WIXLIB

To keep your child covered, we must receive your completed enrollment information within 31 days after theadoption or placement for adoption.You must still enroll the child within 31 days of the adoption or placement for adoption even when coveragedoes not require payment of an additional premium contribution for the child.If you miss this deadline, your adopted child or child placed with you for adoption will not have health benefitsafter the first 31 days.If your coverage ends during this 31 day period, then coverage for your adopted child or child placed with youfor adoption will end on the same date as your coverage. This applies even if the 31 day period has not ended.If you need information or have general questions on dependent enrollment, call Member Services at (800)213-0579.Medicare Eligibility NoticeYou are not eligible for health coverage under this student policy if you have Medicare at the time of enrollment in thisstudent plan.If you obtain Medicare after you enrolled in this student plan, your health coverage under this plan will not end.As used here, “have Medicare” means that you are entitled to benefits under Part A (receiving free Part A) or enrolled inPart B or Premium Part A.In-network Provider NetworkAetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing In-networkProviders because Aetna has negotiated special rates with them, and because the Plan’s benefits are better.If you need care that is covered under the Plan but not available from an In-network Provider, contact Member Servicesfor assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a pre-approval foryou to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, the benefit level isthe same as for In-network Providers.PrecertificationYou need pre-approval from us for some eligible health services. Pre-approval is also called precertification.Precertification for medical services and suppliesIn-network careYour in-network physician is responsible for obtaining any necessary precertification before you get the care. If your innetwork physician doesn't get a required precertification, we won't pay the provider who gives you the care. You won'thave to pay either if your in-network physician fails to ask us for precertification. If your in-network physician requestsprecertification and we refuse it, you can still get the care but the plan won’t pay for it. You will find additional details onrequirements in the Certificate of Coverage.Out-of-network careWhen you go to an out-of-network provider, it is your responsibility to obtain precertification from us for any servicesand supplies on the precertification list. If you do not precertify, your benefits may be reduced, or the plan may not payany benefits. Refer to your schedule of benefits for this information. The list of services and supplies requiringprecertification appears later in this sectionPrecertification callGeorge Washington University 2019-2020ProprietaryPage 7

Precertification should be secured within the timeframes specified below. To obtain precertification, call MemberServices 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 requestprecertification at least 14 days before the date you are scheduled tobe admitted.An emergency admission:You, your physician or the facility must call within 48 hours or as soonas reasonably possible after you have been admitted.An urgent admission:You, your physician or the facility will need to call before you arescheduled to be admitted. An urgent admission is a hospitaladmission by a physician due to the onset of or change in an illness,the diagnosis of an illness, or an injury.Outpatient non-emergency servicesYou or your physician must call at least 14 days before the outpatientrequiring precertification:care is provided, or the treatment or procedure is scheduled.We will provide a written notification to you and your physician of the precertification decision, where required by statelaw. If your precertified services are approved, the approval is valid for 30 days as long as you remain enrolled in theplan.If you require an extension to the services that have been precertified, you, your physician, or the facility will need tocall us at the number on your ID card as soon as reasonably possible, but no later than the final authorized day.If precertification determines that the stay or outpatient services and supplies are not covered benefits, the notificationwill explain why and how you can appeal our decision. You or your provider may request a review of the precertificationdecision. See the When you disagree - claim decisions and appeals procedures section of Certificate of Coverage.What if you don’t obtain the required precertification?If you don’t obtain the required precertification: Your benefits may be reduced, or the plan may not pay any benefits. See the schedule of benefitsPrecertification 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 limitsGeorge Washington University 2019-2020ProprietaryPage 8

What types of services and supplies require precertification?Precertification is required for the following types of services and supplies:Inpatient services and suppliesOutpatient services and suppliesART servicesApplied behavior analysisObesity (bariatric) surgeryCertain prescription drugs and devices*Stays in a hospice facilityComplex imagingStays in a hospitalComprehensive infertility servicesStays in a rehabilitation facilityCosmetic and reconstructive surgeryStays in a residential treatment facility for treatmentEmergency transportation by airplaneof mental disorders and substance abuseStays in a skilled nursing facilityHome health careHospice servicesIntensive outpatient program (IOP) – mental disorder andsubstance abuse diagnosesKidney dialysisKnee surgeryMedical injectable drugs, (immunoglobulins, growthhormones, multiple sclerosis medications, osteoporosismedications, botox, hepatitis C medications)*Outpatient back surgery not performed in a physician’sofficePartial hospitalization treatment – mental disorder andsubstance abuse diagnosesPrivate duty nursing servicesPsychological testing/neuropsychological testingSleep studiesTranscranial magnetic stimulation (TMS)Wrist surgery*For a current listing of the prescription drugs and medical injectable drugs that require precertification, contact MemberServices by calling the toll-free number on your ID card in the How to contact us for help section or by logging onto theAetna 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 otherplan(s) to decide how much each plan pays. This is called coordination of benefits (COB).Here’s how COB works When this is the primary plan, we will pay your medical claims first as if the other plan does not exist When this is the secondary plan, we will pay benefits after the primary plan and will reduce the payment basedon any amount the primary plan paid We will never pay an amount that, together with payments from your other coverage, add up to more than100% of the allowable submitted expensesGeorge Washington University 2019-2020ProprietaryPage 9

For more information about the Coordination of Benefits provision, including determining which plan is primary andwhich is secondary, you may call the Member Services telephone number shown on your ID card. A completedescription of the Coordination of Benefits provision is contained in the Policy issued to George Washington Universityand may be viewed online at www.aetnastudenthealth.com.Description of BenefitsThe Plan excludes coverage for certain services (referred to as exceptions in the certificate of coverage) and haslimitations on the amounts it will pay. While this Plan Design and Benefit Summary document will tell you about some ofthe important features of the Plan, other features may be important to you and some may further limit what the Planwill pay. To look at the full Plan description, which is contained in the Certificate of Coverage issued to you, go towww.aetnastudenthealth.com. If any discrepancy exists between this Benefit Summary and the Certificate ofCoverage, the Certificate will control.How your plan works while you are covered for in-network coverageYour in-network coverage helps you: Get and pay for a lot of – but not all – health care services Pay less cost share when you use an in-network providerThis Plan will pay benefits in accordance with any applicable District of Columbia Law(s).Metallic Level: Gold Tested at 82.79%Policy year deductibleIn-network coverageOut-of-network coverageYou have to meet your policy year deductible before this plan pays for benefits. The policy year deductible will not beapplied until this plan has paid 10,000 in covered benefits. After that, you have to meet your policy year deductiblebefore this plan pays for additional benefits.StudentSpouseEach childFamily 300 per policy year 300 per policy year 300 per policy yearNone 3,000 per policy year 3,000 per policy year 3,000 per policy yearNonePRESCRIBED MEDICINES EXPENSEStudentSpouseEach child 100 per policy year 100 per policy year 100 per policy yearGeorge Washington University 2019-2020ProprietaryPage 10

Policy year deductible waiverThe policy year deductible is waived for all of the following eligible health services: In-network care for Preventive care and wellness Pap Smear Screening Expense; and Mammogram Expense.In addition to state and federal requirements for waiver of the policy year deductible, the plan will waive the policy yeardeductible for: Preferred Care Laboratory and X-Ray Expense;Preferred Care Allergy Testing Expense;Preferred Care Diagnostic Testing For Learning Disabilities Expense; Preferred Care Maternity Expense;Preferred Care Gynecology;Preferred Care Outpatient Treatment of Mental Health;Preferred Care Pediatric Preventive Dental; andPreferred and Non-Preferred Care Pediatric Vision Services.Per visit or admission Deductibles do not apply towards satisfying the Policy Year Deductible. This Policy YearDeductible and the Prescribed Medicine Expense Deductible do not apply towards satisfying each other.Maximum out-of-pocket limitsMaximum out-of-pocket limit per policy yearStudentSpouseEach childFamily 6,350 per policy year 6,350 per policy year 6,350 per policy year 12,700 per policy year 15,000 per policy year 15,000 per policy year 15,000 per policy year 30,000 per policy yearPrecertification covered benefit penaltyThis only applies to out-of-network coverage: The certificate of coverage contains a complete description of theprecertification program. You will find details on precertification requirements in the Medical necessity andprecertification requirements section.Failure to precertify your eligible health services when required will result in the following benefit penalties:- A 500 benefit penalty will be applied separately to each type of eligible health services.The additional percentage or dollar amount of the recognized charge which you may pay as a penalty for failure toobtain precertification is not a covered benefit and will not be applied to the policy year deductible amount or themaximum out-of-pocket limit, if any.The coinsurance listed in the schedule of benefits below reflects the plan coinsurance percentage. This is the coinsuranceamount that the plan pays. You are responsible for paying any remaining coinsurance.George Washington University 2019-2020ProprietaryPage 11

Eligible health services In-network coveragePreventive care and wellnessRoutine physical examsOut-of-network coveragePerformed at a physician’soffice100% (of the negotiated charge) per visit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesCovered persons through age21: Maximum age and visitlimits per policy yearSubject to any age and visit limits provided for in the comprehensive guidelinessupported by the American Academy of Pediatrics/Bright Futures//Health Resourcesand Services Administration guidelines for children and adolescents.For details, contact your physician or Member Services by logging onto your Aetnasecure website at www.aetnastudenthealth.com or calling the toll-free number onyour ID card.Covered persons age 22 andover: Maximum visits perpolicy year1 visitPreventive care immunizationsPerformed in a facility or at aphysician's officeMaximums100% (of the negotiated charge) pervisit.60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesSubject to any age limits provided for in the comprehensive guidelines supported byAdvisory Committee on Immunization Practices of the Centers for Disease Controland PreventionFor details, contact your physician or Member Services by logging onto your Aetnasecure website at www.aetnastudenthealth.com or calling the toll-free number onyour ID card.Well woman preventive visitsRoutine gynecological exams (including Pap smears and cytology tests)Performed at a physician’s,obstetrician (OB),gynecologist (GYN) orOB/GYN office100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesMaximumsSubject to any age limits provided for in the comprehensive guidelines supported bythe Health Resources and Services Administration.1 visitMaximum visits per policyyearGeorge Washington University 2019-2020ProprietaryPage 12

Eligible health services In-network coveragePreventive screening and counseling servicesOut-of-network coverageObesity and/or healthy dietcounseling office visits100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesMaximum visits per policyyear (This maximum appliesonly to covered persons age22 and older.)26 visits (however, of these only 10 visits will be allowed under the plan for healthydiet counseling provided in connection with Hyperlipidemia (high cholesterol) andother known risk factors for cardiovascular and diet-related chronic disease)Misuse of alcohol and/ordrugs counseling office visits100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesMaximum visits per policyyearUse of tobacco productscounseling office visitsMaximum visits per policyyearDepression screeningcounseling office visitsMaximum visits per policyyearSexually transmitted infectioncounseling office visitsMaximum visits per policyyearGenetic risk counseling forbreast and ovarian cancercounseling office visits5 visits100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible applies8 visits100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible applies1 visit100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible applies2 visits100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesAge limitationsGeorge Washington University 2019-2020ProprietaryNot subject to any age limitationsPage 13

Eligible health services In-network coverageOut-of-network coverageRoutine cancer screenings performed at a physician’s office, specialist’s office or facility.Routine cancer screeningsDeductible does not apply toroutine mammographyMaximums100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesSubject to any age; family history; and frequency guidelines as set forth in the mostcurrent: Evidence-based items that have in effect a rating of A or B in the currentrecommendations of the United States Preventive Services Task Force; and The comprehensive guidelines supported by the Health Resources and ServicesAdministration.For details, contact your physician or Member Services by logging onto your Aetnasecure website at www.aetnastudenthealth.com or calling the toll-free number onyour ID card.1 screening every 12 months*Lung cancer screeningmaximums*Important note: Any lung cancer screenings that exceed the lung cancer screening maximum above are coveredunder the Outpatient diagnostic testing section.Prenatal care services (provided by a physician, an obstetrician (OB), gynecologist (GYN),and/or OB/GYN)Preventive care services only100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesImportant note: You should review the Maternity care and Well newborn nursery care sections. They will give youmore information on coverage levels for maternity care under this plan.Comprehensive lactation support and counseling servicesLactation counseling services facility or office visits100% (of the negotiated charge) pervisitDeductible does not apply60% (of the recognized charge) per visitPolicy year deductible applies6 visitsLactation counseling servicesmaximum visits per policyyear either in a group orindividual settingImportant note: Any visits that exceed the lactation counseling services maximum are covered under the Physiciansand other health professionals’ section.Breast feeding durable100% (of the negotiated charge) per60% (of the recognized charge) per visititemmedical equipment: Breastpump supplies andaccessoriesDeductible does not applyPolicy year deductible appliesImportant note: See the Breast feeding durable medical equipment section of the certificate of coverage forlimitations on breast pump and supplies.George Washington University 2019-2020ProprietaryPage 14

Eligible health services In-network coverageFamily planning services – female contraceptivesOut-of-network coverageFemale contraceptivecounseling servicesoffice visit100% (of the negotiated charge) pervisit60% (of the recognized charge) per visitDeductible does not applyPolicy year deductible appliesContraceptive counseling2 visitsservices maximum visits perpolicy ye

Aetna Student Health. Important note regarding coverage for a newborn infant or newly adopted child: Your newborn child is covered on your health plan for the first 31 days from the moment of birth. To keep your newborn covered, you must notify us (or our agent) of the birth and pay any required premium .