2016-2017 Student Health Insurance San Jose State University
International Gateways 2016-2017 Student Health Insurance San Jose State University studentinsurance.wellsfargo.com Underwritten by: Aetna Life Insurance Company Policy #867866 Plan Brokered by: Wells Fargo Insurance Services USA, Inc. CA License No. 0D08408 SBC NOTICE You can view the standard Summary of Benefits & Coverage (SBC) which is required by Health Care Reform. It summarizes your coverage in a format that all insurance companies 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. The California State University International Student Health Insurance Plan is underwritten by Aetna Life Insurance Company. Aetna Student HealthSM is the brand name for products and services provided by Aetna Life Insurance Company and its applicable affiliated companies (Aetna). 15.02.310.1 E
IMPORTANT NOTICE This is a brief description of the Student Health Plan underwritten by Aetna Life Insurance Company (Aetna). The exact provisions governing this insurance, including definitions, are contained in the Master Policy issued to your school and may be viewed online at www.aetnastudenthealth.com. If any discrepancy exists between this Benefit Summary and the Policy, the Master Policy will govern and control the payment of benefits. For information regarding the full Master Policy, please call Aetna Student Health at (866) 378-8885 or send an email through your Aetna Navigator Account. You will be able to obtain a copy of the full Master Policy as soon as it is available. WHEN COVERAGE BEGINS WHEN COVERAGE ENDS Coverage under the Plan once premium has been collected will become effective at 12:01 a.m. on the later of, but no sooner than: 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 Student 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 enrolls past the first date of coverage for which he or she is applying. Final decisions regarding coverage effective dates are made by Aetna Student Health. Insurance of all Insured Persons terminates at 11:59 p.m. on the earlier of: Date the Master Policy terminates for all Insured Persons; or End of the period of coverage for which premium has been paid; or Date the Insured Person ceases to be eligible for the insurance; or Date the Insured Person enters military service. In the event there is overlapping coverage under the same Master Policy number, the policy with the earliest effective date will stay in force through its termination date and the subsequent policy will go into effect immediately afterward with no gap in coverage. The below enrollments will be allowed a 30 day grace period from the term start date to enroll whereby the effective date will be backdated a maximum of 30 days. No policy shall ever start prior to the term start date: 1. All hard-waiver and mandatory (insurance is required as a condition of enrollment on campus) insurance programs. 2. All re-enrollments into the same exact policy if re-enrollment occurs within 30 days of the prior policy termination date. Dependent coverage will not be effective prior to that of the Insured Student or extend beyond that of the Insured Student. COVERAGE IS NOT AUTOMATICALLY RENEWED. Eligible Persons must reenroll when coverage terminates to maintain coverage. NO notification of plan expiration or renewal will be sent. CHOOSE YOUR PLAN Students enrolled in this term should choose. this Plan Fall Full 8/7/16 – 12/31/16 Fall Full Fall Session 1 8/7/16 – 10/8/16 Fall 1 Fall Session 2 10/9/16 – 12/31/16 Fall 2 Spring Full 1/1/17 – 6/3/17 2 San Jose State University - International Gateways Spring Full Students enrolled in this term should choose. this Plan Spring Session 1 Spring Session 2 New Students Spring Session 2 Continuing Students 1/1/17 – 3/11/17 Spring Session 1 Spring 2 3/6/17 – 6/3/17 New Students Spring 2 3/12/17 – 6/3/17 Continuing Students Summer 6/4/17 – 8/6/17 Summer
PLAN COST FALL FULL TERMS OF COVERAGE 8/7/16 - 12/31/16 FALL 1 8/7/16 - 10/8/16 FALL 2 10/9/16 - 12/31/16 Student only 230.94 303.58 525.63 SPRING 2 SPRING 1 SPRING FULL NEW STUDENTS 1/1/17 1/1/17 3/6/17 - 3/11/17 - 6/3/17 - 6/3/17 256.56 551.03 325.68 SPRING 2 CONTINUING STUDENTS 3/12/17 - 6/3/17 303.59 SUMMER 6/4/17 - 8/6/17 234.40 NOTE: Costs below are in addition to the student premium. Dependents must be enrolled for the same term of coverage as student. Dependent enrollment in this plan is voluntary. Spouse only 515.63 220.94 293.58 246.56 541.03 315.68 293.59 224.40 Per Child (Age 0-25) only 515.63 220.94 293.58 246.56 541.03 315.68 293.59 224.40 Rates include premium payable to Aetna Life Insurance Company, as well as administrative fees payable to CSU and Wells Fargo Student Insurance. Rates also include Medical Evacuation and Repatriation and Worldwide Emergency Travel Assistance benefits/services provided through On Call International and its contracted underwriting companies. WHO IS ELIGIBLE TO ENROLL? All international students, visiting faculty, scholars or other persons possessing and maintaining a current passport and valid visa status (F1, J-1 or M-1, etc.), engaged in educational activities at San Jose State University who are temporarily located outside their home country and have not been granted permanent residency status, are required to be insured under the Policy and must directly enroll before registering for classes. Coverage is available for students engaged in “Practical Training”. Enrollment must be accompanied by confirmation of Practical Training from the insured student in the form of a copy of your EAD (OPT coverage is available for the first 12 months of OPT only). Contact Wells Fargo Student Insurance for more details. (A person who is an immigrant or permanent resident alien is not eligible for coverage under the international plan.) To be an Insured Person under the Policy: the student must have paid the required premium; the student’s name, student number and date of birth must have been included in the declaration made by the School or the Administrative Agent to the Insurer; and the student must actively attend classes on campus for 45 consecutive days following the effective date for the term purchased and/or pursuant to the student’s visa requirements for the period for which coverage is purchased, with the exception of school-authorized breaks. A onceper-lifetime exception may be made in cases of a student’s medical withdrawal, when approved by the school and any applicable regulatory authority. Aetna and Wells Fargo Student Insurance maintain the right to investigate student status and attendance records to verify that the Policy eligibility requirements have been met. If and whenever Aetna and/or Wells Fargo Student Insurance discover that the Policy eligibility requirements have not been met, the only obligation is a pro-rata refund of premium. Eligible students who involuntarily lose coverage under another group insurance plan are also eligible to purchase the Student Health Insurance Plan within 30 days of loss of coverage. These students must provide Wells Fargo Student Insurance with proof that they have lost insurance through another group (certificate and letter of ineligibility) within 30 days of the qualifying event. The effective date would be the later of: a) term effective date, or b) the day after prior coverage ends if enrollment request is received by Wells Fargo Student Insurance within 30 days from loss of prior coverage. For questions regarding eligibility for this plan, please call Wells Fargo Student Insurance at 1-800-853-5899. COVERAGE FOR DEPENDENTS Eligible Insured Students may also purchase Dependent coverage at the time of student’s enrollment in the plan; or within 31 days of one of the following qualified events: marriage, addition of domestic partner, birth, adoption or arrival in the U.S. Eligible dependents are the spouse or legally registered and valid domestic partner who resides with the Insured Student and the student’s, the spouse’s, or the domestic partner’s natural child, stepchild or legally adopted child under 26 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” will automatically be covered for preventive care; injury; sickness; premature birth; medically diagnosed congenital defects; and birth abnormalities from birth until 31 days old, providing that the student is covered under this plan. Coverage may be continued for that child when Wells Fargo Insurance is notified in writing within 31 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 Insured Student enrolls. Dependent coverage expires concurrently with that of the Insured Student, and Dependents must re-enroll when coverage terminates to maintain coverage. San Jose State University - International Gateways 3
WHERE DO I GO FOR SERVICE? PREFERRED CARE PROVIDER NETWORK When you need care, consider Student Health Services (SHS) on your campus as your first stop. They can provide many of the routine health services you need. Services obtained at the SHS are reimbursed at the Preferred Care rate. A SHS referral is not required, and it does not guarantee services received will be considered eligible expenses under the plan, nor is it a guarantee of payment. You may visit any licensed health care provider directly for covered services, except for specific Plan restrictions on certain services. However, when you visit a Preferred Care Provider, you’ll generally have less out of pocket expense for your care. To learn more about Preferred Care Providers, visit www.aetnastudenthealth.com. Insured dependents are not eligible to use the SHS. The benefits listed in the Schedule of Benefits are available to the insured dependents. *Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. 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 Provider because savings can be achieved from the Negotiated Charges these providers have agreed to accept as payment for their services. Students are responsible for informing their Physicians of potential out-of-pocket expenses for a referral to both a Preferred Care Provider and a Non-Preferred Care Provider. Preferred Care Providers are independent contractors and are neither employees nor agents of the California State University system nor Aetna Student Health. To find a Preferred Care Provider, you can use Aetna’s online DocFind service located at www.aetnastudenthealth.com. Click on “Find Your School” and enter your school name. You can use DocFind to find out whether a specific provider belongs to Aetna’s network or to find Preferred Care Providers practicing in your area. If a service or supply that a covered person needs is covered under the Plan but not available from a Preferred Care Provider, covered persons should contact Member Services for assistance at the toll-free number on the back of the ID card. In this situation, Aetna may issue a pre-approval for a covered person to obtain the service or supply from a Non-Preferred Care Provider. When a pre-approval is issued by Aetna, covered medical expenses are reimbursed at the Preferred Care network level of benefits. 4 San Jose State University - International Gateways
ID CARDS PREMIUM REFUND/CANCELLATION Providers need your Member ID# from your card to identify you, verify your coverage, and bill Aetna Life Insurance Company. You do not have to have your member ID card with you to be eligible to receive benefits; if you need medical attention but do not have access to your card, benefits will still be payable according to the Policy. Your medical ID card will be shipped within 3 weeks of your policy effective date. Alternately, to access your Member ID Card, go to www.aetnastudenthealth.com, search for your school name, and click “Print your ID card” to view and/or print a temporary Medical ID card that contains your Medical ID number. Note: you will need your Student ID number to log in. You may also use the Aetna Mobile App to view your member ID card, find a doctor, check your benefits, and more. First, log in to www.aetnastudenthealth.com and create your Aetna Navigator account. Next, download the Aetna Mobile App to your mobile device and log in using your Medical ID number (obtained from Aetna’s website, see instructions above). Technical assistance for the Aetna website and Mobile App is available toll free, Monday through Friday, from 8:30 a.m. to 5:30 p.m. local time at (866) 378-8885. Refund requests should be directed to Wells Fargo Student Insurance at (800) 853-5899 or via email at studentinsurance@wellsfargo.com. A refund of premium will be granted for the reasons listed below only. No other refunds will be granted. 1. If you withdraw from school within the first 45 days of the coverage period, you and your insured dependents will receive a full refund of the insurance premium provided that you and your insured dependents did not file a medical claim during this period. Written proof of withdrawal from the school must be provided. If you withdraw after 45 days of the coverage period, your and your insured dependents coverage will remain in effect until the end of the term for which you have paid the premium. 2. If you or your insured dependents enter the armed forces of any country you and your insured dependents will not be covered under the Master Policy as of the date of such entry. If you enter the armed forces the policy will be cancelled. If your dependent enters the armed forces, a pro-rata refund of premium will be made for such person, upon written request received by Wells Fargo Insurance Services within 45 days of entry into service. 3. Refunds will be granted for insured dependents in case of a qualifying event such as legal separation, divorce or death within 31 days of the occurred event, provided that your insured dependents did not file a medical claim during the insured period. Written proof of such qualifying event must be submitted. Refunds will not be prorated. INSURANCE PAYMENTS WITH PERSONAL CHECK (Note: personal checks are not always a payment option. Please check your school’s enrollment form for available payment options.) If you make your or your dependents‘ insurance payment via personal check payable to Wells Fargo Student Insurance and we are unable to process the check (due to insufficient funds, closure of account, etc.), your and your dependents insurance coverage will be terminated retroactive to the effective date of the enrolled term. MEMBER WEB: AETNA NAVIGATOR As an Aetna Student Health insurance member, you have access to Aetna Navigator , your secure member website, packed with personalized benefits and health information. 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. Find healthcare professionals and facilities that participate in your plan. Send an e-mail to Aetna Student Health Customer Service, 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. For help with registering, technical assistance is available toll free, Monday through Friday, from 7 a.m. to 9 p.m. Eastern Time at (800) 225-3375. INFORMED HEALTH LINE The Informed Health Line is a 24-hours-a-day, 7-days-a-week toll-free line for insured students and dependents to access confidential medical advice, or get assistance with locating nearby preferred network providers. Just call (800) 556-1555 to talk to a registered nurse who can provide information on a range of topics. Callers must be enrolled in the Student Health Insurance Plan in order to be eligible to utilize the Informed Health Line. PRESCRIPTION DRUG CLAIM PROCEDURE When obtaining a covered prescription, please present your ID card to a Preferred Pharmacy, along with your applicable copay. The pharmacy will bill Aetna for 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 be reimbursed by submitting a completed Aetna Prescription Drug claim form. You will be reimbursed for covered medications, less your copay. For an Aetna Prescription claim form go to www.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 incapable of billing, must be paid for in full at the time of service and submitted for reimbursement. San Jose State University - International Gateways 5
IMPORTANT NOTICE This is a brief description of the Student Health Plan underwritten by Aetna Life Insurance Company (Aetna). The exact provisions governing this insurance, including definitions, are contained in the Master Policy issued to your school and may be viewed online at www.aetnastudenthealth.com. If any discrepancy exists between this Benefit Summary and the Policy, the Master Policy will govern and control the payment of benefits. For information regarding the full Master Policy, please call Aetna Student Health at (866) 378-8885 or send an email through your Aetna Navigator Account. You will be able to obtain a copy of the full Master Policy as soon as it is available. The Plan will pay benefits in accordance with any applicable California State Insurance Law(s). WAIVER OF ANNUAL DEDUCTIBLE In compliance with Federal Health Care Reform legislation, the Annual Deductible is waived for Preferred Care Covered Medical Expenses rendered as part of the following benefit types: Routine Physical Exam Expense (Office Visits), Pap Smear Screening Expense, Mammogram Expense, Routine Screening for Sexually Transmitted Disease Expense, Routine Colorectal Cancer Screening, Routine Prostate Cancer Screening Expense, Preventive Care Immunizations (Facility or Office Visits), Well Woman Preventive Visits (Office Visits), Screening & Counseling Services (Office Visits) as illustrated under the Routine Physical Exam benefit type, Routine Cancer Screenings (Outpatient), Prenatal Care (Office Visits), Comprehensive Lactation Support and Counseling Services (Facility or Office Visits), Breast Pumps & Supplies, Family Contraceptive Counseling Services (Office Visits), Female Voluntary Sterilization (Inpatient and Outpatient), Pediatric Preventive Vision and Dental Service, Female Contraceptives Generic Prescription Drugs, Brand Prescription Drugs if no Generic equivalent. FDA-Approved Female Generic Emergency Contraceptives. SCHEDULE OF BENEFITS For more details about these benefits, please see the Benefit Descriptions section on page 11. Deductibles The following Deductibles are applied before Covered Medical Expenses are payable: Student/Spouse/Child: 150 per insured per Policy Year *Per visit or admission deductibles do not apply towards satisfying the plan Deductible. Coinsurance Covered Medical Expenses are payable at the coinsurance percentage specified below, after any applicable deductible, up to an Unlimited maximum benefit. Out of Pocket Maximums Preferred Care Individual Out-of-Pocket: 4,000 per Insured per Policy Year; Preferred Care Family Out-of-Pocket: 8,000 per Policy Year Once the Individual or Family Out-of-Pocket Limit for Preferred Care has been satisfied, Covered Medical Expenses will be payable at 100% for the remainder of the Policy Year, up to any benefit maximum that may apply. Coinsurance, Deductibles, Copays and Prescription Drug expenses apply to the Out-of-Pocket Limit. Services that do not apply towards satisfying the Out-Of-Pocket Limit: expenses that are not Covered Medical Expenses; expenses for Designated Care or Non-Preferred care; penalties,and other expenses not covered by this Plan. INPATIENT HOSPITALIZATION EXPENSES PREFERRED CARE NON-PREFERRED CARE Room and Board Expense, Semi-private room. 100% of the Negotiated Charge 75% of the Recognized Charge Intensive Care Room and Board Expense, Overnight stay. 100% of the Negotiated Charge 75% of the Recognized Charge Non-Surgical Physicians Expense, Non-surgical services of the attending Physician, or a consulting Physician. 100% of the Negotiated Charge 75% of the Recognized Charge Miscellaneous Hospital Expense, includes; among others; expenses incurred during a hospital confinement for: anesthesia and operating room; laboratory tests and x rays; oxygen tent; and drugs; medicines; and dressings. 100% of the Negotiated Charge 75% of the Recognized Charge PREFERRED CARE NON-PREFERRED CARE Surgical Expense 100% of the Negotiated Charge 75% of the Recognized Charge Assistant Surgeon Expense (Inpatient and Outpatient) 100% of the Negotiated Charge 75% of the Recognized Charge Ambulatory Surgical Expense 100% of the Negotiated Charge 75% of the Recognized Charge Anesthesia Expense 100% of the Negotiated Charge 75% of the Recognized Charge SURGICAL EXPENSES (INPATIENT & OUTPATIENT) Continued on next page 6 San Jose State University - International Gateways
SCHEDULE OF BENEFITS (CONTINUED) OUTPATIENT BENEFITS PREFERRED CARE NON-PREFERRED CARE 100% of the Negotiated Charge after a 20 Co-pay per visit 75% of the Recognized Charge after a 30 Co-pay per visit 100% of the Negotiated Charge after 250 Co-pay per visit (Co-pay waived if admitted) 100% of the Recognized Charge after 250 Deductible per visit (Deductible waived if admitted) treatment from an urgent care provider if their illness, injury, or condition, is an emergency condition. The covered person should go directly to the emergency room of a hospital or call 911 for ambulance and medical assistance. The copay is in addition to the plan deductible. 100% of the Negotiated Charge after a 20 Co-pay per visit 75% of the Recognized Charge after a 30 Co-pay per visit Ambulance Expense 90% of the Negotiated Charge 90% of the Recognized Charge Physician’s Office Visit Expense, Copay is due at time of visit and is in addition to the plan deductible. 100% of the Negotiated Charge after a 20 Co-pay per visit 75% of the Recognized Charge after a 30 Co-pay per visit Laboratory and X-Ray Expense 100% of the Negotiated Charge 75% of the Recognized Charge Therapy Expense, for the following types of therapy provided on an outpatient basis: Physical Therapy, Chiropractic Care, Speech Therapy, Inhalation Therapy, Cardiac Rehabilitation, or Occupational Therapy. Benefits for Chiropractic Care are limited to 50 visits per Policy Year. 100% of the Negotiated Charge 75% of the Recognized Charge Breast Feeding Durable Medical Equipment Expense, Includes the rental or purchase of breast feeding durable medical equipment for the purpose of lactation support. 100% of the Negotiated Charge 75% of the Recognized Charge Walk-In Clinic Expense, Copay is due at the time of visit and is in addition to the plan deductible. 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 difference between the amount billed by the provider and the amount paid by this Plan. If the provider bills you for an amount above your cost share, you are not responsible for paying that amount. Please send Aetna the bill at the address listed on the back of your member ID card and Aetna will resolve any payment dispute with the provider over that amount. Make sure your member ID number is on the bill. The copay is in addition to the plan deductible. Important Notice: A separate hospital emergency room visit benefit deductible or copay applies for each visit to an emergency room for emergency care. If a covered person is admitted to a hospital as an inpatient immediately following a visit to an emergency room, the emergency room visit benefit deductible or copay is waived. Covered medical expenses that are applied to the emergency room visit benefit deductible or copay cannot be applied to any other benefit deductible or copay under the plan. Likewise, covered medical expenses that are applied to any of the plan’s other benefit deductibles or copays cannot be applied to the emergency room visit benefit deductible or copay. Separate benefit deductibles or copays may apply for certain services rendered in the emergency room that are not included in the hospital emergency room visit benefit. These benefit deductibles or copays may be different from the hospital emergency room visit benefit deductible or copay, and will be based on the specific service rendered. Urgent Care Expense, Please note: A covered person should not seek medical care or Allergy Testing and Treatment Expense, Includes laboratory tests, physician office visits to 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 other Sickness Routine Physical Exam Expense 100% of the Negotiated Charge 75% of the Recognized Charge Hospital Outpatient Department Expense 100% of the Negotiated Charge 75% of the Recognized Charge Continued on next page San Jose State University - International Gateways 7
SCHEDULE OF BENEFITS (CONTINUED) OUTPATIENT BENEFITS (CONTINUED) PREFERRED CARE NON-PREFERRED CARE Consultant Expense 100% of the Negotiated Charge after a 20 Co-pay per visit 75% of the Recognized Charge after a 30 Co-pay per visit High Cost Procedures Expense, Includes CT scans, MRIs, PET scans and Nuclear Cardiac Imaging Tests. 100% of the Negotiated Charge 75% of the Recognized Charge Prosthetic and Orthotic Devices Expense, Includes prosthetic devices to restore a method of speaking for laryngectomy patient. 100% of the Negotiated Charge 75% of the Recognized Charge Pediatric Preventive Care Expense, For the comprehensive preventive care of children 16 years of age or younger, including periodic health evaluations, immunizations, and lab services. 100% of the Negotiated Charge 75% of the Recognized Charge Pediatric Preventive Care Expense, For the comprehensive preventive care of children 17 and 18 years of age, including periodic health evaluations, immunizations, and lab services. 100% of the Negotiated Charge 75% of the Recognized Charge PREFERRED CARE NON-PREFERRED CARE MENTAL HEALTH BENEFITS Severe Mental Illness Expense - Inpatient, For the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age, and of serious emotional disturbances of a child. Payable as any other Sickness Severe Mental Illness Expense - Outpatient 100% of the Negotiated Charge 75% of the Recognized Charge Mental and Nervous Disorders Expense, Inpatient and outpatient. 100% of the Negotiated Charge 75% of the Recognized Charge PREFERRED CARE NON-PREFERRED CARE Inpatient Expense, For the treatment of alcohol and drug addiction. 100% of the Negotiated Charge 75% of the Recognized Charge Outpatient Expense, For the treatment of alcohol and drug addiction. 100% of the Negotiated Charge 75% of the Recognized Charge PREFERRED CARE NON-PREFERRED CARE ALCOHOLISM AND DRUG ADDICTION TREATMENT MATERNITY BENEFITS Maternity Expense, For the care of the covered person and any newborn child. Payable on the same basis as any other Sickness Well Newborn Nursery Care Expense, For the routine care of a covered person’s newborn child. 100% of the Negotiated Charge 75% of the Recognized Charge Contraceptives Important Note: Brand-Name Prescription Drug or Devices for a Preferred Provider will be covered at 100% of the Negotiated Charge, including waiver of per Policy Year Deductible if a Generic Prescription Drug or Device is not available in the same therapeutic drug class or the prescriber specifies Dispense as Written. 100% of the Negotiated Charge 75% of the Recognized Charge Continued on next page 8 San Jose State University - International Gateways
SCHEDULE OF BENEFITS (CONTINUED) ADDITIONAL BENEFITS PREFERRED CARE NON-PREFERRED CARE Preferred Care Pharmacy: 100% of the Negotiated Charge, following a 35 Copay for each Brand Name Prescription Drug or 15 Copay for each Generic Prescription Drug. Non-Preferred Care Pharmacy: 100% of the Recognized Charge, following a 35 Copay for each Brand Name Prescription Drug or 15 Copay for each Generic Prescription Drug Prescribed Medicine Expense Note: Contraceptive Drugs and Device benefits are illustrated under the Family Planning Benefit, as noted in the Benefits Description. Non-Prescription Enteral Formula Expense 100% of the Negotiated Charge 75% of the Recognized Charge Pap Smear Screening Expense 100% of the Negotiated Charge 75% of the Recognized Charge Mammogram Expense 100% of the Negotiated Charge 75% of the Recognized Charge Family Planning Expense, Includes charges incurred for services and supplies that are provided to prevent pregnancy. 100% of the Neg
Aetna Student HealthSM is the brand name for products and services provided by Aetna Life Insurance Company and its applicable affiliated companies (Aetna). SBC NOTICE You can view the standard Summary of Benefits & Coverage (SBC) which is required by Health Care Reform. It summarizes your coverage in a format that all insurance
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The commercial health insurance market is the only source of health insurance directly regulated by the Utah Insurance Department, hereafter referred to as the Insurance Department for the purposes of this report. Approximately 40 percent of Utah's commercial health insurance market is comprehensive health insurance (also known as major medical).
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