University of Southern Maine
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1 Quality health plans & benefits Healthier living Financial well-being Intelligent solutions University of Southern Maine Student Health Insurance Plan Highlights Policy Number: What is the Plan about? Cross Insurance and Aetna Student Health, working with the University of Southern Maine offers a student-focused health insurance plan that covers students at school and at home. You get access to Aetna s nationwide network of participating doctors, hospitals, pharmacies and specialists throughout the country. Learn More! Read all the Plan documents before deciding whether to enroll. You ll learn about the full Plan benefits, what things are not covered, enrollment and waiver dates, and eligibility rules. To view online, go to or and select your school. To contact customer service, call Aetna Student Health at (877) or Cross Insurance at (800) How much does it cost? Who is eligible? All USM students who meet the following eligibility criteria will be required to show proof of health insurance as a condition of course enrollment and are automatically enrolled in this health insurance plan at registration unless proof of comparable coverage is furnished: Coverage Period Coverage Dates Student Rate Annual 08/01/17-07/31/18 $1,692 Spring/Summer 01/01/18-07/31/18 $982 Undergraduate students taking 9 credits or more Graduate or Law students taking 6 credits or more All USM School of Nursing students enrolled in clinical coursework All USM students enrolled in the Occupational Therapy Program Students living outside of Maine enrolled in only online courses, Stonecoast MFA participants and International students with F or J visas are not typically eligible and not automatically enrolled. Deadline Dates: Fall: 10/01/17 Spring: 02/20/18
2 Here s a brief description of the Plan benefits: Preferred Provider Non-Preferred Provider Plan Maximum Unlimited Annual Deductible Individual: $6,000 Per Policy Year after the Plan has paid $2,500 in Covered Medical Expenses. Unlimited $8,000 Per Policy Year after the Plan has paid $2,500 in Covered Medical Expenses. Family: Annual Out-of-Pocket Limit Individual: $6,350 Per Individual Family: Physician s Office Visit 75% of the Negotiated Charge Inpatient Hospitalization 75% of the Negotiated Charge Emergency Room After a $100 Copay, 75% of the Negotiated Charge 55% of the Recognized Charge 55% of the Recognized Charge for a semi-private room After a $100 Copay, 75% of the Recognized Charge Prescription Drugs Prescriptions paid at 100% of the Negotiated Charge with the following copays: $20 Copay for Generic Drugs $30 Copay for Preferred Brand Drugs $60 Copay for Non-Preferred Brand Drugs Non-Preferred prescriptions paid at 80% of the Recognized Charge with the following copays: $20 Deductible for Generic Drugs $30 Deductible for Preferred Brand Drugs $60 Deductible for Non-Preferred Brand Drugs Services Your Plan Generally Does NOT Cover (Check your policy or Plan document for more information and a list of any other excluded services.) Cosmetic Surgery Massage Therapy Routine Foot Care Elective Services Acupuncture Routine eye care (Adult) Services that are not Medically Necessary Weight Loss Programs Long Term Care These are brief highlights of the Student Health Plan. The Plan is available for the University of Southern Maine students. The Plan is underwritten by Aetna Life Insurance Company (Aetna). The exact provisions, including definitions, governing this insurance are contained in the Policy issued to you and may be viewed online at If there is a difference between this Plan Highlights and the Master Policy, the Policy will control.
3 The University of Southern Maine Student Health Insurance Plan is underwritten by Aetna Life Insurance Company. Aetna Student Health is the brand name for products and services provided by Aetna Life Insurance Company and its applicable affiliated companies (Aetna). Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call [insert phone number]. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY (CA HMO customers: PO Box Fresno, CA 93779), , TTY: 711, Fax: (CA HMO customers: ), CRCoordinator@aetna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at , (TDD). Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).
4 TTY: 711 To access language services at no cost to you, call Para acceder a los servicios de idiomas sin costo, llame al (Spanish) 如欲使用免費語言服務, 請致電 (Chinese) Afin d'accéder aux services langagiers sans frais, composez le (French) Para ma-access ang mga serbisyo sa wika nang wala kayong babayaran, tumawag sa (Tagalog) Um auf für Sie kostenlose Sprachdienstleistungen zuzugreifen, rufen Sie an. (German) للحصول على الخدمات اللغوية دون أي تكلفة الرجاء االتصال على الرقم )Arabic( Pou jwenn sèvis lang gratis, rele (French Creole-Haitian) Per accedere ai servizi linguistici, senza alcun costo per lei, chiami il numero (Italian) 言語サービスを無料でご利用いただくには までお電話ください (Japanese) 무료언어서비스를이용하려면 번으로전화해주십시오. (Korean) برای دسترسی به خدمات زبان به طور رايگان با شماره تماس بگيريد. )Persian-Farsi( Aby uzyskać dostęp do bezpłatnych usług językowych proszę zadzwonoć (Polish) Para acessar os serviços de idiomas sem custo para você, ligue para (Portuguese) Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону (Russian) Nếu quý vị muốn sử dụng miễn phí các dịch vụ ngôn ngữ, hãy gọi tới số (Vietnamese)
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REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
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