Student Health Plan (SHP)

Cornell University

Student Health Plan

(SHP)

Certificate of

Coverage 2021-2022

CU2122-01

New York Student Health Plan

This is Your

CERTIFICATE OF COVERAGE

Issued by

Cornell University

This Certificate of Coverage (“Certificate”) explains the benefits available to You under a

Contract between Cornell University (hereinafter referred to as “We”, “Us” or “Our”) and

You. Amendments, riders or endorsements may be delivered with the Certificate or

added thereafter.

You have the right to return this Certificate. Examine it carefully. If You are not

satisfied, You may return this Certificate to Us and ask Us to cancel it. Your request

must be made in writing within ten (10) days from the date You receive this Certificate.

We will refund any Premium paid including any Certificate fees or other charges.

This Certificate offers You the option to receive Covered Services on two benefit levels:

1. In-Network Benefits. In-network benefits are the highest level of coverage

available. In-network benefits apply when Your care is provided by Participating

Providers in Our Aetna Student Health Network and Participating Pharmacies in

Our OptumRx Network. You should always consider receiving health care

services first through the Student Health Services on Your associated campus, if

available, and then in the in-network benefits portion of this Certificate.

2. Out-of-Network Benefits. The out-of-network benefits portion of this Certificate

provides coverage when You receive Covered Services from Non-Participating

Providers. Your out-of-pocket expenses will be higher when You receive out-of-

network benefits. In addition to Cost-Sharing, You will also be responsible for

paying any difference between the Allowed Amount and the Non-Participating

Provider’s charge.

READ THIS ENTIRE CERTIFICATE CAREFULLY. IT DESCRIBES THE

BENEFITS AVAILABLE UNDER THE CERTIFICATE. IT IS YOUR

RESPONSIBILITY TO UNDERSTAND THE TERMS AND CONDITIONS IN THIS

CERTIFICATE.

This Certificate is governed by the laws of New York State.

Joanne M. DeStefano

Executive Vice President and Chief Financial Officer, Cornell University

If You need foreign language assistance to understand this Certificate, You may call Us

at the number on Your ID card.

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TABLE OF CONTENTS

Section I. Definitions ................................................................................................. 4

Section II. How Your Coverage Works .................................................................... 11

Participating Providers ................................................................................................ 11

The Role of Primary Care Physicians ........................................................................... 11

Services Subject to Preauthorization............................................................................ 12

Medical Necessity ........................................................................................................ 13

Important Telephone Numbers and Addresses ........................................................... 16

Section III. Access to Care and Transitional Care ................................................. 17

Section IV. Cost-Sharing Expenses and Allowed Amount .................................... 19

Section V. Who is Covered ....................................................................................... 23

Section VI. Preventive Care ...................................................................................... 28

Section VII. Ambulance and Pre-Hospital Emergency Medical Services ............. 32

Section VIII. Emergency Services and Urgent Care ............................................... 34

Section IX. Outpatient and Professional Services .................................................. 37

Section X. Additional Benefits, Equipment and Devices ....................................... 47

Section XI. Inpatient Services .................................................................................. 54

Section XII. Mental Health Care and Substance Use Services .............................. 58

Section XIII. Prescription Drug Coverage ............................................................... 61

Section XIV. Wellness Benefits ................................................................................ 72

Section XV. Pediatric Vision Care ............................................................................ 73

Section XVI. Pediatric Dental Care ........................................................................... 74

Section XVII. Exclusions and Limitations ............................................................... 76

Section XVIII. Claim Determinations ........................................................................ 79

Section XIX. Grievance Procedures ......................................................................... 81

Section XX. Utilization Review ................................................................................ 83

Section XXI. External Appeal ................................................................................... 92

Section XXII. Termination of Coverage ................................................................... 97

Section XXIII. Extension of Benefits ........................................................................ 99

Section XXIV. Continuation of Coverage ................................................................ 100

Section XXV. Temporary Suspension Rights for Armed Forces’ Members ........ 101

Section XXVI. General Provisions........................................................................... 102

Section XXVII. Other Covered Services ................................................................... 110

Section XXVIII. Schedule of Benefits ...................................................................... 112

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SECTION I

Definitions

Defined terms will appear capitalized throughout this Certificate.

Acute: The onset of disease or injury, or a change in the Member's condition that

would require prompt medical attention.

Allowed Amount: The maximum amount on which Our payment is based for Covered

Services. See the Cost-Sharing Expenses and Allowed Amount section of this

Certificate for a description of how the Allowed Amount is calculated. If Your Non-

Participating Provider charges more than the Allowed Amount, You will have to pay the

difference between the Allowed Amount and the Provider’s charge, in addition to any

Cost-Sharing requirements.

Ambulatory Surgical Center: A Facility currently licensed by the appropriate state

regulatory agency for the provision of surgical and related medical services on an

outpatient basis.

Appeal: A request for Us to review a Utilization Review decision or a Grievance again.

Balance Billing: When a Non-Participating Provider bills You for the difference

between the Non-Participating Provider’s charge and the Allowed Amount. A

Participating Provider may not Balance Bill You for Covered Services.

Certificate: This Certificate issued by Cornell University, including the Schedule of

Benefits and any attached riders.

Child, Children: The Student’s Children, including any natural, adopted or step-

children, unmarried disabled Children, newborn Children, or any other Children as

described in the Who is Covered section of this Certificate.

Coinsurance: Your share of the costs of a Covered Service, calculated as a percent of

the Allowed Amount for the service that You are required to pay to a Provider. The

amount can vary by the type of Covered Service.

Copayment: A fixed amount You pay directly to a Provider for a Covered Service when

You receive the service. The amount can vary by the type of Covered Service.

Cost-Sharing: Amounts You must pay for Covered Services, expressed as

Copayments, Deductibles and/or Coinsurance.

Cover, Covered or Covered Services: The Medically Necessary services paid for,

arranged, or authorized for You by Us under the terms and conditions of this Certificate.

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Deductible: The amount You owe before We begin to pay for Covered Services. The

Deductible applies before any Copayments or Coinsurance are applied. The Deductible

may not apply to all Covered Services. You may also have a Deductible that applies to

a specific Covered Service (e.g., a Prescription Drug Deductible) that You owe before

We begin to pay for a particular Covered Service.

Dependents: The Student’s Spouse and Children.

Durable Medical Equipment (“DME”): Equipment which is:

• Designed and intended for repeated use;

• Primarily and customarily used to serve a medical purpose;

• Generally not useful to a person in the absence of disease or injury; and

• Appropriate for use in the home.

Emergency Condition: A medical or behavioral condition that manifests itself by Acute

symptoms of sufficient severity, including severe pain, such that a prudent layperson,

possessing an average knowledge of medicine and health, could reasonably expect the

absence of immediate medical attention to result in:

• Placing the health of the person afflicted with such condition or, with respect to a

pregnant woman, the health of the woman or her unborn child in serious

jeopardy, or in the case of a behavioral condition, placing the health of such

person or others in serious jeopardy;

• Serious impairment to such person’s bodily functions;

• Serious dysfunction of any bodily organ or part of such person; or

• Serious disfigurement of such person.

Emergency Department Care: Emergency Services You get in a Hospital emergency

department.

Emergency Services: A medical screening examination which is within the capability

of the emergency department of a Hospital, including ancillary services routinely

available to the emergency department to evaluate such Emergency Condition; and

within the capabilities of the staff and facilities available at the Hospital, such further

medical examination and treatment as are required to stabilize the patient. “To

stabilize” is to provide such medical treatment of an Emergency Condition as may be

necessary to assure that, within reasonable medical probability, no material

deterioration of the condition is likely to result from or occur during the transfer of the

patient from a Facility, or to deliver a newborn child (including the placenta).

Exclusions: Health care services that We do not pay for or Cover.

External Appeal Agent: An entity that has been certified by the New York State

Department of Financial Services to perform external appeals in accordance with New

York law.

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Facility: A Hospital; Ambulatory Surgical Center; birthing center; dialysis center;

rehabilitation Facility; Skilled Nursing Facility; hospice; Home Health Agency or home

care services agency certified or licensed under Article 36 of the New York Public

Health Law; a comprehensive care center for eating disorders pursuant to Article 27-J of

the New York Public Health Law; and a Facility defined in New York Mental Hygiene

Law Sections 1.03(10) and (33), certified by the New York State Office of Alcoholism

and Substance Abuse Services, or certified under Article 28 of the New York Public

Health Law (or, in other states, a similarly licensed or certified Facility). If You receive

treatment for substance use disorder outside of New York State, a Facility also includes

one which is accredited by the Joint Commission to provide a substance use disorder

treatment program.

Grievance: A complaint that You communicate to Us that does not involve a Utilization

Review determination.

Habilitation Services: Health care services that help a person keep, learn or improve

skills and functioning for daily living. Habilitative Services include the management of

limitations and disabilities, including services or programs that help maintain or prevent

deterioration in physical, cognitive, or behavioral function. These services consist of

physical therapy, occupational therapy and speech therapy.

Health Care Professional: An appropriately licensed, registered or certified

Physician; dentist; optometrist; chiropractor; psychologist; social worker; podiatrist;

physical therapist; occupational therapist; midwife; speech-language pathologist;

audiologist; pharmacist; behavior analyst; or any other licensed, registered or certified

Health Care Professional under Title 8 of the New York Education Law (or other

comparable state law, if applicable) that the New York Insurance Law requires to be

recognized who charges and bills patients for Covered Services. The Health Care

Professional’s services must be rendered within the lawful scope of practice for that

type of Provider in order to be covered under this Certificate.

Home Health Agency: An organization currently certified or licensed by the State of

New York or the state in which it operates and renders home health care services.

Hospice Care: Care to provide comfort and support for persons in the last stages of a

terminal illness and their families that are provided by a hospice organization certified

pursuant to Article 40 of the New York Public Health Law or under a similar certification

process required by the state in which the hospice organization is located.

Hospital: A short term, acute, general Hospital, which:

• Is primarily engaged in providing, by or under the continuous supervision of

Physicians, to patients, diagnostic services and therapeutic services for

diagnosis, treatment and care of injured or sick persons;

• Has organized departments of medicine and major surgery;

• Has a requirement that every patient must be under the care of a Physician or

dentist;

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• Provides 24-hour nursing service by or under the supervision of a registered

professional nurse (R.N.);

• If located in New York State, has in effect a Hospitalization review plan

applicable to all patients which meets at least the standards set forth in 42 U.S.C.

Section 1395x(k);

• Is duly licensed by the agency responsible for licensing such Hospitals; and

• Is not, other than incidentally, a place of rest, a place primarily for the treatment

of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a

place for convalescent, custodial, educational, or rehabilitory care.

Hospital does not mean health resorts, spas, or infirmaries at schools or camps.

Hospitalization: Care in a Hospital that requires admission as an inpatient and usually

requires an overnight stay.

Hospital Outpatient Care: Care in a Hospital that usually doesn’t require an overnight

stay.

In-Network Coinsurance: Your share of the costs of a Covered Service, calculated as

a percent of the Allowed Amount for the Covered Service that You are required to pay

to a Participating Provider. The amount can vary by the type of Covered Service.

In-Network Copayment: A fixed amount You pay directly to a Participating Provider

for a Covered Service when You receive the service. The amount can vary by the type

of Covered Service.

In-Network Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-

Sharing before We begin to pay 100% of the Allowed Amount for Covered Services

received from Participating Providers. This limit never includes Your Premium or

services We do not Cover.

Medically Necessary: See the How Your Coverage Works section of this Certificate

for the definition.

Medicare: Title XVIII of the Social Security Act, as amended.

Member: The Student or a covered Dependent for whom required Premiums have

been paid. Whenever a Member is required to provide a notice pursuant to a Grievance

or emergency department visit or admission, “Member” also means the Member’s

designee.

Network: The Providers We have contracted with to provide health care services to

You.

Non-Participating Provider: A Provider who doesn’t have a contract with Us to

provide services to You. You will pay more to see a Non-Participating Provider.

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Out-of-Network Coinsurance: Your share of the costs of a Covered Service

calculated as a percent of the Allowed Amount for the service that You are required to

pay to a Non-Participating Provider. The amount can vary by the type of Covered

Service.

Out-of-Network Copayment: A fixed amount You pay directly to a Non-Participating

Provider for a Covered Service when You receive the service. The amount can vary by

the type of Covered Service.

Out-of-Network Deductible: The amount You owe before We begin to pay for

Covered Services received from Non-Participating Providers. The Out-of-Network

Deductible applies before any Copayments or Coinsurance are applied. The Out-of-

Network Deductible may not apply to all Covered Services. You may also have an Out-

of-Network Deductible that applies to a specific Covered Service (e.g., a Prescription

Drug Deductible) that You owe before We begin to pay for a particular Covered Service.

Out-of-Network Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-

Sharing before We begin to pay 100% of the Allowed Amount for Covered Services

received from Non-Participating Providers. This limit never includes Your Premium,

Balance Billing charges or services We do not Cover. You are also responsible for all

differences, if any, between the Allowed Amount and the Non-Participating Provider's

charge for out-of-network services regardless of whether the Out-of-Pocket Limit has

been met.

Out-of-Pocket Limit: The most You pay during a Plan Year in Cost-Sharing before We

begin to pay 100% of the Allowed Amount for Covered Services. This limit never

includes Your Premium, Balance Billing charges or the cost of health care services We

do not Cover.

Participating Provider: A Provider who has a contract with Us to provide services to

You. A list of Participating Providers and their locations is available on Our website at

www.aetnastudenthealth.com or upon Your request to Us. The list will be revised from

time to time by Us.

Physician or Physician Services: Health care services a licensed medical Physician

(M.D. – Medical Doctor or D.O. – Doctor of Osteopathic Medicine) provides or

coordinates.

Plan Year: The 12-month period beginning on the effective date of the Contract or any

anniversary date thereafter, during which the Certificate is in effect.

Preauthorization: A decision by Us prior to Your receipt of a Covered Service,

procedure, treatment plan, device, or Prescription Drug that the Covered Service,

procedure, treatment plan, device or Prescription Drug is Medically Necessary. We

indicate which Covered Services require Preauthorization in the Schedule of Benefits

section of this Certificate.

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Premium: The amount that must be paid for Your health insurance coverage.

Prescription Drugs: A medication, product or device that has been approved by the

Food and Drug Administration (“FDA”) and that can, under federal or state law, be

dispensed only pursuant to a prescription order or refill and is on Our formulary. A

Prescription Drug includes a medication that, due to its characteristics, is appropriate for

self administration or administration by a non-skilled caregiver.

Primary Care Physician (“PCP”): A participating nurse practitioner or Physician who

typically is an internal medicine, family practice or pediatric Physician and who directly

provides or coordinates a range of health care services for You.

Provider: A Physician, Health Care Professional or Facility licensed, registered,

certified or accredited as required by state law. A Provider also includes a vendor or

dispenser of diabetic equipment and supplies, durable medical equipment, medical

supplies, or any other equipment or supplies that are Covered under this Certificate that

is licensed, registered, certified or accredited as required by state law.

Referral: An authorization given to one Participating Provider from another

Participating Provider (usually from a PCP to a participating Specialist), in order to

arrange for additional care for a Member. A Referral can be transmitted electronically or

by Your Provider completing a paper Referral form. Except as provided in the Access

to Care and Transitional Care section of this Certificate, a Referral will not be made to a

Non-Participating Provider.

Rehabilitation Services: Health care services that help a person keep, get back, or

improve skills and functioning for daily living that have been lost or impaired because a

person was sick, hurt, or disabled. These services consist of physical therapy,

occupational therapy, and speech therapy in an inpatient and/or outpatient setting.

Schedule of Benefits: The section of this Certificate that describes the Copayments,

Deductibles, Coinsurance, Out-of-Pocket Limits, Preauthorization requirements, and

other limits on Covered Services.

Service Area: The geographical area, designated by Us and approved by the State of

New York, in which We provide coverage. Our Service Area consists of all 62 counties

in New York State. Please see www.aetnastudenthealth.com for list participating

providers.

SHP: Student Health Plan

Skilled Nursing Facility: An institution or a distinct part of an institution that is:

currently licensed or approved under state or local law; primarily engaged in providing

skilled nursing care and related services as a Skilled Nursing Facility, extended care

Facility, or nursing care Facility approved by the Joint Commission or the Bureau of

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Hospitals of the American Osteopathic Association, or as a Skilled Nursing Facility

under Medicare; or as otherwise determined by Us to meet the standards of any of

these authorities.

Specialist: A Physician who focuses on a specific area of medicine or a group of

patients to diagnose, manage, prevent or treat certain types of symptoms and

conditions.

Spouse: The person to whom the Student is legally married, including a same sex

Spouse. Spouse also includes a domestic partner.

Student: The person to whom this Certificate is issued.

Student Health Services: Any organization, facility, or clinic, operated, maintained, or

supported by the school which provides health care services to a Student and adult

Dependents and has received accreditation by either the Accreditation Association of

Ambulatory Health Care (AAAHC) or the Joint Commission for the ambulatory health

care provided within their student health services.

UCR (Usual, Customary and Reasonable): The cost of a medical service in a

geographic area based on what Providers in the area usually charge for the same or

similar medical service.

Urgent Care: Medical care for an illness, injury or condition serious enough that a

reasonable person would seek care right away, but not so severe as to require

Emergency Department Care. Urgent Care may be rendered in a Physician's office or

Urgent Care Center.

Urgent Care Center: A licensed Facility that provides Urgent Care.

Us, We, Our: Cornell University and anyone to whom We legally delegate

performance, on Our behalf, under this Certificate.

Utilization Review: The review to determine whether services are or were Medically

Necessary or experimental or investigational (i.e., treatment for a rare disease or a

clinical trial).

You, Your: The Member.

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SECTION II

How Your Coverage Works

A. Your Coverage Under this Certificate.

We will provide the benefits described in this Certificate to covered Members of Cornell

University and Weill Cornell Medicine, that is, to a Student and his or her Covered

Dependents. You should keep this Certificate with Your other important papers so that

it is available for Your future reference.

B. Covered Services.

You will receive Covered Services under the terms and conditions of this Certificate only

when the Covered Service is:

• Medically Necessary;

• Provided by a Participating Provider for in-network coverage;

• Listed as a Covered Service;

• Not in excess of any benefit limitations described in the Schedule of Benefits

section of this Certificate and

• Received while Your Certificate is in force.

C. Participating Providers.

To find out if a Provider is a Participating Provider:

• Check Our Provider directory, available at Aetna Student Health;

• Call the number on Your ID card;

• Visit Our website at www.aetnastudenthealth.com; or

• Visit Our website at www.optumrx.com.

The Provider directory will give You the following information about Our Participating

Providers:

• Name, address, and telephone number;

• Specialty;

• Board certification (if applicable);

• Languages spoken; and

• Whether the Participating Provider is accepting new patients.

D. The Role of Primary Care Physicians.

This Certificate requires that, if available, Student Health Services, acts as a Primary

Care Physician (“PCP”). Although You are encouraged to receive care from Your PCP,

You do not need a Referral from Student Health Services or a PCP before receiving

Specialist care.

For purposes of Cost-Sharing, if You seek services from a PCP (or a Physician covering

for a PCP) who has a primary or secondary specialty other than general practice, family

practice, internal medicine, pediatrics and OB/GYN, You must pay the specialty office

visit Cost-Sharing in the Schedule of Benefits section of this Certificate when the

services provided are related to specialty care. Children and Your Spouse covered

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under this Certificate do not need a referral.

E. Access to Providers and Changing Providers.

Sometimes Providers in Our Provider directory are not available. You should call the

Provider to make sure he or she is a Participating Provider and is accepting new

patients.

To see a Provider, call his or her office and tell the Provider that You are a Cornell

University Student Health Plan and Aetna Member, and explain the reason for Your

visit. Have Your ID card available. The Provider’s office may ask You for Your Member

ID number. When You go to the Provider’s office, bring Your ID card with You.

To contact Your Provider after normal business hours, call the Provider’s office. You

will be directed to Your provider, an answering machine with directions on how to obtain

services, or another Provider. If You have an Emergency Condition, seek immediate

care at the nearest Hospital emergency department or call 911.

If We do not have a Participating Provider for certain provider types in the county in

which You live or in a bordering county that is within approved time and distance

standards, We will approve an authorization to a specific Non-Participating Provider

until You no longer need the care, or We have a Participating Provider in Our network

that meets the time and distance standards, and Your care has been transitioned to that

Participating Provider. Covered Services rendered by the Non-Participating Provider

will be paid as if they were provided by a Participating Provider. You will be responsible

only for any applicable in-network Cost-Sharing.

F. Out-of-Network Services.

We Cover the services of Non-Participating Providers. See the Schedule of Benefits

section of this Certificate for the Non-Participating Provider services that are Covered.

In any case where benefits are limited to a certain number of days or visits, such limits

apply in the aggregate to in-network and out-of-network services.

G. Care Outside of the United States.

Claims incurred outside of the United States will be reimbursed at the Participating

Provider level.

H. Services Subject to Preauthorization.

Our Preauthorization is required before You receive certain Covered Services. Student

Health Services or Your Participating Provider is responsible for requesting

Preauthorization for in-network services and You are responsible for requesting

Preauthorization for the out-of-network services listed in the Schedule of Benefits

section of this Certificate.

I. Preauthorization Procedure.

If You seek coverage for services that require Preauthorization, You, Your Provider or

the Student Health Services must call Us at the number on Your ID card.

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After receiving a request for approval, We will review the reasons for Your planned

treatment and determine if benefits are available. Criteria will be based on multiple

sources which may include medical policy, clinical guidelines, and pharmacy and

therapeutic guidelines.

J. Medical Management.

The benefits available to You under this Certificate are subject to pre-service,

concurrent and retrospective reviews to determine when services should be Covered by

Us. The purpose of these reviews is to promote the delivery of cost-effective medical

care by reviewing the use of procedures and, where appropriate, the setting or place

the services are performed. Covered Services must be Medically Necessary for

benefits to be provided.

K. Medical Necessity.

We Cover benefits described in this Certificate as long as the health care service,

procedure, treatment, test, device, Prescription Drug or supply (collectively, “service”)

is Medically Necessary. The fact that a Provider has furnished, prescribed, ordered,

recommended, or approved the service does not make it Medically Necessary or mean

that We have to Cover it.

We may base Our decision on a review of:

• Your medical records;

• Our medical policies and clinical guidelines;

• Medical opinions of a professional society, peer review committee or other

groups of Physicians;

• Reports in peer-reviewed medical literature;

• Reports and guidelines published by nationally-recognized health care

organizations that include supporting scientific data;

• Professional standards of safety and effectiveness, which are generally-

recognized in the United States for diagnosis, care, or treatment;

• The opinion of Health Care Professionals in the generally-recognized health

specialty involved;

• The opinion of the attending Providers, which have credence but do not overrule

contrary opinions.

Services will be deemed Medically Necessary only if:

• They are clinically appropriate in terms of type, frequency, extent, site, and

duration, and considered effective for Your illness, injury, or disease;

• They are required for the direct care and treatment or management of that

condition;

• Your condition would be adversely affected if the services were not provided;

• They are provided in accordance with generally-accepted standards of medical

practice;

• They are not primarily for the convenience of You, Your family, or Your Provider;

• They are not more costly than an alternative service or sequence of services,

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that is at least as likely to produce equivalent therapeutic or diagnostic results;

• When setting or place of service is part of the review, services that can be safely

provided to You in a lower cost setting will not be Medically Necessary if they are

performed in a higher cost setting. For example, We will not provide coverage

for an inpatient admission for surgery if the surgery could have been performed

on an outpatient basis or an infusion or injection of a specialty drug provided in

the outpatient department of a Hospital if the drug could be provided in a

Physician’s office or the home setting.

See the Utilization Review and External Appeal sections of this Certificate for Your right

to an internal Appeal and external appeal of Our determination that a service is not

Medically Necessary.

L. Protection from Surprise Bills.

1. A surprise bill is a bill You receive for Covered Services in the following

circumstances:

• For services performed by a non-participating Physician at a participating

Hospital or Ambulatory Surgical Center, when:

o A participating Physician is unavailable at the time the health care

services are performed;

o A non-participating Physician performs services without Your

knowledge; or

o Unforeseen medical issues or services arise at the time the health

care services are performed.

A surprise bill does not include a bill for health care services when a participating

Physician is available, and You elected to receive services from a non-

participating Physician.

• You were referred by a participating Physician to a Non-Participating

Provider without Your explicit written consent acknowledging that the

referral is to a Non-Participating Provider and it may result in costs not

covered by Us. For a surprise bill, a referral to a Non-Participating

Provider means:

o Covered Services are performed by a Non-Participating Provider in the

participating Physician’s office or practice during the same visit;

o The participating Physician sends a specimen taken from You in the

participating Physician’s office to a non-participating laboratory or

pathologist; or

o For any other Covered Services performed by a Non-Participating

Provider at the participating Physician’s request, when Referrals are

required under Your Certificate.

You will be held harmless for any Non-Participating Provider charges for the

surprise bill that exceed Your In-Network Copayment, Coinsurance or Deductible

if You assign benefits to the Non-Participating Provider in writing. In such cases,

the Non-Participating Provider may only bill You for Your In-Network Copayment,

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Coinsurance or Deductible.

The assignment of benefits form for surprise bills is available at www.dfs.ny.gov

or You can visit Our website at www.aetnastudenthatlh.com for a copy of the

form. You need to mail a copy of the assignment of benefits form to Us at the

address on Your ID card and to Your Provider.

2. Independent Dispute Resolution Process. Either We or a Provider may

submit a dispute involving a surprise bill to an independent dispute resolution

entity (“IDRE”) assigned by the state. Disputes are submitted by completing the

IDRE application form, which can be found at www.dfs.ny.gov. The IDRE will

determine whether Our payment or Provider’s charge is reasonable within 30

days of receiving the dispute.

M. Delivery of Covered Services Using Telehealth.

If Your Participating Provider offers Covered Services using telehealth, We will not deny

the Covered Services because they are delivered using telehealth. Covered Services

delivered using telehealth may be subject to utilization review and quality assurance

requirements and other terms and conditions of the Certificate that are at least as

favorable as those requirements for the same service when not delivered using

telehealth. “Telehealth” means the use of electronic information and communication

technologies by a Provider to deliver Covered Services to You while Your location is

different than Your Provider’s location.

N. Early Intervention Program Services.

We will not exclude Covered Services solely because they are Early Intervention

Program services for infants and toddlers under three years of age who have a

confirmed disability or an established developmental delay. Additionally, if Early

Intervention Program services are otherwise covered under this Certificate, coverage

for Early Intervention Program services will not be applied against any maximum annual

or lifetime dollar limits if applicable. Visit limits and other terms and conditions will

continue to apply to coverage for Early Intervention Program services. However, any

visits used for Early Intervention Program services will not reduce the number of visits

otherwise available under this Certificate.

O. Case Management.

Case management helps coordinate services for Members with health care needs due

to serious, complex, and/or chronic health conditions. Our programs coordinate

benefits and educate Members who agree to take part in the case management

program to help meet their health-related needs.

Our case management programs are confidential and voluntary. These programs are

given at no extra cost to You and do not change Covered Services. If You meet

program criteria and agree to take part, We will help You meet Your identified health

care needs. This is reached through contact and teamwork with You and/or Your

authorized representative, treating Physician(s), and other Providers. In addition, We

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may assist in coordinating care with existing community-based programs and services

to meet Your needs, which may include giving You information about external agencies

and community-based programs and services.

In certain cases of severe or chronic illness or injury, We may provide benefits for

alternate care through Our case management program that is not listed as a Covered

Service. We may also extend Covered Services beyond the benefit maximums of this

Certificate. We will make Our decision on a case-by-case basis if We determine the

alternate or extended benefit is in the best interest of You and Us.

Nothing in this provision shall prevent You from appealing Our decision. A decision to

provide extended benefits or approve alternate care in one case does not obligate Us

to provide the same benefits again to You or to any other Member. We reserve the

right, at any time, to alter or stop providing extended benefits or approving alternate

care. In such case, We will notify You or Your representative in writing.

P. Important Telephone Numbers and Addresses.

• CLAIMS

Aetna Student Health

P.O. Box 981106

El Paso, TX 79998

(Submit claim forms to this address.)

• COMPLAINTS, GRIEVANCES AND UTILIZATION REVIEW APPEALS

Call the number on Your ID card

• ASSIGNMENT OF BENEFITS FORM

Refer to the address on Your ID card

(Submit assignment of benefits forms for surprise bills to this address.)

• MEMBER SERVICES

(800) 859-8475

(Member Services Representatives are available Monday - Friday, 8:30 a.m. –

5:30 p.m.)

• PREAUTHORIZATION

Call the number on Your ID card

• BEHAVIORAL HEALTH SERVICES

Call the number on Your ID card

• OUR WEBSITE

www.aetnastudenthealth.com or www.studenthealthbenefits.cornell.edu

CU2122-01

SECTION III

Access to Care and Transitional Care

A. Authorization to a Non-Participating Provider.

If We determine that We do not have a Participating Provider that has the appropriate

training and experience to treat Your condition, We will approve an authorization to an

appropriate Non-Participating Provider. Your Participating Provider or You must

request prior approval of the authorization to a specific Non-Participating Provider.

Approvals of authorizations to Non-Participating Providers will not be made for the

convenience of You or another treating Provider and may not necessarily be to the

specific Non-Participating Provider You requested. If We approve the authorization, all

services performed by the Non-Participating Provider are subject to a treatment plan

approved by Us in consultation with Your PCP or Student Health Services, the Non-

Participating Provider and You. Covered Services rendered by the Non-Participating

Provider will be covered as if they were provided by a Participating Provider. You will

be responsible only for any applicable in-network Cost-Sharing. In the event an

authorization is not approved, any services rendered by a Non-Participating Provider

will be Covered as an out-of-network benefit if available.

B. When Your Provider Leaves the Network.

If You are in an ongoing course of treatment when Your Provider leaves Our network,

then You may be able to continue to receive Covered Services for the ongoing

treatment from the former Participating Provider for up to 90 days from the date Your

Provider’s contractual obligation to provide services to You terminates. If You are

pregnant and in Your second or third trimester, You may be able to continue care with a

former Participating Provider through delivery and any postpartum care directly related

to the delivery.

In order for You to continue to receive Covered Services for up to 90 days or through a

pregnancy with a former Participating Provider, the Provider must agree to accept as

payment the negotiated fee that was in effect just prior to the termination of Our

relationship with the Provider. The Provider must also agree to provide Us necessary

medical information related to Your care and adhere to our policies and procedures,

including those for assuring quality of care, obtaining Preauthorization, authorizations,

and a treatment plan approved by Us. If the Provider agrees to these conditions, You

will receive the Covered Services as if they were being provided by a Participating

Provider. You will be responsible only for any applicable in-network Cost-Sharing.

Please note that if the Provider was terminated by Us due to fraud, imminent harm to

patients or final disciplinary action by a state board or agency that impairs the Provider’s

ability to practice, continued treatment with that Provider is not available.

C. New Members In a Course of Treatment.

If You are in an ongoing course of treatment with a Non-Participating Provider when

Your coverage under this Certificate becomes effective, You may be able to receive

Covered Services for the ongoing treatment from the Non-Participating Provider for up

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to 60 days from the effective date of Your coverage under this Certificate. This course

of treatment must be for a life-threatening disease or condition or a degenerative and

disabling condition or disease. You may also continue care with a Non-Participating

Provider if You are in the second or third trimester of a pregnancy when Your coverage

under this Certificate becomes effective. You may continue care through delivery and

any post-partum services directly related to the delivery.

In order for You to continue to receive Covered Services for up to 60 days or through

pregnancy, the Non-Participating Provider must agree to accept as payment Our fees

for such services. The Provider must also agree to provide Us necessary medical

information related to Your care and to adhere to Our policies and procedures including

those for assuring quality of care, obtaining Preauthorization, Referrals, and a treatment

plan approved by Us. If the Provider agrees to these conditions, You will receive the

Covered Services as if they were being provided by a Participating Provider. You will

be responsible only for any applicable in-network Cost-Sharing.

CU2122-01

SECTION IV

Cost-Sharing Expenses and Allowed Amount

A. Deductible.

Except where stated otherwise, You must pay the amount in the Schedule of Benefits

section of this Certificate for Covered out-of-network Services during each Plan Year

before We provide coverage. If You have other than individual coverage, the individual

Deductible applies to each person covered under this Certificate. Once a person within

a family meets the individual Deductible, no further Deductible is required for the person

that has met the individual Deductible for that Plan Year. However, after Deductible

payments for persons covered under this Certificate collectively total the family

Deductible amount in the Schedule of Benefits section of this Certificate in a Plan Year,

no further Deductible will be required for any person covered under this Certificate for

that Plan Year.

You have a separate In-Network and Out-of-Network Deductible. Cost-Sharing for out-

of-network services does not apply toward Your In-Network Deductible. Cost-Sharing

for in-network services does not apply toward Your Out-of-Network Deductible. Any

charges of a Non-Participating Provider that are in excess of the Allowed Amount

do not apply toward the Deductible.

There is no Deductible for Covered In-Network Services under this Certificate during

each Plan Year.

B. Copayments.

Except where stated otherwise, after You have satisfied the Deductible as described

above, You must pay the Copayments, or fixed amounts, in the Schedule of Benefits

section of this Certificate for Covered in-network and out-of-network Services.

However, when the Allowed Amount for a service is less than the Copayment, You are

responsible for the lesser amount.

C. Coinsurance.

Except where stated otherwise, after You have satisfied the Deductible described

above, You must pay a percentage of the Allowed Amount for Covered Services. We

will pay the remaining percentage of the Allowed Amount as Your in-network or out-of-

network benefit as shown in the Schedule of Benefits section of this Certificate. You

must also pay any charges of a Non-Participating Provider that are in excess of

the Allowed Amount.

D. In-Network Out-of-Pocket Limit.

When You have met Your In-Network Out-of-Pocket Limit in payment of In-Network

Copayments, Deductibles and Coinsurance for a Plan Year in the Schedule of Benefits

section of this Certificate, We will provide coverage for 100% of the Allowed Amount for

Covered in-network Services for the remainder of that Plan Year. If You have other

than individual coverage, once a person within a family meets the individual In-Network

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Out-of-Pocket Limit in the Schedule of Benefits section of this Certificate, We will

provide coverage for 100% of the Allowed Amount for the rest of that Plan Year for that

person. If other than individual coverage applies, when persons in the same family

covered under this Certificate have collectively met the family In-Network Out-of-Pocket

Limit in payment of In-Network Copayments, Deductibles and Coinsurance for a Plan

Year in the Schedule of Benefits section of this Certificate, We will provide coverage for

100% of the Allowed Amount for the rest of that Plan Year for the entire family.

Cost-Sharing for out-of-network services, except for Emergency Services, and out-of-

network services approved by Us as an in-network exception, does not apply toward

Your In-Network Out-of-Pocket Limit.

E. Out-of-Network Out-of-Pocket Limit.

This Certificate has a separate Out-of-Network Out-of-Pocket Limit in the Schedule of

Benefits section of this Certificate for out-of-network benefits. When You have met Your

Out-of-Network Out-of-Pocket Limit in payment of Out-of-Network Copayments,

Deductibles and Coinsurance for a Plan Year in the Schedule of Benefits section of this

Certificate, We will provide coverage for 100% of the Allowed Amount for Covered out-

of-network Services for the remainder of that Plan Year. If other than individual

coverage applies, when persons in the same family covered under this Certificate have

collectively met the family Out-of-Network Out-of-Pocket Limit in payment of Out-of-

Network Copayments, Deductibles and Coinsurance for a Plan Year in the Schedule of

Benefits section of this Certificate, We will provide coverage for 100% of the Allowed

Amount for Covered out-of-network Services for the rest of that Plan Year for the entire

family. Any charges of a Non-Participating Provider that are in excess of the

Allowed Amount do not apply toward Your Out-of-Network Out-of-Pocket Limit.

Cost-Sharing for in-network services does not apply toward Your Out-of-Network Out-

of-Pocket Limit.

F. Your Additional Payments for Out-of-Network Benefits.

When You receive Covered Services from a Non-Participating Provider, in addition to

the applicable Copayments, Deductibles and Coinsurance described in the Schedule of

Benefits section of this Certificate, You must also pay the amount, if any, by which the

Non-Participating Provider’s actual charge exceeds Our Allowed Amount. This means

that the total of Our coverage and any Cost-Sharing amounts You pay may be less than

the Non-Participating Provider’s actual charge.

When You receive Covered Services from a Non-Participating Provider, We will apply

nationally-recognized payment rules to the claim submitted for those services. These

rules evaluate the claim information and determine the accuracy of the procedure codes

and diagnosis codes for the services You received. Sometimes, applying these rules

will change the way that We pay for the services. This does not mean that the services

were not Medically Necessary. It only means that the claim should have been

submitted differently. For example, Your Provider may have billed using several

procedure codes when there is a single code that includes all of the separate

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procedures. We will make one (1) inclusive payment in that case rather than a separate

payment for each billed code. Another example of when We will apply the payment

rules to a claim is when You have surgery that involves two (2) surgeons acting as “co-

surgeons”. Under the payment rules, the claim from each Provider should have a

“modifier” on it that identifies it as coming from a co-surgeon. If We receive a claim that

does not have the correct modifier, We will change it and make the appropriate

payment.

G. Allowed Amount.

“Allowed Amount” means the maximum amount We will pay for the services or supplies

Covered under this Certificate, before any applicable Copayment, Deductible and

Coinsurance amounts are subtracted. We determine Our Allowed Amount as follows:

The Allowed Amount for Participating Providers will be the amount We have negotiated

with the Participating Provider.

Our payments to Participating Providers may include financial incentives to help

improve the quality or coordination of care and promote the delivery of Covered

Services in a cost-efficient manner. Payments under this financial incentive program are

not made as payment for a specific Covered Service provided to You. Your Cost-

Sharing will not change based on any payments made to or received from Participating

Providers as part of the financial incentive program.

The Allowed Amount for Non-Participating Providers will be determined as follows:

1. Facilities.

For Facilities the Allowed Amount will be a rate based on information provided by

a third-party vendor, which may reflect one (1) or more of the following factors: 1)

the complexity or severity of treatment; 2) level of skill and experience required

for the treatment; or 3) comparable Providers’ fees and costs to deliver care.

Our Allowed Amount for non-participating Facilities equates to approximately

70% of UCR. For this purpose, UCR is the FAIR Health rate at the 80

percentile.

2. For All Other Providers.

For all other Providers, the Allowed Amount will the Fair Health rate at the 80th

percentile.

For Durable Medical Equipment, a prosthetic device or implant, if there is no

code listed or source pricing, the Allowed Amount will be 1.3 times the

manufacturers’ invoice price.

3. Physician-Administered Pharmaceuticals.

For Physician-administered pharmaceuticals, We use gap methodologies that

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are similar to the pricing methodology used by the Centers for Medicare and

Medicaid Services, and produce fees based on published acquisition costs or

average wholesale price for the pharmaceuticals. These methodologies are

currently created by RJ Health Systems, Thomson Reuters (published in its Red

Book), or Us based on an internally developed pharmaceutical pricing resource if

the other methodologies have no pricing data available for a Physician-

administered pharmaceutical or special circumstances support an upward

adjustment to the other pricing methodology.

The Non-Participating Provider’s actual charge may exceed Our Allowed Amount.

You must pay the difference between Our Allowed Amount and the Non-

Participating Provider’s charge. Contact Us at the number on Your ID card for

information on Your financial responsibility when You receive services from a

Non-Participating Provider.

See the Emergency Services and Urgent Care section of this Certificate for the Allowed

Amount for Emergency Services rendered by Non-Participating Providers. See the

Ambulance and Pre-Hospital Emergency Medical Services section of this Certificate for

the Allowed Amount for Pre-Hospital Emergency Medical Services rendered by Non-

Participating Providers.

CU2122-01

SECTION V

Who is Covered

A. Who is Covered Under this Certificate.

You, the Student to whom this Certificate is issued, are covered under this Certificate.

Members of Your family may also be covered depending on the type of coverage You

selected.

B. Types of Coverage.

We offer the following types of coverage:

1. Student Coverage. Students enrolled and registered to a fulltime program, as

defined and reported by the Office of the University Registrar at Cornell University

or Weill Cornell Medical Registrar, including inabsentia students, are covered.

2. Student and Spouse. If You selected Student and Spouse coverage, then You

and Your Spouse are covered.

3. Student and Child/Children. If You selected parent and child/children coverage,

then You and Your Child or Children, as described below, are covered.

4. Student, Spouse and Child/Children. If You selected Student, Spouse and

Child/Children coverage, then You and Your Spouse and Your Child or Children,

as described below, are covered.

C. Children Covered Under this Certificate.

If You selected parent and child/children or family coverage, Children covered under

this Certificate include Your natural Children, legally adopted Children, step Children,

and Children for whom You are the proposed adoptive parent without regard to financial

dependence, residency with You, student status or employment. A proposed adopted

Child is eligible for coverage on the same basis as a natural Child during any waiting

period prior to the finalization of the Child’s adoption. Coverage lasts until the end of

the month in which the Child turns 30 years of age. Foster Children and grandchildren

are not covered.

Any unmarried dependent Child, regardless of age, who is incapable of self-sustaining

employment by reason of mental illness, developmental disability, mental retardation

(as defined in the New York Mental Hygiene Law), or physical handicap and who

became so incapable prior to attainment of the age at which the Child’s coverage would

otherwise terminate and who is chiefly dependent upon You for support and

maintenance, will remain covered while Your insurance remains in force and Your Child

remains in such condition. You have 31 days from the date of Your Child's attainment

of the termination age to submit an application to request that the Child be included in

Your coverage and proof of the Child’s incapacity. We have the right to check whether

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a Child is and continues to qualify under this section.

We have the right to request and be furnished with such proof as may be needed to

determine eligibility status of a prospective or covered Student and all other prospective

or covered Members in relation to eligibility for coverage under this Certificate at any

time.

D. When Coverage Begins.

Coverage under this Certificate will begin as follows:

1. If You, the Student, elect coverage before becoming eligible, or within 30 days of

becoming eligible for other than a special enrollment period, coverage begins on

the date You become eligible, or on the date determined by Us. We cannot

impose waiting periods that exceed 90 days.

2. If You, the Student, do not elect coverage upon becoming eligible or within 30

days of becoming eligible for other than a special enrollment period, and have

not provided proof of alternate coverage that meets Cornell’s waiver criteria via

the waiver process, You are automatically enrolled in the Student Health Plan.

3. If, You, the Student, do not elect coverage upon becoming eligible or within 30

days of becoming eligible for other than a special enrollment period, and have

provided alternate proof of insurance that meets Cornell’s waiver criteria, You

must wait until the next open enrollment period to enroll, except as provided

below.

4. For Dependents, You, the Student, must elect dependent coverage by

completing a dependent enrollment form upon becoming eligible or within 30

days of the plan year start date for other than a special enrollment period, You

must wait until the next open enrollment period to enroll, except as provided

below.

5. If You, the Student, marry while covered, and We receive notice of such marriage

and any Premium payment within 30 days thereafter, coverage for Your Spouse

and Child starts on the date We receive Your application. If We do not receive

notice within 30 days of the marriage, You must wait until the next open

enrollment period to add Your Spouse or Child.

6. If You, the Student, have a newborn or adopted newborn Child and We receive

notice of such birth within 30 days thereafter, coverage for Your newborn starts

at the moment of birth; otherwise, coverage begins on the date on which We

receive notice. Your adopted newborn Child will be covered from the moment of

birth if You take physical custody of the infant as soon as the infant is released

from the Hospital after birth and You file a petition pursuant to Section 115-c of

the New York Domestic Relations Law within 30 days of the infant’s birth; and

provided further that no notice of revocation to the adoption has been filed

pursuant to Section 115-b of the New York Domestic Relations Law, and consent

to the adoption has not been revoked. However, We will not provide Hospital

benefits for the adopted newborn’s initial Hospital stay if one of the infant’s

natural parents has coverage for the newborn’s initial Hospital stay. If You have

individual or individual and Spouse coverage, You must also notify Us of Your

desire to switch to parent and child/children or family coverage and pay any

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additional Premium within 30 days of the birth or adoption in order for coverage

to start at the moment of birth. Otherwise, coverage begins on the date on which

We receive notice, provided that You pay any additional Premium when due.

E. Special Enrollment Periods.

You, and Your Spouse or Child(ren) can also enroll for coverage within 30 days of the

loss of coverage in a health plan if coverage was terminated because You, Your

Spouse or Child(ren) are no longer eligible for coverage under the other health plan due

to:

1. Termination of employment;

2. Termination of the other health plan;

3. Death of the Spouse;

4. Legal separation, divorce or annulment;

5. Reduction of hours of employment;

6. Employer contributions toward a health plan were terminated for You or Your

Dependent’s Coverage; or

7. A Child no longer qualifies for coverage as a Child under another health plan.

You, and Your Spouse or Child(ren) can also enroll 30 days from exhaustion of Your

COBRA or continuation coverage or if You gain a Dependent or become a Dependent

through marriage, birth, adoption or placement for adoption.

We must receive notice and Premium payment within 30 days of one of these events.

Your coverage will begin on the first day of the following month after We receive Your

application. If You gain a Dependent or become a Dependent due to a birth, adoption,

or placement for adoption, Your coverage will begin on the date of the birth, adoption or

placement for adoption.

In addition, You, and Your Spouse or Child(ren) can also enroll for coverage within 60

days of the occurrence of one of the following event:

1. You, and Your Spouse or Child(ren) loses eligibility for Medicaid or Child Health

Plus; or

2. You, and Your Spouse or Child(ren) become eligible for Medicaid or Child Health

Plus.

We must receive notice and Premium payment within 60 days of one of these events.

The effective date of Your coverage will depend on when We receive your application.

Your coverage will be effective the day we receive your application or the first day of the

following month, whichever is earlier.

F. Domestic Partner Coverage.

This Certificate covers domestic partners of Students as Spouses. If You selected

Spouse coverage, Children covered under this Certificate also include the Children of

Your domestic partner. Proof of the domestic partnership and financial

interdependence must be submitted in the form of:

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1. Registration as a domestic partnership indicating that neither individual has been

registered as a member of another domestic partnership within the last six (6)

months, where such registry exists; or

2. For partners residing where registration does not exist, by;

a. An alternative affidavit of domestic partnership. The affidavit must be

notarized and must contain the following:

• The partners are both 18 years of age or older and are mentally

competent to consent to contract;

• The partners are not related by blood in a manner that would bar

marriage under laws of the State of New York;

• The partners have been living together on a continuous basis prior to

the date of the application;

• Neither individual has been registered as a member of another

domestic partnership within the last six (6) months; and

b. Proof of cohabitation (e.g., a driver’s license, tax return or other sufficient

proof); and

c. Proof that the partners are financially interdependent. Two (2) or more of the

following are collectively sufficient to establish financial interdependence:

• A joint bank account;

• A joint credit card or charge card;

• Joint obligation on a loan;

• Status as an authorized signatory on the partner’s bank account, credit

card or charge card;

• Joint ownership of holdings or investments;

• Joint ownership of residence;

• Joint ownership of real estate other than residence;

• Listing of both partners as tenants on the lease of the shared

residence;

• Shared rental payments of residence (need not be shared 50/50);

• Listing of both partners as tenants on a lease, or shared rental

payments, for property other than residence;

• A common household and shared household expenses, e.g., grocery

bills, utility bills, telephone bills, etc. (need not be shared 50/50);

• Shared household budget for purposes of receiving government

benefits;

• Status of one (1) as representative payee for the other’s government

benefits;

• Joint ownership of major items of personal property (e.g., appliances,

furniture);

• Joint ownership of a motor vehicle;

• Joint responsibility for child care (e.g., school documents,

guardianship);

• Shared child-care expenses, e.g., babysitting, day care, school bills

(need not be shared 50/50);

• Execution of wills naming each other as executor and/or beneficiary;

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• Designation as beneficiary under the other’s life insurance policy;

• Designation as beneficiary under the other’s retirement benefits

account;

• Mutual grant of durable power of attorney;

• Mutual grant of authority to make health care decisions (e.g., health

care power of attorney);

• Affidavit by creditor or other individual able to testify to partners’

financial interdependence; or

• Other item(s) of proof sufficient to establish economic interdependency

under the circumstances of the particular case.

CU2122-01

SECTION VI

Preventive Care

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits.

Preventive Care.

We Cover the following services for the purpose of promoting good health and early

detection of disease. Preventive services are not subject to Cost-Sharing (Copayments,

Deductibles or Coinsurance) when performed by a Participating Provider and provided

in accordance with the comprehensive guidelines supported by the Health Resources

and Services Administration (“HRSA”), or if the items or services have an “A” or “B”

rating from the United States Preventive Services Task Force (“USPSTF”), or if the

immunizations are recommended by the Advisory Committee on Immunization

Practices (“ACIP”). However, Cost-Sharing may apply to services provided during the

same visit as the preventive services. Also, if a preventive service is provided during an

office visit wherein the preventive service is not the primary purpose of the visit, the

Cost-Sharing amount that would otherwise apply to the office visit will still apply. You

may contact Us at (607) 255-6363, the number on Your ID card or visit Our website

www.aetnastudenthealth.com for a copy of the comprehensive guidelines supported by

HRSA, items or services with an “A” or “B” rating from USPSTF, and immunizations

recommended by ACIP.

A. Well-Baby and Well-Child Care. We Cover well-baby and well-child care which

consists of routine physical examinations including vision screenings and hearing

screenings, developmental assessment, anticipatory guidance, and laboratory

tests ordered at the time of the visit as recommended by the American Academy

of Pediatrics. We also Cover preventive care and screenings as provided for in

the comprehensive guidelines supported by HRSA and items or services with an

“A” or “B” rating from USPSTF. If the schedule of well-child visits referenced

above permits one (1) well-child visit per Plan Year, We will not deny a well-child

visit if 365 days have not passed since the previous well-child visit.

Immunizations and boosters as recommended by ACIP are also Covered. This

benefit is provided to Members from birth through attainment of age 19 and is not

subject to Copayments, Deductibles or Coinsurance when provided by a

Participating Provider.

B. Adult Annual Physical Examinations. We Cover adult annual physical

examinations and preventive care and screenings as provided for in the

comprehensive guidelines supported by HRSA and items or services with an “A”

or “B” rating from USPSTF.

Examples of items or services with an “A” or “B” rating from USPSTF include, but

are not limited to, blood pressure screening for adults, lung cancer screening,

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colorectal cancer screening, alcohol misuse screening, depression screening and

diabetes screening. A complete list of the Covered preventive Services is

available on Our website at www.aetnastudenthealth.com or will be mailed to

You upon request.

You are eligible for a physical examination once every Plan Year, regardless of

whether or not 365 days have passed since the previous physical examination

visit. Vision screenings do not include refractions.

This benefit is not subject to Copayments, Deductibles or Coinsurance when

provided in accordance with the comprehensive guidelines supported by HRSA

and items or services with an “A” or “B” rating from USPSTF and when provided

by a Participating Provider.

C. Adult Immunizations. We Cover adult immunizations as recommended by

ACIP. This benefit is not subject to Copayments, Deductibles or Coinsurance

when provided in accordance with the recommendations of ACIP and when

provided by a Participating Provider.

D. Well-Woman Examinations. We Cover well-woman examinations which

consist of a routine gynecological examination, breast examination and annual

screening for cervical cancer, including laboratory and diagnostic services in

connection with evaluating cervical cancer screening tests. We also Cover

preventive care and screenings as provided for in the comprehensive guidelines

supported by HRSA and items or services with an “A” or “B” rating from USPSTF.

A complete list of the Covered preventive Services is available on Our website

www.aetnastudenthealth.com, or will be mailed to You upon request. This

benefit is not subject to Copayments, Deductibles or Coinsurance when provided

in accordance with the comprehensive guidelines supported by HRSA and items

or services with an “A” or “B” rating from USPSTF, which may be less frequent

than described above, and when provided by a Participating Provider.

E. Mammograms, Screening and Diagnostic Imaging for the Detection of

Breast Cancer. We Cover mammograms, which may be provided by breast

tomosynthesis (i.e., 3D mammograms), for the screening of breast cancer as

follows:

• One (1) baseline screening mammogram for Member’s age 35 through 39;

• One (1) screening mammogram annually for Members age 40 and over.

If a Member of any age has a history of breast cancer or a first degree relative

has a history of breast cancer, We Cover mammograms as recommended by the

Member’s Provider. However, in no event will more than one (1) preventive

screening per Plan Year be Covered.

Mammograms for the screening of breast cancer are not subject to Copayments,

Deductibles or Coinsurance when provided by a Participating Provider.

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We also Cover additional screening and diagnostic imaging for the detection of

breast cancer, including diagnostic mammograms, breast ultrasounds and MRIs.

Screening and diagnostic imaging for the detection of breast cancer, including

diagnostic mammograms, breast ultrasounds and MRIs are not subject to

Copayments, Deductibles or Coinsurance when provided by a Participating

Provider.

F. Family Planning and Reproductive Health Services. We Cover family

planning services which consist of: FDA-approved contraceptive methods

prescribed by a Provider not otherwise Covered under the Prescription Drug

Coverage section of this Certificate, patient education and counseling on use of

contraceptives and related topics, follow-up services related to contraceptive

methods, including management of side effects, counseling for continued

adherence, and device insertion and removal; and sterilization procedures for

women. Such services are not subject to Copayments, Deductibles or

Coinsurance when provided by a Participating Provider.

We also Cover vasectomies subject to Copayments, Deductibles or Coinsurance.

We do not Cover services related to the reversal of elective sterilizations.

G. Bone Mineral Density Measurements or Testing. We Cover bone mineral

density measurements or tests, and Prescription Drugs and devices approved by

the FDA or generic equivalents as approved substitutes. Coverage of

Prescription Drugs is subject to the Prescription Drug Coverage section of this

Certificate. Bone mineral density measurements or tests, drugs or devices shall

include those covered under the federal Medicare program or those in

accordance with the criteria of the National Institutes of Health. You will also

qualify for Coverage if You meet the criteria under the federal Medicare program

or the National Institutes of Health or if You meet any of the following:

• Previously diagnosed as having osteoporosis or having a family history of

osteoporosis;

• With symptoms or conditions indicative of the presence or significant risk

of osteoporosis;

• On a prescribed drug regimen posing a significant risk of osteoporosis;

• With lifestyle factors to a degree as posing a significant risk of

osteoporosis; or

• With such age, gender, and/or other physiological characteristics which

pose a significant risk for osteoporosis.

We also Cover osteoporosis screening as provided for in the comprehensive

guidelines supported by HRSA and items or services with an “A” or “B” rating

from USPSTF.

This benefit is not subject to Copayments, Deductibles or Coinsurance when

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provided in accordance with the comprehensive guidelines supported by HRSA

and items or services with an “A” or “B” rating from USPSTF, which may not

include all of the above services such as drugs and devices and when provided

by a Participating Provider.

H. Screening for Prostate Cancer. We Cover an annual standard diagnostic

examination including, but not limited to, a digital rectal examination and a

prostate specific antigen test for men age 50 and over who are asymptomatic

and for men age 40 and over with a family history of prostate cancer or other

prostate cancer risk factors. We also Cover standard diagnostic testing

including, but not limited to, a digital rectal examination and a prostate-specific

antigen test, at any age for men having a prior history of prostate cancer.

This benefit is not subject to Copayments, Deductibles or Coinsurance when

provided by a Participating Provider.

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SECTION VII

Ambulance and Pre-Hospital Emergency Medical Services

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits. Pre-Hospital Emergency Medical Services and ambulance

services for the treatment of an Emergency Condition do not require Preauthorization.

A. Emergency Ambulance Transportation.

1. Pre-Hospital Emergency Medical Services. We Cover Pre-Hospital

Emergency Medical Services worldwide for the treatment of an Emergency

Condition when such services are provided by an ambulance service.

“Pre-Hospital Emergency Medical Services” means the prompt evaluation and

treatment of an Emergency Condition and/or non-airborne transportation to a

Hospital. The services must be provided by an ambulance service issued a

certificate under the New York Public Health Law. We will, however, only Cover

transportation to a Hospital provided by such an ambulance service when a

prudent layperson, possessing an average knowledge of medicine and health,

could reasonably expect the absence of such transportation to result in:

• Placing the health of the person afflicted with such condition or, with respect to

a pregnant woman, the health of the woman or her unborn child in serious

jeopardy, or in the case of a behavioral condition, placing the health of such

person or others in serious jeopardy;

• Serious impairment to such person’s bodily functions;

• Serious dysfunction of any bodily organ or part of such person; or

• Serious disfigurement of such person.

An ambulance service must hold You harmless and may not charge or seek

reimbursement from You for Pre-Hospital Emergency Medical Services except

for the collection of any applicable Copayment, Deductible or Coinsurance.

In the absence of negotiated rates, We will pay a Non-Participating Provider the

usual and customary charge for Pre-Hospital Emergency Medical Services,

which shall not be excessive or unreasonable. The usual and customary charge

for Pre-Hospital Emergency Medical Services is the lesser of the FAIR Health

rate at the 80th percentile or the Provider’s billed charges.

2. Emergency Ambulance Transportation. In addition to Pre-Hospital Emergency

Medical Services, We also Cover emergency ambulance transportation

worldwide by a licensed ambulance service (either ground, water or air

ambulance) to the nearest Hospital where Emergency Services can be

performed. This coverage includes emergency ambulance transportation to a

Hospital when the originating Facility does not have the ability to treat Your

Emergency Condition.

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B. Non-Emergency Ambulance Transportation.

We Cover non-emergency ambulance transportation by a licensed ambulance

service (either ground or air ambulance, as appropriate) between Facilities when the

transport is any of the following:

• From a non-participating Hospital to a participating Hospital;

• To a Hospital that provides a higher level of care that was not available at the

original Hospital;

• To a more cost-effective Acute care Facility; or

• From an Acute care Facility to a sub-Acute setting.

C. Limitations/Terms of Coverage.

• We do not Cover travel or transportation expenses, unless connected to an

Emergency Condition or due to a Facility transfer approved by Us, even though

prescribed by a Physician.

• We do not Cover non-ambulance transportation such as ambulette, van or

taxicab.

• Coverage for air ambulance related to an Emergency Condition or air ambulance

related to non-emergency transportation is provided when Your medical condition

is such that transportation by land ambulance is not appropriate; and Your

medical condition requires immediate and rapid ambulance transportation that

cannot be provided by land ambulance; and one (1) of the following is met:

o The point of pick-up is inaccessible by land vehicle; or

o Great distances or other obstacles (e.g., heavy traffic) prevent Your timely

transfer to the nearest Hospital with appropriate facilities.

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SECTION VIII

Emergency Services and Urgent Care

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits.

A. Emergency Services.

We Cover Emergency Services for the treatment of an Emergency Condition in a

Hospital.

We define an “Emergency Condition” to mean: A medical or behavioral condition that

manifests itself by Acute symptoms of sufficient severity, including severe pain, such

that a prudent layperson, possessing an average knowledge of medicine and health,

could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the person afflicted with such condition or, with respect to a

pregnant woman, the health of the woman or her unborn child in serious

jeopardy, or in the case of a behavioral condition, placing the health of such

person or others in serious jeopardy;

• Serious impairment to such person’s bodily functions;

• Serious dysfunction of any bodily organ or part of such person; or

• Serious disfigurement of such person.

For example, an Emergency Condition may include, but is not limited to, the following

conditions:

• Severe chest pain

• Severe or multiple injuries

• Severe shortness of breath

• Sudden change in mental status (e.g., disorientation)

• Severe bleeding

• Acute pain or conditions requiring immediate attention such as suspected heart

attack or appendicitis

• Poisonings

• Convulsions

Coverage of Emergency Services for treatment of Your Emergency Condition will be

provided regardless of whether the Provider is a Participating Provider. We will also

Cover Emergency Services to treat Your Emergency Condition worldwide. However,

We will Cover only those Emergency Services and supplies that are Medically

Necessary and are performed to treat or stabilize Your Emergency Condition in a

Hospital.

Please follow the instructions listed below regardless of whether or not You are in Our

Service Area at the time Your Emergency Condition occurs:

1. Hospital Emergency Department Visits. In the event that You require

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treatment for an Emergency Condition, seek immediate care at the nearest

Hospital emergency department or call 911. Emergency Department Care does

not require Preauthorization. However, only Emergency Services for the

treatment of an Emergency Condition are Covered in an emergency

department. If You are uncertain whether a Hospital emergency department is

the most appropriate place to receive care, You can call Us before You seek

treatment.

We do not Cover follow-up care or routine care provided in a Hospital

emergency department.

2. Emergency Hospital Admissions.

We cover inpatient Hospital services following Emergency Department Care at a

non-participating Hospital at the in-network Cost-Sharing. If Your medical

condition permits Your transfer to a participating Hospital, We will notify You and

work with You to arrange the transfer.

3. Payments Relating to Emergency Services Rendered. The amount We pay a

Non-Participating Provider for Emergency Services will be the amount We have

negotiated with the Non-Participating Provider for the Emergency Service or an

amount We have determined is reasonable for the Emergency Service.

However, the negotiated amount or the amount We determine is reasonable will

not exceed the Non-Participating Provider’s charge and will be at least the

greater of: 1) the amount We have negotiated with Participating Providers for the

Emergency Service (and if more than one amount is negotiated, the median of

the amounts); 2) 100% of the Allowed Amount for services provided by a Non-

Participating Provider (i.e., the amount We would pay in the absence of any

Cost-Sharing that would otherwise apply for services of Non-Participating

Providers); or 3) the amount that would be paid under Medicare.

If a dispute involving a payment for physician or Hospital services is submitted to

an independent dispute resolution entity (“IDRE”), We will pay the amount, if any,

determined by the IDRE for physician or Hospital services.

You are responsible for any in-network Copayment, Deductible or Coinsurance.

You will be held harmless for any Non-Participating Provider charges that exceed

Your Copayment, Deductible or Coinsurance. Additionally, if You assign benefits

to a Non-Participating Provider in writing, the Non-Participating Provider may

only bill You for Your In-Network Copayment, Deductible or Coinsurance. If You

receive a bill from a Non-Participating Provider that is more than Your In-Network

Copayment, Deductible, or Coinsurance, You should contact Us.

B. Urgent Care.

Urgent Care is medical care for an illness, injury or condition serious enough that a

reasonable person would seek care right away, but not so severe as to require

Emergency Department Care. Urgent Care is typically available after normal business

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hours, including evenings and weekends. If You need care after normal business

hours, including evenings, weekends or holidays, You have options. You can call Your

Student Health Services, if applicable, Your Provider’s office for instructions or visit an

Urgent Care Center. If You have an Emergency Condition, seek immediate care at the

nearest Hospital emergency department or call 911. Urgent Care is Covered in or out

of Our Service Area.

1. In-Network. We Cover Urgent Care from a participating Physician or a

participating Urgent Care Center.

2. Out-of-Network. We Cover Urgent Care from a non-participating Urgent Care

Center or Physician. However, You must obtain Preauthorization from Us for

services to be covered at the in-network Cost-Sharing. Please contact Us at the

number on Your ID card and You will be provided with instructions. We are

available 24 hours a day, seven (7) days a week to help You in urgent medical

situations.

If Urgent Care results in an emergency admission, please follow the instructions

for Emergency Hospital Admissions described above.

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SECTION IX

Outpatient and Professional Services

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits.

A. Acupuncture.

We Cover acupuncture services rendered by a Health Care Professional licensed to

provide such services.

• Chronic (minimum 12 weeks duration) neck pain; or

• Chronic (minimum 12 weeks duration) headache; or

• Low back pain; or

• Nausea of pregnancy; or

• Pain from osteoarthritis of the knee or hip (adjunctive therapy); or

• Post-operative and chemotherapy-induced nausea and vomiting; or

• Post-operative dental pain; or

• Temporomandibular disorders (TMD).

B. Advanced Imaging Services.

We Cover PET scans, MRI, nuclear medicine, and CAT scans.

C. Allergy Testing and Treatment.

We Cover testing and evaluations including injections, and scratch and prick tests to

determine the existence of an allergy. We also Cover allergy treatment, including

desensitization treatments, routine allergy injections and serums.

D. Ambulatory Surgical Center Services.

We Cover surgical procedures performed at Ambulatory Surgical Centers including

services and supplies provided by the center the day the surgery is performed.

E. Chemotherapy and Immunotherapy.

We Cover chemotherapy and immunotherapy in an outpatient Facility or in a Health

Care Professional’s office. Chemotherapy and immune therapy may be administered

by injection or infusion. Orally-administered anti-cancer drugs are Covered under the

Prescription Drug Coverage section of this Certificate.

F. Chiropractic Services.

We Cover chiropractic care when performed by a Doctor of Chiropractic (“chiropractor”)

or a Physician in connection with the detection or correction by manual or mechanical

means of structural imbalance, distortion or subluxation in the human body for the

purpose of removing nerve interference and the effects thereof, where such interference

is the result of or related to distortion, misalignment or subluxation of the vertebral

column. This includes assessment, manipulation and any modalities. Any laboratory

tests will be Covered in accordance with the terms and conditions of this Certificate.

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G. Clinical Trials.

We Cover the routine patient costs for Your participation in an approved clinical trial and

such coverage shall not be subject to Utilization Review if You are:

• Eligible to participate in an approved clinical trial to treat either cancer or other

life-threatening disease or condition; and

• Referred by a Participating Provider who has concluded that Your participation in

the approved clinical trial would be appropriate.

All other clinical trials, including when You do not have cancer or other life-threatening

disease or condition, may be subject to the Utilization Review and External Appeal

sections of this Certificate.

We do not Cover: the costs of the investigational drugs or devices; the costs of non-

health services required for You to receive the treatment; the costs of managing the

research; or costs that would not be covered under this Certificate for non-

investigational treatments provided in the clinical trial.

An “approved clinical trial” means a phase I, II III, or IV clinical trial that is:

• A federally funded or approved trial;

• Conducted under an investigational drug application reviewed by the federal

Food and Drug Administration; or

• A drug trial that is exempt from having to make an investigational new drug

application.

H. Dialysis.

We Cover dialysis treatments of an Acute or chronic kidney ailment.

I. Habilitation Services.

We Cover Habilitation Services consisting of physical therapy, speech therapy and

occupational therapy in the outpatient department of a Facility or in a Health Care

Professional’s office for up to 60 visits per condition per Plan Year. The visit limit

applies to all therapies combined. For the purposes of this benefit, "per condition"

means the disease or injury causing the need for the therapy.

J. Home Health Care.

We Cover care provided in Your home by a Home Health Agency certified or licensed

by the appropriate state agency. The care must be provided pursuant to Your

Physician's written treatment plan and must be in lieu of Hospitalization or confinement

in a Skilled Nursing Facility. Home care includes:

• Part-time or intermittent nursing care by or under the supervision of a registered

professional nurse;

• Part-time or intermittent services of a home health aide;

• Physical, occupational or speech therapy provided by the Home Health Agency;

and

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• Medical supplies, Prescription Drugs and medications prescribed by a Physician,

and laboratory services by or on behalf of the Home Health Agency to the extent

such items would have been Covered during a Hospitalization or confinement in

a Skilled Nursing Facility.

Home Health Care is limited to 40 visits per Plan Year. Each visit by a member of the

Home Health Agency is considered one (1) visit. Each visit of up to four (4) hours by a

home health aide is considered one (1) visit. Any Rehabilitation or Habilitation Services

received under this benefit will not reduce the amount of services available under the

Rehabilitation or Habilitation Services benefits.

K. Infertility Treatment.

We Cover services for the diagnosis and treatment (surgical and medical) of infertility.

“Infertility” is a disease or condition characterized by the incapacity to impregnate

another person or to conceive, defined by the failure to establish a clinical pregnancy

after 12 months of regular, unprotected sexual intercourse or therapeutic donor

insemination, or after six (6) months of regular, unprotected sexual intercourse or

therapeutic donor insemination for a female 35 years of age or older. Earlier evaluation

and treatment may be warranted based on a Member’s medical history or physical

findings.

Such Coverage is available as follows:

1. Basic Infertility Services. Basic infertility services will be provided to a Member

who is an appropriate candidate for infertility treatment. In order to determine

eligibility, We will use guidelines established by the American College of

Obstetricians and Gynecologists, the American Society for Reproductive

Medicine, and the State of New York.

Basic infertility services include:

• Initial evaluation;

• Semen analysis;

• Laboratory evaluation;

• Evaluation of ovulatory function;

• Postcoital test;

• Endometrial biopsy;

• Pelvic ultrasound;

• Hysterosalpingogram;

• Sono-hystogram;

• Testis biopsy;

• Blood tests; and

• Medically appropriate treatment of ovulatory dysfunction.

Additional tests may be Covered if the tests are determined to be Medically

Necessary.

2. Comprehensive Infertility Services. If the basic infertility services do not result

in increased fertility, We Cover comprehensive infertility services.

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Comprehensive infertility services include:

• Ovulation induction and monitoring;

• Pelvic ultrasound;

• Artificial insemination;

• Hysteroscopy;

• Laparoscopy; and

• Laparotomy.

3. Fertility Preservation Services. We Cover standard fertility preservation

services when a medical treatment will directly or indirectly lead to iatrogenic

infertility. Standard fertility preservation services include the collecting,

preserving, and storing of ova and sperm. “Iatrogenic infertility” means an

impairment of Your fertility by surgery, radiation, chemotherapy or other medical

treatment affecting reproductive organs or processes.

4. Exclusions and Limitations. We do not Cover:

• In vitro fertilization;

• Gamete intrafallopian tube transfers or zygote intrafallopian tube transfers;

• Costs associated with an ovum or sperm donor, including the donor’s

medical expenses;

• Cryopreservation and storage of sperm and ova except when performed

as fertility preservation services;

• Cryopreservation and storage of embryos;

• Ovulation predictor kits;

• Reversal of tubal ligations;

• Reversal of vasectomies;

• Costs for and relating to surrogate motherhood (maternity services are

Covered for Members acting as surrogate mothers);

• Cloning; or

• Medical and surgical procedures that are experimental or investigational,

unless Our denial is overturned by an External Appeal Agent.

All services must be provided by Providers who are qualified to provide such

services in accordance with the guidelines established and adopted by the

American Society for Reproductive Medicine. We will not discriminate based on

Your expected length of life, present or predicted disability, degree of medical

dependency, perceived quality of life, other health conditions, or based on

personal characteristics including age, sex, sexual orientation, marital status or

gender identity, when determining coverage under this benefit.

L. Infusion Therapy.

We Cover infusion therapy which is the administration of drugs using specialized

delivery systems. Drugs or nutrients administered directly into the veins are considered

infusion therapy. Drugs taken by mouth or self-injected are not considered infusion

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therapy. The services must be ordered by a Physician or other authorized Health Care

Professional and provided in an office or by an agency licensed or certified to provide

infusion therapy. Any visits for home infusion therapy count toward Your home health

care visit limit.

M. Interruption of Pregnancy.

We Cover medically necessary abortions including abortions in cases of rape, incest or

fetal malformation. We Cover elective abortions.

N. Laboratory Procedures, Diagnostic Testing and Radiology Services.

We Cover x-ray, laboratory procedures and diagnostic testing, services and materials,

including diagnostic x-rays, x-ray therapy, fluoroscopy, electrocardiograms,

electroencephalograms, laboratory tests, and therapeutic radiology services.

O. Maternity and Newborn Care.

We Cover services for maternity care provided by a Physician or midwife, nurse

practitioner, Hospital or birthing center. We Cover prenatal care (including one (1) visit

for genetic testing), postnatal care, delivery, and complications of pregnancy. In order

for services of a midwife to be Covered, the midwife must be licensed pursuant to

Article 140 of the New York Education Law, practicing consistent with Section 6951 of

the New York Education Law and affiliated or practicing in conjunction with a Facility

licensed pursuant to Article 28 of the New York Public Health Law. We will not pay for

duplicative routine services provided by both a midwife and a Physician. See the

Inpatient Services section of this Certificate for Coverage of inpatient maternity care.

We Cover breastfeeding support, counseling and supplies, including the cost of renting

or the purchase of one (1) breast pump per pregnancy for the duration of breast feeding

from a Participating Provider or designated vendor.

P. Office Visits.

We Cover office visits for the diagnosis and treatment of injury, disease and medical

conditions. Office visits may include house calls.

Q. Outpatient Hospital Services.

We Cover Hospital services and supplies as described in the Inpatient Services section

of this Certificate that can be provided to You while being treated in an outpatient

Facility. For example, Covered Services include but are not limited to inhalation

therapy, pulmonary rehabilitation, infusion therapy and cardiac rehabilitation.

R. Preadmission Testing.

We Cover preadmission testing ordered by Your Physician and performed in Hospital

outpatient Facilities prior to a scheduled surgery in the same Hospital provided that:

• The tests are necessary for and consistent with the diagnosis and treatment of

the condition for which the surgery is to be performed;

• Reservations for a Hospital bed and operating room were made prior to the

performance of the tests;

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• Surgery takes place within seven (7) days of the tests; and

• The patient is physically present at the Hospital for the tests.

S. Prescription Drugs for Use in the Office and Outpatient Facilities.

We Cover Prescription Drugs (excluding self-injectable drugs) used by Your Provider in

the Provider’s office and Outpatient Facility for preventive and therapeutic purposes.

This benefit applies when Your Provider orders the Prescription Drug and administers it

to You. When Prescription Drugs are Covered under this benefit, they will not be

Covered under the Prescription Drug Coverage section of this Certificate.

T. Retail Health Clinics.

We Cover basic health care services provided to You on a “walk-in” basis at retail health

clinics, normally found in major pharmacies or retail stores. Covered Services are

typically provided by a physician’s assistant or nurse practitioner. Covered Services

available at retail health clinics are limited to routine care and treatment of common

illnesses.

U. Rehabilitation Services.

We Cover Rehabilitation Services consisting of physical therapy, speech therapy and

occupational therapy in the outpatient department of a Facility or in a Health Care

Professional’s office for up to 60 visits per condition per Plan Year. The visit limit

applies to all therapies combined. For the purposes of this benefit, "per condition"

means the disease or injury causing the need for the therapy.

We Cover speech and physical therapy only when:

• Such therapy is related to the treatment or diagnosis of Your illness or injury (in

the case of a covered Child, this includes a medically diagnosed congenital

defect);

• The therapy is ordered by a Physician; and

• You have been hospitalized or have undergone surgery for such illness or injury.

Covered Rehabilitation Services must begin within six (6) months of the later to occur:

• The date of the injury or illness that caused the need for the therapy;

• The date You are discharged from a Hospital where surgical treatment was

rendered; or

• The date outpatient surgical care is rendered.

V. Second Opinions.

1. Second Cancer Opinion. We Cover a second medical opinion by an

appropriate Specialist, including but not limited to a Specialist affiliated with a

specialty care center, in the event of a positive or negative diagnosis of cancer or

a recurrence of cancer or a recommendation of a course of treatment for cancer.

You may obtain a second opinion from a Non-Participating Provider on an in-

network basis.

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2. Second Surgical Opinion. We Cover a second surgical opinion by a qualified

Physician on the need for surgery.

3. Second Opinions in Other Cases. There may be other instances when You

will disagree with a Provider's recommended course of treatment. In such cases,

You may request that we designate another Provider to render a second opinion.

If the first and second opinions do not agree, We will designate another Provider

to render a third opinion. After completion of the second opinion process, We will

approve Covered Services supported by a majority of the Providers reviewing

Your case.

W. Surgical Services.

We Cover Physicians' services for surgical procedures, including operating and cutting

procedures for the treatment of a sickness or injury, and closed reduction of fractures

and dislocations of bones, endoscopies, incisions, or punctures of the skin on an

inpatient and outpatient basis, including the services of the surgeon or Specialist,

assistant (including a Physician’s assistant or a nurse practitioner), and anesthetist or

anesthesiologist, together with preoperative and post-operative care. Benefits are not

available for anesthesia services provided as part of a surgical procedure when

rendered by the surgeon or the surgeon’s assistant.

Sometimes two (2) or more surgical procedures can be performed during the same

operation.

1. Through the Same Incision. If Covered multiple surgical procedures are

performed through the same incision, We will pay for the procedure with the

highest Allowed Amount and 50% of the amount We would otherwise pay under

this Certificate for the secondary procedures, except for secondary procedures

that, according to nationally-recognized coding rules, are exempt from multiple

surgical procedure reductions. We will not pay anything for a secondary

procedure that is billed with a primary procedure when that secondary procedure

is incidental to the primary procedure.

2. Through Different Incisions. If Covered multiple surgical procedures are

performed during the same operative session but through different incisions, We

will pay:

• For the procedure with the highest Allowed Amount; and

• 50% of the amount We would otherwise pay for the other procedures.

X. Oral Surgery.

We Cover the following limited dental and oral surgical procedures:

• Oral surgical procedures for jaw bones or surrounding tissue and dental services

for the repair or replacement of sound natural teeth that are required due to

accidental injury. Replacement is Covered only when repair is not possible.

Dental services must be obtained within 12 months of the injury.

• Oral surgical procedures for jaw bones or surrounding tissue and dental services

necessary due to congenital disease or anomaly.

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• Oral surgical procedures required for the correction of a non-dental physiological

condition which has resulted in a severe functional impairment.

• Removal of tumors and cysts requiring pathological examination of the jaws,

cheeks, lips, tongue, roof and floor of the mouth. Cysts related to teeth are not

Covered.

• Surgical/nonsurgical medical procedures for temporomandibular joint disorders

and orthognathic surgery.

Y. Reconstructive Breast Surgery.

We Cover breast reconstruction surgery after a mastectomy or partial mastectomy.

Coverage includes: all stages of reconstruction of the breast on which the mastectomy

or partial mastectomy has been performed; surgery and reconstruction of the other

breast to produce a symmetrical appearance; and physical complications of the

mastectomy or partial mastectomy, including lymphedemas, in a manner determined by

You and Your attending Physician to be appropriate. We also Cover implanted breast

prostheses following a mastectomy or partial mastectomy.

Z. Other Reconstructive and Corrective Surgery.

We Cover reconstructive and corrective surgery other than reconstructive breast

surgery only when it is:

• Performed to correct a congenital birth defect of a covered Child which has

resulted in a functional defect;

• Incidental to surgery or follows surgery that was necessitated by trauma,

infection or disease of the involved part; or

• Otherwise Medically Necessary.

AA. Telemedicine Program.

In addition to providing Covered Services via telehealth, We Cover online internet

consultations between You and Providers who participate in Our telemedicine program

for medical conditions that are not an Emergency Condition. Not all Participating

Providers participate in Our telemedicine program. You can check Our Provider

directory or contact Us for a listing of the Providers that participate in Our telemedicine

program.

Teladoc is a highly affordable, more convenient and timelier alternative to Emergency

Room (ER) and Urgent Care (UC) center visits for non-emergency medical care. Using

Teladoc can be extremely convenient by preventing the need to arrange for

transportation or travel, childcare, and time off from work just to visit a doctor! Note that

Teladoc is not designed to replace a Primary Care Physician (PCP) relationship, but

rather supplement a member's access to care as an additional and more efficient

option.

Teladoc offers members the ability to consult with a national network of U.S. board-

certified family practitioners, PCPs, pediatricians and internists to diagnose, recommend

treatment, and write short-term (non-DEA prescriptions), when necessary.

Consultations are available by telephone as well as by online video using Teladoc.com

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or through the Teladoc Member mobile app. Teladoc can provide effective resolution to

a wide range of common and routine illnesses helping prevent unnecessary use of the

ER or Urgent Care centers.

Some of the more common illnesses that Teladoc handles are as follows:

• Allergies

• Basic Dermatological issues

• (Episodic) Behavioral Health needs (such as Anxiety, Panic Attacks and

Depression)

• Bronchitis

• Cough

• Ear infection

• Flu

• Nasal congestion

• Pink eye

• Sinus problems

• Upper respiratory infection

• Urinary tract infection

Note: No controlled substances, psychiatric or lifestyle drugs will be prescribed by

Teladoc

Teladoc is available 24 hours a day, 7 days a week:

www.teladoc.com

1-800-835-2362

BB. Transplants.

We Cover only those transplants determined to be non-experimental and non-

investigational. Covered transplants include but are not limited to: kidney, corneal, liver,

heart, and heart/lung transplants; and bone marrow transplants for aplastic anemia,

leukemia, severe combined immunodeficiency disease and Wiskott-Aldrich Syndrome.

All transplants must be prescribed by Your Specialist(s). Additionally, all

transplants must be performed at Hospitals that We have specifically approved

and designated to perform these procedures.

We Cover the Hospital and medical expenses, including donor search fees, of the

Member-recipient. We Cover transplant services required by You when You serve as

an organ donor only if the recipient is a Member. We do not Cover the medical

expenses of a non-Member acting as a donor for You if the non-Member's expenses will

be Covered under another health plan or program.

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We do not Cover: travel expenses, lodging, meals, or other accommodations for donors

or guests; donor fees in connection with organ transplant surgery; or routine harvesting

and storage of stem cells from newborn cord blood.

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SECTION X

Additional Benefits, Equipment and Devices

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits.

A. Autism Spectrum Disorder.

We Cover the following services when such services are prescribed or ordered by a

licensed Physician or a licensed psychologist and are determined by Us to be Medically

Necessary for the screening, diagnosis, and treatment of autism spectrum disorder. For

purposes of this benefit, “autism spectrum disorder” means any pervasive

developmental disorder defined in the most recent edition of the Diagnostic and

Statistical Manual of Mental Disorders at the time services are rendered.

1. Screening and Diagnosis. We Cover assessments, evaluations, and tests to

determine whether someone has autism spectrum disorder.

2. Assistive Communication Devices. We Cover a formal evaluation by a

speech-language pathologist to determine the need for an assistive

communication device. Based on the formal evaluation, We Cover the rental or

purchase of assistive communication devices when ordered or prescribed by a

licensed Physician or a licensed psychologist if You are unable to communicate

through normal means (i.e., speech or writing) when the evaluation indicates that

an assistive communication device is likely to provide You with improved

communication. Examples of assistive communication devices include

communication boards and speech-generating devices. Coverage is limited to

dedicated devices. We will only Cover devices that generally are not useful to a

person in the absence of a communication impairment. We do not Cover items,

such as, but not limited to, laptop, desktop, or tablet computers. We Cover

software and/or applications that enable a laptop, desktop, or tablet computer to

function as a speech-generating device. Installation of the program and/or

technical support is not separately reimbursable. We will determine whether the

device should be purchased or rented.

We Cover repair, replacement fitting and adjustments of such devices when

made necessary by normal wear and tear or significant change in Your physical

condition. We do not Cover the cost of repair or replacement made necessary

because of loss or damage caused by misuse, mistreatment, or theft; however,

We Cover one (1) repair or replacement per device type that is necessary due to

behavioral issues. Coverage will be provided for the device most appropriate to

Your current functional level. We do not Cover delivery or service charges or

routine maintenance.

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3. Behavioral Health Treatment. We Cover counseling and treatment programs

that are necessary to develop, maintain, or restore, to the maximum extent

practicable, the functioning of an individual. We will provide such Coverage

when provided by a licensed Provider. We Cover applied behavior analysis

when provided by a licensed or certified applied behavior analysis Health Care

Professional. “Applied behavior analysis” means the design, implementation,

and evaluation of environmental modifications, using behavioral stimuli and

consequences, to produce socially significant improvement in human behavior,

including the use of direct observation, measurement, and functional analysis of

the relationship between environment and behavior. The treatment program

must describe measurable goals that address the condition and functional

impairments for which the intervention is to be applied and include goals from an

initial assessment and subsequent interim assessments over the duration of the

intervention in objective and measurable terms.

4. Psychiatric and Psychological Care. We Cover direct or consultative services

provided by a psychiatrist, psychologist or a licensed clinical social worker with

the experience required by the New York Insurance Law, licensed in the state in

which they are practicing.

5. Therapeutic Care. We Cover therapeutic services necessary to develop,

maintain, or restore, to the greatest extent practicable, functioning of the

individual when such services are provided by licensed or certified speech

therapists, occupational therapists, physical therapists and social workers to treat

autism spectrum disorder and when the services provided by such Providers are

otherwise Covered under this Certificate. Except as otherwise prohibited by law,

services provided under this paragraph shall be included in any visit maximums

applicable to services of such therapists or social workers under this Certificate.

6. Pharmacy Care. We Cover Prescription Drugs to treat autism spectrum disorder

that are prescribed by a Provider legally authorized to prescribe under Title 8 of

the New York Education Law. Coverage of such Prescription Drugs is subject to

all the terms, provisions, and limitations that apply to Prescription Drug benefits

under this Certificate.

7. Limitations. We do not Cover any services or treatment set forth above when

such services or treatment are provided pursuant to an individualized education

plan under the New York Education Law. The provision of services pursuant to

an individualized family service plan under Section 2545 of the New York Public

Health Law, an individualized education plan under Article 89 of the New York

Education Law, or an individualized service plan pursuant to regulations of the

New York State Office for People With Developmental Disabilities shall not affect

coverage under this Certificate for services provided on a supplemental basis

outside of an educational setting if such services are prescribed by a licensed

Physician or licensed psychologist.

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You are responsible for any applicable Copayment, Deductible or Coinsurance

provisions under this Certificate for similar services. For example, any

Copayment, Deductible or Coinsurance that applies to physical therapy visits will

generally also apply to physical therapy services Covered under this benefit; and

any Copayment, Deductible or Coinsurance for Prescription Drugs will generally

also apply to Prescription Drugs Covered under this benefit. See the Schedule of

Benefits section of this Certificate for the Cost-Sharing requirements that apply to

applied behavior analysis services and assistive communication devices.

Nothing in this Certificate shall be construed to affect any obligation to provide

coverage for otherwise-Covered Services solely on the basis that the services

constitute early intervention program services pursuant to Section 3235-a of the

New York Insurance Law or an individualized service plan pursuant to

regulations of the New York State Office for People With Developmental

Disabilities.

B. Diabetic Equipment, Supplies and Self-Management Education.

We Cover diabetic equipment, supplies, and self-management education if

recommended or prescribed by a Physician or other licensed Health Care Professional

legally authorized to prescribe under Title 8 of the New York Education Law as

described below:

1. Equipment and Supplies.

We Cover the following equipment and related supplies for the treatment of

diabetes when prescribed by Your Physician or other Provider legally authorized

to prescribe:

• Acetone reagent strips

• Acetone reagent tablets

• Alcohol or peroxide by the pint

• Alcohol wipes

• All insulin preparations

• Automatic blood lance kit

• Cartridges for the visually impaired

• Diabetes data management systems

• Disposable insulin and pen cartridges

• Drawing-up devices for the visually impaired

• Equipment for use of the pump

• Glucagon for injection to increase blood glucose concentration

• Glucose acetone reagent strips

• Glucose kit

• Glucose monitor with or without special features for visually impaired,

control solutions, and strips for home glucose monitor

• Glucose reagent tape

• Glucose test or reagent strips

• Injection aides

• Injector (Busher) Automatic

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• Insulin

• Insulin cartridge delivery

• Insulin infusion devices

• Insulin pump

• Lancets

• Oral agents such as glucose tablets and gels

• Oral anti-diabetic agents used to reduce blood sugar levels

• Syringe with needle; sterile 1 cc box

• Urine testing products for glucose and ketones

• Additional supplies, as the New York State Commissioner of Health shall

designate by regulation as appropriate for the treatment of diabetes.

2. Self-Management Education.

Diabetes self-management education is designed to educate persons with

diabetes as to the proper self-management and treatment of their diabetic

condition, including information on proper diets. We Cover education on self-

management and nutrition when: diabetes is initially diagnosed; a Physician

diagnoses a significant change in Your symptoms or condition which

necessitates a change in Your self-management education; or when a refresher

course is necessary. It must be provided in accordance with the following:

• By a Physician, other health care Provider authorized to prescribe under

Title 8 of the New York Education Law, or their staff during an office visit;

• Upon the Referral of Your Physician or other health care Provider

authorized to prescribe under Title 8 of the New York Education Law to

the following non-Physician, medical educators: certified diabetes nurse

educators; certified nutritionists; certified dietitians; and registered

dietitians in a group setting when practicable; and

• Education will also be provided in Your home when Medically Necessary.

3. Limitations.

The items will only be provided in amounts that are in accordance with the

treatment plan developed by the Physician for You. We Cover only basic models

of blood glucose monitors unless You have special needs relating to poor vision

or blindness or otherwise Medically Necessary.

Step Therapy for Diabetes Equipment and Supplies. Step therapy is a

program that requires You to try one type of diabetic Prescription Drug, supply or

equipment unless another Prescription Drug, supply or equipment is Medically

Necessary. The diabetic Prescription Drugs, supplies and equipment that are

subject to step therapy include:

• Diabetic glucose meters and test strips;

• Diabetic supplies (including but not limited to syringes, lancets,

needles, pens);

• Insulin;

• Injectable anti-diabetic agents; and

• Oral anti-diabetic agents.

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For diabetic Prescription Drugs, refer to the step therapy provisions in the

Prescription Drug section and the Step Therapy Protocol Override Determination

provisions in the Utilization Review section of this Certificate.

C. Durable Medical Equipment and Braces.

We Cover the rental or purchase of durable medical equipment and braces.

1. Durable Medical Equipment.

Durable Medical Equipment is equipment which is:

• Designed and intended for repeated use;

• Primarily and customarily used to serve a medical purpose;

• Generally not useful to a person in the absence of disease or injury; and

• Appropriate for use in the home.

Coverage is for standard equipment only. We Cover the cost of repair or

replacement when made necessary by normal wear and tear. We do not Cover

the cost of repair or replacement that is the result of misuse or abuse by You.

We will determine whether to rent or purchase such equipment.

We do not Cover equipment designed for Your comfort or convenience (e.g.,

pools, hot tubs, air conditioners, saunas, humidifiers, dehumidifiers, exercise

equipment), as it does not meet the definition of durable medical equipment.

2. Braces.

We Cover braces, including orthotic braces, that are worn externally and that

temporarily or permanently assist all or part of an external body part function that

has been lost or damaged because of an injury, disease or defect. Coverage is

for standard equipment only. We Cover replacements when growth or a change

in Your medical condition make replacement necessary. We do not Cover the

cost of repair or replacement that is the result of misuse or abuse by You.

D. Hearing Aids.

1. External Hearing Aids.

We Cover hearing aids required for the correction of a hearing impairment (a

reduction in the ability to perceive sound which may range from slight to

complete deafness). Hearing aids are electronic amplifying devices designed to

bring sound more effectively into the ear. A hearing aid consists of a

microphone, amplifier and receiver.

Covered Services are available for a hearing aid that is purchased as a result of

a written recommendation by a Physician and include the hearing aid and the

charges for associated fitting and testing. We Cover a single purchase (including

repair and/or replacement) of hearing aids for one (1) or both ears once every

three (3) years.

2. Cochlear Implants.

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We Cover bone anchored hearing aids (i.e., cochlear implants) when they are

Medically Necessary to correct a hearing impairment. Examples of when bone

anchored hearing aids are Medically Necessary include the following:

• Craniofacial anomalies whose abnormal or absent ear canals preclude the

use of a wearable hearing aid; or

• Hearing loss of sufficient severity that it would not be adequately remedied

by a wearable hearing aid.

Coverage is provided for one (1) hearing aid per ear during the entire period of

time that You are enrolled under this Certificate. We Cover repair and/or

replacement of a bone anchored hearing aid only for malfunctions.

E. Hospice.

Hospice Care is available if Your primary attending Physician has certified that You

have six (6) months or less to live. We Cover inpatient Hospice Care in a Hospital or

hospice and home care and outpatient services provided by the hospice, including

drugs and medical supplies. Coverage is provided for 210 days of Hospice Care. We

also Cover unlimited visits for supportive care and guidance for the purpose of helping

You and Your immediate family cope with the emotional and social issues related to

Your death, either before or after Your death.

We Cover Hospice Care only when provided as part of a Hospice Care program

certified pursuant to Article 40 of the New York Public Health Law. If care is provided

outside New York State, the hospice must be certified under a similar certification

process required by the state in which the hospice is located. We do not Cover: funeral

arrangements; pastoral, financial, or legal counseling; or homemaker, caretaker, or

respite care.

F. Medical Supplies.

We Cover medical supplies that are required for the treatment of a disease or injury

which is Covered under this Certificate. We also Cover maintenance supplies (e.g.,

ostomy supplies) for conditions Covered under this Certificate. All such supplies must

be in the appropriate amount for the treatment or maintenance program in progress.

We do not Cover over-the-counter medical supplies. See the Diabetic Equipment,

Supplies, and Self-Management Education section above for a description of diabetic

supply Coverage.

G. Prosthetics.

1. External Prosthetic Devices.

We Cover prosthetic devices (including wigs) that are worn externally and that

temporarily or permanently replace all or part of an external body part that has

been lost or damaged because of an injury or disease. We Cover wigs only

when You have severe hair loss due to injury or disease or as a side effect of the

treatment of a disease (e.g., chemotherapy). We do not Cover wigs made from

human hair unless You are allergic to all synthetic wig materials.

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We do not Cover dentures or other devices used in connection with the teeth

unless required due to an accidental injury to sound natural teeth or necessary

due to congenital disease or anomaly.

Eyeglasses and contact lenses are not Covered under this section of the

Certificate and are only Covered under the Pediatric Vision Care section of this

Certificate.

We do not Cover shoe inserts.

We Cover external breast prostheses following a mastectomy, which are not

subject to any lifetime limit.

Coverage is for standard equipment only.

We Cover the cost of one (1) prosthetic device, per limb, per Plan Year. We

also Cover the cost of repair and replacement of the prosthetic device and its

parts. We do not Cover the cost of repair or replacement covered under

warranty or if the repair or replacement is the result of misuse or abuse by You.

2. Internal Prosthetic Devices.

We Cover surgically implanted prosthetic devices and special appliances if they

improve or restore the function of an internal body part which has been removed

or damaged due to disease or injury. This includes implanted breast prostheses

following a mastectomy or partial mastectomy in a manner determined by You

and Your attending Physician to be appropriate.

Coverage also includes repair and replacement due to normal growth or normal

wear and tear.

Coverage is for standard equipment only.

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SECTION XI

Inpatient Services

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits.

A. Hospital Services.

We Cover inpatient Hospital services for Acute care or treatment given or ordered by a

Health Care Professional for an illness, injury or disease of a severity that must be

treated on an inpatient basis including:

• Semiprivate room and board;

• General, special and critical nursing care;

• Meals and special diets;

• The use of operating, recovery and cystoscopic rooms and equipment;

• The use of intensive care, special care or cardiac care units and equipment;

• Diagnostic and therapeutic items, such as drugs and medications, sera,

biologicals and vaccines, intravenous preparations and visualizing dyes and

administration, but not including those which are not commercially available for

purchase and readily obtainable by the Hospital;

• Dressings and casts;

• Supplies and the use of equipment in connection with oxygen, anesthesia,

physiotherapy, chemotherapy, electrocardiographs, electroencephalographs, x-

ray examinations and radiation therapy, laboratory and pathological

examinations;

• Blood and blood products except when participation in a volunteer blood

replacement program is available to You;

• Radiation therapy, inhalation therapy, chemotherapy, pulmonary rehabilitation,

infusion therapy and cardiac rehabilitation;

• Short-term physical, speech and occupational therapy; and

• Any additional medical services and supplies which are provided while You are a

registered bed patient and which are billed by the Hospital.

The Cost-Sharing requirements in the Schedule of Benefits section of this Certificate

apply to a continuous Hospital confinement, which is consecutive days of in-Hospital

service received as an inpatient or successive confinement when discharge from and

readmission to the Hospital occur within a period of not more than 90 days for the same

or related causes.

B. Observation Services.

We Cover observation services in a Hospital. Observation services are Hospital

outpatient services provided to help a Physician decide whether to admit or discharge

You. These services include use of a bed and periodic monitoring by nursing or other

licensed staff.

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C. Inpatient Medical Services.

We Cover medical visits by a Health Care Professional on any day of inpatient care

Covered under this Certificate.

D. Inpatient Stay for Maternity Care.

We Cover inpatient maternity care in a Hospital for the mother, and inpatient newborn

care in a Hospital for the infant, for at least 48 hours following a normal delivery and at

least 96 hours following a caesarean section delivery, regardless of whether such care

is Medically Necessary. The care provided shall include parent education, assistance,

and training in breast or bottle-feeding, and the performance of any necessary maternal

and newborn clinical assessments. We will also Cover any additional days of such care

that We determine are Medically Necessary. In the event the mother elects to leave the

Hospital and requests a home care visit before the end of the 48-hour or 96-hour

minimum Coverage period, We will Cover a home care visit. The home care visit will be

provided within 24 hours after the mother's discharge, or at the time of the mother's

request, whichever is later. Our Coverage of this home care visit shall be in addition to

home health care visits under this Certificate and shall not be subject to any Cost-

Sharing amounts in the Schedule of Benefits section of this Certificate that apply to

home care benefits.

We also Cover the inpatient use of pasteurized donor human milk, which may include

fortifiers as Medically Necessary, for which a Health Care Professional has issued an

order for an infant who is medically or physically unable to receive maternal breast milk,

participate in breast feeding, or whose mother is medically or physically unable to

produce maternal breast milk at all or in sufficient quantities or participate in breast

feeding despite optimal lactation support. Such infant must have a documented birth

weight of less than one thousand five hundred grams, or a congenital or acquired

condition that places the infant at a high risk for development of necrotizing

enterocolitis.

E. Inpatient Stay for Mastectomy Care.

We Cover inpatient services for Members undergoing a lymph node dissection,

lumpectomy, mastectomy or partial mastectomy for the treatment of breast cancer and

any physical complications arising from the mastectomy, including lymphedema, for a

period of time determined to be medically appropriate by You and Your attending

Physician.

F. Autologous Blood Banking Services.

We Cover autologous blood banking services only when they are being provided in

connection with a scheduled, Covered inpatient procedure for the treatment of a

disease or injury. In such instances, We Cover storage fees for a reasonable storage

period that is appropriate for having the blood available when it is needed.

G. Habilitation Services.

We Cover inpatient Habilitation Services consisting of physical therapy, speech therapy

and occupational therapy for 60 days per Plan Year. The visit limit applies to all

therapies combined.

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H. Rehabilitation Services.

We Cover inpatient Rehabilitation Services consisting of physical therapy, speech

therapy and occupational therapy for 60 days per Plan Year. The visit limit applies to all

therapies combined.

We Cover speech and physical therapy only when:

1. Such therapy is related to the treatment or diagnosis of Your illness or injury (in

the case of a covered Child, this includes a medically diagnosed congenital

defect);

2. The therapy is ordered by a Physician; and

3. You have been hospitalized or have undergone surgery for such illness or injury.

Covered Rehabilitation Services must begin within six (6) months of the later to occur:

1. The date of the injury or illness that caused the need for the therapy;

2. The date You are discharged from a Hospital where surgical treatment was

rendered; or

3. The date outpatient surgical care is rendered.

I. Skilled Nursing Facility.

We Cover services provided in a Skilled Nursing Facility, including care and treatment in

a semi-private room, as described in “Hospital Services” above. Custodial,

convalescent or domiciliary care is not Covered (see the Exclusions and Limitations

section of this Certificate). An admission to a Skilled Nursing Facility must be supported

by a treatment plan prepared by Your Provider and approved by Us. We Cover up to

200 days per Plan Year for non-custodial care.

J. End of Life Care.

If You are diagnosed with advanced cancer and You have fewer than 60 days to live,

We will Cover Acute care provided in a licensed Article 28 Facility or Acute care Facility

that specializes in the care of terminally ill patients. Your attending Physician and the

Facility’s medical director must agree that Your care will be appropriately provided at

the Facility. If We disagree with Your admission to the Facility, We have the right to

initiate an expedited external appeal to an External Appeal Agent. We will Cover and

reimburse the Facility for Your care, subject to any applicable limitations in this

Certificate until the External Appeal Agent renders a decision in Our favor.

We will reimburse Non-Participating Providers for this end of life care as follows:

1. We will reimburse a rate that has been negotiated between Us and the Provider.

2. If there is no negotiated rate, We will reimburse Acute care at the Facility’s

current Medicare Acute care rate.

3. If it is an alternate level of care, We will reimburse at 75% of the appropriate

Medicare Acute care rate.

K. Limitations/Terms of Coverage.

1. When You are receiving inpatient care in a Facility, We will not Cover additional

charges for special duty nurses, charges for private rooms (unless a private room

is Medically Necessary), or medications and supplies You take home from the

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Facility. If You occupy a private room, and the private room is not Medically

Necessary, Our Coverage will be based on the Facility’s maximum semi-private

room charge. You will have to pay the difference between that charge and the

private room charge.

2. We do not Cover radio, telephone or television expenses, or beauty or barber

services.

3. We do not Cover any charges incurred after the day We advise You it is no

longer Medically Necessary for You to receive inpatient care, unless Our denial is

overturned by an External Appeal Agent.

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SECTION XII

Mental Health Care and Substance Use Services

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits which are no more restrictive than those that apply to medical

and surgical benefits in accordance with the federal Mental Health Parity and Addiction

Equity Act of 2008.

A. Mental Health Care Services. We Cover the following mental health care services

to treat a mental health condition. For purposes of this benefit, “mental health condition”

means any mental health disorder as defined in the most recent edition of the

Diagnostic and Statistical Manual of Mental Disorders.

1. Inpatient Services. We Cover inpatient mental health care services relating to

the diagnosis and treatment of mental health conditions comparable to other

similar Hospital, medical and surgical coverage provided under this Certificate.

Coverage for inpatient services for mental health care is limited to Facilities

defined in New York Mental Hygiene Law Section 1.03(10), such as:

• A psychiatric center or inpatient Facility under the jurisdiction of the New

York State Office of Mental Health;

• A state or local government run psychiatric inpatient Facility;

• A part of a Hospital providing inpatient mental health care services under

an operating certificate issued by the New York State Commissioner of

Mental Health;

• A comprehensive psychiatric emergency program or other Facility

providing inpatient mental health care that has been issued an operating

certificate by the New York State Commissioner of Mental Health;

and, in other states, to similarly licensed or certified Facilities. In the absence

of a similarly licensed or certified Facility, the Facility must be accredited by

the Joint Commission on Accreditation of Health Care Organizations or a

national accreditation organization recognized by Us.

We also Cover inpatient mental health care services relating to the diagnosis and

treatment of mental health conditions received at Facilities that provide

residential treatment, including room and board charges. Coverage for

residential treatment services is limited to Facilities defined in New York Mental

Hygiene Law Section 1.03(33) and to residential treatment facilities that are part

of a comprehensive care center for eating disorders identified pursuant to New

York Mental Hygiene Law Article 30; and, in other states, to Facilities that are

licensed or certified to provide the same level of treatment. In the absence of a

licensed or certified Facility that provides the same level of treatment, the Facility

must be accredited by the Joint Commission on Accreditation of Health Care

Organizations or a national accreditation organization recognized by Us.

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2. Outpatient Services. We Cover outpatient mental health care services,

including but not limited to partial hospitalization program services and intensive

outpatient program services, relating to the diagnosis and treatment of mental

health conditions. Coverage for outpatient services for mental health care

includes Facilities that have been issued an operating certificate pursuant to New

York Mental Hygiene Law Article 31 or are operated by the New York State

Office of Mental Health and, in other states, to similarly licensed or certified

Facilities; and services provided by a licensed psychiatrist or psychologist; a

licensed clinical social worker; a licensed nurse practitioner; a licensed mental

health counselor; or a professional corporation or a university faculty practice

corporation thereof. In the absence of a similarly licensed or certified Facility, the

Facility must be accredited by the Joint Commission on Accreditation of Health

Care Organizations or a national accreditation organization recognized by Us.

B. Substance Use Services. We Cover the following substance use services to treat a

substance use disorder. For purposes of this benefit, “substance use disorder” means

any substance use disorder as defined in the most recent edition of the Diagnostic and

Statistical Manual of Mental Disorders.

1. Inpatient Services. We Cover inpatient substance use services relating to the

diagnosis and treatment of substance use disorders. This includes Coverage for

detoxification and rehabilitation services for substance use disorders. Inpatient

substance use services are limited to Facilities in New York State which are

licensed, certified or otherwise authorized by the Office of Addiction Services and

Support (“OASAS”); and, in other states, to those Facilities that are licensed,

certified or otherwise authorized by a similar state agency and accredited by the

Joint Commission or a national accreditation organization recognized by Us as

alcoholism, substance abuse or chemical dependence treatment programs.

We also Cover inpatient substance use services relating to the diagnosis and

treatment of substance use disorders received at Facilities that provide

residential treatment, including room and board charges. Coverage for

residential treatment services is limited to Facilities that are licensed, certified or

otherwise authorized by OASAS; and, in other states, to those Facilities that are

licensed, certified or otherwise authorized by a similar state agency and

accredited by the Joint Commission or a national accreditation organization

recognized by Us as alcoholism, substance abuse or chemical dependence

treatment programs to provide the same level of treatment.

2. Outpatient Services. We Cover outpatient substance use services relating to

the diagnosis and treatment of substance use disorders, including but not limited

to partial hospitalization program services, intensive outpatient program services,

counseling and medication-assisted treatment. Such Coverage is limited to

Facilities in New York State that are licensed, certified or otherwise authorized by

OASAS to provide outpatient substance use disorder services and, in other

states, to those that are licensed, certified or otherwise authorized by a similar

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state agency and accredited by the Joint Commission or a national accreditation

organization recognized by Us as alcoholism, substance abuse or chemical

dependence treatment programs. Coverage in an OASAS-certified Facility

includes services relating to the diagnosis and treatment of a substance use

disorder provided by an OASAS credentialed Provider. Coverage is also

available in a professional office setting for outpatient substance use disorder

services relating to the diagnosis and treatment of alcoholism, substance use

and dependency or by Physicians who have been granted a waiver pursuant to

the federal Drug Addiction Treatment Act of 2000 to prescribe Schedule III, IV

and V narcotic medications for the treatment of opioid addiction during the Acute

detoxification stage of treatment or during stages of rehabilitation.

Additional Family Counseling. We also Cover up to 20 outpatient visits per

Plan Year for family counseling. A family member will be deemed to be covered,

for the purposes of this provision, so long as that family member: 1) identifies

himself or herself as a family member of a person suffering from a substance use

disorder; and 2) is covered under the same family Certificate that covers the

person receiving, or in need of, treatment for a substance use disorder. Our

payment for a family member therapy session will be the same amount,

regardless of the number of family members who attend the family therapy

session.

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SECTION XIII

Prescription Drug Coverage

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits.

A. Covered Prescription Drugs.

We Cover Medically Necessary Prescription Drugs that, except as specifically provided

otherwise, can be dispensed only pursuant to a prescription and are:

• Required by law to bear the legend “Caution – Federal Law prohibits dispensing

without a prescription”;

• FDA approved;

• Ordered by a Provider authorized to prescribe and within the Provider’s scope of

practice;

• Prescribed within the approved FDA administration and dosing guidelines;

• On Our Formulary; and

• Dispensed by a licensed pharmacy.

Covered Prescription Drugs include, but are not limited to:

• Self-injectable/administered Prescription Drugs.

• Inhalers (with spacers).

• Topical dental preparations.

• Pre-natal vitamins, vitamins with fluoride, and single entity vitamins.

• Osteoporosis drugs and devices approved by the FDA, or generic equivalents as

approved substitutes, for the treatment of osteoporosis and consistent with the

criteria of the federal Medicare program or the National Institutes of Health.

• Nutritional formulas for the treatment of phenylketonuria, branched-chain

ketonuria, galactosemia and homocystinuria.

• Prescription or non-prescription enteral formulas for home use, whether

administered orally or via tube feeding, for which a Physician or other licensed

Provider has issued a written order. The written order must state that the enteral

formula is Medically Necessary and has been proven effective as a disease-

specific treatment regimen. Specific diseases and disorders include but are not

limited to: inherited diseases of amino acid or organic acid metabolism; Crohn’s

disease; gastroesophageal reflux; gastroesophageal motility such as chronic

intestinal pseudo-obstruction; and multiple severe food allergies. Multiple food

allergies include but are not limited to: immunoglobulin E and nonimmunoglobulin

E-mediated allergies to multiple food proteins; severe food protein induced

enterocolitis syndrome; eosinophilic disorders and impaired absorption of

nutrients caused by disorders affecting the absorptive surface, function, length,

and motility of the gastrointestinal tract.

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• Modified solid food products that are low in protein, contain modified protein, or

are amino acid based to treat certain inherited diseases of amino acid and

organic acid metabolism and severe protein allergic conditions.

• Prescription Drugs prescribed in conjunction with treatment or services Covered

under the infertility treatment benefit in the Outpatient and Professional Services

section of this Certificate.

• Off-label cancer drugs, so long as the Prescription Drug is recognized for the

treatment of the specific type of cancer for which it has been prescribed in one

(1) of the following reference compendia: the American Hospital Formulary

Service-Drug Information; National Comprehensive Cancer Networks Drugs and

Biologics Compendium; Thomson Micromedex DrugDex; Elsevier Gold

Standard’s Clinical Pharmacology; or other authoritative compendia as identified

by the Federal Secretary of Health and Human Services or the Centers for

Medicare and Medicaid Services; or recommended by review article or editorial

comment in a major peer reviewed professional journal.

• Orally administered anticancer medication used to kill or slow the growth of

cancerous cells.

• Smoking cessation drugs, including over-the-counter drugs for which there is a

written order and Prescription Drugs prescribed by a Provider.

• Preventive Prescription Drugs, including over-the-counter drugs for which there is

a written order, provided in accordance with the comprehensive guidelines

supported by the Health Resources and Services Administration (“HRSA”) or that

have an “A” or “B” rating from the United States Preventive Services Task Force

(“USPSTF”).

• Prescription Drugs for the treatment of mental health and substance use

disorders, including drugs for detoxification, maintenance and overdose reversal.

• Contraceptive drugs, devices and other products, including over-the-counter

contraceptive drugs, devices and other products, approved by the FDA and as

prescribed or otherwise authorized under State or Federal law. “Over-the-

counter contraceptive products” means those products provided for in

comprehensive guidelines supported by HRSA. Coverage also includes

emergency contraception when provided pursuant to a prescription or order or

when lawfully provided over-the-counter. You may request coverage for an

alternative version of a contraceptive drug, device and other product if the

Covered contraceptive drug, device and other product is not available or is

deemed medically inadvisable, as determined by Your attending Health Care

Provider.

You may request a copy of Our Formulary. Our Formulary is also available on Our

website at www.optumrx.com. You may inquire if a specific drug is Covered under this

Certificate by contacting Optum RX at the number on Your ID card.

B. Refills.

We Cover Refills of Prescription Drugs only when dispensed at a retail or designated

pharmacy as ordered by an authorized Provider. Benefits for Refills will not be provided

beyond one (1) year from the original prescription date. For prescription eye drop

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medication, We allow for the limited refilling of the prescription prior to the last day of the

approved dosage period without regard to any coverage restrictions on early Refill of

renewals. To the extent practicable, the quantity of eye drops in the early Refill will be

limited to the amount remaining on the dosage that was initially dispensed. Your Cost-

Sharing for the limited Refill is the amount that applies to each prescription or Refill as

set forth in the Schedule of Benefits section of this Certificate.

C. Benefit and Payment Information.

1. Cost-Sharing Expenses. You are responsible for paying the costs outlined in

the Schedule of Benefits section of this Certificate when Covered Prescription

Drugs are obtained from a retail or designated pharmacy.

You have a three (3) tier plan design, which means that Your out-of-pocket

expenses will generally be lowest for Prescription Drugs on tier 1 and highest for

Prescription Drugs on tier 3. Your out-of-pocket expense for Prescription Drugs

on tier 2 will generally be more than for tier 1 but less than tier 3.

For most Prescription Drugs, You pay only the Cost-Sharing in the Schedule of

Benefits. An additional charge, called an “ancillary charge,” may apply to some

Prescription Drugs when a Prescription Drug on a higher tier is dispensed at

Your or Your Provider’s request and Our formulary includes a chemically

equivalent Prescription Drug on a lower tier. You will pay the difference between

the full cost of the Prescription Drug on the higher tier and the cost of the

Prescription Drug on the lower tier. The cost difference is not Covered and must

be paid by You in addition to the lower tier Cost-Sharing. If Your Provider thinks

that a chemically equivalent Prescription Drug on a lower tier is not clinically

appropriate, You, Your designee or Your Provider may request that We approve

coverage at the higher tier Cost-Sharing. If approved, You will pay the higher tier

Cost-Sharing only. If We do not approve coverage at the higher tier Cost-

Sharing, You are entitled to an Appeal as outlined in the Utilization Review and

External Appeal sections of this Certificate. The request for an approval should

include a statement from Your Provider that the Prescription Drug at the lower

tier is not clinically appropriate (e.g., it will be or has been ineffective or would

have adverse effects.) We may also request clinical documentation to support

this statement. If We do not approve coverage for the Prescription Drug on the

higher tier, the ancillary charge will not apply toward Your In-Network Out-of-

Pocket Limit.

You are responsible for paying the full cost (the amount the pharmacy charges

You) for any non-Covered Prescription Drug, and Our contracted rates (Our

Prescription Drug Cost) will not be available to You.

2. Participating Pharmacies. For Prescription Drugs purchased at a retail or

designated Participating Pharmacy, You are responsible for paying the lower of:

• The applicable Cost-Sharing; or

• The Prescription Drug Cost for that Prescription Drug.

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(Your Cost-Sharing will never exceed the Usual and Customary Charge of the

Prescription Drug.)

3. Non-Participating Pharmacies. If You purchase a Prescription Drug from a

Non-Participating Pharmacy, You must pay for the Prescription Drug at the time it

is dispensed and then file a claim for reimbursement with Us. We will not

reimburse You for the difference between what You pay the Non-Participating

Pharmacy and Our price for the Prescription Drug. In most cases, You will pay

more if You purchase Prescription Drugs from a Non-Participating Pharmacy.

4. Designated Pharmacies. If You require certain Prescription Drugs including,

but not limited to specialty Prescription Drugs, We may direct You to a

Designated Pharmacy with whom We have an arrangement to provide those

Prescription Drugs.

Generally, specialty Prescription Drugs are Prescription Drugs that are approved

to treat limited patient populations or conditions; are normally injected, infused or

require close monitoring by a Provider; or have limited availability, special

dispensing and delivery requirements and/or require additional patient supports.

If You are directed to a Designated Pharmacy and You choose not to obtain Your

Prescription Drug from a Designated Pharmacy, Your coverage will be subject to

the out-of-network benefit for that Prescription Drug.

Following are the therapeutic classes of Prescription Drugs or conditions that are

included in this program:

• Age related macular edema;

• Anemia, neutropenia, thrombocytopenia;

• Contraceptives;

• Cardiovascular;

• Crohn’s disease;

• Cystic fibrosis;

• Cytomegalovirus;

• Endocrine disorders/neurologic disorders such as infantile spasms;

• Enzyme deficiencies/liposomal storage disorders;

• Gaucher's disease;

• Growth hormone;

• Hemophilia;

• Hepatitis B, hepatitis C;

• Hereditary angioedema;

• HIV/AIDS;

• Immune deficiency;

• Immune modulator;

• Infertility;

• Iron overload;

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• Iron toxicity;

• Multiple sclerosis;

• Oncology;

• Osteoarthritis;

• Osteoporosis;

• Parkinson's disease;

• Pulmonary arterial hypertension;

• Respiratory condition;

• Rheumatologic and related conditions (rheumatoid arthritis, psoriatic

arthritis, ankylosing spondylitis, juvenile rheumatoid arthritis, psoriasis)

• Transplant;

• RSV prevention.

5. Tier Status. The tier status of a Prescription Drug may change periodically, but

no more than four (4) times per Plan Year, or when a Brand-Name Drug

becomes available as a Generic Drug as described below, based on Our tiering

decisions. These changes may occur without prior notice to You. However, if

You have a prescription for a drug that is being moved to a higher tier or is being

removed from Our Formulary, We will notify You at least 30 days before the

change is effective. When such changes occur, Your Cost-Sharing may change.

You may also request a Formulary exception for a Prescription Drug that is no

longer on the Formulary as outlined below and in the External Appeal section of

this Certificate. You may access the most up to date tier status on Our website

www.optumrx.com or by calling the number on Your Optum ID card.

6. When a Brand-Name Drug Becomes Available as a Generic Drug. When a

Brand-Name Drug becomes available as a Generic Drug, the tier placement of

the Brand-Name Prescription Drug may change. If this happens, You will pay the

Cost-Sharing applicable to the tier to which the Prescription Drug is assigned or

the Brand-Name Drug will be removed from the Formulary and You no longer

have benefits for that particular Brand-Name Drug. Please note, if You are

taking a Brand-Name Drug that is being excluded or placed on a higher tier due

to a Generic Drug becoming available, You will receive 30 days’ advance written

notice of the change before it is effective. You may request a Formulary

exception for a Prescription Drug that is no longer on the Formulary as outlined

below and in the External Appeal section of this Certificate.

7. Formulary Exception Process. If a Prescription Drug is not on Our Formulary

You, Your designee or Your prescribing Health Care Professional may request a

Formulary exception for a clinically-appropriate Prescription Drug in writing,

electronically or telephonically. The request should include a statement from

Your prescribing Health Care Professional that all Formulary drugs will be or

have been ineffective, would not be as effective as the non-Formulary drug, or

would have adverse effects. If coverage is denied under Our standard or

expedited Formulary exception process, You are entitled to an external appeal as

outlined in the External Appeal section of this Certificate. Visit Our website at

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www.optumrx.com or call the number on Your ID card to find out more about this

process.

Standard Review of a Formulary Exception. We will make a decision and

notify You or Your designee and the prescribing Health Care Professional by

telephone and in writing no later than 72 hours after Our receipt of Your request.

If We approve the request, We will Cover the Prescription Drug while You are

taking the Prescription Drug, including any refills.

Expedited Review of a Formulary Exception. If You are suffering from a health

condition that may seriously jeopardize Your health, life or ability to regain

maximum function or if You are undergoing a current course of treatment using a

non-Formulary Prescription Drug, You may request an expedited review of a

Formulary exception. The request should include a statement from Your

prescribing Health Care Professional that harm could reasonably come to You if

the requested drug is not provided within the timeframes for Our standard

Formulary exception process. We will make a decision and notify You or Your

designee and the prescribing Health Care Professional by telephone and in

writing no later than 24 hours after Our receipt of Your request. If We approve the

request, We will Cover the Prescription Drug while You suffer from the health

condition that may seriously jeopardize Your health, life or ability to regain

maximum function or for the duration of Your current course of treatment using

the non-Formulary Prescription Drug.

8. Supply Limits. Except for contraceptive drugs, devices, or products, We will

pay for no more than a 30-day supply of a Prescription Drug purchased at a retail

pharmacy. You are responsible for one (1) Cost-Sharing amount for up to a 30

90-day supply. However, for Maintenance Drugs We will pay for up to a 90-day

supply of a drug purchased at a retail pharmacy. You are responsible for up to

three (3) Cost-Sharing amounts for a 90-day supply at a retail pharmacy.

You may have the entire supply (of up to 12 months) of the contraceptive drug,

device or product dispensed at the same time. Contraceptive drugs, devices, or

products are not subject to Cost-Sharing when provided by a Participating

Pharmacy.

Specialty Prescription Drugs may be limited to a 30-day supply when obtained at

a retail pharmacy. You may access Our website www.optumrx.com or by calling

the number on Your ID card for more information on supply limits for specialty

Prescription Drugs.

Some Prescription Drugs may be subject to quantity limits based on criteria that

We have developed, subject to Our periodic review and modification. The limit

may restrict the amount dispensed per Prescription Order or Refill and/or the

amount dispensed per month’s supply. You can determine whether a

Prescription Drug has been assigned a maximum quantity level for dispensing by

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accessing Our website or by calling the number on Your ID card. If We deny a

request to Cover an amount that exceeds Our quantity level, You are entitled to

an Appeal pursuant to the Utilization Review and External Appeal sections of this

Certificate.

9. Initial Limited Supply of Prescription Opioid Drugs. If you receive an initial

limited prescription for a seven (7) day supply or less of any schedule II, III, or IV

opioid prescribed for Acute pain, and You have a Copayment, Your Copayment

will be the same Copayment that would apply to a 30-day supply of the

Prescription Drug. If You receive an additional supply of the Prescription Drug

within the same 30-day period in which You received the seven (7) day supply,

You will not be responsible for an additional Copayment for the remaining 30-day

supply of that Prescription Drug.

10. Cost-Sharing for Orally-Administered Anti-Cancer Drugs. Your Cost-Sharing

for orally-administered anti-cancer drugs is at least as favorable to You as the

Cost-Sharing amount, if any, that applies to intravenous or injected anticancer

medications Covered under the Outpatient and Professional Services section of

this Certificate.

D. Medical Management.

This Certificate includes certain features to determine when Prescription Drugs should

be Covered, which are described below. As part of these features, Your prescribing

Provider may be asked to give more details before We can decide if the Prescription

Drug is Medically Necessary.

1. Step Therapy. Step therapy is a process in which You may need to use one (1)

or more types of Prescription Drugs before We will Cover another as Medically

Necessary. A “step therapy protocol” means Our policy, protocol or program that

establishes the sequence in which We approve Prescription Drugs for Your

medical condition. When establishing a step therapy protocol, We will use

recognized evidence-based and peer reviewed clinical review criteria that also

takes into account the needs of atypical patient populations and diagnoses. We

check certain Prescription Drugs to make sure that proper prescribing guidelines

are followed. These guidelines help You get high quality and cost-effective

Prescription Drugs. The Prescription Drugs that require Preauthorization under

the step therapy program are also included on the Preauthorization drug list. If a

step therapy protocol is applicable to Your request for coverage of a Prescription

Drug, You, Your designee, or Your Health Care Professional can request a step

therapy override determination as outlined in the Utilization Review section of this

Certificate.

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2. Therapeutic Substitution. Therapeutic substitution is an optional program that

tells You and Your Providers about alternatives to certain prescribed drugs. We

may contact You and Your Provider to make You aware of these choices. Only

You and Your Provider can determine if the therapeutic substitute is right for You.

We have a therapeutic drug substitutes list, which We review and update from

time to time. For questions or issues about therapeutic drug substitutes, visit Our

website or call the number on Your ID card.

E. Limitations/Terms of Coverage.

1. We reserve the right to limit quantities, day supply, early Refill access and/or

duration of therapy for certain medications based on Medical Necessity including

acceptable medical standards and/or FDA recommended guidelines.

2. If We determine that You may be using a Prescription Drug in a harmful or

abusive manner, or with harmful frequency, Your selection of Participating

Pharmacies and prescribing Providers may be limited. If this happens, We may

require You to select a single Participating Pharmacy and single Provider that will

provide and coordinate all future pharmacy services. Benefits will be paid only if

You use the selected single Participating Pharmacy. Benefits will be paid only if

Your Prescription Order or Refills are written by the selected Provider or a

Provider authorized by Your selected provider. If You do not make a selection

within 30 days of the date We notify You, We will select a single Participating

Pharmacy or prescribing Provider for You.

3. Various specific and/or generalized “use management” protocols will be used

from time to time in order to ensure appropriate utilization of medications. Such

protocols will be consistent with standard medical/drug treatment guidelines. The

primary goal of the protocols is to provide Our Members with a quality-focused

Prescription Drug benefit. In the event a use management protocol is

implemented, and You are taking the drug(s) affected by the protocol, You will be

notified in advance.

4. Injectable drugs (other than self-administered injectable drugs) and diabetic

insulin, oral hypoglycemics, and diabetic supplies and equipment are not

Covered under this section but are Covered under other sections of this

Certificate.

5. We do not Cover charges for the administration or injection of any Prescription

Drug. Prescription Drugs given or administered in a Physician’s office are

Covered under the Outpatient and Professional Services section of this

Certificate.

6. We do not Cover drugs that do not by law require a prescription, except for

smoking cessation drugs, over-the-counter preventive drugs or devices provided

in accordance with the comprehensive guidelines supported by HRSA or with an

“A” or “B” rating from USPSTF, or as otherwise provided in this Certificate. We

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do not Cover Prescription Drugs that have over-the-counter non-prescription

equivalents, except if specifically designated as Covered in the drug Formulary.

Non-prescription equivalents are drugs available without a prescription that have

the same name/chemical entity as their prescription counterparts. We do not

Cover repackaged products such as therapeutic kits or convenience packs that

contain a Covered Prescription Drug unless the Prescription Drug is only

available as part of a therapeutic kit or convenience pack. Therapeutic kits or

convenience packs contain one or more Prescription Drug(s) and may be

packaged with over-the-counter items, such as gloves, finger cots, hygienic

wipes or topical emollients.

7. We do not Cover Prescription Drugs to replace those that may have been lost or

stolen.

8. We do not Cover Prescription Drugs dispensed to You while in a Hospital,

nursing home, other institution, Facility, or if You are a home care patient, except

in those cases where the basis of payment by or on behalf of You to the Hospital,

nursing home, Home Health Agency or home care services agency, or other

institution, does not include services for drugs.

9. We reserve the right to deny benefits as not Medically Necessary or experimental

or investigational for any drug prescribed or dispensed in a manner contrary to

standard medical practice. If coverage is denied, You are entitled to an Appeal

as described in the Utilization Review and External Appeal sections of this

Certificate.

F. General Conditions.

1. You must show Your ID card to a retail pharmacy at the time You obtain Your

Prescription Drug or You must provide the pharmacy with identifying information

that can be verified by Us during regular business hours.

2. Drug Utilization, Cost Management and Rebates. We conduct various

utilization management activities designed to ensure appropriate Prescription

Drug usage, to avoid inappropriate usage, and to encourage the use of cost-

effective drugs. Through these efforts, You benefit by obtaining appropriate

Prescription Drugs in a cost-effective manner. The cost savings resulting from

these activities are reflected in the Premiums for Your coverage.

We may also, from time to time, enter into agreements that result in Us receiving

rebates or other funds (“rebates”) directly or indirectly from Prescription Drug

manufacturers, Prescription Drug distributors or others. Any rebates are based

upon utilization of Prescription Drugs across all of Our business and not solely on

any one Member’s utilization of Prescription Drugs. Any rebates received by Us

may or may not be applied, in whole or part, to reduce premiums either through

an adjustment to claims costs or as an adjustment to the administrative expenses

component of Our Prescription Drug premiums. Any such rebates may be

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retained by Us, in whole or part, in order to fund such activities as new utilization

management activities, community benefit activities and increasing reserves for

the protection of Members. Rebates will not change or reduce the amount of any

Copayment or Coinsurance applicable under Our Prescription Drug coverage.

G. Definitions.

Terms used in this section are defined as follows. (Other defined terms can be found in

the Definitions section of this Certificate).

1. Brand-Name Drug: A Prescription Drug that: 1) is manufactured and

marketed under a trademark or name by a specific drug manufacturer; or 2) We

identify as a Brand-Name Prescription Drug, based on available data resources.

All Prescription Drugs identified as “brand name” by the manufacturer, pharmacy,

or Your Physician may not be classified as a Brand-Name Drug by Us.

2. Designated Pharmacy: A pharmacy that has entered into an agreement with

Us or with an organization contracting on Our behalf, to provide specific

Prescription Drugs, including but not limited to, specialty Prescription Drugs. The

fact that a pharmacy is a Participating Pharmacy does not mean that it is a

Designated Pharmacy.

3. Formulary: The list that identifies those Prescription Drugs for which coverage

may be available under this Certificate. This list is subject to Our periodic review

and modification (no more than four (4) times per Plan Year or when a Brand-

Name Drug becomes available as a Generic Drug). To determine which tier a

particular Prescription Drug has been assigned visit Our website or call the

number on Your ID card.

4. Generic Drug: A Prescription Drug that: 1) is chemically equivalent to a Brand-

Name Drug; or 2) We identify as a Generic Prescription Drug based on available

data resources. All Prescription Drugs identified as “generic” by the

manufacturer, pharmacy or Your Physician may not be classified as a Generic

Drug by Us.

5. Maintenance Drug: A Prescription Drug used to treat a condition that is

considered chronic or long-term and which usually requires daily use of

Prescription Drugs.

6. Non-Participating Pharmacy: A pharmacy that has not entered into an

agreement with Us to provide Prescription Drugs to Members.

7. Participating Pharmacy: A pharmacy that has:

• Entered into an agreement with Us or Our designee to provide

Prescription Drugs to Members;

• Agreed to accept specified reimbursement rates for dispensing

Prescription Drugs; and

• Been designated by Us as a Participating Pharmacy.

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8. Prescription Drug: A medication, product or device that has been approved by

the FDA and that can, under federal or state law, be dispensed only pursuant to

a Prescription Order or Refill and is on Our Formulary. A Prescription Drug

includes a medication that, due to its characteristics, is appropriate for self

administration or administration by a non-skilled caregiver.

9. Prescription Drug Cost: The amount, including a dispensing fee and any sales

tax, as contracted between Us and Our pharmacy benefit manager for a Covered

Prescription Drug dispensed at a Participating Pharmacy. If Your Certificate

includes coverage at Non-Participating Pharmacies, the Prescription Drug Cost

for a Prescription Drug dispensed at a Non-Participating Pharmacy is calculated

using the Prescription Drug Cost that applies for that particular Prescription Drug

at most Participating Pharmacies.

10. Prescription Order or Refill: The directive to dispense a Prescription Drug

issued by a duly licensed Health Care Professional who is acting within the

scope of his or her practice.

11. Usual and Customary Charge: The usual fee that a pharmacy charges

individuals for a Prescription Drug without reference to reimbursement to the

pharmacy by third parties as required by Section 6826-a of the New York

Education Law.

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SECTION XIV

Wellness Benefits

A. Exercise Facility Reimbursement.

We will partially reimburse the Student and the Student’s covered Spouse for certain

exercise facility fees or membership fees but only if such fees are paid to exercise

facilities which maintain equipment and programs that promote cardiovascular wellness.

Memberships in tennis clubs, country clubs, weight loss clinics, spas or any other

similar facilities will not be reimbursed. Lifetime memberships are not eligible for

reimbursement. Reimbursement is limited to actual workout visits. We will not provide

reimbursement for equipment, clothing, vitamins or other services that may be offered

by the facility (e.g., massages, etc.).

In order to be eligible for reimbursement, You must:

• Be an active member of the exercise facility; and

• Complete 50 visits in a six (6)-month period.

In order to obtain reimbursement, at the end of the six (6)-month period, You must

submit:

• Documentation of the visits from the facility. Only one visit per day counts. All

visits must be able to be verified from the facility attended.

• A copy of Your current facility bill which shows the fee paid for Your membership.

Once We receive documentation of the visits and the bill, You will be reimbursed the

lesser of $200 for the Student and $100 for the Student’s covered Spouse or the actual

cost of the membership per six (6)-month period. Reimbursement must be requested

within 120 days of the end of the six (6)-month period. Reimbursement will be issued

only after You have completed each six (6)-month period even if 50 visits are completed

sooner.

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SECTION XV

Pediatric Vision Care

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits and any Preauthorization or Referral requirements that

apply to these benefits.

A. Pediatric Vision Care.

We Cover emergency, preventive and routine vision care for Members through the end

of the month in which the Member turns 19 years of age.

B. Pediatric Vision Examinations.

We Cover vision examinations for the purpose of determining the need for corrective

lenses, and if needed, to provide a prescription for corrective lenses. We Cover a vision

examination one (1) time per Plan Year, unless more frequent examinations are

Medically Necessary as evidenced by appropriate documentation. The vision

examination may include, but is not limited to:

• Case history;

• External examination of the eye or internal examination of the eye;

• Ophthalmoscopic exam;

• Determination of refractive status;

• Binocular distance;

• Tonometry tests for glaucoma;

• Gross visual fields and color vision testing; and

• Summary findings and recommendation for corrective lenses.

C. Pediatric Prescribed Lenses and Frames.

We Cover standard prescription lenses or contact lenses one (1) time in any 12 month

period, unless it is Medically Necessary for You to have new lenses or contact lenses

more frequently, as evidenced by appropriate documentation. Prescription lenses may

be constructed of either glass or plastic. If You choose non-standard lenses, We will

pay the amount that We would have paid for standard lenses and You will be

responsible for the difference in cost between the standard lenses and the non-standard

lenses. The difference in cost does not apply toward Your Out-of-Pocket Limit.

We also Cover standard frames adequate to hold lenses one (1) time in any 12 month

period, unless it is Medically Necessary for You to have new frames more frequently, as

evidenced by appropriate documentation. If You choose a non-standard frame, We will

pay the amount that We would have paid for a standard frame and You will be

responsible for the difference in cost between the standard frame and the non-standard

frame. The difference in cost does not apply toward Your Out-of-Pocket Limit.

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SECTION XVI

Pediatric Dental Care

Please refer to the Schedule of Benefits section of this Certificate for Cost-Sharing

requirements, day or visit limits, and any Preauthorization or Referral requirements that

apply to these benefits.

We Cover the following dental care services for Members through the end of the month

in which the Members turn 19 years of age:

A. Emergency Dental Care. We Cover Emergency Dental Care, which includes

emergency dental treatment required to alleviate pain and suffering caused by

dental disease or trauma. Emergency Dental Care is not subject to Our

Preauthorization.

B. Preventive Dental Care. We Cover preventive dental care that includes procedures

which help to prevent oral disease from occurring, including:

• Prophylaxis (scaling and polishing the teeth) at six (6) month intervals;

• Topical fluoride application at six (6) month intervals where the local water

supply is not fluoridated;

• Sealants on unrestored permanent molar teeth; and

• Unilateral or bilateral space maintainers for placement in a restored

deciduous and/or mixed dentition to maintain space for normally developing

permanent teeth.

C. Routine Dental Care. We Cover routine dental care provided in the office of a

dentist, including:

• Dental examinations, visits and consultations once within a six (6) month

consecutive period (when primary teeth erupt);

• X-rays, full mouth x-rays or panoramic x-rays at 36-month intervals, bitewing

x-rays at six (6) month intervals, and other x-rays if Medically Necessary

(once primary teeth erupt);

• Procedures for simple extractions and other routine dental surgery not

requiring Hospitalization, including preoperative care and postoperative care;

• In-office conscious sedation;

• Amalgam, composite restorations and stainless steel crowns; and

• Other restorative materials appropriate for children.

D. Endodontics. We Cover routine endodontic services, including procedures for

treatment of diseased pulp chambers and pulp canals, where Hospitalization is not

required.

E. Periodontics. We Cover limited periodontic services. We Cover non-surgical

periodontic services. We Cover periodontic surgical services necessary for

treatment related to hormonal disturbances, drug therapy, or congenital defects. We

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also Cover periodontic services in anticipation of, or leading to, orthodontics that are

otherwise Covered under this Certificate.

F. Prosthodontics. We Cover prosthodontic services as follows:

• Removable complete or partial dentures, for Members 15 years of age and

above, including six (6) months follow-up care;

• Additional services including insertion of identification slips, repairs, relines

and rebases and treatment of cleft palate; and

• Interim prosthesis for Members five (5) to 15 years of age.

We do not Cover implants or implant related services.

Fixed bridges are not Covered unless they are required:

• For replacement of a single upper anterior (central/lateral incisor or cuspid) in

a patient with an otherwise full complement of natural, functional and/or

restored teeth;

• For cleft palate stabilization; or

• Due to the presence of any neurologic or physiologic condition that would

preclude the placement of a removable prosthesis, as demonstrated by

medical documentation.

G. Oral Surgery. We Cover non-routine oral surgery, such as partial and complete

bony extractions, tooth re-implantation, tooth transplantation, surgical access of an

unerupted tooth, mobilization of erupted or malpositioned tooth to aid eruption, and

placement of device to facilitate eruption of an impacted tooth. We also Cover oral

surgery in anticipation of, or leading to orthodontics that are otherwise Covered

under this Certificate.

H. Orthodontics. We Cover orthodontics used to help restore oral structures to health

and function and to treat serious medical conditions such as: cleft palate and cleft

lip; maxillary/mandibular micrognathia (underdeveloped upper or lower jaw); extreme

mandibular prognathism; severe asymmetry (craniofacial anomalies); ankylosis of

the temporomandibular joint; and other significant skeletal dysplasias.

Procedures include but are not limited to:

• Rapid Palatal Expansion (RPE);

• Placement of component parts (e.g. brackets, bands);

• Interceptive orthodontic treatment;

• Comprehensive orthodontic treatment (during which orthodontic appliances

are placed for active treatment and periodically adjusted);

• Removable appliance therapy; and

• Orthodontic retention (removal of appliances, construction and placement of

retainers).

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SECTION XVII

Exclusions and Limitations

No coverage is available under this Certificate for the following:

A. Aviation.

We do not Cover services arising out of aviation, other than as a fare-paying passenger

on a scheduled or charter flight operated by a scheduled airline.

B. Convalescent and Custodial Care.

We do not Cover services related to rest cures, custodial care or transportation.

“Custodial care” means help in transferring, eating, dressing, bathing, toileting and other

such related activities. Custodial care does not include Covered Services determined to

be Medically Necessary.

C. Conversion Therapy.

We do not Cover conversion therapy. Conversion therapy is any practice by a mental

health professional that seeks to change the sexual orientation or gender identity of a

Member under 18 years of age, including efforts to change behaviors, gender

expressions, or to eliminate or reduce sexual or romantic attractions or feelings toward

individuals of the same sex. Conversion therapy does not include counseling or therapy

for an individual who is seeking to undergo a gender transition or who is in the process

of undergoing a gender transition, that provides acceptance, support and understanding

of an individual or the facilitation of an individual’s coping, social support, and identity

exploration and development, including sexual orientation-neutral interventions to

prevent or address unlawful conduct or unsafe sexual practices, provided that the

counseling or therapy does not seek to change sexual orientation or gender identity.

D. Cosmetic Services.

We do not Cover cosmetic services, Prescription Drugs, or surgery, unless otherwise

specified, except that cosmetic surgery shall not include reconstructive surgery when

such service is incidental to or follows surgery resulting from trauma, infection or

diseases of the involved part, and reconstructive surgery because of congenital disease

or anomaly of a covered Child which has resulted in a functional defect. We also Cover

services in connection with reconstructive surgery following a mastectomy, as provided

elsewhere in this Certificate. Cosmetic surgery does not include surgery determined to

be Medically Necessary. If a claim for a procedure listed in 11 NYCRR 56 (e.g., certain

plastic surgery and dermatology procedures) is submitted retrospectively and without

medical information, any denial will not be subject to the Utilization Review process in

the Utilization Review and External Appeal sections of this Certificate unless medical

information is submitted.

E. Dental Services.

We do not Cover dental services except for: care or treatment due to accidental injury to

sound natural teeth within 12 months of the accident; dental care or treatment

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necessary due to congenital disease or anomaly; or dental care or treatment specifically

stated in the Outpatient and Professional Services Pediatric Dental Care section of this

Certificate.

F. Experimental or Investigational Treatment.

We do not Cover any health care service, procedure, treatment, device or Prescription

Drug that is experimental or investigational. However, We will Cover experimental or

investigational treatments, including treatment for Your rare disease or patient costs for

Your participation in a clinical trial as described in the Outpatient and Professional

Services section of this Certificate, when Our denial of services is overturned by an

External Appeal Agent certified by the State. However, for clinical trials, We will not

Cover the costs of any investigational drugs or devices, non-health services required for

You to receive the treatment, the costs of managing the research, or costs that would

not be Covered under this Certificate for non-investigational treatments. See the

Utilization Review and External Appeal sections of this Certificate for a further

explanation of Your Appeal rights.

G. Felony Participation.

We do not Cover any illness, treatment or medical condition due to Your participation in

a felony, riot or insurrection. This exclusion does not apply to Coverage for services

involving injuries suffered by a victim of an act of domestic violence or for services as a

result of Your medical condition (including both physical and mental health conditions).

H. Foot Care.

We do not Cover routine foot care in connection with corns, calluses, flat feet, fallen

arches, weak feet, chronic foot strain or symptomatic complaints of the feet. However,

we will Cover foot care when You have a specific medical condition or disease resulting

in circulatory deficits or areas of decreased sensation in Your legs or feet.

I. Government Facility.

We do not Cover care or treatment provided in a Hospital that is owned or operated by

any federal, state or other governmental entity, except as otherwise required by law

unless You are taken to the Hospital because it is close to the place where You were

injured or became ill and Emergency Services are provided to treat Your Emergency

Condition.

J. Medically Necessary.

In general, We will not Cover any health care service, procedure, treatment, test, device

or Prescription Drug that We determine is not Medically Necessary. If an External

Appeal Agent certified by the State overturns Our denial, however, We will Cover the

service, procedure, treatment, test, device or Prescription Drug for which coverage has

been denied, to the extent that such service, procedure, treatment, test, device or

Prescription Drug

is otherwise Covered under the terms of this Certificate.

K. Medicare or Other Governmental Program.

We do not Cover services if benefits are provided for such services under the federal

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Medicare program or other governmental program (except Medicaid).

L. Military Service.

We do not Cover an illness, treatment or medical condition due to service in the Armed

Forces or auxiliary units.

M. No-Fault Automobile Insurance.

We do not Cover any benefits to the extent provided for any loss or portion thereof for

which mandatory automobile no-fault benefits are recovered or recoverable. This

exclusion applies even if You do not make a proper or timely claim for the benefits

available to You under a mandatory no-fault policy.

N. Services Not Listed.

We do not Cover services that are not listed in this Certificate as being Covered.

O. Services Provided by a Family Member.

We do not Cover services performed by a member of the covered person’s immediate

family. “Immediate family” shall mean a child, spouse, mother, father, sister or brother

of You or Your Spouse.

P. Services Separately Billed by Hospital Employees.

We do not Cover services rendered and separately billed by employees of Hospitals,

laboratories or other institutions.

Q. Services With No Charge.

We do not Cover services for which no charge is normally made.

R. Vision Services.

We do not Cover the examination or fitting of eyeglasses or contact lenses, except as

specifically stated in the Pediatric Vision Care section of this Certificate.

S. War.

We do not Cover an illness, treatment or medical condition due to war, declared or

undeclared.

T. Workers’ Compensation.

We do not Cover services if benefits for such services are provided under any state or

federal Workers’ Compensation, employers’ liability or occupational disease law.

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SECTION XVIII

Claim Determinations

A. Claims.

A claim is a request that benefits or services be provided or paid according to the terms

of this Certificate. When You receive services from a Participating Provider, You will not

need to submit a claim form. However, if You receive services from a Non-Participating

Provider either You or the Provider must file a claim form with Us. If the Non-

Participating Provider is not willing to file the claim form, You will need to file it with Us.

B. Notice of Claim.

Claims for services must include all information designated by Us as necessary to

process the claim, including, but not limited to: Member identification number; name;

date of birth; date of service; type of service; the charge for each service; procedure

code for the service as applicable; diagnosis code; name and address of the Provider

making the charge; and supporting medical records, when necessary. A claim that fails

to contain all necessary information will not be accepted and must be resubmitted with

all necessary information. Claim forms are available from Us by calling the number on

Your ID card or visiting Our website at www.aetnastudenthealth.com. Completed claim

forms should be sent to the address in the How Your Coverage Works section of this

Certificate or on Your ID card. You may also submit a claim to Us electronically by

visiting Our website www.aetnastudenthealth.com and logging into the member portal.

C. Timeframe for Filing Claims.

Claims for services must be submitted to Us for payment within 120 days after You

receive the services for which payment is being requested. If it is not reasonably

possible to submit a claim within the 120-day period, You must submit it as soon as

reasonably possible.

D. Claims for Prohibited Referrals.

We are not required to pay any claim, bill or other demand or request by a Provider for

clinical laboratory services, pharmacy services, radiation therapy services, physical

therapy services or x-ray or imaging services furnished pursuant to a referral prohibited

by Section 238-a(1) of the New York Public Health Law.

E. Claim Determinations.

Our claim determination procedure applies to all claims that do not relate to a medical

necessity or experimental or investigational determination. For example, Our claim

determination procedure applies to contractual benefit denials. If You disagree with Our

claim determination, You may submit a Grievance pursuant to the Grievance

Procedures section of this Certificate.

For a description of the Utilization Review procedures and Appeal process for medical

necessity or experimental or investigational determinations, see the Utilization Review

and External Appeal sections of this Certificate.

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F. Pre-Service Claim Determinations.

1. A pre-service claim is a request that a service or treatment be approved before it

has been received. If We have all the information necessary to make a

determination regarding a pre-service claim (e.g., a covered benefit

determination), We will make a determination and provide notice to You (or Your

designee) within 15 days from receipt of the claim.

If We need additional information, We will request it within 15 days from receipt

of the claim. You will have 45 calendar days to submit the information. If We

receive the information within 45 days, We will make a determination and provide

notice to You (or Your designee) in writing, within 15 days of Our receipt of the

information. If all necessary information is not received within 45 days, We will

make a determination within 15 calendar days of the end of the 45-day period.

2. Urgent Pre-Service Reviews. With respect to urgent pre-service requests, if

We have all information necessary to make a determination, We will make a

determination and provide notice to You (or Your designee) by telephone, within

72 hours of receipt of the request. Written notice will follow within three (3)

calendar days of the decision. If We need additional information, We will request

it within 24 hours. You will then have 48 hours to submit the information. We will

make a determination and provide notice to You (or Your designee) by telephone

within 48 hours of the earlier of Our receipt of the information or the end of the

48-hour period. Written notice will follow within three (3) calendar days of the

decision.

G. Post-Service Claim Determinations.

A post-service claim is a request for a service or treatment that You have already

received. If We have all information necessary to make a determination regarding a

post-service claim, We will make a determination and notify You (or Your designee)

within 30 calendar days of the receipt of the claim if We deny the claim in whole or in

part. If We need additional information, We will request it within 30 calendar days. You

will then have 45 calendar days to provide the information. We will make a

determination and provide notice to You (or Your designee) in writing within 15 calendar

days of the earlier of Our receipt of the information or the end of the 45-day period if We

deny the claim in whole or in part.

H. Payment of Claims.

Where Our obligation to pay a claim is reasonably clear, We will pay the claim within 30

days of receipt of the claim (when submitted through the internet or e-mail) and 45 days

of receipt of the claim (when submitted through other means, including paper or fax). If

We request additional information, We will pay the claim within 30 days (for claims

submitted through the internet or e-mail) or 45 days (for claims submitted through other

means, including paper or fax) of receipt of the information.

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SECTION XIX

Grievance Procedures

A. Grievances.

Our Grievance procedure applies to any issue not relating to a Medical Necessity or

experimental or investigational determination by Us. For example, it applies to

contractual benefit denials or issues or concerns You have regarding Our administrative

policies or access to Providers.

B. Filing a Grievance.

You can contact Us by phone at the number on Your ID card or in writing to file a

Grievance. You may submit an oral Grievance in connection with a denial of a Referral

or a covered benefit determination. We may require that You sign a written

acknowledgement of Your oral Grievance, prepared by Us. You or Your designee has

up to 180 calendar days from when You received the decision You are asking Us to

review to file the Grievance.

When We receive Your Grievance, We will mail an acknowledgment letter within 15

business days. The acknowledgment letter will include the name, address and

telephone number of the person handling Your Grievance, and indicate what additional

information, if any, must be provided.

We keep all requests and discussions confidential and We will take no discriminatory

action because of Your issue. We have a process for both standard and expedited

Grievances, depending on the nature of Your inquiry.

You may ask that We send You electronic notification of a Grievance determination

instead of notice in writing or by telephone. You must tell Us in advance if You want to

receive electronic notifications. To opt into electronic notifications, call the number on

Your ID card. You can opt out of electronic notifications at any time.

C. Grievance Determination.

Qualified personnel will review Your Grievance, or if it is a clinical matter, a licensed,

certified or registered Health Care Professional will look into it. We will decide the

Grievance and notify You within the following timeframes:

Expedited/Urgent Grievances:

By phone, within the earlier of 48 hours of

receipt of all necessary information or 72

hours of receipt of Your Grievance.

Written notice will be provided within 72

hours of receipt of Your Grievance.

Pre-Service Grievances: (A request for a

service or treatment that has not yet been

In writing, within 15 calendar days of

receipt of Your Grievance.

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provided.)

Post-Service Grievances: (A claim for a

service or treatment that has already

been provided.)

In writing, within 30 calendar days of

receipt of Your Grievance.

All Other Grievances: (That are not in

relation to a claim or request for a service

or treatment.)

In writing, within 30 calendar days of

receipt of Your Grievance.

D. Assistance.

If You remain dissatisfied with Our Appeal determination, or at any other time You are

dissatisfied, You may:

Call the New York State Department of Financial Services at 1-800-342-3736 or

write them at:

New York State Department of Financial Services

Consumer Assistance Unit

One Commerce Plaza

Albany, NY 12257

Website: www.dfs.ny.gov

If You need assistance filing a Grievance or Appeal, You may also contact the state

independent Consumer Assistance Program at:

Community Health Advocates

633 Third Avenue 10

Floor

New York, NY 10017

Or call toll free: 1-888-614-5400, or e-mail cha@cssny.org

Website: www.communityhealthadvocates.org

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SECTION XX

Utilization Review

A. Utilization Review.

We review health services to determine whether the services are or were Medically

Necessary or experimental or investigational ("Medically Necessary"). This process is

called Utilization Review. Utilization Review includes all review activities, whether they

take place prior to the service being performed (Preauthorization); when the service is

being performed (concurrent); or after the service is performed (retrospective). If You

have any questions about the Utilization Review process, please call the number on

Your ID card. The toll-free telephone number is available at least 40 hours a week with

an after-hours answering machine.

All determinations that services are not Medically Necessary will be made by: 1)

licensed Physicians; or 2) licensed, certified, registered or credentialed Health Care

Professionals who are in the same profession and same or similar specialty as the

Provider who typically manages Your medical condition or disease or provides the

health care service under review; or 3) with respect to mental health or substance use

disorder treatment, licensed Physicians or licensed, certified, registered or credentialed

Health Care Professionals who specialize in behavioral health and have experience in

the delivery of mental health or substance use disorder courses of treatment. We do

not compensate or provide financial incentives to Our employees or reviewers for

determining that services are not Medically Necessary.

We have developed guidelines and protocols to assist Us in this process. We will use

evidence-based and peer reviewed clinical review that are appropriate to the age of the

patient and designated by OASAS for substance use disorder treatment or approved for

use by OMH for mental health treatment. Specific guidelines and protocols are

available for Your review upon request. For more information, call the number on Your

ID card or visit Our website at www.aetnastudenthealth.com.

You may ask that We send You electronic notification of a Utilization Review

determination instead of notice in writing or by telephone. You must tell Us in advance

if You want to receive electronic notifications. To opt into electronic notifications, call

the number on Your ID card or visit Our website at www.aetnastudentheatlh.com. You

can opt out of electronic notifications at any time.

B. Preauthorization Reviews.

1. Non-Urgent Preauthorization Reviews. If We have all the information

necessary to make a determination regarding a Preauthorization review, We will

make a determination and provide notice to You (or Your designee) and Your

Provider, by telephone and in writing, within three (3) business days of receipt of

the request.

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If We need additional information, We will request it within three (3) business

days. You or Your Provider will then have 45 calendar days to submit the

information. If We receive the requested information within 45 days, We will

make a determination and provide notice to You (or Your designee) and Your

Provider, by telephone and in writing, within three (3) business days of Our

receipt of the information. If all necessary information is not received within 45

days, We will make a determination within 15 calendar days of the earlier of the

receipt of part of the requested information or the end of the 45-day period.

2. Urgent Preauthorization Reviews. With respect to urgent Preauthorization

requests, if We have all information necessary to make a determination, We will

make a determination and provide notice to You (or Your designee) and Your

Provider, by telephone, within 72 hours of receipt of the request. Written notice

will be provided within three (3) business days of receipt of the request. If We

need additional information, We will request it within 24 hours. You or Your

Provider will then have 48 hours to submit the information. We will make a

determination and provide notice to You (or Your designee) and Your Provider by

telephone and in writing within 48 hours of the earlier of Our receipt of the

information or the end of the 48 hour period.

3. Court Ordered Treatment. With respect to requests for mental health and/or

substance use disorder services that have not yet been provided, if You (or Your

designee) certify, in a format prescribed by the Superintendent of Financial

Services, that You will be appearing, or have appeared, before a court of

competent jurisdiction and may be subject to a court order requiring such

services, We will make a determination and provide notice to You (or Your

designee) and Your Provider by telephone within 72 hours of receipt of the

request. Written notification will be provided within three (3) business days of

Our receipt of the request. Where feasible, the telephonic and written notification

will also be provided to the court.

4. Inpatient Rehabilitation Services Review. After receiving a Preauthorization

request for coverage of inpatient rehabilitation services following an inpatient

Hospital admission provided by a Hospital or skilled nursing facility, We will make

a determination and provide notice to You (or Your designee) and Your Provider,

by telephone and in writing, within one (1) business day of receipt of the

necessary information.

C. Concurrent Reviews.

1. Non-Urgent Concurrent Reviews. Utilization Review decisions for services

during the course of care (concurrent reviews) will be made, and notice provided

to You (or Your designee), by telephone and in writing, within one (1) business

day of receipt of all necessary information. If We need additional information, We

will request it within one (1) business day. You or Your Provider will then have

45 calendar days to submit the information. We will make a determination and

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provide notice to You (or Your designee) and Your Provider, by telephone and in

writing, within one (1) business day of Our receipt of the information or, if We do

not receive the information, within the earlier of 15 calendar days of the receipt of

part of the requested information or 15 calendar days of the end of the 45-day

period.

2. Urgent Concurrent Reviews. For concurrent reviews that involve an extension

of urgent care, if the request for coverage is made at least 24 hours prior to the

expiration of a previously approved treatment, We will make a determination and

provide notice to You (or Your designee) and Your Provider by telephone within

24 hours of receipt of the request. Written notice will be provided within one (1)

business day of receipt of the request.

If the request for coverage is not made at least 24 hours prior to the expiration of

a previously approved treatment and We have all the information necessary to

make a determination, We will make a determination and provide written notice

to You (or Your designee) and Your Provider within the earlier of 72 hours or one

(1) business day of receipt of the request. If We need additional information, We

will request it within 24 hours. You or Your Provider will then have 48 hours to

submit the information. We will make a determination and provide written notice

to You (or Your designee) and Your Provider within the earlier of one (1)

business day or 48 hours of Our receipt of the information or, if we do not receive

the information, within 48 hours of the end of the 48-hour period.

3. Inpatient Substance Use Disorder Treatment Reviews. If a request for

inpatient substance use disorder treatment is submitted to Us at least 24 hours

prior to discharge from an inpatient substance use disorder treatment admission,

We will make a determination within 24 hours of receipt of the request and We

will provide coverage for the inpatient substance use disorder treatment while

Our determination is pending.

4. Inpatient Mental Health Treatment for Members under 18 at Participating

Hospitals Licensed by the Office of Mental Health (OMH). Coverage for

inpatient mental health treatment at a participating OMH-licensed Hospital is not

subject to Preauthorization. Coverage will not be subject to concurrent review for

the first 14 days of the inpatient admission if the OMH-licensed Hospital notifies

Us of both the admission and the initial treatment plan within two (2) business

days of the admission. After the first 14 days of the inpatient admission, We may

review the entire stay to determine whether it is Medically Necessary, and We

will use clinical review tools approved by OMH. If any portion of the stay is

denied as not Medically Necessary, You are only responsible for the in-network

Cost-Sharing that would otherwise apply to Your inpatient admission.

5. Inpatient Substance Use Disorder Treatment at Participating OASAS-

Certified Facilities. Coverage for inpatient substance use disorder treatment at

a participating OASAS-certified Facility is not subject to Preauthorization.

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Coverage will not be subject to concurrent review for the first 28 days of the

inpatient admission if the OASAS-certified Facility notifies Us of both the

admission and the initial treatment plan within two (2) business days of the

admission. After the first 28 days of the inpatient admission, We may review the

entire stay to determine whether it is Medically Necessary and We will use

clinical review tools designated by OASAS. If any portion of the stay is denied as

not Medically Necessary, You are only responsible for the in-network Cost-

Sharing that would otherwise apply to Your inpatient admission.

6. Outpatient Substance Use Disorder Treatment at Participating OASAS-

Certified Facilities. Coverage for outpatient, intensive outpatient, outpatient

rehabilitation and opioid treatment at a participating OASAS-certified Facility is

not subject to Preauthorization. Coverage will not be subject to concurrent

review for the first four (4) weeks of continuous treatment, not to exceed 28 visits,

if the OASAS-certified Facility notifies Us of both the start of treatment and the

initial treatment plan within two (2) business days. After the first four (4) weeks of

continuous treatment, not to exceed 28 visits, We may review the entire

outpatient treatment to determine whether it is Medically Necessary and We will

use clinical review tools designated by OASAS. If any portion of the outpatient

treatment is denied as not Medically Necessary, You are only responsible for the

in-network Cost-Sharing that would otherwise apply to Your outpatient treatment.

D. Retrospective Reviews.

If We have all information necessary to make a determination regarding a retrospective

claim, We will make a determination and notify You and Your Provider within 30

calendar days of the receipt of the request. If We need additional information, We will

request it within 30 calendar days. You or Your Provider will then have 45 calendar

days to provide the information. We will make a determination and provide notice to

You and Your Provider in writing within 15 calendar days of the earlier of Our receipt of

all or part of the requested information or the end of the 45-day period.

Once We have all the information to make a decision, Our failure to make a Utilization

Review determination within the applicable time frames set forth above will be deemed

an adverse determination subject to an internal Appeal.

E. Retrospective Review of Preauthorized Services.

We may only reverse a preauthorized treatment, service or procedure on retrospective

review when:

• The relevant medical information presented to Us upon retrospective review is

materially different from the information presented during the Preauthorization

review;

• The relevant medical information presented to Us upon retrospective review

existed at the time of the Preauthorization but was withheld or not made available

to Us;

• We were not aware of the existence of such information at the time of the

Preauthorization review; and

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• Had We been aware of such information, the treatment, service or procedure

being requested would not have been authorized. The determination is made

using the same specific standards, criteria or procedures as used during the

Preauthorization review.

F. Step Therapy Override Determinations.

You, Your designee, or Your Health Care Professional may request a step therapy

protocol override determination for Coverage of a Prescription Drug selected by Your

Health Care Professional. When conducting Utilization Review for a step therapy

protocol override determination, We will use recognized evidence-based and peer

reviewed clinical review criteria that is appropriate for You and Your medical condition.

1. Supporting Rationale and Documentation. A step therapy protocol

override determination request must include supporting rationale and

documentation from a Health Care Professional, demonstrating that:

• The required Prescription Drug(s) is contraindicated or will likely cause an

adverse reaction or physical or mental harm to You;

• The required Prescription Drug(s) is expected to be ineffective based on

Your known clinical history, condition, and Prescription Drug regimen;

• You have tried the required Prescription Drug(s) while covered by Us or

under Your previous health insurance coverage, or another Prescription

Drug in the same pharmacologic class or with the same mechanism of

action, and that Prescription Drug(s) was discontinued due to lack of

efficacy or effectiveness, diminished effect, or an adverse event;

• You are stable on a Prescription Drug(s) selected by Your Health Care

Professional for Your medical condition, provided this does not prevent Us

from requiring You to try an AB-rated generic equivalent; or

• The required Prescription Drug(s) is not in Your best interest because it

will likely cause a significant barrier to Your adherence to or compliance

with Your plan of care, will likely worsen a comorbid condition, or will likely

decrease Your ability to achieve or maintain reasonable functional ability

in performing daily activities.

2. Standard Review. We will make a step therapy protocol override

determination and provide notification to You (or Your designee) and where

appropriate, Your Health Care Professional, within 72 hours of receipt of the

supporting rationale and documentation.

3. Expedited Review. If You have a medical condition that places Your health

in serious jeopardy without the Prescription Drug prescribed by Your Health

Care Professional, We will make a step therapy protocol override

determination and provide notification to You (or Your designee) and Your

Health Care Professional within 24 hours of receipt of the supporting rationale

and documentation.

If the required supporting rationale and documentation are not submitted with a step

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therapy protocol override determination request, We will request the information within

72 hours for Preauthorization and retrospective reviews, the lesser of 72 hours or one

(1) business day for concurrent reviews, and 24 hours for expedited reviews. You or

Your Health Care Professional will have 45 calendar days to submit the information for

Preauthorization, concurrent and retrospective reviews, and 48 hours for expedited

reviews. For Preauthorization reviews, We will make a determination and provide

notification to You (or Your designee) and Your Health Care Professional within the

earlier of 72 hours of Our receipt of the information or 15 calendar days of the end of the

45-day period if the information is not received. For concurrent reviews, We will make a

determination and provide notification to You (or Your designee) and Your Health Care

Professional within the earlier of 72 hours or one (1) business day of Our receipt of the

information or 15 calendar days of the end of the 45-day period if the information is not

received. For retrospective reviews, We will make a determination and provide

notification to You (or Your designee) and Your Health Care Professional within the

earlier of 72 hours of Our receipt of the information or 15 calendar days of the end of the

45-day period if the information is not received. For expedited reviews, We will make a

determination and provide notification to You (or Your designee) and Your Health Care

Professional within the earlier of 24 hours of Our receipt of the information or 48 hours

of the end of the 48-hour period if the information is not received.

If We do not make a determination within 72 hours (or 24 hours for expedited reviews)

of receipt of the supporting rationale and documentation, the step therapy protocol

override request will be approved.

If We determine that the step therapy protocol should be overridden, We will authorize

immediate coverage for the Prescription Drug prescribed by Your treating Health Care

Professional. An adverse step therapy override determination is eligible for an Appeal.

G. Reconsideration.

If We did not attempt to consult with Your Provider who recommended the Covered

Service before making an adverse determination, the Provider may request

reconsideration by the same clinical peer reviewer who made the adverse determination

or a designated clinical peer reviewer if the original clinical peer reviewer is unavailable.

For Preauthorization and concurrent reviews, the reconsideration will take place within

one (1) business day of the request for reconsideration. If the adverse determination is

upheld, a notice of adverse determination will be given to You and Your Provider, by

telephone and in writing.

H. Utilization Review Internal Appeals.

You, Your designee, and, in retrospective review cases, Your Provider, may request an

internal Appeal of an adverse determination, either by phone or in writing.

You have up to 180 calendar days after You receive notice of the adverse determination

to file an Appeal. We will acknowledge Your request for an internal Appeal within 15

calendar days of receipt. This acknowledgment will include the name, address, and

phone number of the person handling Your Appeal and, if necessary, inform You of any

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additional information needed before a decision can be made. The Appeal will be

decided by a clinical peer reviewer who is not subordinate to the clinical peer reviewer

who made the initial adverse determination and who is 1) a Physician or 2) a Health

Care Professional in the same or similar specialty as the Provider who typically

manages the disease or condition at issue.

1. Out-of-Network Service Denial. You also have the right to Appeal the denial of

a Preauthorization request for an out-of-network health service when We

determine that the out-of-network health service is not materially different from an

available in-network health service. A denial of an out-of-network health service

is a service provided by a Non-Participating Provider, but only when the service

is not available from a Participating Provider. For a Utilization Review Appeal of

denial of an out-of-network health service, You or Your designee must submit:

• A written statement from Your attending Physician, who must be a

licensed, board-certified or board-eligible Physician qualified to practice in

the specialty area of practice appropriate to treat Your condition, that the

requested out-of-network health service is materially different from the

alternate health service available from a Participating Provider that We

approved to treat Your condition; and

• Two (2) documents from the available medical and scientific evidence that

the out-of-network service: 1) is likely to be more clinically beneficial to

You than the alternate in-network service; and 2) that the adverse risk of

the out-of-network service would likely not be substantially increased over

the in-network health service.

2. Out-of-Network Authorization Denial. You also have the right to Appeal the

denial of a request for an authorization to a Non-Participating Provider when We

determine that We have a Participating Provider with the appropriate training and

experience to meet Your particular health care needs who is able to provide the

requested health care service. For a Utilization Review Appeal of an out-of-

network authorization denial, You or Your designee must submit a written

statement from Your attending Physician, who must be a licensed, board-certified

or board-eligible Physician qualified to practice in the specialty area of practice

appropriate to treat Your condition:

• That the Participating Provider recommended by Us does not have the

appropriate training and experience to meet Your particular health care

needs for the health care service; and

• Recommending a Non-Participating Provider with the appropriate training

and experience to meet Your particular health care needs who is able to

provide the requested health care service.

I. Standard Appeal.

1. Preauthorization Appeal. If Your Appeal relates to a Preauthorization request,

We will decide the Appeal within 30 calendar days of receipt of the Appeal

request. Written notice of the determination will be provided to You (or Your

designee), and where appropriate, Your Provider, within two (2) business days

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after the determination is made, but no later than 30 calendar days after receipt

of the Appeal request.

2. Retrospective Appeal. If Your Appeal relates to a retrospective claim, We will

decide the Appeal within 30 calendar days of receipt of the information necessary

to conduct the Appeal or 60 days of the receipt of Appeal request. Written notice

of the determination will be provided to You (or Your designee), and where

appropriate, Your Provider, within two (2) business days after the determination

is made, but no later than 60 calendar days after receipt of the Appeal request.

3. Expedited Appeal. An Appeal of a review of continued or extended health care

services, additional services rendered in the course of continued treatment,

home health care services following discharge from an inpatient Hospital

admission, services in which a Provider requests an immediate review, mental

health and/or substance use disorder services that may be subject to a court

order, or any other urgent matter will be handled on an expedited basis. An

expedited Appeal is not available for retrospective reviews. For an expedited

Appeal, Your Provider will have reasonable access to the clinical peer reviewer

assigned to the Appeal within one (1) business day of receipt of the request for

an Appeal. Your Provider and a clinical peer reviewer may exchange information

by telephone or fax. An expedited Appeal will be determined within the earlier of

72 hours of receipt of the Appeal or two (2) business days of receipt of the

information necessary to conduct the Appeal. Written notice of the determination

will be provided to You (or Your designee) within 24 hours after the determination

is made, but no later than 72 hours after receipt of the Appeal request.

If You are not satisfied with the resolution of Your expedited Appeal, You may file

a standard internal Appeal or an external appeal.

Our failure to render a determination of Your Appeal within 30 calendar days of

receipt of the necessary information for a standard Appeal or within two (2)

business days of receipt of the necessary information for an expedited Appeal

will be deemed a reversal of the initial adverse determination.

4. Substance Use Appeal. If We deny a request for inpatient substance use

disorder treatment that was submitted at least 24 hours prior to discharge from

an inpatient admission, and You or Your Provider file an expedited internal

Appeal of Our adverse determination, We will decide the Appeal within 24 hours

of receipt of the Appeal request. If You or Your Provider file the expedited

internal Appeal and an expedited external appeal within 24 hours of receipt of

Our adverse determination, We will also provide coverage for the inpatient

substance use disorder treatment while a determination on the internal Appeal

and external appeal is pending.

J. Full and Fair Review of an Appeal.

We will provide You, free of charge, with any new or additional evidence considered,

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relied upon, or generated by Us or any new or additional rationale in connection with Your

Appeal. The evidence or rationale will be provided as soon as possible and sufficiently

in advance of the date on which the notice of final adverse determination is required to

be provided to give You a reasonable opportunity to respond prior to that date.

K. Appeal Assistance.

If You need Assistance filing an Appeal, You may contact the state independent

Consumer Assistance Program at:

Community Health Advocates

633 Third Avenue 10

Floor

New York, NY 10017

Or call toll free: 1-888-614-5400, or e-mail [email protected]

Website: www.communityhealthadvocates.org

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SECTION XXI

External Appeal

A. Your Right to an External Appeal.

In some cases, You have a right to an external appeal of a denial of coverage. If We

have denied coverage on the basis that a service is not Medically Necessary (including

appropriateness, health care setting, level of care or effectiveness of a Covered

benefit); or is an experimental or investigational treatment (including clinical trials and

treatments for rare diseases); or is an out-of-network treatment, You or Your

representative may appeal that decision to an External Appeal Agent, an independent

third party certified by the State to conduct these appeals.

In order for You to be eligible for an external appeal You must meet the following two (2)

requirements:

• The service, procedure, or treatment must otherwise be a Covered Service under

this Certificate; and

• In general, You must have received a final adverse determination through Our

internal Appeal process. But, You can file an external appeal even though You

have not received a final adverse determination through Our internal Appeal

process if:

o We agree in writing to waive the internal Appeal. We are not required to

agree to Your request to waive the internal Appeal; or

o You file an external appeal at the same time as You apply for an

expedited internal Appeal; or

o We fail to adhere to Utilization Review claim processing requirements

(other than a minor violation that is not likely to cause prejudice or harm to

You, and We demonstrate that the violation was for good cause or due to

matters beyond Our control and the violation occurred during an ongoing,

good faith exchange of information between You and Us).

B. Your Right to Appeal a Determination that a Service is Not Medically

Necessary.

If We have denied coverage on the basis that the service is not Medically Necessary,

You may appeal to an External Appeal Agent if You meet the requirements for an

external appeal in paragraph “A” above.

C. Your Right to Appeal a Determination that a Service is Experimental or

Investigational.

If We have denied coverage on the basis that the service is an experimental or

investigational treatment (including clinical trials and treatments for rare diseases), You

must satisfy the two (2) requirements for an external appeal in paragraph “A” above and

Your attending Physician must certify that Your condition or disease is one for which:

1. Standard health services are ineffective or medically inappropriate; or

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2. There does not exist a more beneficial standard service or procedure Covered by

Us; or

3. There exists a clinical trial or rare disease treatment (as defined by law).

In addition, Your attending Physician must have recommended one (1) of the following:

1. A service, procedure or treatment that two (2) documents from available medical

and scientific evidence indicate is likely to be more beneficial to You than any

standard Covered Service (only certain documents will be considered in support

of this recommendation – Your attending Physician should contact the State for

current information as to what documents will be considered or acceptable); or

2. A clinical trial for which You are eligible (only certain clinical trials can be

considered); or

3. A rare disease treatment for which Your attending Physician certifies that there is

no standard treatment that is likely to be more clinically beneficial to You than the

requested service, the requested service is likely to benefit You in the treatment

of Your rare disease, and such benefit outweighs the risk of the service. In

addition, Your attending Physician must certify that Your condition is a rare

disease that is currently or was previously subject to a research study by the

National Institutes of Health Rare Disease Clinical Research Network or that it

affects fewer than 200,000 U.S. residents per year.

For purposes of this section, Your attending Physician must be a licensed, board-

certified or board eligible Physician qualified to practice in the area appropriate to treat

Your condition or disease. In addition, for a rare disease treatment, the attending

Physician may not be Your treating Physician.

D. Your Right to Appeal a Determination that a Service is Out-of-Network.

If We have denied coverage of an out-of-network treatment because it is not materially

different than the health service available in-network, You may appeal to an External

Appeal Agent if You meet the two (2) requirements for an external appeal in paragraph

“A” above, and You have requested Preauthorization for the out-of-network treatment.

In addition, Your attending Physician must certify that the out-of-network service is

materially different from the alternate recommended in-network health service, and

based on two (2) documents from available medical and scientific evidence, is likely to

be more clinically beneficial than the alternate in-network treatment and that the

adverse risk of the requested health service would likely not be substantially increased

over the alternate in-network health service.

For purposes of this section, Your attending Physician must be a licensed, board

certified or board eligible Physician qualified to practice in the specialty area appropriate

to treat You for the health service.

E. Your Right to Appeal an Out-of-Network Authorization Denial to a Non-

Participating Provider.

If We have denied coverage of a request for an authorization to a Non-Participating

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Provider because We determine We have a Participating Provider with the appropriate

training and experience to meet Your particular health care needs who is able to provide

the requested health care service, You may appeal to an External Appeal Agent if You

meet the two (2) requirements for an external appeal in paragraph “A” above.

In addition, Your attending Physician must: 1) certify that the Participating Provider

recommended by Us does not have the appropriate training and experience to meet

Your particular health care needs; and 2) recommend a Non-Participating Provider with

the appropriate training and experience to meet Your particular health care needs who

is able to provide the requested health care service.

For purposes of this section, Your attending Physician must be a licensed, board

certified or board eligible Physician qualified to practice in the specialty area appropriate

to treat You for the health service.

F. Your Right to Appeal a Formulary Exception Denial.

If We have denied Your request for coverage of a non-formulary Prescription Drug

through Our formulary exception process, You, Your designee or the prescribing Health

Care Professional may appeal the formulary exception denial to an External Appeal

Agent. See the Prescription Drug Coverage section of this Certificate for more

information on the formulary exception process.

G. The External Appeal Process.

You have four (4) months from receipt of a final adverse determination or from receipt of

a waiver of the internal Appeal process to file a written request for an external appeal. If

You are filing an external appeal based on Our failure to adhere to claim processing

requirements, You have four (4) months from such failure to file a written request for an

external appeal.

We will provide an external appeal application with the final adverse determination

issued through Our internal Appeal process or Our written waiver of an internal Appeal.

You may also request an external appeal application from the New York State

Department of Financial Services at 1-800-400-8882. Submit the completed application

to the Department of Financial Services at the address indicated on the application. If

You meet the criteria for an external appeal, the State will forward the request to a

certified External Appeal Agent.

You can submit additional documentation with Your external appeal request. If the

External Appeal Agent determines that the information You submit represents a material

change from the information on which We based Our denial, the External Appeal Agent

will share this information with Us in order for Us to exercise Our right to reconsider Our

decision. If We choose to exercise this right, We will have three (3) business days to

amend or confirm Our decision. Please note that in the case of an expedited external

appeal (described below), We do not have a right to reconsider Our decision.

In general, the External Appeal Agent must make a decision within 30 days of receipt of

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Your completed application. The External Appeal Agent may request additional

information from You, Your Physician, or Us. If the External Appeal Agent requests

additional information, it will have five (5) additional business days to make its decision.

The External Appeal Agent must notify You in writing of its decision within two (2)

business days.

If Your attending Physician certifies that a delay in providing the service that has been

denied poses an imminent or serious threat to Your health; or if Your attending

Physician certifies that the standard external appeal time frame would seriously

jeopardize Your life, health or ability to regain maximum function; or if You received

Emergency Services and have not been discharged from a Facility and the denial

concerns an admission, availability of care, or continued stay, You may request an

expedited external appeal. In that case, the External Appeal Agent must make a

decision within 72 hours of receipt of Your completed application. Immediately after

reaching a decision, the External Appeal Agent must notify You and Us by telephone or

facsimile of that decision. The External Appeal Agent must also notify You in writing of

its decision.

If Your internal formulary exception request received a standard review through Our

formulary exception process, the External Appeal Agent must make a decision on Your

external appeal and notify You or Your designee and the prescribing Health Care

Professional by telephone within 72 hours of receipt of Your completed application. The

External Appeal Agent will notify You or Your designee and the prescribing Health Care

Professional in writing within two (2) business days of making a determination. If the

External Appeal Agent overturns Our denial, We will Cover the Prescription Drug while

You are taking the Prescription Drug, including any refills.

If Your internal formulary exception request received an expedited review through Our

formulary exception process, the External Appeal Agent must make a decision on Your

external appeal and notify You or Your designee and the prescribing Health Care

Professional by telephone within 24 hours of receipt of Your completed application. The

External Appeal Agent will notify You or Your designee and the prescribing Health Care

Professional in writing within 72 hours of receipt of Your completed application. If the

External Appeal Agent overturns Our denial, We will Cover the Prescription Drug while

You suffer from the health condition that may seriously jeopardize Your health, life or

ability to regain maximum function or for the duration of Your current course of

treatment using the non-formulary Prescription Drug.

If the External Appeal Agent overturns Our decision that a service is not Medically

Necessary or approves coverage of an experimental or investigational treatment or an

out-of-network treatment, We will provide coverage subject to the other terms and

conditions of this Certificate. Please note that if the External Appeal Agent approves

coverage of an experimental or investigational treatment that is part of a clinical trial,

We will only Cover the cost of services required to provide treatment to You according

to the design of the trial. We will not be responsible for the costs of investigational

drugs or devices, the costs of non-health care services, the costs of managing the

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research, or costs that would not be Covered under this Certificate for non-

investigational treatments provided in the clinical trial.

The External Appeal Agent’s decision is binding on both You and Us. The External

Appeal Agent’s decision is admissible in any court proceeding.

H. Your Responsibilities.

It is Your responsibility to start the external appeal process. You may start the

external appeal process by filing a completed application with the New York State

Department of Financial Services. You may appoint a representative to assist You with

Your application; however, the Department of Financial Services may contact You and

request that You confirm in writing that You have appointed the representative.

Under New York State law, Your completed request for external appeal must be

filed within four (4) months of either the date upon which You receive a final

adverse determination, or the date upon which You receive a written waiver of

any internal Appeal, or Our failure to adhere to claim processing requirements.

We have no authority to extend this deadline.

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SECTION XXII

Termination of Coverage

Coverage under this Certificate will automatically be terminated on the first of the

following to apply:

1. The Student has failed to pay Premiums within 30 days of when Premiums are

due. Coverage will terminate as of the last day for which Premiums were paid.

2. The end of the month in which the Student ceases to meet the eligibility

requirements as defined by the Us. We will provide written notice to the Student

at least 30 days prior to when the coverage will cease.

3. Upon the Student’s death, coverage will terminate unless the Student has

coverage for Dependents. If the Student has coverage for Dependents, then

coverage will terminate as of the last day of the month for which the Premium

has been paid.

4. For Spouses in cases of divorce, the date of the divorce.

5. For Children, until the end of the month in which the Child turns 30 years of age.

6. For all other Dependents, the end of the month in which the Dependent ceases to

be eligible.

7. The end of the month during which the Student provides written notice to Us

requesting termination of coverage, or on such later date requested for such

termination by the notice.

8. If a Student or the Student’s Dependent has performed an act that constitutes

fraud or the Student has made an intentional misrepresentation of material fact in

writing on his or her enrollment application, or in order to obtain coverage for a

service, coverage will terminate immediately upon written notice of termination

delivered by Us to the Student and/or the Student’s Dependent, as applicable.

However, if a Student makes an intentional misrepresentation of material fact in

writing on his or her enrollment application, We will rescind coverage if the facts

misrepresented would have led Us to refuse to issue the coverage. Rescission

means that the termination of Your coverage will have a retroactive effect of up to

Your enrollment under the Certificate. If termination is a result of the Student’s

action, coverage will terminate for the Student and any Dependents. If

termination is a result of the Dependent’s action, coverage will terminate for the

Dependent.

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9. For such other reasons that are acceptable to the superintendent and authorized

by the Health Insurance Portability and Accountability Act of 1996, Public Law

104-191, and any later amendments or successor provisions, or by any federal

regulations or rules that implement the provisions of the Act.

No termination shall prejudice the right to a claim for benefits which arose prior to such

termination.

Refund Policy

If Your status as a Student changes with the University to cancel/withdraw/no-show

within the first 31 days of a coverage period, you will not be Covered under the

Certificate and the full premium amount paid will be refunded. After 31 days, you will be

Covered for the full period that you have paid the premium for, and a prorated refund

will be applied if you elect to terminate Your coverage.

Refunds will not be provided within 60 days of the policy expiring or termination of

student status (cancel/withdraw, degree complete).

Exception: A Member entering the armed forces of any country will not be covered

under the Certificate as of the date of such entry. In this case, a pro-rata refund of

premium will be made for any such person and any Covered Dependents upon written

request received by Us within 90 days of withdrawal from school.

NOTE: If claims from any provider have been submitted and paid for any period, no full

refund will be provided under any circumstances and the cancellation policy applies.

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SECTION XXIII

Extension of Benefits

When Your coverage under this Certificate ends, benefits stop. But, if You are totally

disabled on the date Your coverage under this Certificate terminates, continued benefits

may be available for the treatment of the injury or sickness that is the cause of the total

disability. If you are pregnant on the date Your coverage under this Certificate

terminates, continued benefits may be available for Your maternity care.

For purposes of this section, “total disability” means You are prevented because of

injury or disease from engaging in any work or other gainful activity. Total disability for a

minor means that the minor is prevented because of injury or disease from engaging in

substantially all of the normal activities of a person of like age and sex who is in good

health.

A. When You May Continue Benefit.

1. If You are totally disabled on the date Your coverage under this Certificate

terminates, We will continue to pay for Your care under this Certificate during an

uninterrupted period of total disability until the first of the following:

• The date You are no longer totally disabled; or

• 90 days from the date extended benefits began (if Your benefits are extended

based on termination of Student status).

2. If You are pregnant on the date Your coverage under this Certificate terminates, We

will continue to pay for Your maternity care under this Certificate through delivery

and any post-partum services directly related to the delivery.

B. Limits on Extended Benefits.

We will not pay extended benefits:

• For any Member who is not totally disabled or pregnant on the date coverage

under this Certificate ends; or

• Beyond the extent to which We would have paid benefits under this Certificate if

coverage had not ended.

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SECTION XXIV

Continuation of Coverage

A. Qualifying Events.

You, the Student, Your Spouse and Your Children may be able to temporarily continue

coverage under this Certificate in certain situations, when You would otherwise lose

coverage, known as qualifying events.

1. If Your coverage ends due to the termination of Your Student status You may

continue coverage. Coverage may be continued for You, Your Spouse and any

of Your covered Children.

2. If You are a covered Spouse, You may continue coverage if Your coverage ends

due to:

• Termination of the Student’s status as a Student;

• Divorce or legal separation from the Student; or

• Death of the Student.

3. If You are a covered Child, You may continue coverage if Your coverage ends

due to:

• Termination of the Student’s status as a Student;

• Loss of covered Child status under the plan rules; or

• Death of the Student.

If You want to continue coverage, You must request continuation from Us in writing and

make the first Premium payment within the 60-day period following the later of:

1. The date coverage would otherwise terminate; or

2. The date You are sent notice electronically or by first class mail of the right of

continuation by Us.

Continued coverage under this section will terminate at the earliest of the following:

1. The date 90 days after the Student’s coverage would have terminated because

of termination of Student status;

2. If You are a covered Spouse or Child, the date 90 days after coverage would

have terminated due to the death of the Student, divorce or legal separation, the

Student’s eligibility for Medicare, or the failure to qualify under the definition of

“Children”;

3. The date You become covered by an insured or uninsured arrangement that

provides hospital, surgical or medical coverage;

4. The date You become entitled to Medicare;

5. The date to which Premiums are paid if You fail to make a timely payment.

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SECTION XXV

Temporary Suspension Rights for Armed Forces’ Members

If You, the Student, are a member of a reserve component of the armed forces of the

United States, including the National Guard, You have the right to temporary

suspension of coverage during active duty and reinstatement of coverage at the end of

active duty if:

1. Your active duty is extended during a period when the president is authorized to

order units of the reserve to active duty, provided that such additional active duty

is at the request and for the convenience of the federal government; and

2. Your service ends during the Plan Year for which this Certificate is effective.

You must make written request to Us to have Your coverage suspended during a period

of active duty. Your unearned Premiums will be refunded during the period of such

suspension.

Upon completion of active duty, Your coverage may be resumed as long as You:

1. Make written application to Us; and

2. Remit the Premium within 60 days of the termination of active duty.

The right of resumption extends to coverage for Your Dependents. For coverage that

was suspended while on active duty, coverage will be retroactive to the date on which

active duty terminated.

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SECTION XXVI

General Provisions

1. Agreements Between Us and Participating Providers.

Any agreement between Us and Participating Providers may only be terminated by Us

or the Providers. This Certificate does not require any Provider to accept a Member as

a patient. We do not guarantee a Member’s admission to any Participating Provider or

any health benefits program.

2. Assignment.

You cannot assign any benefits under this Certificate to any person, corporation or other

organization. You cannot assign any monies due under this Certificate to any person,

corporation or other organization unless it is an assignment to Your Provider for a

surprise bill or to a Hospital for Emergency Services, including inpatient services

following Emergency Department Care. See the How Your Coverage Works section of

this Certificate for more information about surprise bills. Any assignment of benefits by

You other than for monies due for a surprise bill or an assignment of monies due to a

Hospital for Emergency Services, including inpatient services following Emergency

Department Care, will be void and unenforceable.

Assignment means the transfer to another person, corporation or other organization of

Your right to the services provided under this Certificate or Your right to collect money

from Us for those services.

3. Choice of Law.

This Certificate shall be governed by the laws of the State of New York.

4. Clerical Error.

Clerical error, whether by You or Us, with respect to this Certificate, or any other

documentation issued by Us in connection with this Certificate, or in keeping any record

pertaining to the coverage hereunder, will not modify or invalidate coverage otherwise

validly in force or continue coverage otherwise validly terminated.

. Conformity with Law.

Any term of this Certificate which is in conflict with New York State law or with any

applicable federal law that imposes additional requirements from what is required under

New York State law will be amended to conform with the minimum requirements of such

law.

6. Continuation of Benefit Limitations.

Some of the benefits in this Certificate may be limited to a specific number of visits,

and/or subject to a Deductible. You will not be entitled to any additional benefits if Your

coverage status should change during the year. For example, if Your coverage status

changes from covered family member to Student, all benefits previously utilized when

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You were a covered family member will be applied toward Your new status as a

Student.

7. Entire Agreement.

This Certificate including any endorsements, riders and the attached applications, if any,

constitutes the entire Certificate.

8. Furnishing Information and Audit.

All persons covered under this Certificate will promptly furnish Us with all information

and records that We may require from time to time to perform Our obligations under this

Certificate. You must provide Us with information over the telephone for reasons such

as the following: to allow Us to determine the level of care You need; so that We may

certify care authorized by Your Physician; or to make decisions regarding the Medical

Necessity of Your care.

9. Identification Cards.

Identification (“ID”) cards are issued by Us for identification purposes only. Possession

of any ID card confers no right to services or benefits under this Certificate. To be

entitled to such services or benefits, Your Premiums must be paid in full at the time the

services are sought to be received.

10. Incontestability.

No statement made by the Student in an application for coverage under this Certificate

shall avoid the Certificate or be used in any legal proceeding unless the application or

an exact copy is attached to this Certificate.

11. Independent Contractors.

Participating Providers are independent contractors. They are not Our agents or

employees. We and Our employees are not the agent or employee of any Participating

Provider. We are not liable for any claim or demand on account of damages arising out

of, or in any manner connected with, any injuries alleged to be suffered by You, Your

covered Spouse or Children while receiving care from any Participating Provider or in

any Participating Provider's Facility.

12. Input in Developing Our Policies.

Students may participate in the development of Our policies by participating in the

Student Health Benefit Advisory Committee or communicating with a representative of

the Student, Graduate/Professional Student, or University Assemblies. For more

information see: https://studenthealthbenefits.cornell.edu/about/shbac

13. Material Accessibility.

We will give You ID cards, Certificates, riders and other necessary materials.

14. More Information about Your Health Plan.

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You can request additional information about Your coverage under this Certificate.

Upon Your request, We will provide the following information:

• A list of the names, business addresses and official positions of Our board of

directors, officers and members; and Our most recent annual certified financial

statement which includes a balance sheet and a summary of the receipts and

disbursements.

• The information that We provide the State regarding Our consumer complaints.

• A copy of Our procedures for maintaining confidentiality of Member information.

• A copy of Our drug formulary. You may also inquire if a specific drug is

Covered under this Certificate.

• A written description of Our quality assurance program.

• A copy of Our medical policy regarding an experimental or investigational drug,

medical device or treatment in clinical trials.

• Provider affiliations with participating Hospitals.

• A copy of Our clinical review criteria (e.g., Medical Necessity criteria), and

where appropriate, other clinical information We may consider regarding a

specific disease, course of treatment or Utilization Review guidelines, including

clinical review criteria relating to a step therapy protocol override determination.

• Written application procedures and minimum qualification requirements for

Providers.

• Documents that contain the processes, strategies evidentiary standards, and

other factors used to apply a treatment limitation with respect to

medical/surgical benefits and mental health or substance use disorder benefits

under the Certificate.

15. Notice.

Any notice that We give You under this Certificate will be mailed to Your address as it

appears in Our records or delivered electronically if You consent to electronic delivery.

If notice is delivered to You electronically, You may also request a copy of the notice

from Us. You agree to provide Us with notice of any change of Your address. If You

have to give Us any notice, it should be sent by U.S. mail, first class, postage prepaid

to: Cornell University Office of Student Health Benefits, 395 Pine Tree Rd, Ithaca, NY,

14850.

16. Premium Refund.

We will give any refund of Premiums which are paid by You, if due, to You.

17. Recovery of Overpayments.

On occasion, a payment will be made to You when You are not covered, for a service

that is not Covered, or which is more than is proper. When this happens, We will

explain the problem to You and You must return the amount of the overpayment to Us

within 60 days after receiving notification from Us. However, We shall not initiate

overpayment recovery efforts more than 24 months after the original payment was

made unless We have a reasonable belief of fraud or other intentional misconduct.

18. Reinstatement after Default.

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If the Student defaults in making any payment this Certificate, the subsequent

acceptance of payment by Us shall reinstate the Certificate.

19. Right to Develop Guidelines and Administrative Rules.

We may develop or adopt standards that describe in more detail when We will or will not

make payments under this Certificate. Examples of the use of the standards are to

determine whether: Hospital inpatient care was Medically Necessary; surgery was

Medically Necessary to treat Your illness or injury; or certain services are skilled care.

Those standards will not be contrary to the descriptions in this Certificate. If You have a

question about the standards that apply to a particular benefit, You may contact Us and

We will explain the standards or send You a copy of the standards. We may also

develop administrative rules pertaining to enrollment and other administrative matters.

We shall have all the powers necessary or appropriate to enable Us to carry out Our

duties in connection with the administration of this Certificate.

We review and evaluate new technology according to technology evaluation criteria

developed by Our medical directors and reviewed by a designated committee, which

consists of Health Care Professionals from various medical specialties. Conclusions of

the committee are incorporated into Our medical policies to establish decision protocols

for determining whether a service is Medically Necessary, experimental or

investigational, or included as a covered benefit.

20. Right to Offset.

If We make a claim payment to You or on Your behalf in error or You owe Us any

money, You must repay the amount You owe Us. Except as otherwise required by law,

if We owe You a payment for other claims received, We have the right to subtract any

amount You owe Us from any payment We owe You.

21. Severability.

The unenforceability or invalidity of any provision of this Certificate shall not affect the

validity and enforceability of the remainder of this Certificate.

22. Significant Change in Circumstances.

If We are unable to arrange for Covered Services as provided under this Certificate as

the result of events outside of Our control, We will make a good faith effort to make

alternative arrangements. These events would include a major disaster, epidemic, the

complete or partial destruction of facilities, riot, civil insurrection, disability of a

significant part of Participating Providers' personnel, or similar causes. We will make

reasonable attempts to arrange for Covered Services. We and Our Participating

Providers will not be liable for delay, or failure to provide or arrange for Covered

Services if such failure or delay is caused by such an event.

23. Subrogation and Reimbursement.

These paragraphs apply when another party (including any insurer) is, or may be found

to be, responsible for Your injury, illness or other condition and We have provided

benefits related to that injury, illness or condition. As permitted by applicable state law,

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unless preempted by federal law, We may be subrogated to all rights of recovery

against any such party (including Your own insurance carrier) for the benefits We have

provided to You under this Certificate. Subrogation means that We have the right,

independently of You, to proceed directly against the other party to recover the benefits

that We have provided.

Subject to applicable state law, unless preempted by federal law, We may have a right

of reimbursement if You or anyone on Your behalf receives payment from any

responsible party (including Your own insurance carrier) from any settlement, verdict or

insurance proceeds, in connection with an injury, illness, or condition for which We

provided benefits. Under Section 5-335 of the New York General Obligations Law, Our

right of recovery does not apply when a settlement is reached between a plaintiff and

defendant, unless a statutory right of reimbursement exists. The law also provides that,

when entering into a settlement, it is presumed that You did not take any action against

Our rights or violate any contract between You and Us. The law presumes that the

settlement between You and the responsible party does not include compensation for

the cost of health care services for which We provided benefits.

We request that You notify Us within 30 days of the date when any notice is given to

any party, including an insurance company or attorney, of Your intention to pursue or

investigate a claim to recover damages or obtain compensation due to injury, illness or

condition sustained by You for which We have provided benefits. You must provide all

information requested by Us or Our representatives including, but not limited to,

completing and submitting any applications or other forms or statements as We may

reasonably request.

24. Third Party Beneficiaries.

No third party beneficiaries are intended to be created by this Certificate and nothing in

this Certificate shall confer upon any person or entity other than You or Us any right,

benefit, or remedy of any nature whatsoever under or by reason of this Certificate. No

other party can enforce this Certificate’s provisions or seek any remedy arising out of

either Our or Your performance or failure to perform any portion of this Certificate, or to

bring an action or pursuit for the breach of any terms of this Certificate.

25. Time to Sue.

No action at law or in equity may be maintained against Us prior to the expiration of 60

days after written submission of a claim has been furnished to Us as required in this

Certificate. You must start any lawsuit against Us under this Certificate within three (3)

years from the date the claim was required to be filed.

26. Translation Services.

Translation services are available under this Certificate for non-English speaking

Members. Please contact Us at the number on Your ID card to access these services.

27. Venue for Legal Action.

107

CU2122-01

If a dispute arises under this Certificate, it must be resolved in a court located in the

State of New York. You agree not to start a lawsuit against Us in a court anywhere

else. You also consent to New York State courts having personal jurisdiction over You.

That means that, when the proper procedures for starting a lawsuit in these courts have

been followed, the courts can order You to defend any action We bring against You.

28. Waiver.

The waiver by any party of any breach of any provision of this Certificate will not be

construed as a waiver of any subsequent breach of the same or any other provision.

The failure to exercise any right hereunder will not operate as a waiver of such right.

29. Who May Change this Certificate.

This Certificate may not be modified, amended, or changed, except in writing and

signed by Our Executive Vice President and Chief Financial Officer (“EVP/CFO) or a

person designated by the EVP/CFO. No employee, agent, or other person is authorized

to interpret, amend, modify, or otherwise change this Certificate in a manner that

expands or limits the scope of coverage, or the conditions of eligibility, enrollment, or

participation, unless in writing and signed by the EVP/CFO or person designated by the

EVP/CFO.

30. Who Receives Payment under this Certificate.

Payments under this Certificate for services provided by a Participating Provider will be

made directly by Us to the Provider. If You receive services from a Non-Participating

Provider, We reserve the right to pay either You or the Provider. If You assign benefits

for a surprise bill to Your Non-Participating Provider, We will pay the Non-Participating

Provider directly. See the How Your Coverage Works section of this Certificate for

more information about surprise bills.

31. Workers’ Compensation Not Affected.

The coverage provided under this Certificate is not in lieu of and does not affect any

requirements for coverage by workers’ compensation insurance or law.

32. Your Medical Records and Reports.

In order to provide Your coverage under this Certificate, it may be necessary for Us to

obtain Your medical records and information from Providers who treated You. Our

actions to provide that coverage include processing Your claims, reviewing Grievances,

Appeals or complaints involving Your care, and quality assurance reviews of Your care,

whether based on a specific complaint or a routine audit of randomly selected cases.

By accepting coverage under this Certificate, except as prohibited by state or federal

law, You automatically give Us or Our designee permission to obtain and use Your

medical records for those purposes and You authorize each and every Provider who

renders services to You to:

• Disclose all facts pertaining to Your care, treatment, and physical condition to

Us or to a medical, dental, or mental health professional that We may engage

to assist Us in reviewing a treatment or claim, or in connection with a complaint

or quality of care review;

108

CU2122-01

• Render reports pertaining to Your care, treatment, and physical condition to Us,

or to a medical, dental, or mental health professional that We may engage to

assist Us in reviewing a treatment or claim; and

• Permit copying of Your medical records by Us.

We agree to maintain Your medical information in accordance with state and federal

confidentiality requirements. However, to the extent permitted under state or federal

law, You automatically give Us permission to share Your information with the New York

State Department of Health, quality oversight organizations, and third parties with which

We contract to assist Us in administering this Certificate, so long as they also agree to

maintain the information in accordance with state and federal confidentiality

requirements.

33. Your Rights and Responsibilities.

As a Member, You have rights and responsibilities when receiving health care. As Your

health care partner, We want to make sure Your rights are respected while providing

Your health benefits. You have the right to obtain complete and current information

concerning a diagnosis, treatment and prognosis from a Physician or other Provider in

terms You can reasonably understand. When it is not advisable to give such

information to You, the information shall be made available to an appropriate person

acting on Your behalf.

You have the right to receive information from Your Physician or other Provider that You

need in order to give Your informed consent prior to the start of any procedure or

treatment.

You have the right to refuse treatment to the extent permitted by law and to be informed

of the medical consequences of that action.

You have the right to formulate advance directives regarding Your care.

You have the right to access Our Participating Providers.

As a Member, You should also take an active role in Your care. We encourage You to:

• Understand Your health problems as well as You can and work with Your

Providers to make a treatment plan that You all agree on;

• Follow the treatment plan that You have agreed on with Your doctors or

Providers;

• Give Us, Your doctors and other Providers the information needed to help

You get the care You need and all the benefits You are eligible for under Your

Certificate. This may include information about other health insurance

benefits You have along with Your coverage with Us; and

• Inform Us if You have any changes to Your name, address or Dependents

covered under Your Certificate.

109

CU2122-01

For additional information regarding Your rights and responsibilities, visit the FAQs on

Our website at www.aetnastudenthealth.com. If You do not have internet access, You

can call Us at the number on Your ID card to request a copy.

110

CU2122-01

SECTION XXVII

Other Covered Services

SHP provides medical evacuation and repatriation services for Students with an

international visa while You are attending a University outside of Your Home County.

Expatriates are eligible for medical services while in your Host County or while traveling

outside your Home Country.

If the condition is a medical emergency, You should go immediately to the nearest

physician or hospital without delay or call 911.

A. Medical Evacuation and Repatriation Services

1. Emergency Medical Evacuation

We will pay Emergency Medical Evacuation Benefits for expenses incurred for the

medical evacuation of a Member. Benefits are payable if the Member suffers an

illness or injury; and requires Emergency Medical Evacuation.

We will cover emergency medical evacuation services when:

• the Provider ordering the Emergency Medical Evacuation certifies the

severity of the Member’s injury or illness requires an Emergency Medical

Evacuation;

• all transportation arrangements made for the Emergency Medical

Evacuation are by arranged Cornell University Student Health Plan or its

designated service provider;

• the charges incurred are recommended by Your Provider and do not

exceed the usual level of charges for similar transportation, treatment,

services or supplies in the locality where the expense is incurred; and

• does not include charges not coverable by this Certificate.

Benefits will not be payable unless coordinated by Cornell University Student Health

Plan or Our travel assistance designee.

2. Repatriation of Remains

We will pay Repatriation of Remains Benefits for return of a Student’s body to his or

her Home Country if he or she dies due to an injury or illness. Covered expenses

include transporting the remains by the most direct and least costly conveyance and

route possible.

Benefits will not be payable unless coordinated by Cornell University Student Health

Plan.

111

CU2122-01

Definitions

Emergency Medical Evacuation: Emergency medically necessary travel services that

occur while a You are traveling more than 100 miles away from your place of residence

including:

• Immediate transportation from the place where You suffer an illness or injury

resulting in an emergency condition to the nearest Hospital or other medical

facility where appropriate medical treatment can be obtained; or

• Transportation to Your Home Country to obtain further or continuing medical

treatment in a Hospital or other medical facility or to recover after suffering an

injury or illness.

Expatriate: If You are temporarily traveling or residing outside Your Home Country for

ninety (90) consecutive calendar days or who spends a total number of more than one

hundred and eighty days outside of Your Home Country in any plan year. This applies

only to Students who are not United States citizens.

Home Country: the country or territory as shown on Your passport or the country or

territory of which You are a permanent resident. This applies only to Student who are

not United States citizens.

Host Country: with respect to a Student, the country or territory You are visiting or in

which You are living, which is not Your Home Country.

B. Additional Benefits for Transgender Services

We will pay for permanent hair removal, including electrolysis, when a Student is

undergoing sex reassignment surgery. This is not a medically necessary benefit.

Prior authorization is required for this benefit.

CU2122-02

112

SECTION XXVIII

STUDENT HEALTH PLAN SCHEDULE OF BENEFITS

Platinum Level, AV 90.48%

Cornell University

COST-SHARING

Medical Deductible

• Individual

• Family

Out-of-Pocket Limit

• Individual

• Family

Participating Provider

Member Responsibility

for Cost-Sharing

None

$ 3,000

$ 6,000

Non-Participating

Provider

Member Responsibility

for Cost-Sharing

$ 400

$ 800

$ 3,000

$ 6,000

See the Cost-Sharing

Expenses and Allowed

Amount section of this

Certificate for a

description of how We

calculate the Allowed

Amount.

Any charges of a Non-

Participating Provider that

are in excess of the

Allowed Amount do not

apply towards the

Deductible or Out-of-

Pocket Limit. You must

pay the amount of the

Non-Participating

Provider’s charge that

exceeds Our Allowed

Amount.

OFFICE VISITS

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

Primary Care Office Visits

(or Home Visits)

$25 Copayment

30% Coinsurance, after

Deductible

See benefit

for

description

CU2122-02

113

Specialist Office Visits

(or Home Visits)

$25 Copayment

30% Coinsurance,

After Deductible

See benefit

for

description

PREVENTIVE CARE

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

Well Child Visits and

Immunizations*

• Adult Annual Physical

Examinations*

• Adult Immunizations*

• Routine Gynecological

Services/Well Woman

Exams*

• Mammograms,

Screening and

Diagnostic Imaging for

the Detection of Breast

Cancer

• Sterilization

Procedures for

Women*

• Vasectomy

Covered in full

Use Cost-Sharing for

appropriate service

(Surgical Services;

Anesthesia Services;

Ambulatory Surgical

Center Fee; Outpatient

Hospital Surgery Facility

Charge

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

CU2122-02

114

• Bone Density Testing*

• Screening for Prostate

Cancer

• All other preventive

services required by

USPSTF and HRSA.

• *When preventive

services are not

provided in accordance

with the

comprehensive

guidelines supported

by USPSTF and

HRSA.

Covered in full

Use Cost-Sharing for

appropriate service

(Primary Care Office

Visit; Specialist Office

Visit; Diagnostic

Radiology Services;

Laboratory Procedures

and Diagnostic Testing)

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

EMERGENCY CARE

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

Pre-Hospital Emergency

Medical Services

(Ambulance Services)

Covered in full

See benefit

for

description

Non-Emergency

Ambulance Services

Preauthorization

Required

Covered in full

Preauthorization

Required

Covered in full

Preauthorization

Required

See benefit

for

description

Emergency Department

Copayment waived if

Hospital admission

$ 100 Copayment

Health care forensic

examinations performed

under Public Health Law

§ 2805-I are not subject

to Cost-Sharing

$ 100 Copayment, not

subject to Deductible

See benefit

for

description

CU2122-02

115

Urgent Care Center

Preauthorization

Required

$ 50 Copayment

$ 50 Copayment, not

subject to Deductible

Preauthorization

Required for In-Network

Cost Share

See benefit

for

description

PROFESSIONAL

SERVICES and

OUTPATIENT CARE

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

Acupuncture

30% Coinsurance

30%, after Deductible

See benefit

for

description

Advanced Imaging

Services

• Performed in a

Specialist Office

• Performed in a

Freestanding

Radiology Facility

• Performed as

Outpatient Hospital

Services

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Allergy Testing and

Treatment

• Performed in a PCP

Office

• Performed in a

Specialist Office

$25 Copayment,

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Ambulatory Surgical

Center Facility Fee

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

Anesthesia Services

(all settings)

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

CU2122-02

116

Autologous Blood Banking

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

Cardiac and Pulmonary

Rehabilitation

• Performed in a

Specialist Office

• Performed as

Outpatient Hospital

Services

• Performed as Inpatient

Hospital Services

10% Coinsurance

Included as part of

inpatient Hospital service

Cost-Sharing

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

Included as part of

inpatient Hospital service

Cost-Sharing

See benefit

for

description

Chemotherapy and

Immunotherapy

Administration

• Performed in a PCP

Office

• Performed in a

Specialist Office

• Performed as

Outpatient Hospital

Services

• Performed at Home

Chemotherapy and

Immunotherapy

Medications

$25 Copayment

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Chiropractic Services

$25 Copayment

30% Coinsurance, after

Deductible

See benefit

for

description

Clinical Trials

Preauthorization

Required

Use Cost-Sharing for

appropriate service

Preauthorization

Required

Use Cost-Sharing for

appropriate service

Preauthorization

Required

See benefit

for

description

CU2122-02

117

Diagnostic Testing

• Performed in a PCP

Office

• Performed in a

Specialist Office

• Performed as

Outpatient Hospital

Services

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Dialysis

• Performed in a PCP

Office

• Performed in a

Specialist Office

• Performed in a

Freestanding Center

• Performed as

Outpatient Hospital

Services

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Habilitation Services

(Physical Therapy,

Occupational Therapy or

Speech Therapy)

$25 Copayment

30% Coinsurance, after

Deductible

60 visits per

condition, per

Plan Year

combined

therapies

Home Health Care

$25 Copayment

30% Coinsurance, after

Deductible

40 visits per

Plan Year

Infertility Services

Use Cost-Sharing for

appropriate service

(Office Visit; Diagnostic

Radiology Services;

Surgery; Laboratory &

Diagnostic Procedures)

Use Cost-Sharing for

appropriate service

(Office Visit; Diagnostic

Radiology Services;

Surgery; Laboratory &

Diagnostic Procedures)

See benefit

for

description

CU2122-02

118

Infusion Therapy

Administration

• Performed in a PCP

Office

• Performed in Specialist

Office

• Performed as

Outpatient Hospital

Services

• Home Infusion Therapy

Infusion Therapy

Medication

$25 Copayment

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Home

infusion

counts toward

home health

care visit

limits

Inpatient Medical Visits

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

Interruption of Pregnancy

• Medically Necessary

Abortions

• Elective Abortions

Covered in full

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

Unlimited

Unlimited.

Laboratory Procedures

• Performed in a PCP

Office

• Performed in a

Specialist Office

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

CU2122-02

119

• Performed in a

Freestanding

Laboratory Facility

• Performed as

Outpatient Hospital

Services

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

Maternity and Newborn

Care

Prenatal Care

• Prenatal Care provided

in accordance with the

comprehensive

guidelines supported

by USPSTF and HRSA

• Prenatal Care that is

not provided in

accordance with the

comprehensive

guidelines supported

by USPSTF and HRSA

Inpatient Hospital Services

and Birthing Center

Physician and Midwife

Services for Delivery

Breastfeeding Support,

Counseling and Supplies,

Including Breast Pumps

Postnatal Care

Covered in full

Use Cost-Sharing for

appropriate service

(Primary Care Office

Visit, Specialist Office

Visit, Diagnostic

Radiology Services,

Laboratory Procedures

and Diagnostic Testing)

10% Coinsurance, per

admission

10% Coinsurance, per

admission

Covered in full

30% Coinsurance, after

Deductible

Use Cost-Sharing for

appropriate service

(Primary Care Office

Visit, Specialist Office

Visit, Diagnostic

Radiology Services,

Laboratory Procedures

and Diagnostic Testing)

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

One (1)]

home care

visit is

covered at no

Cost-Sharing

if mother is

discharged

from Hospital

early

Covered for

duration of

breast

feeding

CU2122-02

120

Outpatient Hospital

Surgery Facility Charge

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

Preadmission Testing

$25 Copayment

30% Coinsurance, after

Deductible

See benefit

for

description

Prescription Drugs

Administered in Office and

Outpatient Facility

• Performed in a PCP

Office

• Performed in Specialist

Office

• Performed in

Outpatient Facilities

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Diagnostic Radiology

Services

• Performed in a PCP

Office

• Performed in a

Specialist Office

• Performed in a

Freestanding

Radiology Facility

• Performed as

Outpatient Hospital

Services

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Therapeutic Radiology

Services

• Performed in a

Specialist Office

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

CU2122-02

121

• Performed in a

Freestanding

Radiology Facility

• Performed as

Outpatient Hospital

Services

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

Rehabilitation Services

(Physical Therapy,

Occupational Therapy or

Speech Therapy)

• Performed in a PCP

Office

• Performed in a

Specialist Office

• Performed in an

Outpatient Facility

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

60 visits per

condition, per

Plan Year

combined

therapies

Speech and

physical

therapy are

only Covered

following a

Hospital stay

or surgery

Retail Health Clinic Care

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

Second Opinions on the

Diagnosis of Cancer,

Surgery and Other

$25 Copayment

30% Coinsurance, after

Deductible

Second opinions on

diagnosis of cancer are

Covered at participating

Cost-sharing for non-

participating Specialist

See benefit

for

description

Surgical Services

(including Oral Surgery;

Reconstructive Breast

Surgery; Other

Reconstructive and

Corrective Surgery; and

Transplants)

• Inpatient Hospital

Surgery

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

All

transplants

must be

CU2122-02

122

• Outpatient Hospital

Surgery

• Surgery Performed at

an Ambulatory Surgical

Center

• Office Surgery

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

performed at

designated

Facilities

ADDITIONAL SERVICES,

EQUIPMENT and

DEVICES

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

ABA Treatment for Autism

Spectrum Disorder

$25 Copayment

30% Coinsurance, after

Deductible

See benefit

for

description

Assistive Communication

Devices for Autism

Spectrum Disorder

$25 Copayment

30% Coinsurance, after

Deductible

See benefit

for

description

Diabetic Equipment,

Supplies and Self-

Management Education

• Diabetic Equipment,

Supplies and Insulin

(30-day supply)

• Diabetic Education

$25 Copayment

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Durable Medical

Equipment and Braces

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

External Hearing Aids

10% Coinsurance

30% Coinsurance, after

Deductible

Single

purchase

once every

three (3)

years

Cochlear Implants

10% Coinsurance

30% Coinsurance, after

Deductible

One (1) per

ear per time

Covered

CU2122-02

123

Hospice Care

• Inpatient

• Outpatient

Covered in full

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

210 days per

Plan Year

Unlimited

visits for

family

bereavement

counseling

Medical Supplies

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

Prosthetic Devices

• External

• Internal

10% Coinsurance

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

One (1)

prosthetic

device, per

limb, per plan

year, with

coverage for

repairs and

replacements

Unlimited;

See benefit

for

description

INPATIENT SERVICES

and FACILITIES

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

Inpatient Hospital for a

Continuous Confinement

(including an Inpatient

Stay for Mastectomy Care,

Cardiac and Pulmonary

Rehabilitation, and End of

Life Care)

Preauthorization

Required.

However, Preauthorization

is not required for

emergency admissions or

services provided in a

neonatal intensive care

unit of a Hospital certified

pursuant to Article 28 of

the Public Health Law.

10% Coinsurance

Preauthorization

Required.

30% Coinsurance, after

Deductible

Preauthorization

Required.

See benefit

for

description

CU2122-02

124

Observation Stay

10% Coinsurance

30% Coinsurance, after

Deductible

See benefit

for

description

Skilled Nursing Facility

(including Cardiac and

Pulmonary Rehabilitation)

Preauthorization

Required

10% Coinsurance

Preauthorization

Required

30% Coinsurance, after

Deductible

Preauthorization

Required

200 days per

Plan Year

Inpatient Habilitation

Services (Physical Speech

and Occupational

Therapy)

Preauthorization

required

10% Coinsurance

Preauthorization

required

30% Coinsurance, after

Deductible

Preauthorization

required

60 days per

Plan Year

combined

therapies

Inpatient Rehabilitation

Services

(Physical, Speech and

Occupational Therapy)

Preauthorization

Required.

10% Coinsurance

Preauthorization

Required

30% Coinsurance, after

Deductible

Preauthorization

Required

60 days per

Plan Year

combined

therapies

Speech and

physical

therapy are

only Covered

following a

Hospital stay

or surgery

MENTAL HEALTH and

SUBSTANCE USE

DISORDER SERVICES

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

Inpatient Mental Health

Care for a continuous

confinement when in a

Hospital (including

Residential Treatment)

Preauthorization

Required.

However, Preauthorization

is not required for

emergency admissions or

for admissions at

Participating OMH-

licensed Facilities for

Members under 18.

10% Coinsurance

Preauthorization

Required.

30% Coinsurance, after

Deductible

Preauthorization

Required.

See benefit

for

description

CU2122-02

125

Outpatient Mental Health

Care

(including Partial

Hospitalization and

Intensive Outpatient

Program Services)

• Office visits

• All other outpatient

services

$10 Copayment

$25 Copayment

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Inpatient Substance Use

Services for a continuous

confinement when in a

Hospital (including

Residential Treatment)

Preauthorization

Required.

However, Preauthorization

is Not Required for

Emergency Admissions or

for Participating OASAS-

certified Facilities.

10% Coinsurance

Preauthorization

Required.

30% Coinsurance, after

Deductible

Preauthorization

Required.

See benefit

for

description

Outpatient Substance Use

Services (including Partial

Hospitalization, Intensive

Outpatient Program

Services, and Medication

Assisted Treatment)

• Office Visits

• All other outpatient

services

$10 Copayment

$25 Copayment

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

Unlimited; Up

to 20 visits

per Plan Year

may be used

for family

counseling

PRESCRIPTION DRUGS

*Certain Prescription

Drugs are not subject to

Cost-Sharing when

provided in accordance

with the comprehensive

guidelines supported by

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

CU2122-02

126

HRSA or if the item or

service has an “A” or

“B” rating from the

USPSTF.

Retail Pharmacy

30-day supply

Tier 1

Tier 2

Tier 3

Preauthorization is not

required for a Covered

Prescription Drug used to

treat a substance sue

disorder, including a

Prescription Drug to

manage opioid withdrawal

and/or stabilization and for

opioid overdose reversal.

$12 Copayment

$40 Copayment

$60 Copayment

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Up to a 90-day supply for

Maintenance Drugs

Tier 1

Tier 2

Tier 3

$36 Copayment

$120 Copayment

$180 Copayment

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

Enteral Formulas

Tier 1

Tier 2

$12 Copayment

$40 Copayment

30% Coinsurance, after

Deductible

30% Coinsurance, after

Deductible

See benefit

for

description

CU2122-02

127

Tier 3

$60 Copayment

30% Coinsurance, after

Deductible

WELLNESS BENEFITS

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Gym Reimbursement

Up to $200 per six (6)

month period; up to an

additional $100 per six

(6) month period for

Spouse.

Up to $200 per six (6)

month period; up to an

additional $100 per six

(6) month period for

Spouse.

Up to $200

per six (6)

month period;

up to an

additional

$100 per six

(6) month

period for

Spouse.

PEDIATRIC DENTAL and

VISION CARE

Participating Provider

Member Responsibility

for Cost-Sharing

Non-Participating

Provider Member

Responsibility for Cost-

Sharing

Limits

Pediatric Dental Care

• Preventive Dental Care

• Routine Dental Care

• Major Dental Care

(Oral Surgery,

Endodontics,

Periodontics and

Prosthodontics)

• Orthodontics

Covered in full

50% Coinsurance

50% Coinsurance, after

Deductible

50% Coinsurance, after

Deductible

50% Coinsurance, after

Deductible

50% Coinsurance, after

Deductible

One (1)

dental exam

and cleaning

per six (6)-

month period

Full mouth x-

rays or

panoramic x-

rays at 36-

month

intervals and

bitewing x-

rays at six (6)

month

intervals

Pediatric Vision Care

• Exams

• Lenses and Frames

• Contact Lenses

Covered in full

50% Coinsurance

50% Coinsurance, after

Deductible

50% Coinsurance, after

Deductible

50% Coinsurance, after

Deductible

One (1) exam

per 12-month

period

One (1)

prescribed

lenses and

frames per

12-month

period

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128

Other Covered Services

Emergency Medical

Evacuation

Repatriation of Remains

Covered in full

See benefit

for

description

Benefit

maximum is

$15,000

Additional Benefits for

Transgender Services

• Permanent Hair

removal including

electrolysis

Covered in full

Benefit

maximum is

$3,000.00

All in-network Preauthorization requests are the responsibility of Your Participating Provider. You will

not be penalized for a Participating Provider’s failure to obtain a required Preauthorization. However,

if services are not covered under the Certificate, You will be responsible for the full cost of the

services.