SUMMARY OF BENEFITS

Availability of services at SHC locations vary, please verify location when making appointments.
BASIC PLAN COMPREHENSIVE PLAN (Comp)
AND GSHIP
Policy Year Unlimited Unlimited
Maximum
Out-of-Pocket In-Network
Limit Individual: $5,000 per policy year
Family: $10,000 per policy year
Out-of-Network
Individual: $10,000 per policy year
Family: $20,000 per policy year
Once the out-of-pocket limit has been satisfied, eligible expenses
will be payable at 100% for the remainder of the policy year up
to any benefit maximum that may apply.
OUTPATIENT BENEFITS
Doctors Visits At SHC: Specialists, 100% after At SHC: Specialists, 100% after a
a $20 per visit co-pay $20 per visit co-pay for Comp;
In-Network: 75% of the $10 for GSHIP
allowable charge; $30 per visit In-Network: 90% of the
copay; up to the out-of-pocket allowable charge; $30 per visit
limit, 100% thereafter copay; up to the out-of-pocket
Out-of-Network: 50% of limit, 100% thereafter
reasonable and customary Out-of-Network: 60% of
charges; up to the out-of- reasonable and customary
pocket limit, 100% thereafter charges; up to the out-of-pocket
limit, 100% thereafter
Lab and X-ray At SHC: 80% of allowable At SHC: 90% of allowable
Some lab tests at charges charges for Comp; 100% for
SHC are provided GSHIP
In-Network: 75% of the
at no charge. This In-Network: 90% of the
allowable charge up to the out-
is not an insured allowable charges up to the out-
benefit but is of-pocket limit, 100% thereafter
of-pocket limit, 100% thereafter
provided by NYU Out-of-Network: 50% of
Out-of-Network: 60% of
to all matriculated reasonable and customary reasonable and customary
students including charges up to the out-of-pocket charges up to the out-of-pocket
students who limit, 100% thereafter limit, 100% thereafter
waive the NYU
sponsored Plans.
For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu
 BASIC PLAN COMPREHENSIVE PLAN (Comp)
AND GSHIP
Preventive At SHC: Preventive services available and rendered at SHC will be
Services and provided at 100% with no cost sharing
Immunizations In-Network: Preventive services will be covered 100% of eligible
as specified
expenses with no cost-sharing.
by Health Care
Reform (PPACA) Out-of-Network: 50% of the Out-of-Network: 60% of the
(see also Womens reasonable and customary reasonable and customary
Health Benefits, charges up to the out-of- charges up to the out-of-pocket
page 13) pocket limit, 100% thereafter limit, 100% thereafter
Allergy Testing At SHC: 80% of the allowable At SHC: 90% of the allowable
and Shots charge charge
In-Network: 75% of the In-Network: 90% of the allowable
allowable charge up to the charge up to the out-of-pocket
out-of-pocket limit, 100% limit, 100% thereafter
thereafter Out-of-Network: 60% of the
Out-of-Network: 50% of the reasonable and customary
reasonable and customary charges up to the out-of-pocket
charges up to the out-of- limit, 100% thereafter
pocket limit, 100% thereafter
Physical/ At SHC: 100% after a $20 per At SHC: 100% after a $20 per visit
Occupational/ visit co-pay co-pay for Comp; $10 per visit
Speech/Hearing In-Network: 75% of the copay for GSHIP
Therapy and allowable charge; $30 per visit In-Network: 90% of the allowable
Chiropractic copay; up to the out-of-pocket charge; $30 per visit
Service* limit, 100% thereafter copay; up to the out-of-pocket
Out-of-Network: 50% of limit, 100% thereafter
*Limited to 60
visits per condition reasonable and customary Out-of-Network: 60% of
per plan year charges; up to the out-of- reasonable and customary
for all therapies pocket limit, 100% thereafter charges; up to the out-of-pocket
combined limit, 100% thereafter

Hospital In-Network: 75% of the In-Network: 90% of the allowable

Emergency Room allowable charge; $100 per
visit co-pay; up to the out-of-
pocket limit, 100% thereafter
Out-of-Network: 75% of the
reasonable and customary
charges; $100 per visit co-pay;
up to the out-of-pocket limit,
100% thereafter
Referrals from CHP are required for follow-up treatment after an
emergency.
charge; $100 per visit co-pay; up
to the out-of-pocket limit, 100%
thereafter
Out-of-Network: 90% of the
reasonable and customary
charges; $100 per visit co-pay; up
to the out-of-pocket limit, 100%
thereafter

For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu
 BASIC PLAN COMPREHENSIVE PLAN (Comp)
AND GSHIP
WOMENS HEALTH BENEFITS
Routine At SHC: provided at 100% with no cost sharing
Gynecologic
In-Network: covered at 100% In-Network: covered at 100% of
Exam
of Eligible Expenses with no Eligible Expenses with no cost-
cost-sharing sharing
Out-of-Network: 50% of Out-of-Network: 60% of
reasonable and customary reasonable and customary
charges; up to the out-of- charges; up to the out-of-pocket
pocket limit, 100% thereafter limit, 100% thereafter
Pap Smear/ At SHC: provided at 100% with At SHC: provided at 100% with no
Cervical Cancer no cost sharing cost sharing
Screening In-Network: provided at 100% In-Network: provided at 100%
(See Laboratory
with no cost sharing with no cost sharing
Services)
Out-of-Network: 50% of Out-of-Network: 60% of
reasonable and customary reasonable and customary
charges up to the out-of- charges up to the out-of-pocket
pocket limit, 100% thereafter limit, 100% thereafter
Mammography In-Network: Covered at 100% of allowable charge with no cost
Screening and sharing
Diagnostic Out-of-Network: Payable same as Laboratory and X-ray expense
Imaging for the (see page 11)
Detection of
Breast Cancer
Contraceptives At SHC: Covered at 100% of eligible expenses with no cost sharing
(Prescription In-Network: Covered at 100% of eligible expenses with no cost-
Drugs and sharing at Preferred Pharmacies
Devices)
Out-of-Network: see Prescription Drug benefit for Non-Preferred
Pharmacies
Eligible Professional Expenses incurred for outpatient
contraceptive service will be paid under the Out Patient benefit
(i.e.: IUD Insertion)
Benefits are payable for a 90-day supply per prescription or refill
without prior authorization
Lost or stolen prescription drugs will not be covered

For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu
 BASIC PLAN
MATERNITY
Obstetric Services In-Network: 75% of the
allowable charge up to the out-
of-pocket limit, 100% thereafter
Out-of-Network: 50% of
reasonable and customary
charges up to the out-of-
pocket limit, 100% thereafter
Designated Provider: 100% of
negotiated charge* up to the
out-of-pocket limit
*For CPT Code 59400 and CPT
Code 59510 (routine obstetric
care for complete pregnancy
including pre-natal visits,
vaginal or cesarean delivery
and postpartum care).
For a list of designated
providers, please call Student
Health Insurance Services at
(212) 443-1020.
Inpatient Room In-Network: 75% of the
and Board For allowable charge up to the out-
Maternity of-pocket limit, 100% thereafter
Out-of-Network: 50% of
reasonable and customary
charges up to the out-of-
pocket limit, 100% thereafter
Designated Provider: At NYU
Langone Hospital, 100% of
negotiated charge up to the
out-of-pocket limit
TERMINATION OF PREGNANCY
Termination of In-Network: 75% of the
Pregnancy allowable charge up to the out-
of-pocket limit, 100% thereafter
Out-of-Network: 50% of
reasonable and customary
charges up to the out-of-
pocket limit, 100% thereafter
Only one elective termination
covered per policy year
For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu
COMPREHENSIVE PLAN (Comp)
AND GSHIP
In-Network: 90% of the allowable
charge up to the out-of pocket
limit, 100% thereafter
Out-of-Network: 60% of
reasonable and customary
charges up to the out-of pocket
limit, 100% thereafter
Designated Provider: Same as
Basic Plan.
In-Network: 90% of the allowable
charge up to the out-of-pocket
limit, 100% thereafter
Out-of-Network: 60% of
reasonable and customary
charges up to the out-of-pocket
limit, 100% thereafter
Designated Provider: At NYU
Langone Hospital, 100% of
negotiated charge up to the out-
of-pocket limit
In-Network: 90% of the allowable
charge up to the out-of pocket
limit, 100% thereafter
Out-of-Network: 60% of
reasonable and customary
charges up to the out-of pocket
limit, 100% thereafter
Only one elective termination
covered per policy year
 BASIC PLAN COMPREHENSIVE PLAN (Comp)
AND GSHIP
MENTAL HEALTH BENEFITS
Outpatient At SHC: Short-term psychotherapy (talk therapy) visits at SHC are
Mental Health provided at no charge. This is not an insured benefit but is provided
Psychotherapy by NYU to all matriculated students including students who waive
the NYU sponsored plans
In-Network: 75% of the In-Network: 90% of the allowable
allowable charge; up to the out- charge; up to the out-of-pocket
of-pocket limit, 100% thereafter limit, 100% thereafter
Out-of-Network: 50% of Out-of-Network: 60% of
reasonable and customary reasonable and customary charges;
charges; up to the out-of- up to the out-of-pocket limit, 100%
pocket limit, 100% thereafter thereafter
Designated Provider: 100% Designated Provider: Same as
after a $5 per visit co-pay. For Basic Plan
a list of Designated Providers,
please call Student Health
Insurance at 212-443-1020
Inpatient In-Network: 75% of the In-Network: 90% of the negotiated
Mental Health negotiated charge up to the charge up to the out-of-pocket
out-of-pocket limit, 100% limit, 100% thereafter
thereafter Out-of-Network: 60% of
Out-of-Network: 50% of reasonable and customary charges
reasonable and customary up to the out-of-pocket limit, 100%
charges up to the out-of-pocket thereafter
limit, 100% thereafter
Designated Provider: At NYU Langone Hospital, 100% of the
Negotiated Charge
CHEMICAL ABUSE AND DEPENDENCE
Outpatient In-Network: 100% of the allowable charge
Out-of-Network: 100% of reasonable and customary charge
Up to 20 of these visits available for family counseling
Inpatient In-Network: 75% of the In-Network: 90% of the allowable
allowable charge up to the out- charge up to the out-of-pocket
of-pocket limit, 100% thereafter limit, 100% thereafter up to
up to maximum maximum
Out-of-Network: 50% of Out-of-Network: 60% of
reasonable and customary reasonable and customary charges
charges up to the out-of-pocket up to the out-of-pocket limit, 100%
limit, 100% thereafter up to thereafter up to maximum
maximum

For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu
 BASIC PLAN COMPREHENSIVE PLAN
(Comp) AND GSHIP
PRESCRIPTION DRUGS
Prescription Drugs Participating Pharmacy: 100% after a:
$15 copay for generic drugs
$40 copay for preferred brand name drugs
$60 copay for non-preferred brand name drugs
Replacements for lost or stolen prescription drugs are not covered.
Non-Participating Pharmacy: There is a 30% co-insurance.
Benefits are not payable for more than a 30-day supply per
prescription or refill without prior authorization.
Off label prescription drugs for cancer treatment are included.
INPATIENT MEDICAL
Room & Board, In-Network: 75% of the In-Network: 90% of the
Pre-Admission allowable charge up to the out- allowable charge up to the out-
Testing, Non- of-pocket limit, 100% thereafter of-pocket limit, 100% thereafter
Surgical Physician
Out-of-Network: 50% of Out-of-Network: 60% of
Visit, Other
reasonable and customary reasonable and customary
Hospital Services
charges up to the out-of-pocket charges up to the out-of-pocket
limit, 100% thereafter limit, 100% thereafter
SURGICAL BENEFITS (Outpatient & Inpatient)
Surgeon/ In-Network: Covered at 75% In-Network: 90% of the
Assistant Surgeon of the allowable charge up to allowable charge up to the out-
Anesthesia Fees the out-of-pocket limit, 100% of-pocket limit, 100% thereafter
thereafter Out-of-Network: 60% of
Out-of-Network: Covered at reasonable and customary
50% of the reasonable and charges up to the out-of-pocket
customary charges up to the limit, 100% thereafter
out-of-pocket limit, 100%
thereafter
ADDITIONAL BENEFITS
Ambulance 100% coverage per transport to or from hospital.

For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu
 BASIC PLAN COMPREHENSIVE PLAN
(Comp) AND GSHIP
ADDITIONAL BENEFITS (continued)
Vision Services Annual Preventive Eye Exam (One per policy year)
Member over
age 18 At SHC: 100% after a $20 per At SHC:
visit co-pay Comp Plan: 100% after a $20 per
visit co-pay
GSHIP: 100% after a $10 per visit
co-pay
Outside SHC: No benefit
Vision Services Annual Preventive Eye Exam (one per policy year)
through the end
of the month At SHC: At SHC:
in which the 100% with no per visit co-pay Comp Plan: 100% with no per visit
student turns 19 In-Network: Covered at 75% co-pay
years of age of allowable charges; up GSHIP: 100% with no per visit co-pay
to the out-of-pocket limit, In-Network: Covered at 80% of
100% thereafter. $30 per visit allowable charges; up to the
co-pay out-of-pocket limit, 100% there-after;
Out-of-Network: Covered Comp Plan - $30 per visit co-pay;
at 60% of reasonable and GSHIP - $10 per visit co-pay
customary charges; up to Out-of-Network: Covered at 60% of
the out-of-pocket limit, 100% reasonable and customary charges;
thereafter up to the out-of-pocket limit, 100%
thereafter

Lenses and Frames: (One per policy year)

At SHC: 80% of allowable charges; up to the out-of-pocket limit,
100% thereafter; $30 per visit co-pay
In-Network: 60% of allowable charges; up to the out-of-pocket limit,
100% thereafter. $50 per visit co-pay
Out-of-Network: 60% of reasonable and customary charges; up to
the out-of-pocket limit, 100% thereafter

Contact Lenses (Preauthorization Required)

At SHC: 80% of allowable charges; up to the out-of-pocket limit;
100% thereafter; $30 per visit co-pay
In-Network: 60% of allowable charges; up to the out-of-pocket limit;
100% thereafter; $50 per visit co-pay
Out-of-Network: 60% of reasonable and customary charges; up to
the out-of-pocket limit; 100% thereafter
For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu
 BASIC PLAN COMPREHENSIVE PLAN
(Comp) AND GSHIP
ADDITIONAL BENEFITS (continued)
Pediatric Dental Preventive Dental Care: One dental exam and cleaning per
through the end 6-month period
of the month in
which the student At SHC: Not available At SHC: Not available
turns 19 years of In-Network: 75% of allowable In-Network: 80% of allowable
age charges; up to the out-of- charges; up to the out-of-pocket
pocket limit; 100% thereafter; limit; 100% thereafter; $50 per visit
$50 per visit co-pay co-pay
Out-of-Network: 60% of Out-of-network: 60% of allowable
reasonable and customary charges; up to the out-of-pocket
charges; up to the out-of- limit; 100% thereafter
pocket limit; 100% thereafter

Routine Dental Care (Full mouth x-rays or panoramic x-rays at 36

month intervals and bitewing x-rays at 6-12 month intervals)
At SHC: Not available At SHC: Not available
In-Network: 75% of allowable In-Network: 80% of allowable
charges; up to the out-of-pocket charges; up to the out-of-pocket
limit; 100% thereafter; $50 per limit; 100% thereafter; $50 per
visit co-pay visit co-pay
Out-of-Network: 60% of Out-of-network: 60% of
reasonable and customary allowable charges; up to the out-
charges; up to the out-of-pocket of-pocket limit; 100% thereafter
limit; 100% thereafter
Major Dental (Endodontics, Periodontics, Oral Surgery, and
Prosthodontics)
Preauthorization required.
At SHC: Not available
In-Network: 70% of allowable charges; up to the out-of-pocket limit;
100% thereafter; $100 per visit co-pay
Out-of-Network: 60% of reasonable and customary charges; up to
the out-of-pocket limit; 100% thereafter

Orthodontia: Preauthorization required.

At SHC: Not available
In-Network: 60% of allowable charges; up to the out-of-pocket limit;
100% thereafter; $100 per visit co-pay
Out-of-Network: 60% of reasonable and customary charges; up to
the out-of-pocket limit; 100% thereafter

For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu
 BASIC PLAN COMPREHENSIVE PLAN
(Comp) AND GSHIP
ADDITIONAL BENEFITS (continued)
Diabetic Treatment Diabetic Equipment, Supplies and Self-Management Education:
Expense
We Cover diabetic equipment, supplies, and self-management
education if recommended or prescribed by a Physician or other
licensed Health Care Professional.
At SHC: $20 co-pay per prescription
InNetwork: $20 co-pay per prescription
Out-of-Network: 70% co-insurance
Covered medical expenses for self-management education are
payable as follows:
At SHC: 80% of the allowable At SHC: 90% of the allowable
charge up to the out-of-pocket charge up to the out-of-pocket
limit, 100% thereafter limit, 100% thereafter
In-Network: 75% of the In-Network: 90% of the
allowable charge up to the out- allowable charge up to the out-
of-pocket limit, 100% thereafter of-pocket limit, 100% thereafter
Out-of-Network: 50% of Out-of-Network: 60% of
reasonable and customary reasonable and customary
charges up to the out-of-pocket charges up to the out-of-
limit, 100% thereafter pocket limit, 100% thereafter

Durable Medical At SHC: 80% of reasonable and At SHC: Comp Plan: 90% of
Equipment (DME) customary charges all reasonable and customary
and Braces Outside SHC: 75% of reasonable charges; GSHIP: Covered 100%
and customary charges Outside SHC: 90% of
reasonable and customary
charges

Breast Feeding In-Network: Covered at 100% In-Network: Covered at 100%

DME Out-of-Network: 50% of Out-of-Network: 60% of
reasonable and customary reasonable and customary
charges after deductible up to charges after deductible up to
the out-of-pocket limit, 100% the out-of-pocket limit, 100%
thereafter thereafter
Medical and Mental Medical and mental health treatment will be covered according to
Health Treatment the plan benefits at the in-network level.
Away
Other Covered Radiation Therapy, Chemotherapy, Dialysis Treatment, and
Services - Intravenous Home Therapy
sample listing Mastectomy, Lymph Node Dissection and Lumpectomy and
Reconstructive Surgery as a result of Breast Cancer
Hospital Outpatient Services
Partial Hospitalization
Speech and Hearing Therapy, Bone Density Screening Test
Home Health Care
End of Life Care
Travel Assistance Program through Travel Guard

For a more complete description of plan benefits, general terms and conditions, pre-authorization and referral
requirements, etc., please review the 2017-2018 Student Health Insurance Certificate at www.chpstudent.com/nyu