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Aetna Student Health

Plan Design and Benefits Summary
OA Elect Choice EPO

University of San Francisco

Policy Year: 2021–2022
Policy Number: 474887
www.aetnastudenthealth.com
(877) 480-4161

Disclaimer: These rates and benefits are pending approval by the California Department of Insurance and can change.
If they change, we will update this information.
This is a brief description of the Student Health Plan. The plan is available for University of San Francisco students. The
plan is insured by Aetna Life Insurance Company (Aetna). The exact provisions, including definitions, governing this
insurance are contained in the Certificate issued to you and may be viewed online at www.aetnastudenthealth.com. If
there is a difference between this Plan Summary and the Certificate, the Certificate will control.

Your Benefits Travel with You

Aetna Student Health offers Aetna’s broad network of In-network Providers. With over 1 million network providers
nationwide, our plans go where you go. Your Plan covers services by in-network providers in your Service Area which
means wherever you are located at the time services are needed. Visit DocFind to find those providers in your Plan’s
network.

If you are traveling abroad and need travel immunizations, most are covered under the Medical Plan Benefit. If you need
medical services while abroad, you will need to pay out of pocket and submit for a reimbursement. Fill out the claim form
located on the Aetna USF website and your claim will be reviewed and processed according to the benefits of the Plan.

Even Better Access to Care at Dignity Health Medical Group (DHMG)

Health services are provided to USF students through a contractual agreement with Dignity Health Medical Foundation.
Students can call or go online to schedule an appointment at Dignity Health Medical Group (DHMG) clinics. Plan to arrive
20 minutes prior to your scheduled appointment time or your appointment may be rescheduled.

DHMG will not charge current students the co-payment for consultations with a primary care physician. Although there is
no cost to students for the office visit at the DHMG clinics located at St Mary’s Office, Oracle Park Care Center and
Stonestown; the student’s health insurance will be billed for the office visit.

Deductible vs. Copay: What’s the difference?

The USF student health insurance Plan has a deductible of $200 per policy year for In-network coverage, but also has
copays for certain services. This deductible is the amount you pay each policy year for most eligible medical services or
medications before the Plan begins to share in the cost of covered services. A copay is something a bit different. It is a
flat fee that you pay on the spot each time you go to, for example, a physician’s office visit. Both copays and payments
towards your deductible count towards the out-of-pocket maximum of the Plan.

This Plan has certain services where a deductible does not apply. Covered care for Preventive care services, Physician
office visits including specialists, Walk-in clinics and Urgent Care visits, Mental Health and Substance Abuse Outpatient
services and Outpatient Prescription Drugs all waive the deductible.

See the Description of Benefits on page 5 for more information about the Policy year deductible waiver and where
copays apply. If you have any questions on what goes towards the deductible or what a copay is for a certain benefit,
please contact Aetna Student Health at (877) 480-4161.

Free Telemedicine Services Through Teladoc: Aetna’s Preferred Vendor

The USF student health insurance plan offers medical, behavioral health and dermatology telemedicine visits at 100%
coverage, no cost share to USF students on the student health insurance plan. To learn more about these benefits,
please visit the USF Aetna Student Health website here.

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Coverage Periods
Students: Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below, and will terminate at
11:59 PM on the Coverage End Date indicated.

Coverage Period Coverage Start Date Coverage End Date Enrollment/Waiver Deadline
Annual 08/01/2021 07/31/2022 09/01/2021
Fall 08/01/2021 12/31/2021 09/01/2021
Spring/Summer 01/01/2022 07/31/2022 02/01/2022
Summer (only available for
students who start in the 05/01/2022 07/31/2022 05/31/2022
summer semester)

Rates

The rates below reflect premiums for the Plan underwritten by Aetna Health and Life Insurance Company (Aetna), as
well as a University of San Francisco administrative fee.

Undergraduates and Graduate Students

Annual Fall Semester Spring/Summer Semester Summer

Student $3,480 $1,459 $2,021 $877

Student Coverage
Required Enrollment for USF Students

The University of San Francisco automatically bills and enrolls the following students in the USF‐sponsored student
health insurance plan unless proof of comparable coverage is provided by the appropriate deadline.

• All domestic undergraduate students registered for 9 credit hours or more (excluding students in certificate
programs or online programs).
• All domestic graduate students registered for 6 credit hours or more (excluding students in certificate programs
or online programs).
• All international students and scholars registered for at least 1 credit hour or more.

International students, visiting scholars, or other students with a current passport or student visa (e.g., F‐1, J‐1, B‐1/B‐2
visa) who are temporarily located outside their home country and have not been granted permanent residency status
while engaged in educational activities through their University are required to be insured under the USF insurance
policy unless proof of comparable coverage is provided.

Students not automatically billed and enrolled in the USF sponsored student health insurance plan but who are actively
registered in 3 or more credit hours at USF are eligible to voluntarily purchase the plan.

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Students Eligible to Enroll on a Voluntary Basis

All students registered for at least 3 credit hours are eligible to voluntarily enroll in the plan for up to 1 year. Students on
an official medical or academic leave of absence are eligible to voluntarily enroll in the plan for up to 1 year.

Optional Practical Training (OPT) students may voluntarily enroll in the plan for up to 1 year. Students must actively attend
classes for at least the first 31 days after the date for which coverage is purchased.

Independent study and Internet classes may not fulfill the eligibility requirement that the Covered Student actively attends
classes. If eligibility requirements are not met, Aetna’s only obligation is to refund the premium. Once the refund is issued
the student is no longer covered under the plan.

To voluntarily purchase coverage please contact Health Promotion Services at (415) 422‐5797.

Voluntary enrollment will not be accepted after the enrollment deadline unless there is a significant life changing event
that directly affects insurance coverage. (An example of a significant life changing event would be loss of health insurance
coverage under another plan). Students should contact Health Promotion Services immediately at (415) 422‐5797 for
assistance.

Exceptions

A Covered Person entering the armed forces of any country will not be covered under the policy as of the date of such
entry. A pro-rated refund of premium will be made for such person, upon written request received by Aetna within 90
days of withdrawal from school.

If you withdraw from school within the first 31 days of a coverage period, you will not be covered under the Policy and
the full premium will be refunded, less any claims paid. After 31 days, you will be covered for the full period that you
have paid the premium for, and no refund will be allowed. (This refund policy will not apply if you withdraw due to a
covered Accident or Sickness.)

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.

Service area
Your plan generally pays for eligible health services only within a specific geographic area, called a service area. There
are some exceptions, such as for emergency services, urgent care and transplants.

Precertification
You do not need to obtain pre-certification for any services. However, your provider is required to obtain pre-
certification for certain Preferred Care services. Refer to the Precertification provisions in the Coverage section of the
Certificate of Coverage for a complete description of the precertification programs including the types of services,
treatments, procedures, visits or supplies that require precertification. No penalty will be applied to you for a Preferred
Care service that was not pre-certified.

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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.

This Plan will pay benefits in accordance with any applicable California Insurance Law(s).

In-network coverage Out-of-network coverage

Policy year deductibles
Student $200 per policy year N/A
Policy year deductible waiver
The policy year deductible is waived for all of the following eligible health services:
• In-Network Care for Preventive care and wellness, Pediatric Dental Care Services, Well Newborn Nursery Care,
Pediatric Vision Care Services and Supplies, and Outpatient Prescription Drugs
Maximum out-of-pocket limits
In-network coverage Out-of-network coverage
Student $8,150 per policy year N/A

Eligible health services In-network coverage Out-of-network coverage

Routine physical exams
Performed at a physician’s office 100% (of the negotiated charge) per Not Covered
visit

No copayment or policy year

deductible applies
Maximum age and visit limits per Subject to any age and visit limits provided for in the comprehensive guidelines
policy year through age 21 supported by the American Academy of Pediatrics/Bright Futures//Health
Resources and Services Administration guidelines for children and adolescents.
Covered persons age 22 and over: 1 visit
Maximum visits per policy year
Preventive care immunizations
Performed in a facility or at a 100% (of the negotiated charge) per Not Covered
physician's office visit

No copayment or 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
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 Eligible health services In-network coverage Out-of-network coverage
Routine gynecological exams (including Pap smears and cytology tests)
Performed at a physician’s, 100% (of the negotiated charge) per Not Covered
obstetrician (OB), gynecologist visit
(GYN) or OB/GYN office
No copayment or policy year
deductible applies
Maximum visits per policy year 1 visit
Preventive screening and counseling services
Preventive screening and 100% (of the negotiated charge) per Not Covered
counseling services for Obesity visit
and/or healthy diet counseling,
Misuse of alcohol & drugs, No copayment or policy year
Tobacco Products, Depression deductible applies
Screening, Sexually transmitted
infection counseling & Genetic risk
counseling for breast and
ovarian cancer
Stress management counseling 100% (of the negotiated charge) per Not Covered
office visits visit

No copayment or policy year

deductible applies
Chronic condition counseling office 100% (of the negotiated charge) per Not Covered
visits visit

No copayment or policy year

deductible applies
Routine cancer screenings 100% (of the negotiated charge) per Not Covered
visit

No copayment or policy 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*

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 Eligible health services In-network coverage Out-of-network coverage
Prenatal care services -Preventive 100% (of the negotiated charge) per Not Covered
care services only (includes visit
participation in the California
Prenatal Screening Program) No copayment or policy year
deductible applies
Lactation support and counseling 100% (of the negotiated charge) per Not Covered
services visit

No copayment or policy year

deductible applies
Breast pump supplies and 100% (of the negotiated charge) per Not Covered
accessories item

No copayment or policy year

deductible applies
Family planning services – female contraceptives
Female contraceptive counseling 100% (of the negotiated charge) per Not Covered
services visit
office visit
No copayment or policy year
deductible applies
Female contraceptive generic 100% (of the negotiated charge) per Not Covered
prescription drugs and devices item
provided, administered, or
removed, by a provider during an No copayment or policy year
office visit deductible applies

For each 30 day supply or 12

month supply
Female Voluntary sterilization- 100% (of the negotiated charge) Not Covered
Inpatient & Outpatient provider
services No copayment or policy 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
• Male contraceptive methods, sterilization procedures or devices

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 Eligible health services In-network coverage Out-of-network coverage
Physicians and other health professionals
Physician, specialist including $20 copayment then the plan pays Not Covered
Consultants Office visits (non- 100% (of the balance of the
surgical/non-preventive care by a negotiated charge) per visit
physician and specialist) (includes
telemedicine consultations)
Allergy testing and treatment
Allergy testing & Allergy injections Covered according to the type of Not Covered
treatment including Allergy sera benefit and the place where the
and extracts administered via service is received.
injection performed at a physician’s
or specialist’s office
Physician and specialist surgical services
Inpatient surgery performed during 80% (of the negotiated charge) Not Covered
your stay in a hospital or birthing
center by a surgeon
(includes 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
Outpatient surgery performed at a 80% (of the negotiated charge) per Not Covered
physician’s or specialist’s office or visit
outpatient department of a
hospital or surgery center by a
surgeon (includes 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
Alternatives to physician office visits
Walk-in clinic visits $50 copayment then the plan pays Not Covered
(non-emergency visit) 100% (of the balance of the
negotiated charge) per visit

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 Eligible health services In-network coverage Out-of-network coverage
Hospital and other facility care
Inpatient hospital (room and 80% (of the negotiated charge) per Not Covered
board) and other admission
miscellaneous services and
supplies)

Includes birthing center facility

charges
In-hospital non-surgical physician 80% (of the negotiated charge) per Not Covered
services visit
Alternatives to hospital stays
Outpatient surgery (facility 80% (of the negotiated charge) per Not Covered
charges) performed in the 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
Home health Care 80% (of the negotiated charge) per Not Covered
visit
Maximum visits per policy year 100
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
Outpatient private duty nursing 80% (of the negotiated charge) per Not Covered
visit
Hospice-Inpatient 80% (of the negotiated charge) per Not Covered
admission
Hospice-Outpatient 80% (of the negotiated charge) per Not Covered
visit
The following are not covered under this benefit:
• Funeral arrangements
• Financial or legal counseling which includes estate planning and the drafting of a will
• Homemaker or caretaker services that are services which are not solely related to your care and may include:
- Sitter or companion services for either you or other family members
- Transportation
- Maintenance of the house

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 Eligible health services In-network coverage Out-of-network coverage
Skilled nursing facility- 100% (of the negotiated charge) per Not Covered
Inpatient admission
Maximum days of 100
confinement per policy year
Hospital emergency room $200 copayment then the plan pays Paid the same as in-network coverage
80% (of the balance of the negotiated
charge) per visit
Non-emergency care in a hospital Not covered Not covered
emergency room
Important note:
• As out-of-network 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.
The following are not covered under this benefit:
• Non-emergency services in a hospital emergency room facility, freestanding emergency medical care facility
or comparable emergency facility
Urgent care $50 copayment then the plan pays Not covered
100% (of the balance of the
negotiated charge) per visit
Non-urgent use of an urgent care Not covered Not covered
provider
The following is not covered under this benefit:
• Non-urgent care in an urgent care facility (at a non-hospital freestanding facility)
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 charge) per Not covered
visit

No copayment or deductible applies

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 Eligible health services In-network coverage Out-of-network coverage
Type B services 100% (of the negotiated charge) per Not covered
visit

No copayment or deductible applies

Type C services 100% (of the negotiated charge) per Not covered
visit

No copayment or deductible applies

Orthodontic services 100% (of the negotiated charge) per Not covered
visit

No copayment or deductible applies

Dental emergency services Covered according to the type of Covered according to the type of
benefit and the place where the benefit and the place where the
service is received service is received.
Pediatric dental care exclusions
The following are not covered under this benefit:
• Asynchronous dental treatment
• 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. 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 (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:
- For splinting
- 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 this section
• Pontics, crowns, cast or processed restorations made with high noble metals (gold)
• Prescribed drugs
• Replacement of teeth beyond the normal complement of 32
• Services and supplies:
- Done where there is no evidence of pathology, dysfunction, or disease other than covered preventive
services

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 - 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 only for orthodontic reasons, except as medically necessary
• Treatment by other than a dental provider
Eligible health services In-network coverage Out-of-network coverage
Diabetic services and supplies Covered according to the type of Not covered
(including equipment and training) benefit and the place where the
service is received.
Podiatric (foot care) treatment Covered according to the type of Not covered
Physician and specialist non- benefit and the place where the
routine foot care treatment service is received.
The following are not covered under this benefit:
• Services and supplies for:
- The treatment of calluses, bunions, toenails, flat feet, hammertoes, fallen arches
- The treatment of weak feet, chronic foot pain or conditions caused by routine activities, such as walking,
running, working or wearing shoes
- Supplies (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, ankle braces, guards,
protectors, creams, ointments and other equipment, devices and supplies
- Routine pedicure services, such as cutting of nails, corns and calluses when there is no illness or injury of
the feet
Impacted wisdom teeth 80% (of the negotiated charge) Not covered
Accidental injury to sound natural 80% (of the negotiated charge) Not covered
teeth
The following are not covered under this benefit:
• The care, filling, removal or replacement of teeth and treatment of diseases of the teeth
• Dental services related to the gums
• Apicoectomy (dental root resection)
• Orthodontics
• Root canal treatment
• Soft tissue impactions
• Bony impacted teeth
• Alveolectomy
• Augmentation and vestibuloplasty treatment of periodontal disease
• False teeth
• Prosthetic restoration of dental implants
• Dental implants
Temporomandibular joint Covered according to the type of Not covered
dysfunction (TMJ) and benefit and the place where the
craniomandibular joint dysfunction service is received.
(CMJ) treatment
The following are not covered under this benefit:
• Dental implants
Blood and body fluid Covered according to the type of Not covered
exposure benefit and the place where the
service is received.

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 The following are not covered under this benefit:
• Services and supplies provided for the treatment of an illness that results from your clinical related injury as
these are covered elsewhere in the student policy
Eligible health services In-network coverage Out-of-network coverage
Clinical trial (routine patient Covered according to the type of Not covered
costs) benefit and the place where the
service is received.
Coverage is limited to routine patient services from in-network providers.
Dermatological treatment Covered according to the type of Not covered
benefit and the place where the
service is received.
The following are not covered under this benefit:
• Cosmetic treatment and procedures
Obesity bariatric Surgery and Covered according to the type of Not covered
services benefit and the place where the
service is received.
Obesity surgery-travel and lodging
Maximum benefit payable for $130 Not covered
travel expenses for each round trip
– three round trips covered (one
pre-surgical visit, the surgery and
one follow-up visit)

Maximum benefit payable for $130 Not covered

travel expenses per companion for
each round trip – two round trips
covered (the surgery and one
follow-up visit)
Maximum benefit payable for $100 per day up to four days Not covered
lodging expenses per patient and
companion for the pre-surgical and
follow-up visits
Maximum benefit payable for $100 per day up to four days Not covered
lodging expenses per companion
for surgery stay
The following are not covered under this benefit:
• Weight management treatment or drugs intended to decrease or increase body weight, control weight or
treat obesity, including morbid obesity except as described above and in the Eligible health services and
exclusions – Preventive care and wellness section, including preventive services for obesity screening and
weight management interventions. This is regardless of the existence of other medical conditions. Examples
of these are:
- Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food
supplements, appetite suppressants and other medications
- Hypnosis or other forms of therapy
- Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy or
other forms of activity or activity enhancement

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 Eligible health services In-network coverage Out-of-network coverage
Maternity care that is not Covered according to the type of Not covered
considered preventive care benefit and the place where the
(includes delivery and postpartum service is received.
care services in a hospital or
birthing center)
The following are not covered under this benefit:
• Any services and supplies related to births that take place in the home or in any other place not licensed to
perform deliveries
Well newborn nursery 80% (of the negotiated charge) Not covered
care in a hospital or
birthing center No policy year deductible applies
Family planning services – other
Voluntary sterilization 80% (of the negotiated charge) Not covered
for males-surgical services
Reversal of voluntary sterilization 80% (of the negotiated charge) Not covered
Abortion 80% (of the negotiated charge) Not covered
Gender affirming treatment
Surgical, hormone replacement Covered according to the Behavioral Not covered
therapy, and counseling treatment health section
All other cosmetic services and supplies not listed under eligible health services above are not covered under this
benefit. This includes, but is not limited to the following:
• Rhinoplasty
• Face-lifting
• Lip enhancement
• Facial bone reduction
• Blepharoplasty
• Liposuction of the waist (body contouring)
• Hair removal (including electrolysis of face and neck)
• Voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which are
used in feminization
• Voice and communication therapy
• Chest binders
• Chin implants, nose implants, and lip reduction, which are used to assist masculinization, are considered
cosmetic
Mental Health & Substance Abuse Treatment
Coverage provided under the same terms, conditions as any other illness.
Inpatient hospital 80% (of the negotiated charge) per Not covered
(room and board and other admission
miscellaneous hospital
services and supplies)
Outpatient office visits $20 copayment then the plan pays Not covered
(includes telemedicine 100% (of the balance of the
consultations) negotiated charge) per visit

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 Eligible health services In-network coverage Out-of-network coverage
Other outpatient treatment 80% (of the negotiated charge) per Not covered
(includes skilled behavioral health visit
services in the home)
Eligible health services In-network coverage (IOE facility)* Out-of-network coverage
(Includes providers who are otherwise
part of Aetna’s network but are non-
IOE providers)
Transplant services
Inpatient and outpatient transplant Covered according to the type of Covered according to the type of
facility services benefit and the place where the benefit and the place where the
service is received. service is received.
Inpatient and outpatient transplant Covered according to the type of Covered according to the type of
physician and specialist services benefit and the place where the benefit and the place where the
service is received. service is received.
Transplant services-travel and Covered Covered
lodging
Lifetime Maximum payable for $10,000 $10,000
Travel and Lodging Expenses for
any one transplant, including
tandem transplants
Maximum payable for Lodging $50 per night $50 per night
Expenses per IOE patient
Maximum payable for Lodging $50 per night $50 per night
Expenses per companion
The following are not covered under this benefit:
• Services and supplies furnished to a donor when the recipient is not a covered person
• Harvesting and storage of organs, without intending to use them for immediate transplantation for your
existing illness
• Harvesting and/or storage of bone marrow, hematopoietic stem cells, or other blood cells without intending
to use them for transplantation within 12 months from harvesting, for an existing illness
Eligible health services In-network coverage Out-of-network coverage
Treatment of infertility
Basic infertility services Inpatient Covered according to the type of Not Covered
and outpatient care - basic benefit and the place where the
infertility service is received.
Fertility preservation services
Fertility preservation Covered according to the type of Not Covered
benefit and the place where the
service is received.
The following are not covered services under the infertility treatment benefit:
• Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH agonists.
• All charges associated with:
- Surrogacy for you or the surrogate. A surrogate is a female carrying her own genetically related child
where the child is conceived with the intention of turning the child over to be raised by others, including
the biological father
- Thawing of cryopreserved (frozen) eggs, embryos or sperm

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 - The care of the donor in a donor egg cycle which includes, but is not limited to, any payments to the
donor, donor screening fees, fees for lab tests, and any charges associated with care of the donor
required for donor egg retrievals or transfers
- The use of a gestational carrier for the female acting as the gestational carrier. A gestational carrier is a
female carrying an embryo to which the person is not genetically related
- Obtaining sperm from a person not covered under this plan for ART services
- Home ovulation prediction kits or home pregnancy tests
- The purchase of donor embryos, donor oocytes, or donor sperm
- Reversal of voluntary sterilizations, including follow-up care
• Ovulation induction with menotropins, Intrauterine insemination and any related services, products or
procedures
• In vitro fertilization (IVF), Zygote intrafallopian transfer (ZIFT), Gamete intrafallopian transfer (GIFT),
Cryopreserved embryo transfers and any related services, products or procedures (such as
Intracytoplasmic sperm injection (ICSI) or ovum microsurgery)
• ART services are not provided for out-of-network care
Eligible health services In-network coverage Out-of-network coverage
Specific therapies and tests
Diagnostic complex imaging 80% (of the negotiated charge) per Not Covered
services performed in the visit
outpatient department of a
hospital or other facility
Diagnostic lab work and 80% (of the negotiated charge) per Not Covered
radiological services performed in a visit
physician’s office, the outpatient
department of a hospital or other
facility
Outpatient Chemotherapy, 80% (of the negotiated charge) per Not Covered
Radiation & Respiratory Therapy visit
Outpatient infusion therapy Covered according to the type of Not Covered
performed in a covered person’s benefit and the place where the
home, physician’s office, outpatient service is received.
department of a hospital or other
facility
The following are not covered under this benefit:
• Enteral nutrition
• Blood transfusions and blood products
Outpatient physical, occupational, 80% (of the negotiated charge) per Not Covered
speech, and cognitive therapies visit
(including Cardiac and Pulmonary
Therapy)

Combined for short-term

rehabilitation services and
habilitation therapy services

University of San Francisco 2021-2022 Page 16

 Eligible health services In-network coverage Out-of-network coverage
Acupuncture therapy 80% (of the negotiated charge) per Not Covered
visit
The following are not covered under this benefit:
• Acupressure
Chiropractic services 80% (of the negotiated charge) per Not Covered
visit
Specialty prescription drugs Covered according to the type of Not Covered
purchased and injected or infused benefit or the place where the service
by your provider in an outpatient is received.
setting
Other services and supplies
Emergency ground, air, and water 80% (of the negotiated charge) per Paid the same in-network coverage
ambulance (includes non- trip
emergency ambulance)
Durable medical and surgical 80% (of the negotiated charge) per Not Covered
equipment item
The following are not covered under this benefit:
• Whirlpools
• Portable whirlpool pumps
• Sauna baths
• Massage devices
• Over bed tables
• Elevators
• Communication aids
• Vision aids
• Telephone alert systems
• Personal hygiene and convenience items such as air conditioners, humidifiers, hot tubs, or physical exercise
equipment even if they are prescribed by a physician
Nutritional support Covered according to the type of Not Covered
benefit or the place where the service
is received.
The following are not covered under this benefit:
• Any food item, including infant formulas, nutritional supplements, vitamins, plus prescription vitamins,
medical foods and other nutritional items, even if it is the sole source of nutrition
Prosthetic devices including contact 80% (of the negotiated charge) per Not Covered
lenses for aniridia & Orthotics item
The following are not covered under this benefit:
• Services covered under any other benefit
• Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet, unless required for
the treatment of or to prevent complications of diabetes, or if the orthopedic shoe is an integral part of a
covered leg brace
• Trusses, corsets, and other support items
• Repair and replacement due to loss or misuse
• Communication aids

University of San Francisco 2021-2022 Page 17

 Eligible health services In-network coverage Out-of-network coverage
Hearing Exams
Hearing exam $20 copayment then the plan pays Not Covered
100% (of the balance of the
negotiated charge) per visit
Hearing exam maximum One hearing exam every policy year
The following are not covered under this benefit:
• Hearing exams given during a stay in a hospital or other facility, except those provided to newborns as part of
the overall hospital stay
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 charge) per Not Covered
ophthalmologist or optometrist visit
(includes comprehensive low vision
evaluations)
Low vision Maximum One comprehensive low vision evaluation every five years
Fitting of contact Maximum 1 visit
Pediatric vision care services & 100% (of the negotiated charge) per Not Covered
supplies-Eyeglass frames, item
prescription lenses or prescription
contact lenses
Maximum number Per year:
Eyeglass frames One set of eyeglass frames
Prescription lenses One pair of prescription lenses
Contact lenses (includes non- Daily disposables: up to 1 year supply
conventional prescription contact Extended wear disposable: up to 1 year supply
lenses & aphakic lenses prescribed Non-disposable lenses: 1 year supply
after cataract surgery)
Optical devices Covered according to the type of Not Covered
benefit and the place where the
service is received.
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
Adult vision care Limited to covered persons age 19 and over
Adult routine vision exams $20 copayment then the plan pays Not Covered
(including refraction) Performed by 100% (of the balance of the
a legally qualified ophthalmologist negotiated charge) per visit
or therapeutic optometrist, or any
other providers acting within the
scope of their license

Includes fitting of prescription

contact lenses
Maximum visits per policy year 1 visit

University of San Francisco 2021-2022 Page 18

 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
• Eye exams for contact lenses or their fitting
• Eyeglasses or duplicate or spare eyeglasses or lenses or frames
• 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

Eligible health services In-network coverage Out-of-network coverage

Outpatient prescription drugs
Policy year deductible and copayment/coinsurance waiver for risk reducing breast cancer
The policy year deductible and the per prescription copayment/coinsurance will not apply to risk reducing breast
cancer prescription drugs when obtained at a retail in-network, pharmacy. This means that such risk reducing breast
cancer prescription drugs are paid at 100%.
Outpatient prescription drug policy year deductible and copayment waiver for tobacco cessation prescription and
over-the-counter drugs
The prescription drug copayment will not apply to treatment regimens per policy year for tobacco cessation
prescription drugs and OTC drugs when obtained at a in-network pharmacy. This means that such prescription drugs
and OTC drugs are paid at 100%.
Outpatient prescription drug copayment waiver for contraceptives
The prescription drug copayment will not apply to female contraceptive methods when obtained at a in-network
pharmacy.

This means that such contraceptive methods are paid at 100% for:
• Certain over-the-counter (OTC) and generic contraceptive prescription drugs and devices for each of the
methods identified by the FDA. Related services and supplies needed to administer covered devices will also be
paid at 100%.
• If a generic prescription drug or device is not available for a certain method, you may obtain certain brand-
name prescription drug or device for that method paid at 100%.

The prescription drug copayment continue to apply to prescription drugs that have a generic equivalent, biosimilar or
generic alternative available within the same therapeutic drug class obtained at a in-network pharmacy unless you are
granted a medical exception. The certificate of coverage explains how to get a medical exception.

University of San Francisco 2021-2022 Page 19

Eligible health services In-network coverage Out-of-network coverage
Preferred Generic prescription drugs (including specialty drugs)
For each fill up to a 30 day supply $10 copayment per supply then the Not Covered
filled at a retail pharmacy plan pays 100% (of the balance of the
negotiated charge)

No policy year deductible applies

More than a 30 day supply but less $25 copayment per supply then the Not Covered
than a 90 day supply filled at a mail plan pays 100% (of the balance of the
order pharmacy negotiated charge)

No policy year deductible applies

Preferred Brand-Name prescription drugs (including specialty drugs)
For each fill up to a 30 day supply $25 copayment per supply then the Not Covered
filled at a retail pharmacy plan pays 100% (of the balance of the
negotiated charge)

No policy year deductible applies

More than a 30 day supply but less $62.50 copayment per supply then Not Covered
than a 90 day supply filled at a mail the plan pays 100% (of the balance of
order pharmacy the negotiated charge)

No policy year deductible applies

Non-Preferred Generic prescription drugs (including specialty drugs)
For each fill up to a 30 day supply $80 copayment per supply then the Not Covered
filled at a retail pharmacy plan pays 100% (of the balance of the
negotiated charge)

No policy year deductible applies

More than a 30 day supply but less $200 copayment per supply then the Not Covered
than a 90 day supply filled at a mail plan pays 100% (of the balance of the
order pharmacy negotiated charge)

No policy year deductible applies

Non-Preferred Brand-Name prescription drugs (including specialty drugs)
For each fill up to a 30 day supply $80 copayment per supply then the Not Covered
filled at a retail pharmacy plan pays 100% (of the balance of the
negotiated charge)

No policy year deductible applies

More than a 30 day supply but less $200 copayment per supply then the Not Covered
than a 90 day supply filled at a mail plan pays 100% (of the balance of the
order pharmacy negotiated charge)

No policy year deductible applies

University of San Francisco 2021-2022 Page 20

Eligible health services In-network coverage Out-of-network coverage

Orally administered anti-cancer 100% (of the negotiated charge) Not Covered
prescription drugs- For each fill up to
a 30 day supply filled at a retail
pharmacy
Preventive care drugs and 100% (of the negotiated charge per Not Covered
supplements filled at a retail prescription or refill
pharmacy
No copayment or policy year
For each 30 day supply deductible applies
Risk reducing breast cancer 100% (of the negotiated charge) per Not Covered
prescription drugs filled at a prescription or refill
pharmacy
No copayment or policy year
For each 30 day supply deductible applies
Maximums: Coverage will be subject to any sex, age, medical condition, family history, and
frequency guidelines in the recommendations of the United States Preventive
Services Task Force.
Sexual enhancement or dysfunction Paid according to the tier of drug in Not Covered
prescription drugs-Up to 8 pills for the schedule of benefits above
each 30 day supply filled at a retail
pharmacy
Sexual enhancement or dysfunction Paid according to the tier of drug in Not Covered
prescription drugs the schedule of benefits above
Tobacco cessation prescription and 100% (of the negotiated charge per Not Covered
over-the-counter drugs prescription or refill
(Preventive care)-Tobacco cessation
prescription drugs and OTC drugs No copayment or policy year
filled at a pharmacy deductible applies

For each 30 day supply

Maximums: Coverage will be subject to any sex, age, medical condition, family history, and
frequency guidelines in the recommendations of the United States Preventive
Services Task Force.
The following are not covered under the outpatient prescription drugs benefit:
• Biological sera
• Compounded prescriptions containing bulk chemicals not approved by the U.S. Food and Drug Administration
(FDA) including compounded bioidentical hormones
• Cosmetic drugs including medications and preparations used for cosmetic purposes
• Devices, products and appliances, except those that are specially covered
• Dietary supplements
• Drugs or medications
- Which do not, by federal or state law, require a prescription order i.e. over-the-counter (OTC) drugs), even
if a prescription is written except as specifically provided above
- Not approved by the FDA or not proven safe or effective
- Provided under your medical plan while an inpatient of a healthcare facility

University of San Francisco 2021-2022 Page 21

 - Recently approved by the U.S. Food and Drug Administration (FDA), but which have not yet been reviewed
by our Pharmacy and Therapeutics Committee, unless we have approved a medical exception
- That include vitamins and minerals unless recommended by the United States Preventive Services Task
Force (USPSTF)
- For which the cost is covered by a federal, state, or government agency (for example: Medicaid or Veterans
Administration)
- That are used to treat increase sexual desire, including drugs, implants, devices or preparations to correct
or enhance erectile function, enhance sensitivity, or alter the shape or appearance of a sex organ
- That are used for the purpose of weight gain or reduction, including but not limited to stimulants,
preparations, foods or diet supplements, dietary regimens and supplements, food or food supplements,
appetite suppressants or other medications
- That are drugs or growth hormones used to stimulate growth and treat idiopathic short stature unless
there is evidence that the covered person meets one or more clinical criteria detailed in our
precertification and clinical policies
• Duplicative drug therapy (e.g. two antihistamine drugs)
• Immunizations related to travel or work
• Infertility
- Injectable prescription drugs used primarily for the treatment of infertility
• Injectables
- Any charges for the administration or injection of prescription drugs or injectable insulin and other
injectable drugs covered by us.
- Needles and syringes, except for those used for self-administration of an injectable drug.
- Any drug which, due to its characteristics, must typically be administered or supervised by a qualified
provider or licensed certified health professional in an outpatient setting. This exception does not apply to
Depo Provera and other injectable drugs used for contraception.
• Off-label drug use except for indications recognized through peer-reviewed medical literature
• Prescription drugs:
- Filled prior to the effective date or after the termination date of coverage under this plan.
- That are considered oral dental preparations and fluoride rinses, except pediatric fluoride tablets or drops
as specified on the preferred drug guide.
- That are not medically necessary or otherwise improper, and drugs obtained for use by anyone other than
the person identified on the ID card.
• Refills dispensed more than one year from the date the latest prescription order was written
• Replacement of lost or stolen prescriptions
• Test agents except diabetic test agents
• A manufacturer’s product when the same or similar drug (that is, a drug with the same active ingredient or
same therapeutic effect), supply or equipment is on the preferred drug guide
• Any dosage or form of a drug when the same drug (that is, a drug with the same active ingredient or same
therapeutic effect) is available in a different dosage or form on our preferred drug guide

A covered person, a covered person’s designee or a covered person’s prescriber may seek an expedited medical
exception process to obtain coverage for non-covered drugs in exigent circumstances. An “exigent circumstance” exists
when a covered person is suffering from a health condition that may seriously jeopardize a covered person’s life, health,
or ability to regain maximum function or when a covered person is undergoing a current course of treatment using a
non-formulary drug. The request for an expedited review of an exigent circumstance may be submitted by contacting
Aetna's Pre-certification Department at 1-855-240-0535, faxing the request to 1-877-269-9916, or submitting the
request in writing to:

University of San Francisco 2021-2022 Page 22

CVS Health
ATTN: Aetna PA
1300 E Campbell Road
Richardson, TX 75081
Out of Country claims
Out of Country claims should be submitted with appropriate medical service and payment information from the
provider of service. Covered services received outside the United States will be considered at the In-network level of
benefits.

General Exclusions

Alternative health care

• Services and supplies given by a provider for alternative health care. This includes but is not limited to
aromatherapy, naturopathic medicine, herbal remedies, homeopathy, energy medicine, Christian faith-
healing medicine, Ayurvedic medicine, yoga, hypnotherapy, and traditional Chinese medicine.

Armed forces
• Services and supplies received from a provider as a result of an injury sustained, or illness contracted, while in
the service of the armed forces of any country. When you enter the armed forces of any country, we will refund
any unearned pro-rata premium.

Behavioral health treatment

• Services for the following based on categories, conditions, diagnoses or equivalent terms as listed in the most
recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric
Association:
- Stay in a facility for treatment for dementias and amnesia without a behavioral disturbance that
necessitates mental health treatment
- Education service including wilderness treatment programs, or any such related or similar programs
- Services provided in conjunction with school, vocation, work or recreational activities
- Sexual deviations and disorders except for gender identity disorders
- Tobacco use disorders except as described in the Eligible health services and exclusions – Preventive care
and wellness section
- Pathological gambling, kleptomania, pyromania

Breasts
• Services and supplies given by a provider for breast reduction or gynecomastia, except as medically necessary.

Clinical trial therapies (experimental or investigational)

• Your plan does not cover clinical trial therapies (experimental or investigational), except as described in the
Eligible health services and exclusions- Clinical trial therapies (experimental or investigational) section in the
certificate

Cornea or cartilage transplants

• Cornea (corneal graft with amniotic membrane)
• Cartilage (autologous chondrocyte implant or osteochondral allograft or autograft) transplants

University of San Francisco 2021-2022 Page 23

Cosmetic services and plastic surgery
• Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or enhance the shape or
appearance of the body. Whether or not for psychological or emotional reasons. Injuries that occur during
medical treatments are not considered accidental injuries even if unplanned or unexpected.

This exclusion does not apply to:

• Surgery after an accidental injury when performed as soon as medically feasible
• Coverage that may be provided under the Eligible health services under your plan - Gender reassignment (sex
change) treatment section.

Court-ordered services and supplies

• This includes court-ordered services and supplies, or those required as a condition of parole, probation, release
or as a result of any legal proceeding, unless they are a covered benefit under your plan

Custodial care
Examples are:
• Routine patient care such as changing dressings, periodic turning and positioning in bed
• Administering oral medications
• Care of a stable tracheostomy (including intermittent suctioning)
• Care of a stable colostomy/ileostomy
• Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
• Care of a bladder catheter (including emptying/changing containers and clamping tubing)
• Watching or protecting you
• Respite care except in connection with hospice care, adult (or child) day care, or convalescent care
• Institutional care. This includes room and board for rest cures, adult day care and convalescent care
• Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods
• Any other services that a person without medical or paramedical training could be trained to perform
• Any service that can be performed by a person without any medical or paramedical training

Dental care for adults

• Dental services for adults including services related to:
- The care, filling, removal or replacement of teeth and treatment of injuries to or diseases of the teeth
- Dental services related to the gums
- Apicoectomy (dental root resection)
- Orthodontics
- Root canal treatment
- Soft tissue impactions
- Alveolectomy
- Augmentation and vestibuloplasty treatment of periodontal disease
- False teeth
- Prosthetic restoration of dental implants
- Dental implants

This exception does not include removal of bony impacted teeth, bone fractures, removal of tumors, and
odontogenic cysts.

University of San Francisco 2021-2022 Page 24

Educational services
Examples of these services are:
• Any service or supply for education, training or retraining services or testing, except where described in the
Eligible health services and exclusions – Diabetic services and supplies (including equipment and training)
section. This includes:
- Special education
- Remedial education
- Wilderness treatment programs (whether or not the program is part of a residential treatment facility or
otherwise licensed institution)
- Job training
- Job hardening programs
• Educational services, schooling or any such related or similar program

Elective treatment or elective surgery

• Elective treatment or elective surgery except as specifically covered under the student policy and provided while
the student policy is in effect

Examinations
Any health or dental examinations needed:
• Because a third party requires the exam. Examples are, examinations to get or keep a job, or
examinations required under a labor agreement or other contract
• Because a law requires it
• To buy insurance or to get or keep a license
• To travel
• To go to a school, camp, or sporting event, or to join in a sport or other recreational activity

Experimental or investigational
• Experimental or investigational drugs, devices, treatments or procedures unless otherwise covered under clinical
trial therapies (experimental or investigational) or covered under clinical trials (routine patient costs). See the
Eligible health services and exclusions – Other services section in the certificate.

Facility charges
For care, services or supplies provided in:
• Rest homes
• Assisted living facilities
• Similar institutions serving as a persons’ main residence or providing mainly custodial or rest care
• Health resorts
• Spas or sanitariums
• Infirmaries at schools, colleges, or camps

Felony
• Services and supplies that you receive as a result of an injury due to your commission of a felony

University of San Francisco 2021-2022 Page 25

Gene-based, cellular and other innovative therapies (GCIT)
The following are not eligible health services unless you receive prior written approval from us:
• All associated services when GCIT services are not covered. Examples include infusion, laboratory, radiology,
anesthesia, and nursing services.

Please refer to the Medical necessity section.

Genetic care
• Any treatment, device, drug, service or supply to alter the body’s genes, genetic make-up, or the
expression of the body’s genes except for the correction of congenital birth defects

Growth/Height care
• A treatment, device, service or supply to increase or decrease height or alter the rate of growth
• Surgical procedures and devices to stimulate growth

Hearing aids
Any tests, appliances and devices to:
• Improve your hearing
• Enhance other forms of communication to make up for hearing loss or devices that simulate speech]

Incidental surgeries
• Charges made by a physician for incidental surgeries. These are non-medically necessary surgeries performed
during the same procedure as a medically necessary surgery.

Judgment or settlement
• Services and supplies for the treatment of an injury or illness to the extent that payment is made as a judgment
or settlement by any person deemed responsible for the injury or illness (or their insurers)

Medical supplies – outpatient disposable

• Any outpatient disposable supply or device. Examples of these are:
- Sheaths
- Bags
- Elastic garments
- Support hose
- Bandages
- Bedpans
- Splints
- Neck braces
- Compresses
- Other devices not intended for reuse by another patient

Non-medically necessary services and supplies

• Services and supplies which are not medically necessary for the diagnosis, care, or treatment of an
illness or injury or the restoration of physiological functions This includes behavioral health services that
are not primarily aimed at the treatment of illness, injury, restoration of physiological functions or that
do not have a physiological or organic basis. This applies even if they are prescribed, recommended, or
approved by your physician, dental provider, or vision care provider. This exception does not apply to
Preventive care and wellness benefits.

University of San Francisco 2021-2022 Page 26

Non-U.S. citizen
• Services and supplies received by a covered person (who is not a United States citizen) within the covered
person’s home country but only if the home country has a socialized medicine program, except as covered in
the Eligible health services under your plan – Emergency services and urgent care section

Other primary payer

• Payment for a portion of the charge that Medicare or another party pays for as the primary payer

Outpatient prescription or non-prescription drugs and medicines

• Outpatient prescription drugs or non-prescription drugs and medicines provided by the policyholder

Personal care, comfort or convenience items

• Any service or supply primarily for your convenience and personal comfort or that of a third party

School health services

• Services and supplies normally provided without charge by the policyholder’s:
- School health services
- Infirmary
- Hospital
- Pharmacy or

by health professionals who

- Are employed by
- Are Affiliated with
- Have an agreement or arrangement with, or
- Are otherwise designated by

the policyholder.

Services provided by a family member

• Services provided by a spouse, domestic partner, civil union partner parent, child, step-child, brother,
sister, in-law or any household member

Sexual dysfunction and enhancement

• Any treatment, service, or supply to treat sexual dysfunction, enhance sexual performance or increase sexual
desire, including:
- Implants, devices or preparations to correct or enhance erectile function or sensitivity
- Sex therapy, sex counseling, marriage counseling, or other counseling or advisory services

Sinus surgery
• Any services or supplies given by providers for non-medically necessary sinus surgery except for acute purulent
sinusitis

Strength and performance

• Services, devices and supplies that are not medically necessary, such as drugs or preparations designed
primarily for enhancing your:
- Strength
- Physical condition

University of San Francisco 2021-2022 Page 27

 - Endurance
- Physical performance

Students in mental health field

• Any services and supplies provided to a covered student who is specializing in the mental health care field and
who receives treatment from a provider as part of their training in that field

Telemedicine
• Services given when you are not present at the same time as the provider
• Services including:
– Telemedicine kiosks
– Electronic vital signs monitoring or exchanges, (e.g. Tele-ICU, Tele-stroke)

Therapies and tests

• Hair analysis
• Hypnosis and hypnotherapy
• Massage therapy, except when used as a physical therapy modality
• Sensory or auditory integration therapy

Treatment in a federal, state, or governmental entity

• Any care in a hospital or other facility owned or operated by any federal, state or other governmental entity,
except to the extent coverage is required by applicable laws

Wilderness treatment programs

See Educational services within this section

The University of San Francisco Student Health Insurance Plan is underwritten by Aetna Life Insurance Company Aetna
Health and Life Insurance Company (Aetna). Aetna Student HealthSM is the brand name for products and services
provided by Aetna Life Insurance Company Aetna Health and Life Insurance Company and its applicable affiliated
companies (Aetna).

Sanctioned Countries

If coverage provided by this policy violates or will violate any economic or trade sanctions, the coverage is immediately
considered invalid. For example, Aetna companies cannot make payments for health care or other claims or services if it
violates a financial sanction regulation. This includes sanctions related to a blocked person or a country under sanction
by the United States, unless permitted under a written Office of Foreign Asset Control (OFAC) license. For more
information, visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.

Assistive Technology

Persons using assistive technology may not be able to fully access the following information. For assistance, please call
1-877-480-4161.

Smartphone or Tablet

To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App
Store.

University of San Francisco 2021-2022 Page 28

Non-Discrimination

Aetna is committed to being an inclusive health care company. Aetna does not discriminate on the basis of ancestry, race,
ethnicity, color, religion, sex/gender (including pregnancy), national origin, sexual orientation, gender identity or
expression, physical or mental disability, medical condition, age, veteran status, military status, marital status, genetic
information, citizenship status, unemployment status, political affiliation, or on any other basis or characteristic prohibited
by applicable federal, state or local law.

Aetna provides free aids and services to people with disabilities and free language services to people whose primary
language is not English.

These aids and services include:

• Qualified language interpreters

• Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Qualified interpreters
• Information written in other languages

If you need these services, contact the number on your ID card. Not an Aetna member? Call us at 1-877-480-4161.

If you have questions about our nondiscrimination policy or have a discrimination-related concern that you would like to
discuss, please call us at 1-877-480-4161.

Please note, Aetna covers health services in compliance with applicable federal and state laws. Not all health services are
covered. See plan documents for a complete description of benefits, exclusions, limitations, and conditions of coverage.

Language accessibility statement

Interpreter services are available for free.

Attention: If you speak English, language assistance service, free of charge, are available to you. Call 1-877-480-
4161(TTY: 711).

Español/Spanish

Atención: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-877-480-4161(TTY: 711).

አማርኛ/Amharic

ልብ ይበሉ: ኣማርኛ ቋንቋ የሚናገሩ ከሆነ፥ የትርጉም ድጋፍ ሰጪ ድርጅቶች፣ ያለምንም ክፍያ እርስዎን ለማገልገል ተዘጋጅተዋል። የሚከተለው ቁጥር ላይ
ይደውሉ 1-877-480-4161(መስማት ለተሳናቸው: 711).

‫اﻟﻌ���ﺔ‬/Arabic

.(711 :�‫اﻟﻨ‬
‫ي‬ ‫)رﻗﻢ اﻟﻬﺎﺗﻒ‬1-877-480-4161 ‫ اﺗﺼﻞ ﺑﺮﻗﻢ‬.‫ ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐ��ﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ بﺎﻟﻤﺠﺎن‬،‫ إذا ﻛﻨﺖ ﺗﺘﺤﺪث اﻟﻠﻐﺔ اﻟﻌ���ﺔ‬:‫ﻣﻠﺤﻮﻇﺔ‬

Ɓàsɔ̍ɔ̀ Wùɖù/Bassa

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Dè dɛ nìà kɛ dye̍ɖe̍ gbo: Ɔ jǔ ke̍ m̀ dyi Ɓàsɔ̍ɔ̀-wùɖù-po-nyɔ̀ jǔ nı ̍, nìı ̍ à wuɖu kà kò ɖò po-poɔ̀ ɓɛ̍ m̀ gbo kpa̍a. Ɖa̍ 1-877-480-
4161(TTY: 711).

中文/Chinese

注意：如果您说中文，我们可为您提供免费的语言协助服务。请致电 1-877-480-4161(TTY: 711)。

�‫ﻓﺎر‬/Farsi
‫ ﺧﺪﻣﺎت ن‬،‫ ا�ﺮ بﻪ ز�ﺎن ﻓﺎر� ﺻﺤبﺖ � ﮐﻨ�ﺪ‬:‫ﺗﻮﺟﻪ‬
.‫( ﺗﻤﺎس بﮕ ی��ﺪ‬TTY: 711)1-877-480-4161 ‫ بﺎ ﺷﻤﺎرە‬،‫ز�ﺎی را�گﺎن بﻪ ﺷﻤﺎ ارا�ﻪ ﻣ�ﮕﺮدد‬

Français/French

Attention : Si vous parlez français, vous pouvez disposer d’une assistance gratuite dans votre langue en composant le 1-
877-480-4161(TTY: 711).

�ુજરાતી/Gujarati

ધ્યાન આપો: જો તમે �ુજરાતી બોલતા હો તો ભાષાક�ય સહાયતા સેવા તમને િન:�ુલ્ક ઉપલબ્ધ છે . કૉલ કરો 1-877-480-
4161 (TTY: 711).

Kreyòl Ayisyen/Haitian Creole

Atansyon: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-480-4161(TTY: 711).

Igbo

Nrụbama: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 1-877-480-4161(TTY: 711).

한국어/Korean

주의: 한국어를 사용하시는 경우, 언어 지원 서비스가 무료로 제공됩니다. 1-877-480-4161(TTY: 711)번으로 전화해
주십시오.

Português/Portuguese

Atenção: a ajuda está disponível em português por meio do número 1-877-480-4161(TTY: 711). Estes serviços são
oferecidos gratuitamente.

Русский/Russian

Внимание: если вы говорите на русском языке, вам могут предоставить бесплатные услуги перевода. Звоните по
телефону 1-877-480-4161(TTY: 711).

Tagalog

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Paunawa: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng serbisyo ng tulong sa wika nang walang bayad.
Tumawag sa 1-877-480-4161(TTY: 711).

‫اردو‬/Urdu

‫ ا�ﺮ آپ اردو ت‬:‫ﺗﻮﺟﮧ دﯾﮟ‬

.‫ ﭘﺮ کﺎل ﮐ��ﮟ‬1-877-480-4161(TTY: 711) ‫ ﺗﻮ آپ ﮐﻮ ز�ﺎن � ﻣﺪد � ﺧﺪﻣﺎت ﻣﻔﺖ دﺳت�ﺎب ﮨ یں ۔‬،‫ﺑﻮﻟ� ﮨ یں‬

Tiếng Việt/Vietnamese

Lưu ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Gọi số 1-877-480-
4161(TTY: 711).

Yorùbá/Yoruba

Àkíyèsí: Bí o bá nsọ èdè Yorùbá, ìrànlọ́wọ́ lórí èdè, lófẹ̀ ẹ́, wà fún ọ. Pe 1-877-480-4161(TTY: 711).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

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