Student Plan Benefits

The Plan excludes coverage for certain services (referred to as exceptions in the certificate of coverage) and has limitations on the amounts it will pay. While this Plan Design and Benefit Summary document will tell you about some of the important features of the Plan, other features may be important to you and some may further limit what the Plan will pay. To look at the full Plan description, which is contained in the Certificate of Coverage issued to you, go to If any discrepancy exists between this Benefit Summary and the Certificate of Coverage, the Certificate will control.

Policy year deductible

In-network coverage

Out-of-network coverage

You have to meet your policy year deductible before this plan pays for benefits.


$400 per policy year

$750 per policy year


$1,200 per policy year

$2,250 per policy year

Policy Year Deductible Waiver 

The policy year deductible is waived for all of the following eligible medical services:

  • In-network care for Preventive care and wellness
  • In-network care for Pediatric dental care
  • In-network care and out-of-network care for Pediatric vision car
  • In-network care and out-of-network care for Outpatient prescription drugs

Maximum Out-of-Pocket Limits

Maximum out-of-pocket limit per policy year


$7,900 per policy year

$15,000 per policy year


$15,800 per policy year

$20,000 per policy year

Precertification Covered Benefit Penalty 

This only applies to out-of-network coverage: The certificate of coverage contains a complete description of the precertification program. You will find details on precertification requirements in the Medical necessity and precertification requirements section.

Failure to precertify your eligible medical services when required will result in the following benefit penalties: The additional percentage or dollar amount of the recognized charge which you may pay as a penalty for failure to obtain precertification is not a covered benefit, and will not be applied to the policy year deductible amount or the maximum out-of-pocket limit, if any.

Schedule of Benefits

The coinsurance listed in the schedule of benefits below reflects the plan coinsurance percentage. This is the coinsurance amount that the plan pays. You are responsible for paying any remaining coinsurance.

View full schedule of benefits on pp. 8-23 of the Medical Plan Brochure 

A covered person, a covered person's designee or a covered person's prescriber may seek an expedited medical exception process to obtain coverage for non-covered drugs in exigent circumstances. An "exigent circumstance" exists when a covered person is suffering from a health condition that may seriously jeopardize a covered person's life, health, or ability to regain maximum function or when a covered person is undergoing a current course of treatment using a non-formulary drug.

The request for an expedited review of an exigent circumstance may be submitted by contacting Aetna's Pre-certification Department at 855.240.0535, faxing the request to 877.269.9916, or submitting the request in writing to:

CVS Health 
ATTN: Aetna PA 
1300 E Campbell Road 
Richardson, TX 75081