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DEDUCTIBLEThe policy year deductible is waived for Preferred Care coveredmedical expenses that apply to: Preventive Care Expense benefits Outpatient Labs, Outpatient X-rays and Outpatient High CostProceduresPreferred CareIndividual: 250 per Policy YearNon-Preferred CareIndividual: 1,000 per PolicyYearPharmacy Deductible: 125 per Policy YearIn addition to state and federal requirements for waiver of the policyyear deductible, the plan will waive the policy year deductible for: Ambulance Expenses Emergency Room Expenses Services illustrated with a Copay (Additional services providedduring the course of these services, will be subject to the annualdeductible, i.e. surgical procedures etc.)Per visit or admission Copays/Deductibles do not apply towardssatisfying the Policy Year Deductible. This Policy Year Deductible andthe Prescribed Medicine Expense Deductible do not apply towardssatisfying each other.*Annual Deductible does not apply to these services.COINSURANCECoinsurance is both the percentage of covered medical expensesthat the plan pays, and the percentage of covered medical expensesthat you pay. The percentage that the plan pays is referred to as“plan coinsurance” or the “payment percentage,” and varies by thetype of expense. Please refer to the Schedule of Benefits for specificinformation on coinsurance amounts.OUT-OF-POCKET MAXIMUMSOnce the Individual Out-of-Pocket Limit has been satisfied, CoveredMedical Expenses will be payable at 100% for the remainder of thePolicy Year.Covered Medical Expenses are payable at theplan coinsurance percentage specified below,after any applicable Deductible.Individual Out-ofPocket: 1,500 per Policy YearIndividual Out-ofPocket: 3,000 per PolicyYearThe following expenses do not apply toward meeting the plan’spreferred care and non-preferred care out-of-pocket limits: Non-covered medical expenses; Referral penalties because a required referral for the service(s)or supply was not obtained; and Expenses that are not paid or pre-certification benefit reductionsor penalties because a required pre-certification for theservice(s) or supply was not obtained from Aetna.REFERRAL REQUIREMENTSIf a referral is not obtained from the UA Campus Health Service for medical or mental health services in thecommunity, benefits will be paid at the Non-Preferred Care level of benefits. A referral from the UA Campus HealthService is not necessary for the following: Treatment is for an Emergency Medical Condition (all follow-up treatment must be obtained through UA CampusHealth Services) Urgent Care Expenses Maternity Care Obstetric and Gynecological Treatment Annual Eye ExamUniversity of Arizona 2017-2018Page 8

Injury to Sound Natural teethPreventive/Routine Services (services considered preventive according to United States Preventive Services TaskForce, American Academy of Pediatrics/Bright Futures Guidelines for Children and Adolescents, Health Resourcesand Services Administration and/or services rendered not to diagnosis or treat an Accident or Sickness) Pediatric Care VasectomiesINPATIENT HOSPITALIZATION BENEFITSPreferred CareNon-Preferred CareRoom and Board Expense80% of the Negotiated 50% of theThe covered room and board expense does not include any charge in ChargeRecognized Chargeexcess of the daily room and board maximum.for a semi-privateroomIntensive Care80% of the Negotiated 50% of theThe covered room and board expense does not include any charge in ChargeRecognized Chargeexcess of the daily room and board maximum.Miscellaneous Hospital Expense80% of the Negotiated 50% of theIncludes but not limited to: operating room, laboratory tests/X rays, ChargeRecognized Chargeoxygen tent, drugs, medicines and dressings.Licensed Nurse Expense80% of the Negotiated 50% of theIncludes charges incurred by a covered person who is confined in aChargeRecognized Chargehospital as a resident bed patient and requires the services of aregistered nurse or licensed practical nurse.Well Newborn Nursery Care80% of the Negotiated 50% of theCharge*Recognized ChargeNon-Surgical Physicians Expense80% of the Negotiated 50% of theIncludes hospital charges incurred by a covered person who isChargeRecognized Chargeconfined as an inpatient in a hospital for a surgical procedure for theservices of a physician who is not the physician who may haveperformed surgery on the covered person.SURGICAL EXPENSESPreferred CareNon-Preferred CareSurgical Expense (Inpatient and Outpatient)80% of the Negotiated 50% of theWhen injury or sickness requires two or more surgical proceduresChargeRecognized Chargewhich are performed through the same approach, and at the sametime or immediate succession, covered medical expenses onlyinclude expenses incurred for the most expensive procedure.Anesthesia Expense (Inpatient and Outpatient)80% of the Negotiated 50% of theIf, in connection with such operation, the covered person requiresChargeRecognized Chargethe services of an anesthetist who is not employed or retained bythe hospital in which the operation is performed, the expensesincurred will be Covered Medical Expenses.Assistant Surgeon Expense (Inpatient and Outpatient)80% of the Negotiated 50% of theChargeRecognized ChargeOUTPATIENT EXPENSEPreferred CareNon-Preferred CarePhysician or Specialist Office Visit ExpenseAfter a 25 Copay per 50% of theIncludes the charges made by the physician or specialist if a covered visit, 100% of theRecognized Chargeperson requires the services of a physician or specialist in theNegotiated Charge*physician’s or specialist’s office while not confined as an inpatient ina hospital.University of Arizona 2017-2018Page 9

Laboratory and X-ray ExpenseHospital Outpatient Department ExpenseTherapy ExpenseCovered medical expenses include charges incurred by a coveredperson for the following types of therapy provided on an outpatientbasis: Radiation therapy; Inhalation therapy; Chemotherapy, including anti-nausea drugs used in conjunctionwith the chemotherapy; Kidney dialysis; and Respiratory therapy.Pre-Admission Testing ExpenseIncludes charges incurred by a covered person for pre-admissiontesting charges made by a hospital, surgery center, licenseddiagnostic lab facility, or physician, in its own behalf, to test a personwhile an outpatient before scheduled surgery.Ambulatory Surgical ExpenseCovered medical expenses include expenses incurred by a coveredperson for outpatient surgery performed in an ambulatory surgicalcenter. Covered medical expenses must be incurred on the day ofthe surgery or within 24 hours after the surgery.Walk-in Clinic Visit ExpenseUniversity of Arizona 2017-2018100% of theNegotiated Charge*100% of theNegotiated Charge*80% of the NegotiatedCharge50% of theRecognized Charge50% of theRecognized Charge50% of theRecognized ChargePayable in accordancewith the type ofexpense incurred andthe place whereservice is provided.80% of the NegotiatedCharge50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized Charge50% of theRecognized ChargePage 10

Emergency Room ExpenseCovered medical expenses incurred by a covered person for servicesreceived in the emergency room of a hospital while the coveredperson is not a full-time inpatient of the hospital. The treatmentreceived must be emergency care for an emergency medicalcondition. There is no coverage for elective treatment, routine careor care for a non-emergency sickness. As to emergency careincurred for the treatment of an emergency medical condition orpsychiatric condition, any referral requirement will not apply & anyexpenses incurred for non-preferred care will be paid at the samecost-sharing level as if they had been incurred for preferred care.After a 200 Copayper visit (waived ifadmitted), 100% ofthe NegotiatedCharge*After a 200Deductible per visit(waived if admitted),100% of the ActualCharge*Prior Authorization is not required for an initial medical screeningexam and any immediately necessary stabilizing treatment, but maybe required for services arising after the initial screening and/ornecessary stabilizing treatment.Important Notice:A separate hospital emergency room visit benefit deductible orcopay applies for each visit to an emergency room for emergencycare. If a covered person is admitted to a hospital as an inpatientimmediately following a visit to an emergency room, the emergencyroom visit benefit deductible or copay is waived.Covered medical expenses that are applied to the emergency roomvisit benefit deductible or copay cannot be applied to any otherbenefit deductible or copay under the plan. Likewise, coveredmedical expenses that are applied to any of the plan’s other benefitdeductibles or copays cannot be applied to the emergency roomvisit benefit deductible or copay.Separate benefit deductibles or copays may apply for certainservices rendered in the emergency room that are not included inthe hospital emergency room visit benefit. These benefit deductiblesor copays may be different from the hospital emergency room visitbenefit deductible or copay, and will be based on the specific servicerendered.Similarly, services rendered in the emergency room that are notincluded in the hospital emergency room visit benefit may be subjectto coinsurance.Important Note: Please note that Non-Preferred Care Providers donot have a contract with Aetna; the provider may not acceptpayment of your cost share (your deductible and coinsurance) aspayment in full. You may receive a bill for the difference betweenthe amount billed by the provider and the amount paid by this Plan.If the provider bills you for an amount above your cost share, youare not responsible for paying that amount. Please send Aetna thebill at the address listed on the back of your member ID card andAetna will resolve any payment dispute with the provider over thatamount. Make sure your member ID number is on the bill.University of Arizona 2017-2018Page 11

Durable Medical and Surgical Equipment Expense80% of the Negotiated 50% of theDurable medical and surgical equipment would include:ChargeRecognized Charge Artificial arms and legs; including accessories; Arm, back, neck braces, leg braces; including attached shoes (butnot corrective shoes); Surgical supports; Scalp hair prostheses required as the result of hair loss due toinjury; sickness; or treatment of sickness; and Head halters.PREVENTIVE CARE EXPENSESPreventive Care is services provided for a reason other than to diagnose or treat a suspected or identified sickness orinjury and rendered in accordance with the guidelines provided by the following agencies: Evidence-based items that have in effect a rating of A or B in the current recommendations of the United StatesPreventive Services Task Force uspreventiveservicestaskforce.org. Services as recommended in the American Academy of Pediatrics/Bright Futures Guidelines for Children andAdolescents http://brightfutures.aap.org/. For females, screenings and counseling services as provided for in the comprehensive guidelines recommended bythe Health Resources and Services Administration http://www.hrsa.gov/index.html.PREVENTIVE CARE EXPENSESRoutine Physical ExamIncludes routine vision & hearing screenings given as part of theroutine physical exam.Preventive Care ImmunizationsPreferred Care100% of theNegotiated Charge*Non-Preferred Care50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized ChargeWell Woman Preventive VisitsRoutine well woman preventive exam office visit, including Papsmears.Preventive Care Screening and Counseling Services for SexuallyTransmitted InfectionsIncludes the counseling services to help a covered person prevent orreduce sexually transmitted infections.Preventive Care Screening and Counseling Services for Obesityand/or Healthy DietScreening and counseling services to aid in weight reduction due toobesity. Coverage includes: Preventive counseling visits and/or risk factor reductionintervention; Nutritional counseling; and Healthy diet counseling visits provided in connection withHyperlipidemia (high cholesterol) and other known risk factorsfor cardiovascular and diet-related chronic disease.Preventive Care Screening and Counseling Services for Misuse ofAlcohol and/or DrugsScreening and counseling services to aid in the prevention orreduction of the use of an alcohol agent or controlled substance.Coverage includes preventive counseling visits, risk factor reductionintervention and a structured assessment.100% of theNegotiated Charge*50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized ChargeUniversity of Arizona 2017-2018Page 12

Preventive Care Screening and Counseling Services for Use ofTobacco ProductsScreening and counseling services to aid a covered person to stopthe use of tobacco products.Coverage includes: Preventive counseling visits; Treatment visits; and Class visits; to aid a covered person to stop the use of tobaccoproducts.100% of theNegotiated Charge*50% of theRecognized ChargePreventive Care Screening and Counseling Services for Use ofTobacco Products (continued)100% of theNegotiated Charge*50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized ChargeTobacco product means a substance containing tobacco or nicotineincluding: Cigarettes; Cigars Smoking tobacco; Snuff; Smokeless tobacco; and Candy-like products that contain tobacco.Preventive Care Screening and Counseling Services for DepressionScreeningScreening or test to determine if depression is present.Preventive Care Routine Cancer ScreeningsCovered expenses include but are not limited to: Pap smears;Mammograms; Fecal occult blood tests; Digital rectal exams;Prostate specific antigen (PSA) tests; Sigmoidoscopies; Doublecontrast barium enemas (DCBE); Colonoscopies.Includes:- Bowel preparation medications- Anesthesia- Removal of polyps performed during a screening procedure- Pathology exam on any removed polyps); and Lung cancerscreenings.Preventive Care Screening and Counseling Services for Genetic Riskfor Breast and Ovarian CancerCovered medical expenses include the counseling and evaluationservices to help assess a covered person’s risk of breast and ovariancancer susceptibility.University of Arizona 2017-2018Page 13

Preventive Care Prenatal CareCoverage for prenatal care under this Preventive Care Expensebenefit is limited to pregnancy-related physician office visitsincluding the initial and subsequent history and physical exams ofthe pregnant woman (maternal weight, blood pressure, fetal heartrate check, and fundal height).Refer to the Maternity Expense benefit for more information oncoverage for maternity expenses under the Policy, including otherprenatal care, delivery and postnatal care office visits.Preventive Care Lactation Counseling ServicesLactation support and lactation counseling services are coveredmedical expenses when provided in either a group or individualsetting.Preventive Care Breast Pumps and SuppliesPreventive Care Female Contraceptive Counseling Services,Preventive Care Female Contraceptive Generic, Brand Name,Biosimilar Prescription Drugs and Devices provided, administered,or removed, by a Physician during an Office Visit, Preventive CareFemale Voluntary Sterilization (Inpatient), Preventive Care FemaleVoluntary Sterilization (Outpatient)100% of theNegotiated Charge*50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized Charge100% of theNegotiated Charge*100% of theNegotiated Charge*50% of theRecognized Charge50% of theRecognized Charge100% of theNegotiated Charge*50% of theRecognized ChargeIncludes counseling services on contraceptive methods provided bya physician, obstetrician or gynecologist. Such counseling servicesare covered medical expenses when provided in either a group orindividual setting.Voluntary SterilizationIncludes charges billed separately by the provider for femalevoluntary sterilization procedures & related services & suppliesincluding, but not limited to, tubal ligation and sterilization implants.Covered medical expenses under this benefit would not includecharges for a voluntary sterilization procedure to the extent that theprocedure was not billed separately by the provider or because itwas not the primary purpose of a confinement.Preventive Care Female Contraceptive Counseling Services,Preventive Care Female Contraceptive Generic, Brand Name,Biosimilar Prescription Drugs and Devices provided, administered,or removed, by a Physician during an Office Visit, Preventive CareFemale Voluntary Sterilization (Inpatient), Preventive Care FemaleVoluntary Sterilization (Outpatient) (continued)Contraceptives can be paid either under this benefit or theprescribed medicines expense depending on the type of expenseand how and where the expense is incurred. Benefits are paid underthis benefit for female contraceptive prescription drugs and devices(including any related services and supplies) when they are provided,administered, or removed, by a physician during an office visit.University of Arizona 2017-2018Page 14

OTHER FAMILY PLANNING SERVICES EXPENSEVoluntary Sterilization for Males (Outpatient)Covered medical expenses include charges for certain familyplanning services, even though not provided to treat a sickness orinjury as follows. -Voluntary sterilization for males.Preferred CarePayable in accordancewith the type ofexpense incurred andthe place whereservice is provided.AMBULANCE EXPENSEGround, Air, Water and Non-Emergency AmbulanceIncludes charges incurred by a covered person for the use of aprofessional ambulance in an emergency. Covered medicalexpenses for the service are limited to charges for groundtransportation to the nearest hospital equipped to render treatmentfor the condition. Air transportation is covered only when medicallynecessary.ADDITIONAL BENEFITSAllergy Testing and Treatment ExpenseIncludes charges incurred by a covered person for diagnostic testingand treatment of allergies and immunology services.Preferred Car

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