Aetna Student HealthSM Major Medical Outline of Coverage
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Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Aetna Student HealthSM Major Medical Outline of Coverage Preferred Provider Organization (PPO) Drexel University Policy Year: 2020 – 2021 Policy Number: 812834 www.aetnastudenthealth.com (877) 409-7361
This is a brief description of the Student Health Plan. The plan is available for Drexel University students and their eligible dependents. The plan is insured by Aetna Life Insurance Company (Aetna). The exact provisions, including definitions, governing this insurance are contained in the Certificate issued to you and may be viewed online at www.aetnastudenthealth.com. If there is a difference between this Plan Summary and the Certificate, the Certificate will control. Drexel University Health Insurance and Immunizations Offices In case of an emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. For non-emergency situations, please visit or call the Drexel University Health Center for your healthcare needs at (215) 220-4700. Drexel University Health Center is staffed by doctors and nurse practitioners from the Drexel University College of Medicine Department of Family and Community Medicine. Health Center hours are Monday, Wednesday, Friday 8:30am to 5:00pm and Tuesday, Thursday 10:30am to 7:00pm. Drexel University Health Center 3401 Market Street Philadelphia, PA 19104 215-220-4700 For issues regarding the enrollment and the waiver process, please contact the following: University City Main Campus Office of Counseling & Health, Suite 215 Creese Student Center, 3210 Chestnut Street Philadelphia, PA 19104 (215) 895-2507 healthimmu@drexel.edu Center City Campus and Queen Lane College of Medicine Health Insurance and Immunizations-Center City, New College Building, Suite 1106 245 North 15th Street, Philadelphia, PA 19102-1192, (215) 762-4478, vaccinescnhp@drexel.edu Drexel University 2020-2021 Page 2
Coverage Periods
Students: Coverage for all insured students enrolled for coverage in the Plan for the following Coverage Periods.
Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below, and will terminate at 11:59
PM on the Coverage End Date indicated.
Main and Center City Campus
Enrollment/Waiver
Coverage Period Coverage Start Date Coverage End Date Deadline
Annual 09/01/2020 08/31/2021 09/30/2020
*13-Month Annual 08/01/2020 08/31/2021 08/31/2020
Winter 01/01/2021 08/31/2021 01/31/2021
Spring 03/29/2021 08/31/2021 04/30/2021
Summer 06/21/2021 08/31/2021 07/15/2021
*13-Month Annual: 1st year Law students, 1st year Bio Medical Graduate and Post Graduate Studies, and 1st year
Professional Studies in the Health Sciences
College of Medicine
Enrollment/Waiver
Coverage Period Coverage Start Date Coverage End Date Deadline
Annual 09/01/2020 08/31/2021 09/30/2020
13-Month Annual 08/01/2020 08/31/2021 08/31/2020
14-Month Annual 07/01/2020 08/31/2021 08/31/2020
Eligible Dependents: Coverage for dependents eligible under the Plan for the following Coverage Periods.
Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below and will terminate at 11:59
PM on the Coverage End Date indicated. Coverage for insured dependents terminates in accordance with the
Termination Provisions described in the Master Policy.
Enrollment/Waiver
Coverage Period Coverage Start Date Coverage End Date Deadline
Annual 09/01/2020 08/31/2021 09/30/2020
13-Month Annual 08/01/2020 08/31/2021 08/31/2020
Spring 03/29/2021 08/31/2021 04/30/2021
Summer 06/21/2021 08/31/2021 07/15/2021
Drexel University 2020-2021 Page 3Rates
The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna), as well
as Drexel University’s administrative fee.
Main Campus and Center City Students
1st Year
Graduate School of Biomedical
Annual Law Student Sciences and Professional
09/01/2020-08/31/2021 08/01/2020-08/31/2021 Studies
08/01/2020-08/31/2021
Student $2697.00 $2922.68 $2922.68
College of Medicine Students
13-Month Students 14-Month Students
09/01/2020-08/31/2021
08/01/2020-08/31/2021 07/01/2020-08/31/2021
Student $2697.00 $2922.68 $3148.36
Dependent Rates
Annual 13 Month 14 Month
Student + Spouse $5354.00 $5805.36 $6256.72
Student + Child $5354.00 $5805.36 $6256.72
Student + Two or more Children $8011.00 $8688.04 $9365.08
Student + Spouse + One Child $8011.00 $8688.04 $9365.08
Student + Spouse + Two or more $10668.00 $11570.72 $12473.44
Children
Student Coverage
Eligibility
University City (Main Campus) and Center City Campus
Mandatory – All full-time Undergraduate international students holding a J-1 Visa are automatically enrolled in the
Drexel University Student Health Insurance Plan unless other Embassy-sponsored Health Insurance coverage is
verified, otherwise, there is no option to waive participation in this Plan.
Note: International Graduate students holding an F-1 Visa who carry health insurance have the option to waive with
coverage that meets Drexel University's minimum requirements. Failure to provide proof of insurance coverage by
the published deadline date will result in the automatic enrollment in the University-sponsored Dragon Plan, and
your student account will be billed the annual rate.
Drexel University 2020-2021 Page 4Compulsory – All currently enrolled full-time domestic Undergraduate and full-time Graduate students (including online students) are required by Drexel University to carry health insurance or enroll in the Drexel University Student Health Insurance Plan. For information on how to enroll or waive, visit www.aetnastudenthealth.com, Search for Drexel University and select your campus. Once at the student Connection Home page, click on “Medical Plan: Enroll/Waive”, or visit www.drexel.edu/studentlife/ch/II_Main.html. Voluntary – Currently enrolled domestic part-time Undergraduate and part-time domestic Graduate students are eligible to enroll in the Drexel University Student Health Insurance Plan. For questions regarding enrollment, please visit your Student Health Insurance Coordinators, located at the Main Campus, Office of Counseling and Health, Suite 215, Creese Student Center, or the Center City Campus, New College Building, Suite 1106. The enrollment deadline for students is 09/30/2020. Online degree-seeking students are eligible to enroll in the Student Health Insurance Plan. College of Medicine Compulsory All full-time matriculated and qualifying part-time students (undergraduate six credit hours or more) and part time graduate students (four and one-half credit hours or more), who are enrolled at Drexel University, and who actively attend classes for at least the first 31 days, after the date when coverage becomes effective. All full-time matriculated students must carry comprehensive health protection through either an indemnity medical insurance policy or enrollment in a health maintenance organization. To satisfy this requirement, students must enroll in the University-sponsored Student Health Insurance Plan or certify that they are carrying equivalent health coverage through a plan or policy administered elsewhere. Students opting to waive participation in the University sponsored Student Health Insurance Plan must submit an Online Waiver Application. Failure to provide such documentation by 09/30/2020 will result in the automatic enrollment in the University-sponsored Plan. You will be billed the annual rate. Students who lose other coverage due to a significant life event during the school year should enroll in this plan by visiting the office of the Bursar. Enrollment All full-time matriculated students will be automatically enrolled in this Plan, unless the online waiver has been received by Aetna Student Health, by the specified enrollment deadline date of 08/31/2020 (College of Medicine and 1st Year Graduate School of Biomedical Sciences and Professional Studies) or 09/30/2020 (Main & Center City). You must be a full-time student to enroll online. If you are a part time student and would like to enroll in the Drexel Student Health Insurance, you may contact the health insurance and immunization office on your campus and they will assist you. For information on how to enroll, visit www.aetnastudenthealth.com, search for Drexel University and select your campus, and then click on “Medical Plan: Enroll/Waive” or visit www.drexel.edu/studentlife/ch/II_Main.html Home study, correspondence, and television (TV) courses, do not fulfill the eligibility requirement that the student actively attend classes. Drexel University 2020-2021 Page 5
Waiver Process
Drexel University requires ALL full-time domestic Undergraduate and Graduate students to have health insurance
coverage. This Plan is designed to protect you from interrupting your academic progress due to large, unexpected
medical bills. If you are a domestic Undergraduate student taking less than 12 credits or domestic Graduate student
taking less than 9 credits, you do not have to comply with this policy and may disregard this notice. Full time
students can satisfy the health insurance requirement in one of two ways: 1) you may purchase the Drexel
University Student Health Insurance Plan, or 2) submit proof of comparable coverage through the Online Waiver
System. Students whose plan does not meet the minimum standards will be notified and required to show proof of
acceptable coverage. Failure to provide proof of insurance coverage by the published deadline date will result in the
automatic enrollment in the University-sponsored Plan and your student account will be billed.
To complete the waiver or process, new and returning students should visit www.aetnastudenthealth.com, and
search for Drexel University, then select your campus to complete an Online Enrollment or Waiver Application.
The enrollment and/or waiver deadline for University City Main Campus, Center City Campus, and Queen Lane
College of Medicine Campus are as follows:
UNIVERSITY CITY (MAIN CAMPUS)
• Fall Start Full-Time Students 09/30/2020
• 1st Year Law School 08/31/2020
• School of Public Health 09/30/2020
CENTER CITY
• College of Nursing and Health Professions 09/30/2020
• Returning Graduate Students in the
Graduate School of Biomedical Sciences and 09/30/2020
Professional Studies in the College of Medicine
• 1st year Graduate Students in the Graduate
School of Biomedical Sciences and Professional 08/31/2020
Studies in the College of Medicine
COLLEGE OF MEDICINE
• Incoming Students 08/31/2020
• Returning Students(currently enrolled in
09/30/2020
the student health insurance plan)
Dependent Coverage
Eligibility
Covered students may also enroll their lawful spouse and dependent children up to the age of 26.
Drexel University 2020-2021 Page 6Enrollment
To enroll the dependent(s) of a covered student, please complete the Enrollment Form by visiting
www.aetnastudenthealth.com, selecting Drexel University in the school name search, and clicking on the “Plans
& Products Offered to You” link on the left hand side of the screen, or by calling customer service at (877) 409-7361
and requesting that an Enrollment Form be sent in the mail. Please refer to the Coverage Periods section of this
document for coverage dates and deadline dates. Dependent enrollment applications will not be accepted after the
enrollment deadline, unless there is a significant life change that directly affects their insurance coverage. (An
example of a significant life change would be loss of health coverage under another health plan.)
If, while you are covered by this plan, you have a covered dependent child who is called up for active duty (state
National Guard or reserves) while he or she is a full time student, Aetna Student Health will extend this child’s
coverage upon his or her return until you are no longer covered by this plan. This dependent coverage will be
available at the first Fall or Spring enrollment period after the dependent child has 1) returned from duty and 2)
returned to full time student status. The offered coverage for this dependent child will continue until A) you are no
longer a student covered by this plan; or B) the dependent child is no longer a full-time student or a period of time
equal to the duration of the child’s military duty has passed.
Important note regarding coverage for a newborn infant or newly adopted child:
• A newborn child - Your newborn child is covered on your health plan for the first 31 days from the moment of
birth.
- To keep your newborn covered, you must notify us (or our agent) of the birth and pay any required premium
contribution during that 31-day period.
- You must still enroll the child within 31 days of birth even when coverage does not require payment of an
additional premium contribution for the newborn.
- If you miss this deadline, your newborn will not have health benefits after the first 31 days.
- If your coverage ends during this 31-day period, then your newborn‘s coverage will end on the same date as
your coverage. This applies even if the 31-day period has not ended.
• An adopted child or a child legally placed with you for adoption - A child that you, or that you and your spouse
adopts or is placed with you for adoption is covered on your plan for the first 31 days after the adoption or the
placement is complete.
- To keep your child covered, we must receive your completed enrollment information within 31 days after the
adoption or placement for adoption.
- You must still enroll the child within 31 days of the adoption or placement for adoption even when coverage
does not require payment of an additional premium contribution for the child.
- If you miss this deadline, your adopted child or child placed with you for adoption will not have health benefits
after the first 31 days.
- If your coverage ends during this 31-day period, then coverage for your adopted child or child placed with you
for adoption will end on the same date as your coverage. This applies even if the 31-day period has not ended.
If you need information or have general questions on dependent enrollment, call Member Services at (877) 409-
7361.
Medicare Eligibility Notice
You are not eligible to enroll in the student health plan if you have Medicare at the time of enrollment in this
student plan. The plan does not provide coverage for people who have Medicare.
Drexel University 2020-2021 Page 7Termination and Refunds
Withdrawal from Classes – Leave of Absence:
If you withdraw from classes under a school-approved leave of absence, your coverage will remain in force through
the end of the period for which payment has been received and no premiums will be refunded.
Withdrawal from Classes – Other than Leave of Absence:
If you withdraw from classes other than under a school-approved leave of absence within 31 days after the policy
effective date, you will be considered ineligible for coverage, your coverage will be terminated retroactively and any
premiums collected will be refunded. If the withdrawal is more than 31 days after the policy effective date, your
coverage will remain in force through the end of the period for which payment has been received and no premiums
will be refunded. If you withdraw from classes to enter the armed forces of any country, coverage will terminate as
of the effective date of such entry and a pro rata refund of premiums will be made if you submit a written request
within 90 days of withdrawal from classes.
In-network Provider Network
Aetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing In-
network Providers because Aetna has negotiated special rates with them, and because the Plan’s benefits are
better.
If you need care that is covered under the Plan but not available from an In-network Provider, contact Member
Services for assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a pre-
approval for you to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, the
benefit level is the same as for In-network Providers.
Precertification
You need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Your in-
network physician is responsible for obtaining any necessary precertification before you get the care. When you go
to an out-of-network provider, it is your responsibility to obtain precertification from us for any services and
supplies on the precertification list. If you do not precertify when required, there is a $500 penalty for each type of
eligible health service that was not precertified. For a current listing of the health services or prescription drugs that
require precertification, contact Member Services or go to www.aetnastudenthealth.com.
Precertification Call
Precertification should be secured within the timeframes specified below. To obtain precertification, call Member
Services at the toll-free number on your ID card. This call must be made:
Non-emergency admissions: You, your physician or the facility will need to call and request
precertification at least 14 days before the date you are scheduled to be
admitted.
An emergency admission: You, your physician or the facility must call within 48 hours or as soon as
reasonably possible after you have been admitted.
An urgent admission: You, your physician or the facility will need to call before you are
scheduled to be admitted. An urgent admission is a hospital admission by
a physician due to the onset of or change in an illness, the diagnosis of an
illness, or an injury.
Outpatient non-emergency services You or your physician must call at least 14 days before the outpatient care
requiring precertification: is provided, or the treatment or procedure is scheduled.
Drexel University 2020-2021 Page 8We will provide a written notification to you and your physician of the precertification decision, where required by state law. If your precertified services are approved, the approval is valid for 30 days as long as you remain enrolled in the plan. Excess only Your plan is an excess only plan. As an excess only plan, this plan pays its eligible health services after any other medical coverage. We determine covered benefits under this plan without considering any limitation clauses contained in any other medical coverage regarding other coverage. Description of Benefits The Plan excludes coverage for certain services and has limitations on the amounts it will pay. While this Plan Summary document will tell you about some of the important features of the Plan, other features that may be important to you are defined in the Certificate. To look at the full Plan description, which is contained in the Certificate issued to you, go to www.aetnastudenthealth.com. This Plan will pay benefits in accordance with any applicable Pennsylvania Insurance Law(s). Policy year deductible In-network coverage Out-of-network coverage Student $100 per policy year $500 per policy year Spouse $100 per policy year $500 per policy year Each child $100 per policy year $500 per policy year This is the amount you owe for in-network and out-of-network eligible health services each policy year before the plan begins to pay for eligible health services. This policy year deductible applies separately to you and each of your covered dependents. After the amount you pay for eligible health services reaches the policy year deductible, this plan will begin to pay for eligible health services for the rest of the policy year. Policy year deductible waiver The policy year deductible is waived for all of the following eligible health services: • In-network care for Preventive care and wellness • In-network care for Family planning services - female contraceptives • In-network care and out-of-network care for Pap Smear Screening Expense • In-network care and out-of-network care for Child Immunization Services • In-network care and out-of-network care for Nutritional Supplement Services • In-network care and out-of-network care for Prescribed Medicines Expense • In-network care and out-of-network care for Pediatric Preventive Vision Services • In-network care for Pediatric Dental Services • Newborn services for the first 31 days from birth Maximum out-of-pocket limit per policy year Student $3,500 per policy year $7,000 per policy year Spouse $3,500 per policy year $7,000 per policy year Each child $3,500 per policy year $7,000 per policy year Family $7,000 per policy year $14,000 per policy year Eligible health services applied to the out-of-network maximum out-of-pocket limit will not be applied to satisfy the in-network maximum out-of-pocket limit and eligible health services applied to the in-network maximum out-of-pocket limit will not be applied to satisfy the out-of-network maximum out-of-pocket limit. Drexel University 2020-2021 Page 9
Eligible health services In-network coverage Out-of-network coverage
Routine physical exams
Performed at a physician’s office 100% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Maximum age and visit limits per policy Subject to any age and visit limits provided for in the
year through age 21 comprehensive guidelines supported by the American Academy of
Pediatrics/Bright Futures/Health Resources and Services
Administration guidelines for children and adolescents.
Maximum visits per policy year age 22 and 1 visit
over
Preventive care immunizations
Performed in a facility or at a physician's 100% (of the negotiated charge) 50% (of the recognized charge)
office per visit per visit
No copayment or policy year
deductible applies
Maximums Subject to any age limits provided for in the comprehensive
guidelines supported by Advisory Committee on Immunization
Practices of the Centers for Disease Control and Prevention.
Routine gynecological exams (including Pap smears and cytology tests)
Performed at a physician’s, obstetrician 100% (of the negotiated charge) 50% (of the recognized charge)
(OB), gynecologist (GYN) or OB/GYN office per visit per visit
No copayment or policy year
deductible applies
Maximum visits per policy year 1 visit
Preventive screening and counseling services
Preventive screening and counseling 100% (of the negotiated charge) 50% (of the recognized charge)
services for Obesity and/or healthy diet per visit per visit
counseling, Misuse of alcohol & drugs
No copayment or policy year
deductible applies
Obesity/Healthy Diet maximum per policy 26 visits (10 visits will be allowed under the plan for healthy diet
year (Applies to covered persons age 22 counseling provided in connection with Hyperlipidemia (high
and older) cholesterol) and other known risk factors for cardiovascular and
diet-related chronic disease)
Misuse of Alcohol maximum per policy year 5 visits
Drexel University 2020-2021 Page 10Eligible health services In-network coverage Out-of-network coverage
Preventive screening and counseling services (continued)
Preventive screening and counseling 100% (of the negotiated charge) 50% (of the recognized charge)
services for Tobacco Products, Depression per visit per visit
Screening, Sexually transmitted infection
counseling & Genetic risk counseling for No copayment or policy year
breast and ovarian cancer deductible applies
Tobacco Products Counseling maximum 8 visits
per policy year
Depression screening maximum per policy 1 visit
year
STI maximum per policy year 2 visits
Routine cancer screenings 100% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Maximums Subject to any age; family history; and frequency guidelines as set
forth in the most current:
• Evidence-based items that have in effect a rating of A or B in the
current recommendations of the United States Preventive
Services Task Force; and
• The comprehensive guidelines supported by the Health
Resources and Services Administration.
Lung cancer screening maximum 1 screening every 12 months
Prenatal care services (Preventive care 100% (of the negotiated charge) 50% (of the recognized charge)
services only) per visit per visit
No copayment or policy year
deductible applies
Lactation support and counseling services 100% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Lactation counseling services maximum per 6 visits
policy year
Breast pump supplies and accessories 100% (of the negotiated charge) 50% (of the recognized charge)
per item per item
No copayment or policy year
deductible applies
Drexel University 2020-2021 Page 11Eligible health services In-network coverage Out-of-network coverage
Female contraceptive counseling services 100% (of the negotiated charge) 50% (of the recognized charge)
office visit per visit per visit
No copayment or policy year
deductible applies
Contraceptive counseling services 2 visits
maximum per policy year
Female contraceptive prescription drugs 100% (of the negotiated charge) 50% (of the recognized charge)
and devices per item per item
No copayment or policy year
deductible applies
Female voluntary sterilization - Inpatient & 100% (of the negotiated charge) 50% (of the recognized charge)
Outpatient provider services
No copayment or policy year
deductible applies
Physicians and other health professionals
Physician, specialist including Consultants $20 copayment then the plan 50% (of the recognized charge)
Office visits pays 100% (of the balance of per visit
(non-surgical/non-preventive care by a the negotiated charge) per visit
physician and specialist) thereafter
Includes telemedicine consultations
Allergy testing and treatment
Allergy testing & Allergy injections Covered according to the type Covered according to the type
treatment including Allergy sera and of benefit and the place where of benefit and the place where
extracts administered via injection the service is received the service is received
performed at a physician’s or specialist’s
office
Physician and specialist - surgical services
Inpatient surgery performed during your 80% (of the negotiated charge) 50% (of the recognized charge)
stay in a hospital or birthing center by a
surgeon
(includes anesthetist and surgical assistant
expenses)
Outpatient surgery performed at a 80% (of the negotiated charge) 50% (of the recognized charge)
physician’s or specialist’s office or per visit per visit
outpatient department of a hospital or
surgery center by a surgeon
(includes anesthetist and surgical assistant
expenses)
Drexel University 2020-2021 Page 12Eligible health services In-network coverage Out-of-network coverage
Alternatives to physician office visits
Walk-in clinic visits (non-emergency visit) $20 copayment then the plan 50% (of the recognized charge)
pays 100% (of the balance of the per visit
negotiated charge) per visit
thereafter
Hospital and other facility care
Inpatient hospital (room and board) and $250 copayment then the plan $250 copayment then the plan
other miscellaneous services and supplies) pays 80% (of the balance of the pays 50% (of the balance of the
negotiated charge) per recognized charge) per
Includes birthing center facility charges admission admission
In-hospital non-surgical physician services 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Alternatives to hospital stays
Outpatient surgery (facility charges) 80% (of the negotiated charge) 50% (of the recognized charge)
performed in the outpatient department of per visit per visit
a hospital or surgery center
Home Health Care 80% (of the negotiated charge) 80% (of the recognized charge)
per visit per visit
Maximum visits per policy year 60
Hospice-Inpatient 80% (of the negotiated charge) 80% (of the recognized charge)
per admission per admission
Hospice-Outpatient 80% (of the negotiated charge) 80% (of the recognized charge)
per visit per visit
Respite care - maximum 7 days per 6-month period
Skilled nursing facility - Inpatient $250 copayment then the plan $250 copayment then the plan
pays 80% (of the balance of the pays 50% (of the balance of the
negotiated charge) per recognized charge) per
admission admission
Hospital emergency room $150 copayment then the plan Paid the same as in-network
pays 80% (of the balance of the coverage
negotiated charge) per visit
Non-emergency care in a hospital Not covered Not covered
emergency room
Important note:
• As out-of-network providers do not have a contract with us the provider may not accept payment of your
cost share, (copayment/coinsurance), as payment in full. You may receive a bill for the difference between
the amount billed by the provider and the amount paid by this plan. If the provider bills you for an
amount above your cost share, you are not responsible for paying that amount. You should send the bill
to the address listed on the back of your ID card, and we will resolve any payment dispute with the
provider over that amount. Make sure the ID card number is on the bill.
• A separate hospital emergency room copayment/coinsurance will apply for each visit to an emergency
room. If you are admitted to a hospital as an inpatient right after a visit to an emergency room, your
emergency room copayment/coinsurance will be waived and your inpatient copayment/coinsurance will
apply. (continued next page)
Drexel University 2020-2021 Page 13Eligible health services In-network coverage Out-of-network coverage
Important note (continued):
• Covered benefits that are applied to the hospital emergency room copayment/coinsurance cannot be
applied to any other copayment/coinsurance under the plan. Likewise, a copayment/coinsurance that
applies to other covered benefits under the plan cannot be applied to the hospital emergency room
copayment/coinsurance.
• Separate copayment/coinsurance amounts may apply for certain services given to you in the hospital
emergency room that are not part of the hospital emergency room benefit. These
copayment/coinsurance amounts may be different from the hospital emergency room
copayment/coinsurance. They are based on the specific service given to you.
• Services given to you in the hospital emergency room that are not part of the hospital emergency room
benefit may be subject to copayment/coinsurance amounts that are different from the hospital
emergency room copayment/coinsurance amounts.
Urgent Care $30 copayment then the plan $10 copayment then the plan
pays 100% (of the balance of pays 50% (of the balance of the
the negotiated charge) per visit recognized charge) per visit
thereafter thereafter
Non-urgent use of urgent care provider Not covered Not covered
Pediatric dental care
(Limited to covered persons through the end of the month in which the person turns age 19)
Type A services 100% (of the negotiated charge) 80% (of the recognized charge)
per visit per visit
No copayment or deductible
applies
Type B services 70% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible applies
Type C services 50% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible applies
Orthodontic services 50% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible applies
Dental emergency treatment Covered according to the type Covered according to the type
of benefit and the place where of benefit and the place where
the service is received the service is received
Drexel University 2020-2021 Page 14Eligible health services In-network coverage Out-of-network coverage
Specific Conditions
Diabetic services and supplies (including Covered according to the type Covered according to the type
equipment and training) of benefit and the place where of benefit and the place where
the service is received the service is received
Impacted wisdom teeth 80% (of the negotiated charge) 50% (of the recognized charge)
Accidental injury to sound natural teeth 80% (of the negotiated charge) 50% (of the recognized charge)
Maternity care
Maternity care (includes delivery and Covered according to the type Covered according to the type
postpartum care services in a hospital or of benefit and the place where of benefit and the place where
birthing center) the service is received the service is received
Well newborn nursery care in a hospital or 80% (of the negotiated charge) 50% (of the recognized charge)
birthing center
No policy year deductible applies No policy year deductible applies
Family planning services – other
Voluntary sterilization for males - surgical Covered according to the type Covered according to the type
services of benefit and the place where of benefit and the place where
the service is received the service is received
Abortion physician or specialist surgical 80% (of the negotiated charge) 50% (of the recognized charge)
services
Gender reassignment (sex change) treatment
Surgical, hormone replacement therapy, Covered according to the type Covered according to the type
and counseling treatment of benefit and the place where of benefit and the place where
the service is received the service is received
Autism spectrum disorder
Autism spectrum disorder treatment, Covered according to the type Covered according to the type
diagnosis and testing and Applied behavior of benefit and the place where of benefit and the place where
analysis the service is received the service is received
Mental Health & Substance Abuse Treatment
Inpatient hospital $250 copayment then the plan $250 copayment then the plan
(room and board and other miscellaneous pays 80% (of the balance of the pays 50% (of the balance of the
hospital services and supplies) negotiated charge) per recognized charge) per
admission admission
Outpatient office visits $20 copayment then the plan 50% (of the recognized charge)
pays 100% (of the balance of the per visit
(includes telemedicine consultations) negotiated charge) per visit
thereafter
Other outpatient treatment (includes Partial 80% (of the negotiated charge) 50% (of the recognized charge)
hospitalization and Intensive Outpatient per visit per visit
Program)
Drexel University 2020-2021 Page 15Eligible health In-network coverage In-network coverage Out-of-network overage
services Network (IOE Network (Non-IOE
facility) facility)
Transplant services Covered according to Covered according to the Covered according to the
Inpatient and outpatient the type of benefit and type of benefit and the type of benefit and the
facility services the place where the place where the service is place where the service is
service is received received received
Transplant services Covered according to Covered according to the Covered according to the
Inpatient and outpatient the type of benefit and type of benefit and the type of benefit and the
physician and specialist the place where the place where the service is place where the service is
services service is received received received
Transplant services-travel Covered Covered Covered
and lodging
Lifetime Maximum Travel $10,000 $10,000 $10,000
and Lodging Expenses for
any one transplant
Maximum Lodging $50 per night $50 per night $50 per night
Expenses per IOE patient
Maximum Lodging $50 per night $50 per night $50 per night
Expenses per companion
Eligible health services In-network coverage Out-of-network coverage
Basic infertility services Covered according to the type Covered according to the type
of benefit and the place where of benefit and the place where
the service is received the service is received
Comprehensive infertility services Covered according to the type Covered according to the type
of benefit and the place where of benefit and the place where
the service is received the service is received
Specific therapies and tests
Diagnostic complex imaging services 80% (of the negotiated charge) 50% (of the recognized charge)
performed in the outpatient department of per visit per visit
a hospital or other facility
Diagnostic lab work and radiological 80% (of the negotiated charge) 50% (of the recognized charge)
services performed in a physician’s office, per visit per visit
the outpatient department of a hospital or
other facility
Outpatient Chemotherapy, Radiation & 80% (of the negotiated charge) 50% (of the recognized charge)
Respiratory Therapy per visit per visit
Outpatient physical, occupational, speech, 80% (of the negotiated charge) 50% (of the recognized charge)
and cognitive therapies (including Cardiac per visit per visit
and Pulmonary Therapy)
Combined for short-term rehabilitation
services and habilitation therapy services
Drexel University 2020-2021 Page 16Eligible health services In-network coverage Out-of-network coverage
Chiropractic services $20 copayment then the plan 50% (of the recognized charge)
pays 100% (of the balance of the per visit
negotiated charge) per visit
thereafter
Other services and supplies
Emergency ground, air, and water 100% (of the negotiated Paid the same as in-network
ambulance charge) per trip coverage
Durable medical and surgical equipment 80% (of the negotiated charge) 50% (of the recognized charge)
per item per item
Enteral formulas and nutritional Covered according to the type Covered according to the type
supplements of benefit and the place where of benefit and the place where
the service is received the service is received
Prosthetic Devices 80% (of the negotiated charge) 50% (of the recognized charge)
per item per item
Hearing aid exams $20 copayment then the plan 50% (of the recognized charge)
pays 100% (of the balance of the per visit
negotiated charge) per visit
thereafter
Hearing aid exam maximum One hearing exam every policy year
Hearing aids 80% (of the negotiated charge) 50% (of the recognized charge)
per item per item
Hearing Aid Maximum per policy year One hearing aid per ear every policy year
Pediatric vision care
(Limited to covered persons through the end of the month in which the person turns age 19)
Pediatric routine vision exams (including 100% (of the negotiated charge) 80% (of the recognized charge)
refraction)-Performed by a legally qualified per visit per visit
ophthalmologist or optometrist
No policy year deductible applies No policy year deductible applies
Includes visit for fitting of contact lenses
Maximum visits per policy year 1 visit
Fitting of contact Maximum
1 visit
Comprehensive low vision evaluations Covered according to the type Covered according to the type
of benefit and the place where of benefit and the place where
the service is received the service is received
Low vision Maximum One comprehensive low vision evaluation every policy year
Drexel University 2020-2021 Page 17Eligible health services In-network coverage Out-of-network coverage
Pediatric vision care (continued)
(Limited to covered persons through the end of the month in which the person turns age 19)
Pediatric vision care services & supplies- 100% (of the negotiated charge) 80% (of the recognized charge)
Eyeglass frames, prescription lenses or per visit per visit
prescription contact lenses
No policy year deductible applies No policy year deductible applies
Maximum number Per year:
Eyeglass frames One set of eyeglass frames
Prescription lenses One pair of prescription lenses
Contact lenses (includes non-conventional Daily disposables: up to 3-month supply
prescription contact lenses & aphakic Extended wear disposable: up to 6-month supply
lenses prescribed after cataract surgery) Non-disposable lenses: one set
*Important note: Refer to the Vision care section in the certificate of coverage for the explanation of these vision
care supplies. As to coverage for prescription lenses in a policy year, this benefit will cover either prescription
lenses for eyeglass frames or prescription contact lenses, but not both. Coverage does not include the office visit
for the fitting of prescription contact lenses.
Vision Care - Limited to covered persons age 19 and over
Adult routine vision exams (including 80% (of the negotiated charge) 50% (of the recognized charge)
refraction) performed by a legally qualified per visit per visit
ophthalmologist or optometrist
Maximum visits per policy year 1 visit
Outpatient prescription drugs
Copayment/coinsurance waiver for risk reducing breast cancer drugs
The policy year deductible and the per prescription copayment/coinsurance will not apply to risk reducing breast
cancer prescription drugs when obtained at a retail in-network, pharmacy. This means that such risk reducing
breast cancer prescription drugs are paid at 100%.
Outpatient prescription drug copayment waiver for tobacco cessation prescription and over-
the-counter drugs
The prescription drug copayment will not apply to the first two 90-day treatment regimens per policy year for
tobacco cessation prescription drugs and OTC drugs when obtained at a retail in-network pharmacy. This
means that such prescription drugs and OTC drugs are paid at 100%.
Your prescription drug copayment will apply after those two regimens per policy year have been exhausted.
Drexel University 2020-2021 Page 18Outpatient prescription drug copayment waiver for contraceptives
The outpatient prescription drug copayment will not apply to female contraceptive methods when obtained at an
in-network pharmacy.
This means that such contraceptive methods are paid at 100% for:
• Certain over-the-counter (OTC) and generic contraceptive prescription drugs and devices for each of the
methods identified by the FDA. Related services and supplies needed to administer covered devices will
also be paid at 100%.
• If a generic prescription drug or device is not available for a certain method, you may obtain certain
brand-name prescription drug or device for that method paid at 100%.
The outpatient prescription drug copayment continue to apply to prescription drugs that have a generic
equivalent, biosimilar or generic alternative available within the same therapeutic drug class obtained at an in-
network pharmacy unless you are granted a medical exception. The certificate of coverage explains how to get a
medical exception.
Eligible health services In-network coverage Out-of-network coverage
Preferred generic prescription drugs
For each fill up to a 30-day supply filled at a $15 copayment per supply then $15 copayment per supply then
retail pharmacy the plan pays 100% (of the the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
More than a 30-day supply but less than a $45 copayment per supply then Not covered
90-day supply filled at a mail order the plan pays 100% (of the
pharmacy balance of the negotiated
charge)
No policy year deductible
applies
Preferred brand-name prescription drugs
For each fill up to a 30-day supply filled at a $40 copayment per supply then $40 copayment per supply then
retail pharmacy the plan pays 100% (of the the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
More than a 30-day supply but less than a $120 copayment per supply Not covered
90-day supply filled at a mail order then the plan pays 100% (of the
pharmacy balance of the negotiated
charge)
No policy year deductible
applies
Drexel University 2020-2021 Page 19Eligible health services In-network coverage Out-of-network coverage
Outpatient prescription drugs (continued)
Non-preferred generic prescription drugs
For each fill up to a 30-day supply filled at a $75 copayment per supply then $75 copayment per supply then
retail pharmacy the plan pays 100% (of the the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
More than a 30-day supply but less than a $225 copayment per supply Not covered
90-day supply filled at a mail order then the plan pays 100% (of the
pharmacy balance of the negotiated
charge)
No policy year deductible
applies
Non-preferred brand-name prescription drugs
For each fill up to a 30-day supply filled at a $75 copayment per supply then $75 copayment per supply then
retail pharmacy the plan pays 100% (of the the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
More than a 30-day supply but less than a $225 copayment per supply Not covered
90-day supply filled at a mail order then the plan pays 100% (of the
pharmacy balance of the negotiated
charge)
No policy year deductible
applies
Specialty drugs
For each fill up to a 30-day supply filled at a $150 copayment per supply $150 copayment per supply
retail pharmacy then the plan pays 100% (of the then the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
Orally administered anti-cancer 100% (of the negotiated charge) 100% (of the recognized charge)
prescription drugs
No policy year deductible applies No policy year deductible applies
For each fill up to a 30-day supply filled at a
retail pharmacy
Drexel University 2020-2021 Page 20Eligible health services In-network coverage Out-of-network coverage
Preventive care drugs and supplements 100% (of the negotiated charge Paid according to the type of
filled at a retail pharmacy per prescription or refill drug per the schedule of
benefits, above
For each 30-day supply No copayment or policy year
deductible applies
Risk reducing breast cancer prescription 100% (of the negotiated charge) Paid according to the type of
drugs filled at a pharmacy per prescription or refill drug per the schedule of
benefits, above
For each 30–day supply No copayment or policy year
deductible applies
Maximums: Coverage will be subject to any sex, age, medical condition, family
history, and frequency guidelines in the recommendations of the
United States Preventive Services Task Force.
Tobacco cessation prescription drugs and 100% (of the negotiated charge Paid according to the type of
OTC drugs filled at a pharmacy per prescription or refill drug per the schedule of
benefits, above
For each 30–day supply No copayment or policy year
deductible applies
Maximums: Coverage is permitted for two 90-day treatment regimens only.
Coverage will be subject to any sex, age, medical condition, family
history, and frequency guidelines in the recommendations of the
United States Preventive Services Task Force.
A covered person, a covered person’s designee or a covered person’s prescriber may seek an expedited medical
exception process to obtain coverage for non-covered drugs in exigent circumstances. An “exigent circumstance”
exists when a covered person is suffering from a health condition that may seriously jeopardize a covered person’s
life, health, or ability to regain maximum function or when a covered person is undergoing a current course of
treatment using a non-formulary drug. The request for an expedited review of an exigent circumstance may be
submitted by contacting Aetna's Pre-certification Department at 1-855-240-0535, faxing the request to 1-877-269-
9916, or submitting the request in writing to:
CVS Health
ATTN: Aetna PA
1300 E Campbell Road
Richardson, TX 75081
Drexel University 2020-2021 Page 21Exclusions Acupuncture therapy • Maintenance treatment • Acupuncture when provided for the following conditions: - Acute low back pain - Addiction - AIDS - Amblyopia - Allergic rehinitis - Asthma - Autism spectrum disorders - Bell’s Palsy - Burning mouth syndrome - Cancer-related dyspnea - Carpal tunnel syndrome - Chemotherapy-induced leukopenia - Chemotherapy-induced neuopathic pain - Chronic pain syndrome (e.g., RSD, facial pain) - Chronic obstructive pulmonary disease - Diabetic peripheral neuropathy - Dry eyes - Erectile dysfunction - Facial spasm - Fetal breech presentation - Fibromyalgia - Fibrotic contractures - Glaucoma - Hypertension - Induction of labor - Infertility (e.g., to assist oocyte retrieval and embryo transfer during IVF treatment cycle) - Insomnia - Irritable bowel syndrome - Menstrual cramps/dysmenorrhea - Mumps - Myofascial pain - Myopia - Neck pain/cervical spondylosis - Obesity - Painful neuropathies - Parkinson’s disease - Peripheral arterial disease (e.g., intermittent claudication) - Phantom leg pain - Polycystic ovary syndrome - Post-herpetic neuralgia - Psoriasis - Psychiatric disorders (e.g., depression) - Raynaud’s disease pain - Respiratory disorders - Rheumatoid arthritis Drexel University 2020-2021 Page 22
- Rhinitis
- Sensorineural deafness
- Shoulder pain (e.g., bursitis)
- Stroke rehabilitation (e.g., dysphagia)
- Tennis elbow/ epicondylitis
- Tension headache
- Tinnitus
- Tobacco Cessation
- Urinary incontinence
- Uterine fibroids
- Xerostomia
- Whiplash
Air or space travel
Traveling in, on or descending from any aircraft, including a hang glider, while the aircraft is in flight. This includes
descending by a parachute, wingsuit or any other similar device.
This exclusion does not apply if:
• You are traveling solely as a fare-paying passenger
• You are traveling on a licensed, commercial, regularly scheduled non-military aircraft
• You are traveling solely in a civil aircraft with a current valid “Standard Federal Aviation Agency Airworthiness
Certificate” and:
- The civil aircraft is piloted by a person with a current valid pilot’s certificate with proper ratings for the type of
flight and aircraft involved
- You are as a passenger with no duties at all on an aircraft used only to carry passengers or you are a pilot or a
part of the flight crew on an aircraft owned or leased by the policyholder performing duties for the policyholder
Alternative health care
Services and supplies given by a provider for alternative health care. This includes but is not limited to
aromatherapy, naturopathic medicine, herbal remedies, homeopathy, energy medicine, Christian faith-healing
medicine, Ayurvedic medicine, yoga, hypnotherapy, and traditional Chinese medicine.
Ambulance services
• Non-emergency fixed wing air ambulance from an out-of-network provider
• Non-emergency ambulance transports except as covered under the Eligible health services under your plan section
of this certificate of coverage
Armed forces
Services and supplies received from a provider as a result of an injury sustained, or illness contracted, while in the
service of the armed forces of any country. When you enter the armed forces of any country, we will refund any
unearned pro rata premium.
Artificial organs
Any device that would perform the function of a body organ.
Drexel University 2020-2021 Page 23Behavioral health treatment Services for the following categories (or equivalent terms as listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association): • Stay in a facility for treatment for dementias and amnesia without a behavioral disturbance that necessitates mental health treatment • School and/or education service including special education, remedial education, wilderness treatment programs, or any such related or similar programs • Services provided in conjunction with school, vocation, work or recreational activities • Transportation Beyond legal authority Services and supplies provided by a health professional or other provider that is acting beyond the scope of its legal authority Blood (synthetic or substitutes) Examples of these are: • The provision of blood to the hospital, other than blood derived clotting factors • The services of blood donors, apheresis or plasmapheresis • For autologous blood donations, including drawing, storage and transfusion, only administration and processing expenses are covered Breasts Services and supplies given by a provider for breast reduction or gynecomastia. Clinical trial therapies (experimental or investigational) Your plan does not cover clinical trial therapies (experimental or investigational), except as described in the Eligible health services under your plan - Clinical trial therapies (experimental or investigational) section Clinical trial therapies (routine patient costs) • Services and supplies related to data collection and record-keeping that is solely needed due to the clinical trial (i.e. protocol-induced costs) • Services and supplies provided by the trial sponsor without charge to you • The experimental intervention itself (except medically necessary Category B investigational devices and promising experimental and investigational interventions for terminal illnesses in certain clinical trials in accordance with Aetna’s claim policies) • In-network coverage limited to benefits for routine patient services provided within the network Cornea or cartilage transplants • Cornea (corneal graft with amniotic membrane) • Cartilage (autologous chondrocyte implant or osteochondral allograft or autograft) transplants Drexel University 2020-2021 Page 24
Cosmetic services and plastic surgery Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or enhance the shape or appearance of the body whether or not for psychological or emotional reasons. Injuries that occur during medical treatments are not considered accidental injuries even if unplanned or unexpected. This exclusion does not apply to: • Surgery after an accidental injury when performed as soon as medically feasible • Coverage that may be provided under the Eligible health services under your plan - Gender reassignment (sex change) treatment section. Court-ordered services and supplies This Includes those court-ordered services and supplies, or those required as a condition of parole, probation, release or as a result of any legal proceeding, unless they are a covered benefit under your plan Custodial care Examples are: • Routine patient care such as changing dressings, periodic turning and positioning in bed • Administering oral medications • Care of a stable tracheostomy (including intermittent suctioning) • Care of a stable colostomy/ileostomy • Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings • Care of a bladder catheter (including emptying/changing containers and clamping tubing) • Watching or protecting you • Respite care except in connection with hospice care, adult (or child) day care, or convalescent care • Institutional care. This includes room and board for rest cures, adult day care and convalescent care • Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods • Any other services that a person without medical or paramedical training could be trained to perform • Any service that can be performed by a person without any medical or paramedical training Dermatological treatment Cosmetic treatment and procedures Dental care for adults Dental services for adults including services related to: • The care, filling, removal or replacement of teeth and treatment of injuries to or diseases of the teeth • Dental services related to the gums • Apicoectomy (dental root resection) • Orthodontics • Root canal treatment • Soft tissue impactions • Alveolectomy • Augmentation and vestibuloplasty treatment of periodontal disease • False teeth • Prosthetic restoration of dental implants • Dental implants This exception does not include removal of bony impacted teeth, bone fractures, removal of tumors, and odontogenic cysts. Drexel University 2020-2021 Page 25
Durable medical equipment (DME)
Examples of these items are:
• Whirlpools
• Portable whirlpool pumps
• Sauna baths
• Massage devices
• Over bed tables
• Elevators
• Communication aids
• Vision aids
• Telephone alert systems
• Personal hygiene and convenience items such as air conditioners, humidifiers, hot tubs, or physical exercise
equipment even if they are prescribed by a physician
Educational services
Examples of these services are:
• Any service or supply for education, training or retraining services or testing, except where described in the
Eligible health services under your plan – Diabetic services and supplies (including equipment and training) section. This
includes:
- Special education
- Remedial education
- Wilderness treatment programs (whether or not the program is part of a residential treatment facility or
otherwise licensed institution)
- Job training
- Job hardening programs
• Educational services, schooling or any such related or similar program, including therapeutic programs within a
school setting.
Elective treatment or elective surgery
Elective treatment or elective surgery except as specifically covered under the student policy and provided while the
student policy is in effect
Enteral formulas and nutritional supplements
Any food item, including infant formulas, vitamins, plus prescription vitamins, medical foods and other nutritional
items, even if it is the sole source of nutrition, except as covered in the Eligible health services under your plan –
Enteral formulas and nutritional supplements section
Examinations
Any health or dental examinations needed:
• Because a third party requires the exam. Examples are, examinations to get or keep a job, or examinations
required under a labor agreement or other contract
• Because a law requires it
• To buy insurance or to get or keep a license
• To travel
• To go to a school, camp, or sporting event, or to join in a sport or other recreational activity
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