Medical Goods and Services

CMU SHIP Benefit

Notes

Individual Premium

$2,339

A premium is the amount you pay to be enrolled in CMU SHIP.

A monthly payment option is available for a $20 fee to avoid paying a lump sum. See cmu.afford.com for more information and to sign up.

Individual Deductible

$0

A deductible is how much you would need to pay out-of-pocket before Aetna pays. For in-network, there is no deductible (benefits apply right away) but out-of-network it is $250/year.

Maximum Individual Out-of-Pocket Limit

$5,000

This is the maximum amount you could be charged for the year out-of-pocket (excludes premium). After you have paid this amount, Aetna will pay for all covered costs the rest of the year.

If you visit a healthcare provider:

Primary Care Visit

$25 co-pay

A primary care physician (PCP) is a healthcare professional who practices general medicine. They handle preventative care and non-emergency medical visits (everything from annual physicals to check-ups when you have a cold/flu).

**Note: If you schedule a Primary Care type visit at UHS, there is not a visit co-pay, though additional fees may apply for lab work, medication, and certain services.

Specialist Visit

$25 co-pay

To visit a specialist, you do not need a referral, however working with your PCP or UHS can help you find the right kind of specialist for the health services you need. Examples of specialists include: allergists, dermatologists, and gynecologists. Be careful because certain tests and treatments specialists can give may be subject to coverage exclusions.

Immunizations

$0

Covers all preventative immunizations including CMU required shots and annual flu shots.

Routine Physical Exam

$0

SHIP covers 1 routine physical exam per year.

The focus of this exam is screening and prevention rather than response to illness/injury.

If you need a prescription:

Preferred Generic Drugs

$15 co-pay

Prescription drugs have two classifications:

1. Generic vs Brand Name: Generics have the same active ingredient as a Brand Name drug, but may differ in additional components.

2. Preferred vs Non-Preferred: Aetna maintains a list of drugs (called a formulary) that they cover (preferred drugs). If you are prescribed something that is non-preferred, you will be subject to a higher payment.

Copays are waived (meaning you pay nothing out-of-pocket) for many types of female contraceptives, oral anti-cancer drugs, and tobacco cessation prescriptions.

**Note: Listed copays apply for up to a 30 day supply filled at a retail pharmacy. Different copays apply for larger supplies and filling at mail-order pharmacies.

Preferred Brand Name

$35 co-pay

Non-Preferred Brand Name

$65 co-pay

If you need medical attention:

Urgent Care Visit

$25 co-pay

Urgent Care provides same-day doctor’s care in non-emergency situations (non-severe illness and injury). Unlike a Primary Care visit, you do not need an appointment ahead of time.

Emergency Room Services

$125

(waived if admitted)

ER services should be utilized for severe medical conditions where rapid or advanced treatments (such as surgery) may be required. They are recommended for broken bones/ dislocated joints, cuts requiring stitches, persistent chest or abdominal pain, seizures, etc.

While the $125 co-pay is waived if you are admitted to the hospital, you would have to pay the $150 co-pay for inpatient care instead (listed below as “If you have a hospital stay”).

**Note: If you are experiencing an emergency, you should go to the closest ER, regardless of if it is in- or out-of-network. In this instance, Aetna covers the visit the same.

Emergency Medical Transportation

$0

This includes ground, air, and water ambulances. Like ER visits, in an emergency situation, Aetna does not distinguish between in- and out-of-network providers. Non-emergency transports are not covered.

If you have mental health, behavioral health or substance abuse needs:

Outpatient:

• Mental/Behavioral Health

• Substance Use Disorder

$0

Outpatient services include: office visits to a physician or behavior health specialist, partial hospitalization treatments (>4 hours but <24 hours per day of treatment), and intensive outpatient programs (>2 hours per day and >6 hours per week).

**Note: Counseling visits at CaPS are not subject to insurance as they are offered free of charge to all students.

Inpatient:

• Mental/Behavioral Health

• Substance Use Disorder

$150 co-pay

per admission

Inpatient services include: room and board as well as treatment costs at an inpatient hospital/residential treatment facility. Unless an intensive care unit is required, all inpatient stays are subject to a semi-private room rate.

If you have a test:

Diagnostic Test

$25 co-pay

Diagnostic Tests include x-rays and bloodworm. Complex Imaging include CT/PET scans and MRIs. They can be performed in the outpatient hospital facilities, physicians’ offices, or specialists’ facilities.

Complex Imaging

$40 co-pay

If you have outpatient surgery:

Surgical expense

$0

Outpatient Surgeries are covered in full by Aetna for the surgical service and the facilities fees. Exclusions occur in coverage with regards to charges for other physicians who assist in the surgery.

Anaesthesia Expense

$0

Medical Goods and Services

CMU SHIP Benefit

Notes

If you have a hospital stay:

Room and Board Expense

$150 co-pay

per admission

Room and board includes intensive care and is subject to a semi-private room rate.

Inpatient surgery fees are covered in full by Aetna for the surgical service (including anesthetist and surgical assistant charges).

** Note: This does not cover elective and/or cosmetic procedures.

Physician/Surgeon Fees

$0

If you need help recovering:

Chiropractic Therapy

$0

Up to 25 visits are covered per year.

Physical, Occupational,

& Speech Therapy

$0

Short-term outpatient rehabilitation therapies and habilitation therapy services are covered in full. When related to autism spectrum disorders, check with Aetna for coverage rate.

Chemotherapy Expense

$0

Chemotherapy and outpatient radiation therapy are both fully covered by Aetna.

Durable Medical Equipment

$0

Durable medical equipment of many types and prosthetic devices are fully covered by Aetna. Some exclusions do apply so precertification should be performed before purchase.

Diagnostic Testing for Learning Disabilities

$0

You should seek precertification of testing because some exceptions do apply.

**Note: If this is performed at UHS, cost is fully covered.

If you are pregnant:

Pre- and Post-natal Care

$0

Preventative prenatal services (including lactation support and counseling) are covered in full by Aetna with some limits on the number of visits per year. Well newborn nursery care in the hospital or birthing center is also covered in full.

Delivery and All Inpatient Services

$150 co-pay

per admission

Subject to same rules as non-delivery inpatient coverage benefits.