AVÃûʪ

• Coverage for services provided byÌýMedical Services
• Local and national coverage (copays, deductible and coinsurance apply)
• Prescription benefit
• Out-of-pocket maximum of $5,000 for in-network and $10,000 for out-of-network per plan year
• Unlimited policy maximum
• The plan is underwritten by Aetna and administeredÌýby AmeriBen
• Summary of Benefits

Eligible students must actively attend classes for at least the first 31 days after the date for which coverage is purchased.

• Degree-seeking undergraduate students enrolled in six or more credit hours and graduate students enrolled in one credit hour or more are eligible and are automatically enrolled in the Gold Plan.
• Non-degree seeking Continuing Education students enrolled in six or more credit hours, Study Abroad (including Semester at Sea) students, Evening MBA students and students enrolled exclusively in Be Boulder Anywhere course and paying the base student fee and Wardenburg Health Center fees, may be eligible to enroll in the Gold Plan and must do so by visiting Wardenburg Health Center.
• Students approved for the Leave of Absence Program are eligible to enroll in the Gold Plan for one semester that they are not registered for classes and must do so by visiting Wardenburg Health Center.

Spouse and dependent coverage is not available on the Gold Plan.

No copay or deductible for coveredÌýservices provided by Medical Services including:

Medical Care

• Primary and preventive care
• Physical exam
• Treatment forÌýillnesses and injuries
• Travel health services excluding specialty travel immunizations
• Routine vaccinations
• Allergy shots antigen not provided by health center

Nutrition Services

• Nutrition counseling for a variety of concerns

Lab & X-Ray

• Coverage for lab services ordered and managed by a Medical ServicesÌýprovider
• Coverage for x-ray services

Counseling and Psychiatry

• 14Ìýcounseling and psychiatry visits per policy year including:
  • Individual counseling
  • Couples counseling
  • Medication management
  • Crisis care
• 20 counseling and psychiatry visits with a provider in the community at a $20 copay
• Unlimited group therapy
• 50% coverage of psychological testing ordered by a Medical Services provider; subject to availability

Physical Therapy and Integrative Care

• 25Ìýphysical therapy visits per policy year
• 10 chiropractic visits per policy year
• Orthopedic surgeon consultations

Note: CU Sports Medicine at the Champion Center is not part of CU Boulder Medical Services.

Sexual and Reproductive Health

• Annual exam
• Sexually transmitted infection testing and treatment
• Gynecology services
• Birth control consultations
• Transgender patient care and hormone therapy

Please note: Students who require a higher level of care than we can provide will be referred to an outside provider and the deductible and coinsurance will apply.

Specialist Visits

A referral from a Medical Services provider is required for coverage off campus. Please contact Student Health Insurance and ReferralsÌýat 303-492-5107 before scheduling an appointment with a specialist and for information aboutÌýexceptions to the referral requirement. This plan also includes international coverage.

In-Network Providers

• $20 copay per mental health visitÌý(copays do not apply to the deductible)
• $40 copay per other health visit (copays do not apply to the deductible)
• A $500 deductible per person per policy year will apply for some office visit procedures; surgeries; imaging such as MRIs, ultrasounds, and CTs; and lab services.
• Coinsurance applies once the deductible is met; patient pays 20 percent up to a $5,000 out-of-pocket maximum per policy year
• For a complete list of in-network providers visitÌý

Out-of-Network Providers

• A $1,000 deductible per person per policy year will apply.
• Coinsurance applies once the deductible is met; patient pays 50 percent up to a $10,000 out-of-pocket maximum per policy year

The Gold Plan prescription benefits have changed.ÌýYou will need to provide new insurance information to your pharmacy.ÌýAmeriben sent an email to all Gold-insured students in September, giving students access to their electronic insurance card.ÌýÌý If you wish to obtain a paper card, please call Ameriben at 855-639-8676.ÌýA temporary insurance card is availableÌýonlineÌýby phone or email at 303-492-5107/ patientservices@colorado.edu.Ìý

Certain medication can be dispensed in a 90-day supply through the Wardenburg Apothecary.Ìý Please be aware that aÌý90-day supply is not allowed at outside pharmacies without an over-ride.

Mail order information and instructions:

Save time and skip the line with the Aetna Rx Home Delivery pharmacy. Gold Plan members can request their prescriptions to be mailed. Make a request online or print and send in an order form.Ìý

If you have been using the specialty pharmacy to fill your prescriptions, this service will change.Ìý Please contact Ameriben directly at 855-480-4161 for instructions on how to obtain these specialty medications.

The Gold Plan includes:

• Hormone therapy available through Dr. Ann Mattson locatedÌýin the Sexual and Reproductive Health Clinic. This benefit is also available through in-network providers outside of Wardenburg, for which a referral may be necessary.Ìý
• Mental health counseling and pre-approval letters available throughÌýCounseling andÌýPsychiatric Services. This benefit is also available through in-network providers outside of Wardenburg, for which a referral may be necessary.
• Gender Confirmation Surgery Benefit Information. For an explanation of this benefit, contact Student Health Insurance and Referrals.Ìý
• Gender Confirmation Procedural Benefit Codes.ÌýFor an explanation of this benefit, contact Student Health Insurance and Referrals.Ìý

Gender Confirmation Surgery and Related Therapy Eligible Expenses include:

1. mental health counseling;
2. hormone replacement therapy;
3. sexual reassignment surgery:
   1. for female to male:Ìýmastectomy, hysterectomy,Ìýsalpingo-oophorectomy, vaginectomy,Ìýmetoidioplasty, scrotoplasty,Ìýurethroplasty, placement of testicular prosthesis, phalloplasty; or
   2. male to female:Ìýorchiectomy, penectomy, vaginoplasty, clitoroplasty, labiaplasty, breast augmentation.

Students who would like to learn more about accessing their gender confirmation benefits can contact our Ameriben representative, Jennifer Barr, at 1-208-947-9519 or jbarr@ameriben.com.Ìý

The Student Health Insurance and Referrals department is also available to answer questions atÌý303-492-5107.

For moreÌýinformation, see transgender and gender affirmingÌýcare at Medical Services.

• $75 copay per urgent care visit; coinsurance will apply
• $150 copay per emergency room visit; deductible and coinsurance will apply
• $200 charge for hospitalization per admission;Ìýdeductible and coinsurance will apply

Vision

Annual Eye Exam

Gold Plan students are entitled to one routine eye exam per policy year at no additional cost through . This includes visual fields testing, glaucoma screening, refraction, and a dilated exam if needed.Ìý

Contact lens fittings, and medical eye care services are available at an additional fee to the patient. Eyeglass frame and lenses are offered at a discount to students with the CU Gold plan.Ìý

College Optical:Ìý303-444-3092 Ìý| Ìý

Aetna Vision Discount Program

Gold Plan studentsÌýare enrolled in the Aetna Vision Discount Program which provides discounts on glasses, contactsÌýand LASIK with participating providers.Ìý

Dental

Annual Dental Exam, Cleaning and X-Ray

Gold Plan students are entitled to one dental exam, cleaning* and x-ray per policy year at no additional cost through PERFECT TEETHâ„¢.Ìý

PERFECT TEETHâ„¢ Locations:

*Cleaning will be done in the absence of periodontal disease.

PERFECT TEETHâ„¢ Discount Plan

Gold Plan students are entitled to receive additional dental services at the same discounted rates available through the PERFECT TEETH Dental Plan. These expenses are the patient’s responsibility.ÌýÌý

For more informationÌývisit the

Accidental Injury to Sound Natural Teeth and Removal of Impacted Wisdom TeethÌý

Limited benefits for these services are covered by the Gold Plan. Please provide your Gold Health Insurance Card to the dental provider for billing purposes.

Contact Student Health Insurance and Referrals at 303-492-5107 for questions relating to benefit limits and patient financial responsibility.