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Student Insurance Program
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Plan Specifics |
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For a complete brochure go to www.aetnastudenthealth.com and select "Find Your School" and enter policy number 890446 or call 1-877-373-0737.
| Per Sickness or Injury |
$50,000 maximum |
| Lifetime |
$500,000 maximum |
| Out-of-Pocket Maximum (per policy year) |
$3,500 in-network and $5,000 out of network; then policy pays 100% of covered costs |
| Accidental Death & Dismemberment Benefit |
Up to $10,000 per student
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| Repatriation of remains |
No limit through Assist America
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Category
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Out-of-Network
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Notes
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Co-Payment
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Percentage Covered
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Co-Payment
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Percentage Covered
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| Office Visit |
$20 |
75% |
$20 |
50% |
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| Urgent Care Visit |
$50 |
75% |
$50 |
50% |
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| ER Visit-SHS referred or closed |
$50 |
100% to $500, then 75% |
$50 |
100% to $500, then 75% |
Co-payments waived if admitted |
| ER Visit-Not SHS referred |
$100 |
100% to $500, then 75% |
$100 |
100% to $500, then 75% |
Co-payments waived if admitted |
| Hospitalization, including physician expenses |
$250 |
75% |
$250 |
50% |
30 day limit for mental disorders and alcohol and other drug abuse. Otherwise treated like any other medical condition. |
| Clinical laboratory tests |
$20 |
75% |
$20 |
50% |
Includes SHS laboratory as in-network provider |
| Radiology |
$20 |
75% |
$20 |
50% |
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| Physical Therapy, Occupational Therapy, Chiropractor Visits, Acupuncture |
$20 |
75% |
$20 |
50% |
$1,000 policy year maximum |
| Outpatient Mental Psychiatric, Alcohol & Other Drug Abuse |
$20 |
75% |
$20 |
50% |
No co-payment and no charge for services provided in BGSU Counseling Center; policy year maximum $2,000 |
| Category |
BGSU Pharmacy |
Other Pharmacies |
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Co-Insurance |
Co-Insurance |
Policy Year Maximum |
| Prescription Medications |
Student pays 20% |
Student pays 50% |
$3,000 |
Exclusions:
• Pre-existing conditions, for 12 months; waived if seen for the condition at the Student Health Service
• Allergy injections
• Immunizations
• Plastic surgery, except as required to repair an injury
• Assessment or treatment of infertility
• Expenses incurred for the treatment of sports related injuries or accidents resulting from the participation in intercollegiate
athletic
• Voluntary termination of pregnancy without a medical necessity
Inclusions:
• Vital Savings Vision and Dental Discount Plan (see www.aetnastudenthealth.com for details)
• Maternity and newborn nursery care (subject to usual inpatient and outpatient medical care cost limitations and co-payments)
• Pap smear: covered as any other laboratory test
• Self-inflicted illness or injury
• Injury to sound natural teeth: covered to a maximum of $500 annually regardless of provider
• Contraception
• TB tests, required for international students, student teachers and nursing students doing clinical rotations, and other
students requiring a TB test. X-ray, if required, to be covered as any other x-ray
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