George Washington University 2023-2024 Page 2
This is a brief description of the Student Health Plan. The plan is available for George Washington University students
and their eligible dependents. The plan is insured by Aetna Life Insurance Company (Aetna). The exact provisions,
including definitions, governing this insurance are contained in the Certificate issued to you and may be viewed online at
https://www.aetnastudenthealth.com
. If there is a difference between this Plan Summary and the Certificate, the
Certificate will control.
GW Student Health Center
The Student Health Center is the University's on-campus health facility. It is located at 800 21
st
St., NW; University
Student Center Ground Floor, Washington D.C, 20052. It is staffed by Physicians, Nurse Practitioners, Physician Assistants,
Mental Health Providers and Registered Nurses. Please visit https://healthcenter.gwu.edu/
or call 202-994-5300 for
more information and hours of operation.
When the following services are provided at the GW Student Health Center (SHC) they are covered at 100% with no
Copay or Deductible.
• Medical office visits,
• Prescription medications routinely dispensed at Health Service,
• Routine STD screenings, (once annually)
• Physical Examinations
• Immunizations
• A yearly influenza vaccination when provided at the SHC only
Annual Deductible waived for services rendered at GW Counseling and Psychological Services (CAPS)
Office Visits are covered at 100%.
Group Counseling is covered at 100%. Referrals are available to providers in the community.
For more information, call CAPS at (202) 994-5300. In the event of an emergency on-campus, call GW Emergency
Services at (202) 994-6111, or for off campus, call 911.
Additional Products
Vital Savings Dental
Here’s an easy way to keep your smile it’s healthiest. No insurance necessary. In most cases, you can save 15 to 50
percent* on many dental services.
Over 200,000 dental practices welcome your card. Just show it to save on:
• Exams, cleanings, and X-rays
• Fillings and crowns
• Root canals and extractions
• Even braces and whitening
Simply pay the discounted rate directly to the dental office.
Just log in to your member website at https://www.aetnastudenthealth.com
.
George Washington University 2023-2024 Page 3
Telemedicine
What is Telemedicine? Telemedicine means the practice of health care delivery, evaluation, diagnosis, consultation, or
treatment, using the transfer of medical data through audio, video, or data communications that are engaged in over
two or more locations between health care practitioners who are physically separated from the patient or from each
other.
Requesting a Telemedicine appointment Members request a telemedicine appointment by contacting their health care
practitioner just as they would to make an in-office appointment.
Policy Period
Mandatory Students and Dependents
1. Students: Coverage for all insured students that enroll in the Fall semester, will become effective at 12:01 a.m. on
8/12/2023, and will terminate at 11:59 p.m. on 12/31/2023. Students who maintain eligibility for the Spring /
Summer 2024 semester will automatically be re-enrolled effective 12:01 a.m. on 01/01/2024 and will terminate
11:59 p.m. on 08/11/2024.
2. New Spring Semester students: Coverage for all insured students enrolled for the Spring / Summer Semester, will
become effective at 12:01 a.m. on 01/01/2024, and will terminate at 11:59 p.m. on 08/11/2024.
3. Insured dependents: Coverage will become effective on the same date the insured student's coverage becomes
effective, or the day after the postmarked date when the completed application and premium are sent, if later.
Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Master
Policy. Examples include but are not limited to the date the student’s coverage terminates; the date the dependent
no longer meets the definition of a dependent.
Mandatory Student Health Insurance Coverage
Eligibility
The following groups of students are automatically enrolled in the Plan unless proof of comparable coverage is
furnished:
All undergraduate, graduate, law, medical, international, and doctoral students matriculated in a degree granting on
campus program. This includes students on the Foggy Bottom, Mount Vernon and VSTC campuses.
The plan is also available on a voluntary basis for:
• All Non-degree seeking students with 9 or more credit hours
• All students on Continuous enrollment
• All students on a school-approved leave of absence.
• All online Medical and Nursing students who participate in clinical rotation on campus.
George Washington University 2023-2024 Page 4
You must actively attend classes until your program’s add/drop deadline to remain eligible for the Policy.
You cannot meet this eligibility requirement if you take courses through:
• Pre-college program
• On-line students (except for medical and nursing students who participate in clinical rotation on campus.)
• Off campus programs
If we find out that you do not meet this eligibility requirement, we are only required to refund any premium
contribution minus any claims that we have paid.
Coverage Periods
Students: Coverage for all insured students enrolled for coverage in the Plan for the following Coverage Periods.
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/Waiver Deadline
Annual 08/12/2023 08/11/2024 09/12/2023
Fall 08/12/2023 12/31/2023 09/12/2023
Spring 01/01/2024 08/11/2024 02/01/2024
Summer Only 05/01/2024 08/11/2024 05/20/2024
Eligible Dependents: Coverage for dependents eligible under the Plan for the following Coverage Periods. Coverage will,
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 Certificate of Coverage.
Coverage Period Coverage Start Date Coverage End Date Enrollment/Waiver Deadline
Annual 08/12/2023 08/11/2024 09/12/2023
Fall 08/15/2023 12/31/2023 09/12/2023
Spring 01/01/2024 08/11/2024 02/01/2024
Summer Only 05/01/2024 08/11/2024 05/20/2024
George Washington University 2023-2024 Page 5
Rates
The rates below include both premiums for the Plan underwritten by Aetna Life Insurance Company (Aetna), as well as
the George Washington University administrative fee.
Rates
Annual
08/12/23-08/11/24
Fall Semester
08/12/23-12/31/23
Spring/Summer
Semester
01/01/24-08/11/24
Summer Only
05/01/24-08/11/24
Student
$2,841
$1,102
$1,739
$800
Spouse
$2,841
$1,102
$1,739
$800
One Child
$2,841
$1,102
$1,739
$800
Children
$5,682
$2,204
$3,478
$1,600
Please Note: Some GW graduate assistants or graduate research assistants receive subsidized funding to cover the
costs of the GW SHIP. Contact your department or research advisor for more information.
Annual Waiver Deadline for Students: 9/12/2023
WAIVE/ENROLLMENT INFORMATION:
HOW TO WAIVE:
The premium for the Plan will be added to your tuition bill. If you have comparable coverage and wish to waive coverage
under the Plan, you must submit an Online Waiver Form. To complete the Online Waiver Form, visit
www.universityhealthplans.com/GWU or call 833-251-1721.
Voluntarily Enrolled Students and Dependents
1. Students: Coverage for all insured students enrolled for the Fall Semester will become effective at 12:01 a.m. on
08/12/2023 and will terminate at 11:59 p.m. on 12/31/2023. Students who maintain eligibility for the
Spring/Summer semester can re-enroll in coverage that will become effective 12:01 a.m. on 01/01/2024 and
terminate at 11:59 p.m. on 08/11/2024.
2. New Spring Semester students: Coverage for all insured students enrolled for the Spring/Summer Semester, will
become effective at 12:01 a.m. on 01/01/2024, and will terminate at 11:59 p.m. on 8/11/2024.
3. Insured dependents: Coverage will become effective on the same date the insured student's coverage becomes
effective, or the day after the postmarked date when the completed application and premium are sent, if later.
Coverage for insured dependents terminates in accordance with the Termination Provisions described in the Master
Policy. Examples include but are not limited to the date the student’s coverage terminates; the date the dependent
no longer meets the definition of a dependent.
George Washington University 2023-2024 Page 6
Enrollment
Voluntary students may purchase coverage for themselves and their eligible dependents by submitting an Enrollment
Form by the deadline applicable to the desired coverage period. Full payment must be paid online with a credit card or
with a check or money order. The enrollment form is available
at www.universityhealthplans.com/GWU. Please call
833-251-1721 for questions regarding enrollment instructions.
If you withdraw from school before your program’s add/drop deadline, you will not be covered under the Policy and the
full premium will be refunded, less any claims paid. After your program’s add/drop deadline, you will be covered for the
full period that you have paid the premium for, and no refund will be allowed. (This refund policy will not apply if you
withdraw due to a covered Accident or Sickness.)
Dependent Coverage
Eligibility
Covered students may also enroll their lawful spouse, domestic partner (same-sex, opposite sex), and dependent
children up to the age of 26.
Enrollment
To enroll the dependent(s) of a covered student, please complete the Enrollment Form by visiting
www.universityhealthplans.com/GWU
. 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 University Health Plans.
Please call University Health Plans at 833-251-1721 for questions regarding
enrollment instructions.
Important note regarding coverage for a newborn infant or newly adopted child:
Your newborn child is covered on your health plan for the first 31 days from the moment of birth.
o 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.
o 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.
o If you miss this deadline, your newborn will not have health benefits after the first 31 days.
o 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.
A child that you, or that you and your spouse, domestic partner adopts or is placed with you for adoption, is covered on
your plan for the first 31 days after the adoption or the placement is complete.
• To keep your child covered, we must receive your completed enrollment information within 31 days after
the adoption or placement for adoption.
• 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 (800)213-0579.
George Washington University 2023-2024 Page 7
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.
Termination and Refunds
Withdrawal from Classes – Leave of Absence:
If you withdraw from classes under a school-approved leave of absence before your program’s add/drop deadline, 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 before your program’s add/drop deadline,
from classes other than under a school-approved leave of absence before your program’s add/drop deadline, you will be
considered ineligible for coverage, your coverage will be terminated retroactively and any premiums collected will be
refunded. If the withdrawal is after your program’s add/drop deadline, 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.
George Washington University 2023-2024 Page 8
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 pre-certify when required, there is a $500 penalty for each type of eligible health
service that was not pre-certified. For a current listing of the health services or prescription drugs that require
precertification, contact Member Services or go to www.aetna.com.
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
requiring precertification:
You or your physician must call at least 14 days before the outpatient care is
provided, or the treatment or procedure is scheduled.
We will provide a written notification to you and your physician of the precertification decision, where required by state
law. If your pre-certified 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.
George Washington University 2023-2024 Page 9
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 https://www.aetnastudenthealth.com
.
This Plan will pay benefits in accordance with any applicable District of Columbia Insurance Law(s).
Policy year deductible
In-network coverage
Out-of-network coverage
You have to meet your policy year deductible before this plan pays for benefits.
Student
$300 per policy year
$3,000 per policy year
Spouse
$300 per policy year
$3,000 per policy year
Each child
$300 per policy year
$3,000 per policy year
Family
None
None
PRESCRIBED MEDICINES EXPENSE
Student
$100 per policy year
Spouse
$100 per policy year
Each child
$100 per policy year
Individual
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. 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.
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
• Pap Smear Screening Expense; and
• Mammogram Expense.
In addition to state and federal requirements for waiver of the policy year deductible, the plan will waive the policy
year deductible for:
• Preferred Care Laboratory and X-Ray Expense;
• Preferred Care Allergy Testing Expense;
• Preferred Care Diagnostic Testing For Learning Disabilities Expense; Preferred Care Maternity Expense;
• Preferred Care Gynecology;
• Preferred Care Outpatient Treatment of Mental Health;
• Preferred Care Pediatric Preventive Dental; and
• Preferred and Non-Preferred Care Pediatric Vision Services.
Per visit or admission Deductibles do not apply towards satisfying the Policy Year Deductible. This Policy Year
Deductible and the Prescribed Medicine Expense Deductible do not apply towards satisfying each other.
Maximum out-of-pocket limit per policy year
Student
$6,350 per policy year
$15,000 per policy year
Spouse
$6,350 per policy year
$15,000 per policy year
Each child
$6,350 per policy year
$15,000 per policy year
Family
$12,700 per policy year
$30,000 per policy year
George Washington University 2023-2024 Page 10
Eligible health services
In-network coverage
Out-of-network coverage
Preventative care and wellness
Routine physical exams
Routine Physical exam
100% (of the negotiated charge) per
visit
Deductible does not apply
60% (of the recognized charge) per
visit
Policy year deductible applies
Routine physical exam limits for
covered persons through age
21: maximum age and visit
limits per policy year
Subject to any age and visit limits provided for in the comprehensive guidelines
supported by the American Academy of Pediatrics/Bright Futures//Health
Resources and Services Administration guidelines for children and adolescents.
Routine physical exam limits for
covered persons age 22 and
over: maximum visits per policy
year
1 visit
Preventive care immunizations
Performed in a facility or at a physician’s office
Preventive care immunizations
100% (of the negotiated charge) per
visit.
Deductible does not apply
60% (of the recognized charge) per
visit
Policy year deductible applies
Preventive care immunization
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.
The following is not covered under this benefit:
• Any immunization that is not considered to be preventive care or recommended as preventive care, such as
those required due to employment or travel
Routine gynecological exams (including Pap smears and cytology tests)
Performed at a physician’s,
obstetrician (OB), gynecologist
(GYN) or OB/GYN office
100% (of the negotiated charge) per
visit
Deductible does not apply
60% (of the recognized charge) per
visit
Policy year deductible applies
Well woman routine
gynecological exam maximums
1 visit
Well woman preventive visits
Preventive screening and counseling services
Preventive screening and
counseling services for Obesity
and/or healthy diet counseling,
Misuse of alcohol & drugs,
Tobacco Products, Depression
100% (of the negotiated charge) per
visit
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
George Washington University 2023-2024 Page 11
Screening, Sexually transmitted
infection counseling & Genetic
risk counseling for breast and
ovarian cancer
Eligible health services
In-network coverage
Out-of-network coverage
Obesity and/or healthy diet
counseling Maximum visits
Age 22 and older: 26 visits per 12 months, of which up to 10 visits may be used for
healthy diet counseling.
Misuse of alcohol and/or drugs
counseling Maximum visits per
policy year
5 visits
Use of tobacco products
counseling Maximum visits per
policy year
8 visits
Depression screening
counseling Maximum visits per
policy year
1 visit
Sexually transmitted infection
counseling Maximum visits per
policy year
2 visits
Genetic risk counseling for
breast and ovarian cancer
limitations
Not subject to any age or frequency limitations
Genetic risk counseling for
breast and ovarian cancer
Maximum visits per policy year
1 visit
Routine cancer screenings
Deductible does not apply to
routine mammography
100% (of the negotiated charge) per
visit
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
Routine cancer screening
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
• The comprehensive guidelines supported by the Health Resources and Services
Administration.
Lung cancer screening
maximums
1 screening every 12 months
Prenatal care services
(Preventive care services only)
100% (of the negotiated charge) per
visit
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
Lactation counseling services
100% (of the negotiated charge) per
visit
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
George Washington University 2023-2024 Page 12
Eligible health services
In-network coverage
Out-of-network coverage
Lactation counseling services
maximum visits per policy year
either in a group or individual
setting
6 visits
Breast pump supplies and
accessories
100% (of the negotiated charge) per
item
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
Family planning services – female contraceptives
Counseling services
Female contraceptive
counseling services office visit
100% (of the negotiated charge) per
visit
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
Contraceptive counseling
services maximum visits per
policy year either in a group or
individual setting
2 visits
Female contraceptive
prescription drugs and devices
provided, administered, or
removed, by a provider during
an office visit
100% (of the negotiated charge) per
item
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
Female Voluntary sterilization
Inpatient provider services
100% (of the negotiated charge)
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
Outpatient provider services
100% (of the negotiated charge)
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
The following are not covered under this benefit:
• Services provided as a result of complications resulting from a female voluntary sterilization procedure and
related follow-up care
• Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA
• Male contraceptive methods, sterilization procedures or devices, except for male condoms prescribed by a
provider
Physicians and other health professionals
Physician, specialist including
Consultants Office
visits
(non-surgical/non-preventive
care by a physician and
specialist) includes
telemedicine consultations)
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
George Washington University 2023-2024 Page 13
Eligible health services
In-network coverage
Out-of-network coverage
Allergy testing and treatment
Allergy testing performed at a
physician’s or specialist’s office
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the service
is received.
Allergy injections treatment
including Allergy sera and
extracts administered via
injection performed at a
physician’s or specialist’s office
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the service
is received.
Physician and specialist - surgical services
Inpatient surgery performed
during your stay in a hospital or
birthing center by a surgeon
(includes anesthetist and
surgical assistant expenses)
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
The following are not covered under this benefit:
• The services of any other physician who helps the operating physician
• A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital and
other facility care section)
• Services of another physician for the administration of a local anesthetic
Outpatient surgery performed
at a physician’s or specialist’s
office or outpatient
department of a hospital or
surgery center by a surgeon
(includes anesthetist and
surgical assistant expenses)
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
The following are not covered under this benefit:
• The services of any other physician who helps the operating physician
• A stay in a hospital (Hospital stays are covered in the Eligible health services and exclusions – Hospital and
other facility care section)
• A separate facility charge for surgery performed in a physician’s office
•
Services of another physician for the administration of a local anesthetic
Alternatives to physician office visits
Walk-in clinic visits(non-
emergency visit)
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Hospital and other facility care
Inpatient hospital (room and
board) and other
miscellaneous services and
supplies)
Includes birthing center facility
charges
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
George Washington University 2023-2024 Page 14
Eligible health services
In-network coverage
Out-of-network coverage
In-hospital non-surgical
physician services
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Preadmission testing
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the service
is received.
Alternatives to hospital stays
Outpatient surgery (facility
charges) performed in the
outpatient department of a
hospital or surgery center
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
The following are not covered under this benefit:
• The services of any other physician who helps the operating physician
• A stay in a hospital (See the Hospital care – facility charges benefit in this section)
• A separate facility charge for surgery performed in a physician’s office
•
Services of another physician for the administration of a local anesthetic
Home health Care
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge) per visit
Policy year deductible applies
Home health care maximum
visits per episode per policy
year
Unlimited
The following are not covered under this benefit:
• Services for infusion therapy
• Nursing and home health aide services or therapeutic support services provided outside of the home (such
as in conjunction with school, vacation, work or recreational activities)
• Transportation
• Services or supplies provided to a minor or dependent adult when a family member or caregiver is not
present
• Homemaker or housekeeper services
• Food or home delivered services
• Maintenance therapy
Hospice-Inpatient facility
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Maximum days per
confinement per policy year
Unlimited
Hospice-Outpatient
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Maximum visits per policy year
Unlimited
The following are not covered under this benefit:
George Washington University 2023-2024 Page 15
• Funeral arrangements
• Pastoral counseling
• Respite care
• Financial or legal counseling which includes estate planning and the drafting of a will
o Homemaker or caretaker services that are services which are not solely related to your care and may include:
Sitter or companion services for either you or other family members
Transportation
Maintenance of the house
Eligible health services
In-network coverage
Out-of-network coverage
Outpatient private duty nursing
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Skilled nursing facility-Inpatient
facility
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Hospital emergency room
$100 copayment then the plan pays
80% (of the balance of the negotiated
charge) per visit
Policy year deductible applies
Paid the same as in-network coverage
Non-emergency care in a
hospital emergency room
Not covered
Not covered
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.
George Washington University 2023-2024 Page 16
The following are not covered under this benefit:
• Non-emergency services in a hospital emergency room facility
Eligible health services
In-network coverage
Out-of-network coverage
Urgent Care
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Non-urgent use of urgent care
provider
Not covered
Not covered
The following is not covered under this benefit:
•
Non-urgent care in an urgent care facility (at a non-hospital freestanding facility)
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) per
visit
No copayment or deductible applies
70% (of the recognized charge) per visit
Policy year deductible applies
Type B services
70% (of the negotiated charge) per
visit
No copayment or deductible applies
50% (of the recognized charge) per visit
Policy year deductible applies
Type C services
50% (of the negotiated charge) per
visit
No copayment or deductible applies
50% (of the recognized charge) per visit
Policy year deductible applies
Orthodontic services
50% (of the negotiated charge) per
visit
No copayment or deductible applies
50% (of the recognized charge) per visit
Policy year deductible applies
Dental emergency treatment
Covered according to the type of
benefit and the place where the service
is received
Covered according to the type of benefit
and the place where the service is
received.
Pediatric dental care exclusions
The following are not covered under this benefit:
• Any instruction for diet, plaque control and oral hygiene
- Cosmetic services and supplies including:
- Plastic surgery, reconstructive surgery, cosmetic surgery, personalization or characterization of dentures
or other services and supplies which improve, alter or enhance appearance
- Augmentation and vestibuloplasty, and other substances to protect, clean, whiten, bleach or alter the
appearance of teeth, whether or not for psychological or emotional reasons, except to the extent
coverage is specifically provided in the Eligible health services and exclusions section
- Facings on molar crowns and pontics will always be considered cosmetic
• Crown, inlays, onlays, and veneers unless:
- It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material
- The tooth is an abutment to a covered partial denture or fixed bridge
• Dental implants and braces (that are determined not to be medically necessary mouth guards, and other
devices to protect, replace or reposition teeth
George Washington University 2023-2024 Page 17
• Dentures, crowns, inlays, onlays, bridges, or other appliances or services used:
- For splinting
- To alter vertical dimension
- To restore occlusion
- For correcting attrition, abrasion, abfraction or erosion
• Treatment of any jaw joint disorder and treatments to alter bite or the alignment or operation of the jaw,
including temporomandibular joint dysfunction disorder (TMJ) treatment, orthognathic surgery, and
treatment of malocclusion or devices to alter bite or alignment, except as covered in the Eligible health
services and exclusions – Specific conditions section
• General anesthesia and intravenous sedation, unless specifically covered and only when done in connection
with another eligible health service
• Orthodontic treatment except as covered above and in the [Pediatric] dental care section of the schedule of
benefits
• Pontics, crowns, cast or processed restorations made with high noble metals (gold)
• Prescribed drugs, pre-medication or analgesia (nitrous oxide)
• Replacement of a device or appliance that is lost, missing or stolen, and for the replacement of appliances
that have been damaged due to abuse, misuse or neglect and for an extra set of dentures
• Replacement of teeth beyond the normal complement of 32
• Routine dental exams and other preventive services and supplies, except as specifically provided in the
Pediatric dental care section of the schedule of benefits
• Services and supplies:
- Done where there is no evidence of pathology, dysfunction, or disease other than covered preventive
services
- Provided for your personal comfort or convenience or the convenience of another person, including a
provider
- Provided in connection with treatment or care that is not covered under your policy
• Surgical removal of impacted wisdom teeth only for orthodontic reasons
•
Treatment by other than a dental provider
Eligible health services
In-network coverage
Out-of-network coverage
Specific Conditions
Diabetic services and supplies
(including equipment and
training)
Covered according to the type of
benefit and the place where the service
is received.
Covered according to the type of benefit
and the place where the service is
received.
Podiatric (foot care) treatment
Physician and specialist non-
routine foot care treatment
Covered according to the type of
benefit and the place where the service
is received.
Covered according to the type of benefit
and the place where the service is
received.
The following are not covered under this benefit:
- Services and supplies for:
• The treatment of calluses, bunions, toenails, flat feet, hammertoes, fallen arches
• The treatment of weak feet, chronic foot pain or conditions caused by routine activities, such as walking,
running, working or wearing shoes
• Supplies (including orthopedic shoes), foot orthotics, arch supports, shoe inserts, ankle braces, guards,
protectors, creams, ointments and other equipment, devices and supplies
• Routine pedicure services, such as cutting of nails, corns and calluses when there is no illness or injury of
the feet
George Washington University 2023-2024 Page 18
Eligible health services
In-network coverage
Out-of-network coverage
Impacted wisdom teeth
100% (of the negotiated charge) per
visit
Policy year deductible applies
100% (of the recognized charge) per
visit
Policy year deductible applies
Accidental injury to sound
natural teeth
100% (of the negotiated charge) per
visit
Policy year deductible applies
100% (of the recognized charge) per
visit
Policy year deductible applies
The following are not covered under this benefit:
• The care, filling, removal or replacement of teeth and treatment of diseases of the teeth
• Dental services related to the gums
• Apicoectomy (dental root resection)
• Orthodontics
• Root canal treatment
• Soft tissue impactions
• Bony impacted teeth
• Alveolectomy
• Augmentation and vestibuloplasty treatment of periodontal disease
• False teeth
• Prosthetic restoration of dental implants
• Dental implants
Temporomandibular joint
dysfunction (TMJ) and
craniomandibular joint
dysfunction (CMJ) treatment
Covered according to the type of
benefit and the place where the service
is received.
[Covered according to the type of
benefit and the place where the service
is received.]
The following are not covered under this benefit:
Dental implants
Clinical trial (routine patient
costs)
Covered according to the type of
benefit and the place where the service
is received.
[Covered according to the type of
benefit and the place where the service
is received.]
Coverage is limited to routine patient services from in-network providers.
The following are not covered under this benefit:
• 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)
Dermatological treatment
Covered according to the type of
benefit and the place where the service
is received.
Covered according to the type of benefit
and the place where the service is
received.
The following are not covered under this benefit:
Cosmetic treatment and procedures
George Washington University 2023-2024 Page 19
Eligible health services
In-network coverage
Out-of-network coverage
Maternity care
Maternity care (includes
delivery and postpartum care
services in a hospital or
birthing center)
Covered according to the type of
benefit and the place where the service
is received.
Covered according to the type of benefit
and the place where the service is
received.
The following are not covered under this benefit:
Any services and supplies related to births that take place in the home or in any other place not licensed to perform
deliveries
Well newborn nursery care in
a hospital or birthing center
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Family planning services – other
Voluntary sterilization
for males-inpatient surgical
services
80% (of the negotiated charge) per visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Voluntary sterilization
for males -Outpatient
physician or
specialist surgical services
80% (of the negotiated charge) per visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Abortion-Inpatient
physician or specialist surgical
services
80% (of the negotiated charge) per visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Abortion-Outpatient
physician or specialist
surgical services
80% (of the negotiated charge) per visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
The following are not covered under this benefit:
• Reversal of voluntary sterilization procedures, including related follow-up care
Gender affirming treatment
Surgical, hormone
replacement therapy, and
counseling treatment
Covered according to the type of benefit
and the place where the service is
received.
Covered according to the type of benefit
and the place where the service is
received.
Gender affirming treatment additional services
Reduction thyroid
chondroplasty (tracheal
shave) maximum per policy
year
Covered according to the type of benefit
and the place where the service is
received.
Covered according to the type of benefit
and the place where the service is
received.
George Washington University 2023-2024 Page 20
Tracheal shave maximum per
policy year
Unlimited
Electrolysis, laser hair removal
Covered according to the type of benefit
and the place where the service is
received.
Covered according to the type of benefit
and the place where the service is
received.
Electrolysis, laser hair removal
maximum per policy year
$1,200
The following are not eligible health services under this benefit:
• Any treatment, surgery, service or supply that is not in the list above of eligible health services
Eligible health services
In-network coverage
Out-of-network coverage
Autism spectrum disorder
Autism spectrum disorder
treatment, diagnosis and
testing. Includes Applied
behavior analysis and Physical,
occupational, and speech
therapy associated with
diagnosis of autism spectrum
disorder
Covered according to the type of
benefit and the place where the service
is received.
Covered according to the type of benefit
and the place where the service is
received.
Behavioral Health
Mental Health & Substance related disorders treatment
Inpatient hospital
(room and board and other
miscellaneous hospital
services and supplies)
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Outpatient treatment office
visits
(includes telemedicine
cognitive behavioral therapy
consultations)
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Other outpatient treatment
(includes Partial hospitalization
and Intensive Outpatient
Program)
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
George Washington University 2023-2024 Page 21
Eligible health services
In-network coverage
Network (IOE facility)
In-network coverage
Network (Non-IOE
facility)
Out-of-network
coverage
Network
Non-IOE facility and
out-of-network facility
Inpatient and outpatient
transplant facility services
Covered according to the
type of benefit and the
place where the service is
received.
Covered according to the
type of benefit and the
place where the service is
received.
Covered according to
the type of benefit and
the place where the
service is received.
Inpatient and outpatient
transplant physician and
specialist services
Covered according to the
type of benefit and the
place where the service is
received.
Covered according to the
type of benefit and the
place where the service is
received.
Covered according to
the type of benefit and
the place where the
service is received.
Transplant services-travel and
lodging
Covered
Covered
Covered
Lifetime Maximum Travel and
Lodging Expenses for any one
transplant
$10,000
$10,000
$10,000
Maximum Lodging Expenses
per IOE patient
$50 per night
$50 per night
$50 per night
Maximum Lodging Expenses
per companion
$50 per night
$50 per night
$50 per night
The following are not covered under this benefit:
- Services and supplies furnished to a donor when the recipient is not a covered person
- Harvesting and storage of organs, without intending to use them for immediate transplantation for your
existing illness
- Harvesting and/or storage of bone marrow, hematopoietic stem cells, or other blood cells without intending
to use them for transplantation within 12 months from harvesting, for an existing illness
Eligible health services
In-network coverage
Out-of-network coverage
Basic infertility services
Inpatient and outpatient care
Covered according to the type of
benefit and the place where the service
is received.
Covered according to the type of benefit
and the place where the service is
received.
The following are not covered services under the infertility treatment benefit:
• Injectable infertility medication, including but not limited to menotropins, hCG, and GnRH agonists.
• All charges associated with:
• Surrogacy for you or the surrogate. A surrogate is a female carrying her own genetically related child
where the child is conceived with the intention of turning the child over to be raised by others, including
the biological father
• Cryopreservation (freezing) and storage of eggs, embryos, sperm, or reproductive tissue
• Thawing of cryopreserved (frozen) eggs, sperm, or reproductive tissue
• The care of the donor in a donor egg cycle which includes, but is not limited to, any payments to the
donor, donor screening fees, fees for lab tests, and any charges associated with care of the donor
required for donor egg retrievals or transfers
• The use of a gestational carrier for the female acting as the gestational carrier. A gestational carrier is a
female carrying an embryo to which the person is not genetically related
George Washington University 2023-2024 Page 22
• Obtaining sperm [from a person not covered under this plan] for ART services
• Home ovulation prediction kits or home pregnancy tests
• The purchase of donor embryos, donor oocytes, or donor sperm
• Reversal of voluntary sterilizations, including follow-up care
• Ovulation induction with menotropins, Intrauterine insemination and any related services, products or
procedures
• In vitro fertilization (IVF), Zygote intrafallopian transfer (ZIFT), Gamete intrafallopian transfer
(GIFT), Cryopreserved embryo transfers and any related services, products or procedures (such
as Intracytoplasmic sperm injection (ICSI) or ovum microsurgery)
Eligible health services
In-network coverage
Out-of-network coverage
Specific therapies and tests
Diagnostic complex imaging
services performed in the
outpatient department of a
hospital or other facility
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Diagnostic lab work and
radiological services performed
in a physician’s office, the
outpatient department of a
hospital or other facility
80% (of the negotiated charge) per
visit
Deductible does not apply
60% (of the recognized charge) per visit
Policy year deductible applies
Outpatient Chemotherapy,
Radiation & Respiratory
Therapy
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Outpatient infusion therapy
performed in a covered
person’s home, physician’s
office, outpatient department
of a hospital or other facility
Covered according to the type of
benefit and the place where the service
is received.
Covered according to the type of benefit
and the place where the service is
received.
The following are not covered under this benefit:
• Drugs that are included on the list of specialty prescription drugs as covered under your outpatient prescription
drug plan
• Enteral nutrition
• Blood transfusions and blood products
• Dialysis
George Washington University 2023-2024 Page 23
Eligible health services
In-network coverage
Out-of-network coverage
Outpatient physical,
occupational, speech, and
cognitive therapies (including
Cardiac and Pulmonary
Therapy)
Combined for short-term
rehabilitation services and
habilitation therapy services
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Chiropractic services
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Other services and supplies
Emergency ground, air, and
water ambulance
100% (of the negotiated charge) per
visit
Policy year deductible applies
100% (of the recognized charge) per
visit
Policy year deductible applies
The following are not covered under this benefit:
- Ambulance services for routine transportation to receive outpatient or inpatient care
Durable medical and surgical
equipment
80% (of the negotiated charge) per
visit
Policy year deductible applies
80% (of the recognized charge) per visit
Policy year deductible applies
The following are not covered under this benefit:
• 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
Nutritional support
Covered according to the type of
benefit and the place where the
service is received.
Covered according to the type of
benefit and the place where the service
is received.
The following are not covered under this benefit:
- Any food item, including infant formulas, nutritional supplements, vitamins, plus prescription vitamins,
medical foods and other nutritional items, even if it is the sole source of nutrition
George Washington University 2023-2024 Page 24
Eligible health services
In-network coverage
Out-of-network coverage
Prosthetic Devices
80% (of the negotiated charge) per
item
Policy year deductible applies
60% (of the recognized charge) per
item
Policy year deductible applies
The following are not covered under this benefit:
• Services covered under any other benefit
• Orthopedic shoes, therapeutic shoes, foot orthotics, or other devices to support the feet, unless required for
the treatment of or to prevent complications of diabetes, or if the orthopedic shoe is an integral part of a
covered leg brace
• Trusses, corsets, and other support items
• Repair and replacement due to loss, misuse, abuse or theft
• Communication aids
• Cochlear implants
Hearing aids and Exams
Hearing exams
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Hearing exam maximum
One hearing exam every policy year
The following are not covered under this benefit:
- Hearing exams given during a stay in a hospital or other facility, except those provided to newborns as part
of the overall hospital stay
Hearing aids
80% (of the negotiated charge) per
visit
Policy year deductible applies
60% (of the recognized charge) per visit
Policy year deductible applies
Hearing aids maximum per
ear
One hearing aid per ear every policy year
The following are not covered under this benefit:
• A replacement of:
• A hearing aid that is lost, stolen or broken
Replacement parts or repairs for a hearing aid
Batteries or cords
Cochlear implants
A hearing aid that does not meet the specifications prescribed for correction of hearing loss
Any ear or hearing exam performed by a physician who is not certified as an otolaryngologist or otologist
George Washington University 2023-2024 Page 25
Eligible health services
In-network coverage
Out-of-network coverage
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 refraction)-
Performed by a legally qualified
ophthalmologist or optometrist
Includes comprehensive low
vision evaluations. Includes
visit for fitting of contact lenses
100% (of the negotiated charge) per
visit
No policy year deductible applies
70% (of the recognized charge) per visit
No policy year deductible applies
Maximum visits per policy year
Low vision Maximum
Fitting of contact Maximum
1 visit
One comprehensive low vision evaluation every policy year
1 visit
Pediatric vision care services &
supplies-Eyeglass frames,
prescription lenses or
prescription contact lenses
100% (of the negotiated charge) per
visit
No policy year deductible applies
70% (of the recognized charge) per visit
No policy year deductible applies
Maximum number Per year:
Eyeglass frames
Prescription lenses
Contact lenses (includes non-
conventional prescription
contact lenses & aphakic lenses
prescribed after cataract
surgery)
One set of eyeglass frames
One pair of prescription lenses
Daily disposables: up to 3 month supply
Extended wear disposable: up to 6 month supply
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.
The following are not covered under this benefit:
•
Eyeglass frames, non-prescription lenses and non-prescription contact lenses that are for cosmetic purposes
George Washington University 2023-2024 Page 26
Outpatient prescription drugs
Outpatient prescription drug policy year deductibles
A separate policy year deductible applies to prescription drugs
You have to meet your prescription drug policy year deductible below before this plan pays for outpatient
prescription drug benefits.
Student
$100 per policy year
Spouse
$100 per policy year
Each child
$100 per policy year
Policy year deductible and copayment waiver for risk reducing breast cancer
The policy year deductible and the per prescription copayment 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 deductible and copayment waiver for tobacco cessation prescription
and over-the-counter drugs
The outpatient prescription drug policy year deductible and the 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 policy year deductible and any prescription drug copayment will apply after those two regimens per policy
year have been exhausted.
Outpatient prescription drug policy year deductible and copayment waiver for contraceptives
The outpatient prescription drug policy year deductible and the prescription drug copayment will not apply to female
contraceptive methods when obtained at an in-network.
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 policy year deductible and the per prescription drug copayment 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 retail
pharmacy
$15 copayment per supply then the
plan pays 100% (of the negotiated
charge)
Prescription deductible applies
40% (of the recognized charge)
Prescription deductible applies
More than a 30 day supply but
less than a 91 day supply filled
at a mail order pharmacy
$30 copayment per supply then the
plan pays 100% (of the balance of the
negotiated charge)
Prescription deductible applies
Not covered
George Washington University 2023-2024 Page 27
Eligible health services
In-network coverage
Out-of-network coverage
Preferred brand-name prescription drugs
For each fill up to a 30 day
supply filled at a retail
pharmacy
$45 copayment per supply then the
plan pays 100% (of the negotiated
charge)
Prescription deductible applies
40% (of the recognized charge)
Prescription deductible applies
More than a 30 day supply but
less than a 91 day supply filled
at a mail order pharmacy
$90 copayment per supply then the
plan pays 100% (of the balance of the
negotiated charge)
Prescription deductible applies
Not covered
Non-preferred brand-name prescription drugs
For each fill up to a 30 day
supply filled at a retail
pharmacy
$70 copayment per supply then the
plan pays 100% (of the negotiated
charge)
Prescription deductible applies
40% (of the recognized charge)
Prescription deductible applies
More than a 30 day supply but
less than a 91 day supply filled
at a mail order pharmacy
$140 copayment per supply then the
plan pays 100% (of the balance of the
negotiated charge)
Prescription deductible applies
Not covered
Specialty drugs
For each fill up to a 30 day
supply filled at a retail
pharmacy
Copayment per supply of 20% of the
negotiated charge
Prescription deductible applies
Not covered
Diabetic insulin & supplies
Important note:
Your cost share will not exceed $30 per 30 day supply of a covered prescription insulin drug filled at a network
pharmacy. Your cost share will not exceed $100 per 30 day supply of covered diabetic supplies filled at a network
pharmacy. No deductible applies for diabetic supplies and insulin
Contraceptives (birth control)
For each fill up to a 12 month
supply of generic and OTC
drugs and devices filled at a
retail or mail order pharmacy
100% (of the negotiated charge)
No deductible applies
100% (of the recognized charge)
No deductible applies
For each fill up to a 12 month
supply of brand name
prescription drugs and devices
filled at a retail or mail order
pharmacy
Paid according to the type of drug per
the schedule of benefits, above
Paid according to the type of drug per
the schedule of benefits, above
George Washington University 2023-2024 Page 28
Eligible health services
In-network coverage
Out-of-network coverage
Orally administered anti-
cancer prescription drugs- For
each fill up to a 30 day supply
filled at a retail pharmacy
$120 copayment per supply then the
plan pays 100% (of the balance of the
negotiated charge)
No deductible applies
Not covered
Preventive care drugs and
supplements filled at a retail
pharmacy
For each 30 day supply
100% (of the negotiated charge)
No deductible applies
100% (of the recognized charge)
No deductible applies
Risk reducing breast cancer
prescription drugs filled at a
pharmacy
For each 30 day supply
100% (of the negotiated charge) per
prescription or refill
No deductible applies
Paid according to the type of drug per
the schedule of benefits, above
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 OTC drugs filled at a
pharmacy
For each 30 day supply
100% (of the negotiated charge per
prescription or refill
No deductible applies
Paid according to the type of drug per
the schedule of benefits, above
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.
Outpatient prescription drugs exclusions
The following are not covered under the outpatient prescription drugs benefit:
• Biological sera unless specified on the preferred drug guide
• Cosmetic drugs including medications and preparations used for cosmetic purposes
• Devices, products and appliances, except those that are specially covered
• Drugs or medications
- Administered or entirely consumed at the time and place it is prescribed or provided
- Which do not, by federal or state law, require a prescription order i.e. over-the-counter (OTC) drugs),
even if a prescription is written except as specifically provided above
- That are therapeutically equivalent or therapeutically alternative to a covered prescription drug (unless a
medical exception is approved)
- Not approved by the FDA or not proven safe or effective
- Provided under your medical plan while an inpatient of a healthcare facility
- Recently approved by the U.S. Food and Drug Administration (FDA), but which have not yet been
reviewed by our Pharmacy and Therapeutics Committee
George Washington University 2023-2024 Page 29
- That include vitamins and minerals unless recommended by the United States Preventive Services Task
Force (USPSTF)
- For which the cost is covered by a federal, state, or government agency (for example: Medicaid or
Veterans Administration)
- That are used to treat sexual dysfunction, enhance sexual performance or increase sexual desire,
including drugs, implants, devices or preparations to correct or enhance erectile function, enhance
sensitivity, or alter the shape or appearance of a sex organ
- That are used for the purpose of weight gain or reduction, including but not limited to stimulants,
preparations, foods or diet supplements, dietary regimens and supplements, food or food supplements,
appetite suppressants or other medications
- That are drugs or growth hormones used to stimulate growth and treat idiopathic short stature unless
there is evidence that the covered person meets one or more clinical criteria detailed in our
precertification and clinical policies
• Genetic care
- Any treatment, device, drug, service or supply to alter the body’s genes, genetic make-up, or the
expression of the body’s genes except for the correction of congenital birth defects]
• Immunization or immunological agents except as specifically stated in the schedule of benefits or the
certificate
• Injectables
- Any charges for the administration or injection of prescription drugs or injectable insulin and other
injectable drugs covered by us.
- Needles and syringes, except for those used for self-administration of an injectable drug.
- Any drug which, due to its characteristics as determined by us, must typically be administered or
supervised by a qualified provider or licensed certified health professional in an outpatient setting. This
exception does not apply to Depo Provera and other injectable drugs used for contraception.
• Prescription drugs:
- That are ordered by a dentist or prescribed by an oral surgeon in relation to the removal of teeth, or
prescription drugs for the treatment of a dental condition.
- That are considered oral dental preparations and fluoride rinses, except pediatric fluoride tablets or
drops as specified on the preferred drug guide.
- That are being used or abused in a manner that is determined to be furthering an addiction to a habit-
forming substance, or drugs obtained for use by anyone other than the person identified on the ID card.
• Replacement of lost or stolen prescriptions
• Test agents except diabetic test agents
• We reserve the right to exclude:
- A manufacturer’s product when the same or similar drug (that is, a drug with the same active ingredient
or same therapeutic effect), supply or equipment is on the [preferred] drug guide
- Any dosage or form of a drug when the same drug (that is, a drug with the same active ingredient or
same therapeutic effect) is available in a different dosage or form on our [preferred] drug guide
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
George Washington University 2023-2024 Page 30
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:
CVS Health
ATTN: Aetna PA
1300 E Campbell Road
Richardson, TX 75081
George Washington University 2023-2024 Page 31
Exclusions
Acupuncture
• Acupuncture
• Acupressure
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:
o 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
o 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.
Armed forces
• Services and supplies received from a provider as a result of an injury sustained, or illness 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.
Behavioral health treatment
• Services for the following based on categories, conditions, diagnoses or equivalent terms as listed in the most
recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric
Association:
- Stay in a facility for treatment for dementias and amnesia without a behavioral disturbance that
necessitates mental health treatment
- School and/or education service including special education, remedial education, wilderness treatment
programs, or any such related or similar programs
- Services provided in conjunction with school, vocation, work or recreational activities
- Transportation
- Sexual deviations and disorders except as described in the Eligible health services and exclusions section
- Tobacco use disorders except as described in the Eligible health services and exclusions – Preventive care
and wellness section
Beyond legal authority
• Services and supplies provided by a health professional or other provider that is acting beyond the scope of its
legal authority
George Washington University 2023-2024 Page 32
Blood, blood plasma, synthetic blood, blood derivatives or substitutes
Examples of these are:
• The provision of blood to the hospital, other than blood derived clotting factors
• Any related services including processing, storage or replacement expenses
• The services of blood donors, apheresis or plasmapheresis
• For autologous blood donations, only administration and processing expenses are covered
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.
This 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.)
• Coverage that may be provided under the Eligible health services and exclusions - Gender affirming treatment
section.
Court-ordered testing
• Court-ordered testing or care unless medically necessary
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.
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 and exclusions– Diabetic services and supplies (including equipment and training) section
in the certificate. 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
George Washington University 2023-2024 Page 33
within a school setting.
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
Experimental or investigational
• Experimental or investigational drugs, devices, treatments or procedures unless otherwise covered
under clinical trial therapies (experimental or investigational) or covered under clinical trials (routine
patient costs). See the Eligible health services under your plan – Other services section.
Facility charges
For care, services or supplies provided in:
• Rest homes
• Assisted living facilities
o Similar institutions serving as a persons’ main residence or providing mainly custodial or rest care
• Health resorts
• Spas or sanitariums
• Infirmaries at schools, colleges, or camps
Felony
• Services and supplies that you receive as a result of an injury due to your commission of a felony
Gender reassignment (sex change) treatment
- Cosmetic services and supplies such as:
• Rhinoplasty
• Face-lifting
• Lip enhancement
• Facial bone reduction
• Lepharoplasty
• Breast augmentation
• Liposuction of the waist (body contouring)
• Voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which are
used in feminization
• Chin implants, nose implants, and lip reduction, which are used to assist masculinization, are considered
cosmetic
Gene-based, cellular and other innovative therapies (GCIT)
Therapies and treatments including:
• Cellular immunotherapies.
• Genetically modified viral therapy.
• Other types of cells and tissues from and for use by the same person (autologous) and cells and tissues from one
person for use by another person (allogenic) for treatment of certain conditions.
• All human gene therapy that seeks to change the usual function of a gene or alter the biologic properties of
living cells for therapeutic use. Examples include therapies using:
George Washington University 2023-2024 Page 34
- Luxturna® (Voretigene neparvovec)
- Zolgensma® (Onasemnogene abeparvovec-xioi)
- Spinraza® (Nusinersen)
• Products derived from gene editing technologies, including CRISPR-Cas9.
• Oligonucleotide-based therapies. Examples include:
- Antisense. An example is Spinraza® (Nusinersen).
- siRNA.
- mRNA.
- microRNA therapies.
GCIT are defined as any services that are:
• Gene-based
• Cellular and innovative therapeutics
The services have a basis in genetic/molecular medicine and are not covered under the Institutes of Excellence™ (IOE)
programs.
Genetic care
• Any treatment, device, drug, service or supply to alter the body’s genes, genetic make-up, or the
expression of the body’s genes except for the correction of congenital birth defects
Growth/Height care
• A treatment, device, drug, service or supply to increase or decrease height or alter the rate of growth
• Surgical procedures, devices and growth hormones to stimulate growth
Incidental surgeries
• Charges made by a physician for incidental surgeries. These are non-medically necessary surgeries performed
during the same procedure as a medically necessary surgery.
Jaw joint disorder
• Surgical treatment of jaw joint disorders
• Non-surgical treatment of jaw joint disorders
• Jaw joint disorders treatment performed by prosthesis placed directly on the teeth, surgical and non-
surgical medical and dental services, and diagnostic or therapeutics services related to jaw joint
disorders including associated myofascial pain
This exclusion does not apply to covered benefits for treatment of TMJ and CMJ as described in the Eligible
health services under your plan –Temporomandibular joint dysfunction (TMJ) and craniomandibular joint
dysfunction (CMJ) treatment section.
Judgment or settlement
- Services and supplies for the treatment of an injury or illness to the extent that payment is made as a judgment
or settlement by any person deemed responsible for the injury or illness (or their insurers)
Mandatory no-fault laws
- Treatment for an injury to the extent benefits are payable under any state no-fault automobile coverage
George Washington University 2023-2024 Page 35
Maintenance care
• Care made up of services and supplies that maintain, rather than improve, a level of physical or mental
function, except for habilitation therapy services. See the Eligible health services and exclusions –
Habilitation therapy services section in the certificate
Medical supplies – outpatient disposable
• Any outpatient disposable supply or device. Examples of these are:
• Sheaths
• Bags
• Elastic garments
• Support hose
• Bandages
• Bedpans
• Syringes
• Blood or urine testing supplies
• Other home test kits
• Splints
• Neck braces
• Compresses
• Other devices not intended for reuse by another patient
Medicare
• Services and supplies available under Medicare, if you are entitled to premium-free Medicare Part A or enrolled
in Medicare Part B, or if you are not entitled to premium-free Medicare Part A or enrolled in Medicare Part B
because you refused it, dropped it, or did not make a proper request for it
Obesity (bariatric) surgery
• Weight management treatment or drugs intended to decrease or increase body weight, control weight
or treat obesity, including morbid obesity except as described in the Eligible health services under your
plan – Preventive care and wellness section, including preventive services for obesity screening and
weight management interventions. This is regardless of the existence of other medical conditions.
Examples of these are:
o Liposuction, banding, gastric stapling, gastric by-pass and other forms of bariatric surgery
o Surgical procedures, medical treatments and weight control/loss programs primarily intended to
treat, or are related to the treatment of obesity, including morbid obesity
o Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food
supplements, appetite suppressants and other medications
o Hypnosis or other forms of therapy
o Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy
or other forms of activity or activity enhancement
Other primary payer
• Payment for a portion of the charge that Medicare or another party is responsible for as the primary
payer
Personal care, comfort or convenience items
• Any service or supply primarily for your convenience and personal comfort or that of a third party
George Washington University 2023-2024 Page 36
Riot
• Services and supplies that you receive from providers as a result of an injury from your “participation in
a riot”. This means when you take part in a riot in any way such as inciting, or conspiring to incite, the
riot. It does not include actions that you take in self-defense as long as they are not against people who
are trying to restore law and order.
Routine exams
• Routine physical exams, routine eye exams, routine dental exams, routine hearing exams and other
preventive services and supplies, except as specifically provided in the Eligible health services under your
plan section
School health services
- Services and supplies normally provided by the policyholder’s:
• School health services
• Infirmary
• Hospital
• Pharmacy or
by health professionals who
• Are employed by
• Are Affiliated with
• Have an agreement or arrangement with, or
• Are otherwise designated by the policyholder.
Services provided by a family member
• Services provided by a spouse, domestic partner, civil union partner parent, child, step-child,
brother, sister, in-law or any household member
Sinus surgery
• Any services or supplies given by providers for sinus surgery except for acute purulent sinusitis
Strength and performance
• Services, , devices and supplies such as drugs or preparations designed primarily for enhancing your:
-Strength
-Physical condition
-Endurance
-Physical performance
Students in mental health field
• Any services and supplies provided to a covered student who is specializing in the mental health care field
and who receives treatment from a provider as part of their training in that field
Telemedicine
• Services given when you are not present at the same time as the provider
• Services including:
– Telephone calls
– Telemedicine kiosks
– Electronic vital signs monitoring or exchanges, (e.g. Tele-ICU, Tele-stroke)
George Washington University 2023-2024 Page 37
Therapies and tests
• Full body CT scans
• Hair analysis
• Hypnosis and hypnotherapy
• Massage therapy, except when used as a physical therapy modality
• Sensory or auditory integration therapy
Tobacco cessation
• Any treatment, drug, service or supply to stop or reduce smoking or the use of other tobacco products
or to treat or reduce nicotine addiction, dependence or cravings, including, medications, nicotine
patches and gum unless recommended by the United States Preventive Services Task Force (USPSTF).
This also includes:
• Counseling, except as specifically provided in the Eligible health services under your plan –
Preventive care and wellness section
• Hypnosis and other therapies
• Medications, except as specifically provided in the Eligible health services under your plan –
Outpatient prescription drugs section
• Nicotine patches
• Gum
Treatment in a federal, state, or governmental entity
- Any care in a hospital or other facility owned or operated by any federal, state or other governmental entity,
except to the extent coverage is required by applicable laws
Vision care for adults
• Routine vision exam provided by an ophthalmologist or optometrist, including refraction and glaucoma testing
• Vision care services and supplies
Wilderness treatment programs
See Educational services within this section
Work related illness or injuries
• Coverage available to you under worker’s compensation or under a similar program under local, state or
federal law for any illness or injury related to employment or self-employment.
o A source of coverage or reimbursement will be considered available to you even if you waived your right to
payment from that source. You may also be covered under a workers’ compensation law or similar law. If you
submit proof that you are not covered for a particular illness or injury under such law, then that illness or injury
will be considered “non-occupational” regardless of cause.
The George Washington University Student Health Insurance Plan is underwritten by Aetna Life Insurance Company
Aetna Student Health
SM
is the brand name for products and services provided by Aetna Life Insurance Company and its
applicable affiliated companies (Aetna).
If coverage provided by this policy violates or will violate any economic or trade sanctions, the coverage is immediately
considered invalid. For example, Aetna companies cannot make payments for health care or other claims or services if it
violates a financial sanction regulation. This includes sanctions related to a blocked person or a country under sanction
by the United States, unless permitted under a written Office of Foreign Asset Control (OFAC) license. For more
information, visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx
.
George Washington University 2023-2024 Page 38
Assistive Technology
Persons using assistive technology may not be able to fully access the following information. For assistance, please call
1-877-480-4161.
Smartphone or Tablet
To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App
Store.
Non-Discrimination
Aetna is committed to being an inclusive health care company. Aetna does not discriminate on the basis of ancestry, race,
ethnicity, color, religion, sex/gender (including pregnancy), national origin, sexual orientation, gender identity or
expression, physical or mental disability, medical condition, age, veteran status, military status, marital status, genetic
information, citizenship status, unemployment status, political affiliation, or on any other basis or characteristic prohibited
by applicable federal, state or local law.
Aetna provides free aids and services to people with disabilities and free language services to people whose primary
language is not English.
These aids and services include:
1. Qualified language interpreters
2. Written information in other formats (large print, audio, accessible electronic formats, other formats)
3. Qualified interpreters
4. Information written in other languages
If you need these services, contact the number on your ID card. Not an Aetna member? Call us at 1-877-480-4161.
If you have questions about our nondiscrimination policy or have a discrimination-related concern that you would like to
discuss, please call us at 1-877-480-4161.
Please note, Aetna covers health services in compliance with applicable federal and state laws. Not all health services are
covered. See plan documents for a complete description of benefits, exclusions, limitations, and conditions of coverage.
Language accessibility statement
Interpreter services are available for free.
Attention: If you speak English, language assistance service, free of charge, are available to you. Call 1-877-480-
4161 (TTY: 711).
Español/Spanish
Atención: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-877-480-4161 (TTY: 711).
አማርኛ/Amharic
George Washington University 2023-2024 Page 39
ልብ ይበሉ: ኣማርኛ ቋንቋ የሚናገሩ ከሆነ፥ የትርጉም ድጋፍ ሰጪ ድርጅቶች፣ ያለምንም ክፍያ እርስዎን ለማገልገል ተዘጋጅተዋል። የሚከተለው ቁጥር ላይ
ይደውሉ 1-877-480-4161 (መስማት ለተሳናቸው: 711).
/Arabic
:
.
4161-480-877-1 )
:
711
.
(
Ɓàsɔ
̍
ɔ
̀
Wùɖù/Bassa
Dè d nìà k dy
k
dyi às
-wùù-po-ny
j n
, nì
à wuu kà kò ò po-po
gbo kp
a.
1-877-480-4161 (TTY: 711).
中文/Chinese
注意：如果您说中文，我们可为您提供免费的语言协助服务。请致电 1-877-480-4161 (TTY: 711)。
/Farsi
1-877-480-4161 )TTY: 711
Français/French
Attention : Si vous parlez français, vous pouvez disposer d’une assistance gratuite dans votre langue en composant le 1-
877-480-4161 (TTY: 711).
/Gujarati
:
:
.
1-877-480-4161 (TTY: 711).
Kreyòl Ayisyen/Haitian Creole
Atansyon: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-480-4161 (TTY: 711).
Igbo
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주의: 한국어를 사용하시는 경우, 언어 지원 서비스가 무료로 제공됩니다. 1-877-480-4161(TTY: 711)번으로 전화해
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Português/Portuguese
George Washington University 2023-2024 Page 40
Atenção: a ajuda está disponível em português por meio do número 1-877-480-4161 (TTY: 711). Estes serviços são
oferecidos gratuitamente.
Русский/Russian
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Tagalog
Paunawa: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng serbisyo ng tulong sa wika nang walang bayad
.
Tumawag sa 1-877-480-4161 (TTY: 711).
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1-877-480-4161 (TTY: 711) .
Tiếng Việt/Vietnamese
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Àkíyèsí: Bí o bá á, ìrànl
w
lórí èdè, lóf
, wà fú1-877-480-4161 (TTY: 711).
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).
