Student Health Insurance

Transcription

1 Policyholder: New York University n Basic Plan n Comprehensive Plan n GSHIP Student Health Insurance H A N D B O O K Underwritten by National Union Fire Insurance Company of Pittsburgh, Pa. ( the Company ), with its principal place of business in New York, NY Administrator Policy Number: CHH Underwriter Reference Number: CAS Administered by Consolidated Health Plans 2077 Roosevelt Avenue Springfield, MA

2 Notice: Your student health insurance coverage, offered by National Union Fire Insurance Company of Pittsburgh, Pa., may not meet the minimum standards required by the health care reform law for the restrictions on annual dollar limits. The annual dollar limits ensure that consumers have sufficient access to medical benefits throughout the annual term of the policy. Restrictions for annual dollar limits for group and individual health insurance coverage are $1.25 million for policy years before September 23, 2012; and $2 million for policy years beginning on or after September 23, 2012, but before January 1, Restrictions for annual dollar limits for student health insurance coverage are $100,000 for policy years before September 23, 2012, and $500,000 for policy years beginning on or after September 23, 2012, but before January 1, Your student health insurance coverage put an annual limit of $250,000 for the Basic Plan or $1,000,000 for the Comprehensive Plan/GSHIP on Essential Benefits. If you have any questions or concerns about this notice, contact Consolidated Health Plans (CHP) Customer Service at Be advised that you may be eligible for coverage under a group health plan of a parent s employer or under a parent s individual health insurance policy if you are under the age of 26. Contact the plan administrator of the parent s employer plan or the parent s individual health insurance issuer for more information. 1

3 NYU Student Health Center 726 Broadway, 3 rd & 4 th Floors New York, NY Hours of Operation * Student Health Center Clinical Operations Monday & Tuesday 8 am 8 pm; Summer Hours 8 am 6 pm Wednesday & Thursday 8 am 6 pm Friday 10 am 6 pm Saturday 10 am 4 pm Sunday Closed Student Health Insurance Services Monday Thursday 9 am 6 pm Friday 10 am 6 pm Saturday & Sunday Closed *Hours of operation are subject to change. Please check our website at for up-to-date information. Emergencies and After-Hours Crisis Response In a life or limb threatening emergency, dial 911 to reach New York City Emergency Medical Services. For medical and mental health urgent needs when SHC is closed, call the Wellness Exchange Hotline at (212) or the NYU Office of Public Safety at (212) NYU has a team dedicated to assisting students with crises 24/7. If you have been sexually assaulted, we strongly encourage you to obtain help from a professional counselor as soon as you are ready by calling the Wellness Exchange Hotline ( ). The staff at the Wellness Exchange is available 24/7 to discuss your options and feelings. You don t have to give your name if you prefer to remain anonymous. For more information on what to do if you or someone you know has been sexually assaulted, visit www. nyu.edu/health/sexual.assault. If you receive services in a Hospital emergency room: You will be billed by the Hospital for emergency room services, and will be responsible for any copays, deductibles or coinsurance for those services. If you require follow-up care in Manhattan after emergency medical treatment, you must contact the New York University Student Health Center for evaluation by a medical provider. See page 5 for more details about the referral requirement. During NYU Holiday Closings: If you are enrolled in the Basic, Comprehensive or GSHIP plans and you require medical care during an NYU holiday closing, you may visit a healthcare provider without an SHC referral. Seeking services from an In-Network Provider in the Magnacare or MultiPlan network will reduce your out-of-pocket expenses. Dental Emergency Treatment Students have access to emergency dental treatment at no cost as follows: Monday Thursday, 8 am 8 pm and Friday 8 am 4 pm Students should go to the NYU College of Dentistry Faculty Practice 726 Broadway, Suite 350, Saturdays & Sundays, 9 am 5 pm, the College of Dentistry provides limited emergency care at 345 East 24th Street at First Avenue On holidays or after hours, students can go directly to the Bellevue Hospital Center Emergency Room, 462 First Avenue at East 27th Street, Dental emergencies include the unexpected onset of a condition such as bleeding, swelling and/or significant pain, requiring immediate dental care and do not include elective or routine care. Got Questions? Get Answers at As a Consolidated Health Plans (CHP) student health insurance member, you have access to your secure member website. You can take full advantage of our interactive website to complete a variety of self-service transactions online. By logging into you can: Request member ID cards View claim Explanation of Benefits (EOB) statements Send an to CHP Customer Service at your convenience Need help? Assistance is available toll free, Monday through Friday, from 8 am to 5:00 pm Eastern Time at

4 Table of Contents Periods of Coverage...4 Mandatory Plan Eligibility...5 Benefit Description...5 Referral Requirement Dental Injuries Optional Student Health Insurance PlanS Eligibility/Enrollment of Students Special Eligibility/Enrollment...6 Leave of Absence...6 Extending Periods of Coverage Continuation Option...6 Insurance for Dependents...6 Enrollment...6 Periods of Coverage...6 Newly Adopted Children Enrollment and Waiver Semester Deadlines Petition to Change Insurance...7 Adding Insurance...7 Changing Plans...7 Late Waivers...7 Health-Related Services for Matriculated Students Summary of Benefits Summary of Benefits Chart Inpatient Benefits...9 Surgical Benefits...9 Outpatient Benefits Women s Health Benefits Mental Health Benefits...13 Additional Benefits Treatment of Mental Health Disorders Biologically Based Mental Illness Inpatient Benefits...16 Outpatient Benefits...16 Other than Biologically Based Mental Illness Inpatient Benefits...16 Outpatient Benefits...16 Emergency Medical and Travel Assistance...16 Traveler s Assistance Program Medical Evacuation and Repatriation Benefit...16 General Terms and Conditions Coordination of Benefits Benefit Period...17 Extension of Benefits...17 Termination of Coverage New York Mandated Benefits End of Life Care Expense...17 Enteral Formulas...17 Breast Cancer Benefit...18 Second Medical Option...18 Chiropractic Care Benefit...18 Experimental or Investigational Services Recommended by an External Appeal Agent Bone Mineral Density Tests...18 Cancer Screening...18 Pre-Hospital Medical Emergency Services Treatment of Correctable Medical Conditions that Cause Infertility Autism Spectrum Disorder...19 Second Surgical Opinion...19 Pre-Admission Testing...19 Experimental Cancer Drugs...19 Pre-Existing Conditions In-Network/Designated Provider Network...20 Referral Requirements Medical Services Inside Manhattan...21 Initial New York University Student Health Center Referral...21 Referral Limitations...21 Summer Referrals...21 Follow-up After Medical Emergency Medical Services Outside Manhattan...21 Mental Health and Chemical Abuse and Dependence Services...21 Frequently Asked Questions Pre-certification requirement Other CHP Programs...22 Exclusions...23 Filing Claims Follow These Steps to File a Claim If Your Claim is Denied...24 How to Appeal a Claim Prescription Drug Claim Procedure...29 Medications Not Covered by Restat...29 If Your Claim is Denied/How to Appeal a Claim Glossary General Information...34 Pricing Optional NYU-Sponsored Student Health Insurance Plans Dependent Coverage Rates Continuation Options Quick Reference Guide

5 NYU-Sponsored Student Health Insurance Program The NYU-sponsored Student Health Insurance Program consists of the Mandatory Plan and the optional NYU-sponsored Basic, Comprehensive, and GSHIP Plans. It is important that you READ THIS HANDBOOK CAREFULLY since it discusses the details of these plans. Please note that this handbook is intended to be a summary of the benefits afforded under each plan. The actual benefits are governed by the Master Policy, which is on file with the NYU Insurance and Risk Management Department. The Master Policy is available for review by appointment only. To make an appointment, please call the NYU Insurance and Risk Management Department at In addition to the Plan s Aggregate Maximum, the Policy may contain benefit level maximums. Please review the Summary of Benefits section of this handbook for any additional benefit level maximums. Periods of Coverage TERM COVERAGE BEGINS COVERAGE ENDS Annual :01 am, August 21, :01 am, August 21, 2013 Fall :01 am, August 21, :01 am, January 9, 2013 Spring/Summer :01 am, January 9, :01 am, August 21, 2013 Summer :01 am, May 14, :01 am, August 21, 2013 The NYU-sponsored Student Health Insurance Program works in conjunction with the health services provided at the Student Health Center (SHC) to all matriculated NYU students. Whether enrolled in the Basic Plan, Comprehensive Plan, GSHIP or maintaining alternate health insurance coverage, many services are provided at no or reduced cost both inside and outside NYU SHC including: Primary care and women s health office visits, counseling visits and commonly performed laboratory tests at the SHC, located at 726 Broadway.* The Mandatory Insurance Plan which provides limited health insurance coverage for Hospital emergency room treatment of Accidents, psychological and substance abuse emergencies, and up to 30 mental health outpatient visits per year (outside the Counseling and Behavioral Health Services at SHC). See the complete description of the Mandatory Plan benefits on page 5. Treatment of dental emergencies through the NYU College of Dentistry Faculty Practice. * Some procedures performed during the visit may incur a fee. See Sample of Services chart at 4

6 MANDATORY PLAN Eligibility All students enrolled in a degree-granting, advanced certificate or postgraduate certificate programs and registered for one (1) or more credits, or maintaining matriculation, are enrolled automatically in the Mandatory Plan. This plan cannot be waived. Students, spouses, domestic partners and Dependents electing coverage under an optional Student Health Insurance Plan will also be insured under this plan automatically. Emergency Room Benefit LIMIT DEDUCTIBLE $2,500 maximum per Condition per policy year (Not subject to the Policy Year Maximum Benefit.) $100 per Condition per policy year This plan covers outpatient treatment initiated in a Hospital emergency room for: Accidental injuries (not Sickness) Mental health emergencies Chemical abuse emergencies Ambulance services Benefits are as follows: In-Network Care: Out-of-Network Care: 100% of the Allowable Charge 100% of the Reasonable and Customary Charge Outpatient Mental Health Benefit This plan covers up to 30 mental health outpatient visits per policy year at a maximum as follows: In-Network Care: 80% of the Negotiated Charge Out-of-Network Care: 50% of the Reasonable Charge Under the NYU-sponsored Student Health Insurance Program, the maximum number of covered mental health outpatient visits per policy year for the Mandatory, Basic, Comprehensive, and GSHIP Plans combined shall not exceed 30 visits for Non- Biologically Based Conditions. Referral Requirement for Follow-up Care after Emergency Room Treatment After the Covered Person has received initial treatment for accidental Injury in an emergency room, he or she may be required to seek additional treatment or evaluation. 1. Prior to this follow-up medical care, the Covered Student must contact New York University Student Health Center (SHC) for treatment or evaluation required in Manhattan. 2. SHC may require that the Covered Student seek follow-up care through SHC. 3. Referrals cannot be granted after treatment has been rendered. (IMPORTANT: see pages for more details of the referral process.) 4. Covered Dependents; students on an approved leave of absence; and students enrolled in the continuation option do not have access to SHC and therefore are not required to obtain a referral. 5. The Student Health Insurance Program will deny benefits to any Covered Student or to the provider if the Covered Student fails to receive proper authorization from SHC before receiving additional medical care. Dental Injuries The Mandatory Plan does not cover emergency treatment for dental injuries. 5

7 OPTIONAL STUDENT HEALTH INSURANCE PLANS New York University sponsors several optional student health insurance plans: the Basic Plan, the Comprehensive Plan, and the GSHIP Plan. Except for medical emergencies or when seeking services outside of the Manhattan area, Covered Students under any optional NYU-sponsored Student Health Insurance Plan are required first to seek treatment or be evaluated at SHC for most medical conditions. (For details about the referral process and other exclusions to the referral requirements, see page 21). Eligibility/Enrollment of Students n Basic and Comprehensive Plans Eligible students are those who are registered for one (1) or more credits in a degree-granting program or who are maintaining matriculation, and all international students holding F1 or J1 visas. Students are enrolled in the optional student health insurance plans according to the automatic enrollment, selection and waiver processes described in the Guide to Student Healthcare and Health Insurance at New York University available at (See semester deadlines on page 7.) n GSHIP Plan If you are a Graduate Assistant, Research Assistant, Teaching Assistant or specifically designated fully-funded graduate student for whom the University has agreed to pay your student health insurance fee, you will be automatically enrolled in the Graduate Student Health Insurance Plan (GSHIP). An insurance fee may initially appear on your Bursar s Statement of Account, but will be cancelled upon notification of your eligibility to Student Health Insurance Services by your program administrator. Post-Doctoral Research Fellows All full-time Post-Doctoral Research Fellows (persons paid directly with funds from external sponsors) will be automatically enrolled in the Graduate Student Health Insurance Plan (GSHIP). They may waive the fees for this plan if they maintain health insurance coverage in an alternate plan which meets the University s requirements. Special Eligibility/Enrollment Leave of Absence If you filed for a leave of absence that was approved by the Dean s Office of your school, you may be eligible for enrollment in an NYU-sponsored Student Health Insurance Plan. Applicants must have been enrolled in the plan for the immediately preceding semester to be eligible. Leave of Absence applications can be submitted online at The official letter of approval from the Dean s Office must be submitted directly to Consolidated Health Plans, 2077 Roosevelt Avenue, Springfield, MA 01104, or by fax to (See semester deadlines on page 7.) Extending Periods of Coverage Continuation Option Covered students who lose their eligibility to enroll due to graduation, transfer to another university, or dropping out of school entirely may be eligible to purchase University-sponsored coverage to continue their current plan for a 1-month, 3-month or 6-month period through the Continuation Option. Enrollment in the Continuation Option is available only to students covered under the Basic Plan, Comprehensive Plan or GSHIP, for at least 30 consecutive days immediately prior to enrollment under this Continuation Option. The Continuation Option Enrollment Application can be completed online at Consolidated Health Plan s website at The application with payment authorization must be submitted by August 31, 2012 if you are not returning for the fall semester and by January 15, 2013 if you are not returning for the spring semester. Insurance for Dependents Enrollment For an additional premium, Covered Students on the Basic, Comprehensive, or GSHIP Plan may also enroll their eligible Dependents (see glossary on page 28 for a definition of eligible Dependent). 1. Dependents are not eligible to use any services at the SHC. 2. NYU students who are not insured under an NYUsponsored Student Health Insurance Plan may not enroll their Dependents. 3. Covered students and their Dependents must select the same plan. 4. Dependents must enroll at the same time as the Covered Student unless there is a qualifying life event. To enroll a Dependent, complete and submit the Dependent Enrollment Application online at Consolidated Health Plans (CHP) website at nyu. The application with payment authorization must be submitted within the same enrollment period as the student s enrollment. (See semester deadlines on page 7.) Periods of Coverage When enrolling a Dependent, the effective date of coverage is the date of the Covered Student s enrollment (during open enrollment) or the date of the Dependent s enrollment (in the event of a qualifying life event), 6

8 OPTIONAL STUDENT HEALTH INSURANCE PLANS whichever is later. Dependent coverage terminates on the same date the Covered Student s coverage ends or the date such Dependent ceases to meet the eligibility requirement, whichever occurs earlier. Newborn Infant Coverage All newborn children of a Covered Student or insured Dependent spouse are covered automatically at birth for 31 days for an Injury or Sickness. Coverage may be continued after 31 days by providing notification of birth and forwarding the appropriate payment to Consolidated Health Plans within 31 days from the date of the birth. Newly Adopted Children Coverage is provided for a child legally placed for adoption with a Covered Student for 31 days from the moment of placement, provided the child lives in the household of the Covered Student and is dependent upon the Covered Student for support. To extend coverage for an adopted child past the 31 days, the Covered Student must 1) enroll the child within 31 days of placement of such child, and 2) pay any additional premium, if necessary, starting from the date of placement. Payment must be submitted to CHP within 31 days from the date of placement. Enrollment and Waiver Semester Deadlines Fall Term September 30, 2012 Spring Term February 10, 2013 Summer Term June 5, 2013 Petition to Change Insurance Adding Insurance If you were granted a waiver of any NYU-sponsored Student Health Insurance Plan and you then experience a significant life change that directly affects your insurance coverage, you may petition to enroll in an NYU-sponsored plan after the open enrollment period has ended. You must submit a Petition to Change Insurance Status Form along with acceptable proof of the loss of your insurance coverage (e.g., confirmation of insurance termination on employer or insurance company letterhead). Petition to Change forms are available at the SHC Student Health Insurance Service Office or request at health.insurance@nyu.edu. Coverage will become effective on the date the Petition to Change form and accompanying documentation are received by the Student Health Insurance Service Office or day after prior coverage terminated whichever comes later. Any Student or Dependent who enrolls after the open enrollment period is considered a Late Enrollee. Late Enrollees will be subject to rules governing Pre-Existing Conditions, exclusions, and limitations, and will be charged appropriate premiums. You will be required to pay the premium for the entire semester, regardless of when you enroll. (For additional information on Pre-existing Conditions, see page 20.) Conditions of Enrollment: Enrollment for dates other than those above is allowed only upon the loss of other health insurance coverage (i.e., student ages out of a family plan or loses coverage, marriage or birth of a child). Documentation of loss of coverage is required. The Student Health Services Insurance Office or Consolidated Health Plans must be contacted within 31 days of the loss of other coverage. Upon documentation of loss of coverage, the students may select an insurance plan. Late Waivers If extenuating circumstances cause you to miss the deadline for waiving coverage under the NYU-sponsored plans, you must file a Petition to Change Insurance Status Form. The Petition requires a detailed explanation of the reason for lateness and will be reviewed by CHP, the plan administrator, on a case-by-case basis. If the Petition is approved, you will be billed directly for any medical services already received at SHC, 726 Broadway, during the entire period for which you waived coverage. If claims for service outside of SHC have been filed, there is no option to waive the Basic or Comprehensive Plan. You will remain covered and will be responsible for payment of premium. Students will have the opportunity to petition for late waiver of insurance only once during their academic career at NYU. Additional petitions will not be considered. Call the SHC Student Health Insurance Office at for more information. 7

9 Health-Related Services for Matriculated Students All matriculated students may use the NYU Student Health Center (SHC). We encourage you to make appointments whenever possible and carry your NYU Card or health insurance identification card at all times. NYU Student Health Center 726 Broadway, 3 rd & 4 th Floors New York, NY health.center@nyu.edu The SHC is an award-winning student health care facility conveniently located on the Washington Square Campus. Through close collaboration, our multidisciplinary staff of board-certified doctors and highly trained clinicians provide comprehensive health and wellness services in response to the health needs and concerns of the NYU community, and promote a healthier, safer campus. These include medical, psychological, pharmaceutical, educational, crisis response, and support services. Whether your needs involve routine or urgent medical care, counseling, education about a specific wellness issue, prescriptions, or eyewear, the staff at SHC is prepared to provide quality confidential, caring service. Health Services Provided at No or Reduced Cost At the Student Health Center (726 Broadway) at no or reduced cost: primary care and women s health office visits* many diagnostic laboratory tests short term counseling and behavioral health services wellness and health education services starter doses of common medications *Some procedures performed during the visit may incur a fee. See Sample of Services chart at Outside the Student Health Center Mandatory Plan a health insurance plan with limited benefits described on page 5. Treatment of Dental Emergencies Students have access to emergency dental treatment at no cost as follows: Monday -Thursday from 8 am to 8 pm and Friday from 8 am to 4 pm: Students should go to the NYU College of Dentistry Faculty Practice, 726 Broadway, Suite 350, Saturdays and Sundays from 9 am to 5 pm: The College of Dentistry provides limited emergency care at 345 East 24th Street at First Avenue On holidays or after hours: Students can go directly to the Bellevue Hospital Center Emergency Room, 462 First Avenue at East 27th Street Dental emergencies include the unexpected onset of a condition, such as bleeding, swelling and/or significant pain, requiring immediate dental care and do not include elective or routine care. 8

10 BASIC PLAN COMPREHENSIVE PLAN GSHIP SUMMARY OF BENEFITS This section describes benefits for all NYU-sponsored Student Health Insurance Plans. Please note this is ONLY a summary of the insurance. This is only a brief description of the coverage available under policy series S30494NUFIC-NY. The Master Policy may contain definitions, reductions, limitations, exclusions and terminations provisions. A copy of the Master Policy is on file at the NYU Insurance and Risk Management Department, 838 Broadway, 4 th Floor, and may be viewed by appointment. Where a discrepancy exists between this brochure and other printed matter regarding this program and the Master Policy, the Master Policy will take precedence. Call CHP at for additional details about benefits. The Basic, Comprehensive, and GSHIP Plans fulfill the definition of creditable coverage explained in the Health Insurance Portability and Accountability Act (HIPAA) of Should you wish to receive a certification of coverage at any time, please call Customer Service at CHP It is important that you READ THIS BROCHURE carefully. The NYU-sponsored Student Health Insurance Program provides limited benefits for health insurance ONLY. As defined by the New York State Insurance Department, it does NOT provide basic Hospital, basic medical, major medical insurance, Medicare supplement, long term care insurance, nursing home insurance only, home health care insurance only, or nursing home and home health care insurance. The insurance policy itself sets forth the rights and obligations of both you and the insurance company. The plans provide benefits as specifically listed below. Pre-certification required for certain inpatient and outpatient services, including, but not limited to: hospitalization and surgery requiring general anesthesia. Please refer to page 22. BASIC PLAN COMPREHENSIVE (COMP) PLAN / GSHIP Policy Year Maximum $250,000 per Condition $1,000,000 per Condition Out-of-Pocket Limit See page 31 for definition of Out-of-Pocket Limit. In-Network Care $5,000 per policy year Out-of-Network Care $10,000 per policy year In-Network Care $5,000 per policy year Out-of-Network Care $10,000 per policy year 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. INPATIENT BENEFITS BASIC PLAN COMPREHENSIVE (COMP) PLAN / GSHIP Room and Board Other Hospital Services Pre-Admission Testing Inpatient Non-Surgical Doctor Visits Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, 9

11 SURGICAL BENEFITS Outpatient & Inpatient Surgeon s Fees* *For Transsexualism/ Gender Identity Service see Additional Benefits section on page 15 Assistant Surgeon Fees; Anesthesia Fees BASIC PLAN Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, COMPREHENSIVE (COMP) PLAN / GSHIP Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, When Injury or Sickness requires two or more surgical procedures which are performed through the same approach, and at the same time or immediate succession, the Company will pay full value for the most expensive procedure performed and 50% of the value for the second procedure performed. OUTPATIENT BENEFITS BASIC PLAN COMPREHENSIVE (COMP) PLAN / GSHIP Doctor Visits (other than Primary Care office visits at SHC) Most Primary Care office visits at SHC are covered 100%. This is not an insured benefit, but is provided by NYU to all matriculated students including students who waive the Student Health Insurance Plans At SHC: Specialists including, Occupational & Physical Therapy: Covered at 100% (Basic Plan: $30 Co-pay applies) Outside SHC: In-Network Care Covered at 80% of Allowable Charge up to the Out-of-Pocket Limit, at 100% thereafter; $30 per visit Co-pay applies Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Basic Plan $60 per visit Co-pay applies At SHC: Specialists including, Occupational & Physical Therapy: Covered at 100% (Comp Plan: $30 Co-pay applies; $10 for GSHIP) Outside SHC: In-Network Care Covered at 90% of Allowable Charge up to the Out-of-Pocket Limit, at 100% thereafter; $30 per visit Co-pay applies Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Comp Plan $60 per visit Co-pay applies GSHIP $50 per visit Co-pay applies SUMMARY OF BENEFITS Preventive Services including Immunizations as specified by Health Care Reform (PPACA) (For Well-Woman, see page 11) (To view a list of covered preventive services, go to prevention. Please note they are age, gender and risk appropriate.) Allergy Testing and Shots Hospital Outpatient For services rendered in a Hospital on an outpatient basis Students: At SHC: Preventive Services available and rendered at SHC will be covered at 100% of Eligible Expenses with no cost sharing Outside SHC: 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 Dependents: In-Network Care Covered 100% of Eligible Expenses with no cost sharing Out-of-Network Care No coverage Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Allowable Charge; ($40 per visit Co-pay applies) up to the Out-of-Pocket Limit, Out-of-Network Care Covered at 50% of the Reasonable and Customary Charge; ($60 per visit Co-pay applies) up to the Out-of-Pocket Limit, at 100% thereafter Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Allowable Charge: ($35 per visit Co-pay applies) up to the Out-of-Pocket Limit, Out-of-Network Care Covered at 60% of the Reasonable and Customary Charge: ($50 per visit Co-pay applies) up to the Out-of-Pocket Limit, at 100% thereafter Continued 10

12 OUTPATIENT BENEFITS Continued Hospital Emergency Room BASIC PLAN Allowable Charge; ($100 per visit Co-pay applies) up to the Out-of-Pocket Limit, Out-of-Network Care Covered at 80% of Reasonable and Customary Charges ; ($100 per visit Co-pay applies) up to the Out-of-Pocket Limit, COMPREHENSIVE (COMP) PLAN / GSHIP Allowable Charge; ($100 per visit Co-pay applies) up to the Out-of-Pocket Limit, Out-of-Network Care Covered at 90% of Reasonable and Customary Charges; ($100 per visit Co-pay applies) up to the Out-of-Pocket Limit, Laboratory and X-Ray Some commonly performed laboratory tests at SHC will be covered 100%. This is not an insured benefit but is provided by NYU to all matriculated students including those who waive the Student Health Insurance Plans Laboratory tests and X-rays for which there is a fee: Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Laboratory tests and X-rays for which there is a fee: (For GSHIP, X-rays covered at 100% of the Allowable Charge at SHC Only) Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Please note: Lab tests and radiology procedures performed routinely with no symptoms are not covered services, unless coverage is mandated by Healthcare Reform Law. Chiropractic Service Radiation Therapy, Chemotherapy, Dialysis Treatment and Intravenous Home Therapy Payable same as Doctor Visits Outside SHC (see page 10) Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Payable same as Doctor Visits Outside SHC (see page 10) Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Physical Therapy/ Occupational Therapy Payable same as Doctor Visits (see page 10) Payable same as Doctor Visits (see page 10) WOMEN S HEALTH BENEFITS BASIC PLAN COMPREHENSIVE (COMP) PLAN / GSHIP SUMMARY OF BENEFITS Well Woman Care Most Women s Health office visits at SHC are covered 100% This is not an insured benefit but is provided by NYU to all matriculated students including students who waive the Student Health Insurance Plans Routine Annual Gynecologic Exam: Students: At SHC: Covered at 100% of Eligible Expenses with no cost sharing Performed outside SHC: Payable same as Doctor Visits (see page 10) Dependents: In-Network Care Covered at 100% of Allowable Charge with no cost sharing Out-of-Network Care Payable same as Doctor Visits (see page 10) Pap Smear Screening: Students: At SHC: Covered at 100% of Eligible Expenses with no cost sharing Performed outside SHC: Payable same as Laboratory and X-ray expense (see above) Dependents: In-Network Care Covered at 100% of Allowable Charge with no cost sharing Out-of-Network Care Payable same as Laboratory and X-ray expense (see above) Contraceptive Services: Students: At SHC: Covered at 100% of Eligible Expenses with no cost sharing In-Network Care Covered at 100% of Allowable Charge with no cost sharing Out-of-Network Care Payable same as Doctor Visits (see page 10) Dependents: In-Network Care Covered at 100% of Allowable Charge with no cost sharing Out-of-Network Care Payable same as Doctor Visits (see page 10) Mammography: In-Network Care Covered at 100% of Allowable Charge with no cost sharing Out-of-Network Care Payable same as Laboratory and X-ray expense (see above) Continued 11

13 WOMEN S HEALTH BENEFITS Continued BASIC PLAN COMPREHENSIVE (COMP) PLAN / GSHIP Maternity Pays the same benefits for maternity and complications of pregnancy as afforded any Sickness. Note: Well Baby visits are not payable under maternity benefits. See pages 6 & 7 for Dependent enrollment information In the event of an inpatient confinement, such benefits would be payable for inpatient care of the Covered Person, and any newborn child, as Medically Necessary In the event of a Hospital discharge earlier than 48 hours after a vaginal delivery, or 96 hours after a cesarean delivery, coverage is available for at least one (1) home health care visit as Medically Necessary. This visit will be payable at 100% and will not be subject to any applicable plan Co-pays. Coverage also includes parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal and newborn clinical assessments. Obstetric Services: Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Designated Care Covered at 100% of the negotiated rate** up to the Out-of-Pocket Limit Inpatient Room and Board for Maternity: Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, At NYU Tisch Hospital Designated Care 100% of the negotiated rate** Obstetric Services: Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Designated Care Covered at 100% of the negotiated rate** up to the Out-of-Pocket Limit Inpatient Room and Board for Maternity : Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, At NYU Tisch Hospital Designated Care 100% of the negotiated rate** ** For CPT Code (routine obstetric care for complete pregnancy including pre-natal visits, vaginal delivery and postpartum care) and CPT Code (routine obstetric care for complete pregnancy including pre-natal visits, cesarean delivery and postpartum care) ** For a list of designated providers, please call Student Health Insurance Offices at Termination of Pregnancy Contraceptives (all prescribed FDA-approved contraceptive methods) Eligible Expenses payable as any other Condition Prescription Contraceptive Drugs, Devices and Services At SHC: Covered at 100% of Eligible Expenses with no cost sharing In-Network Care Covered at 100% of Eligible Expenses with no cost sharing at Preferred Pharmacies Out-of-Network Care Non-Preferred Pharmacies; see Prescription Drug benefit for Non-Preferred Pharmacy on page 14 SUMMARY OF BENEFITS Mastectomy, Lymph Node Dissection and Lumpectomy; Reconstructive Surgery as a Result of Breast Cancer Eligible Expenses incurred for outpatient contraceptive service will be paid under Contraceptive Services (see Well Woman Care benefit page 11) Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, 12

14 MENTAL HEALTH BENEFITS Inpatient Mental Health BASIC PLAN Out-of-Network Care Covered at 50% of Out-of-Pocket Limit, Designated Care At NYU Tisch Hospital, covered at 100% of the negotiated rate Benefit Maximum (In and Out-of-Network Combined) Biologically Based Conditions: Covered as any other Sickness Non-Biologically Based Conditions: 30 days per policy year COMPREHENSIVE (COMP) PLAN / GSHIP Out-of-Network Care Covered at 60% of Out-of-Pocket Limit, Designated Care At NYU Tisch Hospital, covered at 100% of the negotiated rate Benefit Maximum (In and Out-of-Network Combined) Biologically Based Conditions: Covered as any other Sickness Non-Biologically Based Conditions: Covered as any other Sickness Outpatient Mental Health Psychotherapy Please Note: Shortterm psychotherapy (talk therapy) visits are provided at no charge at SHC Counseling & Wellness Services. This is not an insured benefit but is provided by NYU to all matriculated students including students who waive the Student Health Insurance Plans In-Network Paid as any Sickness* Out-of-Network Care Paid as any Sickness* Benefits payable for services rendered by a Doctor while not Hospital Confined shall not be subject to co-pay amounts. In-Network Paid as any Sickness* Out-of-Network Care Paid as any Sickness* Benefits payable for services rendered by a Doctor while not Hospital Confined shall not be subject to co-pay amounts. Designated Care 100% after a $5 fee For a list of Designated Providers, please call Student Health Insurance at Benefit Maximum (In and Out-of-Network Combined) Biologically Based Conditions: Paid as any other Sickness Non-Biologically Based Conditions: 30 visits per policy year** * Visits 1-10 are paid under the Mandatory Plan (as described on page 5) at 80% for In-Network Providers and 50% for Out-of-Network Providers **A total of 30 outpatient Mental Health visits will be paid between the Mandatory Plan and this Plan. Definitions: Biologically Based Condition: A mental, nervous or emotional condition that is caused by a biological disorder of the brain and results in a clinically significant, psychological syndrome or pattern that substantially limits the functioning of the person with the illness. Such Biologically Based Mental Health Conditions are defined as schizophrenia/psychotic disorders, major depression, bipolar disorder, delusional disorders, panic disorders, obsessive compulsive disorders, bulimia and anorexia. Non-Biologically Based Condition: Any mental health condition other than schizophrenia/psychotic disorders, major depression, bipolar disorder, delusional disorders, panic disorders, obsessive compulsive disorders, bulimia and anorexia. See page 16 for more information. Psychiatric Medication Assessment and Management At SHC: 100% after $20 fee Outside SHC: Payable same as non-shc Doctor visit (see page 10) At SHC: Comp: Same as Basic Plan GSHIP: Covered 100% Outside SHC: Payable same as non-shc Doctor visit (see page 10) SUMMARY OF BENEFITS Inpatient Chemical Abuse and Dependence (Maximum Benefit: 7 days per policy year) Outpatient Chemical Abuse and Dependence Partial Hospitalization In exchange for full hospitalization up to maximum benefit Out-of-Network Care Covered at 50% of Reasonable and Customary Charges up to Out-of-Pocket Limit, up to maximum benefit In-Network Care Covered 100% of Allowable Charges up to maximum benefit Out-of-Network Care Covered at 60% of Reasonable and Customary Charges up to Out-of-Pocket Limit, up to maximum benefit Out-of-Network Care Covered 100% of Reasonable and Customary Charges Benefit Maximum (In and Out-of-Network Combined) 60 visits per policy year with at least 20 of those visits available for family counseling Includes the charges made for treatment received during partial hospitalization. Prior review and approval must be obtained on a case-by-case basis. When approved, benefits will be payable in place of an inpatient admission, whereby two days of partial hospitalization may be exchanged for one day of full hospitalization. 13

15 ADDITIONAL BENEFITS Prescription Drug (Restat Pharmacy Benefit Manager) BASIC PLAN Preferred Pharmacy Covered at 100% after a $15 Co-pay for generic drugs $40 Co-pay for preferred brand name drugs $60 Co-pay for non-preferred brand name drugs $20 Co-pay for all diabetic supplies* Non-Preferred Pharmacy Covered at 70% after a $15 Co-pay for generic drugs $40 Co-pay for preferred brand name drugs $60 Co-pay for non-preferred brand name drugs $20 Co-pay for all diabetic supplies* COMPREHENSIVE (COMP) PLAN / GSHIP Preferred Pharmacy Covered at 100% after a $15 Co-pay for generic drugs $40 Co-pay for preferred brand name drugs $60 Co-pay for non-preferred brand name drugs $20 Co-pay for all diabetic supplies* Non-Preferred Pharmacy Covered at 70% after a $15 Co-pay for generic drugs $40 Co-pay for preferred brand name drugs $60 Co-pay for non-preferred brand name drugs $20 Co-pay for all diabetic supplies* Diabetic supplies include insulin, syringes and testing supplies 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 See page 27 for excluded medications *Special Note Regarding Chronic Conditions Diplomat (a wholly owned specialty pharmacy subsidiary of Restat) provides specialty medications and support to members living with chronic conditions for which there is a mandated benefit and for which a drug is prescribed for the condition. Offered medications may be injected, infused or taken orally. For additional information, call CHP at Accidental Death and Dismemberment Accidental death: $10,000 Loss of two hands, feet or eyes: $10,000 Loss of one hand, foot or eye: $5,000 Ambulance 100% coverage per emergency transport to or from Hospital 100% coverage per emergency transport to or from Hospital Prostate Cancer Screening Eligible Expenses include one annual (or more frequently if recommended by a Doctor) digital rectal exam and Prostate Specific Antigen (PSA) test. Eligible Expenses are payable on the same basis as any other Sickness. Home Health Care Covered at 80% to a maximum of $75 per visit per policy year; maximum of 40 visits per policy year Covered at 90% to a maximum of $75 per visit per policy year; maximum of 40 visits per policy year Orthopedic/Prosthetic Appliances/Braces Covered at 80% of Reasonable and Customary Charges Covered at 90% of Reasonable and Customary Charges SUMMARY OF BENEFITS Durable Medical Equipment Diabetic Treatment Expense Note: Insulin, testing supplies and syringes are payable under the prescription portion of the plan Covered at 80% of Reasonable and Customary Charges At SHC: Comp Plan: Covered at 90% of Reasonable and Customary Charges GSHIP: Covered at 100% of Reasonable and Customary Charges Outside SHC: Covered at 90% of Reasonable and Customary Charges Eligible Expenses including, but not limited to, equipment and self-management education are payable as follows: In-Network Care 80% of the Allowable Charge up to the Out-of-Pocket Limit, 100% thereafter Out-of-Network Care 50% of the Reasonable and Customary Charges for all plans up to the Out-of-Pocket Limit, 100% thereafter In-Network Care 90% of the Allowable Charge up to the Out-of-Pocket Limit, 100% thereafter Out-of-Network Care 60% of the Reasonable and Customary Charges for all plans up to the Out-of-Pocket Limit, 100% thereafter Continued 14

16 ADDITIONAL BENEFITS Continued Speech and Hearing Therapy, Bone Density Screening Test, Enteral Formula for Home Use BASIC PLAN Out-of-Network Care Covered at 50% of the Reasonable and Customary Charges for all plans up to the Out-of-Pocket Limit, COMPREHENSIVE (COMP) PLAN / GSHIP Out-of-Network Care Covered at 60% of the Reasonable and Customary Charges for all plans up to the Out-of-Pocket Limit, End of Life Care/ Hospice Care Eligible Expenses include care provided at acute care facilities which specializes in the treatment of terminally ill patients for members diagnosed with advanced cancer. Reimbursement for services is provided at 100% of the Allowable Charge. In the absence of an Allowable Charge, reimbursement must be provided at 100% of the acute care facilities reimbursement rate under the Medicare program, after any applicable Deductible. Dental Expense For Accidental Injury to tooth/teeth that are substantially free from decay, in good repair, and firmly attached to the jawbone prior to the Accident. Transsexualism/ Gender Identity Services Expense (sexual reassignment surgery is limited to $25,000 per Policy Year) Medical and Mental Health Treatment Abroad Emergency Medical and Travel Assistance Program Out-of-Network Care Covered at 80% of Out-of-Pocket Limit, Out-of-Network Care Covered at 50% of the Out-of-Pocket Limit, Hormone Therapy Covered under Pharmacy Benefit Medical and mental health treatments are covered according to the plan benefits at the 80% In-Network care rate. Prescription medications will also be covered at this 80% rate. Travel assistance services, medical, evacuation and return of mortal remains services up to $250,000. Out-of-Network Care Covered at 90% of Out-of-Pocket Limit, Out-of-Network Care Covered at 60% of the Out-of-Pocket Limit, Hormone Therapy Covered under Pharmacy Benefit Medical and mental health treatments are covered according to the plan benefits at the 90% In-Network care rate. Prescription medications will also be covered at this 90% rate. Note: The first 10 psychotherapy visits are covered under the Mandatory Plan at the 80% In-Network rate (see page 5). Travel assistance services, medical, evacuation and return of mortal remains services up to $1,000,000. SUMMARY OF BENEFITS Vision Services Available at SHC Only Club or Intramural Sports Expense Note: Interscholastic Sports excluded; see page 23 Annual Preventive Eye Examination Basic: 100% after $30 fee Outside SHC: Not available Other Optical Services (Available at SHC Only) Annual Preventive Eye Examination Comp: 100% after $30 fee GSHIP: 100% after $10 fee Outside SHC: Not available SHC provides the following discounts as an added service to all NYU students: 10% discount on already discounted eyeglass frame and lenses package when prescribed by and purchased at SHC Re-evaluation of current contact lens prescriptions New contact lens fittings (lenses not included) Paid as any other sickness/injury. Paid as any other sickness/injury. 15

17 TREATMENT OF MENTAL HEALTH DISORDERS Biologically Based Mental Illness and for Children with Serious Emotional Disturbances Biologically Based Mental Illness means a mental, nervous or emotional condition that is caused by a biological disorder of the brain and results in a clinically significant, psychological syndrome or pattern that substantially limits the functioning of the person with the illness. Such Biologically Based Mental Illnesses are defined as schizophrenia/psychotic disorders, major depression, bipolar disorder, delusional disorders, panic disorder, obsessive-compulsive disorder, bulimia and anorexia. Children with Serious Emotional Disturbances means persons under the age of eighteen (18) years who have diagnoses of attention deficit disorders, disruptive behavior disorders, or pervasive development disorders, and where there are one or more of the following: Serious suicidal symptoms or other life-threatening self-destructive behaviors; Behavior caused by emotional disturbances that place the child at risk of causing personal Injury or significant property damage; or Behavior caused by emotional disturbances that placed the child at substantial risk of removal from the household. Inpatient Eligible Expenses include expenses incurred by a Covered Person while confined as a full-time inpatient in a Hospital or residential treatment facility for the treatment of Biologically Based Mental Illness or Children with Serious Emotional Disturbances. See page 13 for mental health inpatient benefits. Outpatient Eligible Expenses include expenses while a Covered Person is not confined as a full-time inpatient in a Hospital, for the treatment of Biologically Based Mental Illness or Children with Serious Emotional Disturbances. See page 13 for mental health outpatient benefits. Not covered are charges for services: While incarcerated, confined or committed to a local correctional facility or a prison, or a custodial facility for youth. Provided solely because such services are ordered by a court. Deemed to be cosmetic in nature. Other than Biologically Based Mental Illness and Children with Serious Emotional Disturbances Inpatient Eligible Expenses include expenses incurred by a Covered Person while confined as a full-time inpatient in a Hospital or residential treatment facility for the treatment of Mental Illness other than Biologically Based Mental Illness or Children with Serious Emotional Disturbances. See page 13 for mental health inpatient benefits. Outpatient Eligible Expenses include expenses while a Covered Person is not confined as a full-time inpatient in a Hospital, for the treatment of Mental Illness other than Biologically Based Mental Illness or Children with Serious Emotional Disturbances. See page 13 for mental health outpatient benefits. Visits for outpatient treatment of Biologically Based Mental illness and Children with Serious Emotional Disturbances will count against and reduce this maximum. Not covered are charges for services: While incarcerated, confined or committed to a local correctional facility or a prison, or a custodial facility for youth. Provided solely because such services are ordered by a court. Deemed to be cosmetic in nature. EMERGENCY MEDICAL AND TRAVEL ASSISTANCE FrontierMEDEX ACCESS services is a comprehensive program providing You with 24/7 emergency medical and travel assistance services including emergency security or political evacuation, repatriation services and other travel assistance services when you are outside Your home country or 100 or more miles away from your permanent residence. FrontierMEDEX is your key to travel security. For general inquiries regarding the travel access assistance services coverage, please call Consolidated Health Plans at If you have a medical, security, or travel problem, simply call FrontierMEDEX for assistance and provide your name, school name, the group number shown on your ID card, and a description of your situation. If you are in North America, call the Assistance Center toll-free at: or if you are in a foreign country, call collect at: If the condition is an emergency, you should go immediately to the nearest physician or hospital without delay and then contact the 24-hour Assistance Center. FrontierMEDEX will then take the appropriate action to assist you and monitor your care until the situation is resolved. 16

18 GENERAL TERMS AND CONDITIONS FOR ALL NYU-SPONSORED PLANS Coordination of Benefits Benefits will be coordinated with any other group medical surgical or Hospital plan so that combined payments under all programs will not exceed 100% of charges incurred for covered services and supplies. Benefit Period Eligible Expenses incurred by Covered Students or their insured Dependents are covered if they are incurred within the period of coverage up to the Policy Year Maximum Benefit for each Injury or for each Sickness. Except as specifically provided under the Extension of Benefits provision, any expenses incurred beyond the period of coverage are not covered by this program. Extension of Benefits If a Covered Person is Totally Disabled on the date The Policy terminates, Eligible Expenses shall include charges incurred after the date of such termination with respect to Hospital Confinement that begins or Surgery performed during the next 31 days for the Injury or Sickness causing the Total Disability, subject to the applicable Maximum Amounts of this Policy. The Hospital confinement or Surgery must be only for the care and treatment of the Injury or Sickness which caused the Total Disability. If a Covered Person is confined to a Hospital on the date his or her coverage terminates, benefits will be payable for the Eligible Expenses incurred during the continuation of that Hospital Confinement. Such benefits will be payable until the earliest of: (1) the date the Hospital Confinement ends; (2) the end of the 12 month period following the date his or her coverage terminated; or (3) the date the applicable Maximum Amount is reached. In The Event Of Pregnancy. If a Covered Person is pregnant on the date her coverage terminates and the pregnancy commenced while insured while the Policy was in force, benefits will be payable for Eligible Expenses incurred for that pregnancy after her coverage terminates until the earliest of: (a) the date such pregnancy ends; (b) the date the Covered Person becomes insured under another policy; or (c) the date the applicable Maximum Amount is reached. Termination of Coverage For a Covered Student Insurance for a Covered Student will end on the date that the Covered Student withdraws from NYU to enter the armed forces of any country. Premiums will be refunded on a pro-rata basis when application is made within 90 days from withdrawal. If withdrawal from NYU is for a reason other than entering the armed forces, no premium refund will be made. Students will be covered for the policy term during which they are enrolled and for which the premium has been paid. For a Covered Dependent Insurance for a Covered Dependent will end when insurance for the Covered Student ends. Before then, coverage will end: For a child: upon the next premium due date after the child s 26th birthday However, if at the time at which insurance would otherwise cease the child is then incapable of selfsustaining employment due to mental or physical disability, coverage will end on the date the incapacity ends. For a Spouse or Domestic Partner: upon the next premium date after the date the marriage ends in divorce or annulment Termination will not prejudice any claim for a charge that is incurred prior to the date coverage ends. New York State-Mandated Benefits This Program will pay benefits in accordance with any applicable New York State Insurance Law(s). End of Life Care Expenses Eligible Expenses include care provided at an Acute Care Facility that specializes in the treatment of terminally ill patients diagnosed with advanced cancer. Reimbursement for services is provided at 100% of the Allowable Charge. In the absence of an Allowable Charge, reimbursement is provided at 100% of the acute care facility s reimbursement rate under the Medicare program, after any applicable Deductible. If the Company disagrees with the admission of or the provision or continuation of care for the Covered Person by the facility, the Company will initiate an expedited External Appeal in accordance with External Appeal provision in the Policy. Until a decision is rendered on this Appeal, the Company will provide Benefits, subject to the provisions of the Policy. The decision of the External Appeal agent is binding on the Covered Person and the Company. Enteral Formulas When the Policy covers prescription drugs, as part of that Benefit the Company will pay the Eligible Expenses incurred for the cost of enteral formulas for home use when prescribed by a Doctor or other Provider. Any prescription from the Doctor or Provider must state the use of such formulas is clearly Medically Necessary and has been proven effective as a disease specific treatment for a Covered Person who is or who will become malnourished or suffer from disorders, which if left untreated, cause 17

19 GENERAL TERMS AND CONDITIONS FOR ALL NYU-SPONSORED PLANS chronic physical disability, mental retardation or death. Enteral formulas which are Medically Necessary and taken under written prescription from a Doctor for the treatment of specific diseases will be distinguished from nutritional supplements taken electively. Specific diseases for which enteral formulas have been proven effective include, but are not limited to, inherited diseases of amino acid or organic acid metabolism; Crohn s Disease; gastro esophageal reflux with failure to thrive; disorders of the gastrointestinal motility such as chronic intestinal pseudo obstruction; and multiple, severe food allergies which, if left untreated, will cause malnourishment, chronic physical disability, mental retardation or death. Coverage for certain inherited diseases of amino acid and organic acid metabolism will include modified solid food products that are low protein or which contain modified protein which are Medically Necessary. Breast Cancer Benefit Hospital Facility Services will be payable for such period of time as determined by the Doctor, in consultation with You, to be medically appropriate when You are undergoing a lymph node dissection or a lumpectomy for the treatment of breast cancer or a mastectomy covered by the Policy. Eligible Expenses for a mastectomy include prosthesis and physical complications in all stages of mastectomy, including lymph edemas, in a manner determined in consultation with the Doctor and the patient. Such treatment will be subject to any Deductible and Coinsurance amounts shown in the Schedule of Benefits. Second Medical Opinion The Company will pay the Eligible Expenses incurred for a second medical opinion by an appropriate specialist, including but not limited to, a specialist affiliated with a specialty care center for the treatment of cancer in the event of a positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation of a course of treatment for cancer. Chiropractic Care Benefit The Company will pay the Eligible Expenses incurred for chiropractic care, performed by a doctor of chiropractic, to the same extent as would be payable for Doctor s services in a Doctor s office. Chiropractic care must be in connection with the detection or correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for the purpose of removing nerve interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column. Experimental or Investigational Services Recommended by an External Appeal Agent The Company will not exclude Benefits for health care services rendered or proposed to be rendered to a Covered Person on the basis that such service is Experimental or Investigational, is rendered as part of a clinical trial or is a pharmaceutical product prescribed by the Covered Person s attending Doctor for a use other than those uses for which the pharmaceutical product has been approved for marketing by the U.S. Federal Food and Drug Administration, if the services have been recommended by an External Appeals Agent in response to an appeal filed by an Covered Person or his or her attending Doctor. Such an External Appeal recommendation is binding upon the Covered Person, the Doctor and the Company. Any Benefits provided will be subject to the terms and conditions applicable to other Benefits provided under the Policy. Bone Mineral Density Tests When the Policy provides prescription drugs, the Company will pay Eligible Expenses for bone mineral density measurements, test, drugs and devices approved by the Federal Food and Drug Administration or generic equivalents as approved substitutes. These Benefits will be paid according to the criteria of the Federal Medicare program as well as those in accordance with the criteria of the National Institutes of Health, including, as consistent with such criteria, dual energy x-ray absorptiometry. Covered Persons qualifying for Benefits shall at a minimum include Covered Persons: (a) previously diagnosed as having osteoporosis or having a family history of osteoporosis; or (b) with symptoms or conditions indicative of the presence, or the significant risk, of osteoporosis; or (c) with lifestyle factors to such a degree as posing a significant risk of osteoporosis; or (d) on a prescribed drug regimen posing a significant risk of osteoporosis; or (e) with such age, gender and/or other physiological characteristics which pose a significant risk for osteoporosis. In addition to the above, coverage shall be provided for the following items or services for bone mineral density and such coverage shall not be subject coinsurance when services are rendered at the Student Health Center: (i) evidence-based items or services for bone mineral density that have in effect a rating of A or B in the current recommendations of the United States preventive services task force; and (ii) with respect to a female Covered Person, such additional preventive care and screenings for bone mineral density not prescribed in item (a) and as provided for in comprehensive guidelines supported by the health resources and services administration. Cancer Screening The Company will pay the Eligible Expenses incurred for mammography screening for occult breast cancer as follows: a mammogram at any age upon the recommendation of a Doctor, for Covered Persons having a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer; a single baseline mammogram for Covered Persons age 35 to 39 inclusive; and an annual mammogram for Covered Persons age 40 and older. 18

20 GENERAL TERMS AND CONDITIONS FOR ALL NYU-SPONSORED PLANS In addition, coverage shall be provided for the following mammography screening services, and such coverage shall not be subject to coinsurance when services are rendered at the Student Health Center: (i) evidence-based items or services for mammography that have in effect a rating of A or B in the current recommendations of the United States preventive services task force; and (ii) with respect to a female Covered Person, such additional preventive care and screenings for mammography not described in item (i) above and as provided for in comprehensive guidelines supported by the health resources and services administration. The Company will pay the Eligible Expenses incurred for standard diagnostic testing for prostate cancer including but not limited to: a digital rectal examination and a prostate-specific antigen test at any age for men having a prior history of prostate cancer; and an annual standard diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer factors. The Company will pay the Eligible Expenses incurred for an annual cervical cytology screening (PAP tests) for cervical cancer and its precursor states for women age 18 years and older. Such annual screening includes an annual pelvic exam, collection and preparation of the Pap smear and laboratory and diagnostic services provided in conjunction with examining and evaluating the Pap smear. Pre-Hospital Medical Emergency Services The Company will pay the Eligible Expenses incurred for pre-hospital medical emergency services for the treatment of an emergency condition when such services are provided by a certified ambulance service. As used above: Pre-hospital emergency medical services means the prompt evaluation and treatment of an emergency medical condition, and/or non-air-borne transportation of the patient to a Hospital, provided however, where the patient utilizes non-air-borne emergency transportation pursuant to this paragraph, reimbursement will be based on whether a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of such transportation to result in: (1) placing the health of the person affected with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; (2) serious impairment to such person s bodily functions; (3) serious dysfunction of any bodily organ or part of such person; (4) serious disfigurement of such person; or (5) a condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act. Emergency condition means a medical or behavioral condition, the onset of which is sudden, that manifests itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: (1) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; (2) serious impairment to such person s bodily functions; (3) serious dysfunction of any bodily organ or part of such person; (4) serious disfigurement of such person: or (5) a condition described in clause (i), (ii) or (iii) of section 1867(e)(1)(a) of the Social Security Act. Treatment of Correctable Medical Conditions that Cause Infertility The Policy does not exclude coverage for hospital, surgical or medical care for the diagnosis and treatment of correctable medical conditions otherwise covered under the Policy solely because the medical condition results in infertility. Autism Spectrum Disorder The Policy does not exclude coverage for diagnosis and treatment of medical conditions otherwise covered under the Policy because the treatment is provided to diagnose or treat Autism Spectrum Disorder. Second Surgical Opinion The Company will provide coverage for a second surgical opinion by a qualified Doctor on the need for surgery, subject to the following: 1. A qualified Doctor must be a board-certified specialist who by reason of his specialty is an appropriate Doctor to consider the surgical procedure being proposed; 2. Obtaining the second surgical opinion will be at the Covered Person s option; 3. The benefit is applicable to all in-patient surgical procedures of a non-emergency nature covered under the Policy; 4. The benefit is payable only if the Covered Person is examined in person by the Doctor rendering the second surgical opinion and a written report is provided to the Company; and 5. If the Board certified specialist who renders the second surgical opinion also performs the surgery, no second surgical opinion benefit is payable. Pre-Admission Testing The Policy includes coverage for Pre-Admission Testing ordered by a Doctor performed in the out-patient facilities of a Hospital as a planned preliminary to admission of the patient as an in-patient for surgery in the same Hospital provided that: 1. The tests are necessary for and consistent with the diagnosis and treatment of the condition for which surgery is to be performed; 2. Reservations for a hospital bed and for an operating room were made prior to the performance of the tests; 3. The surgery actually takes place within seven days of the tests; and 4. The patient is physically present at the hospital for the tests. 19