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Microsoft word - case_0910_student_brochure.rtf

S t u d e n t M e d i c a l P l a n 2 0 0 9 - 2 0 1 0 Sponsored By:
Extending Eligibility To:
Administered By:
TELEPHONE DIRECTORY
University Health Service
2145 Adelbert Road .216-368-2450
University Counseling Services Sears Bldg., Room 201 .216-368-5872 Appointments: General Clinic . 216-368-4539 Women’s Clinic. 216-368-2453 Mental Health. 216-368-2510/5872 Dear Student: While you are at Case Western Reserve University, we want to ensure that the Student Medical Plan and Services are a positive experience for you. Beginning with the 2008/2009 academic year, the university has contracted with Aetna Student Health in order to offer enhanced services that are easy to use, affordable and adaptable to your health care needs. One of the highlights of the Plan is an extensive nationwide health care network with access to doctors and specialists. The Student Medical Plan is offered as a supplement to the excellent care available to all Case Western Reserve students from the University Health Services and University Counseling Services. The University also offers the Optional Dependent Medical Plan for those students who wish to purchase coverage for their dependent spouse, domestic partner and children. Our intent is to provide you with the opportunity to obtain effective medical coverage. We appreciate your thoughts and suggestions. Questions or comments about either the Student Medical Plan or the Optional Dependent Plan can be directed to the University Health Service at 216-368-3050. Questions/comments about either of the medical plans can be directed to the University Health Service at 216-368-3050. C A S E W E S T E R N R E S E R V E U N I V E RS I T Y TABLE OF CONTENTS
MENTAL HEALTH AND CHEMICAL DEPENDENCY COVERAGE . 3 The fee for the 2009–2010 Student Medical Plan is $660.00 per semester. The fee for the Student Medical Plan is automatically billed each Fall and Spring semester to students registered for at least one credit hour. The fee will appear on the student’s tuition bill each semester. Payment is due in accordance with the University’s tuition schedule. Students who waive the Plan (see waiver option, page 10) will receive a credit of $660.00 on their account. C A S E W E S T E R N R E S E R V E U N I V E RS I T Y ELIGIBILITY
1. Students of Case Western Reserve University registered for at least one credit hour. 2. Residents of University Housing who have a direct affiliation with a University sponsored program. 3. Persons associated with special programs on the campus of Case Western Reserve University may be 4. Students of The Cleveland Institute of Art, and The Cleveland Institute of Music registered for at least NOT ELIGIBLE TO RECEIVE COVERAGE
1. Students cross-registered for classes at Case Western Reserve University or its affiliates. 2. Employees of Case Western Reserve University who are eligible for Benelect. PERIODS OF COVERAGE
CASE WESTERN RESERVE UNIVERSITY SCHOOL OF MEDICINE, CASE WESTERN
RESERVE UNIVERSITY SCHOOL OF DENTAL MEDICINE (MSD) STUDENTS, AND
CLEVELAND CLINIC LERNER COLLEGE OF MEDICINE


ALL STUDENTS EXCEPT THOSE LISTED ABOVE

Fall Semester:

If a student registers after September 4, 2009 for Fall Semester and after January 22, 2010 for Spring Semester, the
Student Medical Plan will become effective on the date the student registers (not on the effective date listed above).


IMPORTANT DEFINITIONS
Injury
– Means bodily damages:
a. Caused directly and independently of all other causes by an accident; and,
b. Which results in loss covered by the Plan.

Sickness
– Means illness or disease for which treatment is received while the person is covered under this Plan.

Disability
– Means either a Sickness or Injury.

Routine Care
– Means any medical service that is performed for preventative purposes or performed in the absence of a
specific diagnosis

Plan Year
– Means fiscal year as described under period of coverage above.
C A S E W E S T E R N R E S E R V E U N I V E RS I T Y N E T W O R K I N F O R M A T I O N
The Student Medical Plan, subject to the outlined benefits, limits and exclusions, protects the student during
the term for which the fee has been paid. The Plan reserves the right to coordinate benefits with any other
medical coverage. Participants of the Student Medical Plan are encouraged to access a national network of Preferred providers in the Aetna network. Participants may realize substantial savings by utilizing preferred providers. A complete listing of Participating Providers is available through the internet by accessing Aetna’s DocFind® Service at www.aetnastudenthealth.com. Click on Find Your School and select Case Western Reserve University from the list. Additionally, information regarding Preferred Providers can be obtained by contacting Aetna Student Health at 877-850-6038.
Failure to utilize a network provider, will result in a benefit reduction to 60% of covered charges.
In the case of a medical emergency as determined by the claims administrator, a participant who obtains
health care from an out-of-network provider will be subject to the in-network limits and restrictions with
respect to such care. When hospital or medical care is required because of a Sickness or Injury eligible for
benefits under this Plan, the reasonable and customary expense actually incurred will be paid, up to the
specified limits for each Sickness or Injury.
M E D I C A L C O V E R A G E
University Health Services:
No Charge for University Health Services Office Visit

Primary Care or Specialist Office Visit:
$20 Copayment* due at the time of service, 80% of remaining
balance is paid for by The Plan, 20% of remaining balance is the responsibility of the student.
*Copayments do not accumulate toward the out-of-pocket maximums
Urgent Care Facility:
$30 Copayment* due at the time of service, 80% of remaining balance is paid for by
The Plan, 20% of remaining balance is the responsibility of the student.

*Copayments do not accumulate toward the out-of-pocket maximums

Emergency Room:
$50 Copayment* due at the time of service (waived if admitted), 80% of remaining
balance is paid for by The Plan, 20% of remaining balance is the responsibility of the student.

*Copayments do not accumulate toward the out-of-pocket maximums

Outpatient Services*:
In-Network:
80% of eligible charges are paid for by The Plan, the remaining 20% of charges are the
responsibility of the student.

Out-of-Network:
60% of eligible charges are paid for by The Plan, the remaining 40% of charges are the
responsibility of the student.
*This includes outpatient maternity services Mammography
The Plan will pay the cost, up to $85 per exam, for routine mammograms as follows: Student Age (Years)
# Exams
35 but less than 40 . 1 every 4 Plan Years 40 but less than 50 . 1 every 2 Plan Years (1 per Plan Year if certified as high risk for breast cancer) over 50 . 1 per Plan Year
Inpatient Services*:
In-Network:
80% of eligible charges are paid for by The Plan, the remaining 20% of charges are the
responsibility of the student.

Out-of-Network:
60% of eligible charges are paid for by The Plan, the remaining 40% of charges are the
responsibility of the student.

*This includes inpatient maternity services

Student Medical Plan Out of Pocket Maximum:
In-Network:
$5,000, per Plan Year

Out-of-Network:
$7,500, per Plan Year
The Plan will pay 100% of the excess of eligible expenses incurred after the out of pocket maximum has been
met, up to a maximum benefit of $250,000 per Plan Year.

Student Medical Plan Year and Lifetime Maximums:
Medical and Prescription Benefits Plan Year Maximum: $250,000
Medical and Prescription Benefits Lifetime Maximum: $2,000,000
MENTAL HEALTH AND CHEMICAL DEPENDENCY COVERAGE
In-Network:
80% of eligible charges are paid for by The Plan, the remaining 20% of charges are the
responsibility of the student.

Out-of-Network:
60% of eligible charges are paid for by The Plan, the remaining 40% of charges are the
responsibility of the student.
Outpatient Mental/Nervous Benefit Limitations: Coverage under The Plan is limited to 26 visits per Plan Year for: diagnosis, treatment and couples counseling, legally rendered by a licensed psychiatrist, psychologist or social worker. Such outpatient service may be provided in a physician’s office, hospital outpatient department, community mental health facility or an alcoholism or drug abuse treatment facility. Inpatient Mental/Nervous:
In-Network:
80% of eligible charges are paid for by The Plan, the remaining 20% of charges are the
responsibility of the student.

Out-of-Network:
60% of eligible charges are paid for by The Plan, the remaining 40% of charges are the
responsibility of the student.

Inpatient Mental/Nervous Benefits Plan Year Maximum: $20,000

C A S E W E S T E R N R E S E R V E U N I V E RS I T Y PRESCRIPTION COVERAGE
Prescription drug expenses are covered under the medical plan the same as other expenses related to a covered
sickness or injury. Students enrolled in the Student Medical Plan are automatically enrolled in the drug plan,
administered through Envision Rx Options. The plan includes a co-payment that is required to be paid when a prescription is purchased. Participants will pay their predetermined co-payment and the plan will pay the remainder of the cost. The Plan will pay up to $5,000 under the co-payment schedule. Once the Plan has paid $5,000 under the co-payment schedule, 60% of eligible charges are paid for by The Plan, the remaining 40% of charges are the responsibility of the student. Prescription reimbursement paid by The Plan in excess of $5,000 will be applied toward the Plan Year Copayment Schedule
Category
Retail (30-day supply)
Mail Order (90-day
Certain over the counter (OTC) medication are available. Participants are encouraged to consult their physician to determine if OTC Prilosec, OTC Claritin, OTC Claritin D, OTC Loratadine or OTC Loratadine D therapy is appropriate. If it is so determined, the participant’s physician must write a prescription specifically for one of these medications and present it to the pharmacist to be eligible for reimbursement under the Plan.
In some cases, it may be necessary to pay the entire cost of the prescription and submit a claim form along with
a pharmacy receipt to Envision Rx Options when a network pharmacy is used.
Prescription benefit cards and direct member reimbursement forms are located at
http://studentaffairs.case.edu/medicalplan/
Address: Envision Rx Options 2181 E. Aurora Rd. To locate a network pharmacy, please visit www.envisionrx.com or call (800) 361-4542 for any customer service related issue. Please note that no prescriptions will be paid for at non-network pharmacies. The participant may be required to show his/her Envision Rx ID card at the point of purchase. The pharmacist will be able to determine to which category the prescription applies in order to collect the correct co-payment at the time of purchase. Envision Rx Options customer service representatives are available to help in this determination as well. The mail order facility for this plan is Walgreens. In addition to receiving a ninety-day supply prescription through the mail, a ninety-day supply may be obtained with a properly written prescription from the participant’s physician by visiting any Walgreens retail location. C A S E W E S T E R N R E S E R V E U N I V E RS I T Y MAIL ORDER
New prescriptions must be mailed to the mail service pharmacy or faxed from the participant’s physician office
on the Walgreens’ Healthcare Plus physician fax form. The form is located at www.walgreensmail.com. For long-
term medications needed right away: the participant should request two prescriptions from his/her physician –
one for a small supply to fill at a participating retail pharmacy and one for a long-term supply to fill through the
mail. Most orders are shipped by the U.S. Postal Service. Controlled substances may require a signature upon
receipt. Packaging does not show any indication that medications are enclosed. Include payment if applicable to
avoid any delays. Do not send cash. Make check payable to Walgreens Healthcare Plus. Credit cards are accepted.
Allow 2 weeks for delivery
Mail Pharmacy Customer Service:
1-800-992-2655 (TTY 1-800-925-0178
Monday – Friday 8:00 a.m. – 8:00 p.m. (Eastern)
Refills by phone:
1-800-749-0009
Internet:

DENTAL COVERAGE
Coverage is provided per the benefits outlined in the Plan for injury to sound, natural teeth. Participants are eligible for the fol owing services only when obtained from the Case Western Reserve University School of Dental Medicine. – Two oral exams and evaluations, including one dental and medical history per Plan Year, at 100% coverage. – Two oral cleanings per Plan Year at 100% coverage. – Periodic Bite Wing x-rays per Plan Year at 100% coverage. – Emergency pain relief at the Dental Clinic (or Case Medical Center Emergency Room when the Dental Clinic – 20% discount on all other dental services offered at the Case Western Reserve University School of Dental Services are provided at the Case Western Reserve University School of Dental Medicine by both Pre- Doctoral and Doctoral Students. Appointments are necessary and may be made by calling the Dental Clinic at 216-368-3200. Please Note: The Case Western Reserve University School of Dental Medicine closes periodically throughout the year. Oral cleanings are not provided when the clinic is closed. Emergency care is limited at this time but can be C A S E W E S T E R N R E S E R V E U N I V E RS I T Y EXTRA DISCOUNTS AND SAVINGS
Aetna VisionSM Discount Program
The Aetna Vision discount program helps you save on many eye care products, including sunglasses, contact
lenses, non-prescription sunglasses, contact lens solutions and other eye care accessories. Plus, you can receive
up to a 15% discount on LASIK surgery (the laser vision correction procedure).
Discount programs provide access to discounted prices and are NOT insured benefits.
Vital SavingsSM on Dental
is a dental discount program helping you and your dependents save an average of
15% to 50% on a wide array of dental services – with one low annual fee of $25 per student. Enroll online at
www.aetnastudenthealth.com.

What Vital Savings Offers
- $25 annual fee
- Access to point-of-purchase discounts on vision, fitness, and alternative health care products and
services – at no additional charge
- No referrals required
- No waiting periods, claims to file or administrative hassles
Price: $25 Student only $44 Spouse $63 Child(ren) * Actual costs and savings vary by provider and geographic area.
The Vital Savings by Aetna® program (the “Program”) is not insurance. The Program provides
Members with access to discounted fees pursuant to schedules negotiated by Aetna Life
Insurance Company for the Vital Savings by Aetna® discount program. The Program does not
make payments directly to the providers participating in the Program. Each Member is obligated
to pay for all services or products but will receive a discount from the providers who have
contracted with the Discount Medical Plan Organization to participate in the Program. Aetna Life
Insurance Company, 151 Farmington Avenue, Hartford, CT 06156, 1-877-698-4825, is the
Discount Medical Plan Organization.

Optional Product
With our Aetna AdvantageTM Dental benefits and insurance plan, you select a primary care dentist
(PCD) and have most of your preventive and restorative services covered by a copayment or reduced fee for
each visit. Enroll online at www.aetnastudenthealth.com.

What the Plan Offers
- Dependable coverage for a range of services.- Easy-to-use benefits. - Visit your
primary care dentist for covered dental care. You’ll just pay a low copay. - Plus, visit any participating dentist for many additional services. You’ll pay a reduced fee. And there’s no need for a referral!
Price: $120 Student only
$125 Spouse
$188 Child(ren)

The Aetna AdvantageTM Dental benefits and insurance plan is underwritten by Aetna Life Insurance Company, Aetna Dental
Inc., Aetna Dental of California Inc. and/or Aetna Health Inc. In Arizona, Advantage Dental is underwritten by Aetna Health Inc. Each insurer has sole financial responsibility for its own products.
Accidental Death and Dismemberment Benefit
This insurance coverage provides Accidental Death and Dismemberment coverage underwritten by United
States Fire Insurance Company. Benefits are payable for the Accidental Death and Dismemberment of the
eligible insureds of up to a maximum of $10,000. (Exclusions and limitations may apply.)
To file a claim for Accidental Death and Dismemberment, please contact Aetna Student Health at (800) 966-7772 for the appropriate claim forms.
On Call International 24/7 Emergency Travel Assistance Services
These services are provided by On Call International and designed to protect Case Western Reserve University
students and/or eligible dependents when traveling more than 100 miles from home, anywhere in the world. Medical
Repatriation and Return of Mortal Remains services are also available at the participant’s campus location.
If you experience a medical emergency while traveling more than 100 miles from your home or campus, you have access to a comprehensive group of emergency assistance services provided by On Call International. Eligible participants have immediate access to doctors, hospitals, pharmacies and other services when faced
with an emergency while traveling. The On Call International Operations Center can be reached 24 hours a day,
365 days a year to provide services including: medical consultation and evaluation, medical referrals, foreign
hospital admission guarantee, prescription assistance, lost luggage assistance, legal and interpreter assistance,
and travel information such as Visa and passport requirements, travel advisories, etc.
Medical Evacuation and Return of Mortal Remains Services
In the event that a participant becomes injured and adequate medical facilities are not available locally, On Call
International will use whatever mode of transport, equipment and personnel necessary to evacuate you to the
nearest facility capable of providing required care. In the event of death of a participant, On Call International
will render every possible assistance in return of mortal remains including locating a sending funeral home, preparing the deceased for transport, procuring required documentation, providing necessary shipping container as well as paying for transport.
Please note: Any third party expenses incurred are the responsibility of the Participant. An On Call
International ID card will be supplied to you once you enroll in the Aetna Student Health Insurance Plan.
Please remember to carry your On Call card and call toll-free within the U.S. at (866) 525-1956 or outside the
U.S. call collect (dial U.S. access code) plus (603) 328-1956 in the event of an emergency when you are traveling. With one phone call, you will be connected to a global network of over 600,000 pre-qualified medical providers. On Call Operations Centers have worldwide assistance capabilities and are known throughout the world as a premier Emergency Assistance Services provider.
NOTE: On Call International pays for all Assistance Services it provides. All Assistance Services must be
arranged and provided by On Call. On Call does not reimburse for services not provided by On Call.
The On Call International program meets and exceeds the requirements of USIA for International Students & Scholars.
Emergency Travel Assistance Services are administered by On Call International.
For questions about:
On Call International 24/7 Emergency Travel Assistance Services
Please contact:
On Call International at (866) 525-1956 (within U.S.). If outside the U.S., call collect by dialing the U.S. access
code plus (603) 328-1956. Please also visit www.aetnastudenthealth.com and visit your school-specific site for
further information. These services, programs or benefits are offered by vendors who are independent contractors and not employees or agents of Aetna.
COVERAGE TERMINATION
Coverage terminates at 11:59 p.m. local time at the address of the University on the earliest of the dates
indicated below:
– The end of the Period of Coverage;
– The date on which the Student Medical Plan terminates;
– The date a student withdraws from school to enter military service; in this case a prorated refund will be
– The first day of any term for which a student waives coverage; – The end of the period for which the required payments have been received, if future payments cease. If Case Western Reserve University terminates and does not replace this Student Medical Plan, students then receiving or entitled to receive benefits for a covered Sickness or Injury will continue to be covered for that
Disability for up to 52 weeks following the date of termination or in accordance with the time period stated
under the Student Medical Plan, whichever is less.
Benefits payable during this period will not be more than the amounts provided under the Plan at the time the
Disability began.
PLEASE NOTE: Any subsequent change in the limits provided under this Plan will not affect the benefits
payable for a Disability for which benefits have been extended under this provision.
PERSONAL MEDICAL LEAVE
Coverage may be continued without interruption for one additional semester for a student who leaves the
University due to a personal medical condition provided the student was registered and enrolled in the
Student Medical Plan during the semester in which the student left.
In order to continue medical coverage under the Student Medical Plan, the Student Medical Plan Coordinator
(located at the University Health Service) must be notified of the leave prior to the semester in which the leave is
to take effect.
Students must provide the following to the University Health Service:
1. A letter from the Dean or Advisor of the School in which the student is enrolled approving the
2. A letter from the student’s medical provider or counselor/therapist confirming the medical necessity for 3. Payment (in cash or check) of the Student Medical Plan fee prior to the beginning of the semester in
This extension does not apply to students who are leaving the University for reasons other than a personal
medical condition.
PLEASE NOTE: When a student is on a leave of absence, the student is not eligible to use the services
offered by the Case Western Reserve University Health Service or the Case Western Reserve University
Counseling Services. When a student is on a personal medical leave of absence, payment of the Student
Medical Plan fee allows coverage under the Student Medical Plan only, subject to the exclusions and
limitations of the Plan, as outlined in this brochure.
IDENTIFICATION CARD
Each student participating in the Student Medical Plan will receive an ID Card however you do not need an ID
card to be eligible to receive benefits. Once you have received your ID card, present it to the provider to
facilitate prompt payment of your claims.
Note: Please be advised you will receive a unique Aetna member ID number on your membership card.
For lost ID cards, contact:
Aetna Student Health or visit aetnastudenthealth.com, and select Case Western Reserve University from
the list.

CLAIM SUBMISSION
Please send all itemized medical bills as soon as possible after treatment is rendered to Aetna Student Health. Your name, identification number and Case Western Reserve University should be written clearly and attached to your medical bills. All information should be mailed to: Aetna Student Health P.O. Box 15708 Boston, MA 02215-0014 877-850-6038 Customer Service Representatives are available 8:30 a.m. to 5:30 p.m. Monday through Friday, for any questions. • Bills must be submitted within 15 months from the date of treatment. • Payment for Covered Medical Expenses will be made directly to the hospital or Physician concerned unless bill receipts and proof of payment are submitted. • If itemized medical bills are available at the time the claim form is submitted, attach them to the claim form. Subsequent medical bills should be mailed promptly to the above address. In all cases, expenses must be filed within 15 months of treatment to be considered for
payment under this Plan.


STUDENT MEDICAL PLAN WAIVER OPTIONS

Under certain conditions, the $660.00 Student Medical Plan fee may be waived.
1. Students who have insurance comparable to the Student Medical Plan may waive the coverage described in this summary plan description. HOWEVER, IT IS EACH STUDENT’S RESPONSIBILITY TO
ENSURE THAT THE ALTERNATE COVERAGE IS ADEQUATE.
Before submitting a waiver,
please note that many commercial insurance plans do not cover a student after a certain age.

2. A WAIVER REQUEST IS VALID FOR ONE SEMESTER ONLY. Students who elect to waive
the Student Medical Plan must submit a waiver EACH SEMESTER in support of their request. The
waiver must be received NO LATER THAN September 4, 2009 for the Fall Semester and no later
than January 22, 2010 for the Spring Semester.


3. Case Western Reserve students can waive the Student Medical Plan on the Student Information
System (SIS) located at http://www.case.edu/provost/registrar/registrar.html 4. Students from CIA and CIM should submit a waiver form to their individual school. Students who waive the Plan for a given semester are eligible to apply for coverage during that semester if they experience a termination of their current medical coverage that is beyond their control. Contact the University Health Service for further details at 216-368-3050. Students must apply for coverage with the Case Western Reserve University Student Medical Plan within 30 days of loss of coverage from their current medical insurance.
REFUND POLICY
After the deadline for submitting a request waiver (see the preceding section), no portion of the fee is

refundable, with one limited exception. If a student withdraws from school to enter military service, a
prorated refund will be available upon request.
APPEAL PROCESS / DENIAL OF BENEFITS

If the participant believes a claim was improperly settled, please complete the following process:
1. Within 60 days of receipt of the claim, the participant may request, in writing, that the plan
administrator conduct a review of the processed claim. The plan administrator will review the processed claim and inform the participant whether or not an error was made. 2. If the participant is not satisfied with the above review, a written request for a second review may be submitted to the plan administrator within 60 days of the first review. The request should state, in clear and concise terms the reason for disagreement with the way the claim was processed. When the written request is received, the claim will be reviewed again and the results of this review furnished in writing to the participant within 60 days in most cases, but no longer than 120 days. All requests for review of denied claims should include a copy of the initial denial letter and any other pertinent information. Send all information to: Aetna Student Health P.O. Box 15708 Boston, MA 02215-0014 877-850-6038 EXCLUSIONS

1. Expenses incurred in connection with routine exams or other care, treatment, services and supplies which are
not medically necessary for the treatment of a Disability, including those which are not consistent with the diagnosed Sickness or Injury. This exclusion is waived for routine mammograms, as specifically included (page 4). 2. Expenses incurred for or in connection with diagnosis, care and treatment of a mental/nervous condition or alcohol/substance abuse, except as specifically provided. 3. Care, treatment, services or supplies rendered in connection with cosmetic procedures, unless needed because of a covered Injury or Sickness. 4. Expenses incurred in connection with Injuries resulting from an accident involving a motor vehicle, to the extent benefits are payable under any other insurance policy or plan of benefits, unless those benefits are paid only as a result of litigation. 5. Expenses in connection with treatment directly to or on the teeth or gums, except as specifically included and when needed due to Injury to sound, natural teeth. 6. Hearing aids or examinations for the prescription and fitting. 7. Expenses incurred in connection with Injury or Sickness which arises out of or in the course of any occupation or employment, for which the covered student is entitled to benefits under any Workers’ Compensation or similar law. 8. Forms of self-care or self-help training and any related diagnostic testing. 9. Care which is not recommended and approved by a Physician. 10. Organ or tissue transplant procedures, unless pre-approved by the Plan. 12. Injuries resulting from air travel except when traveling as a passenger on a regularly scheduled commercial airflight. 13. Custodial Care: for example, help in walking, bathing, preparing meals, and other activities of daily living. 14. Expenses incurred, to the extent that they exceed the usual, customary and reasonable charge. 15. Services or supplies which are experimental or investigational in nature. 16. Injury sustained or Sickness contracted as a result of committing or attempting to commit a felony, or being 17. Services rendered by a person who is an immediate relative of or who ordinarily resides with the 18. Services or supplies rendered or furnished to a covered student while in the active military service of any country. 19. Expenses incurred when no coverage is in force for the person incurring charges. 20. Expenses which the covered student has no legal obligation to pay or for which no charge would be 21. Travel, even though prescribed by a Physician. 22. Expenses for or in connection with procedures intended solely to increase or enhance fertility; artificial insemination, in-vitro fertilization or similar procedures; reversals of previous sterilization procedures; transsexual surgery; or surrogacy. 23. Services or supplies rendered or furnished in a Military or Veterans Administration Hospital, unless rendered in connection with a Disability which is not in any way related to the covered student’s military service. 24. Injury or Sickness caused by war or any act of war, whether declared or undeclared. 25. Expenses in connection with treatment of Injuries received in practice for or participation in intercollegiate sports.

Source: http://students.case.edu/medicalplan/student/0910/doc/09student.pdf

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