University of Missouri St. Louis - International Students
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Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Aetna Student HealthSM Plan Design and Benefits Summary Preferred Provider Organization (PPO) University of Missouri St. Louis – International Students Policy Year: 2020 – 2021 Policy Number: 890440 www.aetnastudenthealth.com (877) 375-7905
Special Missouri Notice
An enrollee who is a member of a group health plan with coverage for elective abortions has the right to exclude
and not pay for coverage for elective abortions if such coverage is contrary to his or her moral, ethical or religious
beliefs.
Your group contract holder has not purchased an optional rider for elective abortions pursuant to VAMS section
376.805.
This is a brief description of the Student Health Plan. The Plan is available for University of Missouri System
students and their eligible dependents. The Plan is underwritten by Aetna Life Insurance Company (Aetna). The
exact provisions, including definitions, governing this insurance are contained in the Certificate of Coverage issued
to you and may be viewed online at www.aetnastudenthealth.com. If there is a difference between this Benefit
Summary and the Certificate of Coverage, the Certificate will control.
Coverage Periods
Students: Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below and will
terminate at 11:59 PM on the Coverage End Date indicated.
Coverage Period Coverage Start Date Coverage End Date Enrollment Deadline
Annual 08/01/2020 07/31/2021 09/06/2020
Fall 08/01/2020 12/31/2020 09/06/2020
Spring/Summer 01/01/2021 07/31/2021 02/07/2021
Summer 06/01/2021 07/31/2021 06/05/2021
Eligible Dependents: Coverage will become effective at 12:01 AM on the Coverage Start Date indicated below and
will terminate at 11:59 PM on the Coverage End Date indicated. Coverage for insured dependents terminates in
accordance with the Termination Provisions described in the Master Policy.
Coverage Period Coverage Start Date Coverage End Date Enrollment Deadline
Annual 08/01/2020 07/31/2021 09/06/2020
Fall 08/01/2020 12/31/2020 09/06/2020
Spring/Summer 01/01/2021 07/31/2021 02/07/2021
Summer 06/01/2021 07/31/2021 06/05/2021
University of Missouri – St. Louis 2020-2021 Page 2
Rates
The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna) as well
as the University of Missouri – St. Louis administrative fee.
Coverage Period Annual Fall Spring/Summer Summer
Student $2,307 $967 $1,340 $385
Student & Spouse $4,494 $1,884 $2,610 $750
Student & Child(ren) $4,494 $1,884 $2,610 $750
Student, Spouse & $6,681 $2,801 $3,880 $1,115
Child(ren)
Student Coverage
Eligibility
All non-immigrant international students, scholars, and Optional Practical Training/Academic Training (OPT)
participants holding F or J visas are eligible for this coverage. Enrollment in this Plan is mandatory and automatic for
all F and J visa holders upon academic enrollment each semester.
Students in online programs are not eligible to enroll in the Plan.
During the 20/21 plan year, students who meet the eligibility requirements but are required to take online courses
either remotely or on campus due to the Covid-19 pandemic, will be eligible to enroll in the Plan.
Enrollment
Non-immigrant international students on F-1 and J-1 visas is mandatory and automatic upon academic enrollment
each semester unless you have coverage under a government-sponsored insurance program and provide proof of
coverage. Premium payment is made to UMSL in the Cashier’s Office.
Enrollment for Scholars and post-completion Optional Practical Training/Academic Training (OPT) participants is
optional and requires completion of an enrollment form each term. Visiting Scholars may obtain enrollment forms
at the Office of International Student and Scholar Services. OPT students may enroll online at
www.aetnastudenthealth.com, choose the University of Missouri – St. Louis, click on View Your School and click
on the Enroll link on the left hand side of the screen to select the appropriate application.
Dependent Coverage
Eligibility
Covered students may also enroll their lawful spouse and/or dependent children up to the age of 26.
Enrollment
Students can also enroll eligible dependents online by visiting www.aetnastudenthealth.com, choose the
University of Missouri – St. Louis, click on View Your School and click on the Enroll link on the left hand side of the
screen. Please refer to the Coverage Periods section of this document for coverage dates and deadline dates.
Dependent enrollment applications will not be accepted after the enrollment deadline, unless there is a significant
life change that directly affects their insurance coverage. (An example of a significant life change would be loss of
health coverage under another health plan). The completed Enrollment Form and premium must be sent to Aetna
Student Health. Please contact the International Student Affairs Office or customer service at (877) 375-7905 to
request an Enrollment Form.
University of Missouri – St. Louis 2020-2021 Page 3
Important note regarding coverage for a newborn infant or newly adopted child:
• A newborn child - Your newborn child born to or adopted by you, is covered on your health plan for the first 31
days from the moment of birth.
- To keep your newborn covered, you must notify us (or our agent) of the birth and pay any required premium
contribution during that 31-day period.
- You must still enroll the child within 31 days of birth even when coverage does not require payment of an
additional premium contribution for the newborn.
- If you miss this deadline, your newborn will not have health benefits after the first 31 days.
- When you tell us of the newborn’s birth, we will send you the forms and instructions to enroll your newborn. We
will also give you an additional ten (10) days from the date we provide these forms to enroll your newborn child.
Your newborn will be covered for treatment of injury or illness, including medically diagnosed congenital
defects and birth abnormalities.
- If your coverage ends during this 31-day period, then your newborn‘s coverage will end on the same date as
your coverage. This applies even if the 31-day period has not ended.
• An adopted child or a child legally placed with you for adoption - A child that you, or that you and your spouse,
adopts or is placed with you for adoption is covered on your plan for the first 31 days from the date of birth or the
date of placement in your home, if a petition for adoption is filed within 31 days of the date of birth, or within 31
days from the date of placement in your home. The child will continue to be considered adopted unless she or he
is removed from your home prior to issuance of a legal decree of adoption. Placement means “in the physical
custody of the adoptive parent.” Coverage includes the necessary care and treatment of medical conditions
existing prior to the date of placement.
- To keep your adopted child covered, we must receive your completed enrollment information within 31 days
from the date of placement for adoption or the final decree of adoption, whichever is earliest.
- You must still enroll the child within 31 days of the adoption or placement for adoption even when coverage
does not require payment of an additional premium contribution for the child.
- If you miss this deadline, your adopted child or child placed with you for adoption will not have health benefits
after the first 31 days.
- If your coverage ends during this 31-day period, then coverage for your adopted child or child placed with you
for adoption will end on the same date as your coverage. This applies even if the 31-day period has not ended.
If you need information or have general questions on dependent enrollment, call Member Services at (877) 375-
7905.
Medicare Eligibility Notice
You are not eligible to enroll in the student health plan if you have Medicare at the time of enrollment in this
student plan. The plan does not provide coverage for people who have Medicare.
University of Missouri – St. Louis 2020-2021 Page 4Termination and Refunds Withdrawal from Classes – Leave of Absence: If you withdraw from classes under a school-approved leave of absence, your coverage will remain in force through the end of the period for which payment has been received and no premiums will be refunded. Withdrawal from Classes – Other than Leave of Absence: If you withdraw from classes other than under a school-approved leave of absence within 31 days after the policy effective date, you will be considered ineligible for coverage, your coverage will be terminated retroactively and any premiums collected will be refunded. If the withdrawal is more than 31 days after the policy effective date, your coverage will remain in force through the end of the period for which payment has been received and no premiums will be refunded. If you withdraw from classes to enter the armed forces of any country, coverage will terminate as of the effective date of such entry and a pro rata refund of premiums will be made if you submit a written request within 90 days of withdrawal from classes. In-network Provider Network Aetna Student Health offers Aetna’s broad network of In-network Providers. You can save money by seeing In- network Providers because Aetna has negotiated special rates with them, and because the Plan’s benefits are better. If you need care that is covered under the Plan but not available from an In-network Provider, contact Member Services for assistance at the toll-free number on the back of your ID card. In this situation, Aetna may issue a pre- approval for you to receive the care from an Out-of-network Provider. When a pre-approval is issued by Aetna, the benefit level is the same as for In-network Providers. Precertification You need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Your in- network physician is responsible for obtaining any necessary precertification before you get the care. When you go to an out-of-network provider, it is your responsibility to obtain precertification from us for any services and supplies on the precertification list. If you do not precertify when required, there is a $500 penalty for each type of eligible health service that was not precertified. For a current listing of the health services or prescription drugs that require precertification, contact Member Services or go to www.aetnastudenthealth.com. Aetna will not retroactively reduce or terminate a previously approved service or supply unless: • Such authorization is based on a material misrepresentation or omission about the treated or cause of the health condition or • The plan terminated before services are provided; or • Coverage terminated before the services were provided. University of Missouri – St. Louis 2020-2021 Page 5
Precertification Call
Precertification should be secured within the timeframes specified below. To obtain precertification, call Member
Services at the toll-free number on your ID card. This call must be made:
Non-emergency admissions: You, your physician or the facility will need to call and request
precertification at least 14 days before the date you are scheduled to be
admitted.
An emergency admission: You, your physician or the facility must call within 48 hours or as soon as
reasonably possible after you have been admitted.
An urgent admission: You, your physician or the facility will need to call before you are
scheduled to be admitted. An urgent admission is a hospital admission by
a physician due to the onset of or change in an illness, the diagnosis of an
illness, or an injury.
Outpatient non-emergency services You or your physician must call at least 14 days before the outpatient care
requiring precertification: is provided, or the treatment or procedure is scheduled.
Access to Obstetrical and Gynecological (Ob/Gyn) Care
You do not need pre-certification from Aetna or from any other person (including a Primary Care Provider) in order
to obtain access or make an appointment to receive obstetrical or gynecological care from a health care
professional in Aetna’s Network who specializes in obstetrics or gynecology. The health care professional, however,
may recommend certain elective medical procedures that may require pre-certification. Preventive care services do
not require pre-certification.
Please see the “Pre-certification” provision in the Certificate of Coverage for a list of services under the Plan that
require pre-certification. Please see the Schedule of Benefits for any penalty or benefit reduction that may apply to
your coverage when pre-certification is not obtained for the listed services or supplies when received from a non-
preferred care provider.
We will provide a written notification to you and your physician of the precertification decision, where required by
state law. If your precertified services are approved, the approval is valid for 30 days as long as you remain enrolled
in the plan.
Coordination of Benefits (COB)
Some people have health coverage under more than one health plan. If you do, we will work together with your
other plan(s) to decide how much each plan pays. This is called coordination of benefits (COB). A complete
description of the Coordination of Benefits provision is contained in the certificate issued to you.
University Health, Counseling & Disability Access Services (HCDAS)
The student health insurance plan is designed to work with your campus student health center. Out-of-pocket costs
are generally lower at the student health center and the location is ideal for students to seek care.
Health, Counseling, and Disability Access Services (HCDAS) is the University’s on campus health facility and is
committed to providing high quality health care for UMSL students. HCDAS is staffed by a board-certified family
nurse practitioner, physician assistant and registered nurse, as well as collaborative care with primary care
physicians.
University of Missouri – St. Louis 2020-2021 Page 6Services offered at HCDAS include:
• Vaccinations and screenings
• Physical exams
• Chronic health management
• Treatment for accidents and illnesses
Students can schedule appointments by calling (314) 516-5671 or through the online portal:
https://health.umsl.edu
Description of Benefits
The Plan excludes coverage for certain services and has limitations on the amounts it will pay. While this Plan
Summary document will tell you about some of the important features of the Plan, other features that may be
important to you are defined in the Certificate. To look at the full Plan description, which is contained in the
Certificate issued to you, go to www.aetnastudenthealth.com.
This Plan will pay benefits in accordance with any applicable Missouri Insurance Law(s).
Policy year deductible In-network coverage Out-of-network coverage
Student $400 per policy year $800 per policy year
Spouse $400 per policy year $800 per policy year
Each child $400 per policy year $800 per policy year
This is the amount you owe for in-network and out-of-network eligible health services each policy year before the
plan begins to pay for eligible health services. See the Policy year deductibles provision at the beginning of this
schedule for any exceptions to this general rule. This policy year deductible applies separately to you and each of
your covered dependents. After the amount you pay for eligible health services reaches the policy year
deductible, this plan will begin to pay for eligible health services for the rest of the policy year.
Eligible health services applied to the out-of-network policy year deductibles will not be applied to satisfy the in-
network policy year deductibles. Eligible health services applied to the in-network policy year deductibles will not
be applied to satisfy the out-of-network policy year deductibles.
Policy year deductible waiver
The policy year deductible is waived for all of the following eligible health services:
• In-network care for Preventive care and wellness, Family planning services - female contraceptives, and
Pediatric Dental Services.
• In-network care and out-of-network care for immunizations for children under five years of age, Prescribed
Medicines Expense, and Pediatric Vision Services.
Maximum out-of-pocket limit per policy year
Student $7,500 per policy year None
Spouse $7,500 per policy year None
Each child $7,500 per policy year None
Family $15,000 per policy year None
Eligible health services applied to the out-of-network maximum out-of-pocket limit will not be applied to satisfy
the in-network maximum out-of-pocket limit and eligible health services applied to the in-network maximum out-
of-pocket limit will not be applied to satisfy the out-of-network maximum out-of-pocket limit.
University of Missouri – St. Louis 2020-2021 Page 7Eligible health services In-network coverage Out-of-network coverage
Routine physical exams
Performed at a physician’s office 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Maximum age and visit limits per policy Subject to any age and visit limits provided for in the
year through age 21 comprehensive guidelines supported by the American Academy of
Pediatrics/Bright Futures/Health Resources and Services
Administration guidelines for children and adolescents.
Maximum visits per policy year age 22 and 1 visit
over
Preventive care immunizations
Performed in a facility or at a physician's 100% (of the negotiated charge) 70% (of the recognized charge)
office per visit per visit
No copayment or policy year Covered 100% for children up
deductible applies to 5 years of age. Deductible &
coinsurance applies thereafter.
Maximums Subject to any age limits provided for in the comprehensive
guidelines supported by Advisory Committee on Immunization
Practices of the Centers for Disease Control and Prevention.
Routine gynecological exams (including Pap smears and cytology tests)
Performed at a physician’s, obstetrician 100% (of the negotiated charge) 70% (of the recognized charge)
(OB), gynecologist (GYN) or OB/GYN office per visit per visit
No copayment or policy year
deductible applies
Maximum visits per policy year 1 visit
Child health supervision services & Well Covered according to the type Covered according to the type
baby of benefit and the place where of benefit and the place where
the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Maximum visits • Limited to 7 exams in the first 12 months
• Limited to 3 exams in the second 12 months
• Limited to 3 exams in the third 12 months
• Limited to 1 exam thereafter per policy year benefit maximum
University of Missouri – St. Louis 2020-2021 Page 8Eligible health services In-network coverage Out-of-network coverage
Early intervention services office visit for Covered according to the type Covered according to the type
children from birth to age 3 of benefit and the place where of benefit and the place where
the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Preventive screening and counseling services
Preventive screening and counseling 100% (of the negotiated charge) 70% (of the recognized charge)
services for Obesity and/or healthy diet per visit per visit
counseling, Misuse of alcohol & drugs,
Tobacco Products, Depression Screening, No copayment or policy year
Sexually transmitted infection counseling & deductible applies
Genetic risk counseling for breast and
ovarian cancer
Obesity/Healthy Diet maximum per policy 26 visits (10 visits will be allowed under the plan for healthy diet
year (Applies to covered persons age 22 counseling provided in connection with Hyperlipidemia (high
and older) cholesterol) and other known risk factors for cardiovascular and
diet-related chronic disease)
Misuse of Alcohol maximum per policy year 5 visits
Tobacco Products Counseling maximum 8 visits
per policy year
Depression screening maximum per policy 1 visit
year
STI maximum per policy year 2 visits
Age and frequency limitations Not subject to any age or frequency limitations
Lead poisoning screening Covered according to the type Covered according to the type
of benefit and the place where of benefit and the place where
the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Routine cancer screenings 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Maximums Subject to any age; family history; and frequency guidelines as set
forth in the most current:
• Evidence-based items that have in effect a rating of A or B in the
current recommendations of the United States Preventive
Services Task Force; and
(continued next page) • The comprehensive guidelines supported by the Health
Resources and Services Administration.
University of Missouri – St. Louis 2020-2021 Page 9Eligible health services In-network coverage Out-of-network coverage
Mammogram maximums Age 35 and older; subject to any family history; and frequency
guidelines as set forth in the most current:
• Evidence-based items that have in effect a rating of A or B in the
current recommendations of the United States Preventive
Services Task Force and
• The comprehensive guidelines supported by the Health
Resources and Services Administration; or
• State law (where stricter).
For details, contact your physician or Member Services by logging
onto your Aetna secure member website at
www.aetnastudenthealth.com or calling the toll-free number on
your ID card in the How to contact us for help section.
Lung cancer screening maximum 1 screening every 12 months
Prenatal care services (Preventive care 100% (of the negotiated charge) 70% (of the recognized charge)
services only) per visit per visit
No copayment or policy year
deductible applies
Lactation support and counseling services 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or policy year
deductible applies
Lactation counseling services maximum per 6 visits
policy year
Breast pump supplies and accessories 100% (of the negotiated charge) 70% (of the recognized charge)
per item per item
No copayment or policy year
deductible applies
Contraceptive counseling services office 100% (of the negotiated charge) 70% (of the recognized charge)
visit per visit per visit
No copayment or policy year
deductible applies
Contraceptive counseling services 2 visits
maximum per policy year
Contraceptive prescription drugs and 100% (of the negotiated charge) 70% (of the recognized charge)
devices per item per item
No copayment or policy year
deductible applies
University of Missouri – St. Louis 2020-2021 Page 10Eligible health services In-network coverage Out-of-network coverage
Voluntary sterilization - Inpatient & 100% (of the negotiated charge) 70% (of the recognized charge)
Outpatient provider services
No copayment or policy year
deductible applies
Physicians and other health professionals
Physician, specialist including Consultants $20 copayment then the plan 50% (of the recognized charge)
Office visits (non-surgical/non-preventive pays 80% (of the balance of the per visit
care by a physician and specialist) negotiated charge) per visit
thereafter
Includes telemedicine consultations
Allergy testing and treatment
Allergy testing & Allergy injections Covered according to the type Covered according to the type
treatment, including Allergy sera and of benefit and the place where of benefit and the place where
extracts administered via injection, the service is received. Refer to the service is received. Refer to
performed at a physician’s or specialist’s the specific cost-sharing in this the specific cost-sharing in this
office schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Physician and specialist - surgical services
Inpatient surgery performed during your 80% (of the negotiated charge) 50% (of the recognized charge)
stay in a hospital or birthing center by a
surgeon (includes anesthetist and surgical
assistant expenses)
Outpatient surgery performed at a 80% (of the negotiated charge) 50% (of the recognized charge)
physician’s or specialist’s office or per visit per visit
outpatient department of a hospital or
surgery center by a surgeon (includes
anesthetist and surgical assistant expenses)
Alternatives to physician office visits
Walk-in clinic visits (non-emergency visit) $20 copayment then the plan 50% (of the recognized charge)
pays 80% (of the balance of the per visit
negotiated charge) per visit
thereafter
Hospital and other facility care
Inpatient hospital (room and board) and $200 copayment then the plan 50% (of the recognized charge)
other miscellaneous services and supplies) pays 80% (of the balance of the per admission
negotiated charge) per
Includes birthing center facility charges admission
In-hospital non-surgical physician services 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
University of Missouri – St. Louis 2020-2021 Page 11Eligible health services In-network coverage Out-of-network coverage
Alternatives to hospital stays
Outpatient surgery (facility charges) 80% (of the negotiated charge) 50% (of the recognized charge)
performed in the outpatient department of per visit per visit
a hospital or surgery center
Home health Care 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Hospice - Inpatient 80% (of the negotiated charge) 50% (of the recognized charge)
per admission per admission
Hospice - Outpatient 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Outpatient private duty nursing 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Skilled nursing facility - Inpatient $200 copayment then the plan 50% (of the recognized charge)
pays 80% (of the balance of the per admission
negotiated charge) per
admission
Hospital emergency room $100 copayment then the plan Paid the same as in-network
pays 80% (of the balance of the coverage
negotiated charge) per visit
Non-emergency care in a hospital Not covered Not covered
emergency room
Important note:
• As out-of-network providers do not have a contract with us the provider may not accept payment of your
cost share, (copayment/coinsurance), as payment in full. You may receive a bill for the difference between
the amount billed by the provider and the amount paid by this plan. If the provider bills you for an
amount above your cost share, you are not responsible for paying that amount. You should send the bill
to the address listed on the back of your ID card, and we will resolve any payment dispute with the
provider over that amount. Make sure the ID card number is on the bill.
• A separate hospital emergency room copayment/coinsurance will apply for each visit to an emergency
room. If you are admitted to a hospital as an inpatient right after a visit to an emergency room, your
emergency room copayment/coinsurance will be waived and your inpatient copayment/coinsurance will
apply.
• Covered benefits that are applied to the hospital emergency room copayment/coinsurance cannot be
applied to any other copayment/coinsurance under the plan. Likewise, a copayment/coinsurance that
applies to other covered benefits under the plan cannot be applied to the hospital emergency room
copayment/coinsurance.
• Separate copayment/coinsurance amounts may apply for certain services given to you in the hospital
emergency room that are not part of the hospital emergency room benefit. These
copayment/coinsurance amounts may be different from the hospital emergency room
copayment/coinsurance. They are based on the specific service given to you.
• Services given to you in the hospital emergency room that are not part of the hospital emergency room
benefit may be subject to copayment/coinsurance amounts that are different from the hospital
emergency room copayment/coinsurance amounts.
University of Missouri – St. Louis 2020-2021 Page 12Eligible health services In-network coverage Out-of-network coverage
Urgent Care 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Non-urgent use of urgent care provider Not covered Not covered
Pediatric dental care
(Limited to covered persons through the end of the month in which the person turns age 19)
Type A services 100% (of the negotiated charge) 70% (of the recognized charge)
per visit per visit
No copayment or deductible
applies
Type B services 70% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible
applies
Type C services 50% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible
applies
Orthodontic services 50% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
No policy year deductible
applies
Dental emergency treatment Covered according to the type Covered according to the type
of benefit and the place where of benefit and the place where
the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Specific Conditions
Diabetic services and supplies (including Covered according to the type Covered according to the type
equipment and training) of benefit and the place where of benefit and the place where
the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Impacted wisdom teeth 80% (of the negotiated charge) 80% (of the recognized charge)
Accidental injury to sound natural teeth 80% (of the negotiated charge) 80% (of the recognized charge)
University of Missouri – St. Louis 2020-2021 Page 13Eligible health services In-network coverage Out-of-network coverage
Maternity care
Maternity care (includes delivery and Covered according to the type Covered according to the type
postpartum care services in a hospital or of benefit and the place where of benefit and the place where
birthing center) the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Well newborn nursery care in a hospital or 80% (of the negotiated charge) 50% (of the recognized charge)
birthing center
No policy year deductible applies No policy year deductible applies
Family planning services – other
Voluntary sterilization for males - surgical 100% (of the negotiated charge) 70% (of the recognized charge)
services
No policy year deductible applies
Gender reassignment (sex change) treatment
Surgical, hormone replacement therapy, Covered according to the type Covered according to the type
and counseling treatment of benefit and the place where of benefit and the place where
the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Autism spectrum disorder
Autism spectrum disorder treatment, Covered according to the type Covered according to the type
diagnosis and testing and Applied behavior of benefit and the place where of benefit and the place where
analysis the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Physical, occupational, and speech therapy 80% (of the negotiated charge) 50% (of the recognized charge)
associated with diagnosis of autism per visit per visit
spectrum disorder
The copayment or coinsurance for any
physical therapy and occupational therapy
services under this benefit will be no
greater than a physician’s office visit copay
University of Missouri – St. Louis 2020-2021 Page 14Eligible health services In-network coverage Out-of-network coverage
Mental Health & Substance Abuse Treatment
Inpatient hospital $200 copayment then the plan 50% (of the recognized charge)
(room and board and other miscellaneous pays 80% (of the balance of the per admission
hospital services and supplies) negotiated charge) per
admission
Outpatient office visits $20 copayment then the plan 50% (of the recognized charge)
(includes telemedicine consultations) pays 80% (of the balance of the per visit
negotiated charge) per visit
thereafter
Other outpatient treatment (includes Partial 80% (of the negotiated charge) 50% (of the recognized charge)
hospitalization and Intensive Outpatient per visit per visit
Program)
Eligible health In-network coverage - In-network coverage - Out-of-network
services Network (IOE facility) Network (Non-IOE coverage
facility)
Transplant services Covered according to the type of benefit and the place where the service is received.
Inpatient and outpatient Refer to the specific cost-sharing in this schedule of benefits that applies to the type
facility services of expense that you incurred
Transplant services Covered according to the type of benefit and the place where the service is received.
Inpatient and outpatient Refer to the specific cost-sharing in this schedule of benefits that applies to the type
physician and specialist of expense that you incurred
services
Maximum Benefit for $30,000 per transplant
donor searches for bone
marrow/ stem cell
transplants for a covered
Transplant procedure
Maximum Benefit for $100,000 per transplant
Dose intensive
chemotherapy/autologous
bone marrow transplants
for stem cell transplants
for breast cancer
treatment incurred while
covered under any Aetna
or Aetna-affiliated plan:
Human Leukocyte Antigen Covered according to the type of benefit and the place where the service is received.
Testing for A, B and DR Refer to the specific cost-sharing in this schedule of benefits that applies to the type
Antigens: of expense that you incurred
University of Missouri – St. Louis 2020-2021 Page 15Eligible health services In-network coverage Out-of-network coverage
Basic infertility services Covered according to the type Covered according to the type
of benefit and the place where of benefit and the place where
the service is received. Refer to the service is received. Refer to
the specific cost-sharing in this the specific cost-sharing in this
schedule of benefits that schedule of benefits that
applies to the type of expense applies to the type of expense
that you incurred that you incurred
Specific therapies and tests
Outpatient diagnostic testing
Diagnostic complex imaging services 80% (of the negotiated charge) 50% (of the recognized charge)
performed in the outpatient department of per visit per visit
a hospital or other facility
Diagnostic lab work and radiological 80% (of the negotiated charge) 50% (of the recognized charge)
services performed in a physician’s office, per visit per visit
the outpatient department of a hospital or
other facility
Outpatient Chemotherapy, Radiation & 80% (of the negotiated charge) 50% (of the recognized charge)
Respiratory Therapy per visit per visit
Important Note: Coverage for orally
administered anti-cancer medication will be
provided under the same terms and
conditions as intravenously administered or
injected anti-cancer medication.
Outpatient physical, occupational, speech, 80% (of the negotiated charge) 50% (of the recognized charge)
and cognitive therapies (including Cardiac per visit per visit
and Pulmonary Therapy)
Includes speech & Hearing
Combined for short-term rehabilitation
services and habilitation therapy services
The copayment or coinsurance for any
physical therapy and occupational therapy
services will be no greater than a
physician’s office visit copay
Chiropractic care 80% per visit 50% per visit
Other services and supplies
Emergency ground, air, and water 80% (of the negotiated charge) Paid the same as in-network
ambulance per trip coverage
Durable medical and surgical equipment 80% (of the negotiated charge) 50% (of the recognized charge
per item per item
Enteral formulas and nutritional 80% (of the negotiated charge) 50% (of the recognized charge
supplements per item per item
University of Missouri – St. Louis 2020-2021 Page 16Eligible health services In-network coverage Out-of-network coverage
Other services and supplies (continued)
Prosthetic Devices 80% (of the negotiated charge) 50% (of the recognized charge
per item per item
Includes cranial prosthetics (medical wigs)
Cochlear implants 80% (of the negotiated charge) 50% (of the recognized charge
per item per item
Hearing aid exams 80% (of the negotiated charge) 50% (of the recognized charge)
per visit per visit
Hearing aid exam maximum One hearing exam every policy year
Hearing aids 80% (of the negotiated charge) 50% (of the recognized charge
per item per item
Hearing Aid Maximum per policy year One hearing aid per ear every policy year
Pediatric vision care
(Limited to covered persons through the end of the month in which the person turns age 19)
Pediatric routine vision exams (including 100% (of the negotiated charge) 70% (of the recognized charge)
refraction)-performed by a legally qualified per visit per visit
ophthalmologist or optometrist
No policy year deductible No policy year deductible
Includes visit for fitting of contact lenses applies applies
Maximum visits per policy year 1 visit
Fitting of contact Maximum 1visit
Comprehensive low vision evaluations Covered according to the type of benefit and the place where the
service is received. Refer to the specific cost-sharing in this
schedule of benefits that applies to the type of expense that you
incurred
Low vision Maximum One comprehensive low vision evaluation every policy year
Pediatric vision care services & supplies- 100% (of the negotiated charge) 70% (of the recognized charge)
Eyeglass frames, prescription lenses or per visit per visit
prescription contact lenses
No policy year deductible No policy year deductible
applies applies
Maximum number Per year:
Eyeglass frames One set of eyeglass frames
Prescription lenses One pair of prescription lenses
Contact lenses (includes non-conventional Daily disposables: up to 3-month supply
prescription contact lenses & aphakic Extended wear disposable: up to 6-month supply
lenses prescribed after cataract surgery) Non-disposable lenses: one set
*Important note: Refer to the Vision care section in the certificate of coverage for the explanation of these vision
care supplies. As to coverage for prescription lenses in a policy year, this benefit will cover either prescription
lenses for eyeglass frames or prescription contact lenses, but not both.
University of Missouri – St. Louis 2020-2021 Page 17Outpatient prescription drugs
Policy year copayment/coinsurance waiver for risk reducing breast cancer drugs
The policy year deductible and the per prescription copayment/coinsurance will not apply to risk reducing breast
cancer prescription drugs when obtained at a retail in-network pharmacy. This means that such risk reducing
breast cancer prescription drugs are paid at 100%.
Outpatient prescription drug policy year copayment waiver for tobacco cessation prescription
and over-the-counter drugs
The outpatient prescription drug copayment will not apply to the first two 90-day treatment regimens per
policy year for tobacco cessation prescription drugs and OTC drugs when obtained at a retail in-network
pharmacy. This means that such prescription drugs and OTC drugs are paid at 100%.
Your outpatient prescription drug copayment will apply after those two regimens per policy year have been
exhausted.
Outpatient prescription drug copayment waiver for contraceptives
The outpatient prescription drug copayment will not apply to female contraceptive methods when obtained at an
in-network pharmacy.
This means that such contraceptive methods are paid at 100% for:
• Certain over-the-counter (OTC) and generic contraceptive prescription drugs and devices for each of the
methods identified by the FDA. Related services and supplies needed to administer covered devices will
also be paid at 100%.
• If a generic prescription drug or device is not available for a certain method, you may obtain certain
brand-name prescription drug or device for that method paid at 100%.
The outpatient prescription drug copayment will continue to apply to prescription drugs that have a generic
equivalent, biosimilar or generic alternative available within the same therapeutic drug class obtained at an in-
network pharmacy unless you are granted a medical exception. The certificate of coverage explains how to get a
medical exception.
Eligible health services In-network coverage Out-of-network coverage
Preferred generic prescription drugs
For each fill up to a 30-day supply filled at a $15 copayment per supply then $15 copayment per supply then
retail pharmacy the plan pays 100% (of the the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
More than a 30-day supply but less than a $30 copayment per supply then $30 copayment per supply then
90-day supply filled at a mail order the plan pays 100% (of the the plan pays 100% (of the
pharmacy balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
University of Missouri – St. Louis 2020-2021 Page 18Eligible health services In-network coverage Out-of-network coverage
Outpatient prescription drugs (continued)
Preferred brand-name prescription drugs
For each fill up to a 30-day supply filled at a $40 copayment per supply then $40 copayment per supply then
retail pharmacy the plan pays 100% (of the the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
More than a 30-day supply but less than a $80 copayment per supply then $80 copayment per supply then
90-day supply filled at a mail order the plan pays 100% (of the the plan pays 100% (of the
pharmacy balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
Non-preferred generic prescription drugs
For each fill up to a 30-day supply filled at a $65 copayment per supply then $65 copayment per supply then
retail pharmacy the plan pays 100% (of the the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
More than a 30-day supply but less than a $130 copayment per supply $130 copayment per supply
90-day supply filled at a mail order then the plan pays 100% (of the then the plan pays 100% (of the
pharmacy balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
Non-preferred brand-name prescription drugs
For each fill up to a 30-day supply filled at a $65 copayment per supply then $65 copayment per supply then
retail pharmacy the plan pays 100% (of the the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
More than a 30-day supply but less than a $130 copayment per supply $130 copayment per supply
90-day supply filled at a mail order then the plan pays 100% (of the then the plan pays 100% (of the
pharmacy balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
University of Missouri – St. Louis 2020-2021 Page 19Eligible health services In-network coverage Out-of-network coverage
Outpatient prescription drugs (continued)
Specialty drugs
For each fill up to a 30-day supply filled at a $100 copayment per supply $100 copayment per supply
retail pharmacy then the plan pays 100% (of the then the plan pays 100% (of the
balance of the negotiated balance of the recognized
charge) charge)
No policy year deductible No policy year deductible
applies applies
Orally administered anti-cancer 100% (of the negotiated charge) 100% (of the recognized charge)
prescription drugs-
For each fill up to a 30-day supply filled at a No policy year deductible applies No policy year deductible applies
retail pharmacy
Preventive care drugs and supplements 100% (of the negotiated charge Paid according to the type of
filled at a retail pharmacy per prescription or refill drug per the schedule of
benefits, above
For each 30–day supply No copayment or policy year
deductible applies
Risk reducing breast cancer prescription 100% (of the negotiated charge) Paid according to the type of
drugs filled at a pharmacy per prescription or refill drug per the schedule of
benefits, above
For each 30–day supply No copayment or policy year
deductible applies
Maximums: Coverage will be subject to any sex, age, medical condition, family
history, and frequency guidelines in the recommendations of the
United States Preventive Services Task Force.
Tobacco cessation prescription drugs and 100% (of the negotiated charge Paid according to the type of
OTC drugs filled at a pharmacy per prescription or refill drug per the schedule of
benefits, above
For each 30–day supply No copayment or policy year
deductible applies
Maximums: Coverage is permitted for two 90-day treatment regimens only.
Coverage will be subject to any sex, age, medical condition, family
history, and frequency guidelines in the recommendations of the
United States Preventive Services Task Force.
A covered person, a covered person’s designee or a covered person’s prescriber may seek an expedited medical
exception process to obtain coverage for non-covered drugs in exigent circumstances. An “exigent circumstance”
exists when a covered person is suffering from a health condition that may seriously jeopardize a covered person’s
life, health, or ability to regain maximum function or when a covered person is undergoing a current course of
treatment using a non-formulary drug. The request for an expedited review of an exigent circumstance may be
submitted by contacting Aetna's Pre-certification Department at 1-855-240-0535, faxing the request to 1-877-269-
9916, or submitting the request in writing to:
University of Missouri – St. Louis 2020-2021 Page 20CVS Health ATTN: Aetna PA 1300 E Campbell Road Richardson, TX 75081 Exclusions Acupuncture therapy • Maintenance treatment • Acupuncture when provided for the following conditions: - Acute low back pain - Addiction - AIDS - Amblyopia - Allergic rhinitis - Asthma - Autism spectrum disorders - Bell’s Palsy - Burning mouth syndrome - Cancer-related dyspnea - Carpal tunnel syndrome - Chemotherapy-induced leukopenia - Chemotherapy-induced neuropathic pain - Chronic pain syndrome (e.g., RSD, facial pain) - Chronic obstructive pulmonary disease - Diabetic peripheral neuropathy - Dry eyes - Erectile dysfunction - Facial spasm - Fetal breech presentation - Fibromyalgia - Fibrotic contractures - Glaucoma - Hypertension - Induction of labor - Infertility (e.g., to assist oocyte retrieval and embryo transfer during IVF treatment cycle) - Insomnia - Irritable bowel syndrome - Menstrual cramps/dysmenorrhea - Mumps - Myofascial pain - Myopia - Neck pain/cervical spondylosis - Obesity - Painful neuropathies - Parkinson’s disease - Peripheral arterial disease (e.g., intermittent claudication) - Phantom leg pain - Polycystic ovary syndrome - Post-herpetic neuralgia University of Missouri – St. Louis 2020-2021 Page 21
- Psoriasis
- Psychiatric disorders (e.g., depression)
- Raynaud’s disease pain
- Respiratory disorders
- Rheumatoid arthritis
- Rhinitis
- Sensorineural deafness
- Shoulder pain (e.g., bursitis)
- Stroke rehabilitation (e.g., dysphagia)
- Tennis elbow/ epicondylitis
- Tension headache
- Tinnitus
- Tobacco Cessation
- Urinary incontinence
- Uterine fibroids
- Xerostomia
- Whiplash
Air or space travel
Traveling in, on or descending from any aircraft, including a hang glider, while the aircraft is in flight. This includes
descending by a parachute, wingsuit or any other similar device.
This exclusion does not apply if:
• You are traveling solely as a fare-paying passenger
• You are traveling on a licensed, commercial, regularly scheduled non-military aircraft
• You are traveling solely in a civil aircraft with a current valid “Standard Federal Aviation Agency Airworthiness
Certificate” and:
- The civil aircraft is piloted by a person with a current valid pilot’s certificate with proper ratings for the type of
flight and aircraft involved
- You are as a passenger with no duties at all on an aircraft used only to carry passengers or you are a pilot or a
part of the flight crew on an aircraft owned or leased by the policyholder performing duties for the policyholder
Alternative health care
Services and supplies given by a provider for alternative health care. This includes but is not limited to
aromatherapy, naturopathic medicine, herbal remedies, homeopathy, energy medicine, Christian faith-healing
medicine, Ayurvedic medicine, yoga, hypnotherapy, and traditional Chinese medicine.
Ambulance services
• Non-emergency transport by fixed wing air ambulance
• Non-emergency ambulance transports except as covered under the Eligible health services under your plan section
of this certificate of coverage
Armed Forces
Services and supplies received from a provider as a result of an injury sustained, or sickness contracted, while in the
service of the Armed Forces of any country. When you enter the Armed Forces of any country, we will refund any
unearned pro rata premium to the policyholder.
University of Missouri – St. Louis 2020-2021 Page 22Artificial organs Any device that would perform the function of a body organ. Behavioral health treatment Services for the following categories (or equivalent terms as listed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association): • School and/or education service including special education, remedial education, wilderness treatment programs, or any such related or similar programs, except for the treatment of autism spectrum disorder • Services provided in conjunction with school, vocation, work or recreational activities • Transportation Beyond legal authority Services and supplies provided by a health professional or other provider that is acting beyond the scope of its legal authority Blood and body fluid exposure Services and supplies provided for the treatment of an illness that results from your clinical related injury as these are covered elsewhere in the student policy Blood, blood plasma, synthetic blood, blood derivatives or substitutes except as specifically provided in the Eligible health services under your plan section. Examples of these are: • The provision of blood to the hospital, other than blood derived clotting factors • The services of blood donors, apheresis or plasmapheresis • For autologous blood donations, only administration and processing expenses are covered Breasts Services and supplies given by a provider for breast reduction or gynecomastia. Clinical trial therapies (experimental or investigational) Your plan does not cover clinical trial therapies (experimental or investigational), except as described in the Eligible health services under your plan - Clinical trial therapies (experimental or investigational) section Clinical trial therapies (routine patient costs) • Services and supplies related to data collection and record-keeping that is solely needed due to the clinical trial (i.e. protocol-induced costs) • Services and supplies provided by the trial sponsor without charge to you • The experimental intervention itself (except medically necessary Category B investigational devices and promising experimental and investigational interventions for terminal illnesses in certain clinical trials in accordance with Aetna’s claim policies) • In-network coverage limited to benefits for routine patient services provided within the network Cartilage transplants Cartilage (autologous chondrocyte implant or osteochondral allograft or autograft) transplants Cornea or cartilage transplants • Cornea (corneal graft with amniotic membrane) • Cartilage (autologous chondrocyte implant or osteochondral allograft or autograft) transplants University of Missouri – St. Louis 2020-2021 Page 23
Cosmetic services and plastic surgery Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or enhance the shape or appearance of the body whether or not for psychological or emotional reasons. This cosmetic services exclusion does not apply to surgery after an accidental injury when performed as soon as medically feasible. Injuries that occur during medical treatments are not considered accidental injuries even if unplanned or unexpected. Court-ordered services and supplies This Includes court-ordered services and supplies, or those required as a condition of parole, probation, release or as a result of any legal proceeding, unless they are a covered benefit under your plan. Custodial care Examples are: • Routine patient care such as changing dressings, periodic turning and positioning in bed • Administering oral medications • Care of a stable tracheostomy (including intermittent suctioning) • Care of a stable colostomy/ileostomy • Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings • Care of a bladder catheter (including emptying/changing containers and clamping tubing) • Watching or protecting you • Respite care, adult (or child) day care, or convalescent care • Institutional care. This includes room and board for rest cures, adult day care and convalescent care • Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods • Any other services that a person without medical or paramedical training could be trained to perform • Any service that can be performed by a person without any medical or paramedical training Dermatological treatment Cosmetic treatment and procedures Dental care for adults Dental services for adults including services related to: • The care, filling, removal or replacement of teeth and treatment of injuries to or diseases of the teeth • Dental services related to the gums • Apicoectomy (dental root resection) • Orthodontics • Root canal treatment • Soft tissue impactions • Alveolectomy • Augmentation and vestibuloplasty treatment of periodontal disease • False teeth • Prosthetic restoration of dental implants • Dental implants This exception does not include removal of bony impacted teeth, bone fractures, removal of tumors, and odontogenic cysts. University of Missouri – St. Louis 2020-2021 Page 24
Durable medical equipment (DME)
Examples of these items are:
• Whirlpools
• Portable whirlpool pumps
• Sauna baths
• Massage devices
• Over bed tables
• Elevators
• Communication aids
• Vision aids
• Telephone alert systems
• Personal hygiene and convenience items such as air conditioners, humidifiers, hot tubs, or physical exercise
equipment even if they are prescribed by a physician
Educational services
Examples of these services are:
• Any service or supply for education, training or retraining services or testing, except where described in the
Eligible health services under your plan – Diabetic services and supplies (including equipment and training) section. This
includes:
- Special education
- Remedial education
- Wilderness treatment programs (whether or not the program is part of a residential treatment facility or
otherwise licensed institution)
- Job training
- Job hardening programs
• Educational services, schooling or any such related or similar program, including therapeutic programs within a
school setting, except for the treatment of autism spectrum disorders.
Elective treatment or elective surgery
Elective treatment or elective surgery except as specifically covered under the student policy and provided while the
student policy is in effect
Enteral formulas and nutritional supplements
Any food item, including infant formulas, vitamins, plus prescription vitamins, medical foods and other nutritional
items, even if it is the sole source of nutrition, except as covered in the Eligible health services under your plan –
Enteral formulas and nutritional supplements section
Examinations
Any health or dental examinations needed:
• Because a third party requires the exam. Examples are, examinations to get or keep a job, or examinations
required under a labor agreement or other contract
• Because a law requires it
• To buy insurance or to get or keep a license
• To travel
• To go to a school, camp, or sporting event, or to join in a sport or other recreational activity
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