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09-10_PSU_INT_AETNA-AETNA_FINAL

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					  Portland State University



STUDENT HEALTH INSURANCE
Brokered by:
Wells Fargo of California Insurance Services, Inc.
Student Insurance Division
                                                     2009-10 International




Underwritten by: Aetna Life Insurance Company
Policy # 474893
       CENTER FOR STUDENT HEALTH AND                                                          This brochure summarizes how the Student Health Insurance Plan (hereafter, “the
             COUNSELING (SHAC)                                                                Plan”) works, what it covers, and who to contact when needing medical services.
                                                                                              After you have read about the Plan, please keep these important facts in mind:
We are a primary health care clinic offering:
     Routine & Immediate Care                                                                    You will receive a Medical ID card 6-8 weeks from beginning of the first term
     Well Women’s Exams                                                                           you are eligible. As long as you continue to meet eligibility requirements
     STI and HIV Screenings                                                                       (see p. 3), your card will be valid all school year. You will not receive a
                                                                                                   new card each term. Please keep your insurance card with you at all times
     Mental Health and Psychiatry Services                                                        and show it to the provider when you seek medical treatment. The provider
     Reduced Cost Dental Care                                                                     will confirm your eligibility prior to receiving medical services. (You do
     Dispensary Services                                                                          not need your medical ID card when using SHAC services).
     Wellness Programs                                                                           When at all possible, go to the Center for Student Health and Counseling,
Eligible students can see a physician, nurse, or mental health clinician at no charge.             located at 1880 SW 6th Ave. Familiarize yourself with the hours of operation
The Basic health insurance included in the mandatory student health fee, will cover                and scope of services it offers. Visit www.shac.pdx.edu.
most labs and x-rays, however there is no prescription coverage.                                  When unable to go to the Center for Student Health and Counseling, you
If a student is prescribed a medication by one of our doctors, and we carry that                   may choose any other provider of your choice. The University has arranged
medication, they can fill the prescription at our dispensary window where we sell                  for you to access the Aetna Preferred Provider Network. It is to your
medications at a reduced cost. Students can pay for prescriptions by having their                  advantage to utilize a Preferred Provider because savings can be achieved
account billed, and submitting a receipt to Aetna Pharmacy Management for reim-                    from the Negotiated Charges these providers have agreed to accept as
bursement only if they have the Mandatory Supplemental Plan.                                       payment for their services. To find a Preferred Provider, you can use Aetna’s
Our professional staff consists of General and Family Medicine doctors, Psychiatrists,             online DocFind® service located on the Portland State University webpage
a Nurse Practitioner, Registered Nurses, Medical Assistants, Dentists, Hygienists,                 at www.aetnastudenthealth.com. Click on “Students: Find Your School”
an Oral Surgeon, a Registered Dietitian, Licensed Clinical Social Workers, Licensed                and enter your school name.
Psychologists; in addition SHAC trains MD, Social Work, and Psychology residents                  When required, please complete all forms accurately and respond promptly
and interns.                                                                                       to requests for information from Aetna Student Health in order to not delay
                                    SHAC HOURS:                                                    medical payments. It is the student’s responsibility to keep the school
         Hours subject to change. Please check www.shac.pdx.edu for updated hours.                 updated with contact information so as not to delay claim processing.
                 Mon – Thurs 8am – 6pm; Fri 8am – 5pm
             Summer and session breaks: Mon – Fri 8am – 5pm                                                   WHEN COVERAGE BEGINS
                             SHAC ADDRESS:                                                    Insurance under the Policy will become effective at 12:01 a.m. on the later of:
           1880 SW Sixth Avenue, Suite 200 Portland , OR 97201                                1. The Policy effective date; (See term dates on page 3)
                         PHONE: 503-725-2800                                                  2. The beginning date of the term for which premium has been paid;
                       WEBSITE: www.shac.pdx.edu                                              IMPORTANT NOTICE - Premiums will not be pro-rated if the Insured enrolls past
   CLOSEST HOSPITALS AND URGENT CARES IN CASE OF MEDICAL EMERGENCY:                           the first date of coverage for which he or she is applying. Final decisions regarding
Your insurance plan has what are called “Participating or Preferred Providers”. “Provider”    coverage effective dates are made by Aetna Student Health.
means any person or facility that provides medical care such as; doctors, urgent care or
immediate care centers, laboratories, hospitals, etc. You can choose any provider, however,   Please see term deadline dates on page 3. Coverage will begin on the start date for
choosing a “Participating Provider” means that costs may be significantly less to you. To     the period of coverage for which you are enrolled. No policy shall ever start prior to
verify if a provider participates in your AETNA insurance group, you can use AETNA’s online   the coverage period start date.
DocFind® service located at www.aetnastudenthealth.com. Click on “Find Your School” and
enter “Portland State University”.
                                                                                                                WHEN COVERAGE ENDS
                           OHSU: (503) 494-8311                                               Insurance of all Insured Persons terminates at 12:01 a.m. on the earlier of:
              3181 SW Sam Jackson Park Road, Portland, OR 97239                                   Date the policy terminates for all Insured Persons; or
               Legacy Good Samaritan Hospital: (503) 413-7711                                     End of the period of coverage for which premium has been paid; or
                  1015 NW 22nd Avenue, Portland, OR 97210                                         Date the Insured Person ceases to be eligible for the insurance; (i.e. if you
                                                                                                    drop below 5 credits before the Add/Drop deadline); or
                   Providence Medical Group: (503) 215-1111
                                                                                                  Date the Insured Person enters military service.
                       4805 NE Glisan, Portland, OR 97213
                                                                                              Coverage for the Basic Plan will automatically renew for Fall, Winter, Spring
                       The Portland Clinic: (503) 221-0161
                                                                                              and Summer, as long as you are taking 5 or more credits per term.
                     800 SW 13th Avenue, Portland, OR 97205
                    Zoom Care, Urgent Care: (503) 684-8252
                           SW, NW and SE Locations

•• Portland State University
       MANDATORY SUPPLEMENTAL PLAN                                                             attend classes for the first 30 consecutive days following their effective date for
                                                                                               the term purchased and/or pursuant to their visa requirements for the period
                                Term Coverage Dates                                            for which coverage is purchased, except in the case of medical withdrawal or
         FALL                 WINTER           SPRING                        SUMMER            during school authorized breaks. The company maintains its right to investigate
      9/20/09                  1/4/10                  3/29/10                6/21/10          student status and attendance records to verity that the Policy eligibility require-
      - 1/4/10               - 3/29/10                - 6/21/10              - 9/20/10         ments have been met.
                           Term Deadline Dates for Submitting:
                     Waivers (Accompanied by Proof of Insurance),                                                                   BASIC PLAN
  Enrollment Requests for; Scholars, OPT, Dependents, Alternate Vacation Term, Excused         Portland State University provides a health insurance program for all international
                     Medical Absence, Change of Level Term Break                               students taking five (5) PSU credit hours or more during the Fall, Winter, Spring and
                                                                                               Summer terms. The Basic Plan has a limited medical maximum of $7,500 per
     10/12/09              1/18/10                    4/12/10              7/5/10              condition per school year. It is automatically included in the Health Fee on the
              Cost Per Term                             Cost SP-SU Combined Fee                student’s tuition bill, and is designed to assist in reducing, but not eliminating some
              Fall & Winter                               Assessed Each Spring                 of the medical expense of most minor sicknesses and injuries.
      Student               $ 183                      Student             $ 366               If you drop below 5 credits during Fall, Winter, Spring or Summer terms, you will
        Spouse                 $ 249                    Spouse                 $ 498           lose access to the Center for Student Health and Counseling and may lose your
        Each Child               $ 194                 Each Child              $ 388           Basic insurance. Remember, if you are enrolled in the Supplemental Plan, you are
  Basic & Supplemental Insurance are both part of the International Plan which means           still required to pay for Basic Insurance, but will just lose your access to the Center
  all students & scholars enrolled in the Plan are required to purchase both Basic &           for Student Health and Counseling. Students are responsible for verifying their
  Supplemental.                                                                                credits and insurance eligibility when they add/drop classes each term.
  Basic Insurance ($63), is included in the $177 Health Service Tuition Fee.                   Note: Most Self-Support or course credits received from TV, Internet, Video or Satellite
                                                                                               are not eligible for this insurance. To verify the types of credits you are taking, you
  The Health Service Fee is for SHAC, the Center for Student Health & Counseling               may visit: http://www.pdx.edu/bao/tuition-fees-self-support-courses.
  located on campus, & is a mandatory tuition fee for all students taking 5 or more PSU
  credit hours during a term including students taking 5 or more credits in the Intensive
  English Language Program (IELP). If you are taking 5 or more regular PSU credits, you                               MANDATORY SUPPLEMENTAL PLAN
  will not see a separate fee; if you are taking 5 or more IELP credits, a separate fee will   Also offered is a Mandatory Supplemental Plan (major medical) that provides addi-
  appear on your account.. (Please note that students taking fewer than 5 credit hours         tional coverage of $95,000 per condition per year once the Basic benefits ($7,500
  are not eligible for Health Services on campus.)                                             per condition per year), have been paid.
  Students taking fewer than 5 PSU credit hours enrolled in the Supplemental Plan are
  still required to pay the Basic Insurance Fee ($63), but, will see the Basic Insurance                    WITHDRAWAL FROM SCHOOL
  Fee as a separate item on your bill.
                                                                                               If you leave Portland State University for reason of a covered accident or sickness,
  This applies for Scholars, & for Students on OPT, Vacation Term, Term Break Between          you may be eligible for continued coverage under this Plan for only the first term
  Change of Level, Excused Medical Leave, etc.                                                 immediately following your leave, provided you were enrolled in this Plan for the
                                                                                               term previous to your leave. Enrollment must be initiated by the student and is not
Rates include premium payable to Aetna Life Insurance Company as well as                       automatic. All applicable enrollment deadline dates apply. Contact your advisor at the
administrative fees payable to other third parties. Rates also include premiums                Office of International Affairs in East Hall.
and fees for Accidental Death and Dismemberment, Medical Evacuation and
Repatriation and Worldwide Emergency Travel Assistance benefits/services
provided through OnCall International and its contracted underwriting                                          PRE-EXISTING CONDITION
companies.
                                                                                               Basic Plan Pre-Existing Condition limitation: Expenses incurred by a Covered
                                                                                               Person as a result of a Pre-Existing Condition will not be considered Covered Medical
     HEALTH INSURANCE REQUIREMENT &                                                            Expenses unless the Covered Person has been covered under the Basic Policy or
                ELIGIBILITY                                                                    other creditable coverage for six consecutive months. This limitation is subject to all
                                                                                               other policy limitations; including benefits listed under the Outpatient section. See
Oregon law requires that all international students and scholars at Portland                   the definition of Pre-Existing Conditions in the definition section of this Brochure.
State University in F-1 & J-1 visa status and each dependent that accompanies                  Supplemental Plan Pre-Existing Condition limitation: Expenses incurred by a
you to the United States in F-2 & J-2 visa status have adequate medical insur-                 Covered Person as a result of a Pre-Existing Condition will not be considered Covered
ance coverage. It is the policy of Portland State University that these students               Medical Expenses unless (a) no charges are incurred or treatment rendered for the
purchase health insurance coverage through the University, unless they meet                    condition for a period of six months while covered under the Supplemental Policy;
the eligibility requirements for a waiver. This means that you and your depen-                 or (b) the covered person has been covered under the Supplemental Policy for six
                                                                                               consecutive months; or (c) the covered person has been covered under a policy
dents are required to have nonstop, year-round insurance coverage including                    considered creditable coverage, other than the Basic Policy, immediately prior to
vacation terms, whether you travel home or not. This also includes, thesis and                 becoming a covered person under the Supplemental Policy.
dissertation research periods, internship training periods, etc. as long as you
are on a valid PSU I-20 & DS-2019. Coverage is available, but not required,
for students engaged in Optional Practical Training. All students must actively
                                                                                                                                                    Portland State University ••
                  CONTINUOUSLY INSURED                                                              Serious impairment to bodily function; or
Persons who have remained continuously insured under the the Policy (Basic                          Serious dysfunction of a body part or organ; or
and/or Supplemental Plan), and prior student health insurance policies issued to                    In the case of a pregnant woman, serious jeopardy to the health of
the school, will be covered for any Pre-Existing Condition, which manifests itself                      the fetus.
while continuously insured. Except for expenses payable under prior policies in the             It does include an Accident or serious illness such as heart attack; stroke; poisoning; loss of
absence of the Policy. Previously Covered Persons must re-enroll for coverage by                consciousness or respiration; and convulsions. It does not include elective care; routine care;
the specified enrollment deadline dates in order to avoid a break in coverage for               care for non-emergency illness; or care required as a result of circumstances which would have
conditions which existed in prior policy years. Once a break in continuous coverage             been foreseen prior to the Covered Person’s departure from the University/College area.
occurs, the Pre-Existing Conditions Limitation will apply. Once a break in continuous           Generic Prescription Drug or Medicine: A Prescription Drug which is not protected by
coverage of 63 days or greater occurs, the Pre-Existing Conditions Limitation will              trademark registration; but is produced and sold under the chemical formulation name.
apply. The student is permitted to have a one vacation term or semester break per               Injury: Bodily injury caused by an accident. This includes related conditions and recurrent
policy year without restarting the pre-existing condition period.                               symptoms of such injury.
                                                                                                Medically Necessary: A service or supply that is: necessary; and appropriate; for the
         PREFERRED PROVIDER NETWORK
                                                                                                diagnosis or treatment of a Sickness; or Injury; based on generally accepted current
Aetna Student Health has arranged for you to access the Aetna Preferred                         medical practice.
Provider Network. It is to your advantage to utilize a Preferred Provider because               In order for a treatment; service; or supply to be considered Medically Necessary; the
savings can be achieved from the Negotiated Charges these providers have                        service or supply must:
agreed to accept as payment for their services. Students are responsible for                    - Be care or treatment which is likely to produce as significant positive outcome as any
informing their Physicians of potential out-of-pocket expenses for a referral to                alternative service or supply; both as to the Sickness or Injury involved and the person’s
both a Preferred Provider and a Non-Preferred Provider. Preferred Providers are                 overall health condition. It must be no more likely to produce a negative outcome than
independent contractors and are neither employees nor agents of Portland State                  any alternative service or supply; both as to the Sickness or Injury involved and the
University, Aetna Student Health, or Aetna Life Insurance Company. To find a                    person’s overall health condition
preferred provider, you can use Aetna’s online DocFind® service located at www.                 - Be a diagnostic procedure which is indicated by the health status of the person. It must
aetnastudenthealth.com. Click on “Find Your School” and enter your school                       be as likely to result in information that could affect the course of treatment as any
name. You can use DocFind® to find out whether a specific provider belongs to                   alternative service or supply; both as to the Sickness or Injury involved and the person’s
Aetna’s network or to find preferred providers practicing in your area.                         overall health condition. It must be no more likely to produce a negative outcome than
                                DEFINITIONS
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 actual charge made for a covered service by the provider who furnishes it.
Aggregate Maximum: The maximum benefit that will be paid under the Policy for all
Covered Medical Expenses incurred by a Covered Person that accumulate from one Policy
Year to the next.
Brand Name Prescription Drug or Medicine: A Prescription Drug which is protected by
trademark registration.
Coinsurance: The percentage of Covered Medical Expenses payable by Aetna under this
Accident and Sickness Insurance Plan.
Co-pay: The amount that must be paid by the Covered Person at the time services are rendered
by a Preferred Provider. Co-pay amounts are the responsibility of the Covered Person.
Covered Medical Expenses: Those charges for any treatment; service; or supplies;
covered by the Policy which are: (a) not in excess of the Reasonable and Customary
charges; or (b) not in excess of the charges that would have been made in the absence
of this coverage; and (c) incurred while the 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 or dependent whose coverage is in effect under the
Policy. See the Eligibility sections of this Brochure for additional information.
Deductible: A specific amount of Covered Medical Expenses that must be incurred
by; and paid for; by the Covered Person before benefits are payable under the Plan.
Deductible amounts are the responsibility of the Covered Person.
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 person’s health in serious jeopardy; or
•• Portland State University
                     DEFINITIONS                    (CONTINUED)                                    the contract remains in effect; and when the pharmacy dispenses a prescription drug under
                                                                                                   the terms of its contract with Aetna.
any alternative service or supply; both as to the Sickness or Injury involved and the
person’s overall health condition; and                                                             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.
- 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                  Reasonable Charge: Only that part of a charge which is reasonable is covered. The
alternative service or supply to meet the above tests.                                             Reasonable Charge for a service or supply is the lowest of:
In determining if a service or supply is appropriate under the circumstances; Aetna will
                                                                                                        The provider’s usual charge for furnishing it; and
take into consideration:                                                                                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
     Information relating to the affected person’s health status;                                         which charges for the service or supply are made; and
     Reports in peer reviewed medical literature;                                                      The charge Aetna determines to be the prevailing charge level made for it in
     Reports and guidelines published by nationally recognized healthcare                                 the geographic area where it is furnished.
        organizations that include supporting scientific data;                                     In some circumstances; Aetna may have an agreement; either directly or indirectly through
     Generally recognized professional standards of safety and effectiveness in the               a third party; with a provider which sets the rate that Aetna will pay for a service or supply.
        United States for diagnosis; care; or treatment;                                           In these instances; in spite of the methodology described above; the Reasonable Charge is
     The opinion of health professionals in the generally recognized health                       the rate established in such agreement.
        specialty involved; and                                                                    In determining the Reasonable Charge for a service or supply that is:
     Any other relevant information brought to Aetna’s attention.                                      Unusual; or
In no event will the following services or supplies be considered to be Medically Necessary:            Not often provided in the area; or
     Those that do not require the technical skills of a medical; a mental health;                     Provided by only a small number of providers in the area.
        or a dental professional; or                                                               Aetna may take into account factors, such as:
     Those furnished mainly for: the personal comfort; or convenience; of the                          The complexity;
        person; any person who cares for him or her; or any person who is part of his                   The degree of skill needed;
        or her family; any healthcare provider; or healthcare facility; or                              The type of specialty of the provider;
     Those furnished solely because the person is an inpatient on any day on which                     The range of services or supplies provided by a facility; and
        the person’s Sickness or Injury could safely and adequately be diagnosed or                     The prevailing charge in other areas.
        treated while not confined; or                                                             Sickness: A disease or illness including related conditions and recurrent symptoms of the
     Those furnished solely because of the setting, if the service or supply could                Sickness. Sickness also includes pregnancy and complications of pregnancy.
        safely and adequately be furnished; in a Physician’s or a dentist’s office; or
                                                                                                                PRE-CERTIFICATION PROGRAM
        other less costly setting.
Negotiated Charge: The maximum charge a Preferred Care Provider has agreed to make                 Pre-Admission Certification is designed to help you receive quality cost effective
as to any service or supply for the purpose of the benefits under this Plan.                       medical care. All requests for certification must be obtained by contacting Aetna
                                                                                                   Student Health. The following inpatient services require pre-certification:
Non-Preferred Care: A healthcare service or supply furnished by a healthcare provider
that is not a Preferred Care Provider; if, as determined by Aetna; (a) the service or supply           All inpatient admissions; including length of stay; to a hospital; convalescent
could have been provided by a Preferred Care Provider; and (b) the provider is of a type                  facility; skilled nursing facility; a facility established primarily for the treatment
that falls into one or more of the categories of providers listed in the Directory.                       of substance abuse; or a residential treatment facility.
Non-Preferred Care Provider (or Non-Preferred Provider): A healthcare provider that
                                                                                                       All inpatient maternity care; after the initial 48/96 hours.
has not contracted to furnish services or supplies at a Negotiated Charge.                             Pre-Certification does not guarantee the payment of benefits for your
                                                                                                          inpatient admission. Each claim is subject to medical policy review; in
Pharmacy: An establishment where prescription drugs are legally dispensed.                                accordance with the exclusions and limitations contained in the Policy; as well
Physician: A legally qualified physician licensed by the state in which he or she practices;              as a review of eligibility; adherence to notification guidelines; and benefit
and any other practitioner that must by law be recognized as a doctor legally qualified                   coverage under the Student Health Insurance Plan.
to render treatment.                                                                                   If you do not secure pre-certification for non emergency inpatient admissions;
Pre-Existing Condition: Any injury, sickness or condition for which a person received                     or provide notification for emergency admissions; your Covered Medical
treatment or services, or took prescribed drugs or medicines within six months of the                     Expenses will be subject to a $200 per admission Deductible.
Covered Person’s effective date of insurance.                                                      Notification of Emergency Admissions:
Preferred Care: Care provided by a Preferred Care Provider; or any healthcare provider for         The patient, patient’s representative; Physician or hospital must telephone within
an emergency condition when travel to a Preferred Care Provider is not feasible.                   one (1) business day following inpatient (or partial hospitalization) admission.
Preferred Care Provider (or Preferred Provider): A healthcare provider that has
contracted to furnish services or supplies for a Negotiated Charge; but only if the provider is,                                     Aetna Student Health
with Aetna’s consent; included in the Directory as a Preferred Care Provider for the service or                                 Attention: Managed Care Dept.
supply involved; and the class of which the Covered Person is a member.                                                                   P.O. Box 15708
Preferred Pharmacy: A pharmacy; including a mail order Pharmacy; which is party to a                                               Boston, MA 02215-0014
contract with Aetna to dispense drugs to persons covered under the Policy; but only while
                                                                                                                                  (877) 850-6062 (toll-free)
                                                                                                                                                              Portland State University ••
                                               SCHEDULE OF MEDICAL EXPENSE BENEFITS
In addition to the Plan’s Aggregate Maximum, the Policy may contain benefit level maximums. Please review this Summary of Benefits section for any additional benefit level
maximums. If you or your physician have any questions regarding benefits, please contact Aetna Student Health at (877) 850-6062.
Please refer to the Exclusions and Definitions listed in this Brochure for more detailed information on covered benefits.
The exact provisions governing this insurance are contained in the Master Policy issued to the University and may be reviewed through the Student Insurance Coordinator during
business hours.
 Basic Plan Policy Year Maximum                                                            $7,00 per Covered Accident or Illness. (Since not all benefits under the Basic
                                                                                           Plan are covered at 100%, you MAY be responsible for some out-of-pocket costs.)
 Mandatory Supplemental Plan Policy Year Maximum                                           $9,000 per Covered Accident or Illness
                                                                                           If Supplemental is purchased, the $95,000 is in addition to the Basic Plan
                                                                                           $7,500 plan maximum for a total of $102,500 per Covered Accident or Illness
                                                                                           per Policy Year. Benefits will be payable under the Supplemental Plan after
                                                                                           benefits have been exhausted under the Basic Plan.
 Basic Plan Policy Year Deductible (in addition to applicable Copays and/or                None
 Per Visit or Per Admission Deductibles)
 Supplemental Plan Policy Year Deductible (in addition to applicable Copays                $100 per individual
 and/or Per Visit or Per Admission Deductibles)
 Supplemental Plan Annual Out-Of-Pocket Maximum                                            Preferred Care: $2,500 per Individual;
                                                                                           Non-Preferred Care: $2,500 per Individual
If student carries any other type of insurance that would otherwise make benefit payments, the first $500 under the Basic Plan will be paid as primary, everything thereafter
will be paid as secondary.
 AFTER SUPPLEMENTAL DEDUCTIBLE, ELIGIBLE EXPENSES ARE COVERED AT:                                 BASIC PLAN                                SUPPLEMENTAL PLAN
 INPATIENT HOSPITAL EXPENSES                                                        PREFERRED CARE         NON-PREFERRED          PREFERRED CARE         NON-PREFERRED
                                                                                                                CARE                                         CARE
 Room and Board Expense, daily semi-private room rate; general nursing care                               60% of Reasonable
    provided by Hospital.                                                           75% of Negotiated     Charge after $250       100% of Negotiated     80% of Reasonable
                                                                                        Charge              Per Admission              Charge                 Charge
                                                                                                              Deductible
 Intensive Care Room and Board Expenses, benefits not to exceed 2.5 times                                 60% of Reasonable
    the semi-private room rate.                                                     75% of Negotiated     Charge after $250       100% of Negotiated     80% of Reasonable
                                                                                        Charge              Per Admission              Charge                 Charge
                                                                                                              Deductible
 Miscellaneous Hospital Expense, includes, amongst others, expenses incurred                              60% of Reasonable
    during a hospital confinement for: anesthesia and operating room; laboratory    75% of Negotiated     Charge after $250       100% of Negotiated     80% of Reasonable
    tests and x-rays; oxygen tent; and drugs; medicines; and dressings.                 Charge              Per Admission              Charge                 Charge
                                                                                                              Deductible
 Physician Hospital Visit Expense, benefits limited to one visit per day.           100% of Negotiated    60% of Reasonable       100% of Negotiated     80% of Reasonable
                                                                                     Charge after $20      Charge after $40
                                                                                      Copay per visit     Deductible per visit         Charge                 Charge
 Licensed Nurse Expense                                                             75% of Negotiated     60% of Reasonable
                                                                                          Charge          Charge after $250       100% of Negotiated     80% of Reasonable
                                                                                                            Per Admission             Charge                  Charge
                                                                                                              Deductible
 SURGICAL EXPENSES (INPATIENT AND OUTPATIENT)
 Surgical Expense, covered Medical Expenses for charges submitted by a physician.   75% of Negotiated     60% of Reasonable       100% of Negotiated     80% of Reasonable
                                                                                        Charge                 Charge                  Charge                 Charge
 Anesthetist & Assistant Surgeon Expense                                             20% of Surgical       20% of Surgical        100% of Negotiated     80% of Reasonable
                                                                                       Allowance             Allowance                 Charge                 Charge
 OUTPATIENT EXPENSES
 Physician’s Office Visit Expenses, limited to one visit per day. Copay waived      100% of Negotiated    60% of Reasonable       100% of Negotiated     80% of Reasonable
    when services performed at SHAC, and payable at 100% of Actual Charge.            Charge after $20      Charge after $25
                                                                                       Copay per visit     Deductible per visit        Charge                 Charge
 Emergency Room Visits, use of the emergency room and supplies. Copay/              100% of Negotiated    100% of Reasonable      100% of Negotiated     80% of Reasonable
   Per Visit Deductible waived if admitted.                                          Charge after $150     Charge after $150
                                                                                       Copay per visit     Deductible per visit        Charge                 Charge
•• Portland State University                                                  Continued on Next Page
AFTER SUPPLEMENTAL DEDUCTIBLE, ELIGIBLE EXPENSES ARE COVERED AT:                                  BASIC PLAN                             SUPPLEMENTAL PLAN
OUTPATIENT EXPENSES (CONTINUED)                                                                            NON-PREFERRED                            NON-PREFERRED
                                                                                    PREFERRED CARE                               PREFERRED CARE
                                                                                                                CARE                                      CARE
Ambulatory Surgical Expense                                                         75% of Negotiated     60% of Reasonable     100% of Negotiated 80% of Reasonable
                                                                                        Charge                 Charge                Charge              Charge
Chemotherapy & Radiation Therapy Expense, including anti-nausea drugs               75% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
   used in conjunction with chemotherapy.                                               Charge                Charge                 Charge               Charge
Hospital Outpatient Department or Walk-In Visit Expense                             75% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
                                                                                        Charge                Charge                 Charge               Charge
MENTAL HEALTH AND SUBSTANCE ABUSE EXPENSES
Inpatient Mental Health and Substance Abuse Expense, include charges
   made for treatment received during partial hospitalization in a hospital or
                                                                                   100% of Negotiated    60% of Reasonable
   treatment facility. Prior review and approval must be obtained from Aetna                                                    100% of Negotiated   80% of Reasonable
                                                                                    Charge after $20      Charge after $40
   Student Health. When approved, benefits will be payable in place of an                                                            Charge               Charge
                                                                                     Copay per visit     Deductible per visit
   inpatient admission, whereby 2 days of partial hospitalization may be
   exchanged for 1 day of full hospitalization.
Outpatient Mental Health Expense, Copay waived when services performed             100% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
   at SHAC, and payable at 100% of Actual Charge.                                   Charge after $20      Charge after $40
                                                                                     Copay per visit     Deductible per visit        Charge               Charge
Outpatient Substance Abuse Expense                                                 100% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
                                                                                    Charge after $20      Charge after $40
                                                                                     Copay per visit     Deductible per visit        Charge               Charge
ADDITIONAL EXPENSES
Pap Smear Screening Expense, annual screening for women 18 and
                                                                                   100% of Negotiated    60% of Reasonable
   older, and anytime upon referral from a woman’s health care provider.                                                        100% of Negotiated   80% of Reasonable
                                                                                    Charge after $20      Charge after $40
   Copay waived when services performed at SHAC, and payable at 100% of                                                              Charge               Charge
                                                                                     Copay per visit     Deductible per visit
   Actual Charge.
Mammogram Expense, Covered Medical Expenses include: Mammograms for
   the purpose of diagnosis in symptomatic or high-risk women at any time upon     100% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
   referral of the woman’s health care provider; and an annual mammogram for        Charge after $20      Charge after $40
   the purpose of early detection for a woman 40 years of age or older, with or      Copay per visit     Deductible per visit        Charge               Charge
   without referral from the woman’s health care provider.
Breast Exam Expense, Covered Medical Expenses include breast exams,
   including a clinical breast exam performed by a health care provider to check
   for lumps and other changes for the purpose of breast cancer detection and      100% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
   prevention. This expense will be paid annually for women 18 and older, and       Charge after $20      Charge after $40
   at any time as recommended by woman’s health care provider. This benefit          Copay per visit     Deductible per visit        Charge               Charge
   is payable even if the provider performs other preventive services or makes
   referrals for other exams at the same appointment.
Well Newborn Care                                                                                                               100% of Negotiated   80% of Reasonable
                                                                                       Not Covered           Not Covered             Charge               Charge
Diagnostic X-Ray Expense, Copay waived when services performed at SHAC ,           100% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
   and payable at 100% of Actual Charge                                             Charge after $20      Charge after $40
                                                                                     Copay per visit     Deductible per visit        Charge               Charge
Diagnostic Laboratory Expense                                                      100% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
                                                                                         Charge                Charge                Charge               Charge
Physical and Occupational Therapy Expense                                          100% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
                                                                                    Charge after $20      Charge after $40
                                                                                     Copay per visit     Deductible per visit        Charge               Charge
High Cost Procedure Expense, Covered Procedures in excess of $200,                  75% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
    such as, but not limited to outpatient diagnostic C.A.T. scans, Magnetic
    Resonance Imaging and Laser Treatments                                              Charge                Charge                 Charge               Charge
Chiropractic and Acupuncture Expense, benefits limited to a combined                75% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
    maximum of 10 visits per Policy Year for Basic Plan; $300 maximum                Charge after $20     Charge after $40
    combined per Policy Year for Supplemental Plan.                                   Copay per visit    Deductible per visit        Charge               Charge
Allergy Testing or Treatment Expense                                                75% of Negotiated    60% of Reasonable      100% of Negotiated   80% of Reasonable
                                                                                          Charge               Charge                Charge               Charge
                                                                               Continued on Next Page
                                                                                                                                           Portland State University •7•
 AFTER SUPPLEMENTAL DEDUCTIBLE, ELIGIBLE EXPENSES ARE COVERED AT:                                 BASIC PLAN                              SUPPLEMENTAL PLAN
 ADDITIONAL EXPENSES                                                               PREFERRED CARE          NON-PREFERRED          PREFERRED CARE     NON-PREFERRED
                                                                                                                CARE                                      CARE
 Testing for Learning Disability/ Attention Deficit Disorder Expense, Copay       100% of Negotiated 60% of Reasonable           100% of Negotiated    80% of Reasonable
    waived when service performed at SHAC, and payable at 100% of Actual           Charge after $20        Charge after $40
    Charge.                                                                         Copay per visit       Deductible per visit        Charge                Charge
 Consultant or Specialist Physician Expense, when requested/approved by           75% of Negotiated       60% of Reasonable      100% of Negotiated    80% of Reasonable
    attending Physician.                                                           Charge after $20        Charge after $25
                                                                                    Copay per visit       Deductible per visit        Charge                Charge
 Maternity Expense                                                                75% of Negotiated       60% of Reasonable      100% of Negotiated    80% of Reasonable
                                                                                      Charge                   Charge                 Charge                Charge
 Elective Abortion Expense, benefits limited to $2,500 per Policy Year            75% of Negotiated       60% of Reasonable
                                                                                                                                    Not Covered           Not Covered
                                                                                      Charge                   Charge
 Family Planning Expense, charges by a physician or hospital for a                75% of Negotiated       60% of Reasonable
    vasectomy or tubal ligation for voluntary sterilization. Covered Medical                                                        Not Covered           Not Covered
    Expenses do not include the reversal of a sterilization procedure.                Charge                   Charge
 Diabetic Supplies, including needles/syringes, test strips, diabetic test
    agents, glucose tablets, lancets, lancets/lancing devices; and alcohol                                                         Covered under         Covered under
                                                                                  75% of Negotiated       60% of Reasonable       Prescription Drug     Prescription Drug
    swabs; insulin and oral hypoglycemics as well as blood glucose                    Charge                   Charge
                                                                                                                                  Expense benefit       Expense benefit
    monitors.
 Outpatient Diabetic Self-Management Education Program Expense                    100% of Negotiated      60% of Reasonable      100% of Negotiated    80% of Reasonable
                                                                                   Charge after $20        Charge after $40           Charge                Charge
                                                                                    Copay per visit       Deductible per visit
 Prosthetic Devices Expense                                                                                                      100% of Negotiated    80% of Reasonable
                                                                                      Not Covered             Not Covered             Charge                Charge
 Durable Medical Equipment Expense                                                                                               100% of Negotiated    80% of Reasonable
                                                                                      Not Covered             Not Covered             Charge                Charge
 Ambulance Expense                                                                75% of Reasonable Charge to a maximum of               80% of Reasonable Charge
                                                                                               $750 per trip
 Dental Expense, benefits limited $100 per tooth for treatment made
    necessary for injury to sound, natural tooth; maximum of $500 per Policy               75% of Reasonable Charge                      80% of Reasonable Charge
    Year for wisdom teeth removal.
 Elemental Enteral Formula Expense, limited to home use only                      75% of Negotiated       60% of Reasonable      100% of Negotiated    80% of Reasonable
                                                                                      Charge                   Charge                 Charge                Charge
 Hospice Expense, benefits limited to $4,000 maximum per Policy Year.                 Not Covered             Not Covered        100% of Negotiated    80% of Reasonable
                                                                                                                                      Charge                Charge
 Home Health Care Expense                                                             Not Covered             Not Covered        100% of Negotiated    80% of Reasonable
                                                                                                                                      Charge                Charge
 Intercollegiate Sports, payable to a maximum of $3,000 per policy year               Not Covered             Not Covered        100% of Negotiated    80% of Reasonable
                                                                                                                                      Charge                Charge
 Routine Colorectal and Prostate Cancer Screening Expense one annual              100% of Negotiated      60% of Reasonable      100% of Negotiated    80% of Reasonable
    exam or once every 5 years for ages 50+                                            Charge                  Charge                 Charge                Charge
 Prescription Drug Expense, includes diabetic testing supplies; prescription                                                       Generic Drugs:      Generic Drugs:
    contraceptives. Benefits limited to $,00 maximum per Policy Year.                                                          100% of Negotiated 100% of Reasonable
    Medication not covered by this benefit include, but are not limited to:                                                       Charge after $15    Charge after $15
    drugs whose sole purpose is to promote or stimulate hair growth; appetite                                                      Copay per visit   Deductible per visit
    suppressants; smoking deterrents; immunization agents and vaccines; and                                                        Preferred Brand     Preferred Brand
    non-self-injectables.                                                                                                        Name Drugs: 100% Name Drugs: 100%
    Please Note: You are required to pay in full at the time of service for all       Not Covered             Not Covered           of Negotiated       of Reasonable
                                                                                                                                  Charge after $25    Charge after $25
    Prescriptions dispensed at a Non-Participating Pharmacy, including SHAC.                                                       Copay per visit   Deductible per visit
                                                                                                                                 Non-Preferred Brand Non-Preferred Brand
                                                                                                                                 Name Drugs: 100% Name Drugs: 100%
                                                                                                                                    of Negotiated       of Reasonable
                                                                                                                                  Charge after $40    Charge after $40
                                                                                                                                   Copay per visit   Deductible per visit
•• Portland State University
          NON-DUPLICATION OF BENEFITS                                                             cept as a fare paying passenger in an aircraft operated by a scheduled airline
                                                                                                  maintaining regular published schedules on a regularly established route.
After the Basic Plan pays $500, benefits under the Basic Plan are reduced if a covered      5.    Expense incurred as a result of an injury or sickness due to working for wage
student:                                                                                          or profit or for which benefits are payable under any Workers’ Compensation
     a) Is covered by any other group or blanket health care plan; and other such                 or Occupational Disease Law.
         coverage makes payment on any expenses; and                                        6.    Expense incurred as a result of an injury sustained or sickness contracted
     b) Would, as a result, receive Medical Expense or service benefits in excess of              while in the service of the Armed Forces of any country. Upon the covered
         the actual expenses incurred.                                                            person entering the Armed Forces of any country; the unearned pro rata
In this case, the medical expense benefits the Basic Plan will pay will be reduced by             premium will be refunded to the Policyholder.
such Excess, and benefits payable under this Basic Plan up to the Annual Maximum
Benefits as indicated in the Schedule of Medical Expense Benefits (see page 6).             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.
                    GENERAL PROVISIONS                                                            However, this exclusion will not apply where prohibited by law. It does not
                                                                                                  apply to services rendered at any hospital owned or operated by the state of
State Mandated Benefits: These plans will always pay benefits in accordance                       Oregon or any state approved community mental health and developmental
with any applicable Oregon Insurance Law(s). Mandated benefits include: Pros-                     disabilities program.
tate Screening Exam; Prescription Contraceptive Drugs and Devices; Elemental
Enteral Formula for home use; and Colorectal Cancer Screening.                              8.    Expense incurred for elective treatment or elective surgery except as specifi-
                                                                                                  cally provided elsewhere in this Policy and performed while this Policy is in
Reimbursement and Subrogation:                                                                    effect.
When a covered person’s injury appears to be someone else’s fault, benefits                 9.    Expense incurred for cosmetic surgery; reconstructive surgery; or other ser-
otherwise payable under this Policy for Covered Medical Expenses incurred as                      vices and supplies which improve; alter; or enhance appearance; whether or
a result of that injury will not be paid unless the covered person or his legal                   not for psychological or emotional reasons; except to the extent needed to:
representative agrees:                                                                                Improve the function of a part of the body that: is not a tooth or struc-
     (a) to repay Aetna for such benefits to the extent they are for losses for                          ture that supports the teeth; and is malformed: as a result of a severe
     which compensation is paid to the covered person by or on behalf of the                             birth defect; including harelip; webbed fingers; or toes; or
     person at fault;                                                                                 as direct result of disease; or surgery performed to treat a disease or
     (b) to allow Aetna a lien on such compensation and to hold such compensa-                           injury.
     tion in trust for Aetna; and                                                                     Repair an injury (including reconstructive surgery for prosthetic device
     (c) to execute and give to Aetna any instruments needed to secure the                               for a covered person who has undergone a mastectomy;) which
     rights under (a) and (b).                                                                           occurs while the covered person is covered under this Policy. Surgery
Further, when Aetna has paid benefits to or on behalf of the injured covered                             must be performed in the calendar year of the accident which causes
person, Aetna will be subrogated to all rights or recovery that the covered per-                         the injury; or in the next calendar year.
son has against the person at fault. These subrogation rights will extend only to           10.   Expense incurred as a result of preventive medicines; serums; vaccines.
recovery of the amount Aetna has paid. The covered person must execute and
deliver any instruments needed and do whatever else is necessary to secure                  11.   Expense incurred as a result of commission of a felony.
those rights to Aetna.                                                                      12.   Expense incurred after the date insurance terminates for a covered person
                                                                                                  except as may be specifically provided in the Extension of Benefits Provi-
              EXCLUSIONS & LIMITATIONS                                                            sion.
The Plan neither covers nor provides benefits for the following:                            13.   Expense incurred for any services rendered by a member of the covered
1. Expense incurred for services normally provided without charge by the Poli-                    person’s immediate family or a person who lives in the covered person’s
      cyholder’s Health Service; Infirmary or Hospital; or by health care providers               home.
      employed by the Policyholder.                                                         14.   Expense incurred by a covered person not a United States Citizen for ser-
2. Expense incurred for eye refractions; vision therapy; radial keratotomy;                       vices performed within the covered person’s home country.
      eyeglasses; contact lenses (except when required after cataract surgery);             15.   Expense incurred for treatment of temporomandibular joint dysfunction and
      or other vision or hearing aids; or prescriptions or examinations except as                 associated myofascial pain.
      required for repair caused by a covered injury.                                       16.   Expense for the contraceptive methods; devices or aids; and charges for or
3. Expense incurred as a result of injury due to participation in a riot. “Participa-             related to artificial insemination; in vitro fertilization; or embryo transfer
      tion in a riot” means taking part in a riot in any way; including inciting the              procedures; elective sterilization or its reversal or elective abortion unless
      riot or conspiring to incite it. It does not include actions taken in self defense;         specifically provided for in this Policy.
      so long as they are not taken against persons who are trying to restore law           17.   Expense incurred for which no member of the covered person’s immediate
      and order.                                                                                  family has any legal obligation for payment.
4. Expense incurred as a result of an accident occurring in consequence of riding           18.   Expenses incurred for or in connection with: procedures; services; or supplies
      as a passenger or otherwise in any vehicle or device for aerial navigation; ex-             that are; as determined by Aetna; to be experimental or investigational. A



                                                                                                                                              Portland State University •9•
          EXCLUSIONS AND LIMITATIOMS                                                      26. Expense incurred for custodial care; private duty nursing services and sup-
                               (CONTINUED)                                                      plies; provided by a sanitarium; or rest cures. Custodial care means services
                                                                                                and supplies furnished to a person; mainly to help him or her in the activities
      drug; a device; a procedure; or treatment will be determined to be experi-                of daily life. This includes room and board and other institutional care. The
      mental or investigational if:                                                             person does not have to be disabled. Such services and supplies are custodial
           There are insufficient outcomes data available from controlled clinical             care without regard to:
             trials published in the peer reviewed literature; to substantiate its                   by whom they are prescribed; or
             safety and effectiveness; for the disease or injury involved; or
                                                                                                     by whom they are recommended; or
           If required by the FDA; approval has not been granted for marketing;
             or                                                                                      by whom or by which they are performed.
           A recognized national medical or dental society or regulatory agency          27.   Expense incurred when the person or individual is acting beyond the scope of
             has determined; in writing; that it is experimental; investigational; or           his/her/its legal authority.
             for research purposes; or                                                    28.   Expense incurred for hearing aids; the fitting; or prescription of hearing aids.
           The written protocol or protocols used by the treating facility; or the       29.   Expense for telephone consultations; charges for failure to keep a scheduled
             protocol or protocols of any other facility studying substantially the             visit; or charges for completion of a claim form.
             same drug; device; procedure; or treatment; or the written informed          30.   Expense for the cost of supplies used in the performance of any occupational
             consent used by the treating facility; or by another facility studying the         therapy.
             same drug; device; procedure; or treatment; states that it is experimen-     31.   Expense for personal hygiene and convenience items; such as air condition-
             tal; investigational; or for research purposes.                                    ers; humidifiers; hot tubs; whirlpools; or physical exercise equipment; even if
      However, this exclusion will not apply with respect to services or supplies               such items are prescribed by a physician.
      (other than drugs) received in connection with a disease; if Aetna determines       32.   Expense for services or supplies provided for the treatment of obesity and/or
      that:                                                                                     weight control.
           The disease can be expected to cause death within one year; in the            33.   Expense for incidental surgeries; and standby charges of a physician.
             absence of effective treatment; and The care or treatment is effective       34.   Expense for treatment and supplies for programs involving cessation of to-
             for that disease; or shows promise of being effective for that disease;            bacco use.
             as demonstrated by scientific data. In making this determination;
             Aetna will take into account the results of a review by a panel of inde-     35.   Expense incurred for injury resulting from the play or practice of intercolle-
             pendent medical professionals. They will be selected by Aetna. This                giate sports in excess of $3,000 per Policy Year (participating in sports clubs;
             panel will include professionals who treat the type of disease involved.           or intramural athletic activities; is not excluded).
             Also, this exclusion will not apply with respect to drugs that:              36.   Expense for contraceptive methods; devices or aids; and charges for services
                  Have been granted treatment investigational new drug (IND); or                and supplies for or related to gamete intrafallopian transfer; artificial insemi-
                  Group c/treatment IND status; or Are being studied at the Phase III           nation; in-vitro fertilization (except as required by the state law); or embryo
                  level in a national clinical trial; sponsored by the National Cancer          transfer procedures; elective sterilization or its reversal; or elective abortion;
                  Institute; If Aetna in conjunction with the Oregon Health Resources           unless specifically provided for in this Policy.
                  Commission determines that available; scientific evidence demon-        37.   Expenses incurred for massage therapy.
                  strates that the drug is effective; or shows promise of being effec-    38.   Expenses incurred for; or in connection with: speech therapy. This exclusion
                  tive; for the disease.                                                        does not apply for charges for speech therapy that is expected to restore
19.   Expenses incurred for gastric bypass; and any restrictive procedures, for                 speech to a person who has lost existing function (the ability to express
      weight loss.                                                                              thoughts; speak words; and form sentences); as a result of an accident or
20.   Expenses incurred for breast reduction/mamoplasty.                                        sickness.
21.   Expenses incurred for gynecal mastea (male breasts).                                39.   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;
22.   Expenses incurred for any sinus surgery; except for acute purulent sinusitis.             does not exceed the recognized charge for that service or supply; by more
23.   Expense incurred for alternative; holistic medicine; and/or therapy; including            than the amount or percentage; specified as the Allowable Variation.
      but not limited to; yoga and hypnotherapy.                                          40.   Expense for charges that are not reasonable charges; as determined by
24.   Expense for: (a) care of flat feet; (b) supportive devices for the foot; (c)              Aetna; except that this will not apply if the charge for a service; or supply;
      care of corns; bunions; or calluses; (d) care of toenails; and (e) care of                does not exceed the reasonable charge for that service or supply; by more
      fallen arches; weak feet; or chronic foot strain; except that (c) and (d) are             than the amount or percentage; specified as the Allowable Variation.
      not excluded when medically necessary; because the covered person is                41.   Expense for treatment of covered students who specialize in the mental
      diabetic; or suffers from circulatory problems.                                           health care field; and who receive treatment as a part of their training in
25.   Expense for injuries sustained as the result of a motor vehicle accident; to              that field.
      the extent that benefits are payable under other valid and collectible insur-       42.   Expenses for treatment of injury or sickness to the extent payment is made;
      ance; whether or not claim is made for such benefits. The Policy will only                as a judgment or settlement; by any person deemed responsible for the
      pay for those losses; which are not payable under the automobile medical                  injury or sickness (or their Insurers).
      payment insurance Policy.
•10• Portland State University
EXCLUSIONS AND LIMITATIONS                                        (CONTINUED)
                                                                                          Any exclusion above will not apply to the extent that coverage is specifically
                                                                                          provided by name in the Policy; or coverage of the charges is required under
43. Expenses for routine physical exams; including expenses in connection with            any law that applies to the coverage.
      well newborn care; routine vision exams; routine dental exams; routine hear-
      ing exams; immunizations; or other preventive services and supplies; except                          EXTENSION OF BENEFITS
      to the extent coverage of such exams; immunizations; services; or supplies is       If a Covered Person is confined to a hospital on the date his or her insurance
      specifically provided in the Policy.                                                terminates, expenses incurred after the termination date and during the
44.   Expense incurred for a treatment; service; or supply; which is not medically        continuance of that hospital confinement shall be payable in accordance with
      necessary; as determined by Aetna; for the diagnosis care or treatment of           the policy, but only while they are incurred during the 90 day period, following
      the sickness or injury involved. This applies even if they are prescribed;          such termination of insurance.
      recommended; or approved; by the person’s attending physician; or dentist.          Termination of Insurance
      In order for a treatment; service; or supply; to be considered medically nec-       Benefits are payable under the Policy only for those Covered Expenses incurred
      essary; the service or supply must:                                                 while the policy is in effect as to the Covered Person. No benefits are payable
       be care; or treatment; which is likely to produce a significant positive          for expenses incurred after the date the insurance terminates, except as may be
          outcome as; and no more likely to produce a negative outcome than; any          provided under the Extension of Benefits provision.
          alternative service or supply; both as to the sickness or injury involved;
          and the person’s overall health condition;
                                                                                                        HOW DO I FILE A CLAIM?
       be a diagnostic procedure which is indicated by the health status of the          On occasion, the claims investigation process will require additional information
          person; and be as likely to result in information that could affect the         in order to properly adjudicate the claim. This investigation will be handled
          course of treatment as; and no more likely to produce a negative outcome        directly by:                  Aetna Student Health
          than; any alternative service or supply; both as to the sickness or injury
          involved; and the person’s overall health condition; and                                          P.O. Box 170, Boston, MA 01-001
                                                                                                                    (77) 0-0 (toll-free)
       as to diagnosis; care; and treatment; be no more costly (taking into
          account all health expenses incurred in connection with the treatment;          Customer Service Representatives are available 8:30 a.m. to 5:30 p.m. (PST),
          service; or supply); than any alternative service or supply to meet the         Monday through Friday, for any questions.
          above tests.                                                                    1. Payment for Covered Medical Expenses will be made directly to the
       In determining if a service or supply is appropriate under the circumstances;            hospital or Physician concerned unless bill receipts and proof of payment
       Aetna will take into consideration: information relating to the affected                 are submitted.
       person’s health status; reports in peer reviewed medical literature; reports       2. If itemized medical bills are available at the time the claim form is
       and guidelines published by nationally recognized health care organizations              submitted, attach them to the claim form. Subsequent medical bills should
       that include supporting scientific data; generally recognized professional stan-         be mailed promptly to the above address.
       dards of safety and effectiveness in the United States for diagnosis; care; or     3. In the event of a disagreement over the payment of a claim, a written
       treatment; the opinion of health professionals in the generally recognized               request to review the claim must be mailed to Aetna Student Health within
       health specialty involved; and any other relevant information brought to                 180 days from the date appearing on the Explanation of Benefits (EOB).
       Aetna’s attention.                                                                 4. You will receive an “Explanation of Benefits” when your claims are processed.
       In no event will the following services or supplies be considered to be medi-            The Explanation of Benefits will explain how your claim was processed;
       cally necessary:                                                                         according to the benefits of your Student Health Insurance Plan.
        those that do not require the technical skills of a medical; a mental
           health; or a dental professional; or
                                                                                                         HOW TO APPEAL A CLAIM
        those furnished mainly for the personal comfort or convenience of the            In the event a Covered Person disagrees with how a claim was processed;
           person; any person who cares for him or her; or any persons who is part        he/she may request a review of the decision. The Covered Person’s requests
           of his or her family; any healthcare provider; or healthcare facility; or      must be made in writing within 180 days of receipt of the Explanation of Benefits
                                                                                          (EOB). The Covered Person’s request must include why he/she disagrees with
        those furnished solely because the person is an inpatient on any day             the way the claim was processed. The request must also include any additional
           on which the person’s sickness or injury could safely; and adequately;
                                                                                          information that supports the claim (e.g., medical records, Physician’s office
           be diagnosed; or treated; while not confined; or those furnished solely
                                                                                          notes; operative reports; Physician’s letter of medical necessity; etc.).
           because of the setting; if the service or supply could safely and ade-
           quately be furnished in a physician’s or a dentist’s office; or other less                               Please submit all requests to:
           costly setting.                                                                                               Aetna Student Health
                                                                                                              P.O. Box 15717, Boston, MA 02215-0014
45.   Expenses incurred as a result of dental treatment; except for treatment result-
                                                                                                   If the dispute is not resolved, you may also write or call the:
      ing from injury to sound natural teeth or for extraction of impacted wisdom
      teeth as provided elsewhere in this Policy.                                                                 Office of Insurance Commissioner
46.   Expenses incurred for: care, treatment, services, or supplies; for or related to                                 Consumer Advocacy Unit
      obstructive sleep apnea; and sleep disorders; including CPAP and UPAP.                              350 Winter Street NE, Room 440, P.O. Box 14480
47.   Expense incurred for; or related to; sex change surgery; or to any treatment                                     Salem, OR 97309-0405
      of gender identity disorder.                                                                         (503) 947-7984 or (888) 877-4894 (toll-free)

                                                                                                                                         Portland State University •11•
  PRESCRIPTION DRUG CLAIM PROCEDURE                                                      Need help with registering onto Aetna Navigator®
                                                                                         Registration assistance is available toll free, Monday through Friday, from 7
When obtaining a covered prescription, please present your ID card to a Preferred        a.m. to 9 p.m. Eastern Time at 1-800-225-3375.
Pharmacy, along with your applicable co-pay. The pharmacy will bill Aetna for
the cost of the drug, plus a dispensing fee, less the co-pay amount.                      ADDITIONAL DISCOUNTS AND SERVICES
When you need to fill a prescription and do not have your ID card, you may               As a member of the Plan, you can also take advantage of the following services,
obtain your prescription from an Aetna Preferred Pharmacy, and be reimbursed             discounts, and programs. These are not underwritten by Aetna. To learn
by submitting a completed Aetna Prescription Drug claim form found at www.               more about these additional services and search for providers, visit www.
aetnastudenthealth.com. You will be reimbursed for covered medications, less             aetnastudenthealth.com.
your co-pay. Prescriptions from a Non-Preferred Pharmacy must be paid for in             Aetna VisionSM Discount Program1 – The Aetna Vision discount program helps
full at time of service, and submitted for reimbursement.                                you save on many eye care products, including sunglasses, contact lenses, non-
If a plan covers prescription drugs it must cover off label drugs that are medically     prescription sunglasses, contact lens solutions and other eye care accessories.
necessary and meet the criteria for use as an off label drug as stated in Oregon         Plus, you can receive up to a 15% discount on LASIK surgery (the laser vision
law. If an urgent condition exists, the plan must cover prescription drugs               correction procedure).
rendered in or provided by a rural clinic.                                               Aetna Beginning Right Maternity Management Program® 2 – The tools you
                                    NOTICE                                               need to give your baby a healthy start. You will have a one-on-one relationship
                                                                                         with an obstetrics-trained nurse and a physician – in person, by phone or through
Aetna considers non-public personal member information (“NPI”) confidential              a website – throughout your pregnancy and up to four months after delivery.
and has policies and procedures in place to protect the information against              Support will be available for depression, pre-term labor, dental screening and
unlawful use and disclosure. When necessary for your care or treatment, the              healthy initiatives, such as smoking.
operation of your health Plan, or other related activities, we use NPI internally,       Fitness Program1 – Aetna’s Fitness Program provides members with access to
share it with our affiliates, and disclose it to healthcare providers (doctors,          services provided by GlobalFit™, the nation’s most comprehensive provider of
dentists, pharmacies, hospitals, and other caregivers), vendors, consultants,            fitness clubs and programs supporting members’ healthy lifestyles. Members can
government authorities, and their respective agents. These parties are required          access GlobalFit’s national network of nearly 10,000 fitness clubs at preferred
to keep NPI confidential as provided by applicable law. Participating Network/           rates* or GlobalFit’s other programs and services, such as at-home weight loss
Preferred Providers are also required to give you access to your medical records         programs, home fitness options and even one-on-one health coaching services.
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   *At some clubs, participation may be restricted to new club members.
of NPI, please call the toll-free Customer Services number on your ID card or visit                              AFTER HOURS NURSE ADVICE
Aetna Student Health on the internet at: www.aetnastudenthealth.com.
                                                                                         Now you can talk to a Registered Nurse any time the Center for Student Health
      MEMBER WEB: AETNA NAVIGATOR®                                                       and Counseling is closed by calling (503) 725-2800. The Portland State
Got Questions? Get Answers with Aetna Navigator®                                         University Nurse Line can help you by:
As an Aetna Student Health insurance member, you have access to Aetna                        Answering questions about any type of sickness or injury.
Navigator®, your secure member website, packed with personalized benefits                    Determining if you need to go to the emergency room.
and health information. You can take full advantage of our interactive website               Deciding whether you need to make an appointment with your doctor.
to complete a variety of self-service transactions online.                                   And much more.
By logging into Aetna Navigator®, you can:
    Review who is covered under your plan.                                              The Portland State University Nurse Line provides valuable, current information
    Request member ID cards.                                                            to help you make important decisions regarding your health.
    View Claim Explanation of Benefits (EOB) statements.
    Estimate the cost of common healthcare services and procedures to better            The Portland State University Nurse Line also provides access to:
      plan your expenses.                                                                    Highly experienced Registered Nurses.
    Research the price of a drug and learn if there are alternatives.                       www.IntelliNurse.com – An on-line health resource that provides links to
    Find healthcare professionals and facilities that participate in your plan.               trusted federal health resources.
    Send an e-mail to Aetna Student Health Customer Service at your                         Our Audio Health Library – a convenient, confidential way to access hundreds
      convenience.                                                                             of prerecorded messages on an array of healthcare topics ranging from the
    View the latest health information and news, and more!                                    common cold to heart disease.
How do I register?
    Go to www.aetnastudenthealth.com                                                    Please keep in mind, The Portland State University Nurse Line is not a substitute
    Click on “Find Your School.”                                                        for medical attention. If you have an emergency medical condition, please call
    Enter your school name and then click on “Search.”                                  911 or your local emergency medical services number.
    Click on Aetna Navigator® and then the “Access Navigator” link.
    Follow the instructions for First Time User by clicking on the “Register            Aetna Natural Products and ServicesSM Program1, 2 – Save on acupuncture,
      Now” link.                                                                         chiropractic care, massage therapy and dietetic counseling. Also, save on over-
    Select a user name, password and security phrase.                                   the-counter vitamins, herbal and nutritional supplements and other health-
                                                                                         related products. All products and services are delivered through American
                                                                                         Specialty Health Networks, Inc. and Healthyroads, Inc.
•1• Portland State University
      ADDITIONAL DISCOUNTS & SERVICES                                                             $2,500 Emergency Return Home in the event of death or life-threatening
                                  (CONTINUED)                                                       illness of a parent or sibling

Health and Wellness Portal2 – This dynamic, interactive website will give you                  Worldwide Emergency Travel Assistance (WETA) Services. On Call provides
healthcare and assessment tools to calculate body mass index, financial health,                the following travel assistance services:
risk activities and health and wellness indicators. The site provides resources for                24/7 Emergency Travel Arrangements
wellness programs and activities.                                                                  Translation Assistance
Quit & Fit TM 2 – This tobacco cessation program that will provide support and collaboration       Emergency Travel Funds Assistance
as you quit smoking. A coaching program can be combined with counseling, interactive
web tools and education. You will also be eligible for awards and rewards.                         Lost Luggage and Travel Documents Assistance
  1
     Discount programs provide access to discounted prices and are NOT insured benefits.
                                                                                                   Assistance with Replacement of Credit Card/Travelers Checks
    The member is responsible for the full cost of the discounted services. Discounts              24/7 U.S. Nurse Help Line
    are subject to change without notice. Discount programs may not be available in                Medical/Dental/Pharmacy Referral Service
    all states. Discount programs may be offered by vendors who are independent                    Hospital Deposit Arrangements
    contractors and not employees or agents of Aetna.
  2
                                                                                                   Dispatch of Physician
      Health information programs provide general health information and are not
    a substitute for diagnosis or treatment by a physician or other healthcare                     Emergency Medical Record Assistance
    professionals.                                                                                 Legal Referral
               ON CALL INTERNATIONAL                                                               Bail Bonds Assistance
Chickering Claims Administrators, Inc. (CCA) has contracted with On Call Inter-                NOTE: In order to obtain coverage, all MER and WETA services must be
national (On Call) to provide Covered Persons with access to certain accidental                provided and arranged through On Call. Reimbursement will NOT be
death and dismemberment benefits, worldwide emergency travel assistance                        provided for any such services not provided and arranged through On Call.
services and other benefits. A brief description of these benefits is outlined                 Although certain medical services may be covered under the terms of the
below.                                                                                         Covered Person’s student health insurance plan (the “Plan”), On Call does
                                                                                               not provide coverage for medical treatment rendered by doctors, hospi-
            Accidental Death and Dismemberment (ADD) Benefits                                  tals, pharmacies or other health care providers. Coverage for such services
Benefits are payable for the Accidental Death and Dismemberment of Covered                     will be provided in accordance with the terms of the Plan and exclusions
Persons, up to a maximum of Ten Thousand Dollars ($10,000).                                    and limitations may apply.
NOTE: For most school plans, ADD benefits are provided by Aetna Life                           To obtain MER and WETA benefits/services, or for any questions related to
Insurance Company (ALIC). However, in some states, ADD benefits may be                         those benefits/services, please call On Call International at the following
provided through a contractual relationship between Chickering Claims                          numbers listed on the On Call ID card provided to Covered Persons when
Administrators, Inc. (CCA) and On Call International (On Call). ADD cover-                     they enroll in the Plan: Toll Free 1- (866) 525-1956 or collect 1-(603)
age provided through On Call is underwritten by United States Fire Insurance                   328-1956. All Covered Persons should carry their On Call ID cards when
Company (USFIC). Please refer to your school’s policy to determine whether                     traveling.
ALIC or USFIC underwrites ADD benefits for your specific Plan. Should you
have questions or need to file a claim please contact (866) 378- 8885.                         CCA and On Call are independent contractors and not employees or
                                                                                               agents of the other. CCA provides access to certain ADD, MER and WETA
   MEDICAL EVACUATION AND REPATRIATION (MER) AND WORLDWIDE                                     benefits/services through a contractual arrangement with On Call. How-
 EMERGENCY TRAVEL ASSISTANCE (WETA) SERVICES PROVIDED THROUGH                                  ever, neither CCA nor any of its affiliates underwrites or administers
                  ON CALL INTERNATIONAL, INC.                                                  any MER or WETA benefits/services. Neither CCA nor any of its affiliates
Chickering Claims Administrators, Inc. (CCA) has contracted with On Call In-                   underwrites or administers any ADD benefits that are provided through
ternational, Inc. (On Call) to provide Covered Persons with access to certain                  On Call. Neither CCA nor any of its affiliates is responsible in any way
Medical Evacuation and Repatriation (MER) and Worldwide Emergency Travel                       for the benefits/services provided by or through On Call, USFIC or VSC.
Assistance (WETA) benefits and/or services.                                                    Premiums/fees for benefits/services provided through On Call, USFIC and
Medical Evacuation and Repatriation (MER) Benefits. The following benefits                     VSC are included in the Rates outlined in this brochure.
are underwritten by Virginia Surety Company (VSC), with medical and travel
assistance services provided by On Call. These benefits are designed to assist
Covered Persons when traveling in a foreign country or when 100 or more miles
from their primary residence, whether on campus or on a trip.
    Unlimited Emergency Medical Evacuation
    Unlimited Medically Supervised Repatriation
    Unlimited Return of Mortal Remains
    Visit by Family Member/Friend During Hospitalization
    Return of Traveling Companion

                                                                                                                                           Portland State University •1•
                                                   WELLS FARGO OF CALIFORNIA INSURANCE SERVICES, INC. PRIVACY POLICY
  We know that your privacy is important to you and we strive to protect the confidentiality of your non-public personal information. We do not disclose any non-public
  personal information about our customers or former customers to anyone, except as permitted or required by law. We believe we maintain appropriate physical, electronic
  and procedural safeguards to ensure the security of your non-public personal information. You may obtain a detailed copy of our privacy policy through your school, or by
  calling us toll-free at (800) 853-5899 or by visiting us at https://studentinsurance.wellsfargo.com.

           CLAIMS ADMINISTERED BY:                                       Aetna Student Health
            Claims and Coverage Questions                                P.O. Box 15708
                                                                         Boston, MA 02215-0014
                                                                         (877) 850-6062 (Toll-Free)
                                                                         www.aetnastudenthealth.com

                    EMERGENCY TRAVEL                                     On Call International 24/7 Emergency Travel
                               ASSISTANCE:                               Assistance Services
             (Provide this information to your                           (866) 525-1956 (within U.S.).
                          Emergency Contact)                             If outside the U.S., call collect by dialing the U.S. access code plus
                                                                         (603) 328-1956.
                                                                         www.aetnastudenthealth.com

                    PREFERRED PROVIDER:                                  Aetna Preferred Provider Network
                   To Find a Doctor or Provider                          (877) 850-6062 (Toll-Free)
                                                                         www.aetna.com/docfind/custom/studenthealth

     AFTER HOURS NURSE ADVICE:                                           (503) 725-2800
        (when the SHAC is closed)

                                 PRESCRIPTIONS:                          Aetna Pharmacy Management
                                                                         (800) 238-6279
                                                                         www.aetna.com/docfind/custom/studenthealth

      THE PLAN ADMINISTERED BY:                                          Wells Fargo of California Insurance Services, Inc.
                      Eligibility and                                    Student Insurance Division
                  General Questions                                      OR License No. 802263
                                                                         11017 Cobblerock Drive, Suite 100
                                                                         Rancho Cordova, CA 95670
                                                                         (800) 853-5899 or (916) 231-3399
                                                                         Fax: (916) 231-3398
                                                                         https://studentinsurance.wellsfargo.com

   For the most current Plan brochure, please refer to the online edition found at https://studentinsurance.wellsfargo.com. The brochure contains a brief description of the student
   health insurance and related benefits available for Portland State University students. This Plan is underwritten by Aetna Life Insurance Company (ALIC) and administered by
   Chickering Claims Administrators, Inc., an affiliate of ALIC. Aetna Student Health is the brand name for products and services provided by these companies. Certain administrative
   services are also provided by Wells Fargo of California Insurance Services, Inc.



                                                                            IMPORTANT NOTE
  Please keep this Brochure; as it provides a general summary of your coverage. A complete description of the benefits and full terms and conditions may be found in the
  Master Policy. If any discrepancy exists between this Brochure and the Policy; the Master Policy will govern and control the payment of benefits.

•1• Portland State University
                                                                                         NOTES




                    NOTICE TO ALL HEALTH CARE PROVIDERS                                                                                          Identification Card
This card is not a guarantee of coverage. For information concerning coverage, co-                                                       Underwritten by: Aetna Life Insurance Company
payment and claim instructions, please call Customer Service at 1(877) 850-6062.
                                                                                               FOLD ALONG DOTTED LINE




                                CLAIM INSTRUCTIONS                                                                      PRINT NAME
Claims must be submitted to the Company within 90 days after date of treatment. Please
mail all medical and hospital bills, along with the patient’s name & insured student’s name,
                                                                                                                              MEMBER ID #
address, student ID number, and name of the university under which the student is insured
to:                                                                                                                           (You may use student ID# while waiting for permanent card)

                                                                                                                              Important Phone Numbers On Reverse
                                Aetna Student Health
                                   P.O. Box 15708                                                                                                  2009-2010 Policy’s # 474893
                              Boston, MA 02215-0014                                                                          Both the effective and termination dates of coverage are at 12:01 A.M.
                                  (877) 850-6062                                                                          and are subject to verification by the Administration. (Address on reverse side)
STUDENT REFERENCE GUIDE
                                  CLAIMS ADMINISTERED BY:
         Claims, Eligibility and Coverage Questions
                                    Aetna Student Health
                                        P.O. Box 15708
                                    Boston, MA 02215-0014
                                        (877) 850-6062
                                   www.aetnastudenthealth.com




•1• Portland State University
              TO FIND A DOCTOR OR PROVIDER:
                                        Preferred Provider:
 Aetna Preferred Provider Network
            (877) 850-6062
www.aetna.com/docfind/custom/studenthealth


                                        PRESCRIPTIONS:
                                 Aetna Pharmacy Management
            (800) 238-6279
www.aetna.com/docfind/custom/studenthealth




                    PSU CENTER FOR STUDENT HEALTH
                          AND COUNSELING:
                             (503) 725-2800
                            www.shac.pdx.edu

                                   PSU SHAC AFTER HOURS
                                       NURSE ADVICE:
                                        (503) 725-2800
                                      www.IntelliNurse.com

                                   OFFICE OF
                           INTERNATIONAL AFFAIRS, PSU
                                        (503) 725-4094




              EMERGENCY TRAVEL ASSISTANCE:
        On Call International 24/7
    Emergency Travel Assistance Services
                                   (866) 525-1956 (within U.S.)
                                    Dial U.S. access code plus
                                 (603) 328-1956 (Outside the U.S.)
                                   www.aetnastudenthealth.com

				
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