Plan year: August 18, 2008–August 17, 2009

Student Gold Health Insurance Plan

Schedule of Medical Benefits of Care Outside Wardenburg Health Center

Inpatient
Outpatient
Other

STUDENT HEALTH INSURANCE PLAN / POLICY #697421 SCHEDULE OF MEDICAL EXPENSE BENEFITS PAID AS SPECIFIED BELOW FOR INJURY AND SICKNESS. AGGREGATE MAXIMUM OF $250,000 PER INSURED, PER LIFETIME. DEDUCTIBLE -- $200 (PER INSURED PERSON) (PER POLICY YEAR)

If two or more covered members of a family are injured in the same accident, only one deductible will be charged each policy year against their combined eligible expenses due to the accident.
Preferred Allowance means the Aetna's Student Health allowance for a specified covered medical expense or the provider’s charge, whichever is less.
After the deductible has been satisfied, covered medical expenses will be paid at the applicable percentage specified below, up to an aggregate maximum of $250,000 per insured, per lifetime.
Prescription drug expenses will be covered at 50 percent up to $3,000 maximum (per policy year).
One eye exam per policy year up to $60 maximum, at Wardenburg Health Center only.
The following will be covered the same as any other sickness: Nasal Sinusitis, Sleep Disorders, Fertility Testing, Bone Density Scan, TMJ (temporomandibular joint dysfunction), and Attention Deficit Disorder (ADHD/ADD test not covered).
Coverage for newborn infants is subject to ALL Policy Provisions.
The Policy provides benefits for the reasonable charges* (UCC) incurred by an Insured Person for loss due to a covered Injury or Sickness.
If you receive care from a Preferred Provider, any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. See Preferred Provider information.
If a Preferred Provider is not available in your Network Area (within 15 miles), benefits will be paid at the level of benefits shown as Preferred Provider benefits.
If the Covered Medical Expenses are incurred due to an emergency treatment, benefits will be paid at the Preferred Provider level of Benefits. In all other situations, reduced, or lower benefits will be provided when an Out-of-Network provider is used.
The Benefits payable are as defined in and subject to all provisions of the Policy.

Inpatient
	In Network (preferred providers)	Out of Network
Location	Aetna PPO www.aetnastudenthealth.com
Hospitalization Fee	$200 per hospitalization in addition to deductible	$200 per hospitalization in addition to deductible
Room & Board/Hospital Miscellaneous, daily semi-private room rate, and general nursing care provided by the hospital. Hospital miscellaneous expenses such as the cost of the operating room, laboratory tests, X-ray examinations, anesthesia, drugs (excluding take-home drugs) or medicines, therapeutic services, and supplies. In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge.	80 percent of Preferred Allowance	50 percent of reasonable charges*
Intensive Care	Paid under Hospital Miscellaneous	Paid under Hospital Miscellaneous
Physiotherapy, benefits are payable only for a condition that required surgery or hospital confinement: 1) within the 30 days immediately preceding such physiotherapy or 2) within the 30 days immediately following the attending physician's release for rehabilitation.	80 percent of Preferred Allowance $2000 maximum per policy year	50 percent of reasonable charges* $2000 maximum per policy year
Surgeon's Fees, if multiple procedures are performed, the first and second procedures will be payable at 80 percent and the third procedure will be payable at 25 percent. Four or more procedures will be paid a composite fee based on the physician' s written report.	80 percent of Preferred Allowance	50 percent of reasonable charges*
Anesthetist	80 percent of Preferred Allowance	80 percent of reasonable charges*
Registered Nurse's Services, private-duty nursing care	80 percent of Preferred Allowance	50 percent of reasonable charges*
Physician's Visits, benefits are limited to one visit per day and do not apply when related to surgery	80 percent of Preferred Allowance	50 percent of reasonable charges*
Pre-Admission Testing, benefits for eligible charges incurred in connection with pre-admission X-rays and laboratory tests when the resulting hospital confinement starts within 10 days.	80 percent of Preferred Allowance	50 percent of reasonable charges*
Psychotherapy (Inpatient), (Nonbiological)	80 percent of Preferred Allowance 45 days maximum (per policy year)	50 percent of reasonable charges* 45 days maximum (per policy year)
Biologically Based Mental Illness	Paid as any other sickness	Paid as any other sickness
Alcoholism/Drug Abuse	80 percent of Preferred Allowance 45 days maximum (per policy year)	50 percent of reasonable charges 45 days maximum (per policy year)

*Based on the Medical Data Research (MDR) Index.

Outpatient
	In Network (preferred providers)	Out of Network
Location	Aetna PPO www.aetnastudenthealth.com
Surgeon's Fees, if multiple procedures are performed, the first and second procedures will be payable at 80 percent and the third procedure will be payable at 25 percent. Four or more procedures will be paid a composite fee based on the physician's written report.	80 percent of Preferred Allowance	50 percent of reasonable charges*
Day Surgery Miscellaneous related to scheduled surgery performed in a hospital, including the cost of the operating room; laboratory tests and X-ray examinations, including professional fees; anesthesia; drugs or medicines; and supplies. reasonable charges* for Day Surgery Miscellaneous are based on the Outpatient Surgical Facility Charge Index.	80 percent of Preferred Allowance	50 percent of reasonable charges*
Anesthetist	80 percent of Preferred Allowance	80 percent of reasonable charges*
Physician's Visits benefits are limited to one visit per day. Benefits for Physician's Visits do not apply when related to surgery or physiotherapy.	80 percent of Preferred Allowance	50 percent of reasonable charges*
Physiotherapy, Dialysis Treatment, Speech and Respiratory Therapy benefits are limited to one visit per day and do not apply when related to physician's visits. Benefits are payable only for a condition that required surgery or hospital confinement: 1) within the 30 days immediately preceding such physiotherapy, or 2) within the 30 days immediately following the attending physician's release for rehabilitation. In addition, physiotherapy visits for other than surgery or hospitalization are available at Wardenburg Health Center only.	80 percent of Preferred Allowance $2000 maximum per policy year	50 percent of reasonable charges* $2000 maximum per policy year
Medical Emergency Expenses, use of the Emergency Room and supplies	$50 per visit in addition to deductible / waived if hospitalized 80 percent of Preferred Allowance	$50 per visit in addition to deductible / waived if hospitalized 80 percent of reasonable charges*
Diagnostic X-ray & Laboratory Services	80 percent of Preferred Allowance	50 percent of reasonable charges*
Radiation Therapy & Chemotherapy	80 percent of Preferred Allowance	50 percent of reasonable charges*
Prescription Drugs, benefits payable for generic drugs (and brand drugs when no generic drugs are available). The policy deductible does not apply to prescriptions. (Limited to 30-day supply or 100 units, whichever is greater, at time of purchase.)	50 percent of negotiated rate $3,000 maximum (per policy year)	50 percent of reasonable charges* $3,000 maximum (per policy year)
Tests & Procedures, diagnostic services and medical procedures performed by a physician; other than physician's visits; physiotherapy; X-rays and lab procedures.	80 percent of Preferred Allowance	50 percent of reasonable charges*
Injections, when administered in the physician's office and charged on the physician's statement	80 percent of Preferred Allowance	50 percent of reasonable charges*
Psychotherapy	80 percent of Preferred Allowance $2,000 maximum (per Policy year)	50 percent of reasonable charges* $2,000 maximum (per Policy year)
Biologically Based Mental Illness	Paid as any other sickness	Paid as any other sickness
Alcoholism/Drug Abuse	80 percent of Preferred Allowance $2,000 maximum (per policy year)	50 percent of reasonable charges* $2,000 maximum (per policy year)

Other
Ambulance Services	80 percent of Preferred Allowance	80 percent of reasonable charges*
Braces and Appliances, a written prescription must accompany the claim when submitted. Replacement braces and appliances are covered if required because of a change in the insured's physical condition. Benefits include prosthetic devices.	80 percent of Preferred Allowance	80 percent of reasonable charges*
Consultant Physician Fees, when requested and approved by the attending physician	80 percent of Preferred Allowance	50 percent of reasonable charges*
Dental Treatment, made necessary by injury to sound, natural teeth	80 percent of Preferred Allowance $2,000 maximum (per policy year)	50 percent of reasonable charges* $2,000 maximum (per policy year)
Maternity/Complications of Pregnancy	Paid as any other sickness	Paid as any other sickness
Repatriation/Medical Evaluation	Benefits provided by Assist America	Benefits provided by Assist America
Mammography The policy deductible will not apply	100 percent Preferred Allowance	50 percent of reasonable charges*

*Based on the Medical Data Research (MDR) Index.

All benefits provided outside of Wardenburg Health Center are underwritten by the Aetna Student Health and the benefits payable are as defined in and subject to all provisions of the Policy. (www.aetnastudenthealth.com; 888-834-4708)