Virginia Tech Aetna Student Health Plan Design and Benefits Summary Preferred Provider Organization (PPO) - Insurance & Risk ...
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Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Aetna Student Health Plan Design and Benefits Summary Preferred Provider Organization (PPO) Virginia Tech Policy Year: 2021–2022 Policy Number: 474968 www.aetnastudenthealth.com (866) 577‐7027
This is a brief description of the Student Health Plan. The Plan is available for Virginia Tech students and their
eligible dependents. The Plan is underwritten by Aetna Life Insurance Company (Aetna). The exact provisions,
including definitions, governing this insurance are contained in the Certificate of Coverage and may be viewed
online at www.aetnastudenthealth.com. If there is a difference between this Benefit Summary and the
Certificate of Coverage, the Certificate will control.
Virginia Tech Health Services
The Schiffert Health Center is the University's on-campus health facility. Staffed by physicians, nurse practitioners
and registered nurses, it is open weekdays from 8:00 a.m. to 5:00 p.m., during the Fall and Spring semesters. A
Physician and nurse practitioner are on call at all times, and conduct clinics during the week.
For more information, call the Health Services at (540) 231-6444. In the event of an emergency, call 911.
Coverage Periods
Students/Eligible Dependents: Coverage will become effective at 12:00 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 Certificate of Coverage.
Coverage Period Coverage Start Date Coverage End Date Open Enrollment Deadline
Annual 08/01/2021 07/31/2022 09/10/2021
Spring /Summer 01/01/2022 07/31/2022 01/31/2022
Rates
Annual Spring Semester
Student $3,343.00 $1,941.69
Spouse/Domestic Partner $3,343.00 $1,941.69
Child $3,343.00 $1,941.69
2+ Children $6,686.00 $3,883.38
Coverage
Eligibility
Students must be enrolled as full-time students at the university on the first day that coverage will be effective.
Students in Cooperative Education and serving approved internships off-campus or performing credited research
hours are considered to be full-time students of the university. However, if the student takes fewer than full-time
hours but is enrolled in the maximum number of hours allowed toward graduation (i.e. working on a dissertation),
the student may obtain a statement to this effect in writing on the department’s letterhead and with the signature
of the department head. This confirmation may be attached to the application for insurance. The student shall then
be considered as full-time and shall be eligible to enroll in the university’s insurance plans.
• Undergraduate Eligibility: 12 or more credit hours
• Graduate Eligibility: 9 or more credit hours
(continued on next page)
Virginia Tech 2021-2022 Page 2• International Students & Veterinary Medicine DVM Students are required to maintain health insurance either
through the school sponsored plan or a comparable plan.
• Eligible Graduate Assistants wishing to use the health care subsidy must in enroll in the Virginia Tech sponsored
plan.
• Graduate students who are defending their thesis are eligible to remain on the insurance program if previously
insured through the end of the month in which they defend. Documentation from the department head must
be provided to the Student Medical Insurance office.
• Visiting Scholars are required to maintain health insurance either though the schools sponsored plan or a
comparable plan during their stay at Virginia Tech.
• Language and Culture Institute VT Advantage students.
Students must actively attend classes for at least the first 31 days, after the date when coverage becomes effective.
Home study, correspondence, Internet classes, and television (TV) courses, do not fulfill the eligibility requirement
that the student actively attend classes. If it is discovered that this eligibility requirement has not been met, our
only obligation is to refund premium, less any claims paid.
Enrollment
To enroll online, log on to www.aetnastudenthealth.com, search for your school, click on Enroll and follow the
steps. Enrollment 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.) The completed Enrollment and premium must be sent to Aetna Student Health.
ID Cards: To print an ID card, log on to www.aetnastudenthealth.com, search for your school, click on Get your ID
card and follow the steps. Please note that the ID card will be available within 7-10 business days after enrollment
is completed.
Please note: Visiting Scholars and Language and Culture Institute students must enroll through the Virginia
Tech Student Medical Insurance office.
Waiver Process/Procedure
International Students & Veterinary Medicine DVM Students are required to maintain health insurance either
through the school sponsored plan or a comparable plan.
To meet the criteria of a comparable insurance plan, coverage must meet or exceed all of the following:
1. The policy must offer adequate provider care within a 50-mile radius of the campus of enrollment. Coverage for
emergency only care does not satisfy this requirement. (Adequate means Preferred Care coverage for non
emergency care.)
2. The policy must have a deductible of $500 per accident or illness or less.
3. The policy must provide major medical benefits of at least $500,000 per accident or illness.
4. The policy must provide a minimum benefit of $25,000 for repatriation of remains and $50,000 medical
evacuation to the home country. (Repatriation provides transportation to your home country in the event of
death.)
5. Medical expenses for pregnancy, childbirth and complications of pregnancy must be treated as any other illness
under the policy.
(continued on next page)
Virginia Tech 2021-2022 Page 36. The policy must provide Prescription Medication coverage (after co-pays) with a minimum of $500,000 per
insured per policy year.
7. Coverage must be valid from either August 01, 2021, or the first day of enrollment at Virginia Tech, until July 31,
2022 or, if graduating, the last day of the month of the student’s graduation.
8. The policy must cover Outpatient and Inpatient Mental Health Care as any other illness.
9. The policy must not have limits or internal dollar caps on coverage, including services, treatment or surgery.
10. The policy must not have a pre-existing condition waiting period.
Waiver submissions will be audited by Virginia Tech, and/or their contractors or representatives. You may be
required to provide, upon request, any coverage documents and/or other records demonstrating that you meet the
school’s requirements for waiving the student health insurance plan.
All International and Veterinary Medicine DVM Students records will be blocked and students will be unable to
register for classes until the university-sponsored insurance or alternate approved insurance is purchased. There
are no exemptions from this requirement. Waivers must be remitted by the deadlines listed below.
Waiver Deadline Dates
1. Students enrolling for the Fall Semester- 09/10/2021
2. Students enrolling for the Spring Semester- 01/31/2022
In order to avoid having a block placed on a student’s account the student must enroll in the Student Medical
Insurance Program or provide details of their current comparable coverage to the Student Medical Insurance Office
before the deadline.
Dependent Coverage
Eligibility
Covered students may also enroll their lawful spouse or domestic partner (same-sex, opposite sex) and any
dependent children up to the age of 26. Verification of Dependent status may be required.
If a child is covered based on being a full-time student and he/she can't attend school because of a medical
condition, the plan must allow the child to stay on the plan, if certified by a physician as medically necessary, until
the earlier of 12 months or when coverage would otherwise terminate for the dependent.
Enrollment
To enroll the dependent(s) of a covered student, please complete the Enrollment by visiting
www.aetnastudenthealth.com, selecting the school name, and clicking on Enroll. Please refer to the Coverage
Periods section of this document for coverage dates and deadline dates. Dependent enrollment 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.) The
completed Enrollment and premium must be sent to Aetna Student Health.
Virginia Tech 2021-2022 Page 4Important 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 60 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 60-day period.
- If coverage does not require an additional premium contribution for the newborn, you must still notify us (or
our agent) within 60 days of birth to enroll the child.
- If you miss this deadline, your newborn will not have health benefits after the first 60 days.
- If your coverage ends during this 60-day period, then your newborn‘s coverage will end on the same date as
your coverage. This applies even if the 60-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 or
domestic partner adopts or is placed with you for adoption, is covered on your plan for the first 60 days after the
adoption or the placement is complete.
- To keep your child covered, we must receive your completed enrollment information within 60 days after the
adoption or placement for adoption.
- If coverage does not require an additional premium contribution for the adopted child, you must still notify us
(or our agent) within 60 days of adoption or placement for adoption to enroll 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 60 days.
- If your coverage ends during this 60-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 60-day period has not ended.
For information or general questions on dependent enrollment, contact Student Medical Insurance at (540) 231
6226
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.
Termination 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.
Virginia Tech 2021-2022 Page 5Preferred Provider Network
Aetna Student Health offers Aetna’s broad network of Preferred Providers. You can save money by seeing
Preferred 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 a Preferred 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 a Non-Preferred Provider. When a pre-approval is issued by Aetna, the
benefit level is the same as for Preferred Providers.
Precertification
You need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Your
Preferred Care physician is responsible for obtaining any necessary precertification before you get the care. When
you go to an Non-Preferred Care 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 $200 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 15 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 You or your physician must call at least 15 days before the outpatient care is
services requiring precertification: provided, or the treatment or procedure is scheduled.
Delivery: You, your physician, or the facility must call within 48 hours of the birth or as
soon thereafter as possible. No penalty will be applied for the first 48 hours
after delivery for a routine delivery and 96 hours for a cesarean delivery.
We 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.
What if you don’t obtain the required pre-certification?
If you don’t obtain the required pre-certification:
• Your benefits may be reduced, or the plan may not pay any benefits. See the schedule of benefits Pre-certification
penalty section.
• You will be responsible for the unpaid balance of the bills.
• Any additional out-of-pocket expenses incurred will not count toward your deductibles or maximum out-of-pocket
limits.
Virginia Tech 2021-2022 Page 6What types of services and supplies require pre-certification?
Pre-certification is required for the following types of services and supplies:
Inpatient services and supplies Outpatient services and supplies
Gender reassignment surgery Applied behavior analysis
Obesity (bariatric) surgery Certain prescription drugs and devices*
Stays in a hospice facility Complex imaging
Stays in a hospital Cosmetic and reconstructive surgery
Stays in a rehabilitation facility Emergency transportation by airplane
Stays in a residential treatment facility for Gender reassignment surgery
treatment of mental disorders and substance
abuse
Stays in a skilled nursing facility Home health care
Hospice services
Intensive outpatient program (IOP) – mental disorder
and substance abuse diagnoses
Kidney dialysis
Knee surgery
Medical injectable drugs, (immunoglobulins, growth
hormones, multiple sclerosis medications, osteoporosis
medications, botox, hepatitis C medications)*
Outpatient back surgery not performed in a physician’s
office
Partial hospitalization treatment – mental disorder
and substance abuse diagnoses
Private duty nursing services
Psychological testing/neuropsychological testing
Sleep studies
Transcranial magnetic stimulation (TMS)
Wrist surgery
*For a current listing of the prescription drugs and medical injectable drugs that require pre-certification, contact Member
Services by calling the toll-free number on your ID card in the How to contact us for help section or by logging onto the
Aetna website at www.aetnastudenthealth.com.
Coordination of Benefits (COB)
Some people have health coverage under more than one health plan. If you do, we will work together with your
other plan(s) to decide how much each plan pays. This is called coordination of benefits (COB). A complete
description of the Coordination of Benefits provision is contained in the certificate issued to you.
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. If any discrepancy exists between this Benefit
Summary and the Certificate of Coverage, the Certificate will control.
This Plan will pay benefits in accordance with any applicable Virginia Insurance Law(s).
Virginia Tech 2021-2022 Page 7Preferred Care Coverage Non-Preferred Care Coverage
Policy year deductibles
You have to meet your policy year deductible before this plan pays for benefits.
Student $450 per policy year $1,000 per policy year
Spouse or domestic partner $450 per policy year $1,000 per policy year
Each child $450 per policy year $1,000 per policy year
Family $900 per policy year $2,000 per policy year
Policy year deductible waiver
The policy year deductible is waived for Preferred Care covered medical expenses that apply to Preventive Care
Expense benefits.
In addition to federal requirements for waiver of the policy year deductible, this Plan will waive the Deductible for:
• Preferred and Non-Preferred Care Emergency Room Services,
• Non-Preferred Care Preventive Health Care Services up to age 7,
• Preferred and Non-Preferred Care Pediatric Care Vision Benefit Expenses,
• Preferred Care Pediatric Dental Services Expenses,
• Preferred and Non-Preferred Care Prescribed Medicines expenses,
• Preferred Care Adult Vision Exam and Vision Supplies Expense,
• Preferred Care Office Visit Expense,
• Preferred Care Walk-in Clinic Visit Expense
• Preferred Care Outpatient Treatment of Mental Disorders Expense,
• Preferred Care Outpatient Treatment of Substance Abuse Expense,
• Preferred Care Urgent Care Expense, and
• Preferred Care Non-Elective Second Surgical Opinion Expense.
Per visit or admission deductibles do not apply towards satisfying the policy year deductible.
Individual Deductible
This is the amount you are obliged to pay for Preferred Care and Non-Preferred Care 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. Refer
to the schedule of benefits section of this document for coverage percentages of individual services.
Family Deductible
This is the amount you and your covered dependents are obliged to pay for Preferred Care and Non-Preferred
Care eligible health services each policy year before the plan begins to pay for eligible health services. After the
amount you and your covered dependents pay for eligible health services reaches this family policy year
deductible, this plan will begin to pay for eligible health services that you and your covered dependents incur for
the rest of the policy year. Refer to the schedule of benefits section of this document for coverage percentages
of individual services.
To satisfy this family policy year deductible limit for the rest of the policy year, the following must happen:
• The combined eligible health services that you and each of your covered dependents incur towards the
individual policy year deductibles must reach this family policy year deductible limit in a policy year.
When this occurs in a policy year, the individual policy year deductibles for you and your covered dependents will
be considered to be met for the rest of the policy year.
Eligible health services applied to the Non-Preferred Care policy year deductibles will not be applied to satisfy
the Preferred Care policy year deductibles. Eligible health services applied to the Preferred Care policy year
deductibles will not be applied to satisfy the Non-Preferred Care policy year deductibles.
Virginia Tech 2021-2022 Page 8Maximum out-of-pocket limits
Preferred Care Coverage Non-Preferred Care Coverage
Student $6,250 per policy year
Spouse or domestic partner $6,250 per policy year
Each child $6,250 per policy year
Family $12,500 per policy year
Once the Individual or Family Out-of-Pocket Limit has been satisfied, Covered Medical Expenses will be payable at
100% for the remainder of the policy year.
The following expenses do not apply toward meeting the plan’s out-of-pocket limits:
• Non-covered medical expenses; and
• Expenses that are not paid or pre-certification benefit reductions or penalties because a required pre-
certification for the service(s) or supply was not obtained from Aetna.
Referral requirement
Students who have initiated care at Schiffert Health Center prior to seeking care in the community and have been
referred to an outside provider for treatment are eligible to receive enhanced benefits for services when care is
provided by a preferred care provider shown as preferred coverage with Referral in the below schedule of
benefits. A new referral must be obtained each policy year.
If a referral is received, preferred care coinsurance increases from 80% to 90% for services rendered at a hospital.
A referral is not required in the following circumstances:
• Emergency Room Services
• Treatment received when Schiffert Health Center is closed.
• Care received outside a 20-mile radius from the Blacksburg Campus
• Maternity
• Satellite Campus enrolled students
• Treatment is for an Emergency Medical Condition
• Obstetric and Gynecological Treatment
• Pediatric Care
• Preventive/Routine Services (services considered preventive according to Health Care Reform and/or services
rendered not to diagnosis or treat an Accident or Sickness).
*Dependents and Visiting Scholars are not eligible to use the services of the School Health Service and therefore
cannot received enhanced benefits shown in tier 1 of the schedule of benefits.
All labs and services provided at Schiffert Health Center are covered at 100%. Students should submit their
itemized paid statements to Aetna Student Health for reimbursement. Retroactive referral requests will not be
accepted or processed.
Virginia Tech 2021-2022 Page 9The coinsurance listed in the schedule of benefits below reflects the plan coinsurance percentage. This is the
coinsurance amount that the plan pays. You are responsible for paying any remaining coinsurance.
Tier I: When a Schiffert Health Center referral is obtained, benefits will be paid at the Tier I Level when rendered
by a Preferred Care provider.
Tier II: When a referral is not obtained but care is rendered by a Preferred Care provider, benefits will be paid
at the Tier II Level.
Tier III: When care is rendered by a Non-Preferred Care provider, benefits will be paid at the Tier III Level.
Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Physician and specialist services
Physician and specialist services $25 copayment then the $25 copayment then the 65% (of the recognized
(non-surgical and non- plan pays 100% (of the plan pays 100% (of the charge) per visit
preventive) - Office hours visits balance of the balance of the
(non-surgical and non- negotiated charge) per negotiated charge) per
preventive care by a physician visit visit
and specialist, includes
telemedicine consultations) No policy year No policy year
deductible applies deductible applies
Urgent care
Urgent care provided by an $25 copayment then $25 copayment then $25 copayment then the
urgent care provider – visit the plan pays 100% (of the plan pays 100% (of plan pays 65% (of the
charge the balance of the the balance of the balance of the
negotiated charge) per negotiated charge) per recognized charge) per
For coverage of complex imaging
visit visit visit
services, lab work, and
radiological services performed
No policy year No policy year
during an urgent medical care
deductible applies deductible applies
visit, refer to the “outpatient
diagnostic testing” section.
Urgent care facility: A facility licensed as a freestanding medical facility by applicable state and federal laws to
treat an urgent condition.
Urgent condition: An illness or injury that requires prompt medical attention but is not an emergency medical
condition. An urgent condition includes earache, sore throat, and fever (not above 104 degrees).
Non-urgent use of an urgent Not covered Not covered Not covered
care provider
The following is not covered under this benefit:
• Non-urgent care in an urgent care facility (at a non-hospital freestanding facility)
If you go to an urgent care facility for what is not an urgent condition, the plan will not cover your expenses.
Examples of non-urgent care are:
• Routine or preventive care (this includes immunizations)
• Follow-up care
• Physical therapy
• Elective treatment
• Any diagnostic lab work and radiological services which are not related to the treatment of the urgent condition
Virginia Tech 2021-2022 Page 10Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Alternatives to physician office visits
Walk-in clinic visits (non- $25 copayment then $25 copayment then 65% (of the recognized
emergency visit) the plan pays 100% (of the plan pays 100% (of charge) per visit
the balance of the the balance of the
negotiated charge) per negotiated charge) per
visit visit
No policy year No policy year
deductible applies deductible applies
Consultant services (non-surgical and non-preventive)
Consultant services - Office 80% (of the negotiated 80% (of the negotiated 80% (of the recognized
hours visits (non-surgical and charge) per visit charge) per visit charge) per visit
non-preventive care)
Includes telemedicine
consultations
Routine physical exams
Performed at a physician’s office 100% (of the negotiated 100% (of the negotiated Under 7 years of age –
charge) per visit charge) per visit 100% of the recognized
charge per visit, no
No copayment or policy No copayment or policy copayment or
year deductible applies year deductible applies deductible applies
7 years of age or older -
100% of the recognized
charge per visit, policy
year deductible applies
Maximum age and visit limits Subject to any age and visit limits provided for in the comprehensive
per policy year through age 21 guidelines supported by the American Academy of Pediatrics/Bright
Futures/Health Resources and Services Administration guidelines for children
and adolescents.
Covered persons age 22 and 1 visit
over: Maximum visits per
policy year
Virginia Tech 2021-2022 Page 11Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Preventive care immunizations
Performed in a facility or at a 100% (of the negotiated 100% (of the negotiated Under 7 years of age –
physician's office charge) per visit charge) per visit 100% of the recognized
charge per visit, no
No copayment or policy No copayment or policy copayment or
year deductible applies year deductible applies deductible applies
7 years of age or older -
100% of the recognized
charge per visit, 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, 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
obstetrician (OB), gynecologist charge) per visit charge) per visit charge) per visit
(GYN) or OB/GYN office
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Maximum visits per policy year Subject to any age limits provided for in the comprehensive guidelines
supported by the Health Resources and Services Administration.
Preventive screening and counseling services
Preventive screening and 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
counseling services for obesity charge) per visit charge) per visit charge) per visit
and/or healthy diet counseling
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Obesity and/or healthy diet Age 0-22: unlimited visits.
counseling - Maximum visits Age 22 and older: 26 visits per 12 months, of which up to 10 visits may be used
for healthy diet counseling.
Preventive screening and 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
counseling services for misuse charge) per visit charge) per visit charge) per visit
of alcohol & drugs
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Misuse of alcohol and/or drugs 5 visits
counseling - Maximum visits per
policy year
Virginia Tech 2021-2022 Page 12Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Preventive screening and counseling services (continued)
Preventive screening and 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
counseling services for use of charge) per visit charge) per visit charge) per visit
tobacco products
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Use of tobacco products 8 visits
counseling - Maximum visits per
policy year
Preventive screening and 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
counseling services for charge) per visit charge) per visit charge) per visit
depression screening
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Depression screening and 1 visit
counseling - Maximum visits per
policy year
Preventive screening and 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
counseling services for sexually charge) per visit charge) per visit charge) per visit
transmitted infection counseling
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Sexually transmitted infection 2 visits
counseling - Maximum visits per
policy year
Preventive screening and 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
counseling services genetic risk charge) per visit charge) per visit charge) per visit
counseling for breast and
No copayment or policy No copayment or policy
ovarian cancer
year deductible applies year deductible applies
Genetic risk counseling for breast Not subject to any age or frequency limitations
and ovarian cancer limitations
Routine cancer screenings 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
charge) per visit charge) per visit charge) per visit
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Maximum: 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*
*Important note: Any lung cancer screenings that exceed the lung cancer screening maximum above are
covered under the Outpatient diagnostic testing section.
Virginia Tech 2021-2022 Page 13Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Prenatal care services (provided by a physician, an obstetrician (OB), gynecologist (GYN), and/or OB/GYN)
Preventive care services only 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
charge) per visit charge) per visit charge) per visit
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Important note: You should review the Maternity care and Well newborn nursery care sections. They will give you
more information on coverage levels for maternity care under this plan.
Comprehensive lactation support and counseling services
Lactation support and 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
counseling services charge) per visit charge) per visit charge) per visit
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Lactation counseling services 6 visits
maximum visits per policy year
either in a group or individual
setting
Important note: Any visits that exceed the lactation counseling services maximum are covered under the
Physicians and other health professionals section.
Breast pump supplies and 100% (of the negotiated 100% (of the negotiated 80% (of the recognized
accessories charge) per item charge) per item charge) per item
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Maximums An electric breast pump (non-hospital grade, cost is covered by your plan once
every three years) or a manual breast pump (cost is covered by your plan once
per pregnancy)
If an electric breast pump was purchased within the previous three-year
period, the purchase of another electric breast pump will not be covered until
a three-year period has elapsed since the last purchase.
Family planning services – female contraceptives
Female contraceptive 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
counseling services charge) per visit charge) per visit charge) per visit
office visit
No copayment or policy No copayment or policy
year deductible applies year deductible applies
Contraceptives (prescription drugs and devices)
Female contraceptive 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
prescription drugs and devices charge) per item charge) per item charge) per item
provided, administered, or
removed, by a physician during No copayment or policy No copayment or policy
an office visit year deductible applies year deductible applies
Virginia Tech 2021-2022 Page 14Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Female voluntary sterilization
Female Voluntary sterilization - 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
Inpatient & Outpatient provider charge) charge) charge)
services
No copayment or policy No copayment or policy
year deductible applies year deductible applies
The following are not covered under this benefit:
• Services provided as a result of complications resulting from a female voluntary sterilization procedure and
related follow-up care
• Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA
• Contraception services during a stay in a hospital or other facility for medical care
• Male contraceptive methods, sterilization procedures or devices
Family planning services – other
Voluntary sterilization for males 90% (of the negotiated 80% (of the negotiated 65% (of the recognized
- surgical services charge) charge) charge)
The following are not covered under this benefit:
• Abortion except when the life of the mother is endangered by a physical disorder, physical illness or physical
injury, including a life-endangering physical condition caused by or arising from the pregnancy itself, or when
the pregnancy is the result of an alleged act of rape or incest
• Reversal of voluntary sterilization procedures, including related follow-up care
• Services provided as a result of complications resulting from a male voluntary sterilization procedure and
related follow-up care
Maternity care
Maternity care (includes Covered according to Covered according to Covered according to
delivery and postpartum care the type of benefit and the type of benefit and the type of benefit and
services in a hospital or the place where the the place where the the place where the
birthing center) service is received service is received service is received
Coverage is provided under the
same terms, conditions as any
other illness.
The following are not covered under this benefit:
• Any services and supplies related to births that take place in the home, except for home delivery by a certified
nurse midwife, or in any other place not licensed to perform deliveries
Well newborn nursery care in a 90% (of the negotiated 90% (of the negotiated 65% (of the recognized
hospital or birthing center charge) charge) charge)
No policy year No policy year No policy year
deductible applies deductible applies deductible applies
Note: The per admission copayment amount and/or policy year deductible for newborns will be waived for nursery
charges for the duration of the newborn’s initial routine facility stay. The nursery charges waiver will not apply for non-
routine facility stays.
Virginia Tech 2021-2022 Page 15Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Physician and specialist -inpatient surgical services
Inpatient surgery performed 90% (of the negotiated 80% (of the negotiated 65% (of the recognized
during your stay in a hospital or charge) charge) charge)
birthing center by a surgeon
(includes anesthesiologist,
anesthetist and surgical
assistant expenses)
The following are not covered under this benefit:
• The services of any other physician who helps the operating physician
• A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital and other
facility care section)
• Services of another physician for the administration of a local anesthetic unless approved by the plan as
medically necessary
Physician and specialist -outpatient surgical services
Outpatient surgery performed 90% (of the negotiated 80% (of the negotiated 65% (of the recognized
at a physician’s or specialist’s charge) per visit charge) per visit charge) per visit
office or outpatient department
of a hospital or surgery center
by a surgeon (includes
anesthesiologist, anesthetist
and surgical assistant expenses)
The following are not covered under this benefit:
• The services of any other physician who helps the operating physician
• A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital and other
facility care section)
• A separate facility charge for surgery performed in a physician’s office
• Services of another physician for the administration of a local anesthetic unless approved by the plan as
medically necessary
Outpatient surgery (facility charges)
Outpatient surgery (facility 90% (of the negotiated 80% (of the negotiated 65% (of the recognized
charges) performed in the charge) per visit charge) per visit charge) per visit
outpatient department of a
hospital or surgery center
The following are not covered under this benefit:
• The services of any other physician who helps the operating physician
• A stay in a hospital (See the Hospital care – facility charges benefit in this section)
• A separate facility charge for surgery performed in a physician’s office
• Services of another physician for the administration of a local anesthetic unless approved by the plan as
medically necessary
Virginia Tech 2021-2022 Page 16Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Hospital and other facility care
Inpatient hospital (room and $300 copayment then $300 copayment then $300 copayment then
board) and other the plan pays 90% (of the plan pays 80% (of the plan pays 65% (of
miscellaneous services and the balance of the the balance of the the balance of the
supplies) negotiated charge) per negotiated charge) per recognized charge) per
admission admission admission
Includes birthing center facility
charges
In-hospital non-surgical physician services
In-hospital non-surgical 90% (of the negotiated 80% (of the negotiated 65% (of the recognized
physician services charge) per visit charge) per visit charge) per visit
Adult vision care - Limited to covered persons age 19 and over
Adult routine vision exams $15 copayment then the $15 copayment then the 65% (of the recognized
(including refraction) performed plan pays 100% (of the plan pays 100% (of the charge) per visit
by a legally qualified balance of the negotiated balance of the negotiated
ophthalmologist or therapeutic charge) per visit charge) per visit
optometrist, or any other
providers acting within the No policy year No policy year
scope of their license deductible applies deductible applies
Maximum visits per policy year 1 visit
Vision correction after surgery Covered according to Covered according to Covered according to
or accident the type of benefit and the type of benefit and the type of benefit and
the place where the the place where the the place where the
service is received service is received service is received
Eyeglass frames, prescription $15 copayment then the $15 copayment then the $15 copayment then the
lenses or prescription contact plan pays 100% (of the plan pays 100% (of the plan pays 65% (of the
lenses* balance of the negotiated balance of the negotiated balance of the
charge) per item charge) per item recognized charge) per
item
No policy year No policy year
deductible applies deductible applies
Maximum per policy year $120
eyeglass frames, prescription
lenses or prescription contact
lenses
*Important note:
Refer to the Vision care section in the certificate of coverage for the explanation of these vision care supplies.
Coverage does not include the office visit for the fitting of prescription contact lenses.
(continued on next page)
Virginia Tech 2021-2022 Page 17Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Adult vision care - Limited to covered persons age 19 and over (continued)
The following are not covered under this benefit:
Adult vision care
• Office visits to an ophthalmologist, optometrist or optician related to the fitting of prescription contact lenses
• Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for cosmetic purposes
Adult vision care services and supplies
• Special supplies such as non-prescription sunglasses
• Special vision procedures, such as orthoptics or vision therapy
• Eye exams during your stay in a hospital or other facility for health care
• Replacement of lenses or frames that are lost or stolen or broken
• Acuity tests
• Eye surgery for the correction of vision, including radial keratotomy, LASIK and similar procedures
• Services to treat errors of refraction
Behavioral Health & Substance Abuse Treatment
Inpatient hospital $300 copayment then $300 copayment then $300 copayment then
(room and board and other the plan pays 90% (of the plan pays 80% (of the plan pays 65% (of
miscellaneous hospital services the balance of the the balance of the the balance of the
and supplies) negotiated charge) per negotiated charge) per recognized charge) per
admission admission admission
Coverage is provided under the
same terms, conditions as any
other illness
Outpatient office visits $25 copayment then $25 copayment then 65% (of the recognized
(includes telemedicine the plan pays 100% (of the plan pays 100% (of charge) per visit
consultations) the balance of the the balance of the
negotiated charge) per negotiated charge) per
visit visit
No policy year No policy year
deductible applies deductible applies
Other outpatient treatment 90% (of the negotiated 80% (of the negotiated 65% (of the recognized
(includes Partial hospitalization charge) charge) charge)
and Intensive Outpatient
Program)
(includes skilled behavioral
health services in the home)
Transplant services
Inpatient and outpatient Covered according to the type of benefit and the place where the service is
transplant facility services received
Inpatient and outpatient Covered according to the type of benefit and the place where the service is
transplant physician and received
specialist services
Virginia Tech 2021-2022 Page 18Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Transplant services (continued)
Transplant services - reasonable Covered
and necessary travel and
lodging costs for the covered
person and for one companion,
or for two companions if the
covered person is a minor child,
and for the donor if the donor
and the covered person are
both covered under this plan
The following are not covered under this benefit:
• Services and supplies furnished to a donor when the recipient is not a covered person
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 100% (of the negotiated 65% (of the recognized
charge) per visit charge) per visit charge) per visit
No copayment or No copayment or
deductible applies deductible applies
Type B services 70% (of the negotiated 70% (of the negotiated 50% (of the recognized
charge) per visit charge) per visit charge) per visit
No policy year No policy year
deductible applies deductible applies
Type C services 50% (of the negotiated 50% (of the negotiated 50% (of the recognized
charge) per visit charge) per visit charge) per visit
No policy year No policy year
deductible applies deductible applies
Orthodontic services 50% (of the negotiated 50% (of the negotiated 50% (of the recognized
charge) per visit charge) per visit charge) per visit
No policy year No policy year
deductible applies deductible applies
Dental emergency services Covered according to Covered according to Covered according to
the type of benefit and the type of benefit and the type of benefit and
the place where the the place where the the place where the
service is received service is received service is received
Pediatric dental care exclusions
The following are not covered under this benefit:
• Any instruction for diet, plaque control and oral hygiene
• Asynchronous dental treatment
(continued on next page)
Virginia Tech 2021-2022 Page 19Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Pediatric dental care exclusions (continued)
The following are not covered under this benefit:
• Cosmetic services and supplies including plastic surgery, reconstructive surgery, cosmetic surgery,
personalization or characterization of dentures or other services and supplies which improve alter or enhance
appearance, augmentation and vestibuloplasty, and other substances to protect, clean, whiten bleach or alter
the appearance of teeth, whether or not for psychological or emotional reasons, except to the extent coverage
is specifically provided in the Eligible health services and exclusions section. Facings on molar crowns and pontics
will always be considered cosmetic.
• Crown, inlays, onlays, and veneers unless:
- It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material or
- The tooth is an abutment to a covered partial denture or fixed bridge
• Dental implants and braces (that are determined not to be medically necessary mouth guards, and other
devices to protect, replace or reposition teeth
• Dentures, crowns, inlays, onlays, bridges, or other appliances or services used:
- To alter vertical dimension
- To restore occlusion
- For correcting attrition, abrasion, abfraction or erosion
• Treatment of any jaw joint disorder and treatments to alter bite or the alignment or operation of the jaw,
including temporomandibular joint dysfunction disorder (TMJ) and craniomandibular joint dysfunction
disorder (CMJ) treatment, orthognathic surgery, and treatment of malocclusion or devices to alter bite or
alignment, except as covered in the Eligible health services and exclusions – Specific conditions section
• General anesthesia and intravenous sedation, unless specifically covered and only when done in connection
with another eligible health service
• Mail order and at-home kits for orthodontic treatment
• Orthodontic treatment except as covered in the Pediatric dental care section of the schedule of benefits
• Pontics, crowns, cast or processed restorations made with high noble metals (gold)
• Prescribed drugs, pre-medication
• Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of appliances that
have been damaged due to abuse, misuse or neglect and for an extra set of dentures, except for replacement
of a lost or broken retainer
• Replacement of teeth beyond the normal complement of 32
• Routine dental exams and other preventive services and supplies, except as specifically provided in the
Pediatric dental care section of the schedule of benefits
• Services and supplies:
- Done where there is no evidence of pathology, dysfunction, or disease other than covered preventive
services
- Provided for your personal comfort or convenience or the convenience of another person, including a
provider
- Provided in connection with treatment or care that is not covered under your policy
• Surgical removal of impacted wisdom teeth that is not medically necessary and only for orthodontic reasons
• Treatment by other than a dental provider that is legally qualified to furnish dental services or supplies
Virginia Tech 2021-2022 Page 20Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Pediatric vision care
(Limited to covered persons through the end of the month in which the person turns age 19)
Performed by a legally qualified 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
ophthalmologist or optometrist charge) per visit charge) per visit charge) per visit
(includes comprehensive low
vision evaluations) No policy year No policy year No policy year
deductible applies deductible applies deductible applies
Maximum visits per policy year 1 visit
Low vision Maximum One comprehensive low vision evaluation every policy year
Fitting of contact Maximum 1 visit
Vision correction after surgery Covered according to Covered according to Covered according to
or accident the type of benefit and the type of benefit and the type of benefit and
the place where the the place where the the place where the
service is received service is received service is received
Pediatric vision care services & 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
supplies - Eyeglass frames, charge) per item charge) per item charge) per item
prescription lenses or
prescription contact lenses No policy year No policy year No policy year
deductible applies deductible applies deductible applies
Maximum number Per year:
Eyeglass frames One set of eyeglass frames
Prescription lenses One pair of standard single vision, bifocal, trifocal, or progressive prescription
lenses
Contact lenses (includes non- Daily disposables: up to 3-month supply
conventional prescription contact Extended wear disposable: up to 6-month supply
lenses & aphakic lenses Non-disposable lenses: one set
prescribed after cataract surgery)
Optical devices 100% (of the negotiated 100% (of the negotiated 65% (of the recognized
charge) per item charge) per item charge) per item
No policy year No policy year No policy year
deductible applies deductible applies deductible applies
Maximum number of optical One optical device
devices per policy year
*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.
The following are not covered under this benefit:
• Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for cosmetic purposes
Virginia Tech 2021-2022 Page 21Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Allergy testing and treatment
Allergy testing & Allergy 80% (of the negotiated 80% (of the negotiated 65% (of the recognized
injections treatment, including charge) per visit charge) per visit charge) per visit
Allergy sera and extracts
administered via injection,
performed at a physician’s or
specialist’s office
Alternatives to hospital stays
Home Health Care
Outpatient 80% (of the negotiated 80% (of the negotiated 80% (of the recognized
charge) per visit charge) per visit charge) per visit
The following are not covered under this benefit:
• Nursing and home health aide services or therapeutic support services provided outside of the home (such as
in conjunction with school, vacation, work or recreational activities)
• Transportation
• Services or supplies provided to a minor or dependent adult when a family member or caregiver is not present
• Homemaker or housekeeper services
• Food or home delivered services
• Maintenance therapy
Hospice Care
Hospice - Inpatient 80% (of the negotiated 80% (of the negotiated 65% (of the recognized
charge) per admission charge) per admission charge) per admission
Hospice - Outpatient 80% (of the negotiated 80% (of the negotiated 65% (of the recognized
charge) per visit charge) per visit charge) per visit
The following are not covered under this benefit:
• Funeral arrangements
• Pastoral counseling
• Financial or legal counseling which includes estate planning and the drafting of a will
• Services which are not related to your care and may include:
- Sitter or companion services for either you or other family members except for respite care
- Transportation
- Maintenance of the house
Skilled Nursing Facility
Inpatient $300 copayment then $300 copayment then $300 copayment then
the plan pays 80% (of the plan pays 80% (of the plan pays 65% (of
the balance of the the balance of the the balance of the
negotiated charge) per negotiated charge) per recognized charge) per
admission admission admission
Virginia Tech 2021-2022 Page 22Eligible health services Tier I Tier II Tier III
Preferred Care Coverage Preferred Care Coverage Non-Preferred Care
with Referral without Referral Coverage
Emergency Services
Hospital emergency room $300 copayment then $300 copayment then Paid the same as
the plan pays 100% (of the plan pays 100% (of Preferred Care
the balance of the the balance of the coverage
negotiated charge) per negotiated charge) per
visit visit
No policy year No policy year
deductible applies deductible applies
The following are not covered under this benefit:
• Non-emergency services in a hospital emergency room facility
If you go to an emergency room for what is not an emergency medical condition, the plan will not cover your
expenses. We will consider a medical condition an “emergency medical condition” based upon whichever one of
the following is most favorable to you as they are reported to us by the hospital emergency room provider:
• The presenting symptoms, or
• The final diagnosis of the medical condition
Important note:
• As Non-Preferred Care 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.
• 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.
Adult dental care for cancer treatments and dental injuries
Adult dental care for cancer 80% (of the negotiated 80% (of the negotiated 80% (of the actual
treatments and dental injuries charge) per visit charge) per visit charge) per visit
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