Illinois State University 2021-2022 Page 2
This is a brief description of the Student Health Plan. The Plan is available for Illinois State University
students. The Plan is underwritten by Aetna Life Insurance Company (Aetna). The exact provisions,
including definitions, governing this insurance are contained in the Policy issued to you and may be
viewed online at www.aetnastudenthealth.com. If there is a difference between this Plan Summary
and the Certificate, the Certificate will control.
Illinois State University Health Services
A Student Health Service referral is not required. However, your needs may best be satisfied, and costs
contained when an organized system of health care providers at the Student Health Service manages the
treatment. If you are under the Student Health Insurance Plan and are eligible to use the Health Services,
this combination of care can minimize your out-of-pocket expenses.
Coverage Periods
Students: Coverage for all insured students enrolled for coverage in the Plan for the following Coverage
Periods. Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below and will
terminate at 11:59 PM on the Coverage End Date indicated.
Coverage Period
Coverage Start
Date
Coverage End
Date
Waiver Deadline
Fall (Students not
enrolled for Summer 20-
21)
08/09/21
01/09/22
Prior to 15
th
calendar day of
semester (08/30/2021)
Fall (Students enrolled
for Summer 20-21)
08/16/21
01/09/22
Prior to 15
th
calendar day of
semester (01/24/2022)
Spring (Students not
enrolled in Fall 2021)
01/06/22
05/08/22
Prior to 15
th
calendar day of
semester (01/24/2022)
Spring (Students
enrolled in Fall 2021)
01/10/22
05/08/22
Prior to 15
th
calendar day of
semester (05/16/2022)
Summer (All Students)
05/09/22
08/21/22
Prior to 8
th
calendar day of
semester (05/16/2022)
Rates
The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company
(Aetna), as well as an Illinois State University administrative fee.
Rates for Students
Fall
Spring
Summer
Student
$281
$281
$211
Updates as of 1/11/22-please refer to the notice at the end of this Plan Summary
Illinois State University 2021-2022 Page 3
Student Coverage
Eligibility
As of the 15th calendar day of Fall and Spring semesters, students who are registered and participating
in nine or more credit hours of course work are automatically enrolled in and assessed a fee for the
Plan.
Registration of at least nine credit hours must occur prior to incurring a claim for insurance to be liable
for that claim. Exceptions will be allowed for students who register after the claim is incurred, and
complete academic credit for at least nine hours for that term. Students with medical withdrawals
causing them to receive a refund of tuition and fees due to conditions arising during the first 15 calendar
days (eight days summer) of the term which cause them to withdraw or to reduce hours below nine, will
remain eligible and insured until the first day of the following term.
Continuous year-round coverage is available. If the student received academic credit for at least nine
hours in spring and will not enroll for sufficient summer hours to be assessed an insurance fee, the
summer fee can be paid prior to the 8
th
calendar day of summer term. If the student is participating in
six or more credit hours of pre-registered summer course work, the student is automatically enrolled
in, and assessed a fee for the Plan.
New students who register for six or more class hours after the first day of Summer School classes have
the option of paying a pro-rated fee for Summer School coverage if they plan to return to school in the
fall. Payment is due the first day of summer classes.
Students with fewer than nine credit hours are eligible to purchase this Plan on an optional basis.
Application and fee payment is due by the 15th day of the term (8th day of summer term). Eligibility is
limited to the following student categories and will be extended for no more than four consecutive
terms by verification of participation in one or a combination of the following:
•
Students participating in the Study Abroad Program are assessed an insurance fee for the semester.
Such students are eligible to apply to expand the coverage period by direct payment of the
premium for the previous or subsequent term, dependent upon program dates and requirements.
• Students enrolling for fewer than nine hours due to the writing of a thesis or dissertation are eligible
to purchase coverage if they were insured the previous term.
• Student teaching, professional practice, internship participants, and Graduate students with
assistantships are eligible to purchase coverage regardless of whether they were insured the previous
term.
• Insured graduating students may continue coverage for the following term.
• Students with a total of at least nine hours who have a combination of regular on-campus fee paying
courses, plus some internet-only courses are eligible to purchase Student Insurance on an optional
basis if they were insured with this Plan in the previous term.
Home study, correspondence, outreach courses, and television (TV) courses, do not fulfill the eligibility
requirement that the student actively attend classes. If it is discovered that this eligibility requirement
has not been met, our only obligation is to refund premium, less any claims paid.
Illinois State University 2021-2022 Page 4
Enrollment
Eligible students will be automatically enrolled in this Plan, unless the completed waiver application has
been received by Illinois State University by the specified waiver deadline dates listed in the Coverage
Periods section of this Plan Design and Benefits Summary.
Waiver Process/Procedure
Waiver of this coverage will be authorized if the student presents evidence of other health insurance
coverage under a plan which provides benefits equivalent to the Plan. Students must present the
evidence of coverage and complete a petition at the Student Insurance Office prior to the 15th calendar
day in any semester or prior to the 8th day of the Summer Semester.
If you withdraw during the first 15 calendar days of the fall/spring Semester or the first eight days of the
summer semester, you will receive a full refund of the insurance fee.
Exception: Students with medical withdrawals causing them to receive a refund of tuition and fees due
to conditions arising during the first 15 calendar days (eight days summer) of the term which cause
them to withdraw or to reduce hours below nine, will remain eligible and insured until the first day of
the following term.
Please Note: A Covered Person entering the armed forces of any country will not be covered under the
Policy, as of the date of such entry. A pro-rata refund of premium will be made for such person, upon
written request, received by Aetna within 90 days of withdrawal from school.
Excess Provision
This Plan is an excess only Plan. As an excess only Plan, this Plan pays the first $100 of Covered Medical
Expenses. If there is no other medical coverage in effect, this Plan will continue to pay Covered Medical
Expenses after the first $100 of Covered Medical Expenses has been paid. If there is other medical
coverage in effect, claims for benefits in excess of the first $100 of Covered Medical Expenses will be
payable by the other medical coverage until those benefits are exhausted. This excess only Plan is then
responsible for the balance of Covered Medical Expenses up to the policy maximum benefit. This Plan’s
liability will be determined without consideration to any limitation clause or clauses regarding other
coverage contained in any other medical coverage. Benefits Payable under this Plan shall be limited to
the Plan’s Covered Medical Expenses and reduced by the amount paid or payable by any other medical
coverage. However, consideration will be given to the other medical coverage’s liability due to a provider
contract or other reasons when calculating this Plan’s Benefits Payable.
For the purposes of calculating a benefit under this Plan, the liability of the other medical coverage shall
be considered and shall not depend upon whether timely application for benefits from other medical
coverage is made by the Covered Person or on the Covered Person’s behalf. If any other medical
coverage provides benefits on an excess only basis, the coverage for the Covered Person which has been
in effect the longest shall pay benefits first.
“Other medical coverage” means any reimbursement for or recovery of any element of incurred covered
charges available from any other source whatsoever whether through an insurance policy or other type
of coverage, except gifts and donations, including but not limited to the following:
Illinois State University 2021-2022 Page 5
•
Any group, accident-only, blanket, individual, or franchise policy of accident, disability, health, or
accident and sickness insurance.
• Any arrangement of benefits for members of a group, whether insured or uninsured.
• Any prepaid service arrangement such as Blue Cross or Blue Shield, individual or group practice plans
or health maintenance organizations.
• Any amount payable as a benefit for accidental bodily injury arising out of a motor vehicle accident to
the extent such benefits are payable under the medical expense payment provision (or, by whatever
terminology used to include such benefits mandated by law) of any motor vehicle insurance policy.
• Any amounts payable for injuries related to the Covered Person’s job to the extent that he or she
actually received benefits under a Workers’ Compensation Law.
• Social Security Disability Benefits, except that Other Medical Insurance shall not include any increase
in Social Security Disability Benefits payable to the Covered Person after the Covered Person becomes
disabled while insured hereunder.
• Any benefits payable under any program provided or sponsored solely or primarily by any
governmental agency or subdivision or through operation of law or regulation.
Medicare Eligibility Notice
You are not eligible to enroll in the student health plan if you have Medicare at the time of enrollment in
this student plan. The plan does not provide coverage for people who have Medicare.
Termination and Refunds
Withdrawal from Classes – Leave of Absence:
If you withdraw from classes under a school-approved leave of absence, your coverage will remain in
force through the end of the period for which payment has been received and no premiums will be
refunded.
In-network Provider Network
Aetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by
seeing In-network Providers because Aetna has negotiated special rates with them, and because the
Plan’s benefits are better.
If you need care that is covered under the Plan but not available from an In-network Provider, contact
Member Services for assistance at the toll-free number on the back of your ID card. In this situation,
Aetna may issue a pre-approval for you to receive the care from an Out-of-network Provider. When a
pre-approval is issued by Aetna, the benefit level is the same as for In-network Providers.
Illinois State University 2021-2022 Page 6
Description of Benefits
The Plan excludes coverage for certain services (referred to as exceptions in the certificate of coverage)
and has limitations on the amounts it will pay. While this Plan Design and Benefit Summary document
will tell you about some of the important features of the Plan, other features may be important to you
and some may further limit what the Plan will pay. To look at the full Plan description, which is contained
in the Certificate of Coverage issued to you, go to www.aetnastudenthealth.com. If any discrepancy
exists between this Benefit Summary and the Certificate of Coverage, the Certificate will control.
This Plan will pay benefits in accordance with any applicable Illinois Insurance Law(s).
Policy year deductible
In-network coverage
Out-of-network coverage
You have to meet your policy year deductible before this plan pays for benefits.
Student
$50 per policy year
Prescription Drug
$50 per policy year
Policy year deductible waiver
The policy year deductible is waived for all of the following eligible health services:
•
In-network and Out-of-Network care for Preventive care and wellness
•
When students have another insurance plan that is primary
Maximum out-of-pocket limits
Maximum out-of-pocket limit per policy year
Student
$1,250 per policy year
The coinsurance listed in the schedule of benefits below reflects the plan coinsurance percentage. This is the
coinsurance amount that the plan pays. You are responsible for paying any remaining coinsurance.
Illinois State University 2021-2022 Page 7
Eligible health services
In-network coverage
Out-of-network coverage
Routine physical exams
Performed at a physician’s
office
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Maximum age and visit
limits per policy year
through age 21
Subject to any age and visit limits provided for in the comprehensive
guidelines supported by the American Academy of Pediatrics/Bright
Futures//Health Resources and Services Administration guidelines for
children and adolescents.
Covered persons age 22 and
over: Maximum visits per
policy year
1 visit
Preventive care immunizations
Performed in a facility or at
a physician's office
100% (of the negotiated charge) per
visit.
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Maximums
Subject to any age limits provided for in the comprehensive guidelines
supported by Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention.
Routine gynecological exams (including Pap smears and cytology tests)
Performed at a physician’s,
obstetrician (OB),
gynecologist (GYN) or
OB/GYN office
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Maximums
1 visit
Preventive screening and counseling services
Preventive screening and
counseling services for
Obesity and/or healthy diet
counseling, Misuse of
alcohol & drugs, Tobacco
Products, Depression
Screening, Sexually
transmitted infection
counseling & Genetic risk
counseling for breast and
ovarian cancer
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Illinois State University 2021-2022 Page 8
Eligible health services
In-network coverage
Out-of-network coverage
Obesity and/or healthy diet
counseling Maximum visits
Age 0-22: unlimited visits. Age 22 and older: 26 visits per 12 months, of
which up to 10 visits may be used for healthy diet counseling.
Substance use disorders
maximum per policy year
5 visits
Use of tobacco products
counseling Maximum visits
per policy year
8 visits
Depression screening
counseling Maximum visits
per policy year
1 visit
Sexually transmitted
infection counseling
Maximum visits per policy
year
2 visits
Skin cancer behavioral
counseling office visits
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Falls prevention counseling
office visits
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Routine cancer screenings
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Maximums
Subject to any age; family history; and frequency guidelines as set forth
in the most current:
•
Evidence-based items that have in effect a rating of A or B in the
current recommendations of the United States Preventive Services
Task Force; and
•
The comprehensive guidelines supported by the Health Resources
and Services Administration.
Lung cancer screening
maximums
1 screening every 12 months
Prenatal care services
(Preventive care services
only)
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
80% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Illinois State University 2021-2022 Page 9
Eligible health services
In-network coverage
Out-of-network coverage
Lactation support and
counseling services
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
80% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Lactation counseling
services maximum visits per
policy year either in a group
or individual setting
6 visits
Breast pump supplies and
accessories
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
80% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Family planning services – female contraceptives
Female contraceptive
counseling services
office visit
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Contraceptive counseling
services maximum visits per
policy year either in a group
or individual setting
2 visits
Female contraceptive
prescription drugs and
devices provided,
administered, or removed,
by a provider during an
office visit
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
Female voluntary
sterilization-Inpatient &
Outpatient provider services
100% (of the negotiated charge) per
visit
No copayment or policy year
deductible applies
100% (of the recognized charge)
per visit
No copayment or policy year
deductible applies
The following are not covered under this benefit:
•
Services provided as a result of complications resulting from a female voluntary sterilization
procedure and related follow-up care
•
Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the
FDA
•
Male contraceptive methods, sterilization procedures or devices
Illinois State University 2021-2022 Page 10
Eligible health services
In-network coverage
Out-of-network coverage
Physicians and other health professionals
Physician, specialist including
Consultants Office
visits (non-surgical/
non-preventive care by a
physician and specialist) includes
telemedicine consultations
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
Allergy testing and treatment
Allergy testing & Allergy
injections treatment
including Allergy sera and
extracts administered via
injection performed at a
physician’s or specialist’s
office
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Physician and specialist - surgical services
Inpatient surgery performed
during your stay in a hospital
or birthing center by a
surgeon
(includes anesthetist and
surgical assistant expenses)
80% (of the negotiated charge)
Policy year deductible applies
$0 copayment then the plan pays
80% (of the balance of the
recognized charge) per admission
Policy year deductible applies
The following are not covered under this benefit:
•
The services of any other physician who helps the operating physician
•
A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions –
Hospital and other facility care section)
•
Services of another physician for the administration of a local anesthetic
Outpatient surgery
performed at a physician’s or
specialist’s office or
outpatient department of a
hospital or surgery center by
a surgeon (includes
anesthetist and surgical
assistant expenses)
80% (of the negotiated charge)
Policy year deductible applies
$0 copayment then the plan pays
80% (of the balance of the
recognized charge) per admission
Policy year deductible applies
The following are not covered under this benefit:
•
The services of any other physician who helps the operating physician
•
A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions –
Hospital and other facility care section)
•
A separate facility charge for surgery performed in a physician’s office
•
Services of another physician for the administration of a local anesthetic
Illinois State University 2021-2022 Page 11
Eligible health services
In-network coverage
Out-of-network coverage
Alternatives to physician office visits
Walk-in clinic visits (non-
emergency visit)
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
Hospital and other facility care
Inpatient hospital (room and
board) and other
miscellaneous services and
supplies)
Includes birthing center
facility charges
80% (of the negotiated charge) per
admission
Policy year deductible applies
80% (of the recognized charge)
per admission
Policy year deductible applies
In-hospital non-surgical
physician services
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
Alternatives to hospital stays
Outpatient surgery (facility
charges) performed in the
outpatient department of a
hospital or surgery center
For physician charges, refer
to the Physician and specialist
- outpatient surgical services
benefit
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
The following are not covered under this benefit:
•
The services of any other physician who helps the operating physician
•
A stay in a hospital (See the Hospital care – facility charges benefit in this section)
•
A separate facility charge for surgery performed in a physician’s office
•
Services of another physician for the administration of a local anesthetic
Home health care
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
The following are not covered under this benefit:
•
Services for infusion therapy
•
Nursing and home health aide services or therapeutic support services provided outside of the
home (such as in conjunction with school, vacation, work or recreational activities)
•
Transportation
•
Services or supplies provided to a minor or dependent adult when a family member or caregiver
is not present
•
Homemaker or housekeeper services
Illinois State University 2021-2022 Page 12
•
Food or home delivered services
•
Maintenance therapy
Eligible health services
In-network coverage
Out-of-network coverage
Hospice-Inpatient
(room and board and other
miscellaneous services and
supplies)
80% (of the negotiated charge) per
admission
Policy year deductible applies
80% (of the recognized charge)
per admission
Policy year deductible applies
Hospice-Outpatient
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
The following are not covered under this benefit:
•
Funeral arrangements
•
Pastoral counseling
•
Bereavement counseling
•
Financial or legal counseling which includes estate planning and the drafting of a will
•
Homemaker or caretaker services that are services which are not solely related to your care and
may include:
-
Sitter or companion services for either you or other family members
-
Transportation
-
Maintenance of the house
Outpatient private duty
nursing
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
Skilled nursing facility-
Inpatient
(room and board and
miscellaneous inpatient care
services and supplies)
Subject to semi-private room
rate unless intensive care
unit is required
Room and board includes
intensive care
80% (of the negotiated charge) per
admission
Policy year deductible applies
80% (of the recognized charge)
per admission
Policy year deductible applies
Hospital emergency room
100% (of the negotiated charge)
per visit
Policy year deductible applies
Paid the same as in-network
coverage
Emergency services resulting
from a criminal sexual
assault or abuse
100% (of the negotiated charge)
per visit
Paid the same as in-network
coverage
Illinois State University 2021-2022 Page 13
Important note:
•
As out-of-network providers do not have a contract with us the provider may not accept payment of
your cost share, (copayment/coinsurance), as payment in full. You may receive a bill for the
difference between the amount billed by the provider and the amount paid by this plan. If the
provider bills you for an amount above your cost share, you are not responsible for paying that
amount. You should send the bill to the address listed on the back of your ID card, and we will
resolve any payment dispute with the provider over that amount. Make sure the ID card number is
on the bill.
•
A separate hospital emergency room copayment/coinsurance will apply for each visit to an
emergency room. If you are admitted to a hospital as an inpatient right after a visit to an emergency
room, your emergency room copayment/coinsurance will be waived and your inpatient
copayment/coinsurance will apply.
•
Covered benefits that are applied to the hospital emergency room copayment/coinsurance cannot
be applied to any other copayment/coinsurance under the plan. Likewise, a copayment/coinsurance
that applies to other covered benefits under the plan cannot be applied to the hospital emergency
room copayment/coinsurance.
•
Separate copayment/coinsurance amounts may apply for certain services given to you in the hospital
emergency room that are not part of the hospital emergency room benefit. These
copayment/coinsurance amounts may be different from the hospital emergency room
copayment/coinsurance. They are based on the specific service given to you.
•
Services given to you in the hospital emergency room that are not part of the hospital emergency
room benefit may be subject to copayment/coinsurance amounts.
Eligible health services
In-network coverage
Out-of-network coverage
Urgent care
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
Pediatric dental care (Limited to covered persons through the end of the month in which the
person turns age 19)
Type A services
100% (of the negotiated charge)
per visit
No copayment or deductible
applies
70% (of the recognized charge)
per visit
Policy year deductible applies
Type B services
70% (of the negotiated charge) per
visit
No copayment or deductible
applies
50% (of the recognized charge)
per visit
Policy year deductible applies
Type C services
50% (of the negotiated charge) per
visit
No copayment or deductible
applies
50% (of the recognized charge)
per visit
Policy year deductible applies
Illinois State University 2021-2022 Page 14
Eligible health services
In-network coverage
Out-of-network coverage
Orthodontic services
50% (of the negotiated charge) per
visit
No copayment or deductible
applies
50% (of the recognized charge)
per visit
Policy year deductible applies
Dental emergency treatment
Covered according to the type of
benefit and the place where the
service is received
Covered according to the type of
benefit and the place where the
service is received.
Pediatric dental care exclusions
The following are not covered under this benefit:
•
Any instruction for diet, plaque control and oral hygiene
•
Cosmetic services and supplies including plastic surgery, reconstructive surgery, cosmetic
surgery, personalization or characterization of dentures or other services and supplies which
improve alter or enhance appearance, augmentation and vestibuloplasty, and other substances
to protect, clean, whiten bleach or alter the appearance of teeth; whether or not for psychological
or emotional reasons; except to the extent coverage is specifically provided in the Eligible health
services and exclusions section. Facings on molar crowns and pontics will always be considered
cosmetic.
•
Crown, inlays, onlays, and veneers unless:
-
It is treatment for decay or traumatic injury and teeth cannot be restored with a filling
material or
-
The tooth is an abutment to a covered partial denture or fixed bridge
•
Dental implants and braces(that are determined not to be medically necessary mouth guards,
and other devices to protect, replace or reposition teeth
•
Dentures, crowns, inlays, onlays, bridges, or other appliances or services used:
-
For splinting
-
To alter vertical dimension
-
To restore occlusion
-
For correcting attrition, abrasion, abfraction or erosion
•
Treatment of any jaw joint disorder and treatments to alter bite or the alignment or operation of
the jaw, including temporomandibular joint dysfunction disorder (TMJ) and craniomandibular
joint dysfunction disorder (CMJ) treatment, orthognathic surgery, and treatment of malocclusion
or devices to alter bite or alignment, except as covered in the Eligible health services and exclusions
–
Specific conditions section
•
General anesthesia and intravenous sedation, unless specifically covered and only when done in
connection with another eligible health service
•
Orthodontic treatment except as covered in the [Pediatric] dental care section of the schedule of
benefits
•
Pontics, crowns, cast or processed restorations made with high noble metals (gold)
•
Prescribed drugs, pre-medication
•
Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of
appliances that have been damaged due to abuse, misuse or neglect and for an extra set of
dentures
Illinois State University 2021-2022 Page 15
•
Routine dental exams and other preventive services and supplies, except as specifically provided
in the [Pediatric] dental care section of the schedule of benefits
•
Services and supplies:
-
Done where there is no evidence of pathology, dysfunction, or disease other than covered
preventive services
-
Provided for your personal comfort or convenience or the convenience of another person,
including a provider
-
Provided in connection with treatment or care that is not covered under your policy
•
Surgical removal of impacted wisdom teeth only for orthodontic reasons
•
Treatment by other than a dentist or dental provider that is legally qualified to furnish
dental services or supplies
Eligible health services
In-network coverage
Out-of-network coverage
Specific conditions
Diabetic services and
supplies (including
equipment and training)
Covered according to the type of
benefit and the place where the
service is received
Covered according to the type of
benefit and the place where the
service is received
Podiatric (foot care)
treatment Physician and
specialist non-routine foot
care treatment
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
The following are not covered under this benefit:
•
Services and supplies for:
-
The treatment of calluses, bunions, toenails, flat feet, hammertoes, fallen arches
-
The treatment of weak feet, chronic foot pain or conditions caused by routine activities, such
as walking, running, working or wearing shoes
-
Supplies (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, ankle
braces, guards, protectors, creams, ointments and other equipment, devices and supplies
-
Routine pedicure services, such as cutting of nails, corns and calluses when there is no
illness or injury of the feet
Impacted wisdom teeth
80% (of the negotiated charge)
Policy year deductible applies
80% (of the recognized charge)
Policy year deductible applies
Accidental injury to sound
natural teeth
80% (of the negotiated charge)
Policy year deductible applies
80% (of the recognized charge)
Policy year deductible applies
The following are not covered under this benefit:
•
The care, filling, removal or replacement of teeth and treatment of diseases of the teeth
•
Dental services related to the gums
•
Apicoectomy (dental root resection)
•
Orthodontics
•
Root canal treatment
•
Soft tissue impactions
•
Bony impacted teeth
•
Alveolectomy
Illinois State University 2021-2022 Page 16
•
Augmentation and vestibuloplasty treatment of periodontal disease
•
False teeth
•
Prosthetic restoration of dental implants
•
Dental implants
Eligible health services
In-network coverage
Out-of-network coverage
Temporomandibular joint
dysfunction (TMJ) [and
craniomandibular joint
dysfunction (CMJ)] treatment
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
The following are not covered under this benefit:
Dental implants
Clinical trial (routine patient
costs)
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
The following are not covered under this benefit:
•
Services and supplies related to data collection and record-keeping that is solely needed due to
the clinical trial (i.e. protocol-induced costs)
•
Services and supplies provided by the trial sponsor without charge to you
•
The experimental intervention itself (except medically necessary Category B investigational
devices and promising experimental and investigational interventions for terminal illnesses in
certain clinical trials in accordance with Aetna’s claim policies)
Dermatological treatment
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
The following are not covered under this benefit:
Cosmetic treatment and procedures
Obesity bariatric Surgery and
services
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
The following are not covered under this benefit:
-
Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and
supplements, food supplements, appetite suppressants and other medications
-
Hypnosis or other forms of therapy
-
Exercise programs, exercise equipment, membership to health or fitness clubs, recreational
therapy or other forms of activity or activity enhancement
Eligible health services
In-network coverage
Out-of-network coverage
Maternity care
Maternity care (includes
delivery and postpartum care
services in a hospital or
birthing center)
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
The following are not covered under this benefit:
Illinois State University 2021-2022 Page 17
•
Any services and supplies related to births that take place in the home or in any other place not
licensed to perform deliveries
Well newborn nursery care in
a hospital or birthing center
80% (of the negotiated charge)
Policy year deductible applies
80% (of the recognized charge)
Policy year deductible applies
Family planning services – other
Voluntary sterilization
for males-surgical services
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Abortion
80% (of the negotiated charge)
Policy year deductible applies
80% (of the recognized charge)
Policy year deductible applies
The following are not covered under this benefit:
•
Reversal of voluntary sterilization procedures, including related follow-up care
•
Services provided as a result of complications resulting from a male voluntary sterilization
procedure and related follow-up care
Gender reassignment (sex change) treatment
Surgical, hormone
replacement therapy, and
counseling treatment
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
All other cosmetic services and supplies not listed under eligible health services above are not covered
under this benefit. This includes, but is not limited to the following:
•
Rhinoplasty
•
Face-lifting
•
Lip enhancement
•
Facial bone reduction
•
Blepharoplasty
•
Breast augmentation
•
Liposuction of the waist (body contouring)
•
Reduction thyroid chondroplasty (tracheal shave)
•
Nipple reconstruction
•
Hair removal (including electrolysis of face and neck)
•
Voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing,
which are used in feminization
•
Voice and communication therapy
•
Chest binders
•
Chin implants, nose implants, and lip reduction, which are used to assist masculinization, are
considered cosmetic
Illinois State University 2021-2022 Page 18
Eligible health services
In-network coverage
Out-of-network coverage
Autism spectrum disorder
Autism spectrum disorder
treatment, diagnosis and
testing and Applied behavior
analysis
(includes physician and
specialist office visits)
Covered according to the type of
benefit and the place where the
service is received
Covered according to the type of
benefit and the place where the
service is received
Mental Health & Substance use disorders related treatment
Inpatient hospital mental
health disorders treatment
(room and board and other
miscellaneous hospital
services and supplies)
Inpatient residential
treatment facility mental
health disorders treatment
(room and board and other
miscellaneous residential
treatment facility services
and supplies)
Subject to semi-private room
rate unless intensive care
unit is required
Mental health disorder room
and board intensive care
80% (of the negotiated charge) per
admission
Policy year deductible applies
80% (of the recognized charge)
per admission
Policy year deductible applies
Outpatient mental health
disorders treatment office
visits to a physician or
behavioral health provider
(includes telemedicine
consultations and
cognitive behavioral therapy
consultations)
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
Other outpatient health
disorders treatment
(includes skilled behavioral
health services in the home)
(includes Partial
hospitalization and Intensive
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge)
per visit
Policy year deductible applies
Illinois State University 2021-2022 Page 19
Outpatient Program)
Eligible health services
In-network coverage
(IOE facility)
In-network coverage
(Non-IOE facility)
Out-of-network
coverage
Transplant services
Inpatient and outpatient
transplant facility services
Covered according to the type of benefit and the place where the service
is received.
Inpatient and outpatient
transplant physician and
specialist services
Covered according to the type of benefit and the place where the service
is received.
Transplant services-travel
and lodging
Covered
Covered
Covered
Maximum payable for Travel
and Lodging Expenses for
any one transplant, including
tandem transplants
$10,000
$10,000
$10,000
Maximum payable for
Lodging Expenses per IOE
patient
$50 per night
$50 per night
$50 per night
Maximum payable for
Lodging Expenses per
companion
$50 per night
$50 per night
$50 per night
The following are not covered under this benefit:
•
Services and supplies furnished to a donor when the recipient is not a covered person
•
Harvesting and storage of organs, without intending to use them for immediate transplantation
for your existing illness
•
Harvesting and/or storage of bone marrow, hematopoietic stem cells, or other blood cells without
intending to use them for transplantation within 12 months from harvesting, for an existing
illness
Eligible health services
In-network coverage
Out-of-network coverage
Treatment of infertility
Basic infertility services
Inpatient and outpatient care
- basic infertility
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Comprehensive infertility
services Inpatient and
outpatient care
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Advanced reproductive
technology (ART) services
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Illinois State University 2021-2022 Page 20
For treatment that includes
an oocyte retrieval,
maximum number of oocyte
retrievals
4, however if a live birth follows a completed oocyte retrieval, 2
additional oocyte retrievals will be covered.
The following are not covered services under the infertility treatment benefit:
•
All charges associated with:
-
Services provided to a surrogate. A surrogate is a female carrying her own genetically related
child where the child is conceived with the intention of turning the child over to be raised by
others, including the biological father. If you choose to use a surrogate, this exclusion does
not apply to the cost for procedures to obtain the eggs, sperm or embryo from a covered
person.
−
Reversal of voluntary sterilizations, including follow-up care. However, if a voluntary sterilization
is successfully reversed, infertility benefits are available if your diagnosis meets the definition of
infertility
•
Travel costs within 100 miles of your home or travel cost not required by Aetna
•
Infertility treatment for covered dependents under age 18
•
Non-medical costs of an egg or sperm donor
−
Experimental or investigational infertility treatment as determined by the American Society for
Reproductive Medicine
•
[ART services are not provided for out-of-network care
Eligible health services
In-network coverage
Out-of-network coverage
Specific therapies and tests
Diagnostic complex imaging
services performed in the
outpatient department of a
hospital or other facility
No additional expense, such
as a copayment or deductible
amount, will be imposed for
mammograms
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge) per
visit
Policy year deductible applies
Diagnostic lab work and
radiological services
performed in a physician’s
office, the outpatient
department of a hospital or
other facility
No additional expense, such
as a copayment or deductible
amount, will be imposed for
mammograms
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge) per
visit
Policy year deductible applies
Illinois State University 2021-2022 Page 21
Eligible health services
In-network coverage
Out-of-network coverage
Outpatient Chemotherapy,
Radiation & Respiratory
Therapy
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge) per
visit
Policy year deductible applies
Outpatient physical,
occupational, speech, and
cognitive therapies (including
Cardiac and Pulmonary
Therapy)
Combined for short-term
rehabilitation services and
habilitation therapy services
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge) per
visit
Policy year deductible applies
Acupuncture therapy
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge) per
visit
Policy year deductible applies
Chiropractic services
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge) per
visit
Policy year deductible applies
Maximum visits per policy
year
25
Specialty prescription drugs
purchased and injected or
infused by your provider in
an outpatient setting
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Other services and supplies
Emergency ground, air, and
water ambulance (includes
non-emergency ambulance)
80% (of the negotiated charge) per
trip
Policy year deductible applies
Paid the same as in-network
coverage
The following are not covered under this benefit:
•
Non-emergency fixed wing air ambulance from an out-of-network provider
•
Ambulance services for routine transportation to receive outpatient or inpatient care
Durable medical and surgical
equipment
80% (of the negotiated charge) per
item
Policy year deductible applies
80% (of the recognized charge)
per item
Policy year deductible applies
The following are not covered under this benefit:
•
Whirlpools
•
Portable whirlpool pumps
•
Sauna baths
•
Massage devices
•
Over bed tables
Illinois State University 2021-2022 Page 22
•
Elevators
•
Communication aids
•
Vision aids
•
Telephone alert systems
•
Personal hygiene and convenience items such as air conditioners, humidifiers, hot
tubs, or physical exercise equipment even if they are prescribed by a physician
Eligible health services
In-network coverage
Out-of-network coverage
Nutritional support
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
The following are not covered under this benefit:
•
Any food item, including infant formulas, nutritional supplements, vitamins, plus prescription
vitamins, medical foods and other nutritional items, even if it is the sole source of nutrition.
except as described above
Prosthetic and customized
orthotic devices (Includes
Cranial prosthetics (Medical
wigs)
80% (of the negotiated charge)
per item
Policy year deductible applies
80% (of the recognized charge) per
item
Policy year deductible applies
The following are not covered under this benefit:
•
Services covered under any other benefit
•
Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet, unless required
for the treatment of or to prevent complications of diabetes, or if the orthopedic shoe is an integral part of
a covered leg brace
•
Trusses, corsets, and other support items
•
Repair and replacement due to loss, misuse, abuse or theft
•
Communication aids
Hearing aids and Exams
Hearing aid exams
80% (of the negotiated charge)
per visit
Policy year deductible applies
80% (of the recognized charge) per
visit
Policy year deductible applies
Hearing aids
80% (of the negotiated charge)
per visit
Policy year deductible applies
80% (of the recognized charge) per
visit
Policy year deductible applies
Hearing aids maximum per
ear
One hearing aid per ear every 12 month consecutive period
The following are not covered under this benefit:
•
A replacement of:
-
A hearing aid that is lost, stolen or broken
-
A hearing aid installed within the prior [6-60 month] period
•
Replacement parts or repairs for a hearing aid
•
Batteries or cords
•
A hearing aid that does not meet the specifications prescribed for correction of hearing loss
Illinois State University 2021-2022 Page 23
•
Any ear or hearing exam performed by a physician who is not certified as an otolaryngologist or
otologist
Eligible health services
In-network coverage
Out-of-network coverage
Pediatric vision care (Limited to covered persons through the end of the month in which the person
turns age 19)
Performed by a legally
qualified ophthalmologist or
optometrist (includes
comprehensive low vision
evaluations)
100% (of the negotiated charge)
per visit
No policy year deductible applies
100% (of the recognized charge)
per visit
Policy year deductible applies
Maximum visits per policy year
1 visit
Low vision Maximum
One comprehensive low vision evaluation every policy year
Fitting of contact Maximum
2 visits
Pediatric vision care services &
supplies-Eyeglass frames,
prescription lenses or
prescription contact lenses
100% (of the negotiated charge)
per visit
No policy year deductible applies
100% (of the recognized charge)
per visit
Policy year deductible applies
Maximum number Per year:
Eyeglass frames
One set of eyeglass frames
Prescription lenses
One pair of prescription lenses
Contact lenses (includes non-
conventional prescription
contact lenses & aphakic
lenses prescribed after
cataract surgery)
Daily disposables: up to 3 month supply
Extended wear disposable: up to 6 month supply
Non-disposable lenses: one set
Optical devices
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the
service is received.
Maximum number of optical
devices per policy year
One optical device
PRESCRIBED MEDICINES EXPENSE
*The prescription drug plan covered percentage is the percentage of prescription drug covered medical
expenses that the plan pays.
Generic and Brand Prescription Drugs
Preferred Care
For each 30 day supply filled at a retail pharmacy. You must pay
out of pocket and then submit your receipt to Aetna Student
Health for reimbursement.
80% of the Actual Charge after the
$50 Prescription Deductible.
Copay and Deductible Waiver
Waiver for Risk-Reducing Breast Cancer Prescription Drugs
Illinois State University 2021-2022 Page 24
Risk-reducing breast cancer generic prescription drugs will be paid at 100%.
Waiver for Prescription Drug Contraceptives
The per prescription coinsurance will not apply to:
Female contraceptives that are:
•
Oral prescription drugs that are generic prescription drugs.
• Injectable prescription drugs that are generic prescription drugs.
o Female contraceptive devices.
o FDA-approved female:
• generic emergency contraceptives; and
• gene
ric over-t
he-counter (OTC) emergency contraceptives.
when obtained at a preferred care pharmacy. This means that such
contraceptive methods will be paid at 100%. The per prescription
coinsurance will continue to apply:
• When the contraceptive methods listed above are obtained at a non-preferred pharmacy.
• To female contraceptives that are:
o Oral prescription drugs that are brand-name prescription drugs and biosimilar prescription drugs.
o Injectable prescription drugs that are brand-name prescription drugs and biosimilar prescription
drugs.
• To female contraceptive devices that are brand-name devices.
• To FDA-approved female:
o brand-name and biosimilar emergency contraceptives; and
o brand-name over-the-counter (OTC) emergency contraceptives.
• To FDA-approved female brand-name over-the-counter (OTC) contraceptives.
• To FDA-approved male brand-name over-the-counter (OTC) contraceptives.
However, the per prescription coinsurance will not apply to such contraceptive methods if:
• A generic equivalent, biosimilar or generic alternative, within the same therapeutic drug class is not
available; or
• A covered person is granted a medical exception; or
• Physician specifies “Dispense as Written” (DAW).
Outpatient prescription drugs exclusions
The following are not covered under the outpatient prescription drugs benefit:
•
Contraceptives
-
Contraceptive methods, procedures, services, and supplies for contraceptive purposes as elected by the
policyholder due to an exemption or accommodation in accordance with applicable federal or state law
and regulation
Illinois State University 2021-2022 Page 25
-
Services provided as a result of complications resulting from voluntary sterilization procedure and
related follow-up care
•
Drugs or medications
-
Administered or entirely consumed at the time and place it is prescribed or provided
-
Which do not, by federal or state law, require a prescription order [i.e. over-the-counter (OTC) drugs)],
even if a prescription is written except as specifically provided above
-
That include the same active ingredient or a modified version of an active ingredient as a covered
prescription drug (unless a medical exception is approved)
-
That are therapeutically equivalent or therapeutically alternative to a covered prescription drug (unless
a medical exception is approved)
-
That are therapeutically equivalent or therapeutically alternative to an over-the-counter (OTC) product
(unless a medical exception is approved
-
Not approved by the FDA or not proven safe or effective
-
Provided under your medical plan while an inpatient of a healthcare facility
-
Recently approved by the U.S. Food and Drug Administration (FDA), but which have not yet been
reviewed by our Pharmacy and Therapeutics Committee
-
That include vitamins and minerals unless recommended by the United States Preventive Services Task
Force (USPSTF)
-
For which the cost is covered by a federal, state, or government agency (for example: Medicaid or
Veterans Administration)
-
That are used to treat sexual dysfunction, enhance sexual performance or increase sexual desire,
including drugs, implants, devices or preparations to correct or enhance erectile function, enhance
sensitivity, or alter the shape or appearance of a sex organ
-
That are used for the purpose of weight gain or reduction, including but not limited to stimulants,
preparations, foods or diet supplements, dietary regimens and supplements, food or food
supplements, appetite suppressants or other medications
-
That are drugs or growth hormones used to stimulate growth and treat idiopathic short stature unless
there is evidence that the covered person meets one or more clinical criteria detailed in our
precertification and clinical policies
•
Genetic care
-
Any treatment, device, drug, service or supply to alter the body’s genes, genetic make-up, or the
expression of the body’s genes except for the correction of congenital birth defects
A covered person, a covered person’s designee or a covered person’s prescriber may seek an expedited
medical exception process to obtain coverage for non-covered drugs in exigent circumstances. An
“exigent circumstance” exists when a covered person is suffering from a health condition that may
seriously jeopardize a covered person’s life, health, or ability to regain maximum function or when a
covered person is undergoing a current course of treatment using a non-formulary drug.
The request for an expedited review of an exigent circumstance may be submitted by contacting Aetna's
Pre-certification Department at 1-855-240-0535, faxing the request to 1-877-269-9916, or submitting the
request in writing to:
CVS Health
ATTN: Aetna PA
1300 E. Campbell Road
Richardson, TX 75081
Illinois State University 2021-2022 Page 26
General Exclusions
Acupuncture therapy
•
Maintenance treatment
• Acupuncture when provided for the following conditions:
- Acute low back pain
- Addiction
- AIDS
- Amblyopia
- Allergic rehinitis
- Asthma
- Autism spectrum disorders
- Bell’s Palsy
- Burning mouth syndrome
- Cancer-related dyspnea
- Carpal tunnel syndrome
- Chemotherapy-induced leukopenia
- Chemotherapy-induced neuopathic pain
- Chronic pain syndrome (e.g., RSD, facial pain)
- Chronic obstructive pulmonary disease
- Diabetic peripheral neuropathy
- Dry eyes
- Erectile dysfunction
- Facial spasm
- Fetal breech presentation
- Fibromyalgia
- Fibrotic contractures
- Glaucoma
- Hypertension
- Induction of labor
- Infertility(e.g., to assist oocyte retrieval and embryo transfer during IVF treatment cycle)
- Insomnia
- Irritable bowel syndrome
- Menstrual cramps/dysmenorrhea
- Mumps
- Myofascial pain
- Myopia
- Neck pain/cervical spondylosis
- Obesity
- Painful neuropathies
- Parkinson’s disease
- Peripheral arterial disease (e.g., intermittent claudication)
- Phantom leg pain
- Polycystic ovary syndrome
- Post-herpetic neuralgia
Illinois State University 2021-2022 Page 27
-
Psoriasis
- Psychiatric disorders (e.g., depression)
- Raynaud’s disease pain
- Respiratory disorders
- Rheumatoid arthritis
- Rhinitis
- Sensorineural deafness
- Shoulder pain (e.g., bursitis)
- Stroke rehabilitation (e.g., dysphagia)
- Tennis elbow/ epicondylitis
- Tension headache
- Tinnitus
- Tobacco Cessation
- Urinary incontinence
- Uterine fibroids
- Xerostomia
- Whiplash
Alternative health care
•
Services and supplies given by a provider for alternative health care. This includes but is
not limited to aromatherapy, naturopathic medicine, herbal remedies, homeopathy, energy
medicine, Christian faith-healing medicine, Ayurvedic medicine, yoga, hypnotherapy, and
traditional Chinese medicine.
Armed forces
• Services and supplies received from a provider as a result of an injury sustained, or illness
contracted, while in the service of the armed forces of any country. When you enter the armed
forces of any country, we will refund any unearned pro-rata premium to the policyholder.
Beyond legal authority
• Services and supplies provided by a health professional or other provider that is acting beyond
the scope of its legal authority
Blood, blood plasma, synthetic blood, blood derivatives or substitutes
Examples of these are:
• The provision of blood to the hospital, other than blood derived clotting factors
• Any related services including processing, storage or replacement expenses
• The services of blood donors, apheresis or plasmapheresis
• For autologous blood donations, only administration and processing expenses are covered
Breasts
• Services and supplies given by a provider for breast reduction or gynecomastia
Illinois State University 2021-2022 Page 28
Clinical trial therapies (experimental or investigational)
•
Your plan does not cover clinical trial therapies (experimental or investigational), except as
described in the Eligible health services under your plan - Clinical trial therapies (experimental or
investigational) section
Cosmetic services and plastic surgery
• Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or enhance
the shape or appearance of the body, whether or not for psychological or emotional
reasons, except where described in the Eligible health services under your plan -
Reconstructive surgery and supplies section. Injuries that occur during medical treatments
are not considered accidental injuries even if unplanned or unexpected.
This exclusion does not apply to:
• Surgery after an accidental injury when performed as soon as medically feasible
• Coverage that may be provided under the Eligible health services under your plan - Gender
reassignment (sex change) treatment section.
• The removal of breast implants due to an illness or injury
Court-ordered services and supplies
• This includes court-ordered services and supplies, or those required as a condition of parole,
probation, release or as a result of any legal proceeding, unless they are a covered benefit under
your plan. This exclusion does not apply to court-ordered FDA-approved prescription drugs for the
treatment of substance use disorders and any associated counseling or wraparound services.
Custodial care
Examples are:
• Routine patient care such as changing dressings, periodic turning and positioning in bed
• Administering oral medications
• Care of a stable tracheostomy (including intermittent suctioning)
• Care of a stable colostomy/ileostomy
• Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
• Care of a bladder catheter (including emptying/changing containers and clamping tubing)
• Watching or protecting you
• Respite care except in connection with hospice care, adult (or child) day care, or convalescent care
• Institutional care. This includes room and board for rest cures, adult day care and convalescent care
• Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or
preparing foods
• Any other services that a person without medical or paramedical training could be trained to
perform
• Any service that can be performed by a person without any medical or paramedical training
Illinois State University 2021-2022 Page 29
Dental care for adults
• Dental services for adults including services related to:
-
The care, filling, removal or replacement of teeth and treatment of injuries to or diseases of
the teeth
- Dental services related to the gums
- Apicoectomy (dental root resection)
- Orthodontics
- Root canal treatment
- Soft tissue impactions
- Alveolectomy
- Augmentation and vestibuloplasty treatment of periodontal disease
- False teeth
- Prosthetic restoration of dental implants
- Dental implants
This exception does not include treatment of accidental injuries to sound natural teeth and
treatment for diseases of the teeth, removal of bony impacted teeth, bone fractures, removal of
tumors, and odontogenic cysts. . This exclusion also does not include tooth extraction surgery in
preparation for radiation treatment of neoplastic jaw or throat diseases.
Educational services
Examples of these services are:
•
Any service or supply for education, training or retraining services or testing, except where
described in the Eligible health services and exclusions– Diabetic services and supplies (including
equipment and training) section in the certificate. This includes:
- Special education
- Remedial education
- Wilderness treatment programs (whether or not the program is part of a residential treatment
facility or otherwise licensed institution)
- Job training
- Job hardening programs
• Educational services, schooling or any such related or similar program, including
therapeutic programs within a school setting.
Elective treatment or elective surgery
•
Elective treatment or elective surgery except as specifically covered under the student policy and
provided while the student policy is in effect
Examinations
Any health or dental examinations needed:
• Because a third party requires the exam. Examples are, examinations to get or keep a job,
or examinations required under a labor agreement or other contract
• Because a law requires it
• To buy insurance or to get or keep a license
• To travel
Illinois State University 2021-2022 Page 30
•
To go to a school, camp, or sporting event, or to join in a sport or other recreational activity
Experimental or investigational
• Experimental or investigational drugs, devices, treatments or procedures unless otherwise
covered under clinical trial therapies (experimental or investigational) or covered under clinical
trials (routine patient costs). See the Eligible health services and exclusions – Other services section .
Note that this exclusion will not impact your ability to obtain an external review of denial of
coverage for a service or supply denied by us as experimental or investigational.
Facility charges
For care, services or supplies provided in:
• Rest homes
• Assisted living facilities
• Similar institutions serving as a persons’ main residence or providing mainly custodial or
rest care
• Health resorts
• Spas or sanitariums
• Infirmaries at schools, colleges, or camps
Genetic care
• Any treatment, device, drug, service or supply to alter the body’s genes, genetic make-up,
or the expression of the body’s genes except for the correction of congenital birth defects
Growth/Height care
• A treatment, device, drug, service or supply to increase or decrease height or alter the rate
of growth
• Surgical procedures, devices and growth hormones to stimulate growth
Illegal Occupation
• Services and supplies that you receive as a result of an injury due to your commission of a felony
to which the contributing cause was the engagement of an illegal occupation
Incidental surgeries
• Charges made by a physician for incidental surgeries. These are non-medically necessary
surgeries performed during the same procedure as a medically necessary surgery.
Jaw joint disorder
• Surgical treatment of jaw joint disorders
• Non-surgical treatment of jaw joint disorders
• Jaw joint disorders treatment performed by prosthesis placed directly on the teeth, surgical
and non-surgical medical and dental services, and diagnostic or therapeutics services
related to jaw joint disorders including associated myofascial pain
This exclusion does not apply to covered benefits for treatment of TMJ and CMJ as described in the
Eligible health services under your plan –Temporomandibular joint dysfunction (TMJ) and
craniomandibular joint dysfunction (CMJ) treatment section.
Illinois State University 2021-2022 Page 31
Judgment or settlement
•
Services and supplies for the treatment of an injury or illness to the extent that payment is made
as a judgment or settlement by any person deemed responsible for the injury or illness (or their
insurers)
Mandatory no-fault laws
• Treatment for an injury to the extent benefits are payable under any state no-fault automobile
coverage or first party medical benefits payable under any other mandatory no-fault law
Maintenance care
• Care made up of services and supplies that maintain, rather than improve, a level of
physical or mental function, except for habilitation therapy services. See the Eligible health
services under your plan – Habilitation therapy services section
Medical supplies – outpatient disposable
• Any outpatient disposable supply or device. Examples of these are:
- Sheaths
- Bags
- Elastic garments
- Support hose
- Bandages
- Bedpans
- Syringes
- Blood or urine testing supplies
- Other home test kits
- Splints
- Neck braces
- Compresses
- Other devices not intended for reuse by another patient
Medicare
• Services and supplies available under Medicare, if you are entitled to premium-free Medicare Part
A or enrolled in Medicare Part B, or if you are not entitled to premium-free Medicare Part A or
enrolled in Medicare Part B because you refused it, dropped it, or did not make a proper request
for it
Non-medically necessary services and supplies
• Services and supplies which are not medically necessary for the diagnosis, care, or
treatment of an illness or injury or the restoration of physiological functions This includes
behavioral health services that are not primarily aimed at the treatment of illness, injury,
restoration of physiological functions or that do not have a physiological or organic basis.
This applies even if they are prescribed, recommended, or approved by your physician,
dental provider, or vision care provider. This exception does not apply to Preventive care
and wellness benefits.
Illinois State University 2021-2022 Page 32
Non-U.S. citizen
•
Services and supplies received by a covered person (who is not a United States citizen) within th e
covered person’s home country but only if the home country has a socialized medicine program.
Obesity (bariatric) surgery and services
• Weight management treatment or drugs intended to decrease or increase body weight, control
weight or treat obesity, including morbid obesity except as described in the Eligible health services
and exclusions – Preventive care and wellness section, including preventive services for obesity
screening and weight management interventions. This is regardless of the existence of other
medical conditions. Examples of these are:
- Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and
supplements, food supplements, appetite suppressants and other medications
- Hypnosis or other forms of therapy
- Exercise programs, exercise equipment, membership to health or fitness clubs, recreational
therapy or other forms of activity or activity enhancement
Other primary payer
•
Payment for a portion of the charge that Medicare or another party is responsible for as
the primary payer
Personal care, comfort or convenience items
• Any service or supply primarily for your convenience and personal comfort or that of a
third party
Riot
• Services and supplies that you receive from providers as a result of an injury from your
“participation in a riot”. This means when you take part in a riot in any way such as inciting,
or conspiring to incite, the riot. It does not include actions that you take in self-defense as
long as they are not against people who are trying to restore law and order.
Routine exams
• Routine physical exams, routine eye exams, routine dental exams, routine hearing exams
and other preventive services and supplies, except as specifically provided in the Eligible
health services under your plan section
School health services
• Services and supplies normally provided by the policyholder’s:
− School health services
− Infirmary
− Hospital
− Pharmacy or
by health professionals who
− Are employed by
− Are Affiliated with
− Have an agreement or arrangement with, or
Illinois State University 2021-2022 Page 33
−
Are otherwise designated by the policyholder.
Services provided by a family member
• Services provided by a spouse, domestic partner, civil union partner parent, child, step-
child, brother, sister, in-law or any household member
Sexual dysfunction and enhancement
• Any treatment, prescription drug, service, or supply to treat sexual dysfunction, enhance
sexual performance or increase sexual desire, including:
− Surgery, prescription drugs, implants, devices or preparations to correct or enhance
erectile function, enhance sensitivity, or alter the shape or appearance of a sex organ
− Sex therapy, sex counseling, marriage counseling, or other counseling or advisory
services
• Not eligible for coverage are prescription drugs in 90 day supplies
Strength and performance
• Services, devices and supplies such as drugs or preparations designed primarily for enhancing
your:
− Strength
− Physical condition
− Endurance
− Physical performance
Therapies and tests
• Full body CT scans
• Hair analysis
• Hypnosis and hypnotherapy
• Massage therapy, except when used as a physical therapy modality
• Sensory or auditory integration therapy
Tobacco cessation
• Any treatment, drug, service or supply to stop or reduce smoking or the use of other
tobacco products or to treat or reduce nicotine addiction, dependence or cravings,
including, medications, nicotine patches and gum unless recommended by the United
States Preventive Services Task Force (USPSTF). This also includes:
− Counseling, except as specifically provided in the Eligible health services under your plan –
Preventive care and wellness section
− Hypnosis and other therapies
− Medications, except as specifically provided in the Eligible health services under your plan
– Outpatient prescription drugs section
− Nicotine patches
− Gum
Illinois State University 2021-2022 Page 34
Treatment in a federal, state, or governmental entity
•
Any care in a hospital or other facility owned or operated by any federal, state or other
governmental entity, except to the extent coverage is required by applicable laws
Vision care for adults
• Routine vision exam provided by an ophthalmologist or optometrist, including refraction and
glaucoma testing
• Vision care services and supplies
Wilderness treatment programs
See Educational services within this section
Work related illness or injuries
• Coverage available to you under worker’s compensation or under a similar program under local,
state or federal law for any illness or injury related to employment or self-employment.
• A source of coverage or reimbursement will be considered available to you even if you waived
your right to payment from that source. You may also be covered under a workers’ compensation
law or similar law. If you submit proof that you are not covered for a particular illness or injury
under such law, then that illness or injury will be considered “non-occupational” regardless of
cause.
Illinois State University 2021-2022 Page 35
Sanctioned Countries
If coverage provided by this policy violates or will violate any economic or trade sanctions, the coverage is
immediately considered invalid. For example, Aetna companies cannot make payments for health care or
other claims or services if it violates a financial sanction regulation. This includes sanctions related to a
blocked person or a country under sanction by the United States, unless permitted under a written Office
of Foreign Asset Control (OFAC) license. For more information, visit http://www.treasury.gov/resource-
center/sanctions/Pages/default.aspx.
Assistive Technology
Persons using assistive technology may not be able to fully access the following information. For
assistance, please call 1-877-480-4161.
Smartphone or Tablet
To view documents from your smartphone or tablet, the free WinZip app is required. It may be available
from your App Store.
Non-Discrimination
Aetna is committed to being an inclusive health care company. Aetna does not discriminate on the basis
of ancestry, race, ethnicity, color, religion, sex/gender (including pregnancy), national origin, s exual
orientation, gender identity or expression, physical or mental disability, medical condition, age, veteran
status, military status, marital status, genetic information, citizenship status, unemployment status,
political affiliation, or on any other basis or characteristic prohibited by applicable federal, state or local
law.
Aetna provides free aids and services to people with disabilities and free language services to people whose
primary language is not English.
These aids and services include:
•
Qualified language interpreters
• Written information in other formats (large print, audio, accessible electronic formats, other
formats)
• Qualified interpreters
• Information written in other languages
If you need these services, contact the number on your ID card. Not an Aetna member? Call us at 1-877-
480-4161.
If you have questions about our nondiscrimination policy or have a discrimination-related concern that you
would like to discuss, please call us at 1-877-480-4161.
Illinois State University 2021-2022 Page 36
Please note, Aetna covers health services in compliance with applicable federal and state laws. Not all health
services are covered. See plan documents for a complete description of benefits, exclusions, limitations, and
conditions of coverage.
Illinois State University 2021-2022 Page 37
Language accessibility statement
Interpreter services are available for free.
Attention: If you speak English, language assistance service, free of charge, are available to you. Call 1-
877-480-4161 (TTY: 711).
Español/Spanish
Atención: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-877-480-4161 (TTY: 711).
አማርኛ/Amharic
ልብ ይበሉ: ኣማርኛ ቋንቋ የሚናገሩ ከሆነ፥ የትርጉም ድጋፍ ሰጪ ድርጅቶች፣ ያለምንም ክፍያ እርስዎን ለማገልገል ተዘጋጅተዋል። የሚከተለው ቁጥር ላይ
ይደውሉ 1-877-480-4161 (መስማት ለተሳናቸው: 711).
Ɓsɔ̍ ɔ Wɖ/Bassa
̀
̍ ̍ ̌ ̍ ̀ ̀ ̌ ̍ ̍ ̀ ̍
̍
D dɛ n kɛ dyeɖe gbo: Ɔ ju ke m̀ dyi Ɓsɔ̍ ɔ-wɖ-po-nyɔ ju ni, ni wuɖu k k ɖ po-poɔ ɓɛ̍ m̀ gbo kpaa.
Ɖa 1-877-480-4161 (TTY: 711).
中文/Chinese
注意：如果您说中文，我们可为您提供免费的语言协助服务。请致电 1-877-480-4161 (TTY: 711)。
Français/French
Attention : Si vous parlez français, vous pouvez disposer d’une assistance gratuite dans votre langue en
composant le 1-877-480-4161 (TTY: 711).
Kreyòl Ayisyen/
Haitian Creole
Illinois State University 2021-2022 Page 38
Atansyon: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-480-4161
(TTY: 711).
Igbo
Nrụbama: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 1-877-480-4161 (TTY: 711).
한국어/Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스가 무료로 제공됩니다. 1-877-480-4161(TTY: 711)번으로
전화해 주십시오.
Português/Portuguese
Atenção: a ajuda está disponível em português por meio do número 1-877-480-4161 (TTY: 711).
Estes serviços são oferecidos gratuitamente.
Русский/Russian
Внимание: если вы говорите на русском языке, вам могут предоставить бесплатные услуги
перевода. Звоните по телефону 1-877-480-4161 (TTY: 711).
Tagalog
Paunawa: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ngserbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-877-480-4161 (TTY: 711).
Tiếng Việt/Vietnamese
Lưu ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dnh cho quý vị.
Gọi số 1-877-480-4161 (TTY: 711).
Yorùbá/Yoruba
kíysí: Bí o bá nsọ d Yorbá, rnlọ́wọ́ lórí èdè, lófẹ̀ẹ́, w fn ọ. Pe 1-877-480-4161 (TTY: 711).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of
subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates
(Aetna).
Page 39
Office of Student Health Insurance
Campus Box 2541
Normal, Illinois 61790
(309) 438-2515
Insurance Identification Card
School Name: Illinois State University
Payer Number: 60054 0315
Student Name:
Id Number:
Group #: 711123
Carry This Card With You At All Times
Hospitalization – 80%
Office visits – 80%
Diagnostic Lab, X-ray,
Surgery, Anesthesia,
Consultation, Inpatient
Physician Care – 80%
Hospital Emergency Room
Emergency Injury – 100%
Emergency Illness – 100%
Emergency Room Expenses
for non-emergency illness
are not covered
$50 Deductible Per Policy Year waived if a coordinating policy also covers the insured.
This Program is underwritten by: Aetna Life Insurance Company (ALIC)
$50 Annual Prescribed Medicines
deductible.
Illinois State University 2021-2022
2021/2022 Plan Design & Benefits Summary Update
The following changes have been made to the original plan design and benefits summary
describing your plan.
Unless otherwise indicated, all changes listed below are retroactive to your plan’s
effective date.
Issue Date of this Update:
Page Number: 17
Voluntary sterilization
for males-surgical services
100% (of the negotiated charge)
No copayment or Policy year
deductible applies
100% (of the recognized charge)
No copayment or Policy year
deductible applies
