STUDENT HEALTH PLAN 2020-2021 - NYU

 
STUDENT HEALTH PLAN 2020-2021 - NYU
2020-2021
                               STUDENT HEALTH PLAN
                                        BASIC PLAN
                                    COMPREHENSIVE PLAN

                                          ("the Policyholder")
                                 Policy Number: WNY2021NYSHIP03
                                      Group Number: ST0645SH
                                  Effective: 8/21/2020 – 8/20/2021

      Underwritten By:                    Provider Network:            Administered By:
                                                                     Wellfleet Group, LLC
Wellfleet New York Insurance
    Co. ("the Company")
STUDENT HEALTH PLAN 2020-2021 - NYU
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

WHAT’S INSIDE (Click on section header below to go to section in brochure.)
      Student Health and Insurance at NYU ...........................................................................................................................3
      Confidentiality ...............................................................................................................................................................3
      Patient Protection and Affordable Care Act (PPACA) ....................................................................................................4
      Student Health Insurance Plans Overview ....................................................................................................................4
      Information for Graduate Employees NYU/UAW Local 2110 ........................................................................................5
      Schedules of Basic Plan (pp. 5-24) and Comprehensive Plan (pp. 25-43) Benefits .......................................................5
             Accidental Death and Dismemberment ..............................................................................................................43
             Referral Requirements.........................................................................................................................................44
             Preauthorization/Notification Procedure ............................................................................................................45
             Student Health Insurance Plan Costs ...................................................................................................................45
             Insurance Payment Options ................................................................................................................................46
             Insurance Cards ...................................................................................................................................................47
      Enrolling in the NYU Sponsored Plans .........................................................................................................................47
             Eligibility...............................................................................................................................................................47
             Automatic Enrollment .........................................................................................................................................47
             Voluntary Enrollment ..........................................................................................................................................48
             Dependents .........................................................................................................................................................48
             How to Enroll .......................................................................................................................................................48
             Enrollment Deadlines ..........................................................................................................................................49
             Important Enrollment Rules for Matriculated Students ......................................................................................49
             Fall 2020/Spring 2021 Automatic Enrollment Guide ...........................................................................................50
             Special Enrollment Periods ..................................................................................................................................51
      Waiving the Student Health Insurance Plans ..............................................................................................................51
             Waiver Criteria Applicable to All Students ..........................................................................................................51
             How to Waive Online ...........................................................................................................................................52
             Waiver Deadlines .................................................................................................................................................52
             Important Waiver Rules .......................................................................................................................................52
      International Students in F-1 or J-1 Visa Status ...........................................................................................................53
             International Students Waiver Process ...............................................................................................................53
      Information for Parents ...............................................................................................................................................54
      Exclusions and Limitations ...........................................................................................................................................55
      Claim Procedures .........................................................................................................................................................57
      Grievances, Utilization Review, and Appeals...............................................................................................................57
      Definitions ...................................................................................................................................................................58
      Contact Information (pp. 63-64) ..................................................................................................................................63
      Students Studying Away Insurance Program ...............................................................................................................65
      Additional Information for Graduate Employees NYU/UAW Local 2110 ....................................................................65
      Stu-Dent Dental Health Program .................................................................................................................................65

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                                                       Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

Student Health and Insurance at NYU
    New York University values the health of its students and is committed to offering all students access to quality
    healthcare and reasonably priced health insurance plans to help protect against financial hardships that may result
    from high healthcare expenses.

    While most undergraduate and graduate students are in good health and face few serious illnesses while in school,
    medical and psychological issues can arise at any time, sometimes without warning. There are also certain health
    concerns that may become apparent for the first time in early adulthood.

    The high cost of healthcare in the United States presents a potentially serious financial risk to students. The absence
    of adequate insurance coverage can result in temporary or permanent interruption of Your education; therefore,
    NYU requires that all students registered in degree-granting programs maintain health insurance.

    Most students are automatically enrolled in and charged a Premium for an NYU sponsored student health insurance
    plan (NYU sponsored plan) as part of the course registration process. Students who maintain alternate health
    insurance coverage that meets the University’s minimum health insurance criteria may waive the NYU sponsored
    student health insurance plan entirely (see Waiving the Student Health Insurance Plans section).

    This brochure has been prepared to help You understand the benefits and levels of coverage the NYU sponsored
    student health insurance plans offer.

    Student Health Center Locations

    Manhattan
    726 Broadway, 2nd, 3rd, and 4th Floors
    New York, NY 10003
    (212) 443-1000

    Brooklyn
    6 MetroTech Center, ROG-B020
    Brooklyn, NY 11201
    (646) 997-3456

Confidentiality
    Your privacy is Our priority. The Student Health Center (SHC) is legally and ethically obligated to protect the privacy
    of a student’s health information.

    Treatment of student health information is governed by the Family Educational Rights and Privacy Act (FERPA) and
    the requirements of applicable New York State law. The SHC will only disclose this information in limited
    circumstances in accordance with applicable law.

    The SHC will not release medical information to anyone, including family, parents/legal guardians, NYU faculty/staff,
    or outside agencies, without the written authorization of the student, except in emergency situations or to comply
    with a subpoena or judicial order. In the case of a minor, the authorization of a parent or legal guardian is required
    to release medical records. In a medical emergency, only relevant health information will be released to another
    healthcare Provider.

    The underwriter and administrator of the NYU-sponsored student health insurance plans also handle student health
    information in connection with the operation of those plans. Treatment of such information is governed by the
    Health Insurance Portability and Accountability Act (HIPAA) and the requirements of applicable New York State law.

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                                     Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

Patient Protection and Affordable Care Act (PPACA)
    The Affordable Care Act (ACA) was enacted to increase the availability of health insurance coverage to more
    Americans. There are a multitude of medical coverage requirements and it is important for You to know that the
    NYU sponsored student health insurance plans are fully ACA compliant.

    Here’s additional information about the ACA to assist You in making coverage decisions:

    Students are eligible to remain on a parent’s plan until age 26. However, You should compare the cost and benefits
    of coverage under a parent’s plan to those of the NYU sponsored student health insurance plans.

    Employer plans held by You or Your parents may be local HMO’s that are not appropriate for a student attending
    school out of state.

    The ACA created health insurance marketplaces for individuals to obtain coverage. However, You should carefully
    review the terms of the coverage to compare with any other alternatives including in terms of: Deductibles,
    Copayments, Coinsurance, and limited Provider networks. If You are interested in exploring this option, the web site
    is www.healthcare.gov. You will be directed to the appropriate online marketplace for Your home state of residence.

    Generally, international students holding an F-1 or J-1 visa are not eligible to purchase insurance through the
    marketplaces because they must show permanent residency.

Student Health Insurance Plans Overview

    Wellfleet Student Health Insurance Plans
    The NYU sponsored student health insurance plans, administered by Wellfleet Group, LLC, are designed to provide
    reasonably priced healthcare coverage. The student health insurance plans supplement the free services (as does
    any other health insurance) provided at the SHC. The NYU sponsored student health insurance plans cover most
    medical treatments and procedures provided at the SHC, for which there is a fee, as well as national coverage for
    medically necessary healthcare services.

    All matriculated students are eligible for enrollment in the Student Health Insurance Plans sponsored by NYU. See
    Voluntary Enrollment section for more information about enrolling Dependents and other eligible enrollees.

    The NYU sponsored student health insurance has two plans designed to provide reasonably priced healthcare
    coverage:
        1. Basic Plan

        2.   Comprehensive Plan

    The Basic and Comprehensive Plans cover the same medical/surgical, mental health and substance use services.
    However, they have different:
        • reimbursement levels,
        • coinsurance,
        • out-of-pocket expenses,
        • and premiums

    Both plans offer coverage for services rendered by healthcare Providers who participate in the Cigna PPO network.
    Referrals are required for services in Manhattan (outside the SHC). Visit www.wellfleetstudent.com/nyu to search
    for Cigna PPO Providers. Out-of-network Providers are also covered but at a lower reimbursement level. (See
    Schedules for Basic Plan and Comprehensive Plan Benefits).

    Please note: The SHC is an in-network Preferred Provider under the NYU sponsored student health insurance plan
    underwritten by Wellfleet New York Insurance Company. (See Referrals/Authorizations.)

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                                    Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

Information for Graduate Employees NYU/UAW Local 2110
    Effective September 1, 2015, the University began providing its student health insurance plan (Basic Health Plan –
    Individual Coverage) at 10% of the applicable premium rate to eligible graduate student employees. In addition,
    eligible graduate student employees will be covered by the Stu-Dent Plan for NYU at no cost and will be automatically
    enrolled in the Stu-Dent Plan upon confirmation of union eligibility.
    This provision does not apply to graduate employees who are covered under the Comprehensive Plan paid for by
    NYU.
    For eligible Washington Square graduate student employees, a Basic Health Plan or Comprehensive Health Plan
    insurance charge may initially appear on the graduate student employee’s tuition bill, but will be adjusted when the
    student’s union eligibility is confirmed. At that time the insurance charge on the Bursar account will be adjusted to
    10% of the Basic Health Insurance Plan charge for that term. If the graduate student employee is enrolled in the
    Comprehensive Plan, the insurance charge will be adjusted to 10% of the Basic Health Insurance Plan charge, plus
    the additional cost for the Comprehensive Health Insurance premium.
    Option to Upgrade Individual Coverage
    Eligible graduate student employees so covered may elect to upgrade their individual coverage to the
    Comprehensive Health Plan –Individual Coverage, at its additional cost. This must be accomplished by the September
    30th enrollment deadline. In the case where an eligible graduate student employee is automatically enrolled in the
    Comprehensive Health Insurance Plan (see Automatic Enrollment Guide), and wishes to change to the Basic Health
    Insurance Plan, the graduate student employee may do so during the online enrollment process (see Automatic
    Enrollment Guide section for more details).
    Dependent Coverage Premium Support Plan
    Effective September 1, 2015, the University established a Graduate Employee Student Health Insurance Dependent
    Premium Support Plan. For Academic Year 2019-2020, the Plan will be funded with $200,000, divided equally
    between the fall and spring semesters.
    Those eligible graduate employees who are doctoral candidates who actually purchase dependent coverage under
    the Basic Health Insurance Plan, or if enrolled in the Comprehensive Plan, paid for by NYU, for individual coverage,
    purchase dependent coverage under the Comprehensive Plan, and provide proof thereof, may, during the subject
    semester, apply for up to 75% reimbursement of dependent coverage premiums. Actual reimbursement will depend
    on the number of applications and the funds allocated for that semester. Unused funds, if any, will not carry over to
    a future semester. The application deadline for reimbursement for fall 2019 is January 8, 2020 and for spring 2020
    is August 20, 2020.
    Please note, eligible graduate student employees who are doctoral candidates and are enrolled in the
    Comprehensive Plan, paid for by NYU, for individual coverage, may only purchase Comprehensive Plan dependent
    care coverage, and in accordance with the agreement between NYU and Local 2110, the premium for such
    Comprehensive Plan dependent coverage will be at the same rate as the premium for dependent coverage under
    the Basic Student Health Insurance Plan.

Schedules of Basic Plan (pp. 5-24) and Comprehensive Plan (pp. 25-43)
Benefits
    One Schedule for BASIC Plan and one Schedule for COMPREHENSIVE Plan
    Availability of services at SHC locations varies, please verify location when making appointments.

    For a more complete description of plan benefits, general terms and conditions, Preauthorization and Referral
    requirements, etc., please review the 2020-2021 Student Health Insurance Certificate at
    www.wellfleetstudent.com/nyu.

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                                    Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

                                                    NEW YORK UNIVERSITY
                                                        BASIC PLAN
                                                      Metal Level: Gold

COST-SHARING             Student Health      Preferred               In- Network               Out-of-Network
                         Center              Provider                Responsibility for        Responsibility for Cost-
                         Responsibility      Responsibility          Cost-Sharing              Sharing
                         for Cost-Sharing    for Cost-Sharing

Deductible               None                None                    None                      None

Out-of-Pocket            $7,350              $7,350                  $7,350                    $14,700
Limit: Individual        $14,700             $14,700                 $14,700                   $29,400
Family
                                                                                               See section IV of this
                                                                                               Certificate for a
                                                                                               description of how We
                                                                                               calculate the Allowed
                                                                                               Amount. Any charges
                                                                                               of a Non- Participating
                                                                                               Provider that are in
                                                                                               excess of the Allowed
                                                                                               Amount do not apply
                                                                                               towards the Out- of-
                                                                                               Pocket Limit. You must
                                                                                               pay the amount by
                                                                                               which the Non-
                                                                                               Participating Provider's
                                                                                               charge exceeds Our
                                                                                               Allowed Amount.

Benefits Subject to
Annual and Lifetime
Limits
Emergency                                                                                                                 $250,000
Medical Evacuation                                                                                                        Annual
                                                                                                                          Limit

Repatriation of                                                                                                           $250,000
Remains                                                                                                                   Annual
                                                                                                                          Limit

Accidental Death                                                                                                          $10,000
and                                                                                                                       Annual and
Dismemberment                                                                                                             Lifetime
                                                                                                                          Maximum

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                                       Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

OFFICE VISITS                Student Health       Preferred              In-Network                Out-of-Network           Limits
                             Center               Provider               Responsibility for        Responsibility for Cost-
                             Responsibility       Responsibility         Cost-Sharing              Sharing
                             for Cost-Sharing     for Cost-Sharing
Primary Care Office          Covered in full      N/A                    $35 Copayment per 50% Coinsurance                 See
Visits (or Home                                                          Visit then                                        Benefit For
Visits)                                                                  20% Coinsurance                                   Description

Specialist Office            $20 Copayment        N/A                    $35 Copayment per 50% Coinsurance                 See
Visits (or Home              per Visit                                   Visit then                                        Benefit For
Visits)                                                                  20% Coinsurance                                   Description

PREVENTIVE CARE              Student Health       Preferred              In-Network                Out-of-Network           Limits
                             Responsibility for   Provider               Responsibility for        Responsibility for Cost-
                             Cost-                Responsibility         Cost-                     Sharing
                             Sharing              for Cost- Sharing      Sharing

•     Well Child Visits                                                                                                    See Benefit
      and                                                                                                                  For
     Immunizations*                                                                                                        Description

        Students             Covered in full      N/A                    Covered in full           50% Coinsurance

        Dependents           N/A                  N/A                    Covered in full           50% Coinsurance

•    Adult Annual
     Physical
     Examinations*

        Students             Covered in full      N/A                    Covered in full           50% Coinsurance

        Dependents           N/A                  N/A                    Covered in full           50% Coinsurance

•    Adult
     Immunizations*

        Students             Covered in full      N/A                    Covered in full           50% Coinsurance

        Dependents           N/A                  N/A                    Covered in full           50% Coinsurance

• Routine
  Gynecological
  Services/Well
  Woman Exams*

        Students             Covered in full      Covered in full        Covered in full           50% Coinsurance

        Dependents           N/A                  Covered in full        Covered in full           50% Coinsurance

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                                           Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PREVENTIVE CARE        Student Health       Preferred              In-Network                Out-of-Network           Limits
                       Responsibility for   Provider               Responsibility for        Responsibility for Cost-
                       Cost-                Responsibility         Cost-                     Sharing
                       Sharing              for Cost- Sharing      Sharing

• Mammography
  Screening and
  Diagnostic
  Imaging for the
  Detection of
  Breast Cancer

       Students        N/A                  N/A                    Covered in full           50% Coinsurance

       Dependents      N/A                  N/A                    Covered in full           50% Coinsurance

• Sterilization
  Procedures for
  Women*

       Students        N/A                  N/A                    Covered in full           50% Coinsurance

       Dependents      N/A                  N/A                    Covered in full           50% Coinsurance

•   Vasectomy

       Students        N/A                  N/A                    Covered in full           50% Coinsurance

       Dependents      N/A                  N/A                    Covered in full           50% Coinsurance

•   Bone Density
    Testing*

       Students        N/A                  N/A                    Covered in full           50% Coinsurance

       Dependents      N/A                  N/A                    Covered in full           50% Coinsurance

• Screening for
  Prostate Cancer

       Students        Covered in full      N/A                    Covered in full           50% Coinsurance

       Dependents      N/A                  N/A                    Covered in full           50% Coinsurance

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                                     Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PREVENTIVE CARE            Student Health       Preferred             In-Network                Out-of-Network           Limits
                           Responsibility for   Provider              Responsibility for        Responsibility for Cost-
                           Cost-                Responsibility        Cost-                     Sharing
                           Sharing              for Cost- Sharing     Sharing
•   All other preventive
    services required by
    USPSTF and HRSA.

        Students           Covered in full      N/A                   Covered in full           50% Coinsurance

        Dependents         N/A                  N/A                   Covered in full           50% Coinsurance

• *When preventive Use Cost Sharing             Use Cost Sharing      Use Cost Sharing for      Use Cost Sharing for
   services are not    for appropriate          for appropriate       appropriate service       appropriate service
   provided in         service (Primary         service (Primary      (Primary Care Office      (Primary Care Office
   accordance with the Care Office Visit;       Care Office Visit;    Visit;                    Visit; Specialist Office
   comprehensive       Specialist Office        Specialist Office     Specialist Office         Visit; Diagnostic
   guidelines          Visit; Diagnostic        Visit; Diagnostic     Visit; Diagnostic         Radiology Services;
   supported by        Radiology                Radiology             Radiology Services;       Laboratory Procedures
   USPSTF and HRSA. Services;                   Services;             Laboratory                & Diagnostic Testing)
                       Laboratory               Laboratory            Procedures &
                       Procedures &             Procedures &          Diagnostic Testing)
                       Diagnostic               Diagnostic Testing
                       Testing)
EMERGENCY CARE         Student Health           Preferred             In-Network                Out-of-Network           Limits
                       Responsibility for       Provider              Responsibility for        Responsibility for Cost-
                       Cost-Sharing             Responsibility        Cost-Sharing              Sharing
                                                for Cost-Sharing
Pre-Hospital               N/A                  N/A                   Covered in full           Covered in full            See Benefit
Emergency Medical                                                                                                          For
Services (Ambulance                                                                                                        Description
Services)
Non-Emergency              N/A                  N/A                   Covered in full           Covered in full            See Benefit
Ambulance Services                                                                                                         For
                                                                                                                           Description
Emergency                  N/A                  N/A                   $250 Copayment per $250 Copayment per                See Benefit
Department                                                            Visit then         Visit then                        For
                                                                      20% Coinsurance    20% Coinsurance                   Description

                                                                      Health care forensic
                                                                      examinations
                                                                      performed under
                                                                      Public Health Law §
                                                                      2805-I are not
                                                                      subject to Cost-
                                                                      Sharing
Urgent Care Center         N/A                  N/A                   $35 Copayment per 50% Coinsurance                    See Benefit
                                                                      Visit then                                           For
                                                                      20% Coinsurance                                      Description

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                                        Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL                Student Health Preferred                    In-Network                Out-of-Network           Limits
SERVICES AND                Responsibility for Provider                 Responsibility for        Responsibility for Cost-
OUTPATIENT                  Cost-Sharing       Responsibility           Cost-Sharing              Sharing
CARE                                           for Cost-Sharing
Advanced Imaging                                                                                                          See Benefit
Services                                                                                                                  For
                                                                                                                          Description
 •   Performed in a         N/A                 N/A                     20% Coinsurance           50% Coinsurance
     Specialist Office

•    Performed in a         N/A                 N/A                     20% Coinsurance           50% Coinsurance
     Freestanding
     Radiology Facility

•    Performed as        N/A                    N/A                     $40 Copayment per 50% Coinsurance
     Outpatient Hospital                                                Visit then
     Services                                                           20% Coinsurance

Preauthorization
Required

Allergy Testing &                                                                                                         See Benefit
Treatment                                                                                                                 For
                                                                                                                          Description
•    Performed in a PCP 20% Coinsurance N/A                             20% Coinsurance           50% Coinsurance
     Office

•    Performed in a         N/A                 N/A                     20% Coinsurance           50% Coinsurance
     Specialist Office

Ambulatory Surgical         N/A                 N/A                     $40 Copayment             50% Coinsurance         See Benefit
Center Facility Fee                                                     per Visit then                                    For
                                                                        20% Coinsurance                                   Description
Preauthorization
Required

Anesthesia Services         N/A                 N/A                     20% Coinsurance           50% Coinsurance         See Benefit
(all settings)                                                                                                            For
                                                                                                                          Description
Preauthorization
Required

Autologous Blood            N/A                 N/A                     20% Coinsurance           50% Coinsurance         See Benefits
Banking                                                                                                                   For
                                                                                                                          Description

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                                          Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL               Student Health Preferred                    In-Network                Out-of-Network           Limits
SERVICES AND               Responsibility for Provider                 Responsibility for        Responsibility for Cost-
OUTPATIENT                 Cost-Sharing       Responsibility           Cost-Sharing              Sharing
CARE                                          for Cost-Sharing
Cardiac &                                                                                                                See Benefits
Pulmonary                                                                                                                For
Rehabilitation                                                                                                           Description

• Performed in a           N/A                 N/A                     $35 Copayment per 50% Coinsurance
  Specialist Office                                                    Visit then
                                                                       20% Coinsurance

• Performed as        N/A                      N/A                     $40 Copayment per 50% Coinsurance
  Outpatient Hospital                                                  Visit then
  Services                                                             20% Coinsurance

• Performed as             N/A                 N/A                     Included As Part of Included As Part of
  Inpatient Hospital                                                   Inpatient Hospital Inpatient Hospital
  Services                                                             Service Cost- Sharing Service Cost-Sharing

Chemotherapy                                                                                                             See Benefit
 • Performed in a PCP N/A                      N/A                     20% Coinsurance           50% Coinsurance         For
   Office                                                                                                                Description

• Performed in a           N/A                 N/A                     20% Coinsurance           50% Coinsurance
  Specialist Office

• Performed as        N/A                      N/A                     $40 Copayment per 50% Coinsurance
  Outpatient Hospital                                                  Visit then
  Services                                                             20% Coinsurance

Preauthorization
Required

Chiropractic Services      N/A                 N/A                     $35 Copayment per 50% Coinsurance                 See Benefit
                                                                       Visit then                                        For
Preauthorization                                                       20% Coinsurance                                   Description
Required

Clinical Trials            Use Cost- Sharing N/A                       Use Cost- Sharing for Use Cost- Sharing for       See Benefit
                           for appropriate                             appropriate service appropriate service           For
                           service                                                                                       Description

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                                         Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL             Student Health Preferred                    In-Network                Out-of-Network           Limits
SERVICES AND             Responsibility for Provider                 Responsibility for        Responsibility for Cost-
OUTPATIENT               Cost-Sharing       Responsibility           Cost-Sharing              Sharing
CARE                                        for Cost-Sharing
Diagnostic Testing                                                                                                     See Benefit
                                                                                                                       For
• Performed in a PCP 20% Coinsurance N/A                             20% Coinsurance           50% Coinsurance         Description
  Office

• Performed in a         20% Coinsurance N/A                         20% Coinsurance           50% Coinsurance
  Specialist Office

• Performed as        N/A                    N/A                     $40 Copayment per 50% Coinsurance
  Outpatient Hospital                                                Visit then
  Services                                                           20% Coinsurance

Dialysis                                                                                                               See Benefit
                                                                                                                       For
•   Performed in a PCP N/A                   N/A                     20% Coinsurance           50% Coinsurance         Description
    Office

• Performed              N/A                 N/A                     20% Coinsurance           50% Coinsurance
  in a
  Specialist
  Office

• Performed in a      N/A                    N/A                     20% Coinsurance           50% Coinsurance
  Freestanding Center

• Performed as        N/A                    N/A                     $40 Copayment             50% Coinsurance
  Outpatient Hospital                                                per Visit then
  Services                                                           20% Coinsurance

• Performed at Home N/A                      N/A                     20% Coinsurance           50% Coinsurance
Habilitation Services                                                                                                  60 visits
                                                                                                                       per condition
(Physical Therapy,    $20 Copayment          N/A                     $35 Copayment per 50% Coinsurance                 per Plan Year
Occupational Therapy) per Visit                                      Visit then                                        (combined
                                                                     20% Coinsurance                                   therapies)

(Speech or Hearing       N/A                 N/A                     $35 Copayment per 50% Coinsurance
Therapy)                                                             Visit then
                                                                     20% Coinsurance

Home Health Care         N/A                 N/A                     20% Coinsurance           20% Coinsurance         40 Visits per
                                                                                                                       Plan Year
Preauthorization
Required

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                                       Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL              Student Health Preferred                    In-Network                Out-of-Network           Limits
SERVICES AND              Responsibility for Provider                 Responsibility for        Responsibility for Cost-
OUTPATIENT                Cost-Sharing       Responsibility           Cost-Sharing              Sharing
CARE                                         for Cost-Sharing
Infertility Services      Use Cost Sharing N/A                        Use Cost Sharing for Use Cost Sharing for      See Benefit
                          for appropriate                             appropriate service appropriate service        For
                          service (Office                             (Office Visit;       (Office Visit; Diagnostic Description
                          Visit; Diagnostic                           Diagnostic Radiology Radiology Services;
                          Radiology                                   Services; Surgery; Surgery; Laboratory &
                          Services; Surgery;                          Laboratory &         Diagnostic Procedures)
                          Laboratory &                                Diagnostic
                          Diagnostic                                  Procedures)
                          Procedures)

Infusion Therapy                                                                                                        See Benefit
                                                                                                                        For
•   Performed in a PCP $20 Copayment N/A                              $35 Copayment per 50% Coinsurance                 Description
    Office             per Visit then                                 Visit then
                       20% Coinsurance                                20% Coinsurance

• Performed in            $20 Copayment N/A                           $35 Copayment per 50% Coinsurance
  Specialist Office       per Visit then                              Visit then
                          20% Coinsurance                             20% Coinsurance

• Performed as        N/A                     N/A                     $40 Copayment per 50% Coinsurance                 Home infusion
  Outpatient Hospital                                                 Visit then                                        counts toward
  Services                                                            20% Coinsurance                                   home health
                                                                                                                        care visit limits
• Home Infusion           N/A                 N/A                     20% Coinsurance           50% Coinsurance
  Therapy

Inpatient Medical         N/A                 N/A                     20% Coinsurance           50% Coinsurance         See Benefit
Visits                                                                                                                  For
                                                                                                                        Description

Interruption of
Pregnancy
                                                                                                                        Unlimited
•    Medically            N/A                  N/A                    Covered in full           50% Coinsurance
     Necessary
     Abortions

•    Elective Abortions N/A                    N/A                    20% Coinsurance           50% Coinsurance         One (1)
                                                                                                                        procedure per
                                                                                                                        Plan Year

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                                        Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL          Student Health           Preferred              In-Network                Out-of-Network           Limits
SERVICES AND          Responsibility for       Provider               Responsibility for        Responsibility for Cost-
OUTPATIENT            Cost-Sharing             Responsibility         Cost-Sharing              Sharing
CARE                                           for Cost-Sharing
Laboratory Procedures                                                                                                   See Benefit
                                                                                                                        For
• Performed in a PCP 20% Coinsurance N/A                              20% Coinsurance           50% Coinsurance         Description
  Office

• Performed in a          N/A                  N/A                    20% Coinsurance           50% Coinsurance
  Specialist Office

• Performed in a          N/A                  N/A                    20% Coinsurance           50% Coinsurance
  Freestanding
  Laboratory Facility

• Performed as         N/A                     N/A                    $40 Copayment per 50% Coinsurance
   Outpatient Hospital                                                Visit then
   Services                                                           20% Coinsurance
Maternity & Newborn                                                                                                     See Benefit
Care                                                                                                                    For
                                                                                                                        Description
• Prenatal Care        N/A                     Covered in full        Covered in full           50% Coinsurance
  provided in
  accordance with the
  comprehensive
  guidelines supported
  by USPSTF and HRSA

• Prenatal Care that is   Use Cost-Sharing     Use Cost-Sharing Use Cost-Sharing for Use Cost-Sharing for
  not provided in         for appropriate      for appropriate     appropriate service appropriate service
  accordance with the     service (Primary     service (Primary (Primary Care Office (Primary Care Office
  comprehensive           Care Office Visit,   Care Office Visit, Visit, Specialist     Visit, Specialist Office
  guidelines supported    Specialist Office    Specialist Office Office Visit,          Visit, Diagnostic
  by USPSTF and HRSA      Visit, Diagnostic    Visit, Diagnostic Diagnostic Radiology Radiology Services,
                          Radiology            Radiology           Services, Laboratory Laboratory Procedures
                          Services,            Services,           Procedures and       and Diagnostic Testing)
                          Laboratory           Laboratory          Diagnostic Testing)
                          Procedures and       Procedures and
                          Diagnostic           Diagnostic Testing)
                          Testing)

•   Inpatient Hospital N/A                     Covered in full        20% Coinsurance           50% Coinsurance         One (1) home
    Services and Birthing                                                                                               care visit is
    Center                                                                                                              Covered at no
                                                                                                                        Cost- Sharing
                                                                                                                        if mother is
                                                                                                                        discharged
                                                                                                                        from Hospital
                                                                                                                        early

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                                        Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL                 Student Health Preferred                   In-Network                Out-of-Network           Limits
SERVICES AND                 Responsibility for Provider                Responsibility for        Responsibility for Cost-
OUTPATIENT                   Cost-Sharing       Responsibility          Cost-Sharing              Sharing
CARE                                            for Cost-Sharing
Maternity & Newborn                                                                                                       Maternity &
Care (continued)                                                                                                          Newborn Care
                                                                                                                          (continued)
•   Physician and        N/A                    Covered in full         20% Coinsurance           50% Coinsurance
    Midwife Services for
    Delivery

•   Breastfeeding       N/A                     N/A                     Covered in full           50% Coinsurance         Covered for
    Support, Counseling                                                                                                   duration of
    and Supplies,                                                                                                         breast feeding
    Including Breast
    Pumps

•   Postnatal Care           N/A                Covered in full         20% Coinsurance           50% Coinsurance

Preauthorization
Required for Inpatient
Services; Breast Pump

Outpatient Hospital          N/A                N/A                     $40 Copayment             50% Coinsurance         See Benefit
Surgery Facility                                                        per Visit then                                    For
Charge                                                                  20% Coinsurance                                   Description

Preauthorization
Required

Preadmission                 N/A                N/A                     20% Coinsurance           50% Coinsurance         See Benefit
Testing                                                                                                                   For
                                                                                                                          Description

Prescription Drugs                                                                                                        See
Administrated in Office or                                                                                                Benefit For
Outpatient Facilities                                                                                                     Description

• Performed in a PCP         20% Coinsurance N/A                        20% Coinsurance           50% Coinsurance
  Office

• Performed in               20% Coinsurance N/A                        20% Coinsurance           50% Coinsurance
  Specialist Office

• Performed in               N/A                N/A                     20% Coinsurance           50% Coinsurance
  Outpatient Facilities

                                                                                                                              15
                                          Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL               Student Health Preferred                   In-Network                Out-of-Network           Limits
SERVICES AND               Responsibility for Provider                Responsibility for        Responsibility for Cost-
OUTPATIENT                 Cost-Sharing       Responsibility          Cost-Sharing              Sharing
CARE                                          for Cost-Sharing
Diagnostic                                                                                                              See Benefit
Radiology Services                                                                                                      For
                                                                                                                        Description
• Performed in a PCP 20% Coinsurance N/A                              20% Coinsurance           50% Coinsurance
  Office

• Performed in a           N/A                N/A                     20% Coinsurance           50% Coinsurance
  Specialist Office

• Performed in a           N/A                N/A                     20% Coinsurance           50% Coinsurance
  Freestanding
  Radiology Facility

•   Performed as        N/A                   N/A                     $40 Copayment per 50% Coinsurance
    Outpatient Hospital                                               Visit then
    Services                                                          20% Coinsurance

Preauthorization
Required
Therapeutic                                                                                                             See Benefit
Radiology Services                                                                                                      For
                                                                                                                        Description
• Performed in a           N/A                N/A                     20% Coinsurance           50% Coinsurance
  Specialist Office

• Performed in a           N/A                N/A                     20% Coinsurance           50% Coinsurance
  Freestanding
  Radiology Facility

• Performed as        N/A                     N/A                     $40 Copayment per 50% Coinsurance
  Outpatient Hospital                                                 Visit then
  Services                                                            20% Coinsurance

Preauthorization
Required
Rehabilitation Services:                                                                                                60 visits per
                                                                                                                        condition per
(Physical Therapy,    $20 Copayment           N/A                     $35 Copayment per 50% Coinsurance                 Plan Year
Occupational Therapy) per Visit                                       Visit then                                        (combined
                                                                      20% Coinsurance                                   therapies)

(Speech or Hearing         N/A                N/A                     $35 Copayment per 50% Coinsurance
Therapy)                                                              Visit then
                                                                      20% Coinsurance

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                                        Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL              Student Health Preferred                    In-Network                Out-of-Network           Limits
SERVICES AND              Responsibility for Provider                 Responsibility for        Responsibility for Cost-
OUTPATIENT                Cost-Sharing       Responsibility           Cost-Sharing              Sharing
CARE                                         for Cost-Sharing
Second Opinions on the    $20 Copayment N/A                           $35 Copayment per 50% Coinsurance          See Benefit
Diagnosis of Cancer,      per Visit                                   Visit then                                 For
Surgery & Other           20% Coinsurance                             20% Coinsurance   Second  Opinions  on     Description
                                                                                        Diagnosis of Cancer are
                                                                                        Covered at
                                                                                        participating Cost-
                                                                                        Sharing for non-
                                                                                        participating Specialist
                                                                                        when a Referral is
                                                                                        obtained.

Surgical Services                                                                                                       See Benefit
(Including Oral                                                                                                         For
Surgery, Reconstructive                                                                                                 Description
Breast Surgery; Other
Reconstructive and
Corrective Surgery; and
Transplants)

• Inpatient Hospital      N/A                 N/A                     20% Coinsurance           50% Coinsurance
  Surgery

• Outpatient Hospital N/A                     N/A                     20% Coinsurance           50% Coinsurance
  Surgery

• Surgery Performed N/A                       N/A                     20% Coinsurance           50% Coinsurance
  at an Ambulatory
  Surgical Center

• Office Surgery          20% Coinsurance N/A                         20% Coinsurance           50% Coinsurance

ADDITIONAL SERVICES, Student Health           Preferred               In-Network                Out-of-Network           Limits
EQUIPMENT &          Center                   Provider                Responsibility for        Responsibility for Cost-
DEVICES              Responsibility           Responsibility          Cost-Sharing              Sharing
                     for Cost-Sharing         for Cost-Sharing
ABA Treatment for    $20 Copayment            N/A                     $35 Copayment per 50% Coinsurance                 See Benefit
Autism Spectrum      per Visit then                                   Visit then                                        For
Disorder             20% Coinsurance                                  20% Coinsurance                                   Description

Assistive             $20 Copayment N/A                               $35 Copayment per 50% Coinsurance                 See Benefit
Communication Devices per Visit then                                  Visit then                                        For
for Autism            20% Coinsurance                                 20% Coinsurance                                   Description
Spectrum Disorder

                                                                                                                            17
                                        Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

ADDITIONAL SERVICES, Student Health         Preferred               In-Network                Out-of-Network           Limits
EQUIPMENT &          Center                 Provider                Responsibility for        Responsibility for Cost-
DEVICES              Responsibility         Responsibility          Cost-Sharing              Sharing
                     for Cost-Sharing       for Cost-Sharing
Diabetic Equipment,                                                                                                   See Benefit
Supplies and Self-                                                                                                    For
Management Education                                                                                                  Description

• Diabetic Equipment, $20 Copayment         N/A                     $20 Copayment per 30% Coinsurance                 See
  Supplies and Insulin per prescription                             prescription                                      Prescription
  (30-Day Supply)                                                                                                     Drug Benefit

 • Diabetic Education   20% Coinsurance N/A                         20% Coinsurance           50% Coinsurance
Durable Medical         20% Coinsurance N/A                         20% Coinsurance           20% Coinsurance         See Benefit
Equipment & Braces                                                                                                    For
                                                                                                                      Description
External Hearing        N/A                 N/A                     20% Coinsurance           20% Coinsurance         Single
Aids                                                                                                                  Purchase Once
                                                                                                                      Every three (3)
                                                                                                                      Years
Cochlear Implants       N/A                 N/A                     20% Coinsurance           50% Coinsurance         One (1) Per
                                                                                                                      Ear Per Time
Preauthorization                                                                                                      Covered
Required
Hospice Care                                                                                                          210 days per
                                                                                                                      Plan Year
• Inpatient             N/A                 N/A                     Covered in full           Covered in full

Preauthorization
Required

• Outpatient            N/A                 N/A                     Covered in full           Covered in full         Five (5) Visits
                                                                                                                      for Family
                                                                                                                      Bereavement
                                                                                                                      Counseling
Medical Supplies        20% Coinsurance N/A                         20% Coinsurance           50% Coinsurance         See Benefit
                                                                                                                      For
                                                                                                                      Description

Prosthetic Devices

• External              20% Coinsurance N/A                         20% Coinsurance           20% Coinsurance         One (1)
                                                                                                                      prosthetic
                                                                                                                      device, per
                                                                                                                      limb, per
                                                                                                                      lifetime

• Internal              N/A                 N/A                     20% Coinsurance           20% Coinsurance         Unlimited; See
                                                                                                                      Benefit For
                                                                                                                      Description

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                                      Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

INPATIENT SERVICES       Student Health       Preferred               In-Network                Out-of-Network           Limits
and FACILITIES           Center               Provider                Responsibility for        Responsibility for Cost-
                         Responsibility       Responsibility          Cost-Sharing              Sharing
                         for Cost-Sharing     for Cost-Sharing
Inpatient Hospital for a N/A                  N/A                     20% Coinsurance           50% Coinsurance         See Benefit
Continuous                                                                                                              For
Confinement (including                                                                                                  Description
an Inpatient Stay for
Mastectomy Care,
Cardiac & Pulmonary
Rehabilitation, and End
of Life Care)

Preauthorization
Required. However,
Preauthorization is not
required for emergency
admissions or services
provided in a neonatal
intensive care unit of a
Hospital certified
pursuant to Article 28 of
the Public Health Law.

Observation Stay            N/A               N/A                     20% Coinsurance           50% Coinsurance         See Benefit
                                                                                                                        For
                                                                                                                        Description
Skilled Nursing Facility    N/A               N/A                     20% Coinsurance           50% Coinsurance         200 days per
(Includes Cardiac &                                                                                                     Plan Year
Pulmonary
Rehabilitation)

Preauthorization
Required

Inpatient Habilitation N/A                    N/A                     20% Coinsurance           50% Coinsurance
Services (Physical,
Speech & Occupational
therapy)

Preauthorization
Required

Inpatient Rehabilitation N/A                  N/A                     20% Coinsurance           50% Coinsurance
Services (Physical,
Speech & Occupational
therapy)

Preauthorization
Required

                                                                                                                            19
                                        Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

MENTAL HEALTH               Student Health      Preferred              In-Network                Out-of-Network           Limits
& SUBSTANCE USE             Center              Provider               Responsibility for        Responsibility for Cost-
DISORDER                    Responsibility      Responsibility         Cost-Sharing              Sharing
SERVICES                    for Cost-Sharing    for Cost-Sharing
Inpatient Mental Health     N/A                 Covered in full        20% Coinsurance           50% Coinsurance         See Benefit
Care for a continuous                                                                                                    For
confinement when in a                                                                                                    Description
Hospital (including
Residential Treatment)

Preauthorization
Required. However,
Preauthorization is not
required for emergency
admissions or for
admissions at
Participating OMH-
licensed Facilities for
Members under 18.

Outpatient Mental           Use Cost-Sharing    $5 Copayment per 20% Coinsurance                 50% Coinsurance         See Benefit
Health Care (Including      for appropriate     Visit            (For neuropsych                 (For neuropsych testing For
Partial Hospitalization &   service             (Copayment       testing only,                   only, Covered in full.) Description
Intensive Outpatient        (For neuropsych     waived for       Covered in full.)
Program Services)           testing only,       neuropsych
                            Covered in full.)   testing only.)
Except for Office Visits,
Preauthorization
Required.

Inpatient Substance    N/A                      N/A                    20% Coinsurance           50% Coinsurance         See Benefit
Use Services for a                                                                                                       For
continuous confinement                                                                                                   Description
when in a Hospital
(including Residential
Treatment)

Preauthorization
Required. However,
Preauthorization is Not
Required for Emergency
Admissions or for
Participating OASAS-
certified Facilities

                                                                                                                             20
                                         Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

MENTAL HEALTH               Student Health     Preferred               In-Network                Out-of-Network           Limits
& SUBSTANCE USE             Center             Provider                Responsibility for        Responsibility for Cost-
DISORDER                    Responsibility     Responsibility          Cost-Sharing              Sharing
SERVICES                    for Cost-Sharing   for Cost-Sharing
Outpatient Substance        N/A                N/A                     Covered in full           Covered in full         Up to 20 visits
Use Services (including                                                                                                  a Plan Year
Partial Hospitalization,                                                                                                 may be Used
Intensive Outpatient                                                                                                     For Family
Program Services, and                                                                                                    Counseling
Medication Assisted
Treatment)

Except for Office Visits,
Preauthorization
Required. However,
Preauthorization is not
required for
Participating OASAS-
certified Facilities.

PRESCRIPTION DRUGS Student Health              Preferred          In-Network                     Out-of-Network           Limits
                   Center                      Provider           Responsibility for             Responsibility for Cost-
                   Responsibility for          Responsibility for Cost-Sharing                   Sharing
                   Cost-Sharing                Cost-Sharing
You may request a copy of the Wellfleet Rx/KPP Formulary. The Formulary is also available on the Wellfleet Rx website at
www.WellfleetRx.com. You may inquire if a specific drug is Covered under the Certificate by contacting Wellfleet Student
at the number on Your ID card, (877) 373-1170.
*Certain Prescription Drugs are not subject to Cost-Sharing when provided in accordance with the comprehensive
guidelines supported by HRSA or if the item or service has an “A” or “B” rating from the USPSTF
Retail Pharmacy
Supply Limits. Except for contraceptive drugs, devices, or products, We will pay for no more than a 30-day supply of a
Prescription Drug purchased at a retail pharmacy. You are responsible for one (1) Cost-Sharing amount for up to a 30-day
supply.
You may have the entire supply (of up to 12 months) of the contraceptive drug, device, or product dispensed at the same
time. Contraceptive drugs, devices, or products are not subject to Cost-Sharing
when provided by a Participating Pharmacy.
Please refer to Certificate of coverage for details.
30 Day Supply                                                                                                            See Benefit
(except contraceptive                                                                                                    For
drugs or devices)*                                                                                                       Description

Tier 1 (Including          $15 Copayment per N/A                       $15 Copayment per 30% Coinsurance
Enteral Formulas)          prescription                                prescription

Tier 2 (Including          $40 Copayment per N/A                       $40 Copayment per 30% Coinsurance
Enteral Formulas)          prescription                                prescription

Tier 3 (Including          $60 Copayment per N/A                       $60 Copayment per 30% Coinsurance
Enteral Formulas)          prescription                                prescription

                                                                                                                             21
                                         Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PRESCRIPTION DRUGS Student Health                 Preferred          In-Network                     Out-of-Network           Limits
                   Center                         Provider           Responsibility for             Responsibility for Cost-
                   Responsibility for             Responsibility for Cost-Sharing                   Sharing
                   Cost-Sharing                   Cost-Sharing

*Contraceptive Drugs
or Devices: Up to a 90
Day Supply

Tier 1                    Covered in full         N/A                     Covered in full           30% Coinsurance

Tier 2                    Covered in full         N/A                     Covered in full           30% Coinsurance

Tier 3                    Covered in full         N/A                     Covered in full           30% Coinsurance

If You have an
Emergency Condition,
Preauthorization is not
required for a five (5)
day emergency supply
of a Covered
Prescription Drug used
to treat a substance
use disorder, including
a Prescription Drug to
manage opioid
withdrawal and/or
stabilization and for
opioid overdose
reversal.

WELLNESS BENEFITS Student Health                  Preferred               In-Network           Out-of-Network
                  Center                          Provider                Responsibility for Responsibility for Cost-
                  Responsibility                  Responsibility          Cost-                Sharing
                  for Cost- Sharing               for Cost- Sharing       Sharing
Gym Reimbursement N/A                             N/A                     Up to $200 per six Up to $200 per six (6) Up to $200
                                                                          (6) month period; up month period; up to an per six (6)
                                                                          to an additional     additional $100 per six month period;
                                                                          $100 per six (6)     (6) month period for up to an
                                                                          month period for     Covered Dependents additional
                                                                          Covered Dependents                           $100 per six
                                                                                                                       (6) month
                                                                                                                       period for
                                                                                                                       Covered
                                                                                                                       Dependents

                                                                                                                                22
                                            Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

DENTAL and ROUTINE Student Health            Preferred               In-Network                Out-of-Network
VISION CARE        Center                    Provider                Responsibility for        Responsibility for Cost-
                   Responsibility            Responsibility          Cost-Sharing              Sharing
                   for Cost-Sharing          for Cost-Sharing

Pediatric Dental                                                                                                          One (1) dental
Care (Members                                                                                                             exam and
through the end of                                                                                                        cleaning per
the month in which                                                                                                        six
the Member turns 19                                                                                                       (6)- month
years of age)                                                                                                             period

                                                                                                                          Full mouth x-
• Preventive Dental N/A                      N/A                     $40 Copayment per 40% Coinsurance                    rays or
  Care                                                               Visit then 20%                                       panoramic x-
                                                                     Coinsurance                                          rays at
                                                                                                                          36 month
                                                                                                                          intervals and
• Routine Dental       N/A                   N/A                     $40 Copayment per 40% Coinsurance                    bitewing x-
  Care                                                               Visit then 20%                                       rays at six
                                                                     Coinsurance                                          (6) - month
                                                                                                                          intervals

• Major Dental       N/A                     N/A                     $40 Copayment per 40% Coinsurance
  (Endodontics,                                                      Visit then 20%
  Periodontics. Oral                                                 Coinsurance
  Surgery and
  Prosthodontics)

• Orthodontia          N/A                   N/A                     $40 Copayment per 40% Coinsurance
                                                                     Visit then 20%
Orthodontics and                                                     Coinsurance
Major Dental Require
Preauthorization;
Referral

                                                                                                                             23
                                       Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

Pediatric Vision Care
(Members through the
end of the month in
which the Member
turns 19 years of age):

Exams                     Covered in full         N/A                     $30 Copayment per 40% Coinsurance       One (1) exam
                                                                          Visit then 20%                          per Plan Year
                                                                          Coinsurance

Lenses and Frames         $30 Copayment           N/A                     $50 Copayment then 40% Coinsurance      One (1)
                          then 20%                                        20% Coinsurance                         prescribed
                          Coinsurance                                                                             lenses and
                                                                                                                  frames per
Contact Lenses            $30 Copayment           N/A                     $50 Copayment then 40% Coinsurance      Plan Year
                          then 20%                                        20% Coinsurance
                          Coinsurance
Contact Lenses
Require
Preauthorization
Adult Vision Care                                                                                                 One (1) exam
(Members over age                                                                                                 per Plan Yea
18)

Exams                     $20 Copayment per N/A                           Not Covered               Not Covered
                          Visit

Benefits Subject to
Limits

Emergency                 N/A                                                                                     $250,000
Medical Evacuation                                                                                                Annual
                                                                                                                  Limit

Repatriation of           N/A                                                                                     $250,000
Remains                                                                                                           Annual
                                                                                                                  Limit

Accidental Death          N/A                                                                                     $10,000
and                                                                                                               Annual and
Dismemberment                                                                                                     Lifetime
                                                                                                                  Maximum

         For a more complete description of plan benefits, general terms and conditions, Preauthorization and Referral
         requirements, etc., please review the 2020-2021 Student Health Insurance Certificate at
         www.wellfleetstudent.com/nyu.

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                                            Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

                                                    NEW YORK UNIVERSITY
                                                    COMPREHENSIVE PLAN
                                                     Metal Level: Platinum

COST-SHARING             Student Health         Preferred          In- Network                     Out-of-Network
                         Center                 Provider           Responsibility for              Responsibility for
                         Responsibility for     Responsibility for Cost-Sharing                    Cost-Sharing
                         Cost-Sharing           Cost-Sharing

Deductible               None                   None                     None                      None

Out-of-Pocket            $5,000                 $5,000                   $5,000                    $10,000
Limit: Individual Family $10,000                $10,000                  $10,000                   $20,000

                                                                                                   See section IV of
                                                                                                   this Policy for a
                                                                                                   description of how
                                                                                                   We calculate the
                                                                                                   Allowed Amount.
                                                                                                   Any charges of a
                                                                                                   Non-
                                                                                                   Participating
                                                                                                   Provider
                                                                                                   that are in excess
                                                                                                   of the Allowed
                                                                                                   Amount do not
                                                                                                   apply towards the
                                                                                                   Out- of-Pocket
                                                                                                   Limit. The Member
                                                                                                   must pay the
                                                                                                   amount by which
                                                                                                   the Non-
                                                                                                   Participating
                                                                                                   Provider's charge
                                                                                                   exceeds Our
                                                                                                   Allowed Amount.
Benefits Subject to
Annual and Lifetime
Limits
Emergency                                                                                                               $1,000,000
Medical Evacuation                                                                                                      Annual
                                                                                                                        Limit
Repatriation of                                                                                                         $1,000,000
Remains                                                                                                                 Annual
                                                                                                                        Limit
Accidental Death                                                                                                        $10,000
and                                                                                                                     Annual and
Dismemberment                                                                                                           Lifetime
                                                                                                                        Maximum
                                                                                                                          25
                                       Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

OFFICE VISITS                 Student Health         Preferred Provider In-Network                      Out-of-Network     Limits
                              Center                 Responsibility     Responsibility for              Responsibility for
                              Responsibility         for Cost-Sharing Cost-Sharing                      Cost-Sharing
                              for Cost-Sharing
Primary Care Office           Covered in full        N/A                      $30 Copayment per         40% Coinsurance    See Benefit
Visits (or Home                                                               Visit then                                   For
Visits)                                                                       10% Coinsurance                              Description
Specialist Office Visits      $20 Copayment per N/A                           $30 Copayment per         40% Coinsurance    See Benefit
(or Home Visits)              Visit                                           Visit then                                   For
                                                                              10% Coinsurance                              Description
PREVENTIVE CARE               Student Health         Preferred Provider In-Network                      Out-of-Network     Limits
                              Responsibility for     Responsibility     Responsibility for              Responsibility for
                              Cost-Sharing           For Cost-Sharing Cost-Sharing                      Cost-Sharing
•     Well Child Visits                                                                                                    See Benefit
      and                                                                                                                  For
     Immunizations*                                                                                                        Description

        Students              Covered in full        N/A                      Covered in full           40% Coinsurance

        Dependents            N/A                    N/A                      Covered in full           40% Coinsurance

•    Adult Annual
     Physical
     Examinations*

        Students              Covered in full        N/A                      Covered in full           40% Coinsurance

        Dependents            N/A                    N/A                      Covered in full           40% Coinsurance

•    Adult
     Immunizations*

        Students              Covered in full        N/A                      Covered in full           40% Coinsurance

        Dependents            N/A                    N/A                      Covered in full           40% Coinsurance

• Routine
  Gynecological
  Services/Well
  Woman Exams*

        Students              Covered in full        Covered in full          Covered in full           40% Coinsurance

        Dependents            N/A                    Covered in full          Covered in full           40% Coinsurance

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                                            Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PREVENTIVE CARE        Student Health         Preferred Provider In-Network                      Out-of-Network     Limits
                       Responsibility for     Responsibility     Responsibility for              Responsibility for
                       Cost-Sharing           For Cost-Sharing Cost-Sharing                      Cost-Sharing

• Mammography
  Screening and
  Diagnostic
  Imaging for the
  Detection of
  Breast Cancer

       Students        N/A                    N/A                      Covered in full           40% Coinsurance

       Dependents      N/A                    N/A                      Covered in full           40% Coinsurance

• Sterilization
  Procedures for
  Women*

       Students        N/A                    N/A                      Covered in full           40% Coinsurance

       Dependents      N/A                    N/A                      Covered in full           40% Coinsurance

•   Vasectomy

       Students        N/A                    N/A                      Covered in full           40% Coinsurance

       Dependents      N/A                    N/A                      Covered in full           40% Coinsurance

•   Bone Density
    Testing*

       Students        N/A                    N/A                      Covered in full           40% Coinsurance

       Dependents      N/A                    N/A                      Covered in full           40% Coinsurance

• Screening for
  Prostate Cancer

       Students        Covered in full        N/A                      Covered in full           40% Coinsurance

       Dependents      N/A                    N/A                      Covered in full           40% Coinsurance

                                                                                                                      27
                                     Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PREVENTIVE CARE            Student Health         Preferred Provider In-Network                     Out-of-Network     Limits
                           Responsibility for     Responsibility     Responsibility for             Responsibility for
                           Cost-Sharing           For Cost-Sharing Cost-Sharing                     Cost-Sharing

•   All other preventive
    services required by
    USPSTF and HRSA.

        Students           Covered in full        N/A                     Covered in full           40% Coinsurance

        Dependents         N/A                    N/A                     Covered in full           40% Coinsurance

• *When preventive         Use Cost Sharing for   Use Cost Sharing        Use Cost Sharing for Use Cost Sharing
  services are not         appropriate service    for appropriate         appropriate service for appropriate
  provided in              (Primary Care Office   service (Primary        (Primary Care Office service (Primary
  accordance with the      Visit;                 Care Office Visit;      Visit; Specialist Office Care Office Visit;
  comprehensive            Specialist Office      Specialist Office       Visit; Diagnostic        Specialist Office
  guidelines supported     Visit; Diagnostic      Visit; Diagnostic       Radiology Services;      Visit; Diagnostic
  by USPSTF and HRSA.      Radiology Services;    Radiology Services;     Laboratory Procedures Radiology Services;
                           Laboratory             Laboratory              & Diagnostic Testing) Laboratory
                           Procedures &           Procedures &                                     Procedures &
                           Diagnostic Testing)    Diagnostic Testing)                              Diagnostic Testing)

EMERGENCY CARE             Student Health         Preferred Provider      In-Network                Out-of-Network     Limits
                           Responsibility for     Responsibility          Responsibility for        Responsibility for
                           Cost-Sharing           for Cost-Sharing        Cost-Sharing              Cost-Sharing
Pre-Hospital               N/A                    N/A                     Covered in full           Covered in full    See Benefit
Emergency Medical                                                                                                      For
Services (Ambulance                                                                                                    Description
Services)
Non-Emergency              N/A                    N/A                     Covered in full           Covered in full      See Benefit
Ambulance Services                                                                                                       For
                                                                                                                         Description
Emergency                  N/A                    N/A                     $100 Copayment per $100 Copayment              See Benefit
Department                                                                Visit then         per Visit then              For
                                                                          10% Coinsurance    10% Coinsurance             Description

                                                                          Health care forensic
                                                                          examinations
                                                                          performed under
                                                                          Public Health Law §
                                                                          2805-I are not subject
                                                                          to Cost-Sharing
Urgent Care Center         N/A                    N/A                     $30 Copayment per 40% Coinsurance              See Benefit
                                                                          Visit then                                     For
                                                                          10% Coinsurance                                Description

                                                                                                                           28
                                        Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL                Student Health         Preferred Provider In-Network                      Out-of-Network     Limits
SERVICES AND                Responsibility         Responsibility     Responsibility for              Responsibility for
OUTPATIENT CARE             for Cost-Sharing       for Cost-Sharing Cost-Sharing                      Cost-Sharing
Advanced Imaging                                                                                                         See Benefit
Services                                                                                                                 For
                                                                                                                         Description
•    Performed in a         N/A                    N/A                      10% Coinsurance           40% Coinsurance
     Specialist Office

•   Performed in a          N/A                    N/A                      10% Coinsurance           40% Coinsurance
    Freestanding
    Radiology Facility

•   Performed as        N/A                        N/A                      $35 Copayment per         40% Coinsurance
    Outpatient Hospital                                                     Visit then
    Services                                                                10% Coinsurance

Preauthorization
Required

Allergy Testing &                                                                                                        See Benefit
Treatment                                                                                                                For
                                                                                                                         Description
•   Performed in a PCP 10% Coinsurance             N/A                      10% Coinsurance           40% Coinsurance
    Office

•   Performed in a          10% Coinsurance        N/A                      10% Coinsurance           40% Coinsurance
    Specialist Office

Ambulatory Surgical         N/A                    N/A                      $35 Copayment per         40% Coinsurance    See Benefit
Center Facility Fee                                                         Visit then                                   For
                                                                            10% Coinsurance                              Description
Preauthorization
Required

Anesthesia Services         N/A                    N/A                      10% Coinsurance           40% Coinsurance    See Benefit
(all settings)                                                                                                           For
                                                                                                                         Description
Preauthorization
Required

Autologous Blood            N/A                    N/A                      10% Coinsurance           40% Coinsurance    See Benefit
Banking                                                                                                                  For
                                                                                                                         Description

                                                                                                                           29
                                          Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
NEW YORK UNIVERSITY • WASHINGTON SQUARE • 2020 - 2021 STUDENT HEALTH INSURANCE PLAN

PROFESSIONAL               Student Health         Preferred Provider In-Network                      Out-of-Network     Limits
SERVICES AND               Responsibility         Responsibility     Responsibility for              Responsibility for
OUTPATIENT CARE            for Cost-Sharing       for Cost-Sharing Cost-Sharing                      Cost-Sharing
Cardiac &                                                                                                               See Benefit
Pulmonary                                                                                                               For
Rehabilitation                                                                                                          Description

• Performed in a           N/A                    N/A                      $30 Copayment per         40% Coinsurance
  Specialist Office                                                        Visit then
                                                                           10% Coinsurance

• Performed as        N/A                         N/A                      $35 Copayment per         40% Coinsurance
  Outpatient Hospital                                                      Visit then
  Services                                                                 10% Coinsurance

• Performed as             N/A                    N/A                      Included As Part of       Included As Part of
  Inpatient Hospital                                                       Inpatient Hospital        Inpatient Hospital
  Services                                                                 Service Cost-Sharing      Service Cost-
                                                                                                     Sharing

Chemotherapy                                                                                                               See Benefit
 • Performed in a PCP N/A                         N/A                      10% Coinsurance           40% Coinsurance       For
   Office                                                                                                                  Description

• Performed in a           N/A                    N/A                      10% Coinsurance           40% Coinsurance
  Specialist Office

• Performed as        N/A                         N/A                      $35 Copayment per         40% Coinsurance
  Outpatient Hospital                                                      Visit then
  Services                                                                 10% Coinsurance

Preauthorization
Required

Chiropractic Services      N/A                    N/A                      $30 Copayment per         40% Coinsurance       See Benefit
                                                                           Visit then                                      For
Preauthorization                                                           10% Coinsurance                                 Description
Required

Clinical Trials            Use Cost-Sharing for N/A                        Use Cost-Sharing for      Use Cost-Sharing      See Benefit
                           appropriate service                             appropriate service       for appropriate       For
                                                                                                     service               Description

                                                                                                                             30
                                         Wellfleet Student PO Box 15369 Springfield, MA 01115-5369
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