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Home study, correspondence, Internet classes, and television (TV) courses, do not fulfill the eligibility requirement that thestudent actively attend classes. If it is discovered that this eligibility requirement has not been met, our only obligation is torefund premium, less any claims paid.Exception: A Covered Person entering the armed forces of any country will not be covered under the Policy as of the date ofsuch entry. A pro rata refund of premium will be made for such person, and any covered dependents, upon written requestreceived by Aetna within 90 days of withdrawal from school.ENROLLMENTTo enroll online or obtain an enrollment form for voluntary coverage, log on to www.aetnastudenthealth.com andsearch for your school, then click on Enroll to complete the online enrollment with Aetna Student Health.Aetna Student Health reserves the right to review, at any time, your eligibility to enroll in this plan. If it is determined thatyou did not meet the school's eligibility requirements for enrollment, your participation in the plan may be rescinded inaccordance with its terms.WAIVER PROCESS/PROCEDURE FOR INTERNATIONAL STUDENTSAll international students (F-1 and J-1 visa holders) have a mandatory requirement to provide proof of healthinsurance for themselves and their dependents that must meet all of the Penn State waiver standards OR to purchasethe Penn State student health insurance plan. To be able to waive the Penn State student health insurance plan, theother policy must be effective the date of arrival into the United States or by the Penn State student health insuranceplan effective dates as reflected under the “RATES” section of this brochure. If a student, spouse,domestic partner, or dependent arrives later in the semester, their policy is to be effective the date of arrival into theUnited States and proof must be provided to the Student Health Insurance office within ten days of their arrival.If the above requirement is not met by either purchasing the Penn State student health insurance plan or by waivingthe Penn State student health insurance plan by the deadlines noted below, a hold will be placed on the student’saccount and a late fee will be applied. The late fee is 50 the first time a deadline is missed and 100 every time thedeadline is missed going forward.Waiver submissions must be submitted online through Aetna Student Health at www.aetnastudenthealth.com.*After deadline noted below, the waivers must be completed at the Student Health Insurance office and a late fee will apply.CategoryAnnual / FallWaiver Deadline DateSeptember 11, 2012Spring/SummerJanuary 22, 2013First Six Week Summer SessionMay 20, 2013Second Six Week Summer SessionJuly 3, 2013If the policy does not meet the Penn State waiver requirements, you will be required to purchase the Penn Statestudent health insurance plan at www.aetnastudenthealth.com.Waiver submissions may be audited by Pennsylvania State University, Aetna Student Health, and/or their contractors orrepresentatives. You may be required to provide, upon request, any coverage documents and/or other records demonstratingthat you meet the school's requirements for waiving the student health insurance plan.By submitting the waiver request, youagree that your current insurance plan may be contacted for confirmation that your coverage is in force for theapplicable policy year and that it meets the school's waiver requirements.7

REFUND POLICYIf you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy and thefull premium will be refunded, less any claims paid. After 31 days, you will be covered for the full period that you have paidthe premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to a coveredAccident or Sickness.)DEPENDENT COVERAGEELIGIBILITYCovered students may also enroll their lawful spouse, domestic partner, and dependent children under age 26.If, while you are covered by this plan, you have a covered dependent child who is called up for active duty (state NationalGuard or reserves) while he or she is a full time student, Aetna Student Health will extend this child’s coverage upon his orher return until you are no longer covered by this plan. This dependent coverage will be available at the first Fall or Springenrollment 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 dutyhas passed.ENROLLMENTTo enroll the dependent(s) of a covered student, please complete the Enrollment Form by either visitingwww.aetnastudenthealth.com, selecting the school name, and clicking on the “Plans & Products Offered to You” link onthe left hand side of the screen, or by calling customer service at (855) 546-5412 and requesting that an Enrollment Form besent in the mail. The Fall enrollment deadline is September 11, 2012. Dependent enrollment applications will not beaccepted after September 11, 2012, unless there is a significant life change that directly affects their insurance coverage. (Anexample of a significant life change would be loss of health coverage under another health plan.)The Spring enrollment deadline is January 22, 2013. The completed Enrollment Card, and premium, must be sent toAetna Student Health.*Graduate Assistants and Graduate Fellows: Please visit the University Health Services website for payroll breakdownsand for directions on adding dependents or declining EWBORN INFANT AND ADOPTED CHILD COVERAGEA child born to a Covered Person shall be covered for Accident, Sickness, and congenital defects, for 31 days from the dateof birth. At the end of this 31 day period, coverage will cease under the Pennsylvania State University Student HealthInsurance Plan. To extend coverage for a newborn past the 31 days, the Covered Student must: 1) enroll the child within31 days of birth, and 2) pay the additional premium, starting from the date of birth.Coverage is provided for a child legally placed for adoption with a Covered Student for 31 days from the moment ofplacement provided the child lives in the household of the Covered Student, and is dependent upon the Covered Student forsupport. To extend coverage for an adopted child past the 31 days, the Covered Student must 1) enroll the child within31 days of placement of such child, and 2) pay any additional premium, if necessary, starting from the date of placement.For information or general questions on dependent enrollment, contact Aetna Student Health at (855) 546-5412.PREFERRED PROVIDER NETWORKAetna Student Health has arranged for you to access a Preferred Provider Network in your local community. Acute carefacilities and mental health networks are also available nationally if you require hospitalization outside the immediate areaof the Pennsylvania State University campus.To maximize your savings and reduce your out-of-pocket expenses, select a Preferred Provider. It is to your advantage touse a Preferred Provider because savings may be achieved from the Negotiated Charges these providers have agreed toaccept as payment for their services. Preferred Providers are independent contractors, and are neither employees nor agentsof The Pennsylvania State University, Aetna Student Health, or Aetna.8

You may obtain information regarding Preferred Providers by contacting Aetna Student Health at (855) 546-5412, orthrough the Internet by accessing DocFind at www.aetnastudenthealth.com1.2.3.4.5.6.7.8.Click on “Enter DocFind”Select zip code, city, or countyEnter criteriaSelect Provider CategorySelect Provider TypeSelect Plan Type – Student Health PlansSelect “Start Search” or “More Options”“More Options” enter criteria and “Search”* Preferred providers are independent contractors and are neither employees nor agents of Aetna Life InsuranceCompany, Chickering Claims Administrators, Inc. or their affiliates. Neither Aetna Life Insurance Company,Chickering Claims Administrators, Inc. nor their affiliates provide medical care or treatment and they are notresponsible for outcomes. The availability of a particular provider(s) cannot be guaranteed and network composition issubject to change.REFERRAL REQUIREMENTS (Applies to students on the University Park Campus only)University Park students and spouse or domestic partner’s health care needs can best be satisfied when an organized systemof health care providers at Penn State University Health Services manages the treatment. If you do not obtain a referral fromthe University Health Services, your benefits will not be payable. A referral is not required in the following circumstances:1. Treatment is for an Emergency Medical Condition (a referral from University Health Services is necessary forfollow-up care),2. The student is more than 20 miles away from the University Health Services,3. The University Health Services is closed,4. When service is rendered at another facility during break or vacation periods,5. Medical care obtained when a student is no longer able to use University Health Services due to a change in student’sstatus,6. Maternity care and OBGYN care,7. Mental health and substance abuse treatment,8. Treatment of dental injury to a sound, natural tooth,9. Extraction of impacted wisdom teeth10. Pediatric Care11. Preventive/Routine Services (services considered preventive according to Health Care Reform and/or servicesrendered not to diagnosis or treat an Accident or Sickness).Dependent children are not eligible to use the services of the University Health Services and are therefore not subject to thereferral requirements and penalties.PRE-CERTIFICATION PROGRAMPre-certification simply means calling Aetna Student Health prior to treatment to obtain approval for a medical procedure orservice. Pre-certification may be done by you, your doctor, a hospital administrator, or one of your relatives. All requests forcertification must be obtained by contacting Aetna Student Health at (855) 546-5412(attention Managed Care Department).If you do not secure pre-certification for non emergency inpatient admissions, or provide notification for emergencyadmissions, your Covered Medical Expenses will be subject to a 200 per admit penalty.If you do not secure pre-certification for partial hospitalizations, your Covered Medical Expenses will be subject to a 200 per admit penalty. The following inpatient and outpatient services or supplies require pre-certification:9

All inpatient admissions, including length of stay, to a hospital, convalescent facility, skilled nursing facility, afacility established primarily for the treatment of substance abuse, or a residential treatment facility.All inpatient maternity care, after the initial 48/96 hours.All partial hospitalization in a hospital, residential treatment facility, or facility established primarily for the treatmentof substance abusePre-Certification does not guarantee the payment of benefits for your inpatient admission. Each claim is subject tomedical policy review, in accordance with the exclusions and limitations contained in the Policy, as well as a review ofeligibility, adherence to notification guidelines, and benefit coverage under the student Accident and Sickness Plan.Pre-Certification of Non-Emergency Inpatient Admissions, Partial Hospitalization, Identified Outpatient Servicesand Home Health Services:The patient, Physician or hospital must telephone at least three (3) business days prior to the planned admission or prior tothe date the services are scheduled to begin.Notification of Emergency Admissions:The patient, patient’s representative, Physician or hospital must telephone within two (2) business days following inpatient(or partial hospitalization) admission.DESCRIPTION OF BENEFITS*Please Note:THE PENNSYLVANIA STATE UNIVERSITY PLAN MAY NOT COVER ALL OF YOUR HEALTH CAREEXPENSES.The Plan excludes coverage for certain services and contains limitations on the amounts it will pay. Please read theThe Pennsylvania State University Plan Brochure carefully before deciding whether this Plan is right for you. Whilethis document will tell you about some of the important features of the Plan, other features may be important to youand some may further limit what the Plan will pay. If you want to look at the full Plan description, which is containedin the Master Policy issued to The Pennsylvania State University, you may view it at Student Health Insurance officeor you may contact Aetna Student Health at (855) 546-5412.Health care providers may bill you for what the Plan does not cover.Subject to the terms of the Policy, benefits are available for you and your eligible dependents only for the coverageslisted below, and only up to the maximum amounts shown. Please refer to the Policy for a complete description of thebenefits available.All insurance coverage is subject to the terms of the Master Policy and applicable state filings. Under health care reformlegislation, student health plans may be required to eliminate or modify certain existing benefit plan provisions, including,but not limited to, exclusions and limitations. Aetna reserves the right to modify its products and services in response tofederal and/or state legislation, regulation or requests of government authorities.10

*Benefit descriptions have been added to this brochure to help illustrate new Health care Reform (HCR) requirements.HCR requirements are currently being filed for support in individual states and will appear in policy contracts andcertificates of coverage once approved.SUMMARY OF BENEFITS CHARTDEDUCTIBLESThe following Deductibles are applied before Covered Medical Expenses are payable:Students: 75 per policy yearSpouse: 75 per policy yearChild: 75 per policy yearFamily: 225 per policy yearWaiver of Annual DeductibleIn compliance with Federal Health Care Reform legislation, the Annual Deductible is waived for Preferred CareCovered Medical Expenses (refer to specific benefit types for list of services) rendered as part of the followingbenefit types: Routine Physical Exam Expense (Office Visits), Pap Smear Screening Expense, MammogramExpense, Chlamydia Screening Test Expense, Routine Screening for Sexually Transmitted Disease Expense,Routine Colorectal Cancer Screening, Routine Prostate Cancer Screening Expense, Well Woman Preventive Visits(Office Visits), Screening & Counseling Services (Office Visits), Routine Cancer Screenings (Outpatient), PrenatalCare (Office Visits), Comprehensive Lactation Support and Counseling Services (Facility or Office Visits), BreastPumps & Supplies, Family Contraceptive Counseling Services (Office Visits), Female Voluntary Sterilization(Inpatient and Outpatient)The Policy Year Deductible is not applicable to the following covered expenses: Female Generic Contraceptive Devices Female Generic Contraceptive Prescription Drugs Female Over-the Counter Contraceptive MethodsCOINSURANCECovered Medical Expenses are payable at the coinsurance percentage specified below,after any applicable deductible.All coverage is based on Recognized charges unless otherwise specified.Inpatient Hospitalization BenefitsRoom and BoardExpenseCovered Medical Expenses are payable as follows:Preferred Care: 100% of the Negotiated Charge.Non-Preferred Care: 80% of the Recognized Charge for a semi-private room.Intensive CareRoom and BoardExpenseCovered Medical Expenses are payable as follows:Preferred Care: 100% of the Negotiated Charge.Non-Preferred Care: 80% of the Recognized Charge for the Intensive Care Room Rate for anovernight stay.MiscellaneousHospitalExpenseCovered Medical Expenses include, but are not limited to: laboratory tests, x-rays, surgicaldressings, anesthesia, supplies and equipment use, and medicines.Benefits are payable as follows:Preferred Care: 100% of the Negotiated Charge.Non-Preferred Care: 80% of the Recognized Charge.11

Non-SurgicalPhysiciansExpenseCovered Medical Expenses for charges for the non-surgical services of the attending Physicianor a consulting Physician are payable as follows:Preferred Ca

Aetna Student Health (855) 546-5412 For questions about: Enrollment Forms University Health Services Referrals Please contact: Penn State University Health Services - Student Health Insurance Phone: (814) 865-7467 Email: studentinsurance@sa.psu.edu For questions about: Status of Pharmacy Claim Pharmacy Claim Forms