Highlights of benefits and services 2011 2012 Student

Highlights of benefits and services. 2011 -2012 Student Medical Insurance Plan Brought to you by Aetna Student Health. SM Information about your health plan Henry M. Goldman School of Dental Medicine

Eligibility requirements. 2011 -2012 Student Medical Insurance Plan. All students of the Henry M. Goldman School of Dentistry will automatically be charged for, and enrolled in, the Boston University Student Medical Insurance Plan (SMIP) PLUS plan. You may elect to waive this coverage if have comparable coverage (for more information on comparable coverage, visit www. bu. edu/studentaccountingservices/resources/medical -insurance/comparable-coverage/). Waivers are completed each year through your Boston University Student Link account. You may also elect to enroll your eligible spouse or dependent children. For more information on eligible dependents or how to enroll them for coverage, please refer to the Plan brochure available on www. aetnastudenthealth. com. NOTE: Dependents of BUGSDM students are only eligible for the SMIP BASIC plan; please refer to the Plan brochure available on www. aetnastudenthealth. com for the benefits Who is covered?

Costs and coverage dates. 2011 -2012 plan costs and coverage dates for the BUGSDM plan. What is the cost for insurance? New AEGD Students Plan active from 7/1/2011 to 8/31/2012 Student $3, 120 (Plus Plan) Spouse $4, 843 (Basic Plan) Child(ren) $2, 648 (Basic Plan) New Oral Biology and Perio 1 Students Plan active from 8/23/2011 to 8/22/2012 Student $2, 647 (Plus Plan) Spouse $4, 140 (Basic Plan) Child(ren) $2, 264 (Basic Plan) New Postdoctoral Students (Except Oral biology) Plan active from 7/1/2011 to 8/22/2012 Student $3, 017 (Plus Plan) Spouse $4, 740 (Basic Plan) Child(ren) $2, 594 (Basic Plan) New Predoctoral Students Plan active from 8/1/2011 to 8/22/2012 Student $2, 801 (Plus Plan) Spouse $4, 497 (Basic Plan) Child(ren) $2, 461 (Basic Plan)

Using your health insurance. Where to go for medical care. For routine & immediate care, men’s or women’s health issues (including annual gynecological exams and testing), or sports medicine, consider making Student Health Services (SHS) your first stop for treatment. Note: only students may utilize the services at SHS is located on the Charles River Campus at 881 Commonwealth Avenue. Practitioners are available Monday through Saturday. For more information, including hours of operation, visit www. bu. edu/shs/about/index. shtml. In the case of a medical emergency, visit the nearest hospital emergency room or call 911. You may choose any provider of your choice. Savings may be obtained by using providers participating in the Aetna Preferred Provider Network. To find a Preferred Provider, visit: www. aetna. com/docfind/custom/studenthealth/ Where do I go for medical treatment?

Covered services. This is only a summary of how services are covered. Please read the Plan brochure for more details. Student Plus Plan In-Network Policy Year Maximum (per person; per Policy Year) Policy Year Deductible Out-of-Network $500, 000 None $250 N/A $2, 500 Hospital $100 Copay, then 100% 80% after Deductible Surgical $50 Copay, then 100% 80% after Deductible Office Visit (36 visit limit per condition) $15 Copay, then 100% 80% after Deductible Emergency Room (Copay waived if admitted) $50 Copay, then 100% $50 Deductible, then 100% Outpatient mental health (36 visit limit per condition ppy) $10 Copay, then 100% 80% after Deductible Routine Physical Exams, Physical Therapy, Chiropractic Care $15 Copay, then 100% 80% after Deductible Out-of-pocket (does not include deductible or Copays) Routine Labs Pap Smear & Mammo; PSA; Serum Cholestrol/HDL; Tuberculin (PDD) Testing (Tine or Intradermal Mantoux skin test); Lead Screening; HIV Testing; STDs 100% Routine Immunizations Prescription Drugs (No maximum; Mail Order 90 -day supply at 2 x Retail Copays) 80% after Deductible Influenza vaccine (Flu); Pneumococcal vaccine; Meningococcal vaccine; Hepatitis A & B vaccine; Lymerix (Lyme Disease); Foreign travel (e. g. . cholera, Japanese B encephalitis, rabies, typhoid, yellow fever, malaria, etc. ); Pneuomoccocal conjugate vaccine (Prevnar, Prevenar) $10 Generic Drug/ $30 Preferred. Brand Name Drug/ $45 Non. Preferred Brand Name Drug Full plan details available at www. aetnastudenthealth. com 80%

After you seek medical treatment. Aetna Student Health is your claims administrator. Present your ID card to medical providers at your visit. Most providers will bill Aetna Student Health directly. If you need to submit a claim for medical treatment yourself, send the itemized statement to: Aetna Student Health P. O. Box 981106 El Paso, TX 79998 Prescription Drug Expenses from Preferred Pharmacies (participating in the Aetna network) will submit claims on your behalf – you will be responsible for applicable copays at the time of service. Claims for prescriptions from Non. Preferred Pharmacies may be submitted to: Aetna Pharmacy Management ATTN: Claim Processing P. O. Box 14024 Lexington, KY 40512 -4024 How do I use the insurance?

Included Programs and Services. For you and your covered dependents. As a member of an Aetna Student Health plan, you and your dependents will have access to the several discount and service programs at no additional cost. On Call International will provide you with unlimited medical evacuation/repatriation, return of mortal remains, as well as travel assistance services whenever you are away from your home country, or more than 100 miles from campus. You and your covered dependents also have a $10, 000 Accidental Death & Dismemberment policy, providing your next of kin added financial piece of mind. You will also have access to the Aetna discount programs, such as Aetna Vision. SM which provides discounts on eye exams glasses, and contact lenses; discounts on fitness equipment and gym memberships; discounts on natural products and services; and much more. Consult the Plan brochure for more details at www. aetnastudenthealth. com. What else does the plan offer?

Health and wellness resources and tools. For you and your covered dependents. As a member of an Aetna Student Health plan, you and your dependents will have access to tools to help you: estimate costs of many common medical tests and procedures; determine if a prescription drug is covered by your plan (and how much it will cost); look-up information to help you stay healthy; and information on many different health topics. You will also be able to look at claim payments, reprint Explanation of Benefits (EOBs), and print temporary insurance ID cards. Once you are enrolled in the Plan, register for your personal Aetna Navigator® account by visiting our website: www. aetnastudenthealth. com, click on Find Your School, select Boston University and follow the instructions under the “For Members” link. What other health resources are available to me?

Important contact information. For questions about fee assessments, enrolling your dependent, waiver questions: Boston University Student Accounting Services phone: (617)353 -2264 email: studenta@bu. edu Who do I contact for additional questions or information? For questions about your bills and claims, benefit coverage, replacement ID cards, or inpatient hospitalization pre-certification: Aetna Student Health phone: (800) 966 -7772 (Toll-Free) For a listing of Preferred Providers in the Aetna network: www. aetna. com/docfind/custom/studenthealth/