DIANins Student Plan

DIANins Blue

 

General Features and Plan Specifications
Network in U.S. Aetna
Maximum annual Unlimited            
Home Country Coverage $500 Per Policy Period
Area of Coverage Worldwide
Pre-Existing Conditions No limits or Exclusions
Benefit Descriptions US In-Network,
Outside US
Out-of Network
Annual Individual Deductible(Per policy year)
Family Deductible is 2 times Individual
After the Deductible has been satisfied, benefits will be paid as listed for the Provider selected based on UCR. Or the negotiated rates
Option 1:$0
Option 2:$250
Option 3:$1500
Option 1:$250
Option 2:$750
Option 3:$2500
Member Coinsurance (after deductible) 80% 60%
Office Visit Co-payment(after deductible) $25 $50
Individual Out-of-Pocket Maximum
Family Out-of-Pocket 2 times Individual
$5,000 Unlimited
INPATIENT AND HOSPITALIZATION BENEFIT: Pre-Authorization Required

  • Room and Board (semi-private room)
  • Intensive Care/Cardiac Care (medically necessary)
  • Hospital Miscellaneous Expenses (plus pre-admission Testing)
  • Inpatient Consultation (Physician or Specialist)
  • Surgeon Expense
  • Assistant Surgeon or Anesthesiologist
  • Diagnostics X-Rays and Lab
  • including Hi-Tech Scans (CT, MRI&PET) (Inpatient & Outpatient)
  • Chemotherapy, Radiotherapy
  • Reconstructive Surgery
  • Inpatient Surgery
80% 60%
Out Patient Benefit

  • Surgeon Expense
  • Advanced Diagnostics including Hi-Tech Scans (CT. MRI&PET)
  • Outpatient or Ambulatory Surgery
80% 60%
Physician’s Visits
Inpatient or outpatient; $25 Copay per visit
80% 60%
Prescription Drug-including contraceptives

  • $25 Deductible per prescription for generic drugs
  • Up to 31-day supply per prescription
80% 60%
Emergency Room Deductible $300 (waived if admitted) 80% 60%
Maternity

  • Normal delivery including prenatal care, postnatal care and complications of pregnancy
  • Fertility/infertility services, tests, treatments, drugs and/or procedures, complications of that pregnancy, delivery and postpartum care are excluded from coverage.
80% 60%
Elective Abortion
Paid as any other sickness
80% 60%
Routine Newborn Care
While Hospital Confined; and routine nursery care provided immediately after birth for an inpatient stay of at least 48 hours following a vaginal delivery or 96 hours following a cesarean delivery. If the mother agrees, the attending Physician may discharge the newborn earlier.
80% 60%
Therapeutic Services, Physiotherapy (Outpatient)
Physical Therapy, Chiropractic, Occupational Therapy, Vocational Speech Therapy. 12 visits per injury per sickness
80% 60%
Homeopathic and Acupuncture
Treatment for a covered illness
**Annual Benefit Maximum: $500
80%** 60%**
Ambulance Services

  • Ground Ambulance
  • Air Ambulance: Pre-Authorization Required
  • Refer to Policy for more specific details
80% 60%
Durable Medical Equipment: Pre-Authorization Required
Reimbursement of rental up to purchase price
80% 60%
Private Duty Nursing: Pre-Authorization Required
Skilled Nursing, Visiting Nurse, Home Health Nursing
80% 60%
Diabetic Supplies: Pre-Authorization Required
Includes Insulin Pumps and associated supplies
80% 60%
Mental Health
Inpatient or Outpatient
80% 60%
Alcohol and Drug Abuse: Pre-Authorization Required
Inpatient or Outpatient
80% 60%
Dental Care
Limited to accident injury or sound natural teeth sustained while covered under the policy
**Annual Benefit Maximum: $250 per tooth; $1,000 per policy period
80%** 60%**
Urgent Care Center
Facility of clinic fee billed by the UCC. All other services rendered during the visit will be paid as specified in the Schedule of Benefits $50 Copay per visit
80% 60%
Tests and Procedures
Diagnostic services and medical procedures performed by a Physician, other than Physician’s Visits Physiotherapy, x-ray and lab procedures. The following therapies will be paid under this benefit: inhalation therapy, infusion therapy, pulmonary therapy and respiratory therapy.
80% 60%
Approved Clinical Trials
Routine patient care costs incurred during participation in an approved clinical trial for the treatment of cancer or other life-threatening condition
80% 60%
Preventive Care / Annual Exams

Child Wellness

  • Includes child immunizations and routine medical exams
  • 0-12 months of age – maximum 9 visits
  • Up to 18 years – Annual visit

Adult Wellness

  • Adult Female and Male Examinations, Mammograms and Immunizations Covered on an Annual Exam Basis
100% N/A
ADDITIONAL BENEFITS
Medical Evacuation Unlimited per policy Period
Repatriation Unlimited per policy Period
War and Terrorism Included                                                                 .
DIAN Blue offers international students an alternative to more expensive university plans; it provides health insurance which meets health insurance waiver requirements of most higher education institutions. Coverage is available to all International Students studying outside their home country who are enrolled and actively attending an accredited high school, college or university. The plan offers worldwide coverage, with no geographic restrictions.

Highlights Include:

  • Unlimited Lifetime Maximum
  • No Annual Maximum
  • Emergency Inpatient and Outpatient Care; Preventative care is covered as well.
  • Worldwide direct-bill network plan, including the Aetna Preferred Provider network in the US, available with the Access plan; there is no need to pay for your health services at the time of delivery.
  • The Aetna network includes healthcare providers and hospitals throughout the 50 states in the United States.
Ages ranges Deductible Option /   Yearly Rates
$0 $250 $1,500
12-24 $961 $899 $706
25-29 $1,625 $1,493 $1,237
30-40 $4,233 $3,995 $3,022
Spouse $9,595 $7,966 $7,171
Child $2,084 $1,761 $1,586
Ages ranges Deductible Option / Monthly Rates
$0 $250  $1,500
12-24 $80 $75 $59
25-29 $135 $124 $103
30-40   $353 $333 $252
Spouse $800 $664 $598
Child $174 $147 $132
Ages ranges Deductible Option    /    Daily Rates
$0 $250 $1,500
12-24 $2.64 $2.47 $1.94
25-29 $4.46 $4.10 $3.40
30-40 $11.63 $10.98 $8.30
Spouse $26.36 $21.88 $19.70
Child $5.72 $4.84 $4.37

Exclusions and Limitations

All services and benefits described below are excluded from coverage or limited under your policy of Insurance.

 

  1. Claims and costs for medical treatment, occurring before the effective date of coverage (including waiting periods) or after the expiration date of the Policy. This includes any portion of a covered Prescription Drugs to be used after the expiration of the current Policy year.
  2. Services, supplies, or treatment including Prescription Drugs and/or emergency services that are provided by or payment is available from: (a) Workers’ Compensation law, Occupational Disease law or similar law concerning job related conditions of any country, (b) the Plan Participant, a family member or any enterprise owned partially or completely by the aforementioned persons, (c) another insurance company or government, (d) under the direction of public authorities related to epidemics.
  3. Services, supplies or treatments, including Prescription Drugs, that are not scientifically or medically recognized for a specific diagnosis, or that is considered as off label use, Experimental or not approved for general use are considered Experimental and/or Investigational and therefore not eligible services.
  4. Any services, supplies, treatments including Prescription Drugs and/or emergency air services: (a) not ordered by a Physician, (b) not Medically Necessary, (c) not recommended or approved by a Physician, (d) not rendered under the scope of the Physician’s licensing, (e) medical and dental services that do not meet professionally recognized standards or are determined by Insurer to be unnecessary for proper treatment.
  5. Telephonic consultations, missed appointments, or “after hours” expenses.
  6. Personal comfort and convenience items including but not limited to television, housekeeping services, telephone charges, take home supplies, ambulance services (other than those provided by this Policy), and all other services and supplies that are not Medically Necessary including expenses related to travel and hotel costs incurred for medical or dental care.
  7. Health check-ups, inoculations, visits, and tests necessary for administrative purposes (e.g. determining insurability, employment, school or sport related physical examinations, travel etc.).
  8. Immunizations, other than provided for under the wellness benefit as listed on the schedule.
  9. Over-the-counter (OTC) drugs, supplies or medical devices, which do not require a Physician prescription, even if recommended by a Physician, including but not limited to: smoking cessation drugs, appetite suppressant, hair regenerative drugs or products, anti-photo aging drugs, cosmetic and beauty aids, acne and rosacea drugs (including hormones and retin A) for cosmetic purposes, megavitamins, vitamins, (other than pre-natal as described under maternity), sexual enhancement devices, supplements, herbs or drugs, for any reason.
  10. Services and supplies related to visual therapy, radial keratotomy procedures, lasik, or eye surgery to correct refractive error or deficiencies, including myopia or presbyopia.
  11. Rest cures, Custodial Care, home-like care, assistance with Activities of Daily Living (ADL), milieu therapy for rest and/or observation, whether or not prescribed by a Physician. Any Admission to a nursing home, home for the aged, long term care or Rehabilitation facility, sanatorium, spa, hydro clinic or similar facilities that do not meet the Policy definition of a Hospital. Any Admission, arranged wholly or partly for domestic reasons, where the Hospital effectively becomes or could be treated as the Plan Participant’s home or permanent abode.
  12. Elective and or cosmetic surgery, procedures, treatments, technologies, drugs, devices, items and supplies that are not Medically Necessary treatment of a covered Accidental injury or Illness or disease, and that may only be provided for the purpose of improving, altering, enhancing, or beautification unless required due to the treatment of an injury, deformity, or Illness that compromises functionality and that first occurred while the Plan Participant was covered under this Policy. This also includes any surgical treatment for nasal or septal deformity that was not induced by trauma. Cosmetic surgery is defined as surgery or therapy performed to improve or alter appearance for self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance.
  13. Any medical complications arising directly or indirectly as a result of a non-authorized elective or cosmetic procedure.
  14. Medical expenses resulting from a motor vehicle Accident in excess of that which is payable under any other valid and collectible insurance.
  15. Sleep studies and other treatments relating to sleep apnea including restless leg syndrome.
  16. Weight related treatment: any expense, service or treatment for obesity, weight control, or any form of food supplement. This includes expenses related to or associated with treatment of morbid or non-morbid obesity, including, but not limited to, gastric bypass, gastric balloons, gastric stapling, jejunal ileal bypass, and any other procedures or complications arising there from.
  17. Organ transplant and related procedures.
  18. Any fertility/infertility services, tests, treatments and/or procedures of any kind, including, but not limited to, fertility/infertility drugs, including drugs to regulate the menstrual cycle/ovulation for family planning purposes, artificial inseminations, in-vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), surrogate mother and all other procedures and services related to fertility and infertility. Any pregnancy resulting from such treatments, pre-natal care, complications of that pregnancy, delivery and postpartum care are also excluded.
  19. Genetic counseling, screening, testing or treatment.
  20. Elective abortions: any voluntarily induced termination of pregnancy, unless the mother’s life is in imminent danger.
  21. Conditions related to sex or gender issues and sexually transmitted diseases. Any expense for gender reassignment, sexual dysfunction including but not limited to impotence, inadequacies, disorders related to sexually transmitted human papillomavirus (HPV), and any other sexually transmitted diseases.
  22. Maternity/delivery preparation classes.
  23. Circumcisions, unless Medically Necessary and Pre-Authorized.
  24. Treatment of any injury arising directly or indirectly from Alcohol or Drug Abuse or addiction. This includes but is not limited to treatment for any injuries caused by, contributed to or resulting from the Plan Participant’s use of alcohol, illegal drugs, or any drugs or medicines that are not taken in the dosage or for the purpose prescribed by the Plan Participant’s Physician.
  25. Injuries and/or Illnesses resulting or arising from or occurring during the commission or perpetration of a violation of law by a Plan Participant.
  26. Eyeglasses, contact lenses or sunglasses.
  27. Prosthesis and corrective devices which are not medically required intra-operatively or equivalent appliances; except prosthesis or Durable Medical Equipment used as an integral part of treatment prescribed by a Physician, meeting the covered categories of Durable Medical Equipment or prosthesis and approved in advance by GBG Assist.
  28. Routine podiatry or other foot treatment not resulting from an Illness or injury. Orthopedic shoes or other supportive devices for the feet, such as, but not limited to, arch supports and orthotic devices or any other preventative services and supplies; any devices resulting from the diagnosis of weak, strained, unstable or flat feet or fallen arches, or any tarsalgaia, metatarsalgia or specified lesions of the feet, such as corns, calluses, and hyperkeratosis, toenails or bunions, pedicures, special shoes and inserts of any form or type.
  29. Growth hormones, unless Medically Necessary and preauthorized by GBG Assist. This includes treatment by a bone growth stimulator, bone growth stimulation or treatment related to growth hormone, regardless of the reason for prescription.
  30. Health care services associated with conditions as a result of travel, following the receipt of advice against travel because of health reasons from any health care Provider.
  31. Hearing aids, hearing devices and bone anchored hearing aids.
  32. Exceptional risks: (a) treatment as a consequence of injury sustained while participating in or training for interscholastic, intercollegiate, semi-professional or professional sports, or hazardous/extreme sports; (b) treatment as a consequence of injury sustained while participating in, or training for, or as a consequence of war (declared or not), acts of Terrorism, acts of foreign enemy hostilities, civil war, rebellion, revolution or insurrection; (c) chemical contamination; (d) contamination by radioactivity from any nuclear material or from the combustion of nuclear fuel; (e) treatment for any loss or expense of nature directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with self-exposure to peril or bodily injury, except in an endeavor to save human life.
  33. Treatment of Acquired Immune Deficiency Syndrome (AIDS), AIDS-related Complex Syndrome (ARCS) and all diseases caused by and/or related to the HIV Virus, if diagnosed as a Pre-Existing Condition.
  34. Except for palliative care or Accidental injury to sound, natural teeth, dental care is excluded from coverage. Treatment, services or supplies related to (a) the teeth; and (b) the gums other than tumors; and (c) any other associated structures; (d) the prevention or correction of teeth irregularities and malocclusion of jaws by wire appliances, braces, or other mechanical aids; and (e) dental implants, regardless of cause.
  35. Treatment services or supplies as the result of prognathism, retrognathism, microtrognathism, or any treatment, services, or supplies to reposition the maxilla (upper jaw), mandible (lower jaw), or both maxilla and mandible. This includes treatment for (TMJD) or Temporomandibular Malocclusion Joint Disorders.
  36. This Policy will not cover any services received by any parties or in any countries where otherwise prohibited by the US/UN/EU law and sanctions.
  37. Coverage is excluded for treatment and services related to infectious diseases declared to be an outbreak, epidemic, or public emergency by the World Health Organization (WHO), Center for Disease Control and Prevention (CDC), or any other Government or Government Agency or ruling body of the country where the outbreak or epidemic has occurred in. Additionally, such coverage is also excluded if there has been an official warning issued against travel to the area, by the State Department, Embassy, Airline or other Governmental Agency, prior to travel to the affected country. This exclusion will not apply if exposure occurs Accidentally or unknowingly while travelling to or from areas not declared to be at risk, or if exposure occurs as a result of residing or working in the area prior to the outbreak.
  38. Benefits for enrolling solely for the purpose of obtaining medical treatment, while on a wait list for a specific treatment, or while travelling against the advice of a Physician.
  39. Treatment of a hernia, including sports hernia, whether or not caused by a covered Accident.
  40. Any loss caused directly or indirectly from extortion, kidnap & ransom or wrongful detention of the Plan Participant or hijacking of any aircraft, motor vehicle, train or waterborne vessel on which the Plan Participant is traveling.
  41. Any loss resulting as a fare-paying passenger in a scheduled aircraft or in an employer owned or hired jet or helicopter for transportation of employees.