soon as possible. If you need medical attention before the ID card is received, benefitswill be payable according to the Policy. You do not need an ID card to be eligible to receive benefits. Once youhave received your ID card, present it to the provider to facilitate prompt payment of your claims.

For lost ID cards, contact:

Aetna Student Health

(800) 878-1938


Enrollment Leave of AbsencePlease contact:

DePaul University

Office of Student Affairs Dean of Students Office

For questions about: Status of Pharmacy Claim Pharmacy Claim Forms Excluded Drugs and Pre-Authorization Provider ListingsPlease contact:

Aetna Student Health

(800) 878-1938

A complete list of providers can be found at Aetnas DocFindService at eitherwww.aetna.com/docfind/custom/studenthealth/index.htmlor www.aetnastudenthealth.com.

For questions about: On Call International 24/7 Emergency Travel Assistance ServicesPlease contact:

On Call International at (866) 525-1956 (within U.S.).If outside the U.S., call collect by dialingthe U.S. access code plus (603) 328-1956. Please also visitwww.aetnastudenthealth.com and visit your school-specific site for further information.

IMPORTANT NOTEPlease keep this Brochure, as it provides a general summary of your coverage. A complete description of thebenefits and full terms and conditions may be found in the Master Policy issued to DePaul University. If anydiscrepancy exists between this Brochure and the Policy, the Master Policy will govern and control the payment ofbenefits. The Master Policy may be viewed by calling Aetna Student Health at (800) 878-1938.

This Student Plan fulfills the definition of Creditable Coverage explained in the Health Insurance Portability andAccountability Act (HIPAA) of 1996. At any time should you wish to receive a certification of coverage, please callthe customer service number on your ID card.

Subject to the terms of the Policy, benefits are available for you and your eligible dependents only for thecoverage listed below, and only up to the maximum amounts shown.

4


5/46

ON CALL INTERNATIONALChickering Claims Administrators, Inc. (CCA) has contracted with On Call International (On Call) to provide

Covered Persons with access to certain accidental death and dismemberment benefits, worldwide emergency travelassistance services and other benefits. A brief description of these benefits is outlined below.

ACCIDENTAL DEATH AND DISMEMBERMENT (ADD) BENEFITS1

These benefits are underwritten by United States Fire Insurance Company (USFIC) and include the following:Benefits are payable for the Accidental Death and Dismemberment ofCovered Persons, up to a maximum of$10,000.

1These services, programs or benefits are offered by vendors who are independent contractors and not employees

or agents of Aetna.

MEDICAL EVACUATION AND REPATRIATION (MER) BENEFITS

The following benefits are underwritten by Virginia Surety Company (VSC), with medical and travel assistance

services provided by On Call. These benefits are designed to assist Covered Persons when traveling in a foreigncountry or when 100 or more miles from their primary residence, whether on campus or on a trip:

Unlimited Emergency Medical Evacuation Unlimited Medically Supervised Repatriation Unlimited Return of Mortal Remains Visit by Family Member/Friend During Hospitalization Return of Traveling Companion $2,500 Emergency Return Home in the event of death or life-threatening illness of a parent or siblingWORLDWIDE EMERGENCY TRAVEL ASSISTANCE (WETA) SERVICES

On Call provides the following travel assistance services:

24/7 Emergency Travel Arrangements Translation Assistance Emergency Travel Funds Assistance Lost Luggage and Travel Documents Assistance Assistance with Replacement of Credit Card/Travelers Checks

24/7 U.S. Nurse Help Line Medical/Dental/Pharmacy Referral Service Hospital Deposit Arrangements Dispatch of Physician Emergency Medical Record Assistance Legal Referral Bail Bonds AssistanceThe On Call International Operations Center can be reached 24 hoursa day, 365 daysa year.

The information contained above is a just summary of the ADD, MER and WETA benefits and servicesavailable through On Call, USFIC and VSC. For a copy of the Plan documents applicable to the ADD, MERand WETA coverage, including a full description of coverage, exclusions and limitations, please contact

Aetna Student Health at www.aetnastudenthealth.com or (800) 966-7772.

NOTE: In order to obtain coverage, all MER and WETA services must be provided and arranged throughOn Call. Reimbursement will not be provided for any services not provided and arranged through On Call.Although certain emergency medical services may be covered under the terms of the Covered PersonsStudent Health Insurance Plan (the Plan), neither On Call, USFIC nor WETA provides coverage foremergency medical treatment rendered by doctors, hospitals, pharmacies or other health care providers.Coverage for such services will be provided in accordance with the terms of the Plan and exclusions andlimitations may apply.

5


6/46

To file a claim for ADD benefits, or to obtain MER and WETA benefits/services, or for any questions relatedto those benefits/services, please call On Call International at the following numbers listed on the On Call IDcard provided to Covered Persons when they enroll in the Plan: Toll Free (866) 525-1956 orcollect (603) 328-1956. All Covered Persons should carry their On Call ID card when traveling.

CCA and On Call are independent contractors and not employees or agents of the other. CCA provides access to

ADD, MER and WETA benefits/services through a contractual arrangement with On Call. However, neither CCAnor any of its affiliates provides or administers ADD, MER or WETA benefits/services and neither CCA nor any ofits affiliates is responsible in any way for the benefits/services provided by or through On Call, USFIC or VSC.Premiums/fees for benefits/services provided through On Call, USFIC and VSC are included in the Rates outlinedin this Brochure.

STUDENT COVERAGE

ELIGIBILITY

Students enrolled at DePaul University for one or more credit hours are eligible for coverage.

Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased.Part-time study, independent study, Internet classes and television (TV) courses may not fulfill the eligibility

requirements stating that the covered student actively attends classes. If the eligibility requirements are not met,Aetnas only obligation is to refund the premium, less any claims paid.

If you lose your DePaul student eligibility due to a medical withdrawal from the University, please contact the Dean

of Students Office to arrange continuation as a Covered Person through the end of the coverage period for whichyou enrolled.

Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as ofthe date of such entry. A pro-rata refund of premium will be made for such person, and any covered dependents,upon written request received by Aetna within 90 days of withdrawal from school.

DEPENDENT COVERAGE

ELIGIBILITY

Covered students may also enroll their lawful spouse, and unmarried dependent children under age 26, who residewith, and are fully supported by, the covered student.

Dependent children who are covered because they are full-time college students will be allowed to continue on thePlan if they are on medical leave or reduce to part-time due to a catastrophic illness or injury. Coverage to extend

for twelve months or the normal terminating age (earlier of). The Plan will allow unmarried dependents up to age30 if they reside in IL, have served in the US Armed Forces (AF), and were discharged from the AF other thandishonorable discharge.

ENROLLMENT

To enroll the dependent(s) of a covered student, please enroll on-line at www.aetnastudenthealth.com. If theenrollment is completed and premiums paid before September 30, 2009, there will be no break in coverage. If theenrollment is completed and premiums paid after September 30, 2009, you must pay the pro-rated annual premiumin full, and the coverage becomes effective the day after you enroll. Your enrollment is subject to the completion ofpayment processing. For information or general questions on dependent enrollment contact Aetna Student Health at(800) 878-1938.

NEWBORN INFANT AND ADOPTED CHILD COVERAGE

A child born to a Covered Person shall be covered for accident, sickness, and congenital defects, for 31 days fromthe date of birth. At the end of this 31 day period, coverage will cease under the DePaul University Student HealthInsurance Plan. To extend coverage for a newborn past the 31 days, the covered student must: 1) enroll the childwithin 31 days of birth, and 2) pay the additional premium, starting from the date of birth.

6
http://www.aetnastudenthealth.com/http://www.aetnastudenthealth.com/


7/46

Coverage is provided for a child legally placed for adoption with a covered student for 31 days from the momentof placement provided the child lives in the household of the covered student, and is dependent upon the coveredstudent for support. To extend coverage for an adopted child past the 31 days, the covered student must 1) enrollthe child within 31 days of placement of such child, and 2) pay any additional premium, if necessary, starting fromthe date of placement.

For information or general questions on dependent enrollment, contact Aetna Student Health at

(800) 878-1938.

ENROLLMENT PROCESSTo enroll, please visit:

Log onto www.aetnastudenthealth.com. Click on Find My Schools Plan under Member Quick Links. Enter DePaul. Click Plans and Products Offered to You.

CONTINUOUSLY INSUREDInitial enrollment in the 2009-2010 DePaul University Student Health Insurance Plan does not offer continuouscoverage from any other Policy, except for the 2008-2009 DePaul University Health Insurance Plan. Previously

insured dependents and students must re-enroll for coverage by September 30, 2009, in order to avoid a break incoverage for conditions that existed in prior Policy Years. Once a break in continuous insurance occurs, thedefinition of a pre-existing condition will apply in determining coverage of any condition, which existed duringsuch break.

PREFERRED PROVIDER NETWORK

Aetna Student Health has arranged for you to access a Preferred Provider Network in your local community. Acutecare facilities and mental health networks are available nationally if you require hospitalization outside the

immediate area of the DePaul University campus.

To maximize your savings and reduce your out-of-pocket expenses, select a Preferred Provider. It is to youradvantage to use a Preferred Provider because savings may be achieved from the Negotiated Charges theseproviders have agreed to accept as payment for their services.

You may also obtain information regarding Preferred Providers by contacting Aetna Student Health at(800) 878-1938, or through the Internet by accessing DocFind atwww.aetna.com/docfind/custom/studenthealth/index.html.1. Click on Enter DocFind2. Select zip code, city, or county3. Enter criteria4. Select Provider Category5. Select Provider Type6. Select Plan Type Student Health Plans7. Select Start Search or More Options8. More Options enter criteria and SearchPreferred Providers are independent contractors and are neither employees nor agents of Aetna Life

Insurance Company, Chickering Claims Administrators, Inc. or their affiliates. Neither Aetna Life

Insurance Company, Chickering Claims Administrators, Inc. nor their affiliates provide medical care or

treatment and they are not responsible for outcomes. The availability of a particular provider(s) cannot be

guaranteed and network composition is subject to change.

7


8/46

PRE-CERTIFICATION REQUIREMENTS

Pre-certification simply means calling Aetna Student Health prior to treatment to obtain approval for a medicalprocedure or service. Pre-certification may be done by you, your doctor, a hospital administrator, or one of yourrelatives. All requests for certification must be obtained by contacting Aetna Student Health at (800) 878-1938(attention Managed Care Department).

If you do not secure pre-certification for non emergency inpatient admissions, your Covered Medical Expenseswill be subject to a $200 per admission Deductible.

The following inpatient services require pre-certification:

All inpatient admissions, including length of stay, to a hospital, skilled nursing facility, a residential facility. All inpatient maternity care, after the initial 48/96 hours. All partial hospitalization in a hospital, or a residential treatment facility.PRE-CERTIFICATION DOES NOT GUARANTEE THE PAYMENT OF BENEFITS FOR YOUR

INPATIENT ADMISSION

Each claim is subject to Medical Policy Review, in accordance with the exclusions and limitations contained in thePolicy, as well as a review of eligibility, adherence to notification guidelines, and benefit coverage under theStudent Accident and Sickness Plan.

PRE-CERTIFICATION OF NON-EMERGENCY INPATIENT ADMISSIONS, PARTIAL

HOSPITALIZATION

The patient, physician or hospital must telephone at least three business days prior to the planned admission orprior to the date the services are scheduled to begin.

NOTIFICATION OF EMERGENCY ADMISSIONS

The patient, patients representative, physician or hospital must telephone within one business day followinginpatient (or partial hospitalization) admission, or as soon as reasonably possible.

PRE-EXISTING CONDITIONS/CONTINUOUSLY INSURED PROVISIONS

PRE-EXISTING CONDITIONA pre-existing condition is an injury or disease that was present before your first day of coverage under a grouphealth insurance Plan. If you received treatment or services for that injury or disease that would have caused aprudent person to seek diagnosis or treatment, or you took prescription drugs or medicines for that injury or diseaseduring the twelve months prior to your first day of coverage, that injury or disease will be considered a pre-existingcondition.

Genetic information will not be treated as a pre-existing condition in the absence of a diagnosis of the conditionrelated to that genetic information.

LIMITATIONPre-existing conditions are not covered during the first 365 days that you are covered under this Plan. However,there is an important exception to this general rule if you have been continuously insured. Expenses incurred by a

Covered Person as a result of a pre-existing condition will no be considered Covered Medical Expenses unless(a) no charges are incurred or treatment rendered for the condition for a period ofsix months while covered underhis/her Policy, or (b) the Covered Person has been continuously insured or has been covered under this Policy fortwelve consecutive months which happened first.

CONTINUOUSLY INSURED

Initial enrollment in the 2009-2010 DePaul University Student Health Insurance Plan does not offer continuouscoverage from any other policy, except for the 2008-2009 DePaul University Health Insurance Plan. Previously

insured dependents and students must re-enroll for coverage by September 30, 2009, in order to avoid a break incoverage for conditions that existed in prior Policy Years. Once a break in continuous Insurance Occurs, the

8


9/46

definition of a pre-existing condition will apply in determining coverage of any condition, which existed duringsuch break.

POLICY PERIOD

1. Students: Annual coverage for all insured students will become effective at 12:01 a.m. on September 1, 2009,and will terminate at 12:01 a.m. on September 1, 2010. If you enroll and pay your premium prior toSeptember 30, 2009, your effective date will be September 1, 2009. If you enroll and pay your premiumsafterSeptember 30, 2009, the effective date will be the day after you enroll. You will be enrolled for the remainderof the Policy Year, and you will pay an annual prorated premium. Your enrollment is subject to the completionof payment processing.

2. Insured Dependents: Coveragewill become effective on the same date the insured students coveragebecomes effective, or the day after the postmarked date when the completed application and premium are sent,if later. Coverage for insured dependents terminates in accordance with the termination provisions described inthe Master Policy. For more information on termination ofcovered dependents see page (28) of this Brochure.Examples include, but are not limited to: the date the students coverage terminates, the date the dependent nolonger meets the definition of a dependent.

PAYMENT OPTIONSBy enrolling in the fall you are electing annual coverage. You may either pay the premium in full or you may electto pay your premium in four installments. If you want to pay in four installments, you must elect that option whenyou initially enroll, and the first installment is due at the time of enrollment. The initial enrollment deadline date is

September 30, 2009. Any student enrolling after September 30, 2009, must pay the pro-rated annual premium infull, and coverage will begin the day after your enrollment date. Please contact Aetna Student Health at

(800) 878-1938 to obtain pro-rated premium information.

If there is a lapse in coverage, you are subject to the pre-existing limitation (see Brochure).

Below are the two options for paying four installments.

Option One Billed Quarterly: You will pay the remaining three installments online. You will receive twopayment reminders directing you to www.aetnastudenthealth.com where payment can be made. We will mail twopayment reminders to you at the address we have on file. Failure to receive the payment reminder due to an error onbehalf of Aetna Student Health, or the US Post Office, or a student address change will not exempt you frommaking your payment on time.

Option Two Auto-Charged Quarterly: You will authorize Aetna Student Health to automatically electronicallywithdraw payment from your checking account, or debit your credit card. You will not receive any reminder noticesof the upcoming auto-charge.

9


10/46

Below is the quarterly billing notification / auto-charge schedule.

QuarterOption 1 Billed

QuarterlyNoticeDates

Option 2 Auto-chargedQuarterly

Auto-ChargeDates

Quarter 1

9/1/09 11/30/09

Enrollment Deadline 09/30/09 Enrollment Deadline 09/30/09

Payment Reminder #1 11/06/09 Auto Charge Attempt #1 11/06/09

Payment Reminder #2 11/16/09 Auto Charge Attempt #2 11/16/09Quarter 212/1/09 2/28/10

Termination Letter 12/11/09 Termination Letter 12/01/09







RATESMEDICAL PLAN 2009/2010

Plan I - $100,000 MaximumAnnual Insurance Rate

9/1/09 8/31/10Quarterly Insurance Rate

Student Only $1,839 $460

Spouse Only $4,141 $1,036

Each Child $2,120 $530

MEDICAL PLAN 2009/2010

Plan II - $250,000 MaximumAnnual Insurance Rate

9/1/09 8/31/10Quarterly Insurance Rate

Student Only $2,075 $519

Spouse Only $4,668 $1,167

Each Child $2,385 $597

Note: PLAN II may be purchased ONLY at the time of initial enrollment in the Policy. It may not be purchased at alater date or in a subsequent year. Please call Aetna Student Health at (800) 878-1938 for premium information ifthe effective date is other than September 1, 2009.

10


11/46

CONTINUATION PLAN - 2009/2010

Continuation Plan IThree Months

9/1/09 11/30/09Six Months

9/1/09 2/28/10Nine Months

9/1/09 5/31/10

Student Only $727 $1,456 $2,183

Spouse Only $1,637 $3,276 $4,912

Each Child $838 $1,673 $2,511

CONTINUATION PLAN - 2009/2010

Continuation Plan IIThree Months

9/1/09 11/30/09Six Months

9/1/09 2/28/10Nine Months

9/1/09 5/31/10

Student Only $819 $1,642 $2,460

Spouse Only $1,842 $3,694 $5,534

Each Child $943 $1,886 $2,829

Note: If you enroll in one of the Continuation Plans, it must be the same Plan you were enrolled in when you lostcoverage. Continuation PLAN II may be purchased ONLY if you initially purchased Medical Plan II, at the time ofinitial enrollment in the Policy. It may not be purchased at a later date or in a subsequent year.

DEDUCTIBLES

The following Deductibles are applied before Covered Medical Expenses are payable:

Individual Deductible of$300 per insured, per Policy Year. No more than two individual Deductibles must besatisfied in a Policy Year by persons enrolled under one family coverage.

Eligible charges applied to Deductible during the last three months of the Policy Year will also be credited tothe next Policy Year Deductible.

REFUND POLICY

Any student withdrawing from school during the first 31 days of the period, for which premium has been paid, shallnot be covered under the Policy, and a full refund of the premium will be made. Students withdrawing after such31days, will remain covered under the Policy for the full period, for which premium has been paid. No refund willbe allowed.(This Refund Policy will not apply to any student withdrawing due to a covered accident or sickness.)

Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy, as ofthe date of such entry. A pro-rata refund of premium will be made for such person, and any covered dependents,upon written request, received by Aetna within 90 days of withdrawal from school.

DESCRIPTION OF BENEFITS

Please Note: Please read the DePaul University Student Health Insurance Plan Brochure carefully before decidingwhether this Plan is right for you. While this document and the DePaul University Student Health Insurance Planbrochure describe important features of the Plan, there may be other specifics of the Plan that are important to youand some limit what the Plan will pay. If you want to look at the full Plan description, which is contained in the

Master Policy you may contact us at (800) 878-1938.

11


12/46

This Plan will never pay more than a lifetime maximum or $100,000 for Plan I per accident and sickness, and$250,000 for Plan II per accident and sickness. Additional Plan maximums may also apply. Some illnesses may costmore to treat and health care providers may bill you for what the Plan does not cover.

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 your savings and reduce out-of-pocket

expenses, select a Preferred Provider. It is to your advantage to utilize a Preferred Provider because significantsavings can be achieved from the substantially lower rates these providers have agreed to accept as payment fortheir services.Non-Preferred Care is subject to the Reasonable Charge allowance maximums. Any charges in excess of theReasonable Charge allowance are not covered under the Plan.

A complete listing of Preferred Providers is available by accessing Aetnas DocFindService at eitherwww.aetna.com/docfind/custom/studenthealth/index.htmlor www.aetnastudenthealth.com.

You may also contact Aetna Student Health at (800) 878-1938.

SUMMARY OF BENEFITS CHART

DEDUCTIBLESThe following Deductibles are applied before Covered Medical Expenses are payable:Individual Deductible of$300 per insured, per Policy Year. No more than two individual Deductibles must besatisfied in a Policy Year by persons enrolled under one family coverage.

Eligible charges applied to Deductible during the last three months of the Policy Year will also be credited to thenext Policy Year Deductible.

COINSURANCECovered Medical Expenses are payable at the coinsurance percentage specified below, after any applicableDeductible, up to a maximum benefit of:

Plan I Lifetime Maximum of$100,000 for any one accident, or any one sickness. Plan II Lifetime Maximum of$250,000 for any one accident, or any one sickness.OUT-OF-POCKET MAXIMUMSOnce theIndividual Out-of-Pocket Limit has been satisfied, Covered Medical Expenses will be payable at100% for the remainder of the Policy Year, up to any benefit maximum that may apply. Deductible is not appliedtowards the Out-of-Pocket maximum.

Preferred Care Individual Out-of-Pocket: $4,000Non-Preferred Care Individual Out-of-Pocket: $10,000

All coverage is based on Reasonable Charges unless otherwise specified.

Inpatient Hospitalization BenefitsHospital Roomand BoardExpenses

Covered Medical Expenses are payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge for a semi-private room.

Intensive CareUnit Expenses

Covered Medical Expenses are payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge for the Intensive Care Room Rate for anovernight stay.

12


13/46

MiscellaneousHospitalExpenses

Covered Medical Expenses are payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

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

PhysicianHospital Visit/ConsultationExpenses

Covered Medical Expenses for charges for the non-surgical services of the attendingphysician, or a consulting physician, are payable as follows:

Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

Surgical Benefits (Inpatient and Outpatient)SurgicalExpenses

Covered Medical Expenses for charges for surgical services, performed by a physician, arepayable as follows:

Preferred Care: 80% of the Negotiated Charge.

Non-Preferred Care: 50% of the Reasonable Charge.

Anesthetist andAssistantSurgeonExpenses

Covered Medical Expenses for charges for the surgical services performed by a physicianare payable as follows:


OutpatientHospitalServices forSurgeryExpenses


AmbulatorySurgicalExpenses

Covered Medical Expenses for outpatient surgery performed in an ambulatory surgicalcenter are payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

Covered Medical Expenses must be incurred on the day of the surgery or within 48 hoursafter the surgery.

Outpatient BenefitsCovered Medical Expenses include but are not limited to: physicians office visits, hospital or outpatientdepartment or emergency room visits, durable medical equipment, clinical lab, or radiological facility.

OutpatientHospitalExpenses

Covered Medical Expenses for outpatient treatment in a hospital are payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

EmergencyRoom Expenses

Covered Medical Expenses incurred for treatment of an Emergency Medical Condition arepayable as follows:


13


14/46

Urgent CareExpenses

Benefits include charges for treatment by an urgent care provider.

Please Note: A Covered Person should not seek medical care or treatment from anurgent care provider if their illness, injury, or condition, is an emergency condition. TheCovered Person should go directly to the emergency room of a hospital or call 911(or the local equivalent) for ambulance and medical assistance.

Urgent CareBenefits include charges for an urgent care provider to evaluate and treat an urgent condition.

Covered Medical Expenses for urgent care treatment are payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

When travel to a Preferred Care Provider for treatment of an urgent condition is not feasible,

a Covered Person may call Aetna to request authorization to see a Non-Preferred urgent careprovider so that such treatment may be paid at the Preferred level of benefits. If it is notfeasible to request authorization prior to treatment, then it should be done as soon as possibleafter treatment but not later than:

the next day during normal business hours, or if the Covered Person is confined in a hospital directly after receiving urgent care, notlater than 48 hours following the start of the confinement unless it is not possible for theCovered Person to request authorization within that time. In that case, it must be done assoon as reasonably possible.

However:

if the treatment is received, or the confinement occurs,on a Friday or Saturday, authorization must be requested within 72 hours following treatmentor the start of the confinement.

If the Covered Person does not request authorization from Aetna to see a Non-Preferredurgent care provider, charges incurred for urgent care will be paid at the Non-Preferredcovered percentage after the Non-Preferred Deductible.

The Covered Person should contact their Primary Care Physician after medical care isprovided to treat an urgent condition.

Non-Urgent CareCovered Medical Expenses for charges made by an urgent care provider to treat a non-urgent condition are payable as follows:


No benefit will be paid under any other part of this Plan for charges made by an urgent careprovider to treat a non-urgent condition.

Non-urgent care includes, but is not limited to, the following:

routine or preventive care (this includes immunizations), follow-up care, physical therapy, elective surgical procedures, and any lab and radiologic exams which are not related to the treatment of the urgent

condition.

14


15/46

A separate Preferred urgent care Copay/Deductible applies to each visit for urgent care by a

Covered Person to a Preferred urgent care provider. This does not apply if the CoveredPerson is admitted to a hospital as an inpatient right after a visit to an urgent care provider.

AmbulanceExpenses

Covered Medical Expenses are payable at 100% of the Actual Charge to a maximum of$100 per trip 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.

Pre-AdmissionTestingExpenses

Covered Medical Expenses for Pre-Admission testing charges while an outpatient beforescheduled surgery are payable as follows:


PhysiciansOffice VisitExpenses


Laboratory andX-ray Expenses

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

Non-Preferred Care: 50% of the Reasonable Charge.

High CostProceduresExpenses

Covered Medical Expenses include charges incurred by a Covered Person are payable asfollows:


TherapyExpenses

Covered Medical Expenses for chemotherapy, including anti-nausea drugs used inconjunction with the chemotherapy, radiation therapy, tests and procedures, physiotherapy(for rehabilitation only after a surgery), and expenses incurred at a radiological facility.

Covered Medical Expenses also include expenses for the administration of chemotherapyand visits by a health care professional to administer the chemotherapy. Such expenses are

payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

DurableMedicalEquipmentExpenses


ProstheticDevicesExpenses

Benefits include charges for: artificial limbs, or eyes, and other non-dental prosthetic devices,

as a result of an accident or sickness. Covered Medical Expenses do not include: eye exams,eyeglasses, vision aids, hearing aids, communication aids, and orthopedic shoes, footorthotics, or other devices to support the feet.


OutpatientPhysicalTherapyExpenses

Covered Medical Expenses for physical therapy are payable as follows when provided by alicensed physical therapist and only when physical therapy begins within six months of theonset of symptoms:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

15


16/46

Dental InjuryExpenses

Covered Medical Expenses include dental work, surgery, and orthodontic treatment neededto remove, repair, replace, restore, or reposition:

Natural teeth damaged, lost, or removed, or Other body tissues of the mouth fractured or cut due to injury. The accident causing the

injury must occur while the person is covered under this Plan.

Any such teeth must have been: Free from decay, or In good repair, and Firmly attached to the jawbone at the time of the injury.The treatment must be done in the calendar year of the accident or the next one.

If:

Crowns (caps), or Dentures (false teeth), or Bridgework, or In-mouth appliances,are installed due to such injury, Covered Medical Expenses include only charges for: The first denture or fixed bridgework to replace lost teeth, The first crown needed to repair each damaged tooth, and An in-mouth appliance used in the first course of orthodontic treatment after the injury.Surgery needed to:

Treat a fracture, dislocation, or wound. Cut out cysts, tumors, or other diseased tissues. Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance

therapy alone cannot result in functional improvement.

Non-surgical treatment of infections or diseases. This does not include those of, or related to,the teeth.

Covered Medical Expenses are payable as follows:100% of the Actual Charge to a maximum of$150 per accident for the treatment of injury tosound natural teeth.

There is no maximum on treatment for Emergency Medical Conditions.

Allergy TestingExpense

Covered Medical Expenses include, but are not limited to, charges for the following:

Testing only

Covered Medical Expenses are payable as follows:

Preferred Care:, 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

16


17/46

MusculoskeletalTherapyExpenses

Benefits include charges incurred by a Covered Person for Musculoskeletal Therapy,provided on an outpatient basis.

For purposes of this benefit, Musculoskeletal Therapy means the diagnosis and treatmentby manual or mechanical means of the musculoskeletal structure, following an injury.


Consultant orSpecialistExpenses

Covered Medical Expenses include the expenses for the services of a consultant orspecialist, when referred by the School Health Services. The services must be requested bythe attending physician for the purpose of confirming or determining to confirm or determinea diagnosis.

Covered Medical Expenses are covered as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

Mental Health BenefitsInpatientExpenses

Covered Medical Expenses for the treatment of a mental health condition while confined asa inpatient in a hospital or facility licensed for such treatment are payable as follows:


Covered Medical Expenses also include the charges made for treatment received duringpartial hospitalization in a hospital or treatment facility. Prior review and approval must beobtained on a case-by-case basis by contacting Aetna Student Health. When approved,benefits will be payable in place of an inpatient admission, whereby two days of partialhospitalization may be exchanged for one day of full hospitalization.

Inpatient mental health treatment is limited to a maximum of30 days per Policy Year.

OutpatientExpenses

Covered Medical Expenses for outpatient treatment of a mental health condition are payableas follows:Preferred Care: 50% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

Maximum of60 visits per Policy Year, Plan pays maximum of$50 per visit.

17


18/46

Substance Abuse BenefitsAlcoholismInpatientExpenses

Covered Medical Expenses for the diagnosis, detoxification, inpatient confinement, andtreatment of medical complications resulting from alcoholism are payable on the same basis asany other sickness.


AlcoholismOutpatientExpenses

Covered Medical Expenses for outpatient treatment of alcoholism are payable as follows:Preferred Care: 50% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

Outpatient treatment of alcoholism and substance abuse treatment, is payable up to a

combined maximum of$1,000 per Policy Year.

SubstanceAbuse InpatientExpenses

Covered Medical Expenses for the treatment of a substance abuse condition while confinedas a inpatient in a hospital or facility licensed for such treatment are payable on the same basisas any other sickness.



SubstanceAbuseOutpatientExpenses

Covered Medical Expenses for outpatient treatment of a substance abuse condition arepayable as follows:


Outpatient treatment of alcoholism and substance abuse treatment, is payable up to a

combined maximum of$1,000 per Policy Year.

Maternity BenefitsMaternityExpenses

Covered Medical Expenses include inpatient care of the Covered Person and any newbornchild for a minimum of48 hours after a vaginal delivery and for a minimum of96 hours aftera cesarean delivery. A referral is not required for this benefit.

Any decision to shorten such minimum coverages shall be made by the attending physician inconsultation with the mother. In such cases, covered services may include: home visits, parenteducation, and assistance and training in breast or bottle-feeding.

Covered Medical Expenses for pregnancy, complications of pregnancy, Prenatal HIVTesting, and childbirth are payable on the same basis as any other sickness.

18


19/46

Well NewbornNursery CareExpenses

Benefits include charges for routine care ofa Covered Persons newborn child as follows:

hospital charges for routine nursery care during the mothers confinement, but for notmore than four days (for a normal delivery),

physicians charges for circumcision, and physicians charges for visits to the newborn child in the hospital and consultations, but

for not more than one visit per day.


Additional BenefitsPrescriptionDrug Benefit

This Pharmacy benefit is provided to cover Medically Necessary Prescriptions associated witha covered Sickness or Accident occurring during the Policy Year.

Prescription Drug Benefits are payable as follows:Covered Medical Expenses are payable at 80% of the Reasonable Charge.

Diabetic TestingSuppliesExpenses

Benefits include charges for testing material used to detect the presence of sugar in thepersons urine or blood for monitoring glycemic control.

Diabetic Testing Supplies are limited to

Lancet devices, glucose monitors, and test strips.Syringes, insulin, or other items used in the treatment of diabetes are not covered by thisbenefit.

Covered MedicalExpenses are payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

HypodermicNeedlesExpenses

Covered Medical Expenses for hypodermic needles and syringes used in the treatment ofDiabetes are payable as follows:


OutpatientDiabetic Self-managementEducationProgramsExpenses

Covered Medical Expenses for Outpatient Diabetic Self-Management Education Programsare payable on the same basis as any other condition.

Please see the definition on page 40 of this Brochure for more information on Outpatient

Diabetic Self-Management Education Programs.

ElementalFormulaExpenses

Benefits include charges for amino acid-based elemental formulas, regardless of deliverymethod for the diagnosis and treatment of Eosinophilic disorders and Short Bowel Syndrome.

Covered Medical Expenses are payable on the same basis as any other condition.

19


20/46

Tempo-romandibularand Cranio-mandibularJointDysfunctionExpenses

Covered Medical Expenses include charges incurred by a Covered Person for testing ofTemporomandibular and Craniomandibular Joint (TMJ) Dysfunction.

Diagnosis testing is only covered under lab benefit.

PrescriptionContraceptiveDevicesExpenses

This is an

Illinois State

Mandate.

Covered Medical Expenses for contraceptive drugs are payable at 80% of the ReasonableCharge.

Covered Medical Expenses include:

Charges incurred for contraceptive drugs and devices that by law need a physiciansprescription and that have been approved by the FDA.

Related outpatient contraceptive services such as:o Consultations,o Exams,o Procedures, ando

Other medical services and supplies.

Covered Medical Expenses for contraceptive devices and outpatient contraceptive servicesare payable on the same basis as any other condition.

Pap SmearExpenses

Covered Medical Expenses include one annual routine Pap smear screening for women age18 and older.

Covered Medical Expenses are payable on the same basis as any other outpatient expense:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

A referral is not required for this benefit.

MammographyExpenses

Covered Medical Expenses include one baseline mammogram for women between age 35and 40. Coverage is also provided for one routine annual mammogram for women age 40 andolder, as well as when medically indicated for women with risk factors who are under age 40.Risk factors who are under age 40. Risk factors for women under 40 are:

Prior personal history of breast cancer; Positive Genetic Testings; Family history of breast cancer; or Other risk factors.Mammogram screenings coverage must also include comprehensive ultrasound screening forthe entire breast or breasts if a mammogram demonstrates heterogenous or dense breast tissueand when determined to be medically necessary by a licensed physician.

Covered Medical Expenses are payable on the same basis as any expense:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

A referral is not required for this benefit.

20


21/46

Mastectomy andBreastReconstructionExpenseBenefits

Coverage will be provided to a Covered Person who is receiving benefits for a necessarymastectomy and who elects breast reconstruction after the mastectomy for:1. reconstruction of the breast on which a mastectomy has been performed,2. surgery and reconstruction of the other breast to produce a symmetrical appearance,3. prostheses,4. treatment of physical complications of all stages of mastectomy, including lymphedemas,

and5. reconstruction of the nipple/areolar complex following a mastectomy is covered without

regard to the lapse of time between the mastectomy and the reconstruction. This is subjectto the approval of the attending physician.

Benefits are paid on the same basis as any other disease.


This coverage will be provided in consultation with the attending physician and the patient. Itwill be subject to the same annual Deductibles and coinsurance provisions that apply to themastectomy.

Surgical SecondOpinionExpenses

To the extent that this Policy provides coverage for surgery, this Policyshall provide coveragefor expenses incurred for a second opinion consultation by a specialist on the need for surgerywhich has been recommended by the Covered Persons physician. The specialist must beboard certified in the medical field relating to the surgical procedure being proposed.Coverage will also be provided for any expenses incurred for required X-rays and diagnostictests done in connection with that consultation. Aetna must receive a written report on thesecond opinion consultation.

Covered Medical Expenses will not include any charge in excess of thedaily room andboardmaximum for semi-privateaccommodations.

Covered Medical Expenses for Surgical Second Opinion Expenses are covered as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

ElectiveSurgical SecondOpinionExpenses

To the extent that this Policy provides coverage for surgery, this Policy shall provide coveragefor expenses incurred for a second opinion consultation by a specialist on the need for

non-emergency elective surgery which has been recommended by the Covered Personsphysician. The specialist must be board certified in the medical field relating to the surgicalprocedure being proposed. Coverage will also be provided for any expenses incurred forrequired X-rays and diagnostic tests done in connection with that consultation. Aetna mustreceive a written report on the second opinion consultation.

Covered Medical Expenses will not include any charge in excess of thedaily room andboardmaximum for semi-privateaccommodations.

Covered Medical Expenses for Elective Surgical Second Opinion Expenses are covered asfollows:


21


22/46

Acupuncture inLieu ofAnesthesiaExpenses

Covered Medical Expenses include acupuncture therapy, when acupuncture is used in lieu ofother anesthesia, for a surgical or dental procedure covered under this Plan.

The acupuncture must be administered by a health care provider who is a legally qualifiedphysician, practicing within the scope of their license.


DermatologicalExpenses

Benefits include charges for the diagnosis and treatment of skin disorders, excludinglaboratory fees. Related laboratory expenses are covered under the Outpatient ExpenseBenefit.

Covered Medical Expenses are payable as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge

Covered Medical Expenses do not include treatment for acne, or cosmetic treatment andprocedures.

PodiatricExpenses

Benefits include charges for podiatric services, provided on an outpatient basis following aninjury.

Covered Medical Podiatric Expenses are covered at:

80%, if treatment is within three calendar days of an injury, or 80% for: diagnostic X-rays, laboratory tests, and surgical services.Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

Expenses for routine foot care, such as trimming of corns, calluses, and nails, are notCovered Medical Expenses.

22


23/46

Home HealthCare Expenses

Covered Medical Expenses include charges incurred by a Covered Person for home healthcare services made by a home health agency pursuant to a home health care plan, but only if:(a) The services are furnished by, or under arrangements made by, a licensed home health

agency,(b) The services are given under a home care plan. This plan must be established pursuant to

the written order of a physician, and the physician must renew that plan every 60 days.Such physician must certify that the proper treatment of the condition would requireinpatient confinement in a hospital or skilled nursing facility if the services and supplieswere not provided under the home health care plan. The physician must examine the

Covered Person at least once a month,(c) Except as specifically provided in the home health care services, the services are

delivered in the patients place of residence on a part-time, intermittent visiting basiswhile the patient is confined,

(d) The care starts within seven days after discharge from a hospital as an inpatient, and(e) The care is for the same condition that caused the hospital confinement, or one related to

it.


Home Health Care Services include:1. Part-time or intermittent nursing care by: a registered nurse (R.N.), a licensed practical

nurse, (L.P.N.), or under the supervision on a R.N. if the services of a R.N. are notavailable,

2. Part time or intermittent home health aide services, that consist primarily of care of amedical or therapeutic nature by other than a R.N.,

3. Physical, occupational speech therapy, or respiratory therapy,4. Medical supplies, drugs and medicines, and laboratory services. However, these items are

covered only to the extent they would be covered if the patient was confined to a hospital,5. Medical social services by licensed or trained social workers,6. Nutritional counseling.Covered Medical Expenses will not include: 1) services by a person who resides in theCovered Persons home, or is a member of the Covered Persons immediate family,2) homemaker or housekeeper services, 3) maintenance therapy, 4) dialysis treatment,5) purchase or rental of dialysis equipment, or 6) food or home delivered services.

Home Health Care Expense benefits are payable as follows:


A visit means a maximum offour continuous hours of home health service.

Home Health care requires pre-certification.

Transfusion orDialysis ofBlood Expenses

Benefits include charges for the transfusion or dialysis of blood, including the cost of: wholeblood, blood components, and the administration thereof.


23


24/46

Licensed NurseExpenses

Covered Medical Expenses include charges incurred by a Covered Person who is confinedin a hospital as a resident bed-patient, and requires the services of a registered nurse orlicensed practical nurse.

Covered Medical Expenses for a licensed nurse are covered as follows:Preferred Care: 80% of the Negotiated Charge.Non-Preferred Care: 50% of the Reasonable Charge.

Skilled NursingFacilityExpenses

Covered Medical Expenses include charges incurred by a Covered Person for confinementin a skilled nursing facility for treatment rendered:

in lieu of confinement in a hospital as a full time inpatient, or within 24 hours following a hospital confinement and for the same or related cause(s) as

such hospital confinement.

Covered Medical Expenses are payable as follows:Preferred Care: 80% of the Negotiated Charge for the semi-private room rate.Non-Preferred Care: 80% of the Reasonable Charge for the semi-private room rate.

Benefits for Skilled Nursing require pre-certification.

RehabilitationFacilityExpenses

Covered Medical Expenses include charges incurred by a Covered Person for confinementas a full time inpatient in a rehabilitation facility. Confinement in the rehabilitation facility

must follow within 24 hours of, and be for the same or related cause(s) as, a period ofhospital or skilled nursing facility confinement.

Covered Medical Expenses for Rehabilitation Facility Expenses are covered as follows:Preferred Care: 80% of the Negotiated Charge for the rehabilitation facilitysdaily room andboard maximum for semi-privateaccommodations.Non-Preferred Care: 50% of the Reasonable Charge for the rehabilitation facilitys dailyroom and board maximum for semi-private accommodations.

Benefits for Rehabilitation Facility expenses require pre-certification.

ShinglesVaccineExpenses

Must provide a shingles vaccine approved for marketing by the Federal Food and DrugAdministration. The vaccine is covered when: ordered by a physician for members 60 years ofage or older.

Covered Medical Expenses are covered on the same basis as any other condition.

DiagnosticTesting forAttentionDisorders andLearning

DisabilitiesExpenses

Covered Medical Expenses for diagnostic testing for:

Attention Deficit Disorder, or Attention Deficit Hyperactive Disorder, or Dyslexia,are payable as follows:


24


25/46

ADDITIONAL SERVICES AND DISCOUNTSAs a member of the Plan, you can also take advantage of the following services, discounts, and programs. These arenot underwritten by Aetna. To learn more about these additional services and search for providers visitwww.aetnastudenthealth.com.

Vital SavingsSM on Dental* is a dental Discount Program helping you and your dependents save an average of

15% to 50% on a wide array of dental services with one low annual fee of $29 per person. Enroll online atwww.aetnastudenthealth.com.Student: $29Student + 1 dependent: $51Student + 2 or more dependents: $73*Actual costs and savings vary by provider and geographic area.

Vital SavingsSM on Pharmacy is a Discount Program helping you and your dependents lower your prescriptiondrug costs. Present your card to participating pharmacies and receive a discount at the time of purchase, no claims tofile. Enroll online at www.aetnastudenthealth.com.

Student: $29Student + 1 dependent: $51Student + 2 or more dependents: $73

Vital SavingsSM on Pharmacy and Dental is a Discount Program helping you and your dependents save onprescription drug costs and a wide array of dental services. Enroll online at www.aetnastudenthealth.com. Savetime and money on enrollment fees by joining both programs in one step.Student: $46Student + 1 dependent: $81Student + 2 or more dependents: $115

*The Vital Savings by Aetna

Program (the Program) is not insurance. The Program

provides Members with access to discounted fees pursuant to schedules negotiated by Aetna Life

Insurance Company for the Vital Savings by Aetna

Discount Program. The Program does not

make payments directly to the providers participating in the Program. Each Member is obligated

to pay for all services or products but will receive a discount from the providers who havecontracted with the Discount Medical Plan Organization to participate in the Program. Aetna

Life Insurance Company, 151 Farmington Avenue, Hartford, CT 06156, 1-877-698-4825, is the

Discount Medical Plan Organization.

Aetna VisionSM Discount Program:The Aetna Vision Discount Program helps you save on vision exams andmany eye care products, including sunglasses, contact lenses, non-prescription sunglasses, contact lens solutionsand other eye care accessories. Plus, you can receive up to a 15% discount on LASIK surgery (the laser visioncorrection procedure).

Aetna FitnessSM Discount Program: Aetnas Fitness Discount Program provides members with access to Preferredmembership rates at nearly 10,000 fitness clubs nationwide and in Canada in the GlobalFitTM network. Members

can also save on GlobalFits other programs and services, such as at-home weight loss programs, home fitnessequipment and videos and even one-on-one health coaching services* to help them quit smoking, reduce stress, loseweight, or meet any other health goal.*Offered by WellCall, Inc. through GlobalFit.

Aetna Weight ManagementSM Discount Program: Helps you achieve your weight loss goals and develop abalanced approach to your active lifestyle. This program provides members and their eligible family membersaccess to discounts on Jenny Craig weight loss programs and products. Start with a FREE 30-day trialmembership* then choose either a six* or twelve* month program** thats right for you. You also receiveindividual weight loss consultations, personalized menu planning, tailored activity planning, motivational materialsand much more.

25
http://www.aetnastudenthealth.com/http://www.aetnastudenthealth.com/http://www.aetnastudenthealth.com/http://www.aetnastudenthealth.com/


26/46

*Offers good at participating centers in the United States, Canada and Puerto Rico and through Jenny Direct

at-home. Additional cost for all food purchases and shipping where applicable.

**Additional weekly food discounts will grow throughout the year, based on active participation.

Find a meal plan that works for you at eDiets:Get a personalized plan for healthy eating that fits your lifestyle,and save 25% on weekly eDiets dues. Youll have access to customized weekly menus, recipes, support boards,

chats, nutrition tools and fitness tips.

Use Zagat reviews as a guide for your night out:Planning a night on the town? Or, want to visit a city whereyouve never been? Subscribe to Zagat online and get a 30% discount on their members-only services. You can signup for access to restaurant reviews only, or choose full access and get ratings and reviews on hotels, restaurants,movies and other attractions. You can even order printed guides at a discount!

Give the gift of relaxation to yourself or a friend through SpaWish: Get a 10% discount when you buy a giftcertificate of at least $100, good for services at any of over 1,000 spas across the U.S. Choose a spa close to homeor near your favorite place to visit!

Get trusted health information from the MayoClinic.com Bookstore:Choose from newsletters and books with recipes for healthy living, advice on staying in shape, guides on living with certain health conditions and more.

Its all at your fingertips and at a discount! The size of the discount will depend on the item price and otheravailable discounts.

Aetnas Informed Health Line: Get answers from a registered nurse at any time just call our toll-freeInformed Health Line. With one simple call, you can:

Learn more about health conditions that you or your family members have. Find out more about a medical test or procedure. Come up with questions to ask your doctor.Talk to a registered nurse:Our nurses can discuss more than 5,000 health and wellness topics. Call them anytimeyou have a health question.

Listen to our Audio Health Library:* Call and learn about a topic that interests you. Choose from thousands of

health conditions. Listen in English or Spanish. You can also transfer to a registered nurse at any time during yourcall.*Not all topics discussed within the Audio Health Library are covered expenses under your health insurance Plan.

Go online for even more health information:If you like to go online for health information, check out theHealthwise Knowledgebase. You can learn more about a health condition you have, medications you take, andmore. Link to it through your secure Aetna Navigator website at www.aetnanavigator.com.

Health and Wellness Portal: This dynamic, interactive website will give you health care and assessment tools tocalculate body mass index, financial health, risk activities and health and wellness indicators. The site providesresources for wellness programs and activities.

Beginning Right Maternity Program: Give your baby a healthy start. Our Beginning Right Maternity Program

comes with your health insurance Plan. Use it throughout your pregnancy and after your baby is born. If you havehealth conditions or risk factors that may need special attention, we can help. Our nurses can give you personal casemanagement to help you find ways to lower your risks. The more you know the better chance you have for goodhealth for you and your baby.

Aetna Natural Products and ServicesSM Discount Program: Offers members access to reduced rates on servicesfrom natural therapy professionals, including acupuncturists, chiropractors, massage therapists and dieteticcounselors, and access to discounts on over-the-counter vitamins, herbal and nutritional supplements andhealth-related products, such as foot care and natural body care products.

26


27/46

Quit Tobacco Cessation Program: Say good-bye to tobacco and hello to a healthier future! The one-year QuitTobacco program is provided by Healthyroads, a leading provider of tobacco cessation programs. Youll getpersonal attention from health professionals that can help find what works for you.

Discount programs and other programs above provide access to discounted prices and are NOT insured benefits.

The member is responsible for the full cost of the discounted services. Discounts are subject to change without

notice. Discount programs may not be available in all states. Discount programs may be offered by vendors whoare independent contractors and not employees or agents of Aetna.

Health information programs provide general health information and are not a substitute for diagnosis or

treatment by a physician or other health care professionals.

GENERAL PROVISIONS

STATE MANDATED BENEFITS

This Plan will pay benefits in accordance with any applicable Illinois Insurance Law(s).

RIGHT OF RECOVERY

Subrogation

Whenever Aetna has paid benefits due to sickness or injury of a Covered Person under this Policy, resulting from aThird Partys wrongful act or negligence, to the extent of its payment Aetna shall reserve the right to assume thelegal claim any Covered Person may have against that Third Party. This means that Aetna may choose to take legalaction against the negligent Third Party or their representatives and to recover from them the amount of claimbenefits paid to the Covered Person for loss caused by the Third Party.

ReimbursementBy accepting benefits under this Plan, the Covered Person also specifically acknowledges Aetnas right ofreimbursement. If a Covered Person incurs expenses for sickness or injury that occurred due to the negligence of aThird Party: (a) Aetna has the right to reimbursement for all benefits Aetna paid from any and all damages collectedfrom the Third Party for those same expenses whether by action at law, settlement, or compromise, by the CoveredPerson, Covered Persons parents, if the Covered Person is a minor, or Covered Persons legal representative asa result of that sickness or injury, and (b) Aetna is assigned the right to recover from the Third Party, or his/her

insurer, to the extent of the benefits Aetna paid for that sickness or injury.

Aetna shall have the right to first reimbursement out of all funds the Covered Person, the Covered Personsparents, if the Covered Person is a minor, or the Covered Persons legal representative, is or was able to obtain forthe same expenses Aetna has paid as a result of that sickness or injury.

The Covered Person is required to furnish any information or assistance or provide any documents that Aetna mayreasonably require in order to obtain our rights under this provision. This provision applies whether or not the ThirdParty admits liability.

This right of reimbursement attaches when this Plan has paid health care benefits for expenses incurred due to ThirdParty Injuries and the Covered Person or the Covered Persons representative has recovered any amounts from aThird Party. By providing any benefit under this Certificate, Aetna is granted an assignment of the proceeds of any

recovery, settlement, or judgment received by the Covered Person to the extent of the full cost of all benefitsprovided by this Plan. Aetnas right of reimbursement is cumulative with and not exclusive of Aetnas subrogationright and Aetna may choose to exercise either or both rights of recovery.

As used herein, the term:Third Party, means any party that is, or may be, or is claimed to be responsible for injuries or illness to a CoveredPerson. Such injuries or illness are referred to as Third Party Injuries. Third Party includes any partyresponsible for payment of expenses associated with the care or treatment of Third Party Injuries.

Effect of other Plan coverage: This provision applies if a covered student:

27


28/46

(a) is covered by any other group or blanket health care plan: and(b) would, as a result, receive medical expense or service benefits in excess of the actual expenses incurred.

In this case, the medical expense benefits Aetna will pay will be reduced by such excess.

EXTENSION OF BENEFITSIf Basic Sickness Expense, Supplemental Sickness Expense coverage for a Covered Person ends while he/she istotally disabled, benefits will continue to be available for expenses incurred for that person, only while theCovered Person continues to be totally disabled. Benefits will end three months from the date coverage ends.

If a Covered Person is confined to a hospital on the date his/her insurance terminates, expenses incurred after thetermination date and during the continuance of that hospital confinement, shall be payable in accordance with the

Policy, but only while they are incurred during the 90 day period, following such termination of insurance.

TERMINATION OF INSURANCE

Benefits are payable under this Policy only for those Covered Medical Expenses incurred while the Policy is ineffect as to the Covered Person. No benefits are payable for expenses incurred after the date the insuranceterminates, except as may be provided under the Extension of Benefits provision.

TERMINATION OF STUDENT COVERAGE

Insurance for a covered student will end on the first of these to occur:(a) the date this Policy terminates,(b) the last day for which any required premium has been paid,

(c) the date on which the covered student withdraws from the school because of entering the armed forces of anycountry. Premiums will be refunded on a pro-rata basis when application is made within 90 days fromwithdrawal,

(d) the date the covered student is no longer in an eligible class.

If withdrawal from school is for other than entering the armed forces, no premium refund will be made. Studentswill be covered for the Policy term for which they are enrolled, and for which premium has been paid.

TERMINATION OF DEPENDENT COVERAGE

Insurance for a covered studentsdependent will end when insurance for the covered student ends. Before then,coverage will end:(a) For a child, on the first premium due date following the first to occur of:

1. the date the child is no longer chiefly dependent upon the student for support and maintenance,2. the date of the childs marriage, and3. the childs 26th birthday.

(b) The date the covered student fails to pay any required premium.(c) For the spouse, the date the marriage ends in divorce or annulment.

(d) The date dependent coverage is deleted from this Policy.(e) The date the dependent ceases to be in an eligible class.

Termination will not prejudice any claim for a charge that is incurred prior to the date coverage ends.

INCAPACITATED DEPENDENT CHILDREN

Insurance may be continued for incapacitated dependent children who reach the age at which insurance wouldotherwise cease. The dependent child must be chiefly dependent for support upon the covered student and beincapable of self-sustaining employment because of mental or physical handicap.

Due proof of the childs incapacity and dependency must be furnished to Aetna by the covered student within120 days after the date insurance would otherwise cease. Such child will be considered a covered dependent, solong as the covered student submits proof to Aetna at reasonable intervals during the two years following the

28


29/46

childs attainment of the limiting age and each year thereafter, that the child remains physically or mentally unableto earn his/her own living. The premium due for the childs insurance will be the same as for a child who is not soincapacitated.

The childs insurance under this provision will end on the earlier of:(a) the date specified under the provision entitled Termination of Dependent Coverage, or

(b) the date the child is no longer incapacitated and dependent on the covered student for support.

CONTINUATION OF COVERAGE

A covered student who has graduated or is otherwise ineligible for coverage under this Policy, and has beencontinuously insured under the Plan offered by the Policyholder (regular Student Plan), may be covered for up to

three, six or nine months provided that: (1) a written request for continuation has been forwarded to Aetna 31days prior to the termination of coverage, and (2) premium payment has been made. Coverage under this provisionceases on the date this Policy terminates.

EXCLUSIONSThis Policy does not cover nor provide benefits for:1. Expenses incurred for services normally provided without charge by the Policyholders Health Service,

Infirmary or Hospital, or by health care providers employed by the Policyholder.

2. Expenses incurred for eye refractions, vision therapy, radial keratotomy, eyeglasses, contact lenses (exceptwhen required after cataract surgery), or other vision or hearing aids, or prescriptions or examinations exceptas required for repair caused by a covered injury.

3. Expenses incurred as a result ofinjury due to participation in a riot. Participation in a riot means taking partin a riot in any way, including inciting the riot or conspiring to incite it. It does not include actions taken inself-defense, so long as they are not taken against persons who are trying to restore law and order.

4. Expenses incurred as a result of an accident occurring in consequence of riding as a passenger or otherwise inany vehicle or device for aerial navigation, except as a fare-paying passenger in an aircraft operated by ascheduled airline maintaining regular published schedules on a regularly established route.

5. Expenses incurred as a result of an injury or sickness due to working for wage or profit or for which benefitsare payable under any Workers Compensation or Occupational Disease Law.

6. Expenses incurred as a result of an injury sustained or sickness contracted while in the service of the ArmedForces of any country. Upon the Covered Person entering the Armed Forces of any country, the unearnedpro-rata premium will be refunded to the Policyholder.

7. Expenses incurred for treatment provided in a governmental hospital unless there is a legal obligation to paysuch charges in the absence of insurance.

8. Expenses incurred for elective treatment or elective surgery except as specifically provided elsewhere in thisPolicy and performed while this Policy is in effect.

9. Expenses incurred for cosmetic surgery, reconstructive surgery, or other services and supplies which improve,alter, or enhance appearance, whether or not for psychological or emotional reasons, except to the extendneeded to:

Improve the function of a part of the body that:o is not a tooth or structure that supports the teeth, ando is malformed:

as a result of a severe birth defect, including harelip, webbed fingers, or toes, or as direct result of:

disease, or

29


30/46

surgery performed to treat a disease or injury. Repair an injury (including reconstructive surgery for prosthetic device for a Covered Person who has

undergone a mastectomy,) which occurs while the Covered Person is covered under this Policy. Surgerymust be performed:

o in the calendar year of the accident which causes the injury, oro in the next calendar year.

10. Expenses covered by any other valid and collectible medical, health or accident insurance to the extent thatbenefits are payable under other valid and collectible insurance whether or not a claim is made for suchbenefits.

11. Expenses incurred as a result of preventive medicines, serums, vaccines or oral contraceptive, unless statedotherwise in this Policy.

12. Expenses incurred as a result of commission of a felony.13. Expenses incurred after the date insurance terminates for a Covered Person except as may be specifically

provided in the Extension of Benefits Provision.

14. Expenses incurred for any services rendered by a member of the Covered Persons immediate family or aperson who lives in the Covered Persons home.15. Expenses incurred for treatment of Temporomandibular Joint Dysfunction and associated myofascial pain.16. Expenses for the contraceptive methods, devices or aids, and charges for or related to artificial insemination,

in-vitro fertilization, or embryo transfer procedures, elective sterilization or its reversal or elective abortionunless specifically provided for in this Policy.

17. Expenses for treatment ofinjury or sickness to the extent that payment is made, as a judgment or settlement,by any person deemed responsible for the injury or sickness (or their insurers).

18. Expenses incurred for which no member of the Covered Persons immediate family has any legal obligationfor payment.

19. Expenses incurred for custodial care. Custodialcare means services and supplies furnished to a person mainlyto help him/her in the activities of daily life. This includes room and board and other institutional care. Theperson does not have to be disabled. Such services and supplies are custodial care without regard to:

by whom they are prescribed, or by whom they are recommended, or by whom or by which they are performed.

20. Expenses incurred for the removal of an organ from a Covered Person for the purpose of donating or sellingthe organ to any person or organization. This limitation does not apply to a donation by a Covered Person to aspouse, child, brother, sister, or parent.

21. Expenses incurred for blood or blood plasma, except charges by a hospital for the processing or administrationof blood.22. Expenses incurred for the repair or replacement of existing artificial limbs, orthopedic braces, or orthotic

devices.

23. Expenses incurred for or in connection with: procedures, services, or supplies that are, as determined by Aetna,to be experimental or investigational. A drug, a device, a procedure, or treatment will be determined to beexperimental or investigational if:

There are insufficient outcomes data available from controlled clinical trials published in the peer reviewedliterature, to substantiate its safety and effectiveness, for the disease or injury involved, or

30


31/46

If required by the FDA, approval has not been granted for marketing, or A recognized national medical or dental society or regulatory agency has determined, in writing, that it is

experimental, investigational, or for research purposes, or

The written protocol or protocols used by the treating facility, or the protocol or protocols of any otherfacility studying substantially the same drug, device, procedure, or treatment, or the written informedconsent used by the treating facility, or by another facility studying the same drug, device, procedure, or

treatment, states that it is experimental, investigational, or for research purposes.

However, this exclusion will not apply with respect to services or supplies (other than drugs) received inconnection with a disease, if Aetna determines that:

The disease can be expected to cause death within one year, in the absence of effective treatment, and The care or treatment is effective for that disease, or shows promise of being effective for that disease, as

demonstrated by scientific data. In making this determination, Aetna will take into account the results of areview by a panel of independent medical professionals. They will be selected by Aetna. This panel willinclude professionals who treat the type of disease involved.

Also, this exclusion will not a