ou con view te stondrd Sura of Benet & Covers (SEC) which etd] by Heath Care Rear. summarizes yu avrg in foret tao isu corpries now use, To view yor ln S3C goo: tdennsurace. welfrg.com ol (600) 853-5699 o eqs paper oy lhe ‘The Calfoena Stote Univesity International student heath insurance plants underwritten by Aetna life Insurance Company (Aetna) and odministered by ing Coims Administrotors, Inc. (CCA. Aetna Student Helis the rn name fx prov and seis proted by Aen nd CCA nd tropa file compan 15.02,310.10 You an vente sda Summary of enels& Conroge (SBC which sete] by Heath Ca Reform. snmanzs your cogs in femal insane compas nm eT view yr din BC: stdetnsranc nelfrgocom cl (800) 8535899 oes opapr oy of che aetna ‘toa Lf wane Can aetna The Caf Site Unive erntond student eth nonce ons undeiten by Aen Lie nsacce ins Admits, re, (CH. era St Hens Cpr Gat) en ctl y Cie bend Pas ponad ann Chord yb sae ones the brn noe rps and sis po Wal Fxg lsc Sens USA, ‘Wels Fag nonce Senices USA, ne Sint snc sonIMPORTANT NOTICE Ths if dessin of your bens, For iomoton gui the ful Nase Ply which nds pon bi, xcs nd ints, ord if mason choot fondest, ow to fl canted benos ond oe impatn oration) plas cl era Sunt Heat (866) 378-8885 or send an eno hgh your At Kg curt oa hn://wn etude com/ customer-service /cusomer service aspx You ileal fo bina coy ofthe fl Haste Policy soon as ts val, ‘Insurance under the Master Policy will become effective at 12:01 a.m. on the Insurance of cl Insured Persons terninates ct 11:59 p.m, on the earlier of: toler of Dt the Moser Poli f + Dot te estar Poly tenis foal sed Psns or + The Master Poly eflecive ha + En ofthe pera of coverage for wich prim hos been pi or +The bagiming date of the fe for which prea has bean pi + Date the Insured Person ceases tobe eligle forthe insurance; or + Tho cay of he Enllnet Form if apie) ard pemim payment Se hind Pason enters mitay sec, 3 techy Wal Fao ns, ied ator Unis; © Sree hes neegpg cere ud he ome Hast Pley +The dy afr dte of asian the Elan om mal. rb, he poly whe est ec dae wl tay fee IMPORTANT NOTICE Premios wil no be pro-aedif he Insured enol throughs finn lod he subsequent oy wl go ic ‘posttest datf coverage or whichhoor shes oppying Fn deco imma fered tho gop i corr tegardng coveroge effecive dates are made by KtnaStudent Heath The below enrollments wil be allawed a 30 day groce period from the term ‘sort date to enroll whereby the effective date will be bockdated « maximum OF 30 day poly sh 1. All hard-woiver ond mandatory (insurance is requited os a condition of ‘enrollment on campus) insurance programms. 2. All re-envollments into the same exact policy # re-enrollment occurs ‘nithin 30 dys ofthe pir poly finan dat. Dependent coveroge wil tbe fective pro tht ofthe sued Student or nerd beyond ht fied Stet COVERAGE 1S NOT AUTOMATICALLY RENEWED. Eig Persons mst re eh et ht te: aval when coverage terminates fo mann coverage. NO notation of an expiration or rneal wil be sent | oNTHOY | TERS OF COVERAGE anes | Stentor WOT Cas alo ae nit oe ste pion |epedens ms be erode same er af coreage os sent Spouse oly $286.95 Pe hid Age 025) oy | $1397 sin pan ppt foe Coys lesen opp Lesa rr soa le ed con ard prin nd Word eryeny vel Asse elise proied ugh On Cal temo ods conc nding capa 92° Gu Soe Foun - Let WOrNen ‘AV trond sues, iting foc, slash pasos posing nd ning acute passport ond void visa sts (FF a, ee), gaged in elcaiorl ais ot Cl Sole Fulton who a tipray laced ouside thet hae courtry and hive not been ged pera rien sh, eq to be ised unde the oly. Conon i nicl forstuansengoged in “Pic Tn”, Ercient rust be compare by carfmaicn of rick Tring fom the insured sen inthe fom of 0 copy of you EAD (OPT coveone & able for he fist 12.monts of OFT of). Contac Wels Fro Isuronce Srics USA, Inc's Costes Sener mre deals (peson who an nmigat x pronet test den sot eigble for ong ude nena plan.) Tobe on sued Pas unde he Pol, th sent must hve paid eed prea ad is/hex nav, sare ond ot of bith rst oe been inde inte dedrsion mad y he Sha he iste Agent he Iie Alsons mst oc ond cases on cong fo: 45 conseuive days cling tc ffi de fr he ta pursed on/p fo ‘hiv reuremeis forthe psd far ubich coverage spurts, except in the ase mca widow cr ding schol authorized bens -AUCand Wels Fargo roc nin th ight forse ster sas ond toc recast wily ht he Ply egy egies hoe bean met. ord wheneer And/or Wels Fg Insane cove hat the Plc elgbly requiem hve not been me, he ol obigtn 0 rot rd of pram, Ell stuns wt mono se covaroge unde another rum nonce pln eos eit opuchose te Stet Heth sun Pn within 30 fos os con, se sus st pote Ws og sae ik poet he sn eg (fi a ltr fing) within 30 days ce unig erent. The ive de wou be the aero 0 erm eect dt, orb he dy afer pr overoge nds if nln ousted by Wes Foose win 30 dos fe ss of income Coa eed Eig nied Shen's ray co purchase Dependent coae ft tne cf sun’ enollent in th pan; wii 31 doys of oof the folaving poled eres: marge, aden of domes pars, bh, adoption o rive inthe US gb dependents the spouse gay egitred ond vad desc pn’ wha ses wh he sed Serta these’, the spouses, oth mesic pono rival i, phi egy fod chide 26 yn foe Dependents fo igi Internoona tet or visting oly mre must pases vl asp ond o proper vis 2, 42,02). A “Nenbon wil ora be coved fr yo Sites frm bith nl 31 dys, povding th the students coed unde is slo, Cveoge maybe conned frat chi when Wels Fargo suc i rf in wing within 3-day fo the doe o bi nd by poment oF ny oral peu, Dependents mus! be enol forth same form of coverage for which the Insured Student enrol. Dependent coverage cies concur with that ofthe Insured Studer, and Dependenis mst earl when covergeferminats fo nti overage. Pa Refund requests should be dreced to Wels Fargo Inswonce ot (2) 03599 vert sarin els cm ‘Aefund of premiuen willbe granted forthe reasons ited below andy. No other Ret hel ea yt wihog fa sel iin he fis 45 dos of te ewe petd you ard your sted dependents wl eee fl rr ofthe ‘insurance premium provided that you ond your insured dependents tid not crt om ng ste eof wo school must be provided. if you withdraw after 45 days of the coverage pad yo an eri ens cna en ‘until the end ofthe term for which you have poid the premium. 2. ysl pens nr oma fs of acon you ond your intl depetders wi ot be coved unde the Nasr Faye gta ery yt oe he ae ese aly vibe cna. If yor dependent ents the med fos, «pra ‘hn of ema lb roe heya in ns Teche by Wal Fargo Inaronce Serves win 4 das of ety cance 3. Refunds whe qr arise dependentsin cas of quoi event suche el sen, deo th in 3 dnl coe ver, proved a yor nsed depends rt He« medal dim ring the insured period. Werte proof of such qualdying event must be subritted. Refund ‘not be prorated. ura Pa WH RSORAL CHECK ‘Note: personal checks are not always @ poyment option, Please check your scio!Sewalnent for far avec payment opis.) H you rake your nu dependents’ insurance payment via personal check ie 0 Wells Forgo Insurance and we are unable fo process the check (due to inutficent funds, cls of ec, ec),yout and yur dependents isa cverge vl be face dato eae em | | ‘mina toate jo (Sn Faues-Lvcae * 3°WHERE DO I GO FOR SI ca ‘When you need care, corsider Student Heolth Services (SHS) on your campus 5 your fis stop. They can provide many of the routine hedth services you ‘eed, Services obtained at tho SHS ore reimbursed ot the Prefered Core rote ‘A'SHS referal is not requied, ond it does not guarantee services recived will be considered eligible expanses under the plan, nor is it quoraniae of ‘poyment. You moy vit any censed heath cae provider diecty for covered Sots, et spat a esces neta servis, Hower, when You via Pere Cae Pri, yl gewaly haves out pdt ‘expense for your cae, To leon more about Prefered Care Providers, visit ‘winw.aetnastudenthealth.com. Insured dependents arent ell ows the SHS, The benef sted in the Schedule of Benefits are available to the insured dependents “*Providers ove independent contractors and are not agents of Aetna. Provider ‘participation moy ‘nge without notice. Aeing does not provide care ar garages 1 heath sre. Tou kee ai ‘eno Student Heh as aranged fo you to es the Hana Pere ae Pod mou aero aie td a Fer bectse songs canbe ative fom fe Neg hares hese provides ave aed ooo os pyre ote snc. Shido espesle fering Physcns of pion xf pode evpensesfor relerao hatha eed Cre Poder ono Korea Cr Povide,Pforel Cae Provider oe inependert contactors nd renter anpayess nr aan of ‘he Colfer Sii Urivesty system noc Retna Shident Heath To finda Metre Coe Provide, you can sein’ one DcFind® sei loa ot ‘nn.cetnastudentheath.com. ick oid You chal” od eter yor School woe. You con wse acd fo find out vk spectc por belongs to dats retwok oro find Pelee Coe Provides practing in your en Cran ‘CLAIM PROCEDURE le eng ood sci, Hee pest yo Ica fared Pharma log with er onprl coy. The pharmacy wb eka fetneastl ecg so desi, he py oT, When yell a per, dp ive 0 cod wh yo, od may ein your pescpin from on eno Pfr Pharmacy be renbused by submitngo contd ena Pesciion Dg dain fr. You wl be intusol for coveted means, ss your copay. Far an in Pesci, cin fm gto wv. atnstdenthea com Fd you shal, the ik “Pesci oon on X i fom, Ox al (866) 378-888, Prescpions fom o Non? Pharma, oa heath cent ghar ine ble of biling, mast be pada in fl ot he fine of sn ond sbi reinbasren 4 Gu Sot Faun -Lct edi 1D cards mayb shined before win 3 weks of your oy eflecive do, Provides red you Nees Df your D cad oie yeu, vey yor coverage ond il Aetna Le sence Company. You do not need on 1D ca oe eg to recie bens, you need mead atetn bolo reciing your 1D cr, ends wl be payee oxadg To the Ply. One you hae rire your 0 cx, rsa it the poi Yo foo png get cy cin. oon ka iy et ‘wncelnstdentheoth com The Informed Health Line is 0 24hourscdoy, 7-loyscweek tolhfee line for insured students and dependents to access confidential medical odvice, ‘of get assistance with locating neorby preferred network provider. Just cll (alo) 556-1555 to tlk to a registered nurse who can provide information on a ronge of topics. Callers must be encoled inthe Student Health Insurance Plan irdeto be gl ois form Heth i CIMT e cin e Got Questions? Get Answers with Aetna Navigator? son fein Student Heath isrnce mabey, yo have acess to Ano Navig®, you secre member west, poked th pesonozed bees cn at aon, a ce oko wes tocol ot of else tnsoctens one Br egg i et vg you «+ eve whois covered ne your on, 4 eqs mba ID cards + View Chim Epon of eels (08) teres + iat the cost of ormonheatcarsnes nd procedures beter lan our exes + Reseach he pce fo do emf tere re tates. Find heat oki nd fakin thal otic in you ln + Sond on ena to Aetna Student Heath Customer Serie ot your comeren, ete oes ea infra od news, ond mare! How do register? * Goo mmostnstdententhcom + Cickn “Find our Sho” + Ear your shoal ae an then cick on “Seo,” Chek etn Noo ond the the “Aces Nair” * fl te srs sn sig ne" Now” + Slate name, puso ond secuty prose. ead wth episering ai evi? Tatil sisi oval il fe, Monday tough dy from 7 a ‘9 pm Fostr Tie ot (00) 225-3975, IMPORTANT NOTICE hiss oh sain fy es ion agg el Nase ey oth ics ons er nd nso fo but fund rqvess, hw oi o ain, monde benefits and fer rg nfm pease cal Ata Stent Hel ot (66) 378-8685 or | send ema og yo ein Nig Aout oa l//wn eased com/ustomerservice/cusomer serve aspx | ‘You wl ol fo brain con fh fl aster Paros 00 itis be, The Pan il poy beefs in accordance wth any applicable Colfrsia Soe Insane Las) WAIVER OF ANNUAL DEDU: J ‘In compliance with Federal Heath Core Reform legislation, the Annucl Deductible is waived for Preferred Care Covered (Medical Expenses rendered as pat of the flowing Sent pes. Rone Ps Exam Expense (Oc Vis), Pop SnenrSaeeing Exes, Mammogram ere, Roane Sceenian fat Sealy Tarsnited Disease Ere ai lec CS, Psa Cn Soig Le Pec Gems Fey Oe ik), el ann Feven ‘Visits (Office Visits), Sceening & Counseling Services (Office Visits} as ilustated under the Routine Physical Exam benefit type, Routine Concer Screenings (Outpatient), Prenatal Core (Office Visits), Compeehensive Loctotion Support and Counseling Services (Facity or Office Visits), Breast Pumps & Supplies, Family Contraceptive Counsaling ‘Sevices (Office Visits), Femaie Voluntary Sterilization Gipent ond Outpatient), Padiakic Preventive Vision and Dental Service, Female Controceptives Ganeric Prescription ‘Drugs, Brond Prescrigtion Drugs if no Generic equivalent, FOAAnproved Fernale Generic Emergency Contraceptives, | Deductbls™ The falling Oeil ae appl bee Covered Neal panes oe payable: Suden/Spouse/ Child: $100 pe Insured per Poly Yeor | | *Pecvsit radon degunbles do ot poly towards sting he ln Deductible, | Goinsurance | | Covered thedical Expenses ore payable a the coinsurance percentage specified below, after any appicoble deductible, up to an Unlimited maxim benefit | | ut of Poke Maximum | Preferred Care Individual Out-of-Pocket: $2,250 per insured per Policy Yeor; Preferred Core Family Out-of-Pocket: $4,500 per Policy’ ‘Once the Individual or Fomidy Out Pocket Limit fr Prefered Core has been sated, Covered Medical Expenses will be payoble ot 100% for he raainder ofthe | Part upto ary bene maximun that may apply. Cainsurace, Deductible, Copays od Pei Dea the Outof Pocket int Series | that donot opoly towards sting the OutOFPocet Limit expenses that ore not Covered Medical pense, expenses for Designated Creo MonPtefered cae; | penis dar expenses no creed is Pon, | INPATIENT HOSPTAIATON Room and Board Expense, seripivate oom Intensive Care Room and Bord Expense, overnight sta. ‘Miscellaneous Hospital Expense, includes; among others; expenses incurred during 0 ‘hospital confinement for: anesthesia and operating roomy laboratory tests and x rays; ‘oygen tnt and rugs; mens; an desing. SURGICAL EXPE (INPATIENT & OUTPATIENT) REFERRED CARE | _WON-PREFERRED CARE 100% ofthe Neo Charge | 75% of he Recognized Cre 100% oF te Negntted tage | 75% ofthe RcoizedChage_| 12 a 00% of he Negotitd Charge | 75h ot the Reozed Cage | fiat (on | 100% ot Nos Cape |. 75% Rcoiz! Cape 75%oF the Rcagizd Charge | 100% ofthe Negotiated Charge iia | 0% ofthe NegotintedChaye | 75% ofthe Reoonizd Cage | cha 15 Copuy avid | fer 0 $30 Coney pa vit CTC | Wallin inc Expense. Cn coat ie ire ot ann an oe pln | alt | Emergeney Room Vit Expense ant lene har os Nard Care Pr | neste ocd wh ee pode at omen oa Sa deo conse) espera fy moe i ee he Neo Carye | 100% Ried Cage tv eon ey del on pays en tee | "OQ Me Meat howe | 100 he ao! Cn | yor cc he oy sare oo es ag tara ese | "S130 Copy pt st | ar 150 Dede pr st | Sind lan kee des tom bak oye cd nano ese | COBOY wed abi) | (Oeuf) | exp eet eh de yi rb | | bit he cya ot pn dace, | | ‘ned on net page bee (uSurFsrer-tasace *5°Er eae) Oe | Urgent Care apes. Ae aA cee person stl sek edi Peeters atom ees eo | ein jd fs rey on hoc | franc mel osstve ecg shaditn Repo ade | | Ambulance Physician’ Ofc Vist Expense Cops de on of vist nisin adn oto pln deci, Laboratory = | Theropy Expos, ae folowing types of eran rove on on ovpaent es: Phys They, (horace, Spach Tay, lon Thay, Croc habit of Ocapnona Ther. Bnets fr Cipro Cree ited to 0 vis parPliy oon oe | Brent Feeding Durable Medical Equipment Expense, nes the elo purchase fas etn duce ml equip fore pups of lan spe ‘Ary Tesing on Time Expense es, psn fc vss ‘to administer injections, prescribed medications for testing and treatment ofthe allergy, ‘ond other med ay supplies ond sevice. | Routine Physical Exam Expense | Feit Preventive Cr xan, ra ona poe coo ode | Teens ee rune, vig pid hth edt, runian,od | absences. Pedic rovenve Cae Expense, he conpeease even ca och | 17 and 18 yeors of age, induding periodic heath evaluations, immunizations, and lab saves | Sovre ent ness Expense - Inpatient fe dans ond icy noc | ont f see mail hess apo af ona, oss enon jones of ch | Seva Mentl les xpens- Outpatient nil ond rvs Dorder Expense, niet nd ovat. Coe Tele Inptont Expense fe neomet of oakland ain upton! Epes, the tcent fal od dg on, ——T nae Meee ‘OO% fe Nog Charge | 75% ofthe Regie Charge | fora $15 Cony pervst | fer0S30 Copy pr vist | | 50% of fe Negotiated Chango | 90% othe Recized hans Toft Nogod Charge | 75% ce Recoied Chae afro 515 ony pect | ira $30 Coppi 100% ofthe Negotiated Charge | 75% ofthe Recognized Charge | ia |e | 100% of th egoted Charge | 79%o the Recognized Charge t Oot ho eel he | Kl he Reid Ce | Fadeonte seta asds | 7S Rize Chage 100% of the Negoised Chage 75% ofthe Recognized Chage | fees io Peyote os ny ober Sikes copied Cage | 10 the eof Chge | 75% of te 100% the Negotiated Charge | 75% o the Rempized Charge PREFERRED ARE | NOM-PREFERRED RE 100%of te Noid Chops | 75% he Roi Chae | 100% ofthe egrted Cage | 75% ofthe Recognized Charge Cotinued on not poge 96% Gu Sie uma Lace Teas | Maternity Expens, forthe coe ofthe coveted arson an ary nebo hd | Well ewborn Nursery Core Expense, forthe rote coe ofa coved parson's roto il Ed Prescribed Mediine Expense Not: Cntaxepve gs and Dov bolts usted under th arly lang ‘Bene, os ced ia the Benfs Descpon on page 8 Pap Smear Seeing Expose Marra Expense | Fay Plnning Expense ines chayes cared for serices od ops ta ae ove o pret pegang. Routine Sresing Expense ince charges fr Cam, Sexy Hosited Die, and alec ms Rehabilitation Fclty Expense cher Implant Expense intl implanted devices ‘Adult Routine Eye Bxom, ey exons eatin, edive Abortion Expense | Sori Sugery Expense, exeses inde srs ended spar of edly | neces barat srr eaten fr mari bei | Human Organ respon Expense | cia Vision Care Services and Supplies PaciatricVsion Care Exam Expense Pedic Dena Diagnostic nd Preventive Care Pediatric Dntl Basic Restorative Care Pedic Dental Major Restorative Care 100% ofthe NepoedChge “Fy on sre bss ny te Sees | 100 of Neood Chap | 75% of te Rcopized hare PREFERRED CARE iis Student Heath Center Pharmacy: 100% fhe Atul Cage fo ech escton Dan (Bent ison endusaent bison) Prefered Care Pharmacy 50% ol he Negoined Chay foreach Brand Name resco Dg reach Gea Pescipon Dg Non-Preferted Core Pharmacy: Sot ofthe Reed Charger ech Bnd Rae Prescition | ug ech Gee Pescipon Dug | 10% oie egocied Ge | 7: 100% oft Neaiced Gg | 75% ofthe xpi Chae | 100% ofthe Negtted Cage | 75% ofthe Recognized Chage T5%o the Recognized Charge 110% he Ngoc Cage | 75% of he RecyizedChage | 100% oft god Ce | 75% of te Rcd Choge 100 the epic Gage | 75% al he Reorzd Chapa Poyatleon he same bass os any ater Snes Pyle hsm bas os oy te Scns 100% othe Ngoc Chae | 75% the ecrizedChage [oot eae he | St heel Che | Toole egal age | 75%al te eogize Chae | re tm eid Cag | Sole Rez hae | | Sof the Neotited Chae | 50% othe Recrized Charge For mre details obout these benefits, please se the Benefit Descations secon on page 8. (Soe auc Lue °7®Routine Physical Exam Expense: Beefs inte exes fr arti pyst calm perma by psn, IF chars fx ovine phys ea gen to cid who 0 carl dpanan cored under arya bene se fn, ths charge wo be covered und hs secon ‘aun psi evan i © met exon gen by o physic, fr a eso0 ier tho To dogs ent suspeced or identi ny of ehes, hl a pate na + Rvie vin an ating scenings gen os pr ofthe run hs vm. + Yrs, bon ote ess ie in coecion wh yam, od + ft the oinstn of munitions fifi dens ond sing fo ube, iad ways ors girs may ite Pcl im cs Col Ne Eres le ss end ncn wh, 7 stn ons nt via foci ol AB in te can ‘eee hen Ss Prove Services ask Fare. + For fama, soesings and counseling sevice spoil frin he conprcensie quienes econ bythe Heath Resources and Saris Aisa. These erices may nde bt nt ite + Screg ond cousin servis, sch: © Inepsnal and domestic vic; © Soanly onsite detses" on Haran ane eieney Vis (HN) inocins + Sceting or gestaonel dats + Highs Huma apexes (HP) ONA esting fo women ope 18 od ole andi ance yt yo. *Seuly tose ésetsesverng expense i Uriel a un sceeigs per Poy Ya ‘+ ys, ab and oar e's gion in comedon wh he xa, + Tnmotizatons fines disses on th msi x oniniston af immunizations thot have been recommended by the Advisory Cnr on irmarznon Pacis o tC fr Disease Cont nd renin. + te pln ince dependen coe, for covered navbar, onic has heck, Imprint ote: Fer dts on the foquncy ond gels that only o Rate Phys col Gams and Raine Cane Scesigs, 0 covered pason my coat Is ber scan oc Maber Series by lging ot te Sena ebste nn gna.com cig te lee nero the bck fh 1 ca Scena ous ufos Co cl pense chs rd opystcan non dul rip sein reflow: Depeso Senin, Ts soiled fo ace ey Obes: Seerng ond cuseg servis fo oi in waht rection de a best, Covey ntes: * eve cunselng vs ond/or isk fac redone, + Neal mon top Nuttin’ cus, * Hay dec Ws pods naman wi hei (gh cesta) and ater knawn sk foc fr cardovscar nd Gekted deni des. 8% Gu Sot Fuse Luce Sviesin tis caogay rset facie it ot 26 ini gop is by cy recoied provi oy Yn. + Tw 10 Healy it Coursing vss wil be oted toward the tot cures of vist alive fr best consing isu ofNeool nd/or Drugs: Sceern ar cursing sevice olin he retin oeuion ofthe se fon kl aetna Cova ints pene consi vs, adr redo eon ond sched eset + Seis in ts cogary ae aj oo cabin rit of 5 indi o yup vis by ny coz pt Pay Ye Use of obec Produ: Scena ond cose seis o io cored psn o top the ws of tbaco pres org ines + Freveivecuosig vis 4 Teatont ists; nd + Cassis Joa coved paso oso to se foc procs ‘ba pou! mens aust craig ob orion nding: cites ns, stoking bac uf smokes bo and + cake pouch conn bn Linton: Uns seid ce, ot coved nds Song ond Coursing Serves benef recaps inane fr Sars hh re coed any eter unde ay the part of is lon + Seis in isco ce sujet oa combi nt of 8 inv or ru vit yan conned provides Pay Yn. Family Ploming pense: Fr femos wih epoucie copy, Coed Ne Esc hse dys nal ss sas ge prod io prevent pega Al secs an ss covered under his barley th fod ac ry Adinstoton (08), Conzoge ines consi serves on canter mahds povided by 0 piysin, oso or gees. Such cursing srs Covel Hei bxpses he oie in ster ogaup ind sting Te foloning cca thls a conse expenses ris beet Volo Sieriizoon: ove expres ine hays ile sey by he pe end tay sain psi on lat es ples ng, vot ie, tl gton ond tii ngs, Cvs exes under is Peentve Cr bereft wl not ndde hs fora ohn scan posite hh proce ws ot ile ser yy te provider ase the inary pupae of caren Litas: Uns sted ce, ot coe nda sent crags for + Senices wich re come any exten nr oy te pt isn + Snices and splits ined foron brio, + Seis provi so rest of comalico esting fom ory Strain pocket allow co, + Sis whith a fr he eine fo dee ies rin, + Sis tht at gen yas oad is char deci, + Poi pyelogi pearly a ential sing or exos, ult Cote on next pogo + ay contest oy “own” by fe FD nd ot “epsoed by he Dk + AGE mao, sion odes docs ‘Tete! vn sean pees, ng ay ated lori ca. Inga not: Buon Fsipfion Dg or Dies be ced TOD a te Net Crag, dig wane lal Daft a tc Pepin ug Des sl veh sane hemp deste wesibe species Ds os ite, Pedic Pevenive Cr Exe: Cove dal ress indole chaps forte once eee cof len 16 yn of og ong, cess wh Remco fr Penh Petrc heath a cine ken kee Paci. Coveted Een il ine pd ekins muna db secs Ped retenive Care ges Coe dd Ears de hayes foro omar evens cl ton 7 on Byes lp, ten wh he ered Poetic Cac ned by bo hneton Kony of Pao. Coed Nec bes wi nce oder nunca nd es hap Ens: Cow ok epson eli pes el ey pedo en vp + ysl Temp, + Gap Ca, * Sper ony, > in ay, © Cox fio Occ Tp tapas Gc Co ow Cond Neil Ege, fh teil neaonsosel odin an cing og fon: he bk of el, re, nt con Epes Spe oC Tepes Cved Maa Ess, ony sh hoes et eyo sc Conse eid Eero chan, dng ooasen ds wd in oan wih he denabwony, recon ton as ol pede, Dish Co etinin a ft oss al epee aed {7 agli, Cnel Hed Bye cbo ce pens the edit of denote an vs yo alc lesa shat when Benet sf fis elo Cael ed ges, an i sam sy hess lay einen Teter xan: isin cays ned fo hess eont of es rd inmalysaes Coe ied or tt, eg eo i * ban, 5 pn vis, ing ts odie eas, psd ions fer sig and Renato tear, ing any rpm nth ena of peed mao, an «+ her meiay neces sop sais, Serr len ls of pers of an oe and Sus Enon Ds tunes a Cl nin Epona Coe Wedel pens Be res nt mea es pati iat oe a ess Tapes nye nels aera kes oo cid pp ns le snared oor sis chlo he same basis sanyo Sides Cove hel Exess oo ind the hogs mn fo eet ed sig pa pian td tet Foy Fin gr (row mse cin on oases bass canacing Rein She el ‘ini Rviw Services fo nos inc ew sacs, os eg by the Cll Wel and stun Cad, te pode eo coved person ho nr nd whois confine in a ft ite ina pte ata Peal fact ne case of hs pent grr, te foliving cages wil be nts Coed Ned Egos + Cages fr he cnc eve’ saices othe ext ich sees we td by Clana Wee od nto ca, «+ Chae an, fr sanes of ov hue. on + Shans fans apes iso, Svar Mena es of persons af ony og and Serious EncionalDis turbos ofc Chill Oupofient Expense: vee Nadel Expenses forthe | dag ond mote cess cfc reser nding pescipon gs, of sere ment esses of «psn of any op, tf ts tn istration sane bss any athe sides. Meril and Nerous Diodes Ingen Expense: Coveted Nac apenss, | ctr tse fs mel os on ss enon dubs foi, chained yo covered peson while conined ws tie inet ino hsp or eset aient ay fre tect of iat od ns ses, Covel Eomss ao nd the chrges ml foresee hing pail hsiuzaon in «hs or ramen fay, Por eew nd ‘pp ust br otonod on a seb cae bss by concng Kee Stud Heth ic Review Services for Miners: cil en sis, a5 eid by the Coma Weir! stun Ca, x red ro coved pean vo sain on who sonia nos fdFime mate na picid | Heth fcity onthe coset of his parent rquarfan, the folning chaps wil | bein s Cored Neca genes + Charges fhe nical ew seis the exe uch avis ce rnqaie by th Conia Wefr ond ison code, Choy, fon, for sees of nna, ond + hrs ony snipes ih coc, ent and ervous Dsarders Outpatient Expes: Covered Met Epes «5 che thn nse for see mol nes ox/ seus ean ds Bones ao il inte cages fr tetment of ment an evs does whi the covredpason stati os 0 fir nt in ahs Hols Expese: Coed etc Expres ide past cae fe cor fa perro ry oan Gil emai 48 us ag ebay ad fom of 9 ous cro cesta hy Any decison fost such minum cones sl be ae bythe ten ing Pysn, i cosaon wih the tex. ich ses, Covered eda ‘pees may inde home vss, ren van, od assoc and iting ines rbot fodng Pen gos fat dsr ofthe eb meas of dogs proce dhs of gh perc, Hiety Bese, od Complains of Pry fy pol o se ss iy dt es Prenat ae: Fecal lb cove for sie ced yo pragmant Continued on next page Swe Fan Lane *9°foe pins ic’ acs ib a ctr esi below Conrae far peat car unde is anf ited 4» pagan fed gyscon oie ss indo the nal nd subsequent Hiren ysl exams of he pregnant warn (naenal weit, Hood presse ond fl hot rae chu) Camprehersve Lacon Sopor and Counseling Srvies: Cove Mail Expenses wl nds compres lian spt (ssc ond ring inks ede) al can as ovals go tnd nthe pest ped by cif aaron sport ride, Thos at ele 60 ein el ling es Erk Ged eens ume henge pstpatun peal ao nde he wea ops of ben fig eqn Laon spt an aon couse Svs recovered epee when in ei oun inv te el Newborn Nursery Core Expense: Bnet rl ofa coved poss nebor cid oss +H ds sec ig tse, bot fox not mre thn four dys, + Physi chars for rameso, nd + Phys’ ches foc vss othe newborn hi inthe hostel ad co ot me ft | sp Pap Smear Screening Expenst: Cove Neda Exess inde oe rune nal Pap sar scering (oan ative crv cae ssi es wn tec by phys a ea cae pri), ond on FO agoved Funan paplomnns seeing tor ware ge 18 on et Nammogrom Expese: Covered Neticl Exess ince coveoge er mare nora or srering dogs uses upon feral of ruse practi ceed muse, son ssi, or pysion hag fr ote coe °10* Gu Sue Fun - Lace Peta Von Care Srvies and Suppl, Cored exes inde charges {othe loving von xe snes nd spins: +" ce vt an opamalgs,opamotist oon elt oe fg of eset cat + jogs es, pst ses or prescigtion cr ses Cone ies crges ined fr * Harconetion!pesipion contactless that xe uted o cone evel auto 20/40 rt inthe et ead ht canetin co be clad wth caer sts, ghkc psc ses prs af ctout pry kas ee permed. Low so sas ‘ising of ho eto oth vision nwa provides ude hs Plan can be ‘ca of wang com ws. Be se fo ek ot he opine ison net pris Ising a eps Yo you po, sede! Aaa plows if evs tf pos. Yx mt pe y co ae ¥en pat vit the in of svi, Ths beet jo he xis Shown ote Shes of Bees so coxa fo pescon less 0 caked ya, his bea wl cer ther presciton sss fomes x psp cat ess, bt not th Limittions: Unless spected above, no covered unde this benefit cre chops iced fo serves nd sips: + yegisfomes, norgrescipon ses and nonescipan contact es th a for cosmo poss Hun Org espe Exar: Fors of gs, se, bre na. ride pay drained Src a oped vr ro hy ce Hebi) co wh gies or dro Sees ota hae. etree ed IMPORTANT NOTICE: Tiss iusto bs spn of you bene. or inf rn gag the ful Maser Poy (vith des on be fs, exlsons tl ites, oe iformaton dou wind ess, How to leo doin, mo Sa nits ae mr mn pec ee Se ah (866) 378-885 re anasto tena ough you eta Novia cont rt el on/asoma sree sericea ‘nm "You wil be abe to obton a copy ofthe full Master Poly os soon asi is ovale. ‘lon benefits are subjct to cl onplicuble state ond federal lows ane regulations, wih te ae orth oes pts a teleloing 1 ‘Expense incurred for services normally provided without chorge by the Pol ‘ojholders Heath Service; Infirmary or Hospital o by health core providers ‘employed by the Pobcyholder, Expense incured for eye retoctons; vision therapy; rodial keratatorny, ‘eyeglasses; contact lenses (except when required ofer cofarnct surgery), Toe wn fei aiscpespins xmas exes eid for repr uso by caved i Expense incurred os a result of injury due to participation ina sot. “Paric inn en gp eg ‘the rot o conspiring to incite i. It does not incude actions token in sl ‘defense; so long as they are not token against persons who ore trying to estore low ond order. Expense incwed os a result of on accident occuring in consequence caf riding as « passenger or otherwise in ony vehicle or device for aerial naa, excepts 0 fore paying passenger in an circrat operated by. ‘scheduled airine maintaining requir published schedules on a regulary established route. ‘Expense incured os 0 result of an injury or sickness due to woking for ‘wage or profit r for which benefits ore payable under any Workers’ Com ynsation oF Occupational Disease Low. Eins ned eso a ys sss contac ‘while inthe service of the Armed Forces of any country. Upon the covered person entering the Armed Forces of a country, the unecmed pro-voto emi wil be refunded to the Policyholde. Forse ‘ncured fo treatment provided ina governmental | hos unless ‘there is «legal obligation to poy such charges inthe absence of insurance. Expense incured for elactive freabmant or elective surgery ep 0s 5 cically provided elsewhere in this Policy and performad white tis Policy Sine xponse incured for casmetic surgery, recnstucive surgery, or other ser vices ond supplies which improve, cle, or enhance appearance whether or ‘not for psychalgical or emotional reasons. This exclusion wil not apply Yo the ‘exent needed fo: (a) Improve the function or crete w normal appearance ‘othe extent possible ofc port ofthe body that is nota tooth or srucure ‘thot supports the teeth and is malformed as result of o congenital defect, hed pst 9 had bo Sy fod ote ode) aia Cceg ‘ocansiucive surgery for prosthetic device for 0 covered person who has ‘undergone « mastectomy) which occurs while the covered person is covered ‘unde his Policy. Surgry must be performed inthe calendar year ofthe oc dent wich causes wy or in the next calendar yeor. Ep covered by any other valid ond collectible medical; heath or ac ‘cident insurance to the extent that benefits are payable under other vad hf calle wher rot der ih as. n, 12 1a 14 00. a, {pen na ef isi ff. ‘Betse crad fe he doe ise temic for coed gesan gayi al owl fot destin ps inne x eis al aed de by Be schol arc conse by hl fe fr sacs Expt ned roy serves edd yo mabe of he coed pele ana swe ese cd pe agri fin esting frm he ploy pie of cle ar ater spr; nd calegte oil spots nd inauts frets forte contocapte mods; dees ors; on cages for ork acl sain, ioe ent re precedes ee rain os vel or deci oboron ness Sc oil as, Foes for enment of inay oS tthe ext ft pomen is inde; oder ert any peso eed spn fr the iy or sks rte ise) fans rar wich ro mabe of he coved esas ieee {ary has ny al elgaion for poy. Epes cme fo itd car. Cis ce eos sees and ses el 0 os rn hp i ah is of diy Me Ths les rom and bro on oe sina a The pan doesnt be bese. Such ses nd sues ae cast rw oud: by whom fey ae presberbywhom ‘eye rece by wha ot by wh hay prod {sexo teen of nag fam cored peso he past egg Hob open gn. Ts fo does a pyc dean by corse pestn oops, chi: brs tee prt Expenses incumed fo tin conection wih procedures, services, or spe thst cc tei by Ho, ws isi bed Kee, oc a ie ed egies) he nse oom daa txt tan creed cil ls pte th peeved i tre oss sy an eevee ses ony novo: feed yb Dk yh ged moro eeepc nn mode del soe of qd owe es dete wats genet, nests cf sah sso Te wt proc usd By he etig fy, rte peal apo, fon ar fcy ‘he nso, epoca tan the win ned cost se ye tang fay, by cor fey sone me dg, ete, pos, oxen, Ss that exten vest ox eseuch upases, Hawes, thsexcason wl op wih sed secs ose (oa hon fm ie cin fh dso fata Eis tt (al a ees canbe expat couse ch win one ya i sof ee eal) Th eee for ft dsese or hos panes of beng fective fr tht dont os eran by efi do. In ekg this trinaon ea wi too coe ess of eve by a uel ede rd {a gdesions, They wl Be saced by Be Ts pel wl ince (Contiwed on not page (Gu Swe Fusron- Lauer #11 ¢2. 2. 4, 8, 16. 0. 2. 2. 30. 31 32 3. 34 35 3. 31. arson ho teat he fp of dese nao (Te covered eso hs been ace ino phos Io 1 anpoed cacar ocd dh eed pyc opened he pon. in, ‘ean ol a wih ee osha He bn ee ce erie ug (fp eet IND soso) Ne bang tio ho Phase le onl lca ta; sponsared by the National Concer ste Aetna determines ‘that ovale, scientiic evidence demanstrates thot the drug is effective or sows poise ting eect fs th ease {agen vad os esl of deal emer expt for mail nc 25 et rfl ssw pat esc ‘stay for pl process po eseuhe ins Ply {ages red by cveed peso Uni Sites ize rs vies penne win he cored peso’ ame coun, he coved esas hone cay es soled meine poga Epes tered rena ois maine c/o hyn ing bt rot iad vega bypoteop. Ein ca tet) spi des a te ce of cs; burs, ots, () eof tena; ond () cx of fle rs ek ft con fo stent (and (@) 9 tl ele en ni es fos he oe psn doktor ales fom cc bln pos fa essed se et fo motor eid oct fo the cet Pets ee payee ude oe veld end cole anc; wth oo dar made such bis, Te Foc wl oy payor hose ses, which ar a poole udet he cuore meal pais oan when te pason rin acing beyond the scope Tishaa Ex al hee a; He ii psi of ig oi Expansefr cr ots othe extent the cage woud have been corr unde Heda Prt Ar Pt 8; re gh the cvd pasan is igi, but dio eel in PB, 7 Expense for tephone contains; chogs fo fie to koapo sha: ets o cha fo compen fo aim fm ere forthe cast of spps used in the penne of any cape fond hac. ‘ens fo esol hyn and consists sachs cnn huis; ot us, ious of phys eecse equipment ven if sch tems presbed by 0 physan pense srices or sup poe forthe teoent of besiy on’ x weaht cna ues aerse pode ns hn, Expense fornia supers, nd soy charges fo psn gs fecal puns ting cst lca us, aos obs orden fi bere pele soos ls sel eds po ral acy fayenes cad or rin comecion wi sph apy Th xchsin oso orl fr cages fr pec hapa epee to ese speech oc parstn who fs st esing hon (ie oily a exes ugh; speak wrt; an form sentences); 05 res fon acient casiless 12° Gu Sot Fuson- Lose 21 an ag et ot eel as ied fect is le ap ese does ot xed the eagized hoe fo: that sae spr by ce than hone rected sh Moule Vara, 29. fps fea of evo ses wo pc he el ii oa av oo ot Ha ata 40, Egon ensndlg xen cmcn wth ‘al vio ce, fi vstn tas aie dl ans the honing eons, mrs a ope sees an snes exept exer cee sc suns, ez, ss Stes ship in te Pl. 41, Fees ons sia hot eda tes temied by eho edgo e romet a fh sides ery ibed, Ts plese ha epee ‘commended ot eprved by eps cen pyar das. Ie een ra cel iy tes, he seo aura 0) be cae ome vi a peda pd etn my fo poco nga ovae fy, fone seo ph bolts te ses ey ceded he er owl a ca, be ast ce wih ee by eh Shs ofthe ptan od be say oe mal that cl fat hereof teen, nro ot ape eg butane fo any cen Ss esl Bl a he sos cin ited a he esas oral eal conn od (es Gags, c,d ten, Be mo ces i ca ot xt extn erection ey, oF Sx) ro ete ssp mee he eb es ‘dering ces sa © ge nse crass Aen lke intense oman nee aie pasa eh tos) opts a er eveved med eee, () Feo ob biel yey aoe co rans hte soning Seni a, ges gazed sano snags a sally and efecienes jn he Util Sales br ges, a, ect (0) fe pn of bath pesos at ech nal al iyo tema oman fu oa ena oe vl {bwin saves cr spss bo ontdred pbs etealy wens (0) hes it rote tek oreo rh heh, oa del posto) ase hed aly fe pasind cana cone of he pesca paso hs Sim otk aro ssn wn pa sah oy yh soa re ay fe ro Tes den nig nay wich pe ees iy {cl fel ede be dogs or ee hl oe, ts md bec fe stg fa aves spy cold 225) al eka pcre ote scot 4, Fass ata fr beaten ce Aan be wt pe extent at cone a the rapes roared nr oy alts heen ithe Conse Pason fs isured ander mw tan one group hth on, te bonis of he pian hoes te sued std il be wsed bo tse rps reo depen. Non oh msi rp hath lr apo covarge se agenda, he belie pn o ‘he pe ths ith els earn er lb us fs The ents vale under is an mayb orate wih athens aoe a Covad Parson under ny aise, Nake’ Conger, Neda, or har ome The Pn pays era wih the ules et rh in Ase Poiy. iinet i Covred Peon scorned toa haspital on he dt is oer sence temas, gases nae ofr te enon date and ding the cae ‘inane ofthat hsp cotnemen, shall Seroj in ocodance wih the tla ot whee ore ge pet lg seh Feo of irs. CEM eed nrc, th is inesigtin pos wil eration ifonaton in eer to apy ua th cin, Ts investi wl be handed teat by Aina Siodent Hoth 0, Box 981106, EPs, 1K 79998 (866) 378-8885 (ol-ee) (stoma Serve Rapestnnis il 6:30 om, 05:20 pm (PSD, Many tug Fay, fr any quests. Ci forms canbe bined bj dling he niet cove ry visting wa aenastudetheth. com 1st be subi win 99 days rahe oe of tet 2 Foe Coed Nel pe wl ene ih oe espa Ps coxered uns bil aces rd pol of oat are ibid. 3. orice med tis oat ot he tna the din fri submited, toch them the i form. Subsequent mata is shuld mad pong oh oboe oes. 4. Inte evento dsageament ove the yen faci, wien reust ovevi the om mst ba me fo Ana St Heth vin 180 days om the doe appaning on the Exlaraton of ants (es) 5. You wl cio on “Egon of Sees" wien your dims oe cessed The Elation of Beli wil expla, how your chim sso cag es of oS Acted hess nonce ln ‘ADDITIONAL DISCOUNTS AND SERVICES ‘Asa member of ln you cn as tke dntageof dation discus, tnd progam sh os fines dscounts ond weight management rogans These a not unerritin by Aetna ond ae NO insurance. The mabe i responsbl fre ful cs of he discounted serves eae not! these rogues to change witout noice. To ara more about hese of ‘iaal sane and sec fo riders vis, ww. aehastudentfenth com. Inthe erento CavedPason dogs wi how oi as pos, b/ she may requestor ath decison. The Covered Paso’ reqs st bea nt wi oe had (10 dy ct wo! ‘xlnton of Bers EO). The Caveed Paso’ reqves us inch wy he/she dsoies wih the woy the cin was pose, The reqvest most ck ince ony odio iforncion hr suppor he ci (mae rea, ysis fice os, ope repr, Physi i of medical neces ec). ese abit reqs etna PO, Box 14464 Lexington, KY 40512 ‘Ratna considers nonpublic personol member information (“NPI”) confideninl nd ‘has policies and procedures in ploce fo protect the information against unlawful ‘use ond disdosure. When necessary far your care or treatment, the operation caf your health Plan, or other veloted octties, we use MPI intemally, share it src ais on de ec pes (ca, ds, sharocies, hospitals, ond other caregivers), vendors, consuftnts, government vail ht sce pT pra qed ty HA confidential as povided by applicable aw. Poricipoting Network /Prefered Care Providers ore. te erited to give you access to your medical records within a ‘reasonable amount af time after you make a request, To attain a cony of our ‘notice describing in greater detail our practices concerning use ond disclosure of NPI, please call the tlliee Customer Services number on your ID card or vist Ja Sat eth ne ene ot casera ce Se Fuso Lace #13‘Accident: An occurence which (0) is unforeseen, (b) is not due to or contributed toby sickness or disease of any kind, and (c) couses injury. ‘Actul Charge: The charge rade fro covered sence by the prover who umishas it. Cnsuranc: The paxceatae of Covered Hac! Expenses poyble by tna nerfs ede is veel. (Copa, This is fee charged to 0 person fr Covered Medical Expenses, For Peed pes, eo pe Su perme feread psc, teil a tes pense, Ino overt vil the conny be rater hn the kana’ career pep, kof Crete Medial Bxgene hose choes fran tment, sie ot supp coved y this Ply which ce ren ae nae any dos ‘+ notin excess of the charges that would have bean made in the absence ofthis coverage, and + incaed wile ths Ply in face os othe coved person except Ha) respect fo any expenses payable under the Extension of Benefit vise Covered person: cone stident non cover dependent wile coveroge nda ts Pac in effet - e Deductible: The amount of Covered Medical Expenses that are paid by each ‘covered person during the policy year before benefits are pod. Designated Cre Cae provided by oDasigaed Care Pride pon reel ‘rom the School Heath Services. Designated Care Provider: A heothy cre provider (or pharmacy) thot is afte od hes on ogvonst nth Shel Heath Sas ih sores ond supplies at a negotted chare Emergency Medical Condition: This means a recent ond severe medical ‘onde, ‘ding, but ‘not ltd to, severe pon, wich woul lod ‘prudent | lepesen possessing an average knowledge af medicine and health, ‘o believe that his or her condition, sickness, or njny, is of such o nature that ‘failure to get immediate medical care could result in: *+ Pac the ps’ eh in serius jeopardy ot ++ Serious impairment to bodily function, ar {Seu tne obny pre og, . . ‘the cose of a pegnant woman, setious jeopardy to the health ofthe ns enercPesciption Drug or Medicine: yrescipon dug which snot ro tected by trademark egistaion, but produced ard sold under the chee {eter nae. Hospice: 1. "Hospice care” means 0 conalyoinstred progom of pl ois sete aie roel yon spy fom ced hin. ones Ne preven opr Fil asl sp eros ae erin ad $i fons he crs my be pie nh bons, tal ty roto medial acy ot ny time ofthe dy orig Th em nce the ‘pot care and ves povided fo th omy ter tho potent ds, 2. As used in his section: (0 “ary nds the immo fry, the son who rmory cared oth potent and ther persons with sigan ‘personal fies tothe patent, whether or not related by blood. 14 Sie Fun - Lae (© ‘Wovsaa’ monsoons male a next epee ein i pets etfs res sah ost soa reson, swe, dma nd tried vole. Inary Badly in cased by on det. This indus eltedcontions andere spon of shin Medically Heesarykseice yt: easy, nd apap, tart dass tear of soe, cy, bed ot gow ace cot aie! praia, fr de fro cient, san, apy be ose ry css, he seve rip mus: + Be care otra which Hk to proces sia postive uf as ony alr service x sup, oh asthe sks in iohod ad he pas vert cnn, fst be no mre epee gree tae hay het sea «sippy, bth sf th tks ony ied andthe paso’ ove lh conn _ . + Bea dogastic roca whch sina byt heath sts lho pason. I rt Be skal Yo en fora ht cud fet He cso aia lente sep hs ‘he seks cin inated th persons rol hea andon. Ist he no roe itl To pode a agave ota than any atooav seve rip, bth so the ses ony inohed andthe persons evel health condition, and + Js digs oe, tic ne cay ing scout oath expenses ind conrcian wit trex, sane, er spy) tan any late Src upto eet ha above ess In dt save or spl opprpice unde he reunsins, Jen il kin conser + ifnatn ling eof pera tos, + repatsin poe edewed media ie, + repatsond giles tisha by natn recognized heath coe cigarztns hata supa scent cao, * oly min psn si ot syncs inthe Ute Sts fo dogs a orient, + hpi fet psi elcid ath spe ine, on «ary ie reevatifomaion rough oA’ tein, {ono eve il healing sevice sls be casero be medal recs Those thot do rot eq the etnias of 0 medic, 0 ment heat or dei ptessionl + Tse fund mt forthe pasonal anf, comin, ofthe isn ys whos ett, ay pen pt elite any on ecnce poetical, + Those fished sly becouse peso a patito ay doy an ih he paso sides ony coud soy ond ogee ba sogrsed trated whe ot cone, + These fished sly becuse of th sein if te service spy col safely a equi bo frie, a physica ra des ole, ter ses stig. (otioved on next poge Coed Indetemining th regi charge fr service or soppy tha Negotiated chage: The maximum chage 0 Pere Core Provider ot Desired Povile os agreed to mke os Yo oy service sup fr the pues hens nd i Fly, Hon-efred Car: heath coe eric sly used by oho cae oi Des Ce Ps oho orld a Bra ia tained ye: +e gic sche been deb «Prd a Prove, on + the providers of pe tha flint one or more of he categaris of roves ised in the deny. Non Pefered Care Provider: * eat cre provi tnt hos nat contd fo ish seis or supplies fanatic, Pharma: An establishment whe pescipfion ds ep dispensed Physio: eal uci ys cee by the soe in wich eo she pris, on (0) any oar cone ht must bylaw be caged 15. docr egal quedo ede treatment Prefered Cr: Cr provided by *0conered pes’ ory cr physi or prefred aepoidar ofthe primary are «phys, ot + heath oe poet «Pore Cue rif emerge edical condtion when toe to Peered Ce Provide, ist ens, +a Nonfrefered Urgent Core Fovier hen oe to. Pree Urgent Cote rover fr tert sat feast, od utozed by Aa, Prefered Cre Provider: heath cor povie that os otacted to furish sees ies pe a,b af hpi ih Aa cs ne hats Pere Ca de fo ‘tse rin + the dss of covered parsons of whch you ae menba refered Pharmac: A phornoc,indding a maior pracy, ich patty foo contact wih dea odspnsedogsto persons covered under ts Poly, ut ni ie contact emai in fe, ond + wie sch a phomocy dieses pesction rg, ude the tems ofits conta wih etn Psp: od fo esi ic pesto dg i en cd, rust be pomp put in wing by he aac. Fecal hg: palace sd coe The eognzd dye fo a service supose los of + Tho pride’ ul ce fr urishng ond ¢ The cg ein dating ob porte, based on focos sch «sth ast of proving the am ro sir sec supa the ei gs te se a +The cage ee detrines abe te pevaing charge vl ae for itn the geoponic ao whee its fared In same craton, Atma may hoe on open, eter deco indy though aid pry, wth provider which ses the rate ha Aetna toy arose estas nse afte mato testbed cho, the reagized cages the roe estbihed in sc oeemet Uso Nat fen pvt th re, + Peovided by one smal umber of prvi in the eto oy tke nto orcourt fcr, sachs: The compa, The degre ofl need, The type of spec ofthe provide, Thera sp piel by fay nd The rvaing charge in theres, (Sir rus -Locace #15°Provided by On Call International GLOBAL RESPONSE CENTER: (677) 3188901 (le win he US) (#03) 3261909 (Ouse te US.) On loware Die Sole, NH 03079 ail: ma@oneaitrinal com ‘ww onclintoratonl com 94 ei es yo rail Mal ss inure so be sibel Yo ou Hel lana re sie othe ply Fst your eth cose Al sso services mus be ornged od viel by On Cl trata. Chis or endure wi tbe cep PROGRAM GUIDELINES US. ss stil in a. atone ilu serves when nosing rare tho 100 mes ony or ek ponent ese or conus aon {orup to ony. hil taspratn services od repoioon of aes ramos sees cial o cs aon. US. sur suing ood or ell fr sence both ot nd way fom ‘tine conps cian fou ne yo* Forgn nana stents study the US. oe ele fr On Cal nna ‘onl saves, bth anor ony om cpus o while tae ino couy ‘hats oth cou fig "Mortar sal be ell for sence dig the tr offs died Po umn pag ce cn he nena es pai dopa. EY SERVICES adil Honing: On Cal's ed to wil communicate wih he mene tse nl esi of es ops wi ty in epoca wt acl mil pasnned And ely neces fran ite Hb nd Foy, Emergency Medial Evan If adeante med facts a nto cielo, On al wil mks orogens tose wee mode of tens, examen andrei peso esr svn a mana foe ear going ath ena do, lied Reporte! sekay neds ae, ts mei ois befor the member sek further cot home, On Cal wl ens ho mere hom oo 0 medal fay ssf ome wit «medio nae nbc esc 5 cs Compassionate Vis: fc menbersrovelng dar od wl be hailed foc re thon seven days, Gn Cal wl provide economy, wun, cneran Carior onsortaon to the place of hosplztion and arrange lodging for © ses fly nb end (re of Ninor Clr: omer ston th depen chien ond Shag! oof ome ena ome en red, (1 Cal wil orange forthe tonsportion of he uated chien foe ome, wih on tno i ees, Rum of Deceased Romans: On (al wl ost wi the logit of ting ‘mene’ eis hme inf vet ofr ht de Tis seine 16 GaSe Fuso Lose ax He gadis, eid ‘mention, prong the necessary shiping conan! os wel os poying foe forger ‘Medical, Dental ond Pharmacy Referrals: On Cail will provide refers 10 al el pesos ne pen grog rs ‘of western style medical fois and English speoking powders in on area ‘ay On aloe er ps. ipl isn Gano 0 nae sil ens y slot a anbes heh ce yoy fuse hsa {dy ache finds shal be charged othe emer ceca at he ine che) Presripon Asssianc: Ha member needs placement prescition wile ‘rovelng, On Call wil assist in fg that prescription. ay ‘expenses associated ‘nth pescipion apc are fe mans spnshity Emergency Message Sena Call wil receive ond transmit outho fel erage ees leg Cnsittion and Rell: omnes aay fury hone ad (guste savrs of tomey, On Cl bal eange fan ilies consultation with an attorney without charge to the member. If necessory, the rb willbe cfene oo fc atamey. ‘Lost Luggage Assistance: On Call will assist the member with the tracking of legge ri st Lost/Stolen Travel Document Assistance: On Coll will provide assistance by raga fate replacment of psn, vss, cine doce, ith ct. ‘ificates ond other ravelrelated documents. Any expenses related to replacing lst dct ees esi, Interpreter & Legal Referrals: Qn Coll wil refer mambers to aco translatos on res onan ples cre! led vee Pre-trip Information: On Cail affees members reports vio email, fx or pastol iain vs, pospat ond ince eqirmen's,cfuel ifort, weather canbton mes ond consulate referals, foreign exchange rotes, end el hss ny eso. Jsamenbs, you cn cl wen docs, hosts, phomacs ard athe se vies ue TOD nis off yo pee es, Tarps lction or ord, 24 ows doy, 365 ds yer, One phon ‘call connacts you to a stateafthe ort Global Response Centar staffed oround- theclack with trained multfingucl professionals to handle medical emergen- Ces tye fen fst US. nto era sss Gr, 0 36painer gobo neva of Independent asians compan, ‘including more than 53 olor centers, On Call Interatianal has immediate ‘epore capcblies word wih a ldba ebro re quid wdc ‘providers, inciuding air and ground ambulance services. Coniued on ex poge Mie) CONDITIONS & ExcLUSIONS (1 Cal rational il no poy fr servis he follwing instances 1+ Services rena witout cnn od pve a On Ca + Internal safe ines, sero aang ea exept hen hospfoize son inant. Expases ned he onl or nil purpose of the mb’ tip is abion meta teinet Forks no de or unde a of wax, stab inseciono on cient ccaring wile the mabe i serving on fuse or active aly in he cred Foxes of ny cut. Pacpatn inn itera cathy fe in cf being usa far erent urose, orn ity oc (ncn th try Act Corman of the United Saas sir it rsp Series Acct of the) or whl senso mee he coco sc + Use of any ltl or dry uss pesca by 0 physica o except if hospitalized son ingot. “Any snes provided to on je petson wher the mane is eid to eceve reinbusement fr Such sxpenses under any gop isons prog rnin by the rene insnce company ot plot oui or nosing mel pobls, sch os sip aches, sides, wih on be eed by local cso doc prevent the ined parson rom cng the po tuing hae. + ny eke expense roe to chitin, miscarigeo pepaney ne a pl peony il ogee per ich endangers th of ha mote n/a brn cd ding the fist tenfoeweks fear + Armeaet ena xan rst st prt eet wil not be end oo hosp ft hasnt (Cal como bel tess for fue fo prvi sees fdas caved by candi bys co ind, bt ot rt, ht wear cnn, tks ufoesan cone apa eas esti ‘ins, fief campy wih On Cal's commendations, or whore rendering of serie poe by lol lus etry opens. Heres moy be regard o reese On Cal roy che prove Fo Tilly ding emergency evomationon/oeaion. Vihot imiing the foeging, On Cal's cigs nd obignns under tis Aes inst nly, od ll cil xs oie by mea professionals umn scl! by Neb. On Ca snot ible fox ary Int erode, bear pov, ce. Cn al ts sale dscetn wi ess Nambu no faerie so iret lng dre Unions and Uncover Snes. Col r= sees eh sede ees arr nates oF prepoyrert onde fom the Member it trending such sei on feos bss Su fausmn- Lue *17®WELLS FARGO INSURANCE PRIVACY INFORMATION Wein typing yo dm te pe cacy fy psa om, do Go ay ese meet etme ome ets ya, relied yikes pe bho ou Sd op rooms) op or ped ose rl tes, es ty sot: og sl Ie er np sponse sel eset. a sara tae yo iy ah yo yin (0) 59589 ees. UUnderniten by Aetna Uf Insurance Company (ALC) CLAIMS ADMINISTERED BY: ‘Claims and Coverage Questions PREFERRED CARE PROVIDER: To Find a Doctor or Provider in the ‘Aetna Preferred Care Provider NeWwork 24-HOUR NURSE ADVICE: PRESCRIPTIONS: EMERGENCY TRAVEL ASSISTANCE: (Provide this information to your Emergency Contact) ‘THE PLAN BROKERED BY: Elgibiliy, Enrollment and General Questions Aetna Student Health P.O. Box 981106 El Paso, TX 79998 (866) 378-8885 (tollfroe) wwrw.aetnastudenthealth.com ‘Aetna Preferred Care Provider Network {866} 381-1529 (tollfree) hiip:/ /www-aetno.com/docfind/custom/studenthealth Aetna Informed Health® Line (800) 556-1555 ‘Aetna Pharmacy Management (888) 792-3862 hip://wvw-ceina.com/docfind/custom/studenthoalth On Call International (One Delaware Drive Salem, NH 03079 (877) 318.6901 (Tollfree within the U.S) (603) 328.1909 (Outside the U.S.) ‘wirw.oncallinternational.com Wells Farge Insurance Student Insurance Dir CA license No. OD08408 10940 White Rock Road, 2nd Floor Rancho Cordova, CA 95670 (800) 853-5899 Fax: (877) 612-7966 studentinsurance.wellsfargo.com sion ‘Ts mfr nani on afl ort con Heath soe prs cnn exsist: ord baat maximus. Pies open ‘etn and ot ge of Ate, Pride pues mn change wi a. Ando ol oie car grr casa hah svi, mete lid Yobe ccc sof te pane howere sae once. foc foms ed Kinde, GR96T34, TCE ty psn vin whit ig diay ae pny: oh on em cs fg one hi eo ay liye as rh cc po mde om cgay is cine cr sts xh eon iil and prc. mk cons afar sie 0, wich THFORANT OTE ele py ver ot re nny i nan eased Cy ins Mio 16.0231010 Stet echsthe tnd mare for pos src by tess aris lable iced ons, we Eee CAL STATE FULLERTON LANGUAGE - HEALTH INSURANCE PLAN Ng alo ‘2014-2015 MONTHLY ENROLLMENT FORM ‘sto ana ST SRE STUDENTS WANE. ria ce aA sro. OREO RT ka US. ang ADDRESS STR ares eae sta fou) ‘a sme iF Gag DDR EDT ae a arene NE sda pC a sweeney MIEN co GROUTT ca RICTCLTRONNE CvSTASDITY ca scHOUR ATP ati) OCOD aa) LEGER DEPSUDENTS 10 GE SURED BELOW. DEPENDENT COVERNGE Ss NTLABE ONY FTHESTODENT ASO SURED, Dao ou nn ot an de of fel is aie US) [ons ust / ie rast aE MDE TL GER ONE OF ORT st [od] STE — sr Fo T |ER—RE OF BRIT tc] [DOSE TE | DDE DTA OED DE OF BRT so [oo Jassie ST IE | GHEE OF RT st ya aca an TORE conmcrrenson | at mies You can ew the snd Sarmary of Beets & Cveroge (SBC wih srl by Hell Cae Blom summaries your cverge no fame that nrc] cma now ws, To ven yout pon SBC, go: stdetsurane elsforg com cl 800-8535899 rosa oer copy of ce | ID CARDS Motil 0 cas ay be ship bel win 3 weeks of yout payee di, Pres need you Mer DF fam you ID ca iat you vest your ost ae nr ng, ov rod Db is od ai ee bo ge bens wi be yale acorn the Poy. Oce ou he revel your D carps th rier fact emp poyment of your ci, Yo cons pit er PLEASE SEE OTHER SIDE FOR RATES AND PAYMENT INFORMATION © YOU MUST COMPLETE BOTH SIDES OF THIS ENROLLMENT FORM Underriten by Ato if isuance Company (AUC) TWELS FARGO NGURANCE PRIVACY INFORMATION rng ss ou felt ei eee pore de orcas ee eng ree em on at she psa b pes ert arlene ho ssp ssid my aly oe apy ho yay MET ys ereUnderuritn by Aetna Life Insurance Company (LIQ) CALSTATE FULLERTON LANGUAGE» HEALTH INSURANCE PLAN ‘2014-2015 MONTHLY ENROLMENT FORM ‘MONTHLY RATE AVAILABLE FROM: 871/14 7731/15 Sts | want his overage ogi on: [Sos el oromr | 20695 | Pe Cio Grant | fog 025) "| $1897 oa navel assistance and sav sorvices, Prenivm | Fates ri pyle ena ie sae Conpny, os wel sans fees pyle (SU od Wels Fao lace. Rts cs nde Med San of pain Weis nee Fo Ast bleep Cl tet ons cae vin cng PAYMENT METHOD (Rr US Fonds Oni) TAKE ENROLLMENT FORM TO ALP OFFICE NOTE: This is limited term coverage only. Coverage will end on the last date specified inthe plan you select, unless you enrol to continue insurance for an dion term, Premios oe calculated based onthe plan fem ond wil not be prorated iis. o roid als oreo atin fon ise fhe purse of dea he isu oc ay aber peso, Pnais inde ngsanment finan, nist may deny sane bees foe ifomaon me reed tow cai ws potest he apart. ‘YOU HUST COMPLETE BOTH SIDES OFTHE ENROLLNENT FORM AND SIGN BELOW {ts y sing bow tat hoe ena ih roman proved on sop oni bs cf ny knowlege ord ee, ise nd act wh no omsons a mislead hae read ond undrstond the Pon rch. Msg below ces thar hae read nd urdstad the Stet Heth Instn Pan oho gos ooops api fh sd cts id thr SIUTURE OF STUDENT Sere THE PLAN BROKERED BY: “Gove Cress 24-HOUR NURSE ADVICE: Informed Health Line 7600 556.1555 TOO (800) 5561555 ‘CLAIMS ADMINISTERED BY: ‘lois, Big end Comtage short ‘eine Student Health TOFIND A DOCTOR OR PROVIDER: ain ile trance Co, (ash 378868 father) PO Box 981106, encodrasdenhech com Fos, 1.79908 24/7 EMERGENCY “Chere No. 0008408 (856) S78 88S fatiee) TRAVEL ASSISTAN (600) 858-5629 si aac com On Call International studennsrones elon om (6771 318-901 fwikin US) Did US cece cre par 603] 328 1909 (ouside he US) vrwenclinernahonal om [ase| 792'3002 evn tna com FULLERTON | Foreign Language/ALP Yo an view te stondord Summary of Berets & Cuomge (SBC) whichis etd] by Heo Coe Ream, suramorzes your cverge in frat tat al se companies now use Tove you pln SBC, goo: stdenisrance larga oc (800) 853-5699 oequst a oper op eo cag. The Califia Soe Univ teatnd std heath nance plans ndewiten by ann Uf sence {amp en) el ised y Cn Cis Miss, (Cl Sea et the ond rae fx prs ond secs povided by Ata and CA ond he ppb oid compris 1.023100 aetna Underritenb Ao enc Canany Policy #66786: Plo rk by: Wels ago Insc Serica USA, ‘Sant insurance ivsion