2017-2018

San José State University
International Student Health Insurance Plan

https://studentinsurance.wellsfargo.com

Underwritten by: Plan Brokered by:
Aetna Life Insurance Company Wells Fargo Insurance Services USA, Inc.
Policy #867866 CA License No. 0D08408

The California State University Student Health Insurance Plan is underwritten by Aetna Life Insurance Company. Aetna Student HealthSM is the brand name for products and
services provided by Aetna Life Insurance Company and its applicable affiliated companies (Aetna).
You can view the standard Summary of Benefits & Coverage (SBC) which is required by Health Care Reform. It summarizes your coverage in a
format that all insurance companies now use. To view your plan SBC, go to: https://studentinsurance.wellsfargo.com
or call 800-853-5899 to request a paper copy free of charge.
15.02.310.1 E

50 $624. Rates also include Medical Evacuation and Repatriation and Worldwide Emergency Travel Assistance benefits/services provided through On Call International and its contracted underwriting companies. To obtain a copy of our notice describing in greater detail roll when coverage terminates to maintain coverage.33 $886. Dependents must be enrolled for the same term of coverage as student. parties are required to keep NPI confidential as provided by applicable law. When both parents have • The beginning date of the term for which premium has been paid group health plans that provide coverage as a dependent. as well as administrative fees payable to CSU and Wells Fargo Student Insurance. and their respective agents. sation. When Coverage Ends Insurance of all Insured Persons terminates at 11:59 p. ven- its termination date and the subsequent policy will go into effect immediately dors. the fective at 12:01 a. including definitions. against unlawful use and disclosure. hospitals. Final decisions regarding coverage effective dates are made by Aetna Student Health. access to your medical records within a reasonable amount of time after you COVERAGE IS NOT AUTOMATICALLY RENEWED.Premiums will not be pro-rated if the Insured enrolls past the first date of coverage for which he or she is applying. Spouse only $1. on the earlier of: • Date the Master Policy terminates for all Insured Persons. Extension of Benefits The below enrollments will be allowed a 30 day grace period from the term If a covered person is totally disabled on the termination date of the Policy.aetnastudenthealth. please call Aetna Stu- dent Health at (866) 378-8885 or send an email through your Aetna Navigator Account. the operation of your health Plan.489. on the later of. the Master Policy will govern and control the payment of benefits. please call the toll-free expiration or renewal will be sent. The benefits available under this Plan may be coordinated with other benefits versity. expenses incurred after the termination date and during the con- within 30 days of the prior policy termination date. and other caregivers). or Notice • End of the period of coverage for which premium has been paid. Medicare. government authorities.International .16 Per Child (Age 0-25) only $1.m. The Plan pays in accordance with the rules set forth in the Master Policy. are received by Wells Fargo Student Insurance.com. but only while they are incurred during the 30 day period. No policy shall ever start prior to the term start date: treat medical conditions causing or directly related to the disability as deter- 1. the policy with the earliest effective date will stay in force through viders (doctors.50 $644. When necessary for your care or treat- ment. follow- ing such termination of insurance.12/31/17 1/1/18 . When Coverage Begins Coordination of Benefits Coverage under the Plan once premium has been collected will become ef.com.16 Rates include premium payable to Aetna Life Insurance Company. or other related activities. All hard-waiver and mandatory (insurance is required as a condition of mined by Aetna. You will be able to obtain a copy of the full Master Policy as soon as it is available. share it with our affiliates.489. start date to enroll whereby the effective date will be backdated a maximum benefits will be extended to provide covered benefits that are necessary to of 30 days.16 NOTE: Costs below are in addition to the student premium. PROGRAM COSTS ANNUAL FALL SPRING/SUMMER Terms of Coverage 8/1/17 . make a request. shall be payable in accordance with the policy. but no sooner than: benefits of the plan that covers the insured student will be used before those • The Master Policy effective date. Eligible Persons must re-en. No notification of plan our practices concerning use and disclosure of NPI. IMPORTANT NOTICE This is a brief description of the Student Health Plan underwritten by Aetna Life Insurance Company (Aetna). Dependent enrollment in this plan is voluntary. Dependent coverage will not be effective prior to that of the Insured Student Participating Network/Preferred Care Providers are also required to give you or extend beyond that of the Insured Student.33 $865. If the Covered Person is insured under more than one group health plan. All re-enrollments into the same exact policy if re-enrollment occurs terminates.aetnastudenthealth. or dential and has policies and procedures in place to protect the information • Date the Insured Person enters military service. are contained in the Master Policy issued to your school and may be viewed online at www. If any discrepancy exists between this Benefit Summary and the Policy. These afterward with no gap in coverage. If a Covered Person is confined to a hospital on the date his or her insurance 2. •2• San José State University . Authorized Agent or Uni.7/31/18 Student only $1. of a plan that provides coverage as a dependent. For information regarding the full Master Policy.50 $624. consultants.33 $865. and disclose it to healthcare pro- number. tinuance of that hospital confinement.529. pharmacies. Workers’ Compen- • The day after the date of postmark if the Enrollment Form is mailed. we use In the event there is overlapping coverage under the same Master Policy NPI internally. IMPORTANT NOTICE . or available to the Covered Person under any auto insurance. dentists.7/31/17 8/1/17 . The exact provisions governing this insurance. Customer Services number on your ID card or visit Aetna Student Health on the internet at: www. enrollment on campus) insurance programs. or Aetna considers non-public personal member information (“NPI”) confi- • Date the Insured Person ceases to be eligible for the insurance. or other coverage. the benefits of the • The day after the Enrollment Form (if applicable) and premium payment plan of the parent whose birth date falls earlier in the year will be used first.m.

the date of birth and by payment of any additional premium.m. (Note: personal checks are not always a payment option.Health Insurance Requirement Premium Refund/Cancellation and Eligibility Refund requests should be directed to Wells Fargo Student Insurance at (800) 853-5899 or via email at studentinsurance@wellsfargo. All international students. or within 31 days of one of the following quali- • If itemized medical bills are available at the time the claim form is sub- fied events: marriage. and birth abnormalities from birth until 31 days old. according to the benefits of your Student Accident and Sickness when Wells Fargo Student Insurance is notified in writing within 31 days from Insurance Plan. details. Monday through Friday. Contact Wells Fargo Student Insurance for more premium. • Dependents must be enrolled for the same term of coverage for which the Insured Student enrolls.O. visiting faculty. adoption or arrival mitted. your and your dependents insurance cover- met.). the only obligation is a pro-rata refund of premium. etc.). A ing event must be submitted. These students must provide Wells Fargo On occasion. a written spouse’s. •3• San José State University . If and whenever Aetna and/or Wells Fargo Stu. medical claim during the insured period. Box 981106. did not file a medical claim during this period. Refunds will not be prorated. birth. the claims investigation process will require additional infor- Student Insurance with proof that they have lost insurance through another mation in order to properly adjudicate the claim. This investigation will be group (certificate and letter of ineligibility) within 30 days of the qualifying handled directly by: event. when approved by the school and any applicable regulatory INSURANCE PAYMENTS WITH PERSONAL CHECK authority. injury. Agent to the Insurer.S. upon writ- • the student’s name.com. Dependents of an Eligible International student within 180 days from the date appearing on the Explanation of Benefits or visiting faculty member must possess a valid passport and a proper visa (EOB). (F-2. Written proof of with- Coverage is available for students engaged in “Practical Training”.aetnastudenthealth. occurred event. The effective date would be the later of: a) term effective date. pro-rata refund of premium will be made for such person. please call Wells Fargo Student Insur. domestic partner who resides with the Insured Student and the student’s.) you and your insured dependents will not be covered under the Master Policy as of the date of such entry. closure of account. and 3. dent’s enrollment in the plan. and Dependents must re-enroll when coverage terminates to maintain coverage. Coverage for Dependents • Bills must be submitted within 90 days from the date of treatment. age will be terminated retroactive to the effective date of the enrolled term.International . A “Newborn” will automatically be covered for preventive care. A refund of premium will be granted for the reasons listed below only. Please check your Aetna and Wells Fargo Student Insurance maintain the right to investigate school’s enrollment form for available payment options. scholars or other persons possess. a • the student must have paid the required premium.m. Written proof of such qualify- erage is purchased. (A person who is an immigrant or permanent resident alien is not 2. If you withdraw after 45 days must be accompanied by confirmation of Practical Training from the insured of the coverage period. • You will receive an “Explanation of Benefits” when your claims are pro- fects. attach them to the claim form. your and your insured dependents coverage will student in the form of a copy of your EAD (OPT coverage is available for the remain in effect until the end of the term for which you have paid the first 12 months of OPT only). Refunds will be granted for insured dependents in case of a qualifying • the student must actively attend classes on campus for 45 consecutive event such as legal separation. student number and date of birth must have been ten request received by Wells Fargo Student Insurance within 45 days included in the declaration made by the School or the Administrative of entry into service. providing that the cessed. or your dependents‘ insurance payment via personal check payable to Wells quirements have been met. you and your insured dependents will receive a full refund of permanent residency status. once-per-lifetime exception may be made in cases of a student’s medical withdrawal. addition of domestic partner. for any questions. If you or your insured dependents enter the armed forces of any country eligible for coverage under the international plan. If your dependent enters the armed forces.) If you make your student status and attendance records to verify that the Policy eligibility re. If you withdraw from school within the first 45 days of the coverage temporarily located outside their home country and have not been granted period. If you enter the armed forces the To be an Insured Person under the Policy: policy will be cancelled. Eligible dependents are the spouse or legally registered and valid be mailed promptly to the above address. are required to be insured under the Policy and the insurance premium provided that you and your insured dependents must directly enroll before registering for classes. The Explanation of Benefits will explain how your claim was pro- student is covered under this plan. etc. or M-2). with the exception of school-authorized breaks. or b) Aetna Student Health the day after prior coverage ends if enrollment request is received by Wells P. Customer Service Representatives are available 8:30 a.com. Eligible students who involuntarily lose coverage under another group insur- ance plan are also eligible to purchase the Student Health Insurance Plan How Do I File a Claim? within 30 days of loss of coverage. pital or Physician concerned unless bill receipts and proof of payment sured Students may also purchase Dependent coverage at the time of stu. El Paso. engaged in educational activities at San José State University who are 1. are submitted. Coverage may be continued for that child cessed. premature birth. the • In the event of a disagreement over the payment of a claim. medically diagnosed congenital de. Claim forms can be obtained by calling the number above or by visiting www. or the domestic partner’s natural child. Enrollment drawal from the school must be provided. (PST). • Dependent coverage expires concurrently with that of the Insured Stu- dent. • Payment for Covered Medical Expenses will be made directly to the hos- Note: dependent enrollment in this plan is on a voluntary basis. No ing and maintaining a current passport and valid visa status (F-1. (866) 378-8885 (toll-free) tions regarding eligibility for this plan. J-2. other refunds will be granted. TX 79998 Fargo Student Insurance within 30 days from loss of prior coverage. J-1 or M-1. divorce or death within 31 days of the days following the effective date for the term purchased and/or pur. to 5:30 p. For ques. stepchild or legally adopted request to review the claim must be mailed to Aetna Student Health child under 26 years of age. Fargo Insurance and we are unable to process the check (due to insufficient dent Insurance discover that the Policy eligibility requirements have not been funds. provided that your insured dependents did not file a suant to the student’s visa requirements for the period for which cov. Subsequent medical bills should in the U. Eligible In. ance at 1-800-853-5899. sickness.

www. For help with registering.aetnastudenthealth. less your copay. ferred Pharmacy. responsible for the full cost of the discounted services. nor is it a guarantee of pay. must be paid for in full at the time of service and submit- ted for reimbursement.aetnastudenthealth. Students are responsible for By logging into Aetna Navigator®. Click on “Find Your School” and enter your How do I register? school name. from 7 a.com belongs to Aetna’s network or to find Preferred Care Providers practicing in • Click on “Find Your School. The Informed Health Line is a 24-hours-a-day. When obtaining a covered prescription. you can use Aetna’s online DocFind® service located at • Send an e-mail to Aetna Student Health Customer Service. Please note that these When you need to fill a prescription. and be ditional services and search for providers visit. see instructions the Schedule of Benefits are available to the insured dependents. The member is Aetna for the cost of the drug. To learn more about these ad- you may obtain your prescription from an Aetna Preferred Pharmacy.aetnastudenthealth. operative reports.m. less the copay amount. Aetna does not provide care 378-8885.m.m. Physician’s office notes.” If a service or supply that a covered person needs is covered under the Plan • Click on Aetna Navigator® and then the “Access Navigator” link.m. visit www.O. • Follow the instructions for First Time User by clicking on the “Register tact Member Services for assistance at the toll-free number on the back of Now” link.com. covered medical expenses are reim. reimbursed by submitting a completed Aetna Prescription Drug claim form. go to www. through Friday. Pro. along with your applicable copay. search A SHS referral is not required. P. you can: informing their Physicians of potential out-of-pocket expenses for a referral to • Review who is covered under your plan.g. and it does not guarantee services received will for your school name. technical assistance is available toll free. vices. The benefits listed in ing your Medical ID number (obtained from Aetna’s website. and do not have your ID card with you.aetnastudenthealth. KY 40512 Electronic ID Cards Providers need your Member ID# from your card to identify you. Lexington. you can also take advantage of additional discounts. above). Physician’s letter of medical necessity. Preferred Care • Request member ID cards. bursed at the Preferred Care network level of benefits. www. Note: you ment. To learn more about Preferred Care Providers.aetnastudenthealth. Monday through Friday. and click “Print your ID card” to view and/or print a be considered eligible expenses under the plan. you have access to Aetna Aetna Student Health has arranged for you to access the Aetna Preferred Care Navigator®.International . or a health center pharmacy incapable of billing.com. if you need When you need care. In this situation. • Enter your school name and then click on “Search. and more. when You may also use the Aetna Mobile App to view your member ID you visit a Preferred Care Provider. password and security phrase. The request Callers must be enrolled in the Student Health Insurance Plan in order to be must also include any additional information that supports the claim (e. Prescriptions from a Non-Preferred Pharmacy. Technical assistance for the Aetna website and Mobile App is available toll *Providers are independent contractors and are not agents of Aetna. then click “Prescription” to obtain an RX claim form. 7-days-a-week toll-free line he/she may request a review of the decision. Please submit all requests to: Aetna. To access your Member ID Card. the ID card. Providers are independent contractors and are neither employees nor agents of • View Claim Explanation of Benefits (EOB) statements. Monday When a pre-approval is issued by Aetna. It is to your advantage to utilize a Preferred Care Provider and health information. check your benefits.aetnastudenthealth. download the Aetna Mobile App to your mobile device and log in us- Insured dependents are not eligible to use the SHS. First. Prescription Drug Claim Procedure Additional Discounts and Services As a member of the Plan. • Find healthcare professionals and facilities that participate in your plan.aetnastudenthealth. you’ll generally have less out of pocket card. Services obtained at the SHS are reimbursed at the Preferred Care rate. packed with personalized benefits Provider network. Aetna may issue a pre-approval for a covered • Select a user name.com. You do not have to have Where Do I Go For Care? your member ID card with you to be eligible to receive benefits. Find your school. to 9 p. Or call (877) 378-8885.). For an Aetna Prescription claim form go to www. medical records.How to Appeal a Claim Informed Health Line In the event a Covered Person disagrees with how a claim was processed. temporary Medical ID card that contains your Medical ID number. person to obtain the service or supply from a Non-Preferred Care Provider. •4• San José State University . will need your Student ID number to log in. both a Preferred Care Provider and a Non-Preferred Care Provider. However. To find a Pre.. to 5:30 p. etc. and more! www. why he/she disagrees with the way the claim was processed. consider Student Health Services (SHS) on your campus medical attention but do not have access to your card.com and create your Aetna Navigator® account. plus a dispensing fee. need.com. You will be reimbursed for covered medications. except for specific Plan restrictions on certain services. eligible to utilize the Informed Health Line. Next. programs are subject to change without notice. Just call (800) 556-1555 to the Explanation of Benefits (EOB). the California State University system nor Aetna Student Health. covered persons should con. or get assistance must be made in writing within one hundred eighty (180) days of receipt of with locating nearby preferred network providers. but not available from a Preferred Care Provider. because savings can be achieved from the Negotiated Charges these providers have agreed to accept as payment for their services. Member Web: Aetna Navigator® Preferred Care Provider Network As an Aetna Student Health insurance member. local time at (866) vider participation may change without notice. ferred Care Provider. You can use DocFind® to find out whether a specific provider • Go to www. You may visit any licensed health care provider directly for covered ser. free. Box 14464. please present your ID card to a Pre- and programs such as fitness discounts and weight management programs. The Covered Person’s request must include talk to a registered nurse who can provide information on a range of topics. The Covered Person’s requests for insured students to access confidential medical advice. and bill Aetna Life Insurance Company. benefits will still be as your first stop.” your area. verify your coverage. or guarantee access to health services. from 8:30 a. find a doctor. your secure member website. log in to expense for your care.com. They can provide many of the routine health services you payable according to the Policy. The pharmacy will bill These are not underwritten by Aetna and are NOT insurance. Eastern Time at (800) 225-3375.

Pre-certification simply means calling Aetna Student Health prior to treatment to get approval for a medi- cal procedure or service. Semi-private room. Overnight stay. includes.000 per Insured per Policy Year. Routine Cancer Screenings (Outpatient). Covered Medical Expenses are payable at the coinsurance percentage specified below. Pre-certification does not guarantee the payment of benefits for your inpatient admission. in accordance with the exclusions and limitations contained in the Policy. Family Contraceptive Counseling Services (Office Visits). Preventive Care Immunizations (Facility or Office Visits). the Annual Deductible is waived for Preferred Care Covered Medical Expenses rendered as part of the following benefit types: Routine Physical Exam Expense (Office Visits). after the initial 48 hours for a vaginal delivery or 96 hours for a cesarean section. Mammogram Expense. 100% of the Negotiated Charge 75% of the Recognized Charge Intensive Care Room and Board Expense.Schedule of Benefits The Plan will pay benefits in accordance with any applicable California State Insurance Law(s). Deductibles.000 per Policy Year Once the Individual or Family Out-of-Pocket Limit for Preferred Care has been satisfied. 100% of the Negotiated Charge 75% of the Recognized Charge oxygen tent. or facility established primarily for the treatment of substance abuse. after any Coinsurance applicable deductible. and drugs. Pediatric Preven- tive Vision and Dental Service. Pre-certification may be done by you. Deductibles & Maximums The following Deductibles are applied before Covered Medical Expenses are payable: Benefit year deductible Student/Spouse/Child: $150 per Insured per Policy Year *Per visit or admission deductibles do not apply towards satisfying the plan Deductible. as well as a review of eligibility. • If you do not get pre-certification for non-emergency inpatient admissions. Breast Pumps & Supplies. treatment. Well Woman Preventive Visits (Office Visits). Copays and Prescription Drug expenses apply to the Out-of-Pocket Limit. Female Contraceptives Generic Prescription Drugs. Brand Prescription Drugs if no Generic equivalent. Comprehensive Lactation Support and Counseling Services (Facility or Office Visits). Schedule of Benefits Inpatient Hospitalization Expenses Preferred Care Non-Preferred Care Room and Board Expense. Female Voluntary Sterilization (Inpatient and Outpatient). or a 100% of the Negotiated Charge 75% of the Recognized Charge consulting Physician. Routine Screening for Sexu- ally Transmitted Disease Expense. • If you do not secure pre-certification for the below listed covered medical services and supplies obtained from a non-preferred provider your covered medical expenses may be subject to a $500 per service. your doctor. The pre-certification process can be initiated by calling Aetna at the telephone number listed on your ID card. up to any benefit maximum that may apply. up to an Unlimited maximum benefit. medicines. to a hospital. skilled nursing facility. Miscellaneous Hospital Expense. • All inpatient maternity care.International . expenses incurred during a hospital confinement for: anesthesia and operating room. including length of stay. procedure. expenses for Designated Care or Non-Preferred care. and benefit coverage under the student Accident and Sickness Plan. adherence to notification guidelines. a facility established primarily for the treatment of substance abuse. 100% of the Negotiated Charge 75% of the Recognized Charge Non-Surgical Physicians Expense. Surgical Expenses (Inpatient and Outpatient) Preferred Care Non-Preferred Care Surgical Expense 100% of the Negotiated Charge 75% of the Recognized Charge Assistant Surgeon Expense (Inpatient and Outpatient) 100% of the Negotiated Charge 75% of the Recognized Charge Ambulatory Surgical Expense 100% of the Negotiated Charge 75% of the Recognized Charge Anesthesia Expense 100% of the Negotiated Charge 75% of the Recognized Charge Continued on next page •5• San José State University . Preferred Care Family Out-of-Pocket: $8. Prenatal Care (Office Visits). Screening & Counseling Services (Office Visits) as illustrated under the Routine Physical Exam benefit type. Pap Smear Screening Expense. Covered Medical Expenses Out of Pocket Maximums will be payable at 100% for the remainder of the Policy Year. the hospital. residential treatment facility. FDA-Approved Female Generic Emergency Contraceptives. or a residential treatment facility.and other expenses not covered by this Plan. Each claim is subject to medical policy review. Routine Colorectal Cancer Screening. Non-surgical services of the attending Physician. Coinsurance. IMPORTANT: Pre-certification Program Your Plan requires pre-certification for a hospital stay. or supply benefit reduction You’ll need pre-certification for the following inpatient services: • All inpatient admissions. Waiver of Annual Deductible In compliance with Federal Health Care Reform legislation. laboratory tests and x rays. Preferred Care Individual Out-of-Pocket: $4. penalties. • All partial hospitalization in a hospital. your covered medical expenses will be subject to a $500 per admission Deductible. and dressings. or give notification for emergency admissions from a non-preferred provider. among others. Services that do not apply towards satisfying the Out-Of-Pocket Limit: expenses that are not Covered Medical Expenses. visit. or one of your relatives. Routine Prostate Cancer Screening Expense.

injury. For the comprehensive preventive care of children 16 years of age or younger. If a covered person is admitted to a hospital as an inpatient after $250 Co-pay per visit after $250 Deductible per visit immediately following a visit to an emergency room. for the following types of therapy provided on an outpatient basis: Physical Therapy. For the diagnosis and medically necessary treatment of severe mental illnesses of a person of any age. Includes CT scans. Separate benefit deductibles or copays may apply for certain services rendered in the emergency room that are not included in the hospital emergency room visit benefit. and lab 100% of the Negotiated Charge 75% of the Recognized Charge services. Covered medical expenses that are applied to the emergency room visit benefit deductible or co- pay cannot be applied to any other benefit deductible or copay under the plan. Inhalation Therapy. Copay is due at time of visit and is in addition to the 100% of the Negotiated Charge 75% of the Recognized Charge plan deductible. immunizations. Routine Physical Exam Expense 100% of the Negotiated Charge 75% of the Recognized Charge Hospital Outpatient Department Expense 100% of the Negotiated Charge 75% of the Recognized Charge 100% of the Negotiated Charge 75% of the Recognized Charge Consultant Expense after a $20 Co-pay per visit after a $30 Co-pay per visit High Cost Procedures Expense. Pediatric Preventive Care Expense. For the comprehensive preventive care of children 17 and 18 years of age. physician office visits to administer injections. Likewise. the emergency room visit benefit deductible (Co-pay waived if admitted) (Deductible waived if admitted) or copay is waived. Severe Mental Illness Expense. Benefits for Chiropractic Care are limited to 50 visits per Policy Year. PET scans and Nuclear Cardiac 100% of the Negotiated Charge 75% of the Recognized Charge Imaging Tests. after a $20 Co-pay per visit after a $30 Co-pay per visit Emergency Room Visit Expense. Speech Therapy. 100% of the Negotiated Charge 75% of the Recognized Charge Continued on next page •6• San José State University . Allergy Testing and Treatment Expense. Cardiac 100% of the Negotiated Charge 75% of the Recognized Charge Rehabilitation. Make sure your member ID number is on the bill. after a $20 Co-pay per visit after a $30 Co-pay per visit Laboratory and X-Ray Expense 100% of the Negotiated Charge 75% of the Recognized Charge Therapy Expense. Pediatric Preventive Care Expense.International . The copay is in addition to the plan deductible. Urgent Care Expense. and 100% of the Negotiated Charge 75% of the Recognized Charge lab services. These benefit deductibles or copays may be different from the hospital emergency room visit benefit deductible or copay. Breast Feeding Durable Medical Equipment Expense. or condition. The copay is in addition to the plan deductible. you are not responsible for paying that amount. or Occupational Therapy. the provider may not accept payment of your cost share (your deductible and coinsurance) as payment in full. Includes prosthetic devices to restore a 100% of the Negotiated Charge 75% of the Recognized Charge method of speaking for laryngectomy patient. including periodic health evaluations. The covered person should go directly to the emergency room of after a $20 Co-pay per visit after a $30 Co-pay per visit a hospital or call 911 for ambulance and medical assistance. Inpatient and outpatient. Outpatient 100% of the Negotiated Charge 75% of the Recognized Charge Mental and Nervous Disorders Expense. Copay is due at the time of visit and is in addition to the plan 100% of the Negotiated Charge 75% of the Recognized Charge deductible. including periodic health evaluations. immunizations. Please send Aetna the bill at the address listed on the back of your member ID card and Aetna will resolve any payment dispute with the provider over that amount. and of serious emotional Payable as any other Sickness disturbances of a child. MRIs. Includes laboratory tests. Mental Health Benefits Preferred Care Non-Preferred Care Severe Mental Illness Expense. is an 100% of the Negotiated Charge 75% of the Recognized Charge emergency condition. Important note: Please note that as Non-Preferred Care Provid- ers do not have a contract with Aetna. Ambulance Expense 90% of the Negotiated Charge 90% of the Recognized Charge Physician’s Office Visit Expense. You may receive a bill for the difference between the amount billed by the provider and the amount paid by this Plan. Prosthetic and Orthotic Devices Expense.Schedule of Benefits Outpatient Benefits Preferred Care Non-Preferred Care Walk-In Clinic Expense. Please note: A covered person should not seek medical care or treatment from an urgent care provider if their illness. Includes the rental or purchase of 100% of the Negotiated Charge 75% of the Recognized Charge breast feeding durable medical equipment for the purpose of lactation support. Inpatient. If the provider bills you for an amount above your cost share. Important Notice: A separate hospital emergency room visit benefit deductible or copay applies for each visit to an 100% of the Negotiated Charge 100% of the Recognized Charge emergency room for emergency care. covered medical expenses that are applied to any of the plan’s other benefit deductibles or copays cannot be applied to the emergency room visit benefit deductible or copay. Chiropractic Care. prescribed medications for testing and treatment of the allergy. and will be based on the specific service rendered. Payable on the same basis as any other Sickness and other medically necessary supplies and services.

following a $35 Copay for each Brand Name Prescription Drug or $15 Copay for each Prescribed Medicine Expense Generic Prescription Drug Note: Contraceptive Drugs and Device benefits are illustrated under the Family Planning Benefit. Benefits are provided to covered persons until 70% of the Negotiated Charge 50% of the Recognized Charge the end of the month in which the covered person turns 19. For the treatment of alcohol and drug addiction. 100% of the Negotiated Charge 75% of the Recognized Charge Outpatient Expense. Human Organ Transplant Expense Payable on the same basis as any other Sickness Non-Prescription Enteral Formula Expense 100% of the Negotiated Charge 75% of the Recognized Charge Gender Reassignment (Sex Change) Treatment Expense. Internally implanted devices. Routine Screening Expense. Includes charges incurred for services and supplies that are 100% of the Negotiated Charge 75% of the Recognized Charge provided to prevent pregnancy. Benefits are provided to covered persons until 50% of the Negotiated Charge 50% of the Recognized Charge the end of the month in which the covered person turns 19.Schedule of Benefits Alcoholism and Drug Addiction Treatment Preferred Care Non-Preferred Care Inpatient Expense. Eye exams for refraction. Requires pre-certification. following a $35 Copay for each Brand Name Prescription Drug or $15 Copay for each Generic Prescription Drug •7• San José State University . as noted in the Benefits Description.International . place where service is provided. Contraceptives Important Note: Brand-Name Prescription Drug or Devices for a Preferred Provider will be covered at 100% of the Negotiated Charge. For the routine care of a covered person’s newborn 100% of the Negotiated Charge 75% of the Recognized Charge child. Rehabilitation Facility Expense 100% of the Negotiated Charge 75% of the Recognized Charge Cochlear Implant Expense. Pediatric Vision Care Services and Supplies 100% of the Negotiated Charge 75% of the Recognized Charge Pediatric Vision Care Exam Expense. Payable on the same basis as any other Sickness Well Newborn Nursery Care Expense. 100% of the Negotiated Charge 75% of the Recognized Charge Maternity Benefits Preferred Care Non-Preferred Care Maternity Expense. including waiver of per Policy Year Deductible if a Generic Prescrip. For the treatment of alcohol and drug addiction. Sexually Transmitted 100% of the Negotiated Charge 75% of the Recognized Charge Disease. and Colorectal Cancer screenings.100% of the Negotiated Charge 75% of the Recognized Charge tion Drug or Device is not available in the same therapeutic drug class or the prescriber specifies Dispense as Written. Non-Preferred Care Pharmacy: 100% of the Recognized Charge. Pediatric Dental Diagnostic and Preventive Care. PPO Providers & Other Health Outpatient Drugs and Medications Care Providers Non-PPO Providers Preferred Care Pharmacy: 100% of the Negotiated Charge. Expenses include services rendered as part of medically Payable on the same basis as any other Sickness necessary bariatric surgery treatment for morbid obesity. Benefits are limited to 100 days per policy year. 100% of the Negotiated Charge 75% of the Recognized Charge Acupuncture Expense 100% of the Negotiated Charge 75% of the Recognized Charge Hospice Benefit 100% of the Negotiated Charge 75% of the Recognized Charge Home Health Care Expense 100% of the Negotiated Charge 75% of the Recognized Charge Licensed Nurse Expense 100% of the Negotiated Charge 75% of the Recognized Charge 100% of the Negotiated Charge 75% of the Recognized Charge Skilled Nursing Facility Expense. for the semi-private room rate for the semi-private room rate Elective Abortion Expense 100% of the Negotiated Charge 75% of the Recognized Charge Bariatric Surgery Expense. Additional Benefits Preferred Care Non-Preferred Care Pap Smear Screening Expense 100% of the Negotiated Charge 75% of the Recognized Charge Mammogram Expense 100% of the Negotiated Charge 75% of the Recognized Charge Family Planning Expense. Benefits are provided to covered persons until the 100% of the Negotiated Charge 75% of the Recognized Charge end of the month in which the covered person turns 19. Includes charges for Chlamydia. For the care of the covered person and any newborn child. See Payable in accordance with the type of expense incurred and the Benefit Descriptions section for details. Pediatric Dental Basic Restorative Care. Benefits are provided to covered 100% of the Negotiated Charge 75% of the Recognized Charge persons until the end of the month in which the covered person turns 19. 100% of the Negotiated Charge 75% of the Recognized Charge Adult Routine Eye Exam. Pediatric Dental Major Restorative Care.

• Any contraceptive methods that are only “reviewed” by the FDA and not es made by a physician in an individual or group setting for the following: “approved” by the FDA. lab and other tests given in connection with the exam. mary purpose of a confinement. Sexually transmitted diseases*. es for the comprehensive preventive care of children 17 and 18 years of age. exam given to a child who is a covered dependent are covered under any • Treatment visits. but not limited to. and Generic Prescription Drug or Device is not available in the same therapeutic • Healthy diet counseling visits provided in connection with Hyperlipid. Therapy Expense: Covered Medical Expenses include charges incurred by a Use of Tobacco Products: Screening and counseling services to aid a covered person to stop the use of tobacco products. and lab services. • Services in this category are subject to a combined limit of 8 individual In addition to any state regulations or guidelines regarding mandated Routine or group visits by an recognized provider per Policy Year. lab. smokeless tobacco. snuff. products that contain tobacco. Limitations: Unless specified above. 100% of the Negotiated Charge. including waiver of Annual Deductible if a • Nutritional counseling. If charges for a routine physical • Preventive counseling visits. Such counseling services are Cov- to: ered Medical Expenses when provided in either a group or individual setting. Obesity: Screening and counseling services to aid in weight reduction due to • The reversal of voluntary sterilization procedures. cal exam. Tobacco product means a substance containing tobacco or nicotine including: Included as a part of the exam are: cigarettes. as adopted by the American Academy of Pediatrics. and other tests given in connection with the exam. obstetrician or gynecologist. psychological. under this benefit must be approved by the Food and Drug Administration • For females. implants. Important note: Brand-Name Prescription Drug or Devices will be covered at • Medical nutrition therapy. • Class visits. as adopted by the American Academy of Pediatrics. Plan. immunizations number of visits allowed for Obesity counseling. Covered • The 10 Healthy Diet Counseling visits will be counted toward the total Medical Expenses will include periodic health evaluations.aetna. cigars. such as: Interpersonal and domestic The following contraceptive methods are covered expenses under this ben- violence.Benefit Descriptions Routine Physical Exam Expense: Benefits include expenses for a routine Coverage includes: physical exam performed by a physician. intervention and a structured assessment. a covered person may contact his • Services which are for the treatment of an identified illness or injury. consistent with the Recommendations for Preventive Pediatric or group visits by any recognized provider per Policy Year. stance. or her physician or Member Services by logging onto the Aetna website • Services that are not given by a physician or under his or her direction. screenings and counseling services as provided for in the (FDA). emia (high cholesterol) and other known risk factors for cardiovascular Pediatric Preventive Care Expense: Covered Medical Expenses include and diet-related chronic disease. Misuse of Alcohol and/or Drugs: Screening and counseling services to aid in Pediatric Preventive Care Expense: Covered Medical Expenses include charg- the prevention or reduction of the use of an alcohol agent or controlled sub. Continued on next page •8• San José State University . including any related obesity.com or calling the toll-free number on the back of the ID card. health Care. • Services and supplies incurred for an abortion. Covered in conjunction with. for a reason To aid a covered person to stop the use of tobacco products. Coverage includes: follow-up care. Covered Medical Expenses include services rendered Family Planning Expense: For females with reproductive capacity. • Male contraceptive methods. charges for a voluntary sterilization procedure to the extent that the proce- • X-rays. personality or emotional testing or exams. • Preventive counseling visits and/or risk factor reduction intervention. and other benefit section. tubal ligation and sterilization and older and limited to once every three years. Exams and Routine Cancer Screenings. Screening and Counseling Services: Covered Medical Expenses include charg. Depression Screening: This service is limited to once per year. and Counseling Services benefit are charges incurred for: • Materials for the administration of immunizations for infectious disease • Services which are covered to any extent under any other part of this Plan and testing for tuberculosis. A routine physical exam is a medical exam given by a physician. Physical Exam services. • Services which are covered to any extent under any other part of this • If the plan includes dependent coverage. by the provider for female voluntary sterilization procedures and related ser- • High risk Human Papillomavirus (HPV) DNA testing for women age 18 vices and supplies including. those charges will not be covered under this section. These services may include but are not limited a physician. dure was not billed separately by the provider or because it was not the pri- • Immunizations for infectious diseases and the materials for administra. an ini. risk factor reduction consistent with the Recommendations for Preventive Pediatric health Care. Covered Medical Expens- • Services in this category are subject to a combined limit of 5 individual es will include periodic health evaluations. not covered under this benefit are charges for: and Prevention. tion of immunizations that have been recommended by the Advisory Limitations: Committee on Immunization Practices of the Centers for Disease Control Unless specified above. for covered newborns. All services and supplies covered recommendations of the United States Preventive Services Task Force. • Screening and counseling services. • Psychiatric. not covered under this Screening and • X-rays. and Human Immune Deficien. immunizations and lab services or group visits by any recognized provider per Policy Year. www. other than to diagnose or treat a suspected or identified injury or sickness. sterilization procedures or devices. Medical Expenses include those charges incurred for services and supplies • Evidence-based items that have in effect a rating of A or B in the current that are provided to prevent pregnancy. tial hospital check up. efit: cy Virus (HIV) infections. Important Note: • Services provided as a result of complications resulting from a voluntary For details on the frequency and age limits that apply to Routine Physical sterilization procedure and related follow-up care. and candy-like • Routine vision and hearing screenings given as part of the routine physi. *Sexually transmitted disease screening expense is limited to two screenings Covered expenses under this Preventive Care benefit would not include per Policy Year.International . drug class or the prescriber specifies Dispense as Written. comprehensive guidelines recommended by the Health Resources and Coverage includes counseling services on contraceptive methods provided by Services Administration. Coverage includes preventive counseling visits. Voluntary Sterilization: Covered expenses include charges billed separately • Screening for gestational diabetes. smoking tobacco. charges for the comprehensive preventive care of children 16 years of age • Services in this category are subject to a combined limit of 26 individual or younger.

of severe mental illnesses of a person of any age. optometrist or optician related to Mental and Nervous Disorders Inpatient Expense: Covered Medical Ex. vision network provider listing that applies to your plan. Aetna Student Health. Prior lenses prescribed after cataract surgery has been performed. and an • Charges. tests and pro.com website. the following charges will be included as Covered Medical Expenses: Continued on next page •9• San José State University . Maternity Expenses. is limited to pregnancy-related physician office visits including the initial and Covered Medical Expenses include. charges will be included as Covered Medical Expenses: Pap Smear Screening Expense: Covered Medical Expenses include one rou- • Charges for the clinical review services to the extent such services are tine annual Pap smear screening (or an alternative cervical cancer screening required by the California Welfare and Institution code. and • Chiropractic Care. are provided for a covered per. Covered expenses incurred during the post-partum of a person of any age. and other medically necessary supplies and services. if such care is a hospital. as required by ment. of Pregnancy are payable on the same basis as any other Sickness. You must present your ID card to mental health facility on the consent of his parent or guardian. physician office visits. certified nurse-midwife. nant female in a physician’s. tion cannot be obtained with conventional lenses.Benefit Descriptions (continued) covered person for the following types of therapy provided on an outpatient • Charges for the clinical review services to the extent such services are basis: required by the California Welfare and Institution code. Lactation support and lactation counseling services are covered expenses Covered Medical Expenses also include the charges made for treatment re. Be sure to look at the appropriate the California Welfare and Institution Code. review and approval must be obtained on a case-by-case basis by contacting • Low vision services. Aphakic prescription ceived during partial hospitalization in a hospital or treatment facility. • Charges. including anti-nausea drugs tending Physician. are provided for a covered per. but for not more than 1 visit per day. if any. for services of an interpreter. for services of an interpreter. parent education. other than those for severe mental illness and/or serious emotional • Eyeglass frames. training in breast feeding) and counseling services provided to females during Severe Mental Illness of persons of any age and Serious Emotional Distur. older. Prenatal diagnosis of genetic disorders of the fetus by means of diagnostic penses for the administration of chemotherapy and visits by a health care procedures of a high-risk pregnancy. the California Welfare and Institution Code. The “post-partum period” means the 60 day period directly following nosis and medically necessary inpatient treatment of severe mental illnesses the child’s date of birth. and of serious emotional disturbances of a child are period also include the rental or purchase of breast feeding equipment. physiotherapy (for rehabilitation only after a surgery). cal Expenses will include comprehensive lactation support (assistance and tion. subsequent history and physical exams of the pregnant woman (maternal lowing: laboratory tests. only if such therapies are a result of injury or sickness. if any.International . Prior Well Newborn Nursery Care Expense: Benefits include charges for routine review and approval must be obtained on a case-by-case basis by contacting care of a covered person’s newborn child as follows: Aetna Student Health. ceived during partial hospitalization in a hospital or treatment facility. and Complications professional to administer the chemotherapy. Comprehensive Lactation Support and Counseling Services: Covered Medi- including any equipment used in the administration of prescribed medica. and expenses and training in breast or bottle-feeding. disorders while the covered person is not confined as a full-time inpatient in Expenses for Chiropractic Care are Covered Medical Expenses. and assistance cedures. • Physical Therapy. and son who is a minor and who is confined in as a full-time inpatient in a private • Physician’s charges for visits to the newborn child in the hospital and mental health facility on the consent of his parent or guardian. Mammogram Expense: Covered Medical Expenses include coverage for bances of a Child Outpatient Expense: Covered Medical Expenses for the mammograms for screening or diagnostic purposes upon referral of a nurse diagnosis and medically necessary outpatient treatment. Covered used in conjunction with the chemotherapy. A listing of the locations of the vision network providers under this Plan can Clinical Review Services for Minors: If clinical review services. prescription lenses or prescription contact lenses disturbances of a child. practitioner.If clinical review services. for services of patients’ rights advocate. Coverage for prenatal care under this benefit diagnostic testing and treatment of allergies and immunology services.aetna. but for not more than four days. obstetrician’s. test when recommended by a physician or a health care provider). rect visual acuity to 20/40 or better in the better eye and that correc- Covered Medical Expenses also include the charges made for treatment re. if any. blood pressure and fetal heart rate check). as required by be accessed at www. covered person and any newborn child for a minimum of 48 hours after a Expenses for Speech and Occupational Therapies are Covered Medical Ex. other than those for severe mental illness and/or serious emotional • Cardiac Rehabilitation. Mental and Nervous Disorders Outpatient Expense: Covered Medical Ex- • Inhalation Therapy. for services of a patients’ rights advocate. penses. including visits to administer weight. related to neuromusculoskeletal conditions and conditions arising from: the Maternity Expense: Covered Medical Expenses include inpatient care of the lack of normal nerve. but are not limited to. vider. radiation therapy. since different Aetna son who is a minor and who is confined in as a full-time inpatient in a private plans use different networks of providers. muscle. Prenatal Care: Prenatal care will be covered for services received by a preg- es. prescribed medications for testing and treatment of the allergy. if any. or physician. • Physician’s charges for circumcision. the following consultations. incurred at a radiological facility. vaginal delivery and for a minimum of 96 hours after a cesarean delivery. tion drugs. Medical Expenses may include home visits. Severe Mental Illness of persons of any age and Serious Emotional Distur. Benefits for these types of therapies are payable for Covered Medical Expens. or gynecologist’s office but only Allergy Testing and Treatment Expense: Benefits include charges incurred for to the extent described below. and FDA approved human papillomavirus screening test for women age 18 and • Charges. • Charges. pregnancy and in the post-partum period by a certified lactation support pro- bances of a Child Inpatient Expense: Covered Medical Expenses for the diag. penses. In such cases. penses. include charges incurred by a covered person while Coverage includes charges incurred for: confined as a full-time inpatient in a hospital or residential treatment facility • Non-conventional prescription contact lenses that are required to cor- for the treatment of mental and nervous disorders. injections. • Hospital charges for routine nursery care during the mother’s confine- Clinical Review Services for Minors . include charges for treatment of mental and nervous • Occupational Therapy. • Speech Therapy. physician assistant. payable on the same basis as any other Sickness. • Office visits to an ophthalmologist. or disturbances of a child. Any decision to shorten such minimum coverage shall be made by the at- Covered Medical Expenses for chemotherapy. and of serious Pediatric Vision Care Services and Supplies: Covered expenses include charg- emotional disturbances of a child are payable on the same basis as any other es for the following vision care services and supplies: sickness. charges for the fol. on the same basis as any other sickness. the fitting of prescription contact lenses. including prescrip. in consultation with the mother. Covered Medical Expenses also include ex. and/or joint function. when provided in either a group or individual setting.

including incit. non-prescription lenses and non-prescription contact plies. or bone • Charges for outpatient diagnostic laboratory and x-rays. except as required for repair caused by a covered injury or as provided 13. contact lenses (except when required after cataract sur. tion in the Master Policy for more information. so long as they are not taken against persons who are 15. are custodial care without regard to: by whom they are prescribed. 11. 14. Expense incurred for elective treatment or elective surgery except as the purpose of donating or selling the organ to any person or organiza- specifically provided elsewhere in this Policy and performed while this tion. 9. • Charges made by a behavioral health provider for gender reassignment Gender Reassignment (Sex Change) Treatment Expense: Includes charges counseling. the unearned The person does not have to be disabled. and scription lenses in a calendar year. or by whom or by which they are unless there is a legal obligation to pay such charges in the absence of performed. provided in this Policy. health or accident insurance to the extent that benefits are payable under other 1. lenses for eyeglass frames or prescription contact lenses. Compensation or Occupational Disease Law. and information about refund requests. son except as may be specifically provided in the Extension of Benefits gery). not covered under this benefit are charg. For information regarding the full Master Policy please call or as a direct result of disease or surgery performed to treat a disease or Aetna Student Health at (877) 378-9478 or send an email through your Aetna injury. reconstructive surgery. 20. Expenses for treatment of injury or sickness to the extent that payment scheduled airline maintaining regular published schedules on a regularly is made. webbed fingers or toes. Expense incurred as a result of an injury sustained or sickness contract. 18. elective sterilization or its reversal or elective abor- of riding as a passenger or otherwise in any vehicle or device for aerial tion unless specifically provided for in this Policy.aspx occurs while the covered person is covered under this Policy. how not a tooth or structure that supports the teeth and is malformed as a to file a claim. es incurred for services and supplies: • Charges made by a Skilled Nursing Facility for inpatient services and sup- • Eyeglass frames. as a judgment or settlement. 12. Expense incurred for services normally provided without charge by the valid and collectible insurance whether or not a claim is made for such Policyholder’s Health Service. 19. child. a spouse. 2. must be performed in the calendar year of the accident which causes lations. Human Organ Transplant Expense: Transplants of organs. for donor Services at no charge. sister. Refer to the Pre-certification sec- covered dependent has obtained pre-certification from Aetna. 5. marrow. as it is available. or by health care benefits. (b) Repair an injury (including reconstructive surgery for prosthet- Navigator Account or at www. Expense incurred for custodial care. in self-defense. Expense incurred for voluntary or elective abortions unless otherwise elsewhere in this plan unless otherwise provided in this policy. Expense incurred for cosmetic surgery. We provide or pay for donation-related Services for actual or poten. lenses that are for cosmetic purposes. made in connection with a medically necessary gender reassignment surgery No benefits will be paid for covered medical expenses under this benefit un- (sometimes called sex change surgery) as long the covered student or their less they have been pre-certified by Aetna.International . Expense incurred for treatment provided in a governmental hospital by whom they are recommended. devices or aids. Expense incurred for the removal of an organ from a covered person for 8. This includes room and board and other institutional care. 3. ing outpatient surgery). • Charges for blood transfusion and the cost of unreplaced blood and tial donors (whether or not they are Members) in accord with our guidelines blood products. Expense incurred for which no member of the covered person’s immedi- wage or profit or for which benefits are payable under any Workers’ ate family has any legal obligation for payment. exclusions and limitations. or enhance appearance whether or not for psychological or emotional reasons. Such services and supplies pro-rata premium will be refunded to the Policyholder. and charges trying to restore law and order. or other vision or hearing aids. this benefit will cover either prescription Pre-operative and post-operative hospital and office visits. services. in-vitro fertilization. or embryo 4. Expense incurred as a result of injury due to participation in a riot. Custodial care means services and 6. mandated benefits and other important information) as soon result of a congenital defect.Benefit Descriptions (continued) the vision network provider at the time of service. but not both. • Charges made for the administration of anesthetics. Upon the of daily life. • Charges made by a physician for: Performing the surgical procedure. or er services and supplies which improve. person’s immediate family or a person who lives in the covered person’s ing the riot or conspiring to incite it.aetnastudenthealth. Surgery Plan benefits are subject to all applicable state and federal laws and regu. radial keratotomy. This limitation does not apply to a donation by a covered person to Policy is in effect. which are subject to change. Expense incurred as a result of an injury or sickness due to working for 17. sible for the injury or sickness (or their insurers). supplies furnished to a person mainly to help him or her in the activities ed while in the service of the Armed Forces of any country. This benefit is subject to Covered medical expenses include: the maximums shown on the Schedule of Benefits. “Par. covered person entering the Armed Forces of any country. providers employed by the Policyholder. It does not include actions taken home. Expenses incurred for or in connection with procedures.com/customer-service/ ic device for a covered person who has undergone a mastectomy) which customer-service. for or related to artificial insemination. Infirmary or Hospital. Expense incurred for any services rendered by a member of the covered ticipation in a riot” means taking part in a riot in any way. Expense for the contraceptive methods. Expense incurred for eye refractions. You will will not apply to the extent needed to: (a) Improve the function or create be able to obtain a copy of the full Master Policy (which includes plan ben. or parent. As to coverage for pre. Expense incurred as a result of commission of a felony. This exclusion Continued on next page •10• San José State University . or oth. Exclusions and Limitations IMPORTANT NOTICE: This is just a brief description of your benefits. insurance. except as a fare-paying passenger in an aircraft operated by a 16. • Charges made by a hospital for inpatient and outpatient services (includ- Limitations: Unless specified above. alter. vision therapy. brother. Expense incurred as a result of an accident occurring in consequence transfer procedures. benefits for the following: 10. by any person deemed respon- established route. tissue. The plan neither covers nor provides the injury or in the next calendar year. Expense incurred after the date insurance terminates for a covered per- eyeglasses. including harelip. Expense covered by any other valid and collectible medical. navigation. or prescriptions or examinations Provision. or 7. a normal appearance to the extent possible of a part of the body that is efits.

whether or not claim is made for such benefits. except to the extent coverage of such exams. Expense incurred when the person or individual is acting beyond the tention. sickness or injury involved and the person’s overall health condition. investi. or other preventive services and sionals who treat the type of disease involved. supply. or (b) those aids. or for research purposes. and (b) The care or treatment is effective for that disease health care field. the person’s sickness or injury could safely and adequately be diagnosed charges for failure to keep a scheduled visit. holistic medicine. to be experimental or in. or for research purposes. even if such items are prescribed by a physician. II. including expenses in connection count the results of a review by a panel of independent medical profes. sionals. (e) the opin- only pay for those losses. (c) as to diagnosis. or by another facility studying the same drug.International . as determined by Aetna. or treatment will be deter. outcomes data available from controlled clinical trials published in the 34. or in connection with. bunions. even though the covered per. the service or supply must: (a) be care or treatment or shows promise of being effective for the disease. and standby charges of a physician. express thoughts. es is required under any law that applies to the coverage. for could affect the course of treatment as. Expense incurred for alternative. or healthcare facility. or prescription of hearing skills of a medical. or chronic foot strain. In determining if a service or supply is appropriate under fallen arches. dental society or regulatory agency has determined in writing that it is 36. Expenses incurred for gastric bypass. Aetna will take into consideration: (a) information re- not excluded when medically necessary. in. except as otherwise provided in this Plan. a procedure. as a result of an device. and form sentences). except that (c) and (d) are the circumstances. Expense incurred for hearing aids. or calluses. both as to the covered person’s home country has a socialized medicine program. or her family. Expense for: (a) care of flat feet. account all health expenses incurred in connection with the treatment. or (c) those son is eligible. weight loss except as provided elsewhere in the policy. pational therapy. or treatment. furnished solely because the person is an inpatient on any day on which 29. or IV approved cancer clinical services. the disease or injury involved. mined to be experimental or investigational if: (a) There are insufficient 33. but did not enroll in Part B. recommended. 37. This panel will include profes. which are not payable under the automobile ion of health professionals in the generally recognized health specialty medical payment insurance Policy. 24. and any restrictive procedures. sponsored by the National Cancer Institute if Aetna determines or dentist. ditioners. this 40. any alternative service or necessary dental or orthodontic services that are an integral part of re. Expense for incidental surgeries. Expense for personal hygiene and convenience items. setting if the service or supply could safely and adequately be furnished 30. and/or weight control. or the protocol restore speech to a person who has lost existing function (the ability to or protocols of any other facility studying substantially the same drug. Expenses for routine physical exams. to be medically necessary: (a) those that do not require the technical 27. states that it is experimental. weak feet. unless used exclusively to pro- has not been granted for marketing or a recognized national medical or mote healing. Expense for care or services to the extent the charge would have been any person who cares for him or her. or any persons who is part of his covered under Medicare Part A or Part B. 39. or suffers from circulatory problems. whirlpools. by ply with respect to services or supplies (other than drugs) received in more than the amount or percentage. or supplies is specifically provided in the Policy. The Policy will ness in the United States for diagnosis. Expense incurred for the use of orthotics. and treatment. Expense for injuries sustained as the result of a motor vehicle accident. and (e) care of above tests. immunizations. or treatment. In order for a treatment. ply. (b) reports in peer reviewed diabetic. This applies even if they are pre- status. Expenses incurred for. cal trial. Expense for services or supplies provided for the treatment of obesity vestigational. 41. care. speech therapy. yoga and hypnotherapy. Expense for telephone consultations (except Telemedicine services). has been accepted into a phase I. 28. except for medically likely to produce a negative outcome than. They will be selected by Aetna. routine hearing exams. and who receive treatment as a part of their training or shows promise of being effective for that disease as demonstrated in that field. investigational. and 23. Expense incurred as a result of dental treatment. sion does not apply for charges for speech therapy that is expected to ten protocol or protocols used by the treating facility. be no more costly (taking into cluding but not limited to. In no event will the following services or supplies be considered scope of his/her/its legal authority. Any exclusion above will not apply to the extent that coverage of the charg- ment. procedure. procedure. scribed. and/or therapy. if the negative outcome than. and (f) any other relevant information brought to Aetna’s at- 26. Aetna. and no more likely to produce a services performed within the covered person’s home country. or treatment. both as to the sickness or injury involved and the person’s overall constructive surgery for cleft palate procedures as provided elsewhere health condition. scientific evidence demonstrates that the drug is effective medically necessary. or the written informed consent used accident or sickness. a device. be expected to cause death within one year in the absence of effective 38. or (c) The writ. in a physician’s or a dentist’s office or other less costly setting. specified as the Allowable Varia- connection with a disease if Aetna determines that: (a) The disease can tion. the fitting. to the extent that benefits are payable under other valid and collectible (d) generally recognized professional standards of safety and effective- insurance. service. for 31. medical literature. any healthcare provider. (c) reports and guidelines published by nationally rec- 25. by the treating facility. this exclusion will not ap. care. except that this will not apply if the charge for a service. hot tubs. which is likely to produce a significant positive outcome as. In making this determination. because the covered person is lating to the affected person’s health status. or supply) than any alternative service or supply to meet the care of corns. or supply which is not medi- exclusion will not apply with respect to drugs that: (a) Have been grant. involved. service. or those furnished solely because of the of a claim form. trial and the attending physician recommended the program. or a dental professional. as determined by device. health status of the person and be as likely to result in information that 22. ognized health care organizations that include supporting scientific data. cally necessary as determined by Aetna for the diagnosis care or treat- ed treatment investigational new drug (IND) or Group c/treatment IND ment of the sickness or injury involved. (d) care of toenails. Expense for treatment of covered students who specialize in the mental treatment. and no more 21. routine dental exams. does not exceed the recognized charge for that service or supply. Expense incurred for a treatment. or approved by the person’s attending physician. (c) service. a mental health. Expense for charges that are not recognized charges. (b) be a diagnostic procedure which is indicated by the in this Policy. immunizations. or sup- gational. or supply to be considered that available. (b) supportive devices for the foot. unless otherwise provided in this plan. furnished mainly for the personal comfort or convenience of the person. speak words. routine vision exams. or (b) Are being studied at the Phase III level in a national clini. Aetna will take into ac. such as air con. or charges for completion or treated while not confined. by scientific data. Also. However. or (c) The covered person supplies. A drug. •11• San José State University . approval 35. 32. Expense incurred by a covered person. with well newborn care. or physical exercise equip. Expense for the cost of supplies used in the performance of any occu. III. or (b) If required by the FDA. any alternative service or supply.Exclusions and Limitations (continued) supplies that are. Expense for treatment and supplies for programs involving cessation of peer reviewed literature to substantiate its safety and effectiveness for tobacco use. humidifiers. not a United States citizen. This exclu- experimental.

but not limited to. In no event will the following services or supplies be considered to be medi- Designated Care Provider: A health care provider (or pharmacy. severe pain. or a preferred care provider and recurrent symptoms of such injury. based on generally ac- • a health care provider that is not a Preferred Care Provider for an emer- cepted current medical practice. It must be no Continued on next page more likely to produce a negative outcome than any alternative service •12• San José State University . psy. overall health condition Actual Charge: The charge made for a covered service by the provider who • Be a diagnostic procedure which is indicated by the health status of the furnishes it. The care may be provided in the home. service. and Designated Care: Care provided by a Designated Care Provider upon referral • any other relevant information brought to Aetna’s attention. and trained volunteer. a mental vices and supplies at a negotiated charge. the Non-Preferred Care Provider: a health care provider that has not contracted person who primarily cared for the patient and other persons with significant to furnish services or supplies at a negotiated charge personal ties to the patient. at the time it is dispensed. social worker. if. or a dental professional. but is produced and sold under the nated Provider has agreed to make as to any service or supply for the purpose chemical formulation name. and if authorized by Aetna. which would lead a prudent the person. It Copay: This is a fee charged to a person for Covered Medical Expenses.International . or that is not a Preferred directed by a physician. or • Those furnished solely because of the setting if the service or supply • In the case of a pregnant woman. as determined by Aetna: chological. or injury. Pharmacy: An establishment where prescription drugs are legally dispensed. or other less costly setting. It must be as likely to result in information that could affect the Coinsurance: The percentage of Covered Medical Expenses payable by Aetna course of treatment as any alternative service or supply. • not in excess of the charges that would have been made in the absence Aetna will take into consideration: of this coverage. Covered Medical Expense: Those charges for any treatment. kit. part of his or her family. kit. • Those that do not require the technical skills of a medical. • generally recognized professional standards of safety and effectiveness age under this Policy is in effect. is not In order for a treatment. both as to the under this Accident and Sickness Insurance Plan. to be. • Those furnished mainly for: the personal comfort. lieve that his or her condition. or In determining if a service or supply is appropriate under the circumstances. or for the diagnosis or treatment of a sickness. or sary. and treatment.) than any alternative service or supply to meet the plies covered by this Policy which are: above tests. sickness or injury involved and the person’s overall health condition.) that is affili. person. and appropriate. or healthcare facility. both as to the sickness or injury involved and the person’s overall health condition. is of such a nature that or failure to get immediate medical care could result in: • Those furnished solely because the person is an inpatient on any day • Placing the person’s health in serious jeopardy. sickness. of the primary care Medically Necessary: A service or supply that is: necessary. • incurred while this Policy is in force as to the covered person except • reports in peer reviewed medical literature. and (b) any other practitioner that must by law be recognized cludes such persons as a physician. The term includes the • the provider is of a type that falls into one or more of the categories of supportive care and services provided to the family after the patient dies. gency medical condition when travel to a Preferred Care Provider. • physician. organizations that include supporting scientific data. count all health expenses incurred in connection with the treatment. be no more costly (taking into ac- or refill. Preferred Care: Care provided by: Injury: Bodily injury caused by an accident. and (c) causes injury. specialty involved. and • information relating to the affected person’s health status. Deductible: The amount of Covered Medical Expenses that are paid by each • the opinion of health professionals in the generally recognized health covered person during the policy year before benefits are paid. and or at a medical facility at any time of the day or night. from the School Health Services. or Emergency Medical Condition: This means a recent and severe medical con. This includes related conditions • a covered person’s primary care physician. In no event person’s overall health condition. or on which the person’s sickness or injury could safely and adequately be • Serious impairment to bodily function. and will the copay be greater than the pharmacy’s charge per: prescription. • As to diagnosis. care. cally necessary: ated. • not in excess of the recognized and customary charges. (b) “Interdisciplinary team” means a group of persons who work collectively Physician: (a) legally qualified physician licensed by the state in which he or to meet the special needs of terminally ill patients and their families and in. of the benefits under this Policy. the copay is payable directly to the pharmacy tive service or supply. health. or supply. Care Provider. 2. Non-Preferred Care: A health care service or supply furnished by a health liative services and supportive services provided by an interdisciplinary team care provider that is not a Designated Care Provider. or supply. custodial and spiritual care for persons who are terminally ill and • the service or supply could have been provided by a Preferred Care Pro- their families. whether or not related by blood. or refill. or • Serious dysfunction of a body part or organ. The program includes the provision of physical. both as to the sickness or injury involved and the person’s uted to by sickness or disease of any kind. including. at a residential facility vider. any healthcare provider. clergyman as a doctor legally qualified to render treatment. service. in the United States for diagnosis. “Hospice care” means a centrally administered program of pal. providers listed in the directory. or supply to be considered medically neces- feasible. the service or supply must: • a Non-Preferred Urgent Care Provider when travel to a Preferred Urgent • Be care or treatment which is likely to produce as significant positive Care Provider for treatment is not feasible. any person who cares for him or her. As used in this section: (a) “Family” includes the immediate family. Hospice: 1. and has an agreement with the School Health Services to furnish ser. care. or treatment. (b) is not due to or contrib. of dition. or injury. registered nurse. serious jeopardy to the health of the could safely and adequately be furnished. Covered person: A covered student and any covered dependent while cover. in a physician’s or a dentist’s fetus. or convenience. For must be no more likely to produce a negative outcome than any alterna- Prescribed Medicines Expense. she practices. or diagnosed or treated while not confined.Definitions Accident: An occurrence which (a) is unforeseen. outcome as any alternative service or supply. service or sup. • Generic Prescription Drug or Medicine: A prescription drug which is not Negotiated Charge: The maximum charge a Preferred Care Provider or Desig- protected by trademark registration. with respect to any expenses payable under the Extension of Benefit • reports and guidelines published by nationally recognized health care Provisions. office. or any person who is layperson possessing an average knowledge of medicine and health. both as to the sickness or injury involved and the for each: prescription.

One Delaware Drive • Salem. Legal Consultation and Referral: If a member is away from home and requires Visit by Family / Friend: If the Participant has or will be hospitalized for three the services of an attorney. traveling.S. and directly through a third party. On Call shall make and pay for travel arrangements and suitable member will be referred to a local attorney. including a mail order pharmacy. this Policy. spouse or US students studying in a US location are eligible for services when traveling participant partner suffers a life-threatening illness or death. the recognized charge is the rate established in such party to a contract with Aetna to dispense drugs to persons covered under agreement. hotel accommodations for a person of the Participant’s choice to join them up to $5. procuring required documentation. Any expenses associ- Medical Repatriation: If after being treated at a medical facility. Unlimited Benefit. with a provider which sets the rate that Aetna • the class of covered persons of which you are member. with a medical escort. Prescription: An order of a prescriber for a prescription drug. All assistance services must be arranged ation that prevents the Participant from returning to his/her program. as the cost of providing the same or a similar service or supply and the manner in which charges for the service or supply are made. Emergency Message Transmission: On Call will receive and transmit autho- ery. able locally. dental professionals and pharmacies in the given geographic loca- ber’s attending physician and obtain a full understanding of the situation. On Call shall arrange for an initial telephone con- (3) or more days while outside either the Country of Domicile or the Country sultation with an attorney without charge to the member. such as: order. validating a member’s health coverage or by advancing funds to the hospital. either directly or in- • the service or supply involved. it is medically ated with prescription replacement are the member’s responsibility. (Any advance of funds shall be charged to the member’s credit card at the port. and • The range of services or supplies provided by a facility. Unlimited Benefit. On Call will more than 100 miles away from their permanent residence including campus arrange and pay for economy airfare for the Participant to go to the family location. costs incurred should be submitted to your health plan and are subject to the Return of Personal Belongings: In the event of a Participant’s death or evacu- policy limits of your health coverage. will pay for a service or supply. On Call will make arrangements to use whatever mode of trans. Aetna may have an agreement. equipment and medical personnel necessary to evacuate a member to time of service). Recognized Charge: Only that part of a charge which is recognized is covered. child. the program location for up to one year. and • Unusual. but only if the provider is. In these instances. included in the directory as a Preferred Care Provider for: In some circumstances. which is ogy described above. On Call will transport the member home. Claims for reimbursement will not be Call will arrange and pay for shipment of personal effects to the Participant’s accepted.S.International . Continued on next page •13• San José State University . under the terms • Not often provided in the area. with it in the geographic area where it is furnished. The recognized charge for a service or supply is the lowest of: • The type of specialty of the provider. On and provided by On Call International. providing the necessary shipping container as well On Call International does not replace your medical insurance. or of its contract with Aetna.Definitions (continued) Preferred Care Provider: A health care provider that has contracted to furnish • The charge Aetna determines to be the prevailing charge level made for services or supplies for a negotiated charge.com ing a member’s remains home in the event of his or her death. and • The charge Aetna determines to be appropriate. All medical as paying for transport. in spite of the methodol- Preferred Pharmacy: A pharmacy. This service www.) • (603) 945-0103 (Text Message) them Home. and when participating in study abroad programs for up to one year. but only: In determining the recognized charge for a service or supply that is: • while the contract remains in effect. sibling. On Call will also return the Partici- US student studying abroad are eligible for services both at and away from pant to his/her program within 90 days of the departure date up to $2. • The complexity. If it is an oral Aetna may take into account factors.500. On Call will arrange and pay for an assigned advocate to the US. If the benefit allows. personnel and relay necessary information to the Member and Family. • The degree of skill needed. On Call will assist in filling that prescription. NH 03079 Return of Deceased Remains: On Call will assist with the logistics of return- E-mail: mail@oncallinternational. • Provided by only a small number of providers in the area. it must be promptly put in writing by the pharmacy. PROGRAM GUIDELINES Emergency Return Home: If a Participant’s parent. home or family.) hospitalization. or to a medical facility close to rized emergency messages for members. the nearest facility capable of providing a high standard of care.000. home. tions of western style medical facilities and English speaking providers in an Medical professionals will stay in regular communication with local medical area served by On Call to the extent possible. KEY SERVICES Medical.oncallinternational. or • while such a pharmacy dispenses a prescription drug. medical. Up to $1. On Call shall make and pay for travel arrangements to return (603) 328-1909 (Outside the U. Unlimited Prescription Assistance: If a member needs a replacement prescription while Benefit.000.com includes arranging the preparation of the remains for transport.500. the of Residence. and Emergency Assistance Services: On Call International Provided by On Call International Return of Dependent Children: If the Participant’s Dependent(s) are pres- GLOBAL RESPONSE CENTER: ent but left unattended as a result of the Participant’s Medical Evacuation or (877) 318-6901 (Toll-free within the U. Aetna’s consent. member’s location. including a non-medical escort as needed. Hospital Admission Guarantee: On Call will guarantee hospital admission by Emergency Medical Evacuation: If adequate medical facilities are not avail. • The provider’s usual charge for furnishing it. Dental and Pharmacy Referrals: On Call will provide referrals to Medical Monitoring: On Call’s medical staff will communicate with the mem. If necessary. based on factors such • The prevailing charge in other areas. necessary for the member to return home to seek further care or for recov. Bereavement Reunion: In the event a covered Participant dies while covered Foreign national students are eligible for services on or away from campus in under the Program. fly to the location of the deceased to identify and accompany the remains back to the Participant’s Home Country up to $2.

as a passenger travelling on a business related activity in a fixed wing Pre-trip Information: On Call offers members reports via email. On Call will not be liable for any expenses resulting from: On Call cannot be held responsible for failure to provide services or for delays a. or attorney. This exception shall not apply dering of service is prohibited by local laws or regulatory agencies. Without limiting the foregoing. a 36-partner global network of independent assistance companies. tion. embassy and consulate referrals. Any expense incurred for Participant(s) when travelling contrary to the Agreement are ministerial in nature. fax or postal aircraft owned or leased to the Subscriber unless the form of aerial flight mail including visa. or and interpreters if communication problems cannot be solved via telephone. but not limited to. unforeseen changes to airport regulations or b. cal professionals ultimately selected by a Member. i. healthcare provider. will assist Members on a fee-for-service basis for d. antees or pre-payment or indemnification from the Member prior to render- cian. to Emergency Medical Evacuation from remote or primitive areas when Member may be required to release On Call or any healthcare provider from On Call cannot be contacted in advance and delay might reasonably be liability during emergency evacuation and/or repatriation. On Call is not liable for ing medical treatment or for rest and recuperation following any prior any malpractice performed by a local doctor. the Participant can be adequately treated locally. and/ reserves the right. expected to result in loss of life or harm to the Participant. tered practitioner not in accordance with the standard medical practice As a member. strikes. Any Losses incurred by Participant or the Client if Participant or they fail including more than 53 alarm centers. and travel advisories for any destination. foreign exchange g. at its sole discretion. cultural informa. member of the International Assistance turning to their residence. failure to comply with On Call’s recommendations. Any expenses incurred as a direct or indirect result of elective surgery or campus location or abroad. where the Participant. simple connects you to a state-of-the art Global Response Center staffed around-the.International . can travel as an ordinary passenger without arranging for the replacement of passports. flight any single medical condition of an Participant during the Policy Period. in the opinion of the Emergency Medical Assis- Lost/Stolen Travel Document Assistance: On Call will provide assistance by tance Provider’s physician. be reasonably delayed until the Participant returns to their Country of Domicile. Any expense incurred for Emergency Medical Evacuation or Repatriation interventions falling under the Limitations and Uncovered Services. On Call if the Participant is not suffering from a Serious Medical Condition. Any expense incurred for Emergency Medical Evacuation or Repatriation luggage lost or delayed in transit. Any valid claim costs that have been increased by the Client’s or the cal providers. at its sole discretion. or where ren- by On Call and/or not arranged by them. response capabilities worldwide with a global network of pre-qualified medi. j. passport and inoculation requirements. Participant’s failure to follow the advice of On Call. accident or illness. k. including air and ground ambulance services. Any expense related to the Participant engaging in any form of aerial placing lost travel documents are the member’s responsibility. flight except as a passenger on a scheduled airline flight. On Call. The Participant being within 100 miles of their Primary Residence while CONDITIONS & EXCLUSIONS in their Country of Domicile. 24 hours a day. fractures or illness which can be treated by local doctors and do not clock with trained multilingual professionals to handle medical emergencies prevent the Insured person from continuing their Insured Journey or re- quickly and efficiently. visas. birth a medical escort. On Call’s actions and obligations under this c. f. On Call International has immediate to follow the advice of On Call. certificates and other travel-related documents. has been declared to and accepted by Us in writing prior to travel. you can call upon doctors. pharmacies and other ser. weather conditions. or weather conditions. 365 days a year. Any expenses related to re. to request additional financial guar- or in the opinion of Our Emergency Medical Assistance Provider’s physi. h. as a passenger Interpreter & Legal Referrals: On Call will refer members to local translators on a licensed charter fixed wing aircraft over an established route. and all medical care is provided by medi- advice of a Qualified Medical Practitioner. vices whenever traveling 100 miles or more from your permanent address.Emergency Assistance Services: On Call International (continued) Lost Luggage Assistance: On Call will assist the member with the tracking of e. Any cost or expense not expressly covered in advance and in writing restrictions. More than one Emergency Medical Evacuation and/or Repatriation for caused by conditions beyond its control including. or treatment can ing such service on a fee-for-service basis. airline documents. •14• San José State University . hospitals. as defined in the country of treatment. As the U. One phone call cosmetic surgery or routine or non-disabling medical problems. Any expense related to treatment performed or ordered by a non-regis- rates. or for the purpose of obtain. Group.S.

International .•15• San José State University .

oncallinternational. Important Contacts CLAIMS AND COVERAGE QUESTIONS: Aetna Student Health P. Aetna does not provide care or guarantee access to health services. Providers are inde- pendent contractors and are not agents of Aetna. The California State University Student Health Insurance Plan is underwritten by Aetna Life Insurance Company.S. Box 981106 El Paso. ENROLLMENT.O. which is a crime and subjects such person to criminal and civil penalties. NOTICE: Any person who knowingly and with intent to injure.com/docfind/custom/studenthealth 24-HOUR NURSE ADVICE: Aetna Informed Health® Line (800) 556-1555 TDD (800) 270-2386 EMERGENCY TRAVEL ASSISTANCE: On Call International (Provide this information to your Emergency Contact) One Delaware Drive Salem..com ELIGIBILITY. Provider participation may change without notice. You may obtain a detailed copy of our privacy policy through your school or by calling us at 800-853-5899 or by visiting us at https://studentinsurance. information concerning any fact material thereto commits a fraudulent insurance act. Informa- tion is believed to be accurate as of the production date.) (603) 328-1909 (Outside the U. defraud or deceive any insurance company or other person files an application for insurance or statement of claim containing any materially false information or who conceals for the purpose of misleading.02.) www. 15.wellsfargo. To protect your personal information from unauthorized access and use.S. limitations and benefit maximums.aetna. it is subject to change. These measures include computer safeguards and secured files and buildings.com This material is for information only and is not an offer or invitation to contract.wellsfargo. however. 8am-5pm PST Fax: (877) 612-7966 Email: studentinsurance@wellsfargo.g.com https://studentinsurance. we use security measures that comply with federal law.310.1 E . Aetna Student HealthSM is the brand name for products and services provided by Aetna Life Insurance Company and its applicable affiliated companies (Aetna). TX 79998 (866) 378-8885 (toll-free) www. WELLS FARGO INSURANCE PRIVACY INFORMATION We know that your privacy is important to you and we strive to protect the confidentiality of your personal information. information you provide to us may be shared with your school to process your insurance transaction). NH 03079 (877) 318-6901 (Toll-free within the U. except as permitted or required by law (e. Policy forms issued in OK include: GR-96134. Health insurance plans contain exclusions. We do not disclose any personal information about our plan participants.com.aetnastudenthealth.com FIND A MEDICAL PROVIDER IN THE Aetna Preferred Care Provider Network PREFERRED CARE NETWORK: (866) 381-1529 (toll-free) http://www. Wells Fargo Student Insurance AND GENERAL QUESTIONS: (800) 853-5899 Mon-Fri.

) HOME COUNTRY: (if applicable) PLEASE LIST DEPENDENTS TO BE INSURED BELOW.aetnastudenthealth.aetnastudenthealth. 8am-5pm PST (866) 378-8885 (toll-free) 24/7 Emergency Travel Assistance: https://studentinsurance.S. NEW Underwritten by Aetna Life Insurance Company  RENEWING SAN JOSÉ STATE UNIVERSITY INTERNATIONAL INTERNATIONAL 8 0 STUDENT & DEPENDENT ENROLLMENT FORM Wells Fargo Student Insurance Medical ID# 2017-2018 HEALTH INSURANCE PLAN ENROLLMENT FORM LAST / SURNAME STUDENT’S NAME FIRST NAME MIDDLE INITIAL STUDENT I. www.S.com www.oncallinternational.S. .) MIDDLE DATE OF BIRTH LAST / SURNAME FIRST NAME GENDER INITIAL (Month. (Dependents must be enrolled on the date the student is enrolled or within 31 days of date of birth. access code plus Wells Fargo Insurance (888) 792-3862 (603) 328-1909 (Outside the U. etc.) Plan brokered by: Management Dial U. Year) SOCIAL SECURITY # (U. J-1. go to: https://studentinsurance. YOU MUST COMPLETE BOTH SIDES OF THIS ENROLLMENT FORM.Fri. To view your plan SBC.com CA License No 0D08408 PLEASE SEE OTHER SIDE FOR RATES AND PAYMENT INFORMATION.com Prescriptions: On Call International Aetna Pharmacy (877) 318-6901 (within U. Inc.wellsfargo.S.S. DEPENDENT COVERAGE IS AVAILABLE ONLY IF THE STUDENT IS ALSO ENROLLED IN THE SCHOOL PLAN. Day. It summarizes your coverage in a format that all insurance companies now use. IMPORTANT CONTACTS Claims.com www.) Services USA. Year) SPOUSE/DOMESTIC PARTNER:  Female  Male CHILD:  Female  Male CHILD:  Female  Male CHILD:  Female  Male CHILD:  Female  Male You can view the standard Summary of Benefits & Coverage (SBC) which is required by Health Care Reform. eligibility To find a doctor or 24-Hour Nurse Advice: General questions: and coverage questions: health care provider: Informed Health Line Wells Fargo Aetna Student Health Aetna Life Insurance Co.wellsfargo. (800) 556-1555 Student Insurance PO Box 981106 (866) 378-8885 (toll-free) TDD (800) 270-2386 (800) 853-5899 El Paso.aetnastudenthealth. MAILING ADDRESS STREET APARTMENT # (Use school address if none) CITY STATE ZIP PHONE # EMAIL ADDRESS (REQUIRED) Please check appropriate box: Please check appropriate box: Please check appropriate box:  FEMALE  MALE  SINGLE  MARRIED/DOMESTIC PARTNER  UNDERGRADUATE  GRADUATE  PRACTICAL TRAINING  VISITING FACULTY  SCHOLAR VISA TYPE (if applicable: F-1.com or call 800-853-5899 to request a paper copy free of charge. or arrival in U. # DATE OF BIRTH (Month.S.D. TX 79998 www.com Mon . Citizens and Permanent Residents only) U. marriage. Day.

50  $644. Spouse only  $1. Penalties include imprisonment or fine. unless you enroll to continue insurance for an additional term.wellsfargo.33  $865.) Mail or fax enrollment form and payment to: Wells Fargo Student Insurance. except as permitted or required by law (e. your and/or your dependents’ insurance coverage will be terminated retroactive to the effective date of the enrolled term and you will be responsible for any claims incurred. NOTE: This is limited term coverage only. It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.12/31/17 1/1/18 .7/31/18 Student only  $1. We do not disclose any personal information about our plan participants. as well as administrative fees payable to CSU and Wells Fargo Student Insurance. it is true and accurate with no omissions or misstatements and I have read and understand the Plan Brochure..g. 10940 White Rock Road. Premiums are calculated based on the plan term and will not be pro-rated.33  $886. . In addition. To protect your personal information from unauthorized access and use. CA 95670 • Fax (877) 612-7966 You may also purchase this plan online at https://studentinsurance. 2nd Floor. information you provide to us may be shared with your school to process your insurance transaction).489.16 NOTE: Costs below are in addition to the student premium. My signature below certifies that I have read and understand the Student Health Insurance Plan brochure and agree to accept as applicable to me the terms and conditions stated therein. PAYMENT METHOD (Remit in US Funds Only) NOTE: If we are unable to process your payment (due to insufficient funds.com.16 Per Child (Age 0-25) only  $1.16 Rates include premium payable to Aetna Life Insurance Company.7/31/17 8/1/17 .33  $865. Coverage will end on the last date specified in the plan you select. closure of account. year): Cardholder’s Name: (Enter/Print Cardholder’s name exactly as it appears on card. Dependents must be enrolled for the same term of coverage as student.com. etc.50  $624. Underwritten by Aetna Life Insurance Company PAYMENT IN FULL IS SAN JOSÉ STATE UNIVERSITY INTERNATIONAL INTERNATIONAL REQUIRED FOR THE TERM 2017-2018 HEALTH INSURANCE PLAN ENROLLMENT FORM STUDENT & DEPENDENT PURCHASED ENROLLMENT FORM PROGRAM COSTS ANNUAL FALL SPRING/SUMMER Terms of Coverage 8/1/17 . we use security measures that comply with federal law. YOU MUST COMPLETE BOTH SIDES OF THE ENROLLMENT FORM AND SIGN BELOW I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief. SIGNATURE OF STUDENT ______________________________________________________ DATE ________________________________ WELLS FARGO INSURANCE PRIVACY INFORMATION We know that your privacy is important to you and we strive to protect the confidentiality of your personal information.  Check/Money Order – MAKE CHECKS PAYABLE TO: Wells Fargo Student Insurance  Credit Card:  Visa  MasterCard  Discover Credit Card Account Number: Expires (month.529.50  $624. You may obtain a detailed copy of our privacy policy through your school or by calling us at (800) 853-5899 or by visiting us at https://studentinsurance. These measures include computer safeguards and secured files and buildings. an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Rancho Cordova.489. Rates also include Medical Evacuation and Repatriation and Worldwide Emergency Travel Assistance benefits/services provided through On Call International and its contracted underwriting companies. Dependent enrollment in this plan is voluntary.wellsfargo.).

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