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Aetna Student Health Gold: Loyola Marymount University/Loyola Law School Coverage Period: Beginning on or after 8/1/16Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: Student Plan Type: EPOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plandocument at http://www.aetnastudenthealth.com/lmu or by calling 1-877-409-7356.Important QuestionsWhat is the overalldeductible?Are there otherdeductibles for specificservices?AnswersPreferred: 500/Non-Preferred: 2,000 per PolicyYear. Does not apply to Outpatient Mental Health& Substance Abuse, Physician’s Office Visit,Consults, Walk in Clinic, AIDS Vaccine, OutpatientNicotine Treatment, Preferred Preventative Care,Preferred Pediatric Preventive Dental, Preferred andNon-Preferred Pediatric Preventive Vision.No.Is there an out-of-pocketlimit on my expenses?Yes, Individual: Preferred 5,000Non-Preferred: 10,000What is not included inthe out-of-pocket limit?Is there an overall annuallimit on what the planpays?Penalties, premiums, balance-billed charges, andhealth care this plan doesn’t cover.Does this plan use anetwork of providers?Do I need a referral to seea specialist?Are there services thisplan doesn’t cover?Why this Matters:You must pay all the costs up to the deductible amount before this planbegins to pay for covered services you use. Check your policy or plandocument to see when the deductible starts over (usually, but not always,January 1st). See the chart starting on page 2 for how much you pay forcovered services after you meet the deductible.You don’t have to meet deductibles for specific services, but see thechart starting on page 2 for other costs for services this plan covers.The out-of-pocket limit is the most you could pay during a coverageperiod (usually one year) for your share of the cost of covered services.This limit helps you plan for health care expenses.Even though you pay these expenses, they don’t count toward the out-ofpocket limit.No.The chart starting on page 2 describes any limits on what the plan will payfor specific covered services, such as office visits.Yes. For a list of preferred providers, seehttp://www.aetnastudenthealth.com/lmu orcall 1-877-409-7356.If you use an in-network doctor or other health care provider, this planwill pay some or all of the costs of covered services. Be aware, your innetwork doctor or hospital may use an out-of-network provider for someservices. Plans use the term in-network, preferred, or participating forproviders in their network. See the chart starting on page 2 for how thisplan pays different kinds of providers.No.Yes.You can see the specialist you choose without permission from this plan.Some of the services this plan doesn’t cover are listed on page 5. See yourpolicy or plan document for additional information about excludedservices.Questions: Call 1-877-409-7356 or visit us at http://www.aetnastudenthealth.com/lmu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.healthreformplanSBC.com or call 1-877-409-7356 to request a copy.500499-912071-9008681 of 3

Aetna Student Health Gold: Loyola Marymount University/Loyola Law School Coverage Period: Beginning on or after 8/1/16Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Student Plan Type: EPOCopayments are fixed dollar amounts (for example, 15) you pay for covered health care, usually when you receive the service.Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if theplan’s allowed amount for an overnight hospital stay is 1,000, your coinsurance payment of 20% would be 200. This may change if youhaven’t met your deductible.The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowedamount, you may have to pay the difference. For example, if an out-of-network hospital charges 1,500 for an overnight stay and the allowedamount is 1,000, you may have to pay the 500 difference. (This is called balance billing.)This plan may encourage you to use preferred providers by charging you lower deductibles, copayments and coinsurance amounts.Common MedicalEventServices You May NeedYour Cost If YouUse a PreferredProviderYour Cost If You Use aNon-PreferredProviderLimitations & ExceptionsPrimary care visit to treatan injury or illness 25 Copay per visitNot -- Specialist visit 25 Copay per visitNot -- If you visit a healthcare provider’s office or Other practitioner tionDiagnostic test (x-ray,blood work)If you have a testImaging (CT/PET scans,MRIs)If you need drugs toGeneric drugstreat your illness orconditionPreferred brand drugsMore information aboutNon-preferred brandprescription drugdrugscoverage is available atwww.aetna.com/formu Specialty drugslary20% CoinsuranceNo Charge20% Coinsurance20% Coinsurance 15 Copay perprescription (retail) 40 Copay perprescription (retail) 80 Copay perprescription (retail)Not CoveredNot CoveredNot CoveredNot CoveredRefers to Chiropractic & ------- -------------------------none---------------- The Annual deductible will be waived if service isprovided in the Emergency Room.Not CoveredNot CoveredNot CoveredCovers up to a 30 day supply (retail)2.5 Copays per 90 day supply (mail order).Questions: Call 1-877-409-7356 or visit us at http://www.aetnastudenthealth.com/lmu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.healthreformplanSBC.com or call 1-877-409-7356 to request a copy.500499-912071-9008682 of 3

Aetna Student Health Gold: Loyola Marymount University/Loyola Law School Coverage Period: Beginning on or after 8/1/16Summary of Benefits and Coverage: What this Plan Covers & What it CostsCommon MedicalEventIf you have outpatientsurgeryIf you need immediatemedical attentionServices You May NeedFacility fee (e.g.,20% Coinsuranceambulatory surgery center)If you have mentalhealth, behavioralhealth, or substanceabuse needsYour Cost If You Use aNon-PreferredProviderNot CoveredNot CoveredLimitations & ----- -------------------------none---------------- Physician/surgeon fees20% CoinsuranceEmergency room services 150 Copay per visit,20% Coinsurance 150 Copay per visit, 20%CoinsuranceCopay waived if admitted.20% Coinsurance20% ------ 20% CoinsuranceNot -- Not Covered 500 per admission penalty applied to care which isnot pre-certified. If the cost of the covered medicalexpenses to Aetna is less than 500, the penaltywill not exceed the cost of the covered medicalexpenses.Emergency medicaltransportationUrgent careIf you have a hospitalstayYour Cost If YouUse a PreferredProviderCoverage for: Student Plan Type: EPOFacility fee (e.g., hospitalroom)20% CoinsurancePhysician/surgeon fee20% CoinsuranceMental/Behavioral healthoutpatient services 25 Copay per visitMental/Behavioral healthinpatient services20% CoinsuranceSubstance use disorderoutpatient services 25 Copay per visitSubstance use disorderinpatient services20% CoinsuranceNot CoveredNot CoveredNot CoveredNot CoveredNot -- -------------------------none---------------- 500 per admission penalty applied to care which isnot pre-certified. If the cost of the covered medicalexpenses to Aetna is less than 500, the penaltywill not exceed the cost of the covered ----------- 500 per admission penalty applied to care which isnot pre-certified. If the cost of the covered medicalexpenses to Aetna is less than 500, the penaltywill not exceed the cost of the covered medicalexpenses.Questions: Call 1-877-409-7356 or visit us at http://www.aetnastudenthealth.com/lmu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.healthreformplanSBC.com or call 1-877-409-7356 to request a copy.500499-912071-9008683 of 3

Aetna Student Health Gold: Loyola Marymount University/Loyola Law School Coverage Period: Beginning on or after 8/1/16Summary of Benefits and Coverage: What this Plan Covers & What it CostsIf you are pregnantIf you need helprecovering or haveother special healthneedsIf your child needsdental or eye carePrenatal and postnatalcareNo ChargeDelivery and all inpatientservices20% CoinsuranceHome health care20% CoinsuranceRehabilitation services20% CoinsuranceHabilitation services20% CoinsuranceCoverage for: Student Plan Type: EPONot -- Not CoveredDuring the initial 48 or 96 hours; no precertificationis required for the mother or her newly born child.Precertification required after the 48 or 96 hours.Not -- Not CoveredRefers to Physical, Occupational & SpeechTherapies.Refers to Physical, Occupational & SpeechTherapies. 500 per admission penalty applied to care which isnot pre-certified. If the cost of the covered medicalexpenses to Aetna is less than 500, the penaltywill not exceed the cost of the covered medicalexpenses.Not CoveredNot CoveredSkilled nursing care20% CoinsuranceDurable medicalequipment20% CoinsuranceHospice service20% CoinsuranceEye examNot CoveredNot CoveredGlassesNot CoveredNot CoveredDental check-upNot CoveredNot CoveredNot CoveredNot -- 500 per admission penalty applied to care which isnot pre-certified. If the cost of the covered medicalexpenses to Aetna is less than 500, the penaltywill not exceed the cost of the covered medicalexpenses.Questions: Call 1-877-409-7356 or visit us at http://www.aetnastudenthealth.com/lmu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.healthreformplanSBC.com or call 1-877-409-7356 to request a copy.500499-912071-9008684 of 3

Aetna Student Health Gold: Loyola Marymount University/Loyola Law School Coverage Period: Beginning on or after 8/1/16Summary of Benefits and Coverage: What this Plan Covers & What it CostsCoverage for: Student Plan Type: EPOExcluded Services & Other Covered Services:Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Dental care (Adult) Hearing aids Infertility treatment, except for the diagnosisand surgical treatment of underlyingconditions. Private-duty nursing Routine foot careLong term care Weight loss programsOther Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for theseservices.) Acupuncture Bariatric surgery Chiropractic care Non-emergency care when traveling outsidethe U.S. Routine eye careQuestions: Call 1-877-409-7356 or visit us at http://www.aetnastudenthealth.com/lmu.If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossaryat www.healthreformplanSBC.com or call 1-877-409-7356 to request a copy.500499-912071-9008685 of 3