Csu Long Beach: International

2014-2015
studenti nsurance. wel l sfargo. com

You can view the standard Summary of Benefits & Coverage (SBC) which is required
by Health Care Reform. It summarizes your coverage in a format that all insurance
companies now use. To view your plan SBC, go to: studentinsurance.wellsfargo.com
or call (800) 853-5899 to request a paper copy free of charge.
The California State University International student health insurance plan is underwritten by Aetna Life Insurance
Company (Aetna) and administered by Chickering Claims Administrators, Inc. (CCA). Aetna Student Health
SM
is
the brand name for products and services provided by Aetna and CCA and their applicable afliated companies.
15.02.310.1 D
Underwritten by:
Aetna Life Insurance Company
Policy #867860
The Plan Brokered by:
Wells Fargo Insurance Services USA, Inc.
Student Insurance Division
INTERNATIONAL
CSU LONG BEACH

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CSU Long BeaCh - InternatIonaL

WHEN COVERAGE BEGINS
Insurance under the Master Policy will become effective at 12:01 a.m. on the
later of:
The Master Policy effective date;
The beginning date of the term for which premium has been paid;
The day after the Enrollment Form (if applicable) and premium payment
are received by Wells Fargo Insurance, Authorized Agent or University; or
The day after the date of postmark if the Enrollment Form is mailed.
IMPORTANT NOTICE - Premiums will not be pro-rated if the Insured enrolls
past the first date of coverage for which he or she is applying. Final decisions
regarding coverage effective dates are made by Aetna Student Health.

The below enrollments will be allowed a 30 day grace period from the term
start date to enroll whereby the effective date will be backdated a maximum
of 30 days. No policy shall ever start prior to the term start date:
1. All hard-waiver and mandatory (insurance is required as a condition of
enrollment on campus) insurance programs.
2. All re-enrollments into the same exact policy if re-enrollment occurs
within 30 days of the prior policy termination date.
WHEN COVERAGE ENDS
Insurance of all Insured Persons terminates at 11:59 p.m. on the earlier of:
Date the Master Policy terminates for all Insured Persons; or
End of the period of coverage for which premium has been paid; or
Date the Insured Person ceases to be eligible for the insurance; or
Date the Insured Person enters military service.
In the event there is overlapping coverage under the same Master Policy
number, the policy with the earliest effective date will stay in force
through its termination date and the subsequent policy will go into effect
immediately afterward with no gap in coverage.
Dependent coverage will not be effective prior to that of the Insured Student or
extend beyond that of the Insured Student.
COVERAGE IS NOT AUTOMATICALLY RENEWED. Eligible Persons must re-
enroll when coverage terminates to maintain coverage. NO notification of
plan expiration or renewal will be sent.
PLAN COST
TERMS OF COVERAGE
ANNUAL
8/10/14 - 8/9/15
FALL
8/10/14 - 1/9/15
SPRING/SUMMER
1/10/15 - 8/9/15
Student only $1,046.91 $448.46 $619.59
NOTE: Costs below are in addition to the student premium. Dependents must be enrolled for the same term of coverage as student.
Spouse only $3,394.09 $1,429.11 $1,966.20
Per Child (Age 0-25) only $1,702.21 $717.05 $986.60
Rates include premium payable to Aetna Life Insurance Company, as well as administrative fees payable to CSU and Wells Fargo Insurance. Rates also include Medical
Evacuation and Repatriation and Worldwide Emergency Travel Assistance benefits/services provided through On Call International and its contracted underwriting companies.
IMPORTANT NOTICE
This is just a brief description of your benets. For information regarding the full Master Policy (which includes plan benets, exclusions and limitations, and infor-
mation about refund requests, how to le a claim, mandated benets and other important information) please call Aetna Student Health at (866) 378-8885 or
send an email through your Aetna Navigator Account or at http://www.aetnastudenthealth.com/customer-service/customer-service.aspx
You will be able to obtain a copy of the full Master Policy as soon as it is available.

3
All international students, visiting faculty, scholars or other persons possessing

and maintaining a current passport and valid visa status (F-1, J-1 or M-1, etc.),
engaged in educational activities at CSU Long Beach who are temporarily located
outside their home country and have not been granted permanent residency
status, are required to be insured under the Policy. Coverage is available for
students engaged in Practical Training. Enrollment must be accompanied by
confirmation of Practical Training from the insured student in the form of a copy
of your EAD (OPT coverage is available for the first 12 months of OPT only).
Contact Wells Fargo Insurances Customer Service for more details. (A person
who is an immigrant or permanent resident alien is not eligible for coverage
under the international plan.)
To be an Insured Person under the Policy, the student must have paid the required
premium and his/her name, student number and date of birth must have been
included in the declaration made by the School or the Administrative Agent to the
Insurer. All students must actively attend classes on campus for 45 consecutive
days following their effective date for the term purchased and/or pursuant to
their visa requirements for the period for which coverage is purchased, except in
the case of medical withdrawal or during school authorized breaks.
ALIC and Wells Fargo Insurance maintain the right to investigate student status
and attendance records to verify that the Policy eligibility requirements have
been met. If and whenever ALIC and/or Wells Fargo Insurance discover that
the Policy eligibility requirements have not been met, the only obligation is a
pro-rata refund of premium.
Eligible students who involuntarily lose coverage under another group insurance
plan are also eligible to purchase the Student Health Insurance Plan within 30
days of loss of coverage. These students must provide Wells Fargo Insurance
with proof that they have lost insurance through another group (certificate and
letter of ineligibility) within 30 days of the qualifying event. The effective date
would be the later of: a) term effective date, or b) the day after prior coverage
ends if enrollment request is received by Wells Fargo Insurance within 30 days
from loss of prior coverage.
COVERAGE FOR DEPENDENTS
Eligible Insured Students may also purchase Dependent coverage at the time
of students enrollment in the plan; or within 31 days of one of the following
qualified events: marriage, addition of domestic partner, birth, adoption or
arrival in the U.S. Eligible dependents are the spouse or legally registered and
valid domestic partner who resides with the Insured Student and the students,
the spouses, or the domestic partners natural child, stepchild or legally adopted
child under 26 years of age. Dependents of an Eligible International student or
visiting faculty member must possess a valid passport and a proper visa (F-2,
J-2, or M-2). A Newborn will automatically be covered for Injury or Sickness
from birth until 31 days old, providing that the student is covered under this
plan. Coverage may be continued for that child when Wells Fargo Insurance is
notified in writing within 31 days from the date of birth and by payment of
any additional premium. Dependents must be enrolled for the same term
of coverage for which the Insured Student enrolls. Dependent coverage
expires concurrently with that of the Insured Student, and Dependents
must re-enroll when coverage terminates to maintain coverage.
WHO IS ELIGIBLE TO ENROLL? PREMIUM REFUND/CANCELLATION
Refund requests should be directed to Wells Fargo Insurance at
(800) 853-5899 or via email at [email protected].
A refund of premium will be granted for the reasons listed below only. No other
refunds will be granted.
1. If you withdraw from school within the rst 45 days of the coverage
period, you and your insured dependents will receive a full refund of the
insurance premium provided that you and your insured dependents did not
le a medical claim during this period. Written proof of withdrawal from the
school must be provided. If you withdraw after 45 days of the coverage
period, your and your insured dependents coverage will remain in effect
until the end of the term for which you have paid the premium.
2. If you or your insured dependents enter the armed forces of any country
you and your insured dependents will not be covered under the Master
Policy as of the date of such entry. If you enter the armed forces the policy
will be cancelled. If your dependent enters the armed forces, a pro-rata
refund of premium will be made for such person, upon written request
received by Wells Fargo Insurance Services within 45 days of entry into
service.
3. Refunds will be granted for insured dependents in case of a qualifying event
such as legal separation, divorce or death within 31 days of the occurred
event, provided that your insured dependents did not le a medical claim
during the insured period. Written proof of such qualifying event must be
submitted. Refunds will not be prorated.
INSURANCE PAYMENTS WITH PERSONAL CHECK
(Note: personal checks are not always a payment option. Please check your
schools enrollment form for available payment options.) If you make your or
your dependents insurance payment via personal check payable to Wells Fargo
Insurance and we are unable to process the check (due to insufcient funds,
closure of account, etc.), your and your dependents insurance coverage will be
terminated retroactive to the effective date of the enrolled term.

4

WHERE DO I GO FOR SERVICE?
When you need care, consider Student Health Services (SHS) on your campus
as your rst stop. They can provide many of the routine health services you
need. Services obtained at the SHS are reimbursed at the Preferred Care rate.
A SHS referral is not required, and it does not guarantee services received
will be considered eligible expenses under the plan, nor is it a guarantee of
payment. You may visit any licensed health care provider directly for covered
services, except for specic Plan restrictions on certain services. However, when
you visit a Preferred Care Provider, youll generally have less out of pocket
expense for your care. To learn more about Preferred Care Providers, visit
www.aetnastudenthealth.com.
Insured dependents are not eligible to use the SHS. The benets listed in
the Schedule of Benets are available to the insured dependents.
*Providers are independent contractors and are not agents of Aetna. Provider
participation may change without notice. Aetna does not provide care or
guarantee access to health services.
PREFERRED CARE PROVIDER NETWORK
Aetna Student Health has arranged for you to access the Aetna Preferred Care
Provider network. It is to your advantage to utilize a Preferred Care Provider
because savings can be achieved from the Negotiated Charges these providers
have agreed to accept as payment for their services. Students are responsible
for informing their Physicians of potential out-of-pocket expenses for a referral to
both a Preferred Care Provider and a Non-Preferred Care Provider. Preferred Care
Providers are independent contractors and are neither employees nor agents of
the California State University system nor Aetna Student Health. To find a
Preferred Care Provider, you can use Aetnas online DocFind
service located at
www.aetnastudenthealth.com. Click on Find Your School and enter your
school name. You can use DocFind
to find out whether a specific provider

belongs to Aetnas network or to find Preferred Care Providers practicing in
your area.
PRESCRIPTION DRUG
CLAIM PROCEDURE
When obtaining a covered prescription, please present your ID card to a Pre-
ferred Pharmacy, along with your applicable copay. The pharmacy will bill Aetna
for the cost of the drug, plus a dispensing fee, less the copay amount.
When you need to fill a prescription, and do not have your ID card with you,
you may obtain your prescription from an Aetna Preferred Pharmacy, and be
reimbursed by submitting a completed Aetna Prescription Drug claim form. You
will be reimbursed for covered medications, less your copay.
For an Aetna Prescription claim form go to www.aetnastudenthealth.com.
Find your school, then click Prescription to obtain an RX claim form. Or call
(866) 378-8885.
Prescriptions from a Non-Preferred Pharmacy, or a health center pharmacy inca-
pable of billing, must be paid for in full at the time of service and submitted
for reimbursement.
ID CARDS
Medical ID cards may be shipped before or within 3 weeks of your policy
effective date. Providers need your Member ID# from your ID card to identify
you, verify your coverage and bill Aetna Life Insurance Company. You do
not need an ID card to be eligible to receive benefits, if you need medical
attention before receiving your ID card, benefits will be payable according to
the Policy. Once you have received your ID card, present it to the provider to
facilitate prompt payment of your claim. You can also print your ID cards at
www.aetnastudenthealth.com.
INFORMED HEALTH
LINE
The Informed Health Line is a 24-hours-a-day, 7-days-a-week toll-free line
for insured students and dependents to access condential medical advice,
or get assistance with locating nearby preferred network providers. Just call
(800) 556-1555 to talk to a registered nurse who can provide information on
a range of topics. Callers must be enrolled in the Student Health Insurance Plan
in order to be eligible to utilize the Informed Health Line.
MEMBER WEB: AETNA NAVIGATOR

Got Questions? Get Answers with Aetna Navigator
As an Aetna Student Health insurance member, you have access to Aetna

Navigator
, your secure member website, packed with personalized benefits

and health information. You can take full advantage of our interactive website
to complete a variety of self-service transactions online.
By logging into Aetna Navigator
, you can:
Review who is covered under your plan.
Request member ID cards.
View Claim Explanation of Benefits (EOB) statements.
Estimate the cost of common healthcare services and procedures to better
plan your expenses.
Research the price of a drug and learn if there are alternatives.
Find healthcare professionals and facilities that participate in your plan.
Send an e-mail to Aetna Student Health Customer Service at your
convenience.
View the latest health information and news, and more!
How do I register?
Go to www.aetnastudenthealth.com
Click on Find Your School.
Enter your school name and then click on Search.
Click on Aetna Navigator
and then the Access Navigator link.

Follow the instructions for First Time User by clicking on the Register
Now link.
Select a user name, password and security phrase.
Need help with registering onto Aetna Navigator
Technical assistance is available toll free, Monday through Friday, from 7 a.m.
to 9 p.m. Eastern Time at (800) 225-3375.

5
WAIVER OF ANNUAL DEDUCTIBLE

In compliance with Federal Health Care Reform legislation, the Annual Deductible is waived for Preferred Care Covered Medical Expenses rendered as part of the following
benet types: Routine Physical Exam Expense (Ofce Visits), Pap Smear Screening Expense, Mammogram Expense, Routine Screening for Sexually Transmitted Disease
Expense, Routine Colorectal Cancer Screening, Routine Prostate Cancer Screening Expense, Preventive Care Immunizations (Facility or Ofce Visits), Well Woman Preventive
Visits (Ofce Visits), Screening & Counseling Services (Ofce Visits) as illustrated under the Routine Physical Exam benet type, Routine Cancer Screenings (Outpatient),
Prenatal Care (Ofce Visits), Comprehensive Lactation Support and Counseling Services (Facility or Ofce Visits), Breast Pumps & Supplies, Family Contraceptive Counseling
Services (Ofce Visits), Female Voluntary Sterilization (Inpatient and Outpatient), Pediatric Preventive Vision and Dental Service, Female Contraceptives Generic Prescription
Drugs, Brand Prescription Drugs if no Generic equivalent. FDA-Approved Female Generic Emergency Contraceptives.
SCHEDULE OF BENEFITS
Deductibles*
The following Deductibles are applied before Covered Medical Expenses are payable: Student/Spouse/Child: $150 per Insured per Policy Year
*Per visit or admission deductibles do not apply towards satisfying the plan Deductible.
Coinsurance
Covered Medical Expenses are payable at the coinsurance percentage specied below, after any applicable deductible, up to an Unlimited maximum benet.
Out of Pocket Maximums
Preferred Care Individual Out-of-Pocket: $6,350 per Policy Year; Preferred Care Family Out-of-Pocket: $12,700 per Policy Year
Once the Individual or Family Out-of-Pocket Limit for Preferred Care has been satised, Covered Medical Expenses will be payable at 100% for the remainder of the
Policy Year, up to any benet maximum that may apply. Coinsurance, Deductibles, Copays and Prescription Drug expenses apply to the Out-of-Pocket Limit. Services
that do not apply towards satisfying the Out-Of-Pocket Limit: expenses that are not Covered Medical Expenses; expenses for Designated Care or Non-Preferred care;
penalties,and other expenses not covered by this Plan.
INPATIENT HOSPITALIZATION EXPENSES PREFERRED CARE NON-PREFERRED CARE
Room and Board Expense, semi-private room. 90% of the Negotiated Charge 75% of the Recognized Charge
Intensive Care Room and Board Expense, overnight stay. 90% of the Negotiated Charge 75% of the Recognized Charge
Miscellaneous Hospital Expense, includes; among others; expenses incurred during a
hospital connement for: anesthesia and operating room; laboratory tests and x rays;
oxygen tent; and drugs; medicines; and dressings.
90% of the Negotiated Charge 75% of the Recognized Charge
SURGICAL EXPENSE (INPATIENT & OUTPATIENT) PREFERRED CARE NON-PREFERRED CARE
Surgical Expense 90% of the Negotiated Charge 75% of the Recognized Charge
Anesthesia Expense 90% of the Negotiated Charge 75% of the Recognized Charge
OUTPATIENT BENEFITS PREFERRED CARE NON-PREFERRED CARE
Walk-In Clinic Expense. Copay is due at the time of visit and is in addition to the plan
deductible.
90% of the Negotiated Charge
after a $10 Co-pay per visit
75% of the Recognized Charge
Emergency Room Visit Expense. Important note: Please note that as Non-Preferred Care Pro-
viders do not have a contract with Aetna, the provider may not accept payment of your cost share
(your deductible and 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. Please
send Aetna the bill at the address listed on the back of your member ID card and Aetna will resolve
any payment dispute with the provider over that amount. Make sure your member ID number is on
the bill. The copay is in addition to the plan deductible.
after $150 Co-pay per visit
(Co-pay waived if admitted)
after $150 Deductible per visit
(Deductible waived if admitted)
Continued on next page
IMPORTANT NOTICE
This is just a brief description of your benets. For information regarding the full Master Policy (which includes plan benets, exclusions and limitations, and infor-
mation about refund requests, how to le a claim, mandated benets and other important information) please call Aetna Student Health at (866) 378-8885 or
send an email through your Aetna Navigator Account or at http://www.aetnastudenthealth.com/customer-service/customer-service.aspx
The Plan will pay benets in accordance with any applicable California State Insurance Law(s).

6

SCHEDULE OF BENEFITS (CONTINUED)
OUTPATIENT BENEFITS PREFERRED CARE NON-PREFERRED CARE
Urgent Care Expense. Please note: A covered person should not seek medical care or
treatment from an urgent care provider if their illness, injury, or condition, is an emergency
condition. The covered person should go directly to the emergency room of a hospital or call 911
for ambulance and medical assistance. The copay is in addition to the plan deductible.
Ambulance Expense 90% of the Negotiated Charge 90% of the Recognized Charge
Physicians Ofce Visit Expense. Copay is due at time of visit and is in addition to the
plan deductible.
Laboratory and X-Ray Expense 90% of the Negotiated Charge 75% of the Recognized Charge
Therapy Expense, for the following types of therapy provided on an outpatient basis:
Physical Therapy, Chiropractic Care, Speech Therapy, Inhalation Therapy, Cardiac
Rehabilitation, or Occupational Therapy. Benets for Chiropractic Care are limited to 50
visits per Policy Year.
Breast Feeding Durable Medical Equipment Expense, includes the rental or purchase
of breast feeding durable medical equipment for the purpose of lactation support.
Allergy Testing and Treatment Expense, includes laboratory tests, physician ofce visits
to administer injections, prescribed medications for testing and treatment of the allergy,
and other medically necessary supplies and services.
Payable on the same basis as any other Sickness
Routine Physical Exam Expense 100% of the Negotiated Charge 75% of the Recognized Charge
Pediatric Preventive Care Expense, for the comprehensive preventive care of children
16 years of age or younger, including periodic health evaluations, immunizations, and
lab services.
Pediatric Preventive Care Expense, for the comprehensive preventive care of children
17 and 18 years of age, including periodic health evaluations, immunizations, and lab
services.
MENTAL HEALTH BENEFITS PREFERRED CARE NON-PREFERRED CARE
Severe Mental Illness Expense - Inpatient, for the diagnosis and medically necessary
treatment of severe mental illnesses of a person of any age, and of serious emotional
disturbances of a child.
Payable as any other Sickness
Severe Mental Illness Expense - Outpatient 90% of the Negotiated Charge 75% of the Recognized Charge
Mental and Nervous Disorders Expense, inpatient and outpatient. 90% of the Negotiated Charge 75% of the Recognized Charge
ALCOHOLISM AND DRUG ADDICTION TREATMENT PREFERRED CARE NON-PREFERRED CARE
Inpatient Expense, for the treatment of alcohol and drug addiction. 90% of the Negotiated Charge 75% of the Recognized Charge
Outpatient Expense, for the treatment of alcohol and drug addiction. 90% of the Negotiated Charge 75% of the Recognized Charge

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SCHEDULE OF BENEFITS (CONTINUED)

MATERNITY BENEFITS PREFERRED CARE NON-PREFERRED CARE
Maternity Expense, for the care of the covered person and any newborn child. Payable on the same basis as any other Sickness
Well Newborn Nursery Care Expense, for the routine care of a covered persons
newborn child.
ADDITIONAL BENEFITS PREFERRED CARE NON-PREFERRED CARE
Prescribed Medicine Expense
Note: Contraceptive Drugs and Device benets are illustrated under the Family Planning
Benet, as noted in the Benets Description on page 8.
Student Health Center Pharmacy:
90% of the Actual Charge for each Prescription Drug
(Benet is on a reimbursement basis only.)
Preferred Care Pharmacy:
50% of the Negotiated Charge for each Brand Name Prescription
Drug or each Generic Prescription Drug
Non-Preferred Care Pharmacy:
50% of the Recognized Charge for each Brand Name Prescription
Drug or each Generic Prescription Drug
Pap Smear Screening Expense 100% of the Negotiated Charge 75% of the Recognized Charge
Mammogram Expense 100% of the Negotiated Charge 75% of the Recognized Charge
Family Planning Expense, includes charges incurred for services and supplies that are
provided to prevent pregnancy.
Routine Screening Expense, includes charges for Chlamydia, Sexually Transmitted
Disease, and Colorectal Cancer screenings.
Rehabilitation Facility Expense 90% of the Negotiated Charge 75% of the Recognized Charge
Cochlear Implant Expense, internally implanted devices. 90% of the Negotiated Charge 75% of the Recognized Charge
Adult Routine Eye Exam, eye exams for refraction. 100% of the Negotiated Charge 75% of the Recognized Charge
Elective Abortion Expense 90% of the Negotiated Charge 75% of the Recognized Charge
Bariatric Surgery Expense, expenses include services rendered as part of medically
necessary bariatric surgery treatment for morbid obesity.
Payable on the same basis as any other Sickness
Human Organ Transplant Expense Payable on the same basis as any other Sickness
Pediatric Vision Care Services and Supplies 100% of the Negotiated Charge 75% of the Recognized Charge
Pediatric Vision Care Exam Expense 100% of the Negotiated Charge 75% of the Recognized Charge
Pediatric Dental Diagnostic and Preventive Care 100% of the Negotiated Charge 75% of the Recognized Charge
Pediatric Dental Basic Restorative Care 70% of the Negotiated Charge 50% of the Recognized Charge
Pediatric Dental Major Restorative Care 50% of the Negotiated Charge 50% of the Recognized Charge
For more details about these benets, please see the Benet Descriptions section on page 8.

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BENEFIT DESCRIPTIONS
Routine Physical Exam Expense: Benets include expenses for a routine physi-
cal exam performed by a physician. If charges for a routine physical exam given
to a child who is a covered dependent are covered under any other benet sec-
tion, those charges will not be covered under this section.
A routine physical exam is a medical exam given by a physician, for a reason
other than to diagnose or treat a suspected or identied injury or sickness. In-
cluded as a part of the exam are:
Routine vision and hearing screenings given as part of the routine physical
exam.
X-rays, lab, and other tests given in connection with the exam, and
Materials for the administration of immunizations for infectious disease
and testing for tuberculosis.
In addition to any state regulations or guidelines regarding mandated Routine
Physical Exam services, Covered Medical Expenses include services rendered in
conjunction with,
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.
For females, screenings and counseling services as provided for in the
comprehensive guidelines recommended by the Health Resources and
Services Administration. These services may include but are not limited to:
Screening and counseling services, such as:
o Interpersonal and domestic violence;
o Sexually transmitted diseases*; and
o Human Immune Deciency Virus (HIV) infections.
Screening for gestational diabetes.
High risk Human Papillomavirus (HPV) DNA testing for women age 18 and
older and limited to once every three years.
*Sexually transmitted disease screening expense is limited to two screenings
per Policy Year.
X-rays, lab and other tests given in connection with the exam.
Immunizations for infectious diseases and the materials for administration
of immunizations that have been recommended by the Advisory
Committee on Immunization Practices of the Centers for Disease Control
and Prevention.
If the plan includes dependent coverage, for covered newborns, an initial
hospital check up.
Important Note:
For details on the frequency and age limits that apply to Routine Physi-
cal Exams and Routine Cancer Screenings, a covered person may contact
his or her physician or Member Services by logging onto the Aetna website
www.aetna.com or calling the toll-free number on the back of the ID card.
Screening and Counseling Services: Covered Medical Expenses include charges
made by a physician in an individual or group setting for the following:
Depression Screening: This service is limited to once per year.
Obesity: Screening and counseling services to aid in weight reduction due to
obesity. Coverage includes:
Preventive counseling visits and/or risk factor reduction intervention;
Medical nutrition therapy;
Nutritional counseling; and
Healthy diet counseling visits provided in connection with Hyperlipidemia
(high cholesterol) and other known risk factors for cardiovascular and
diet-related chronic disease.
Services in this category are subject to a combined limit of 26 individual or
group visits by any recognized provider per Policy Year.
The 10 Healthy Diet Counseling visits will be counted toward the total
number of visits allowed for Obesity counseling.
Misuse of Alcohol and/or Drugs: Screening and counseling services to aid in the
prevention or reduction of the use of an alcohol agent or controlled substance.
Coverage includes preventive counseling visits, risk factor reduction intervention
and a structured assessment.
group visits by any recognized provider per Policy Year.
Use of Tobacco Products: Screening and counseling services to aid a covered
person to stop the use of tobacco products.
Coverage includes:
Preventive counseling visits;
Treatment visits; and
Class visits;
To aid a covered person to stop the use of tobacco products.
Tobacco product means a substance containing tobacco or nicotine including:
cigarettes;
cigars;
smoking tobacco;
snuff;
smokeless tobacco; and
candy-like products that contain tobacco.
Limitations: Unless specied above, not covered under this Screening and
Counseling Services benet are charges incurred for:
Services which are covered to any extent under any other part of this Plan
group visits by an recognized provider per Policy Year.
Family Planning Expense: For females with reproductive capacity, Covered
Medical Expenses include those charges incurred for services and supplies that
are provided to prevent pregnancy. All services and supplies covered under this
benet must be approved by the Food and Drug Administration (FDA).
Coverage includes counseling services on contraceptive methods provided by a
physician, obstetrician or gynecologist. Such counseling services are Covered
Medical Expenses when provided in either a group or individual setting.
The following contraceptive methods are covered expenses under this benet:
Voluntary Sterilization: Covered expenses include charges billed separately by the
provider for female voluntary sterilization procedures and related services and sup-
plies including, but not limited to, tubal ligation and sterilization implants.
Covered expenses under this Preventive Care benet would not include charges for a
voluntary sterilization procedure to the extent that the procedure was not billed sepa-
rately by the provider or because it was not the primary purpose of a connement.
Limitations:
Unless specified above, not covered under this benefit are charges for:
Services which are covered to any extent under any other part of this Plan;
Services and supplies incurred for an abortion;
Services provided as a result of complications resulting from a voluntary
sterilization procedure and related follow-up care;
Services which are for the treatment of an identified illness or injury;
Services that are not given by a physician or under his or her direction;
Psychiatric, psychological, personality or emotional testing or exams;

9

BENEFIT DESCRIPTIONS (CONTINUED)
Any contraceptive methods that are only reviewed by the FDA and not
approved by the FDA;
Male contraceptive methods, sterilization procedures or devices;
The reversal of voluntary sterilization procedures, including any related
follow-up care.
Important note: Brand-Name Prescription Drug or Devices will be covered at
100% of the Negotiated Charge, including waiver of Annual Deductible if a Ge-
neric Prescription Drug or Device is not available in the same therapeutic drug
class or the prescriber species Dispense as Written.
Pediatric Preventive Care Expense: Covered Medical Expenses include charges
for the comprehensive preventive care of children 16 years of age or younger,
consistent with the Recommendations for Preventive Pediatric health Care, as
adopted by the American Academy of Pediatrics. Covered Medical Expenses will
include periodic health evaluations, immunizations and lab services.
Pediatric Preventive Care Expense: Covered Medical Expenses include charges
for the comprehensive preventive care of children 17 and 18 years of age, consis-
tent with the Recommendations for Preventive Pediatric health Care, as adopted
by the American Academy of Pediatrics. Covered Medical Expenses will include
periodic health evaluations, immunizations and lab services
Therapy Expense: Covered Medical Expenses include charges incurred by a cov-
ered person for the following types of therapy provided on an outpatient basis:
Physical Therapy,
Chiropractic Care,
Speech Therapy,
Inhalation Therapy,
Cardiac Rehabilitation, or
Occupational Therapy.
Expenses for Chiropractic Care are Covered Medical Expenses, if such care is
related to neuromusculoskeletal conditions and conditions arising from: the lack
of normal nerve, muscle, and/or joint function.
Expenses for Speech and Occupational Therapies are Covered Medical Expenses,
only if such therapies are a result of injury or sickness.
Covered Medical Expenses for chemotherapy, including anti-nausea drugs used
in conjunction with the chemotherapy, radiation therapy, tests and procedures,
physiotherapy (for rehabilitation only after a surgery), and expenses incurred
at a radiological facility. Covered Medical Expenses also include expenses for
the administration of chemotherapy and visits by a health care professional to
administer the chemotherapy.
Benets for these types of therapies are payable for Covered Medical Expenses,
on the same basis as any other sickness.
Allergy Testing and Treatment Expense: Benets include charges incurred for
diagnostic testing and treatment of allergies and immunology services.
Covered Medical Expenses include, but are not limited to, charges for the fol-
lowing:
laboratory tests,
physician office visits, including visits to administer injections, prescribed
medications for testing and treatment of the allergy, including any
equipment used in the administration of prescribed medication, and
other medically necessary supplies and services.
Severe Mental Illness of persons of any age and Serious Emotional Dis-
turbances of a Child Inpatient Expense: Covered Medical Expenses for the
diagnosis and medically necessary inpatient treatment of severe mental illnesses
of a person of any age, and of serious emotional disturbances of a child are pay-
able on the same basis as any other Sickness.
Covered Medical Expenses also include the charges made for treatment received
during partial hospitalization in a hospital or treatment facility. Prior review and ap-
proval must be obtained on a case-by-case basis by contacting Aetna Student Health.
Clinical Review Services for Minors - If clinical review services, as required by
the California Welfare and Institution Code, are provided for a covered person
who is a minor and who is conned in as a full-time inpatient in a private mental
health facility on the consent of his parent or guardian, the following charges will
be included as Covered Medical Expenses:
Charges for the clinical review services to the extent such services are
required by the California Welfare and Institution code,
Charges, if any, for services of an interpreter, and
Charges, if any, for services of a patients rights advocate.
Severe Mental Illness of persons of any age and Serious Emotional Dis-
turbances of a Child Outpatient Expense: Covered Medical Expenses for the
diagnosis and medically necessary outpatient treatment, including prescription
drugs, of severe mental illnesses of a person of any age, and of serious emotional
disturbances of a child are payable on the same basis as any other sickness.
Mental and Nervous Disorders Inpatient Expense: Covered Medical Expenses,
other than those for severe mental illness and/or serious emotional disturbances
of a child, include charges incurred by a covered person while conned as a full-
time inpatient in a hospital or residential treatment facility for the treatment of
mental and nervous disorders.
Covered Medical Expenses also include the charges made for treatment received
during partial hospitalization in a hospital or treatment facility. Prior review and
approval must be obtained on a case-by-case basis by contacting Aetna Student
Health.
Clinical Review Services for Minors: If clinical review services, as required by
the California Welfare and Institution Code, are provided for a covered person
who is a minor and who is conned in as a full-time inpatient in a private mental
health facility on the consent of his parent or guardian, the following charges will
be included as Covered Medical Expenses:
Charges for the clinical review services to the extent such services are
required by the California Welfare and Institution code,
Charges, if any, for services of an interpreter, and
Charges, if any, for services of patients rights advocate.
Mental and Nervous Disorders Outpatient Expense: Covered Medical Expens-
es, other than those for severe mental illness and/or serious emotional distur-
bances of a child, include charges for treatment of mental and nervous disorders
while the covered person is not conned as a full-time inpatient in a hospital.
Maternity Expense: Covered Medical Expenses include inpatient care of the cov-
ered person and any newborn child for a minimum of 48 hours after a vaginal
delivery and for a minimum of 96 hours after a cesarean delivery.
Any decision to shorten such minimum coverage shall be made by the attend-
ing Physician, in consultation with the mother. In such cases, Covered Medical
Expenses may include home visits, parent education, and assistance and training
in breast or bottle-feeding.
Prenatal diagnosis of genetic disorders of the fetus by means of diagnostic proce-
dures of a high-risk pregnancy, Maternity Expenses, and Complications of Preg-
nancy are payable on the same basis as any other Sickness.
Prenatal Care: Prenatal care will be covered for services received by a pregnant

10

female in a physicians, obstetricians, or gynecologists ofce but only to the
extent described below. Coverage for prenatal care under this benet is limited
to pregnancy-related physician ofce visits including the initial and subsequent
history and physical exams of the pregnant woman (maternal weight, blood
pressure and fetal heart rate check).
Comprehensive Lactation Support and Counseling Services: Covered Medical
Expenses will include comprehensive lactation support (assistance and training
in breast feeding) and counseling services provided to females during pregnancy
and in the post-partum period by a certied lactation support provider. The post-
partum period means the 60 day period directly following the childs date of
birth. Covered expenses incurred during the post-partum period also include the
rental or purchase of breast feeding equipment.
Lactation support and lactation counseling services are covered expenses when
provided in either a group or individual setting.
Well Newborn Nursery Care Expense: Benets include charges for routine care
of a covered persons newborn child as follows:
Hospital charges for routine nursery care during the mothers confinement,
but for not more than four days,
Physicians charges for circumcision, and
Physicians charges for visits to the newborn child in the hospital and
consultations, but for not more than 1 visit per day.
Pap Smear Screening Expense: Covered Medical Expenses include one routine
annual Pap smear screening (or an alternative cervical cancer screening test when
recommended by a physician or a health care provider), and an FDA approved
human papillomavirus screening test for women age 18 and older.
Mammogram Expense: Covered Medical Expenses include coverage for mam-
mograms for screening or diagnostic purposes upon referral of a nurse practitio-
ner, certied nurse-midwife, physician assistant, or physician.
BENEFIT DESCRIPTIONS (CONTINUED)
Pediatric Vision Care Services and Supplies: Covered expenses include charges
for the following vision care services and supplies:
Office visits to an ophthalmologist, optometrist or optician related to the
fitting of prescription contact lenses.
Eyeglass frames, prescription lenses or prescription contact lenses
Coverage includes charges incurred for:
Non-conventional prescription contact lenses that are required to correct
visual acuity to 20/40 or better in the better eye and that correction
cannot be obtained with conventional lenses. Aphakic prescription lenses
prescribed after cataract surgery has been performed.
Low vision services.
A listing of the locations of the vision network providers under this Plan can be
accessed at www.aetna.com website. Be sure to look at the appropriate vision
network provider listing that applies to your plan, since different Aetna plans
use different networks of providers. You must present your ID card to the vision
network provider at the time of service. This benet is subject to the maximums
shown on the Schedule of Benets. As to coverage for prescription lenses in a
calendar year, this benet will cover either prescription lenses for eyeglass frames
or prescription contact lenses, but not both.
Limitations: Unless specied above, not covered under this benet are charges
incurred for services and supplies:
Eyeglass frames, non-prescription lenses and non-prescription contact
lenses that are for cosmetic purposes.
Human Organ Transplant Expense: Transplants of organs, tissue, or bone marrow.
We provide or pay for donation-related Services for actual or potential donors (whether
or not they are Members) in accord with our guidelines for donor Services at no charge.

11
EXCLUSIONS & LIMITATIONS

IMPORTANT NOTICE: This is just a brief description of your benets. For infor-
mation regarding the full Master Policy (which includes plan benets, exclusions
and limitations, and information about refund requests, how to le a claim, man-
dated benets and other important information) please call Aetna Student Health
at (866) 378-8885 or send an email through your Aetna Navigator Account or at
www.aetnastudenthealth.com/customer-service/customer-service.aspx
Plan benets are subject to all applicable state and federal laws and regulations,
which are subject to change. The plan neither covers nor provides benets for
the following:
1. Expense incurred for services normally provided without charge by the Poli-
cyholders Health Service; Inrmary or Hospital; or by health care providers
employed by the Policyholder.
2. Expense incurred for eye refractions; vision therapy; radial keratotomy;
eyeglasses; contact lenses (except when required after cataract surgery);
or other vision or hearing aids; or prescriptions or examinations except as
required for repair caused by a covered injury.
3. Expense incurred as a result of injury due to participation in a riot. Partici-
pation in a riot means taking part in a riot in any way; including inciting
the riot or conspiring to incite it. It does not include actions taken in self-
defense; so long as they are not taken against persons who are trying to
restore law and order.
4. Expense incurred as a result of an accident occurring in consequence
of riding as a passenger or otherwise in any vehicle or device for aerial
navigation; except as a fare-paying passenger in an aircraft operated by
a scheduled airline maintaining regular published schedules on a regularly
established route.
5. Expense incurred as a result of an injury or sickness due to working for
wage or prot or for which benets are payable under any Workers Com-
pensation or Occupational Disease Law.
6. Expense incurred as a result of an injury sustained or sickness contracted
while in the service of the Armed Forces of any country. Upon the covered
person entering the Armed Forces of any country; the unearned pro-rata
premium will be refunded to the Policyholder.
7. Expense incurred for treatment provided in a governmental hospital unless
there is a legal obligation to pay such charges in the absence of insurance.
8. Expense incurred for elective treatment or elective surgery except as spe-
cically provided elsewhere in this Policy and performed while this Policy
is in effect.
9. Expense incurred for cosmetic surgery, reconstructive surgery, or other ser-
vices and supplies which improve, alter, or enhance appearance whether or
not for psychological or emotional reasons. This exclusion will not apply to the
extent needed to: (a) Improve the function or create a normal appearance
to the extent possible of a part of the body that is not a tooth or structure
that supports the teeth and is malformed as a result of a congenital defect,
including harelip, webbed ngers or toes, or as a direct result of disease or
surgery performed to treat a disease or injury; (b) Repair an injury (including
reconstructive surgery for prosthetic device for a covered person who has
undergone a mastectomy) which occurs while the covered person is covered
under this Policy. Surgery must be performed in the calendar year of the ac-
cident which causes the injury or in the next calendar year.
10. Expense covered by any other valid and collectible medical; health or ac-
cident insurance to the extent that benets are payable under other valid
and collectible insurance whether or not a claim is made for such benets.
11. Expense incurred as a result of commission of a felony.
12. Expense incurred after the date insurance terminates for a covered person
except as may be specically provided in the Extension of Benets Provision.
13. Expense incurred for services normally provided without charge by the
school and covered by the school fee for services.
14. Expense incurred for any services rendered by a member of the covered
persons immediate family or a person who lives in the covered persons
home.
15. Expense incurred for injury resulting from the play or practice of collegiate
or intercollegiate sports; including collegiate or intercollegiate club sports
and intramurals.
16. Expense for the contraceptive methods; devices or aids; and charges for
or related to articial insemination; in-vitro fertilization; or embryo transfer
procedures; elective sterilization or its reversal or elective abortion unless
specically provided for in this Policy.
17. Expenses for treatment of injury or sickness to the extent that payment is
made; as a judgment or settlement; by any person deemed responsible for
the injury or sickness (or their insurers).
18. Expense incurred for which no member of the covered persons immediate
family has any legal obligation for payment.
19. Expense incurred for custodial care. Custodial care means services and
supplies furnished to a person mainly to help him or her in the activities
of daily life. This includes room and board and other institutional care.
The person does not have to be disabled. Such services and supplies are
custodial care without regard to: by whom they are prescribed; or by whom
they are recommended; or by whom or by which they are performed.
20. Expense incurred for the removal of an organ from a covered person for the
purpose of donating or selling the organ to any person or organization. This
limitation does not apply to a donation by a covered person to a spouse;
child; brother; sister; or parent.
21. Expenses incurred for or in connection with procedures, services, or sup-
plies that are, as determined by Aetna, to be experimental or investiga-
tional. A drug, a device, a procedure, or treatment will be determined to be
experimental or investigational if: (a) There are insufcient outcomes data
available from controlled clinical trials published in the peer reviewed lit-
erature to substantiate its safety and effectiveness for the disease or injury
involved; or (b) If required by the FDA, approval has not been granted for
marketing or a recognized national medical or dental society or regulatory
agency has determined in writing that it is experimental, investigational,
or for research purposes; or (c) The written protocol or protocols used
by the treating facility, or the protocol or protocols of any other facility
studying substantially the same drug, device, procedure, or treatment, or
the written informed consent used by the treating facility, or by another
facility studying the same drug, device, procedure, or treatment, states
that it is experimental, investigational, or for research purposes. However,
this exclusion will not apply with respect to services or supplies (other than
drugs) received in connection with a disease if Aetna determines that:
(a) The disease can be expected to cause death within one year in the
absence of effective treatment; and (b) The care or treatment is effective
for that disease or shows promise of being effective for that disease as
demonstrated by scientic data. In making this determination; Aetna will
take into account the results of a review by a panel of independent medi-
cal professionals. They will be selected by Aetna. This panel will include

12

professionals who treat the type of disease involved; or (c) The covered
person has been accepted into a phase I, II, III, or IV approved cancer
clinical trial and the attending physician recommended the program. Also,
this exclusion will not apply with respect to drugs that: (a) Have been
granted treatment investigational new drug (IND) or Group c/treatment
IND status; or (b) Are being studied at the Phase III level in a national
clinical trial; sponsored by the National Cancer Institute if Aetna determines
that available, scientic evidence demonstrates that the drug is effective or
shows promise of being effective for the disease.
22. Expense incurred as a result of dental treatment; except for medically nec-
essary dental or orthodontic services that are an integral part of reconstruc-
tive surgery for cleft palate procedures as provided elsewhere in this Policy.
23. Expense incurred by a covered person; not a United States citizen; for ser-
vices performed within the covered persons home country; if the covered
persons home country has a socialized medicine program.
24. Expense incurred for alternative; holistic medicine; and/or therapy; includ-
ing but not limited to; yoga and hypnotherapy.
25. Expense for: (a) care of at feet; (b) supportive devices for the foot; (c)
care of corns; bunions; or calluses; (d) care of toenails; and (e) care of
fallen arches; weak feet; or chronic foot strain; except that (c) and (d) are
not excluded when medically necessary; because the covered person is
diabetic; or suffers from circulatory problems.
26. Expense for injuries sustained as the result of a motor vehicle accident; to
the extent that benets are payable under other valid and collectible insur-
ance; whether or not claim is made for such benets. The Policy will only
pay for those losses; which are not payable under the automobile medical
payment insurance Policy.
27. Expense incurred when the person or individual is acting beyond the scope
of his/her/its legal authority.
28. Expense incurred for hearing aids; the tting; or prescription of hearing
aids.
29. Expense for care or services to the extent the charge would have been
covered under Medicare Part A or Part B; even though the covered person
is eligible; but did not enroll in Part B.
30. Expense for telephone consultations; charges for failure to keep a sched-
uled visit; or charges for completion of a claim form.
31. Expense for the cost of supplies used in the performance of any occupa-
tional therapy.
32. Expense for personal hygiene and convenience items; such as air condition-
ers; humidiers; hot tubs; whirlpools; or physical exercise equipment; even
if such items are prescribed by a physician.
33. Expense for services or supplies provided for the treatment of obesity and/
or weight control, unless otherwise provided in this plan.
34. Expense for incidental surgeries; and standby charges of a physician.
35. Expense for treatment and supplies for programs involving cessation of
tobacco use, except as otherwise provided in this Plan.
36. Expense incurred for the use of orthotics; unless used exclusively to pro-
mote healing.
37. Expenses incurred for; or in connection with; speech therapy. This exclusion
does not apply for charges for speech therapy that is expected to restore
speech to a person who has lost existing function (the ability to express
thoughts; speak words; and form sentences); as a result of an accident
or sickness.
38. Expense for charges that are not recognized charges; as determined by
Aetna; except that this will not apply if the charge for a service; or supply;
does not exceed the recognized charge for that service or supply; by more
than the amount or percentage; specied as the Allowable Variation.
39. Expense for treatment of covered students who specialize in the mental
health care eld; and who receive treatment as a part of their training in
that eld.
40. Expenses for routine physical exams; including expenses in connection with
well newborn care; routine vision exams; routine dental exams; routine
hearing exams; immunizations; or other preventive services and supplies;
except to the extent coverage of such exams; immunizations; services; or
supplies is specically provided in the Policy.
41. Expense incurred for a treatment, service, or supply which is not medically
necessary as determined by Aetna for the diagnosis care or treatment of
the sickness or injury involved. This applies even if they are prescribed,
recommended, or approved by the persons attending physician; or dentist.
In order for a treatment, service, or supply to be considered medically
necessary, the service or supply must: (a) be care or treatment which
is likely to produce a signicant positive outcome as, and no more likely
to produce a negative outcome than, any alternative service or supply,
both as to the sickness or injury involved and the persons overall health
condition; (b) be a diagnostic procedure which is indicated by the health
status of the person and be as likely to result in information that could
affect the course of treatment as, and no more likely to produce a negative
outcome than, any alternative service or supply, both as to the sickness
or injury involved and the persons overall health condition; and (c) as to
diagnosis, care, and treatment, be no more costly (taking into account
all health expenses incurred in connection with the treatment, service, or
supply) than any alternative service or supply to meet the above tests. In
determining if a service or supply is appropriate under the circumstances,
Aetna will take into consideration: (a) information relating to the affected
persons health status; (b) reports in peer reviewed medical literature; (c)
reports and guidelines published by nationally recognized health care orga-
nizations that include supporting scientic data; (d) generally recognized
professional standards of safety and effectiveness in the United States
for diagnosis, care, or treatment; (e) the opinion of health professionals
in the generally recognized health specialty involved; and (f) any other
relevant information brought to Aetnas attention. In no event will the
following services or supplies be considered to be medically necessary:
(a) those that do not require the technical skills of a medical, a mental
health, or a dental professional; or (b) those furnished mainly for the
personal comfort or convenience of the person, any person who cares for
him or her, or any persons who is part of his or her family, any healthcare
provider, or healthcare facility; or (c) those furnished solely because the
person is an inpatient on any day on which the persons sickness or injury
could safely and adequately be diagnosed or treated while not conned, or
those furnished solely because of the setting if the service or supply could
safely and adequately be furnished in a physicians or a dentists ofce or
other less costly setting.
42. Expenses incurred for the treatment of acne.
Any exclusion above will not apply to the extent that coverage of the charges is
required under any law that applies to the coverage.
EXCLUSIONS & LIMITATIONS (CONTINUED)

13
COORDINATION OF BENEFITS
If the Covered Person is insured under more than one group health plan, the
benefits of the plan that covers the insured student will be used before those of
a plan that provides coverage as a dependent. When both parents have group
health plans that provide coverage as a dependent, the benefits of the plan of
the parent whose birth date falls earlier in the year will be used first. The benefits
available under this Plan may be coordinated with other benefits available to the
Covered Person under any auto insurance, Workers Compensation, Medicare,
or other coverage. The Plan pays in accordance with the rules set forth in the
Master Policy.
EXTENSION OF BENEFITS
If a Covered Person is conned to a hospital on the date his or her insurance
terminates, expenses incurred after the termination date and during the con-
tinuance of that hospital connement, shall be payable in accordance with the
policy, but only while they are incurred during the 30 day period, following such
termination of insurance.
HOW DO I FILE A CLAIM?
On occasion, the claims investigation process will require additional information
in order to properly adjudicate the claim. This investigation will be handled
directly by:
Aetna Student Health
P.O. Box 981106, El Paso, TX 79998
(866) 378-8885 (toll-free)
Customer Service Representatives are available 8:30 a.m. to 5:30 p.m. (PST),
Monday through Friday, for any questions. Claim forms can be obtained by
calling the number above or by visiting www.aetnastudenthealth.com.
1. Bills must be submitted within 90 days from the date of treatment.
2. Payment for Covered Medical Expenses will be made directly to the
hospital or Physician concerned unless bill receipts and proof of payment
are submitted.
3. If itemized medical bills are available at the time the claim form is
submitted, attach them to the claim form. Subsequent medical bills
should be mailed promptly to the above address.
4. In the event of a disagreement over the payment of a claim, a written
request to review the claim must be mailed to Aetna Student Health
within 180 days from the date appearing on the Explanation of Benefits
(EOB).
5. You will receive an Explanation of Benefits when your claims are
processed. The Explanation of Benefits will explain how your claim
was processed; according to the benefits of your Student Accident and
Sickness Insurance Plan.
ADDITIONAL DISCOUNTS AND SERVICES
As a member of the Plan, you can also take advantage of additional discounts,
and programs such as tness discounts and weight management programs.
These are not underwritten by Aetna and are NOT insurance. The member is
responsible for the full cost of the discounted services. Please note that these
programs are subject to change without notice. To learn more about these ad-
ditional services and search for providers visit, www.aetnastudenthealth.com.
HOW TO APPEAL A CLAIM
In the event a Covered Person disagrees with how a claim was processed, he/
she may request a review of the decision. The Covered Persons requests must
be made in writing within one hundred eighty (180) days of receipt of the
Explanation of Benets (EOB). The Covered Persons request must include why
he/she disagrees with the way the claim was processed. The request must
also include any additional information that supports the claim (e.g., medical
records, Physicians ofce notes, operative reports, Physicians letter of medical
necessity, etc.). Please submit all requests to:
Aetna
P.O. Box 14464
Lexington, KY 40512
NOTICE
Aetna considers non-public personal member information (NPI) confidential and
has policies and procedures in place to protect the information against unlawful
use and disclosure. When necessary for your care or treatment, the operation
of your health Plan, or other related activities, we use NPI internally, share it
with our affiliates, and disclose it to healthcare providers (doctors, dentists,
pharmacies, hospitals, and other caregivers), vendors, consultants, government
authorities, and their respective agents. These parties are required to keep NPI
confidential as provided by applicable law. Participating Network/Preferred Care
Providers are also required to give you access to your medical records within a
reasonable amount of time after you make a request. To obtain a copy of our
notice describing in greater detail our practices concerning use and disclosure of
NPI, please call the toll-free Customer Services number on your ID card or visit
Aetna Student Health on the internet at: www.aetnastudenthealth.com.

14

Accident: An occurrence which (a) is unforeseen, (b) is not due to or
contributed to by sickness or disease of any kind, and (c) causes injury.
Actual Charge: The charge made for a covered service by the provider who
furnishes it.
Coinsurance: The percentage of Covered Medical Expenses payable by Aetna
under this Accident and Sickness Insurance Plan.
Copay: This is a fee charged to a person for Covered Medical Expenses. For
Prescribed Medicines Expense, the copay is payable directly to the pharmacy
for each: prescription, kit, or refill, at the time it is dispensed. In no event will
the copay be greater than the pharmacys charge per: prescription, kit, or refill.
Covered Medical Expense: Those charges for any treatment, service or
supplies covered by this Policy which are:
not in excess of the recognized and customary charges, or
not in excess of the charges that would have been made in the absence
of this coverage, and
incurred while this Policy is in force as to the covered person except
with respect to any expenses payable under the Extension of Benefit
Provisions.
Covered person: A covered student and any covered dependent while coverage
under this Policy is in effect.
Deductible: The amount of Covered Medical Expenses that are paid by each
covered person during the policy year before benefits are paid.
Designated Care: Care provided by a Designated Care Provider upon referral
from the School Health Services.
Designated Care Provider: A health care provider (or pharmacy;) that is
affiliated; and has an agreement with the School Health Services to furnish
services and supplies at a negotiated charge.
Emergency Medical Condition: This means a recent and severe medical
condition, including, but not limited to, severe pain, which would lead a
prudent layperson possessing an average knowledge of medicine and health,
to believe that his or her condition, sickness, or injury, is of such a nature that
failure to get immediate medical care could result in:
Placing the persons health in serious jeopardy, or
Serious impairment to bodily function, or
Serious dysfunction of a body part or organ, or
In the case of a pregnant woman, serious jeopardy to the health of the
fetus.
Generic Prescription Drug or Medicine: A prescription drug which is not pro-
tected by trademark registration, but is produced and sold under the chemical
formulation name.
Hospice: 1. Hospice care means a centrally administered program of
palliative services and supportive services provided by an interdisciplinary
team directed by a physician. The program includes the provision of physical,
psychological, custodial and spiritual care for persons who are terminally ill and
their families. The care may be provided in the home, at a residential facility
or at a medical facility at any time of the day or night. The term includes the
supportive care and services provided to the family after the patient dies.
2. As used in this section: (a) Family includes the immediate family, the
person who primarily cared for the patient and other persons with significant
personal ties to the patient, whether or not related by blood.
(b) Interdisciplinary team means a group of persons who work collectively to
meet the special needs of terminally ill patients and their families and includes
such persons as a physician, registered nurse, social worker, clergyman and
trained volunteer.
Injury: Bodily injury caused by an accident. This includes related conditions
and recurrent symptoms of such injury.
Medically Necessary: A service or supply that is: necessary, and appropriate,
for the diagnosis or treatment of a sickness, or injury, based on generally
accepted current medical practice.
In order for a treatment, service, or supply to be considered medically
necessary, the service or supply must:
Be care or treatment which is likely to produce as significant positive
outcome as any alternative service or supply, both as to the sickness or
injury involved and the persons overall health condition. It must be no
more likely to produce a negative outcome than any alternative service
or supply, both as to the sickness or injury involved and the persons
overall health condition
Be a diagnostic procedure which is indicated by the health status of the
person. It must be as likely to result in information that could affect
the course of treatment as any alternative service or supply, both as to
the sickness or injury involved and the persons overall health condition.
It must be no more likely to produce a negative outcome than any
alternative service or supply, both as to the sickness or injury involved
and the persons overall health condition, and
As to diagnosis, care, and treatment, be no more costly (taking into
account all health expenses incurred in connection with the treatment,
service, or supply,) than any alternative service or supply to meet the
above tests.
In determining if a service or supply is appropriate under the circumstances,
Aetna will take into consideration:
information relating to the affected persons health status,
reports in peer reviewed medical literature,
reports and guidelines published by nationally recognized health care
organizations that include supporting scientific data,
generally recognized professional standards of safety and effectiveness
in the United States for diagnosis, care, or treatment,
the opinion of health professionals in the generally recognized health
specialty involved, and
any other relevant information brought to Aetnas attention.
In no event will the following services or supplies be considered to be medically
necessary:
Those that do not require the technical skills of a medical, a mental
health, or a dental professional, or
Those furnished mainly for: the personal comfort, or convenience, of the
person, any person who cares for him or her, or any person who is part
of his or her family, any healthcare provider, or healthcare facility, or
Those furnished solely because the person is an inpatient on any day
on which the persons sickness or injury could safely and adequately be
diagnosed or treated while not confined, or
Those furnished solely because of the setting if the service or supply
could safely and adequately be furnished, in a physicians or a dentists
office, or other less costly setting.
DEFINITIONS

15
Negotiated Charge: The maximum charge a Preferred Care Provider or

Designated Provider has agreed to make as to any service or supply for the
purpose of the benefits under this Policy.
Non-Preferred Care: A health care service or supply furnished by a health care
provider that is not a Designated Care Provider, or that is not a Preferred Care
Provider, if, as determined by Aetna:
the service or supply could have been provided by a Preferred Care
Provider, and
the provider is of a type that falls into one or more of the categories of
providers listed in the directory.
Non-Preferred Care Provider:
a health care provider that has not contracted to furnish services or
supplies at a negotiated charge, or
Pharmacy: An establishment where prescription drugs are legally dispensed.
Physician: (a) legally qualified physician licensed by the state in which he or
she practices, and (b) any other practitioner that must by law be recognized
as a doctor legally qualified to render treatment.
Preferred Care: Care provided by
a covered persons primary care physician, or a preferred care provider
of the primary care
physician, or
a health care provider that is not a Preferred Care Provider for an
emergency medical condition when travel to a Preferred Care Provider,
is not feasible, or
a Non-Preferred Urgent Care Provider when travel to a Preferred Urgent
Care Provider for treatment is not feasible, and if authorized by Aetna.
Preferred Care Provider: A health care provider that has contracted to furnish
services or supplies for a negotiated charge, but only if the provider is, with
Aetnas consent, included in the directory as a Preferred Care Provider for:
the service or supply involved, and
the class of covered persons of which you are member.
Preferred Pharmacy: A pharmacy, including a mail order pharmacy, which is
party to a contract with Aetna to dispense drugs to persons covered under this
Policy, but only:
while the contract remains in effect, and
while such a pharmacy dispenses a prescription drug, under the terms
of its contract with Aetna.
Prescription: An order of a prescriber for a prescription drug. If it is an oral
order, it must be promptly put in writing by the pharmacy.
Recognized Charge: Only that part of a charge which is recognized is covered.
The recognized charge for a service or supply is the lowest of:
The providers usual charge for furnishing it, and
The charge Aetna determines to be appropriate, based on factors such
as the cost of providing the same or a similar service or supply and the
manner in which charges for the service or supply are made, and
The charge Aetna determines to be the prevailing charge level made for
it in the geographic area where it is furnished.
In some circumstances, Aetna may have an agreement, either directly or
indirectly through a third party, with a provider which sets the rate that Aetna
will pay for a service or supply. In these instances, in spite of the methodology
described above, the recognized charge is the rate established in such
agreement.
In determining the recognized charge for a service or supply that is:
Unusual, or
Not often provided in the area, or
Provided by only a small number of providers in the area.
Aetna may take into account factors, such as:
The complexity,
The degree of skill needed,
The type of specialty of the provider,
The range of services or supplies provided by a facility, and
The prevailing charge in other areas.
DEFINITIONS (CONTINUED)

16

On Call International does not replace your medical insurance. All medical costs
incurred should be submitted to your health plan and are subject to the policy
limits of your health coverage. All assistance services must be arranged and pro-
vided by On Call International. Claims for reimbursement will not be accepted.
PROGRAM GUIDELINES
U.S. students studying in a U.S. location are eligible for services when traveling
more than 100 miles away from their permanent residence or campus location
for up to one year. Medical transportation services and repatriation of deceased
remains services are available at campus location.*
U.S. students studying abroad are eligible for services both at and away from
their new campus location for up to one year.*
Foreign national students studying in the U.S. are eligible for On Call Interna-
tionals services, both on or away from campus or while traveling in a country
that is not their country of origin.*
*Member shall be eligible for services during the term of his/her dened Pro-
gram as long as his/her program is still effective and the membership fee has
been paid prior to departure.
KEY SERVICES
Medical Monitoring: On Calls medical staff will communicate with the mem-
bers attending physician and obtain a full understanding of the situation. Medi-
cal professionals will stay in regular communication with local medical personnel
and relay necessary information to the Member and Family.
Emergency Medical Evacuation: If adequate medical facilities are not avail-
able locally, On Call will make arrangements to use whatever mode of transport,
equipment and medical personnel necessary to evacuate a member to the near-
est facility capable of providing a high standard of care.
Medical Repatriation: If after seeking medical attention, it is medically advis-
able for the member to seek further care at home, On Call will transport the
member home or to a medical facility closer to home with a medical or non-
medical escort, as necessary.
Compassionate Visit: If a member is traveling alone and will be hospitalized
for more than seven days, On Call will provide economy, round-trip, common
carrier transportation to the place of hospitalization and arrange lodging for a
designated family member or friend.
Care of Minor Children: If a member is traveling with dependent children and
is hospitalized as a result of a medical emergency for more than seven days,
On Call will arrange for the transportation of the unattended children to their
home, with an attendant if necessary.
Return of Deceased Remains: On Call will assist with the logistics of returning
a members remains home in the event of his or her death. This service includes
EMERGENCY ASSISTANCE SERVICES
Provided by On Call International
GLOBAL RESPONSE CENTER:
(877) 318-6901 (Toll-free within the U.S.)
(603) 328-1909 (Outside the U.S.)
One Delaware Drive Salem, NH 03079
E-mail: [email protected]
www.oncallinternational.com
arranging the preparation of the remains for transport, procuring required docu-
mentation, providing the necessary shipping container as well as paying for
transport.
Medical, Dental and Pharmacy Referrals: On Call will provide referrals to
medical, dental professionals and pharmacies in the given geographic locations
of western style medical facilities and English speaking providers in an area
served by On Call to the extent possible
Hospital Admission Guarantee: On Call will guarantee hospital admission by
validating a members health coverage or by advancing funds to the hospital.
(Any advance of funds shall be charged to the members credit card at the time
of service).
Prescription Assistance: If a member needs a replacement prescription while
traveling, On Call will assist in lling that prescription. Any expenses associated
with prescription replacement are the members responsibility.
Emergency Message Transmission: On Call will receive and transmit autho-
rized emergency messages for members.
Legal Consultation and Referral: If a member is away from home and re-
quires the services of an attorney, On Call shall arrange for an initial telephone
consultation with an attorney without charge to the member. If necessary, the
member will be referred to a local attorney.
Lost Luggage Assistance: On Call will assist the member with the tracking of
luggage lost or delayed in transit.
Lost/Stolen Travel Document Assistance: On Call will provide assistance by
arranging for the replacement of passports, visas, airline documents, birth cer-
ticates and other travel-related documents. Any expenses related to replacing
lost travel documents are the members responsibility.
Interpreter & Legal Referrals: On Call will refer members to local translators
and interpreters if communication problems cannot be solved via telephone.
Pre-trip Information: On Call offers members reports via email, fax or postal
mail including visa, passport and inoculation requirements, cultural information,
weather conditions, embassy and consulate referrals, foreign exchange rates,
and travel advisories for any destination.
As a member, you can call upon doctors, hospitals, pharmacies and other ser-
vices whenever traveling 100 miles or more from your permanent address,
campus location or abroad, 24 hours a day, 365 days a year. One phone
call connects you to a state-of-the art Global Response Center staffed around-
the-clock with trained multilingual professionals to handle medical emergen-
cies quickly and efciently. As the U.S. member of the International Assistance
Group, a 36-partner global network of independent assistance companies,
including more than 53 alarm centers, On Call International has immediate
response capabilities worldwide with a global network of pre-qualied medical
providers, including air and ground ambulance services.

17
Any treatment or expense related to childbirth, miscarriage or pregnancy

except for any abnormal pregnancy or vital complication of pregnancy
which endangers the life of the mother and/or unborn child during the
first twenty-four weeks of pregnancy.
A member on an organ transplant list prior to enrollment will not be
entitled to a transport for that transplant.
On Call cannot be held responsible for failure to provide services or for delays
caused by conditions beyond its control including, but not limited to, ight or
weather conditions, strikes, unforeseen changes to airport regulations or restric-
tions, failure to comply with On Calls recommendations, or where rendering of
service is prohibited by local laws or regulatory agencies.
Member may be required to release On Call or any healthcare provider from
liability during emergency evacuation and/or repatriation.
Without limiting the foregoing, On Calls actions and obligations under this
Agreement are ministerial in nature, and all medical care is provided by medical
professionals ultimately selected by a Member. On Call is not liable for any
malpractice performed by a local doctor, healthcare provider, or attorney.
On Call, at its sole discretion, will assist Members on a fee-for-service basis for
interventions falling under the Limitations and Uncovered Services. On Call re-
serves the right, at its sole discretion, to request additional nancial guarantees
or pre-payment or indemnication from the Member prior to rendering such
service on a fee-for-service basis.
CONDITIONS & EXCLUSIONS
On Call International will not pay for services in the following instances:
Services rendered without the coordination and approval of On Call
Intentionally self-inflicted injuries, suicide or any attempted threat except
when hospitalized as an inpatient.
Expenses incurred if the original or ancillary purpose of the members trip
is to obtain medical treatment.
Participation in a declared or undeclared act of war, civil disturbance or
insurrection or an accident occurring while the member is serving on
full-time or active duty in the Armed Forces of any country. *Participation
in an international authority flight in aircraft being used for experimental
purpose, or in military aircraft (except the Military Aircraft Command of
the United States or similar air transport Services Account of other) or
while serving as a member of the crew of any aircraft.
Use of any alcohol or drug unless prescribed by a physician or except
if hospitalized as an inpatient. *Any services provided to an injured
person where the member is entitled to receive reimbursement for
such expenses under any group insurance program maintained by the
members insurance company or employer.
Routine or non-disabling medical problems, such as simple fractures, or
sickness, which can be treated by local doctors and do not prevent the
injured person from continuing the trip or returning home.
EMERGENCY ASSISTANCE SERVICES (CONTINUED)
WELLS FARGO INSURANCE PRIVACY INFORMATION
We know that your privacy is important to you and we strive to protect the condentiality of your personal information. We do not disclose any personal information about our customers or former
customers to anyone, except as permitted or required by law (e.g., information you provide to us may be shared with your school to process your insurance transaction). To protect your personal
information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured les and buildings. You may obtain a
detailed copy of our privacy policy through your school or by calling us at (800) 853-5899 or by visiting us at studentinsurance.wellsfargo.com.
CLAIMS ADMINISTERED BY:
Claims and Coverage Questions
P.O. Box 981106
El Paso, TX 79998
(866) 378-8885 (toll-free)
www.aetnastudenthealth.com
PREFERRED CARE PROVIDER:
To Find a Doctor or Provider in the
Aetna Preferred Care Provider Network
Aetna Preferred Care Provider Network
(866) 381-1529 (toll-free)
http://www.aetna.com/docfind/custom/studenthealth
24-HOUR NURSE ADVICE: Aetna Informed Health
Line
(800) 556-1555
PRESCRIPTIONS: Aetna Pharmacy Management
(888) 792-3862
http://www.aetna.com/docfind/custom/studenthealth
EMERGENCY TRAVEL
ASSISTANCE:
(Provide this information to your
Emergency Contact)
On Call International
One Delaware Drive
Salem, NH 03079
(877) 318-6901 (Toll-free within the U.S.)
(603) 328-1909 (Outside the U.S.)
THE PLAN BROKERED BY:
Eligibility, Enrollment and
General Questions
Wells Fargo Insurance
CA License No. 0D08408
10940 White Rock Road, 2nd Floor
Rancho Cordova, CA 95670
(800) 853-5899
Fax: (877) 612-7966
studentinsurance.wellsfargo.com
IMPORTANT NOTE
The California State University International Student Health Insurance Plan is underwritten by Aetna Life Insurance Company (ALIC) and administered by Chickering Claims Administrators,
Inc. Aetna Student Health is the brand name for products and services provided by these companies and their applicable afliated companies.
This material is for information only and is not an offer or invitation to contract. Health insurance plans contain exclusions, limitations and benet maximums. Providers are independent
contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is believed
to be accurate as of the production date; however, it is subject to change. Policy forms issued in OK include: GR-96134.
NOTICE: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person les an application for insurance or statement of claim
containing any materially false information or who conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which
is a crime and subjects such person to criminal and civil penalties.
15.02.310.1 D
STUDENTS NAME
LAST / SURNAME
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
FIRST NAME
| | | | | | | | | | | | | | | | | | | | | | | | | | |
MIDDLE INITIAL
STUDENT I.D. # DATE OF BIRTH (Month, Day, Year)
U.S. MAILING ADDRESS
(Use school address if none)
STREET
| | | | | | | | | | | | | | | | | | | | | | | | |
APARTMENT #
CITY

STATE ZIP
PHONE # EMAIL ADDRESS (REQUIRED)
Please check appropriate box:
FEMALE MALE
Please check appropriate box:
SINGLE MARRIED
Please check appropriate box(es):
UNDERGRADUATE GRADUATE PRACTICAL TRAINING VISITING FACULTY SCHOLAR
VISA TYPE (if applicable: F-1, J-1, etc.) HOME COUNTRY: (if applicable)
PLEASE LIST DEPENDENTS TO BE INSURED BELOW. DEPENDENT COVERAGE IS AVAILABLE ONLY IF THE STUDENT IS ALSO INSURED.
(Dependents must be enrolled on the date the student is enrolled or within 31 days of date of birth, marriage, or arrival in U.S.)
SPOUSE LAST / SURNAME FIRST NAME MIDDLE INITIAL GENDER DATE OF BIRTH (Month, Day, Year)
CHILD LAST / SURNAME FIRST NAME MIDDLE INITIAL GENDER DATE OF BIRTH (Month, Day, Year)
EMERGENCY
CONTACT PERSON
NAME RELATIONSHIP PHONE #
EMAIL ADDRESS
Underwritten by Aetna Life Insurance Company (ALIC)
CSU LONG BEACH INTERNATIONAL - HEALTH INSURANCE PLAN
2014-2015 ENROLLMENT FORM
NEW
RENEWING
Wells Fargo Insurance Medical ID#
8 0
PLEASE SEE OTHER SIDE FOR RATES AND PAYMENT INFORMATION YOU MUST COMPLETE BOTH SIDES OF THIS ENROLLMENT FORM
WELLS FARGO INSURANCE PRIVACY INFORMATION
We know that your privacy is important to you and we strive to protect the condentiality of your personal information. We do not disclose any personal information about our customers or former customers to anyone, except as permitted or required
by law (e.g., information you provide to us may be shared with your school to process your insurance transaction). To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These
measures include computer safeguards and secured les and buildings. You may obtain a detailed copy of our privacy policy through your school or by calling us at (800) 853-5899 or by visiting us at studentinsurance.wellsfargo.com.
ID CARDS
Medical ID cards may be shipped before or within 3 weeks of your policy effective date. Providers need your Member ID# from your ID card to identify you, verify your
coverage and bill Aetna Life Insurance Company. You do not need an ID card to be eligible to receive benefits, if you need medical attention before receiving your ID card,
benefits will be payable according to the Policy. Once you have received your ID card, present it to the provider to facilitate prompt payment of your claim. You can also print
your ID cards at www.aetnastudenthealth.com.
You can view the standard Summary of Benefits & Coverage (SBC) which is required by Health Care Reform. It summarizes your coverage in a format that all insurance
companies now use. To view your plan SBC, go to: studentinsurance.wellsfargo.com or call 800-853-5899 to request a paper copy free of charge.
PAYMENT IN FULL IS
REQUIRED FOR THE
TERM PURCHASED
CSU LONG BEACH INTERNATIONAL - HEALTH INSURANCE PLAN
2014-2015 ENROLLMENT FORM
TERMS OF COVERAGE
ANNUAL
8/10/14 - 8/9/15
FALL
8/10/14 - 1/9/15
SPRING/SUMMER
1/10/15 - 8/9/15
Student only $1,046.91 $448.46 $619.59
NOTE: Costs below are in addition to the student premium. Dependents must be enrolled for the same term of coverage as student.
Spouse only $3,394.09 $1,429.11 $1,966.20
Per Child (Age 0-25) only $1,702.21 $717.05 $986.60
PAYMENT METHOD (Remit in US Funds Only):
To pay with a credit card visit studentinsurance.wellsfargo.com
Cashiers Check/Money Order (no personal checks) MAKE CHECKS PAYABLE TO: Wells Fargo Insurance
Mail or fax enrollment form and payment to: Wells Fargo Insurance, 10940 White Rock Road, 2nd Floor, Rancho Cordova, CA 95670 Fax (877) 612-7966
You may drop off your enrollment form and/or purchase a money order at the
CSULB Wells Fargo Bank Branch located on campus in the University Student Union
PAYMENT IN FULL IS
REQUIRED FOR THE
TERM PURCHASED
It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment or
ne. In addition, an insurer may deny insurance benets if false information materially related to a claim was provided by the applicant.
YOU MUST COMPLETE BOTH SIDES OF THE ENROLLMENT FORM AND SIGN BELOW
I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief, it is true and accurate with
no omissions or misstatements and I have read and understand the Plan Brochure. My signature below certies that I have read and understand the Student Health
Insurance Plan brochure and agree to accept as applicable to me the terms and conditions stated therein.
SIGNATURE OF STUDENT ___________________________________________________ DATE ______________________
NOTE: This is limited term coverage only. Coverage will end on the last date specied in the plan you select, unless you enroll to continue insurance
for an additional term. Premiums are calculated based on the plan term and will not be pro-rated.
CLAIMS ADMINISTERED BY:
Claims, Eligibility
and Coverage Questions
PO Box 981106
El Paso, TX 79998
(866) 378-8885 (toll-free)
TO FIND A
DOCTOR OR PROVIDER:
Aetna Life Insurance Co.
(866) 378-8885 (toll-free)
PRESCRIPTIONS:
Aetna Pharmacy
Management
(888) 792-3862
24-HOUR NURSE ADVICE:
Informed Health Line
(800) 556-1555
& TDD (800) 556-1555
24/7 EMERGENCY
TRAVEL ASSISTANCE:
On Call International
(877) 318-6901 (within U.S.)
Dial U.S. access code plus
(603) 328-1909 (Outside the U.S.)
THE PLAN BROKERED BY:
General Questions
Wells Fargo Insurance Services
USA, Inc.
CA License No. 0D08408
(800) 853-5899
studentinsurance.wellsfargo.com
Rates include premium payable to Aetna Life Insurance Company, as well as administrative fees payable to CSU and Wells Fargo Insurance. Rates also include Medical
Evacuation and Repatriation and Worldwide Emergency Travel Assistance benefits/services provided through On Call International and its contracted underwriting companies.

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2014-2015

studenti nsurance. wel l sfargo. com

CSU Long BeaCh - InternatIonaL

All international students, visiting faculty, scholars or other persons possessing

CSU Long BeaCh - InternatIonaL

to find out whether a specific provider

As an Aetna Student Health insurance member, you have access to Aetna

, your secure member website, packed with personalized benefits

and then the Access Navigator link.

WAIVER OF ANNUAL DEDUCTIBLE

CSU Long BeaCh - InternatIonaL

SCHEDULE OF BENEFITS (CONTINUED)

CSU Long BeaCh - InternatIonaL

Continued on next page

CSU Long BeaCh - InternatIonaL

EXCLUSIONS & LIMITATIONS

CSU Long BeaCh - InternatIonaL

CSU Long BeaCh - InternatIonaL

Negotiated Charge: The maximum charge a Preferred Care Provider or

CSU Long BeaCh - InternatIonaL

Any treatment or expense related to childbirth, miscarriage or pregnancy

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