Insurance Booklet

University of North Texas
Aetna Student Health Plan and Benefits Summary

Aetna Student Health

Plan Design and Benefits Summary
University of North Texas System
Denton Campus
2014-2015
III
Student Health and Wellness Center
Table of Contents
Table of Contents
Introduction
Coverage Periods
1
3
Rates
Enrollment Deadlines
5
5
Rates for Domestic Students
Rates for Intensive English Language Institute Students
Student Coverage
Dependent Coverage
11
Preferred Provider Network
13
Texas Department of Insurance Notice
13
13
Pre-Authorization Program
15
Notification of Emergency Admissions
15
Descriptions of Benefits
17
Exclusions
25
Introduction
Student Health & Wellness Center

University of North Texas Denton Campus
The UNT Student Health & Wellness Center is the universitys on-campus health facility. The center is staffed
by doctors, nurse practitioners, physician assistants, and nurses.It is open weekdays from 8:00 a.m. to 6:00
p.m., during the Fall and Spring semesters and from 8:00 a.m. to 5:00 p.m. during the Summer semesters.
Students paying the student medical service fee are allowed access to providers for medical treatment, but will
incur charges for ancillary (lab, x-rays, prescriptions, etc) services and for specialty visits.
The following are covered at the Student Health and Wellness Center:
Pap coverage except as mandated: Chlamydia, Thin Prep, Gonorrhea, RPR (Syphilis), H/H (anemia),
HIV testing, urinalysis (chem), and CMP (blood chemistry);
CMP(blood chemistry), STD testing and H/H;
Acne treatment;
All CDC recommended immunizations, including HPV and Bacterial Meningitis;
Screening for TB by administering theT-spot test.If the test result is positive, a 1-view chest x-ray
to determine if contagious.
Coverage Periods
Coverage Periods
Students
The Master Policy on file at the school becomes

effective at 12:01 AM on August 14, 2014 and
terminates at 11:59 PM on August 13, 2015.
The individual students coverage becomes effective
on the first day of the period for which the premium
is paid or the date the enrollment form and full
premium are received by the company (or its designated
representative), whichever is later.Coverage terminates
on the Coverage End Date indicated.
Eligible Dependents
Coverage for dependents eligible under the Plan for the

following Coverage Periods shown below.
Coverage will become effective at 12:01 AM on the
Coverage Start Date and will terminate at 11:59 PM on
the Coverage End Date.
Coverage for insured dependents will not be effective
prior to that of the insured student or extend beyond
that of the insured student.
For more information, call the Student Health and
Wellness Center at (940) 565-2333.
Rates
Rates
The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna),
as well as a University of North Texas System administrative fee.
Enrollment Deadlines
Domestic Students
International Students
Term
Deadline
Term
Deadline
Annual
September 8, 2014
Annual
September 8, 2014
Fall
September 8, 2014
Fall
September 8, 2014
Spring
February 2, 2015
Spring
February 2, 2015
Spring/Summer
February 2, 2015
Spring/Summer
February 2, 2015
Summer
May 21, 2015
Summer
May 21, 2015
Summer I
June 11, 2015
Summer I
June 11, 2015
Summer II
July 16, 2015
Summer II
July 16, 2015
Intensive English Language Institute

Students
Graduate Assistants/Teaching Assitants
Term
Deadline
Term
Deadline
Annual
September 8, 2014
Annual
September 8, 2014
Fall I
September 8, 2014
Fall II
October 31, 2014
Spring I
February 2, 2015
Spring II
April 3, 2015
Summer
June 12, 2015
Rates for Domestic Students

Student Only
Children
Spouse
Term
Rate
Term
Rate
Term
Rate
Annual
$1724
Annual
$4,452
Annual
$2,564
Fall
$661
Fall
$1,708
Fall
$983
Spring
$647
Spring
$1,671
Spring
$962
Spring/Summer $1,063
Summer
$420
Summer
$1,086
Summer
$625
Summer I
$321
Summer I
$829
Summer I
$478
Summer II
$156
Summer II
$403
Summer II
$232
Rates for International Students

Student Only
Spouse
Children
Term
Rate
Term
Rate
Term
Rate
Annual
$1,729
Annual
$4,452
Annual
$2,564
Fall
$666
Fall
$1,708
Fall
$983
Spring
$652
Spring
$1,671
Spring
$962
Summer
$463
Summer
$1,183
Summer
$681
Summer I
$364
Summer I
$927
Summer I
$534
Summer II
$199
Summer II
$500
Summer II
$288
Rates for Intensive English Language Institute Students

Student Only
Spouse
Children
Term
Rate
Term
Rate
Term
Rate
Annual
$1,725
Annual
$4,452
Annual
$2,564
Fall I
$346
Fall I
$891
Fall I
$513
Fall II
$346
Fall II
$891
Fall II
$513
Spring I
$346
Spring I
$891
Spring I
$513
Spring II
$346
Spring II
$891
Spring II
$513
Summer
$346
Summer
$891
Summer
$513
Rates for Graduate Assistants/Teaching Assistants

Student Only
Term
Rate
Annual
$1,724
Student Coverage
Student Coverage
Eligibility
All domestic students enrolled at University of North
Texas are eligible to enroll in this insurance plan.
All registered international students, scholars or
other persons with a current passport and student
visa engaged in educational activities at the university
are automatically enrolled in this insurance plan at
registration and the premium for coverage is added to
their tuition billing, unless proof of comparable
coverage is provided and their insurance waiver is
approved by the Student Health and Wellness Center
or the UNT International for IELI students.
This includes students enrolled in Intensive
English Language Institute, international students
engaged in curricular practical training, Optional
Practical Training, Internship, Practicum, Academic
Training, Study Abroad, or other credit or non-credit
activity as a bona fide UNT student.
Home study, correspondence, Internet classes,
and television (TV) courses, do fulfill the eligibility
requirement for Texas residents that actively attend class.
If it is discovered that this eligibility requirement
has not been met, our only obligation is to refund
premium, less any claims paid.
Enrollment
Domestic students may enroll online or obtain an application for voluntary coverage, log on to
www.aetnastudenthealth.com and search for your school, then click on Enroll to download the form.
Eligible International students will be automatically enrolled in this plan when registering for classes.
Exceptions
A Covered Person entering the armed forces of any country will not be covered under the Policy
as of the date of such entry. A pro rata refund of premium will be made for such person, and any covered
dependents, upon written request received by Aetna within 90 days of withdrawal from school.
Dependent Coverage
Dependent Coverage
Eligibility
Covered students may also enroll their spouse and the
covered students children who are under 26 years of
age.
The term child includes:
Your biological children.
Your adopted children.
Your stepchildren.
For health expense coverage, your grandchild
whom you support on the date of his or her initial
application for coverage.
Enrollment
To enroll the dependent(s) of a covered student, please
complete the Enrollment Form by visiting
www.aetnastudenthealth.com, selecting the school name,
and clicking on the Plans & Products Offered to You
link on the left hand side of the screen, or by calling
customer service at (877) 410-6570 and requesting that
an Enrollment Form be sent in the mail.
Please refer to the Coverage Periods section
of this document for coverage dates and deadline
dates. Dependent enrollment applications will not be
accepted after the enrollment deadline, unless there
is a significant life change that directly affects their
insurance coverage. (An example of a significant life
change would be loss of health coverage under another
health Plan.) The completed Enrollment Form and
premium must be sent to Aetna Student Health.
11
Aetna Student Health has arranged for you to access a

Preferred Provider Network in your local community.
To maximize your savings and reduce your out-ofpocket expenses, select a Preferred Provider. It is to
youradvantage to use a Preferred Provider because
savings may be achieved from the Negotiated Charges
these providers have agreed to accept as payment for
their services.
Texas Department of Insurance Notice
You have the right to an adequate network of

preferred providers. If you believe that the
network is inadequate, you may file a complaint
with the Department of Insurance.
If you obtain out-of-network services because
no preferred provider was reasonably available, you

may be entitled to have the claim paid at the innetwork coinsurance rate and your out-of-pocket
expenses counted toward your in-network, out-ofnetwork, or general out-of-pocket maximum, as
appropriate.
You have the right to obtain advance estimates of
the amounts that the providers may bill for projected
services, from your out-of-network provider; and
of the amounts that the insurer may pay for the
projected services, from your insurer. You may obtain
a current directory of preferred providers at the
following website: www.aetnastudenthealth.com for
assistance in finding available preferred providers.
If the directory is materially inaccurate, you may be
entitled to have an out-of-network claim paid at the
in-network level of benefits.
If you are treated by a provider or hospital that is
not contracted with your insurer, you may be billed
for anything not paid by the insurer.
If the amount you owe to an out-of-network
hospital-based radiologist, anesthesiologist,
pathologist, emergency department physician, or
neonatologist is greater than $1,000 (not including
your copayment, coinsurance, and deductible
responsibilities) for services received in a network
hospital, you may be entitled to have the parties
participate in a teleconference, and, if the result is not
to your satisfaction, in a mandatory mediation at no
cost to you. You can learn more about mediation at
the Texas Department of Insurance website: www.tdi.
state.tx.us/consumer/cpmmediation.html.
13
Your plan requires pre-authorization for a hospital stay.

Pre-authorization simply means calling us prior to
treatment to get approval for a medical procedure or service.
Pre-authorization may be done by you, your doctor,
a hospital administrator, or one of your relatives.
All requests for authorization must be obtained by
contacting Aetna Student Health at (877) 410-6570.
Please refer to the Master Policy for more
information regarding pre-authorization.
If you do not secure pre-authorization for
non-emergency inpatient admissions, or provide
notification for emergency admissions, your Covered
Medical Expenses will be subject to medical necessity
review. The following inpatient services require
pre-authorization:
All inpatient admissions, including length of stay, to
a hospital, skilled nursing facility, a facility
established primarily for the treatment of substance
abuse, or a residential treatment facility;
patient, Physician or hospital must telephone at least

three (3) business days prior to the planned admission or
prior to the date the services are scheduled to begin.
Notification of Emergency Admissions
The patient, patients representative, Physician or

hospital must telephone within one (1) business day
following inpatient (or partial hospitalization) admission.
All inpatient maternity care, after the initial 48 hours

for a vaginal delivery or 96 hours for a cesarean
section;
All partial hospitalization in a hospital, residential
treatment facility, or facility established primarily for

the treatment of substance abuse
Pre-authorization DOES NOT guarantee the payment

of benefits for your inpatient admission.
Each claim is subject to medical policy review, in
accordance with the exclusions and limitations contained
in the Policy, as well as a review of eligibility, adherence
to notification guidelines, and benefit coverage under
the student Accident and Sickness Plan.
For the pre-authorization of non-emergency
inpatient admissions and partial hospitalization, the
15
Descriptions of Benefits
Description of Benefits
The plan excludes coverage for certain services and contains limitations on the amounts it will pay. While this
Plan Design and Benefits 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 Master Policy issued to the University of North
Texas System, you may access it online at www.aetnastudenthealth.com. If any discrepancy exists between this
Brochure and the Policy, the Master Policy will govern and control the payment of benefits. All coverage is based
on Recognized Charges unless otherwise specified.
Payment
Preferred Care
Non-Preferred Care
Deductible*
Individual:
$400 per Policy Year
Individual:
$800 per Policy Year
Out of Pocket Maximum**
Individual Out-of-Pocket:
$6,350 per Policy Year
N/A
Family Out-of-Pocket:
$12,700 per Policy Year
N/A
Coinsurance
Covered Medical Expenses are payable at the coinsurance percentage specified

below, after any applicable Deductible.
* Unless otherwise indicated, the Policy Year Deductible must be met prior to benefits being payable.
In compliance with Texas State Mandate(s) the Policy Year Deductible is waived for Newborn Hearing Screenings and Childhood Immunizations from birth to age 6.
** Once the Individual or Family Out-of-Pocket Limit has been satisfied, Covered Medical Expenses will be payable at 100%
for the remainder of the Policy Year. The following expenses do not apply toward meeting the Out-of-Pocket Limit:
Expenses that are not covered medical expenses;
Expenses for non-preferred care;
Penalties
17
Inpatient Hospitalization Preferred Care

Benefits
Non-Preferred Care
Room and Board Expense
80% of the Negotiated Charge
Miscellaneous Hospital Expense

Non-Surgical Physicians
Expense
60% of the recognized charge for a semiprivate room

60% of the Recognized Charge
Surgical Expenses
Preferred Care
Non-Preferred Care
Surgical Expense (Inpatient

and Outpatient)
Anesthesia Expense
(Inpatient and Outpatient)
Assistant Surgeon Expense

(Inpatient and Outpatient)
Ambulatory Surgical Expense 80% of the Negotiated Charge
18
Outpatient Expense
Preferred Care
Non-Preferred Care
Hospital Outpatient Department Expense
Walk-in Clinic Visit Expense
Emergency Room Expense
Urgent Care Expense
Ambulance Expense
Physicians Office Visit

Expense
Laboratory and X-ray

Expense
High Cost Procedures

Expense
Therapy Expense
Durable Medical and Surgical 80% of the Negotiated Charge

Equipment Expense
Prosthetic Devices Expense
Hearing Aids Expense
19
Outpatient Expense
Autism/Pervasive
Development Disorder
Expense
Covered Medical Expenses are payable on the same basis as any other
Sickness, member cost sharing is based on the type of service performed and
place of service where it is rendered
Allergy Testing and

Treatment Expense
Covered Medical Expenses are payable on the same basis as any other Sickness,
member cost sharing is based on the type of service performed and the place of
service where it is rendered
Diagnostic Testing For
Learning Disabilities Expense member cost sharing is based on the type of service performed and the place of
Therapy Expense
Dental Injury Expense
80% of the Actual Charge
Preventive Care
Preferred Care
Non-Preferred Care
Gynecological Exam and Pap 100% of the Negotiated Charge 60% of the Recognized Charge
Smear Screening Expense
Mammogram Expense
100% of the Negotiated Charge 60% of the Recognized Charge
Immunizations Expense
Child Immunizations
100% of the Negotiated Charge 100% of the Negotiated Charge
Expense
Routine Physical Exam
Expense
Routine Screening for Sexually 100% of the Negotiated Charge 60% of the Recognized Charge
Transmitted Disease Expense
Routine Colorectal Cancer
Screening Expense
20
Preventive Care
Preferred Care
Non-Preferred Care
Routine Prostate Cancer

Screening
Pediatric Vision Care Exam

Expense
Pediatric Routine Dental
Exam Expense
Pediatric Basic Dental Care
Expense
Pediatric Major Dental Care
Expense
Pediatric Orthodontia
Expense

Treatment of Mental and Preferred Care

Nervous Disorders
Non-Preferred Care
Inpatient Expense
Outpatient Expense
Alcoholism and Drug

Addiction Treatment
Preferred Care
Non-Preferred Care
Inpatient Expense
Outpatient Expense
21
Maternity Benefits
Preferred Care
Non-Preferred Care
Prenatal Care/Comprehensive
Lactation Support and
Counseling Services
Breast Feeding Durable
Medical Equipment
Well Newborn Nursery Care
Expense
Maternity Expense

Covered Medical Expenses for pregnancy, childbirth, and complications of pregnancy are payable on the same basis as any other sickness, member cost
sharing is based on the type of service performed and the place of service where
it is rendered
Family Planning Expense Preferred Care
Non-Preferred Care
Voluntary Sterilization
Contraceptives
Unless specified below, not covered under this benefit are charges for:
Services which are covered to any extent under any other part of this plan;
Services and supplies incurred for an abortion;
Services provided as a result of complications resulting from a voluntary sterilization
Procedure and related follow-up care;
Services which are for the treatment of an identified illness or injury;
Services that are not given by a physician or under his or her direction;
Psychiatric, psychological, personality or emotional testing or exams;
Any contraceptive methods that are only reviewed by the FDA and not approved by the FDA;
Male contraceptive methods, sterilization procedures or devices;
The reversal of voluntary sterilization procedures, including any related follow-up care
22
Prescription Drug
Coverage
Prescribed Medicines
Expense
Preferred Care
Non-Preferred Care
100% of the Negotiated Charge, 60% of the Recognized Charge

following a
$40 Copay for Non-Formulary
Brand Name Prescription Drug,
a
$25 Copay for each Brand Name
Prescription Drug, or a
$40 Copay for Non-Formulary Brand Name

Prescription Drug, a
$10 Copay for each Generic

Prescription Drug
$10 Copay for each Generic Prescription Drug
Additonal Benefits
Preferred Care
Non-Preferred Care
Diabetic Testing Supplies

Expense
member cost sharing is based on the type of service performed and
the place of service where it is rendered
Outpatient Diabetic Selfmanagement Education

Programs Expense
Temporomandibular Joint
Dysfunction Expense
Covered Medical Expenses are payable on the same basis as any other
Sickness, member cost sharing is based on the type of service performed and the
place of service where it is rendered
Hospice Benefit
Home Health Care Expense
Licensed Nurse Expense
$25 Copay for each Brand Name Prescription

Drug, or a
23
Additonal Benefits
Preferred Care
Non-Preferred Care
Skilled Nursing Facility

Expense

for the semi-private room rate
60% of the Recognized Charge for the semiprivate room rate
Rehabilitation Facility
Expense

60% of the Recognized Charge for the
for the rehabilitation facilitys dai- rehabilitation facilitys daily room and board
ly room and board maximum for maximum for semi-private accommodations
semi-private accommodations
Cosmetic Surgery
Routine Foot Care

Transplant Expense
Convalescent Facility
Expense
24
Exclusions
Exclusions
This Plan does not cover nor provide benefits for:
Services
Expenses incurred for services normally provided without charge by the Policyholders Health Service;
Infirmary or Hospital; or by health care providers employed by the Policyholder.
Expense incurred for services normally provided without charge by the school and covered by the school fee
for services.
Expense incurred for any services rendered by a member of the covered persons immediate family or a
person who lives in the covered persons home.
Expense for services or supplies provided for the treatment of obesity and/or weight control, unless
otherwise provided in the Policy.
Injuries
Expenses incurred as a result of injury due to participation in a riot. Participation in a riot means taking
part in a riot in any way; including inciting the riot or conspiring to incite it. It does not include actions taken
in selfdefense; so long as they are not taken against persons who are trying to restore law and order.
Expense incurred as a result of an accident occurring in consequence of riding as a passenger or otherwise in

any vehicle or device for aerial navigation; except as a fare paying passenger in an aircraft operated by a
scheduled airline maintaining regular published schedules on a regularly established route.
Expense incurred as a result of an injury or sickness due to working for wage or profit or for which benefits
are payable under any Workers Compensation or Occupational Disease Law.
Expense incurred as a result of an injury sustained or sickness contracted while in the service of the Armed
Forces of any country. Upon the covered person entering the Armed Forces of any country; the unearned
prorata premium will be refunded to the Policyholder.
Exams
Expenses for routine physical exams; including expenses in connection with well newborn care; routine vision exams;
routine dental exams; routine hearing exams; immunizations; or other preventive services and supplies; except to the
extent coverage of such exams; immunizations; services; or supplies is specifically provided in the Policy.
25
Treatment
Expense incurred for treatment provided in a governmental hospital unless there is a legal obligation to pay
such charges in the absence of insurance.
Expense for treatment of covered students who specialize in the mental health care field; and who receive
treatment as a part of their training in that field.
Expenses for treatment of injury or sickness to the extent payment is made; as a judgement or settlement; by
any person deemed responsible for the injury or sickness (or their Insurers).
Expense incurred as a result of dental treatment; including extraction of wisdom teeth; except for treatment
resulting from injury to sound natural teeth; as provided elsewhere in this Policy.
Surgeries
Expense incurred for elective treatment or elective surgery except as specifically provided elsewhere in this
Policy and performed while this Policy is in effect.
Expense incurred for cosmetic surgery; reconstructive surgery; or other services and supplies which improve;
alter; or enhance appearance; whether or not for psychological or emotional reasons; except to the extend
needed to 1) Improve the function of a part of the body that is not a tooth or structure that supports the
teeth; and is malformed as a result of a severe birth defect; including A) harelip; webbed fingers; or toes; or
B) as direct result of disease; or C) surgery performed to treat a disease or injury. 2) Repair an injury
(including reconstructive surgery for prosthetic device for a covered person who has undergone a
mastectomy ;) which occurs while the covered person is covered under this Policy. Surgery must be
performed in the calendar year of the accident which causes the injury; or in the next calendar year. This
exclusion will not apply to reconstructive surgery for craniofacial abnormalities performed on a dependent
child who is under 18 years of age. As used here, reconstructive surgery for craniofacial abnormalities
means reconstructive surgery to improve the function of; or to attempt to create a normal appearance of an
abnormal structure caused by congenital defects, developmental deformities, trauma, tumors, infections or disease.
Expenses incurred for gastric bypass; and any restrictive procedures; for weight loss.
Expenses incurred for breast reduction/mammoplasty.
Expenses incurred for gynecomastia (male breasts).
Expense incurred for; or related to; sex change surgery.
26
Expense incurred for the removal of an organ from a covered person for the purpose of donating or selling
the organ to any person or organization. This limitation does not apply to a donation by a covered person to a
spouse; child; brother; sister; or parent.
Holistic Medicine
Expense incurred for acupuncture; unless services are rendered for anesthetic purposes.
Expense incurred for alternative; holistic medicine; and/or therapy; including but not limited to; yoga and
hypnotherapy.
Other
Expense incurred as a result of commission of a felony.

Expense incurred for voluntary or elective abortions unless otherwise provided in this Policy.
Expense incurred after the date insurance terminates for a covered person except as may be specifically
provided in the Extension of Benefits Provision.
Expense incurred for which no member of the covered persons immediate family has any legal obligation for payment.
Expense incurred for custodial care. Custodial care means services and supplies furnished to a person mainly
to help him or her in the activities of daily life. This includes room and board and other institutional care.
The person does not have to be disabled. Such services and supplies are custodial care without regard to: (a)
by whom they are prescribed; or (b) by whom they are recommended; or (c) by whom or by which they are performed.
Expenses incurred for or in connection with: procedures, services, or supplies that are, as determined by
Aetna, to be experimental or investigational. A drug, a device, a procedure, or treatment will be determined to

be experimental or investigational if: a) There are insufficient outcomes data available from controlled clinical
trials published in the peer reviewed literature, to substantiate its safety and effectiveness, for the disease or
injury involved, or b) If required by the FDA, approval has not been granted for marketing, or c) A
recognized national medical or dental society or regulatory agency has determined, in writing, that it is
experimental, investigational, or for research purposes, or d) The written protocol or protocols used by the
treating facility, or the protocol or protocols of any other facility studying substantially the same drug, device,
procedure, or treatment, or the written informed consent used by the treating facility, or by another facility
studying the same drug, device, procedure, or treatment, states that it is experimental, investigational, or for
research purposes. However, this exclusion will not apply with respect to services or supplies (other than
drugs) received in connection with a disease, if Aetna determines that: a) The disease can be expected to cause
27
death within one year, in the absence of effective treatment, and b) The care or treatment is effective for that
disease, or shows promise of being effective for that disease, as demonstrated by scientific data. In making
this determination, Aetna will take into account the results of a review by a panel of independent medical
professionals. They will be selected by Aetna. This panel will include professionals who treat the type of
disease involved. Also, this exclusion will not apply with respect to drugs that: a) Have been granted treatment
investigational new drug (IND), or b) Group c/treatment IND status, or c) Are being studied at the Phase III
level in a national clinical trial, sponsored by the National Cancer Institute, d) If Aetna determines that available,
scientific evidence demonstrates that the drug is effective, or shows promise of being effective, for the disease.
Expense incurred by a covered person; not a United States citizen; for services performed within the covered
persons home country; if the covered persons home country has a socialized medicine program.
Expense incurred when the person or individual is acting beyond the scope of his/her/its legal authority.
Expense for care or services to the extent the charge would have been covered under Medicare Part A or Part
B; even though the covered person is eligible; but did not enroll in Part B.
Expense; charges for failure to keep a scheduled visit; or charges for completion of a claim form.
Expense for personal hygiene and convenience items; such as air conditioners; humidifiers; hot tubs;
whirlpools; or physical exercise equipment; even if such items are prescribed by a physician.
Expense for contraceptive methods; devices or aids; and charges for services and supplies for or related to
gamete intrafallopian transfer; artificial insemination; in-vitro fertilization (except as required by the state
law); or embryo transfer procedures; elective sterilization or its reversal; or elective abortion; unless specifically
provided for in this Policy.
Expense for charges that are not recognized charges, as determined by Aetna, except that this will not apply
if the charge for a service, or supply, does not exceed the recognized charge for that service or supply, by
more than the amount or percentage, specified as the Allowable Variation.
Expense incurred for a treatment; service; or supply; which is not medically necessary; as determined by
Aetna; for the diagnosis care or treatment of the sickness or injury involved. This applies even if they are
prescribed; recommended; or approved; by the persons attending physician; or dentist. In order for a
treatment; service; or supply; to be considered medically necessary; the service or supply must: (a) be care; or
treatment; which is likely to produce a significant positive outcome as; and no more likely to produce a
negative outcome than; any alternative service or supply; both as to the sickness or injury involved; and the
persons overall health condition; (b) be a diagnostic procedure which is indicated by the health status of the
28
person; and be as likely to result in information that could affect the course of treatment as; and no more likely
to produce a negative outcome than; any alternative service or supply; both as to the sickness orinjury involved;
and the persons overall health condition; and (c) as to diagnosis; care; and treatment; be no more costly (taking
into account all health expenses incurred in connection with the treatment; service; or supply); than any alternative
service or supply to meet the above tests.
In determining if a service or supply is appropriate under the circumstances; Aetna will take into consideration:
information relating to the affected persons health status; reports in peer reviewed medical literature; reports and
guidelines published by nationally recognized health care organizations that include supporting scientific data;
generally recognized professional standards of safety and effectiveness in the United States for diagnosis; care; or
treatment; the opinion of health professionals in the generally recognized health specialty involved; and any other
relevant information brought to Aetnas attention.
In no event will the following services or supplies be considered to be medically necessary: (a) those that do not
require the technical skills of a medical; a mental health; or a dental professional; or (b) those furnished mainly
for the personal comfort or convenience of the person; any person who cares for him or her; or any persons who
is part of his or her family; any healthcare provider; or healthcare facility; or (c) those furnished solely because
the person is an inpatient on any day on which the persons sickness or injury could safely; and adequately; be
diagnosed; or treated; while not confined; or those furnished solely because of the setting; if the service or supply
could safely and adequately be furnished in a physicians or a dentists office; or other less costly settings.
29
Index
Index
A
Alcoholism and Drug Addiction Treatment 15
Allergy Testing and Treatment Expense 14
Ambulance Expense 13
Anesthesia Expense 12
Autism/Pervasive Development Disorder Expense 14
B
Breast Feeding Durable Medical Equipment 16
C
Colorectal Cancer Screening Expense 14
Contraceptives 16
Cosmetic Surgery 18
Coverage Periods V, 2
D
Dental Injury Expense 14
Dependent Coverage V, 7
Description of Benefits V, 11
Diabetic Testing Supplies Expense 17
Diagnostic Testing For Learning Disabilities Expense 14
E
Emergency Room Expense 13
Enrollment Deadlines V, 3
Exams 19
Exclusions V, 19
F
Family Planning Expense 16
Foot Care 18
G
Gastric Bypass 20
Graduate Assistants 3, 5
Gynecological Exam 14
31
H
Hearing Aids Expense 13
Holistic Medicine 21
Hospice Benefit 17
I
Immunizations Expense 14
Injuries 19
Inpatient Hospitalization Benefits 12
Intensive English Language Institute V, 3, 5
L
Laboratory and X-ray Expense 13
Licensed Nurse Expense 17
M
Mammogram Expense 14
Maternity Benefits 16
Mental and Nervous Disorders 15
N
Notification of Emergency Admissions V, 9
O
Obesity 19
Outpatient Expense 13
P
Pap Coverage 1
Pap Smear Screening Expense 14
Pediatric Orthodontia Expense 15
Pediatric Routine Dental Exam Expense 15
Pediatric Vision Care Exam Expense 15
Physical Exam Expense 14
Physicians Office Visit Expense 13
Pre-Authorization Program V, 9
Preferred Provider Network V, 8
Prenatal Care/Comprehensive Lactation Support and Counseling Services 16
Prescribed Medicines Expense 17
Prescription Drug Coverage 17
Preventive Care 14
Prostate Cancer Screening 15
32
Prosthetic Devices Expense 13
R
Rates V, 3
Rehabilitation Facility Expense 18
Room and Board Expense 12
S
Screening for Sexually Transmitted Disease Expense 14
Student Coverage V, 6
Surgeries 20
Surgical Expenses 12
T
Teaching Assistants 3, 5
Temporomandibular Joint Dysfunction Expense 17
Texas Department of Insurance Notice V, 8
Therapy Expense 13, 14
Transplant Expense 18
U
Urgent Care Expense 13
V
Voluntary Sterilization 16
W
Walk-in Clinic Visit Expense 13
Weight Control 19
33

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Insurance Booklet

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University of North Texas

Aetna Student Health Plan and Benefits Summary

Aetna Student Health

Student Health and Wellness Center

Rates for Domestic Students

Rates for Intensive English Language Institute Students

Preferred Provider Network

Texas Department of Insurance Notice

Preferred Provider Network

Notification of Emergency Admissions

Student Health and Wellness Center

Student Health & Wellness Center

Student Health and Wellness Center

The Master Policy on file at the school becomes

Coverage for dependents eligible under the Plan for the

Student Health and Wellness Center

May 21, 2015

May 21, 2015

June 11, 2015

June 11, 2015

July 16, 2015

July 16, 2015

Intensive English Language Institute

Graduate Assistants/Teaching Assitants

October 31, 2014

June 12, 2015

Student Health and Wellness Center

Rates for Domestic Students

Rates for International Students

Student Health and Wellness Center

Rates for Intensive English Language Institute Students

Rates for Graduate Assistants/Teaching Assistants

Student Health and Wellness Center

Student Health and Wellness Center

Student Health and Wellness Center

Preferred Provider Network

Aetna Student Health has arranged for you to access a

Texas Department of Insurance Notice

You have the right to an adequate network of

Preferred Provider Network

no preferred provider was reasonably available, you

Student Health and Wellness Center

Your plan requires pre-authorization for a hospital stay.

patient, Physician or hospital must telephone at least

Notification of Emergency Admissions

The patient, patients representative, Physician or

All inpatient maternity care, after the initial 48 hours

All partial hospitalization in a hospital, residential

treatment facility, or facility established primarily for

Pre-authorization DOES NOT guarantee the payment

Student Health and Wellness Center

Out of Pocket Maximum**

Covered Medical Expenses are payable at the coinsurance percentage specified

Student Health and Wellness Center

Inpatient Hospitalization Preferred Care

Room and Board Expense

80% of the Negotiated Charge

Miscellaneous Hospital Expense

80% of the Negotiated Charge

60% of the recognized charge for a semiprivate room

80% of the Negotiated Charge

60% of the Recognized Charge