SUMMARY OF BENEFITS. Out-of-Network Care: $10,000 per policy year

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1 OUTPATIENT BENEFITS Most Primary Care office visits at SHC are provided at no charge. This is not an insured benefit but is provided by NYU to all matriculated students including students who waive the Student Health Insurance Plans. Lab and X-ray Some lab tests at SHC are provided at no charge. This is not an insured benefit but is provided by NYU to all matriculated students including students who waive the Student Health Insurance Plans. SUMMARY OF BENEFITS BASIC PLAN In-Network Care: 80% of the allowable charge; $30 per visit copay; up to the out-of-pocket Out-of-Network Care: 50% of reasonable and customary charges; $60 per visit deductible up to the out-of-pocket Out-of-Network Care: $10,000 per policy year COMPREHENSIVE PLAN/GSHIP Once the Out-of-Pocket Limit has been satisfied, Eligible Expenses will be payable at 100% for the remainder of the policy year up to any benefit maximum that may apply. to the out-of-pocket limit,100% thereafter At SHC: Specialists, 100% after a $30 per visit fee for Comprehensive; $10 for GSHIP In-Network Care: 90% of the allowable charge; $30 per visit copay; up to the out-of-pocket Out-of-Network Care: 60% of reasonable and customary charges; $60 per visit deductible for Comp; $50 per visit deductible for GSHIP; up to the out-of-pocket In-Network Care: 90% of the allowable charges up to the out-ofpocket to the out-of-pocket Please note: Lab tests and radiology procedures performed routinely with no symptoms are not covered services, unless coverage is mandated by Healthcare Reform Law. Policy Year Maximum Unlimited Unlimited Out-of-Pocket Limit In-Network Care: $5,000 per policy year Doctor s Visits At SHC: Specialists, 100% after a $30 per visit fee. 12

2 Preventive Services and Immunizations as specified by Health Care Reform (PPACA) (see also Women s Health Benefits, page 14) Allergy Testing and Shots Physical/Occupational Therapy and Chiropractic Service Hospital Emergency Room At SHC: Preventive Services available and rendered at SHC will be provided at 100% with no cost sharing In-Network Care: Preventive services that are not available at SHC will be covered at 100% of Eligible Expenses with no cost-sharing. Out-of-Network Care: No coverage (To view a list of covered preventive services, go to Please note that coverage is age, gender, and risk appropriate.) Out-of-Network Care: 50% of the reasonable and customary charges up to the out-of-pocket At SHC: 100% after a $30 per visit fee. In-Network Care: 80% of the allowable charge; $30 per visit copay; up to the out-of-pocket Out-of-Network Care: 50% of reasonable and customary charges; $60 per visit deductible up to the out-of-pocket limit, 100% thereafter In-Network Care: 80% of the allowable charge; $100 per visit copay; up to the out-of-pocket Out-of-Network Care: 80% of the reasonable and customary charges; $100 per visit copay; up to the out-of-pocket In-Network Care: 90% of the allowable charge up to the out-of-pocket Out-of-Network Care: 60% of the reasonable and customary charges up to the out-of-pocket At SHC: 100% after a $30 per visit fee for Comprehensive; $10 copay for GSHIP In-Network Care: 90% of the allowable charge; $30 per visit copay; up to the out-of-pocket Out-of-Network Care: 60% of reasonable and customary charges; $60 per visit deductible for Comp; $50 per visit deductible for GSHIP; up to the out-of-pocket In-Network Care: 90% of the allowable charge; $100 per visit copay; up to the out-of-pocket Out-of-Network Care: 90% of the reasonable and customary charges; $100 per visit copay; up to the out-of-pocket For a more complete description of plan benefits, general terms and conditions, referral requirements, etc., please review the Student Health Insurance Handbook at 13

3 WOMEN S HEALTH BENEFITS Routine Gynecologic Exam Most Women s Health office visits at SHC are provided at no charge. This is not an insured benefit but is provided by NYU to all matriculated students including students who waive the Student Health Insurance Plans. Pap Smear Screening Mammography Contraceptives In-Network Care: covered at 100% of Eligible Expenses with no costsharing. Out-of-Network Care: 50% of reasonable and customary charges; $60 per visit deductible up to the out-of-pocket to the out-of-pocket Prescription Contraceptive Drugs, Devices and Services At SHC: Covered at 100% of Eligible Expenses with no cost sharing At SHC: provided at 100% with no cost sharing At SHC: provided at 100% with no cost sharing In-Network Care: covered at 100% of Eligible Expenses with no costsharing. Out-of-Network Care: 60% of reasonable and customary charges; $60 per visit deductible for Comp; $50 per visit deductible for GSHIP; up to the out-of-pocket In-Network Care: 90% of the allowable charges up to the out-ofpocket to the out-of-pocket In-Network Care: Covered at 100% of allowable charge with no cost sharing Lost or stolen prescription drugs will not be covered. Eligible Expenses incurred for outpatient contraceptive service will be paid under Contraceptvie Services (see Well Woman Care benefit) BASIC PLAN COMPREHENSIVE PLAN/GSHIP Out-of-Network Care: Payable same as Laboratory and X-ray expense (see page 12) Out-of-Network Care: Non-Preferred Pharmacies; see Prescription Drug benefit for Non-Preferred Pharmacy In-Network Care: Covered at 100% of eligible expenses with no cost-sharing at Preferred Pharmacies 14

4 MATERNITY Obstetric Services Inpatient Room and Board For Maternity TERMINATION OF PREGNANCY Termination of Pregnancy to the out-of-pocket to the out-of-pocket Designated Care: At NYU Langone Hospital, 100% of negotiated charge up to the out-of-pocket limit to the out-of-pocket Copays may apply. Only one covered per policy year. Designated Care: 100% of negotiated charge* up to the out-of-pocket limit In-Network Care: 90% of the allowable charge up to the out-of pocket to the out-of pocket In-Network Care: 90% of the allowable charge up to the out-of-pocket to the out-of-pocket Designated Care: At NYU Langone Hospital, 100% of negotiated charge up to the out-of-pocket limit In-Network Care: 90% of the allowable charge up to the out-of pocket to the out-of pocket Copays may apply. Only one covered per policy year. * For CPT Code and CPT Code (routine obstetric care for complete pregnancy including pre-natal visits, vaginal or cesarean delivery and postpartum care). For a list of designated providers, please call Student Health Insurance Services at (212) For a more complete description of plan benefits, general terms and conditions, referral requirements, etc., please review the Student Health Insurance Handbook at 15

5 MENTAL HEALTH BENEFITS Outpatient Mental Health Psychotherapy (outside SHC) Short-term psychotherapy (talk therapy) visits at SHC are provided at no charge. This is not an insured benefit but is provided by NYU to all matriculated students including students who waive the Student Health Insurance Plans. Psychiatric Medication Assessment and Management Inpatient Mental Health BASIC PLAN COMPREHENSIVE PLAN/GSHIP In-Network Care: 80% of the allowable charge; up to the out-of-pocket Out-of-Network Care: 50% of reasonable and customary charges; up to the out-of-pocket Benefit Maximum (In and Out-of-Network) At SHC: 100% after a $20 per visit fee. Outside SHC Biologically Based Conditions: Pay as any other Sickness Non-Biologically Based Conditions: Pay as any other sickness. In-Network Care: 80% of the allowable charge; $30 per visit copay; up to the out-of-pocket Out-of-Network Care: 50% of reasonable and customary charges; $60 per visit deductible up to the out-of-pocket In-Network Care 80% of the negotiated charge up to the out-ofpocket Out-of-Network Care 50% of reasonable and customary charges up to the out-of-pocket Benefit Maximum (In and Out-of-Network) Biologically Based Conditions: Pay as any other Sickness Non-Biologically Based Conditions: Pay as any other sickness. In-Network Care: 90% of the allowable charge; up to the out-of-pocket Out-of-Network Care: 60% of reasonable and customary charges; up to the out-of-pocket At SHC: Comp: 100% after a $20 per visit fee; GSHIP: covered 100% In-Network Care: 90% of the allowable charge; $30 per visit copay; up to the out-of-pocket Out-of-Network Care: 60% of reasonable and customary charges; $60 per visit deductible for Comp; $50 per visit deductible for GSHIP; up to the out-of-pocket In-Network Care 90% of the negotiated charge up to the out-ofpocket Out-of-Network Care 60% of reasonable and customary charges up to the out-of-pocket Designated Care At NYU Langone Hospital, 100% of the Negotiated Charge Benefit Maximum (In and Out-of-Network) Biologically Based Conditions: Pay as any other Sickness Non-Biologically Based Conditions: Pay as any other sickness. Designated Care: 100% after a $5 fee. For a list of Designated Providers, please call Student Health Insurance at

6 CHEMICAL ABUSE AND DEPENDENCE Outpatient Inpatient PRESCRIPTION DRUGS Prescription Drugs INPATIENT MEDICAL Room & Board, Pre- Admission Testing, Non-Surgical Physician Visit, Other Hospital Services Preferred Pharmacy: 100% after a Lost or stolen prescription drugs are not covered. In-Network Care: 100% of the allowable charge up to maximum to the out-of-pocket up to maximum - $15 copay for generic drugs - $40 copay for preferred brand name drugs - $60 copay for non-preferred brand name drugs - $20 copay for all diabetic supplies (insulin, syringes and testing supplies) Non-Preferred Pharmacy: See the Student Health Insurance Handbook, available at Benefits are not payable for more than a 30-day supply per prescription or refill without prior authorization. Off label prescription drugs for cancer treatment are included. to the out-of-pocket Out-of-Network Care: 100% of reasonable and customary charges Up to 20 of these visits available for family counseling In-Network Care: 90% of the allowable charge up to the out-of-pocket up to maximum to the out-of-pocket up to maximum In-Network Care: 90% of the allowable charge up to the out-of-pocket to the out-of-pocket SURGICAL BENEFITS (Outpatient & Inpatient) Surgeon/ Assistant Surgeon Anesthesia Fees In-Network Care: Covered at 80% of the allowable charge up to the out-of-pocket Out-of-Network Care: Covered at 50% of the reasonable and customary charges up to the out-of-pocket In-Network Care: 90% of the allowable charge up to the out-of-pocket to the out-of-pocket For a more complete description of plan benefits, general terms and conditions, referral requirements, etc., please review the Student Health Insurance Handbook at 17

7 GENDER MEDICAL MODIFICATION BENEFITS Sexual Realignment Surgery (Limited to $25,000 per policy year) Hormone Therapy ADDITIONAL BENEFITS Ambulance Vision Services Over age 19 Up to age 19 Annual Preventive Eye Exam At SHC: BASIC PLAN COMPREHENSIVE PLAN/GSHIP In-Network Care: Covered at 80% of the allowable charge up to the out-of-pocket Out-of-Network Care: Covered at 50% of the reasonable and customary charges up to the out-of-pocket 100% after a $30 fee No benefit Annual Preventive Eye Exam At SHC: 100% with no copay In Network: Covered at 80% of allowable charges; up to the out-of-pocket. $30 copay per visit. Out-of-Network: Covered at 60% of reasonable and customary charges; up to the out-of-pocket ; $30 copay per visit Covered under Prescription Drugs Benefit (see page 17) 100% coverage per transport to or from hospital Annual Preventive Eye Exam At SHC: Comp Plan: 100% after a $30 fee GSHIP: 100% after a $10 fee No benefit The following optical services are available at the Student Health Center, but are not covered under the Student Health Insurance Program: New contact lens fittings (lenses not included) Re-evaluation of current contact lens prescriptions Eyeglass frames and lenses In-Network Care: Covered at 90% of the allowable charge up to the out-of-pocket Out-of-Network Care: Covered at 60% of the reasonable and customary charges up to the out-of-pocket Annual Preventive Eye Exam At SHC: Comp Plan: 100% with no copay GSHIP: 100% with no copay In Network: Covered at 80% of allowable charges; up to the out-of-pocket ; Comp Plan - $40 copay; GSHIP - $10 copay Out-of-Network: Covered at 60% of rasonable and customary charges; up to the out-of-pocket ; Comp Plan - $30 copay per visit. GSHIP - $10 copay per visit. 18

8 Pediatric Dental Up to age 19 Lenses and Frames: (One per policy year) At SHC: 80% of allowable charges; up to the out-of-pocket limit, 100% thereafter; $30 copay per visit In Network: 60% of allowable charges; up to the out-of-pocket limit, 100% thereafter. $50 copay per visit. Out-of-Network: 60% of reasonable and customary charges; up to the out-of-pocket ; $50 copay per visit In Network: 60% of allowable charges; up to the out-of-pocket limit; 100% thereafter; $50 copay per visit. Out of Network: 60% of reasonable and customary charges; up to the out-of-pocket limit; 100% thereafter; $50 copay per visit. Preventive Dental Care: One dental exam and cleaning per 6-month period At SHC: Not available Contact Lenses (Preauthorization Required) At SHC: 80% of allowable charges; up to the out-of-pocket limit; 100% thereafter; $30 copay per visit. Preferred Provider: 100% with no copay In Network: 80% of allowable charges; up to the out-of-pocket limit; 100% thereafter; $50 copay per visit. Out of Network: 60% of reasonable and customary charges; up to the out-of-pocket limit; 100% thereafter; $75 copay per visit. Routine Dental Care (Full mouth x-rays or panoramic x-rays at 36 month intervals and bitewing x-rays at 6-12 month intervals) At SHC: Not available Preferred Provider: 100% with no copay In Network: 80% of allowable charges; up to the out-of-pocket limit; 100% thereafter; $50 copay per visit. Out of Network: 60% of reasonable and customary charges; up to the out-of-pocket limit; 100% thereafter; $75 copay per visit. 19

9 ADDITIONAL BENEFITS (cont d) Pediatric Dental (cont d) Up to age 19 Prostate Cancer Screening BASIC PLAN COMPREHENSIVE PLAN/GSHIP Major Dental (Endodontics and Prosthodontics) Preauthorization required. At SHC: Not available Preferred Provider: 90% of allowable charges; up to the out-ofpocket limit; 100% thereafter; $25 copay per visit. In Network: 70% of allowable charges; up to the out-of-pocket limit; 100% thereafter; $100 copay per visit. Out of Network: 60% of reasonable and customary charges; up to the out-of-pocket limit; 100% thereafter; $150 copay per visit. Orthodontia: Preauthorization required. At SHC: Not available Preferred Provider: 70% of allowable charges; up to the out-ofpocket limit; 100% thereafter; $50 copay per visit. In Network: 60% of allowable charges; up to the out-of-pocket limit; 100% thereafter; $100 copay per visit. Out of Network: 60% of reasonable and customary charges; up to the out-of-pocket limit; 100% thereafter; $200 copay per visit. SHC: 90% of the allowable charges up to the out-of-pocket limit. No copay in network. Out-of-Network Care: 60% of allowable charges up to the out-of-pocket limit. No copay. 20

10 Diabetic Treatment Expense Insulin, testing supplies and syringes are payable under the prescription portion of the plan (see page 17). Orthopedic/Prosthetic Appliances/Braces Durable Medical Equipment Medical and Mental Health Treatment Abroad Covered medical expenses including, but not limited to, equipment and self-management education are payable as follows: Non-Preferred Care: 50% of reasonable and customary charges up to the out-of-pocket 80% of reasonable charges 80% of reasonable and customary charges Medical and mental health treatment will be covered according to the plan benefits at the in-network level. Mastectomy, Lymph Node Dissection and Lumpectomy and Reconstructive Surgery as a result of Breast Cancer Hospital Outpatient Services Partial Hospitalization Speech and Hearing Therapy, Bone Density Screening Test, Enteral Formula for Home Use Home Health Care End of Life Care Travel Assistance Program For benefit details visit the Student Health Insurance Handbook, available at In-Network Care: 90% of the allowable charge up to the out-of-pocket Non-Preferred Care: 60% of reasonable and customary charges up to the out-of-pocket 90% of reasonable charges At SHC: Comp Plan: 90% of all reasonable and customary charges; GSHIP: Covered 100% 90% of all reasonable and customary charges Medical and mental health treatment will be covered according to the plan benefits at the in-network level. Mental health visits 1-10 are covered under the Mandatory Plan at the 80% In-Network rate (see page 11) For a more complete description of plan benefits, general terms and conditions, referral requirements, etc., please review the Student Health Insurance Handbook at Other Covered Services Radiation Therapy, Chemotherapy, Dialysis Treatment, and Intravenous Home Therapy 21