University of Pennsylvania student health insurance

Penn Student Insurance Plan is an Accident and Sickness Medical Expense policy underwritten by Aetna Life Insurance Company. The policy number is 724535. The complete policy brochure is available online. The information below is meant to be a brief summary of coverage and does not include all of the policy details. In the event of a discrepancy between the information below and the actual policy, the policy will prevail.

Annual premium per student: $2,642 for medical plus $205 for optional dental coverage

Deductible: $250 in network / $1,500 out-of-network

Hospital deductible: $100 per admission

Surgical or Outpatient procedure Deductible: $150

Co-payments as a percentage of total charges: 30% for out-of-network hospital charges, 10% for dental injury or impacted wisdom teeth and vision care, 10% in network or 30% for out-of-network routine exams, 10% in-network or 40% out-of-network for immunizations, 30% of out-of-network mental health treatment, 30% of out-of-network alcohol or drug treatment.

Co-payments for outpatient  office visits: $25 for walk-in clinic, outpatient therapy, routine exam, urgent care facility or outpatient drug or alcohol treatment, $75 for emergency room, $35 for lab expenses, $50 high cost procedures, $30 for name brand drug, $15 for generic prescriptions.

Maximum benefit: $2,000,000

Other limitations on coverage: maximum 30 days per year of hospitalization for each mental health condition, maximum $80 paid for out-of-network therapist, maximum 50 outpatient visits per year for mental health treatment, 120 maximum lifetime outpatient mental health visits.

Eligibility: full and part time students and their dependents

Referral: required from Student Health Services for treatment by a specialist within 25 miles of Philadelphia.

Pre-certification: for non-emergency medical procedures.

Emergency hospital admission: Notice must be provided within 48 hours of admission.

Maternity: covered

Diabetic treatment: covered

Prescriptions: covered

Dental: available as an option

Pre-existing medical conditions: covered