1/16/2017 AetnaStudentHealth>WaiverApplicationConfirmation

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Step 6 Transaction Conrmation

Yourwaiverhasbeensubmied
Detailsofyourwaivertransaconareavailablebelow.

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Your waiver application has been submitted. Please see the
confirmation below.

WaiverReceived,PendingApproval
Dear Robin:

We have received your request for a waiver of 16/17 Annual

Medical Plan Waiver for International Students.

The Pennsylvania State University Student Health Insurance

office will review and verify the information you have
provided. If your plan does not meet the waiver requirements,

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Additional plans available for you

16/17Medical 16/17VitalSavings
Evacuaon/Repatriaon Dental

These benefits are designed to
assist Covered Persons when
traveling more than 100 miles
from home, anywhere in the
world.
Select Plan
Vital SavingsSM on Dental is a
dental discount program that
helps you and your dependents
save.
Select Plan

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Member Disclosure Legal No ces Find a Doctor or Hospital
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77 South Bedford Street Burlington, MA 01803. Aetna Student Health Agency Inc.
is a duly licensed broker for student accident and health insurance in the
Commonwealth of Massachusetts. Massachusetts license number: 10041444.
California license number: OB84599.

Aetna Student HealthSM is the brand name for products and services provided by
Aetna Life Insurance Company and its applicable affiliated companies (Aetna).
Fully insured student health insurance plans are underwritten by Aetna Life
Insurance Company.

Self insured plans are funded by the applicable school, with claims administration
services provided by Aetna Life Insurance Company.

Language services can be provided by calling the number

on your member ID card. For addi onal language assistance:
Espaol | | Ting Vit | | Tagalog | |
| Kreyl | Franais | Polski | Portugus | Italiano |
Deutsch | | | Other Languages

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