Student Plan Benefits

Inpatient Hospitalization Benefits Preferred Care Non-Preferred Care
Room and Board Expense 80% of the Negotiated Charge 60% of the Recognized Charge for a semi-private room
Intensive Care Room and Board Expense 80% of the Negotiated Charge 60% of the Recognized Charge for a semi-private room
Non-Surgical Physicians Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Licensed Nurse Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Miscellaneous Hospital Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Non-Surgical Physicians Expense 80% of the Negotiated Charge 60% of the Recognized Charge
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Surgical Expenses Preferred Care Non-Preferred Care
Surgical Expense (Inpatient and Outpatient) 80% of the Negotiated Charge 60% of the Recognized Charge
Anesthesia Expense (Inpatient and Outpatient) 80% of the Negotiated Charge 60% of the Recognized Charge
Assistant Surgeon Expense (Inpatient and Outpatient) 80% of the Negotiated Charge 60% of the Recognized Charge
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Outpatient Expense Preferred Care Non-Preferred Care
Hospital Outpatient Department Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Walk-in Clinic Visit Expense After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
Ambulatory Surgical Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Emergency Room Expense

Important Note: Please note that Non-Preferred Care Providers do not have a contract with Aetna. The provider may not accept payment of your cost share (your deductible and coinsurance) as payment in full. You may receive a bill for the difference between the amount billed by the provider and the amount paid by this Plan. If the provider bills you for an amount above your cost share, you are not responsible for paying that amount. Please send Aetna the bill at the address listed on the back of your member ID card and Aetna will resolve any payment dispute with the provider over that amount. Make sure your member ID number is on the bill.
After a $100 Copay per visit (waived if admitted), 80% of the Negotiated Charge After a $100 Deductible per visit (waived if admitted), 80% of the Recognized Charge
Urgent Care Expense After a $30 Copay per visit, 80% of the Negotiated Charge After a $30 Deductible per visit, 60% of the Recognized Charge
Ambulance Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Physician's Office Visit Expense This benefit includes visits to specialists After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
Laboratory and X-ray Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Consultant Expense After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
High Cost Procedures Expense Includes CT scans, MRIs, PET scans and Nuclear Cardiac Imaging Tests. 80% of the Negotiated Charge 60% of the Recognized Charge
Therapy Expense Includes Physical and Occupational Therapy 80% of the Negotiated Charge 60% of the Recognized Charge
Therapy Expense Includes Speech Therapy 80% of the Negotiated Charge 60% of the Recognized Charge
Therapy Expense Includes charges incurred by a covered person for the following types of therapy provided on an outpatient basis: Radiation therapy, Chemotherapy, including anti-nausea drugs used in conjunction with the chemotherapy, Dialysis, and Respiratory therapy Payable in accordance with the type of expense incurred and the place where service is provided.
Cardiac Rehabilitation Services – Outpatient 80% of the Negotiated Charge 60% of the Recognized Charge
Pulmonary Rehabilitation Therapy 80% of the Negotiated Charge 60% of the Recognized Charge
Chiropractic Therapy Expense After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
Durable Medical and Surgical Equipment Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Prosthetic Devices Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Durable Medical and Surgical Equipment Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Prosthetic Devices Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Non-Prescription Enteral Formula Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Second Surgical Opinion After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
Durable Medical and Surgical Equipment Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Dental Injury Expense 80% of the Actual Charge
Allergy Testing and Treatment Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Podiatric Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Diagnostic Testing For Learning Disabilities
Expense Covered Medical Expenses include charges incurred by a covered student for diagnostic testing for:
  • attention deficit disorder; or
  • attention deficit hyperactive disorder
Once a covered person has been diagnosed with one of these conditions, medical treatment will be payable as detailed under the outpatient Treatment of Mental and Nervous Disorders portion of this Plan.
80% of the Negotiated Charge 60% of the Recognized Charge
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Preventive Care Preferred Care Non-Preferred Care
Pap Smear Screening Expense 100% of the Negotiated Charge* 60% of the Recognized Charge
Mammogram Expense 100% of the Negotiated Charge* 60% of the Recognized Charge
Immunizations Expense
Includes travel immunizations and flu shots.
100% of the Negotiated Charge* 60% of the Recognized Charge
Well Baby Care Expense 100% of the Negotiated Charge* 60% of the Recognized Charge
Routine Physical Exam Expense
Includes routine tests and related lab fees.
100% of the Negotiated Charge* 60% of the Recognized Charge
Routine Screening for Sexually Transmitted Disease Expense 100% of the Negotiated Charge* 60% of the Recognized Charge
Routine Colorectal Cancer Screening Expense 100% of the Negotiated Charge* 60% of the Recognized Charge
Routine Prostate Cancer Screening 100% of the Negotiated Charge* 60% of the Recognized Charge
Pediatric Vision Care Services and Supplies Supplies are limited to 1 Pair of glasses (lenses and frames) per Policy Year. Benefits are provided to covered persons through age 18. 100% of the Negotiated Charge* 60% of the Recognized Charge
Pediatric Routine Dental Exam Expense Benefits are limited to 1 exam every 6 months. Benefits are provided to covered persons through age 18. 100% of the Negotiated Charge* 70% of the Recognized Charge
Pediatric Basic Dental Care Expense Benefits are provided to covered persons through age 18. 70% of the Negotiated Charge* 50% of the Recognized Charge
Pediatric Major Dental Care Expense Benefits are provided to covered persons through age 18. 50% of the Negotiated Charge* 50% of the Recognized Charge
Pediatric Orthodontia Expense
Benefits are provided to covered persons through age 18.
50% of the Negotiated Charge* 50% of the Recognized Charge
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*Annual Deductible does not apply to these services

Alcoholism and Drug Addiction Treatment Preferred Care Non-Preferred Care
Inpatient Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Outpatient Expense After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
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Treatment of Mental and Nervous Disorders Preferred Care Non-Preferred Care
Inpatient Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Outpatient Expense After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
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Maternity Benefits Preferred Care Non-Preferred Care
Maternity Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Prenatal Care/Comprehensive Lactation Support and Counseling Services 100% of the Negotiated Charge* After a $20 Deductible per visit, 60% of the Recognized Charge
Breast Feeding Durable Medical Equipment 100% of the Negotiated Charge* 60% of the Recognized Charge
Well Newborn Nursery Care Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Family Planning Expense
Unless specified below, not covered under this benefit are charges for:
  • Services which are covered to any extent under any other part of this Plan;
  • Services and supplies incurred for an abortion;
  • Services provided as a result of complications resulting from a voluntary sterilization
  • Procedure and related follow-up care;
  • Services which are for the treatment of an identified illness or injury;
  • Services that are not given by a physician or under his or her direction;
  • Psychiatric, psychological, personality or emotional testing or exams;
  • Any contraceptive methods that are only "reviewed" by the FDA and not "approved" by the FDA;
  • Male contraceptive methods, or devices;
The reversal of voluntary sterilization procedures, including any related follow-up care
Voluntary Sterilization
Coverage for tubal ligation for voluntary sterilization.
100% of the Negotiated Charge* 60% of the Recognized Charge
Voluntary Sterilization
Coverage for vasectomy for voluntary sterilization.
80% of the Negotiated Charge 60% of the Recognized Charge
Contraceptives
Important Note: Brand-Name Prescription Drug or Devices for a Preferred Provider will be covered at 100% of the Negotiated Charge, including waiver of per Policy Year Deductible if a Generic Prescription Drug or Device is not available in the same therapeutic drug class or the prescriber specifies Dispense as Written.
100% of the Negotiated Charge* 60% of the Recognized Charge
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*Annual Deductible does not apply to these services

Prescription Drug Coverage Preferred Care Non-Preferred Care
Prescribed Medicines Expense
Prior Authorization may be required for certain Prescription Drugs and some medications may not be covered under this Plan. For assistance and a complete list of excluded medications, or drugs requiring prior authorization, please contact Aetna Pharmacy Management at (888) RX-AETNA (available 24 hours).

Aetna Specialty Pharmacy provides specialty medications and support to members living with chronic conditions. The medications offered may be injected, infused or taken by mouth. For additional information please go to www.AetnaSpecialtyRx.com
Oral Chemotherapy must be payable on the same basis as IV Chemotherapy.
100% of the Negotiated Charge following a $15 Copay for each Generic Prescription Drug, a $40 Copay for each Formulary Brand Name Prescription Drug, or a $70 Copay for each Non-Formulary Brand Name Prescription Drug. 80% of the Negotiated Charge for each Specialty Drug. 60% of the Recognized Charge. You must pay out of pocket for Prescriptions at a Non-Preferred Pharmacy and then submit the receipt with a Prescription Claim Form for reimbursement.
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Additional Benefits Preferred Care Non-Preferred Care
Diabetic Testing Supplies Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Outpatient Diabetic Self-management Education Program Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Hypodermic Needles Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Temporomandibular Joint Dysfunction Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Dermatological Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Elective Abortion Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Acupuncture In Lieu Of Anesthesia Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Hospice Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Home Health Care Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Skilled Nursing Facility Expense 80% of the Negotiated Charge for the semi-private room rate 60% of the Recognized Charge for the semi-private room rate
Rehabilitation Facility Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Cochlear Implant Expense 80% of the Negotiated Charge 60% of the Recognized Charge
Foot Orthotics & Orthopedic Shoes Expense Includes Medically Necessary foot orthotics and orthopedic shoes for covered persons with diabetes. 80% of the Negotiated Charge 60% of the Recognized Charge
Private Duty Nursing Expense Includes home nursing services provided through home health care. Limit applies to Private duty nursing in home setting. 80% of the Negotiated Charge 60% of the Recognized Charge for a semi-private room
Transfusion or Dialysis of Blood Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Human Organ Transplants Includes medically necessary human organ and tissue transplant services. When a human organ or tissue transplant is provided from a living donor to a covered person, both the recipient and the donor may receive the benefits of the health Plan. Payable in accordance with the type of expense incurred and the place where service is provided.
Human Organ Transplant - Transportation and Lodging 100% of the Actual Charge
Nutritional Counseling Expense After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
Non-Routine Dental Services Expense Limited to facility charges for Outpatient Services for the removal of teeth or for other dental processes only if the patient's medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient; 2) Dental xrays, supplies, & appliances and all associated expenses, including hospitalization and anesthesia are limited to services/treatments for: transplant preparation; initiation of immunosuppresives; or direct treatment of acute traumatic injury, cancer, or cleft palate. After a $20 Copay per visit, 80% of the Negotiated Charge After a $20 Deductible per visit, 60% of the Recognized Charge
Vision Correction after Surgery or Accident Includes prescription glasses or contact lenses when required as a result of surgery or for the treatment of accidental injury. Payable in accordance with the type of expense incurred and the place where service is provided.
Mastectomy And Reconstructive Surgery Expense Payable in accordance with the type of expense incurred and the place where service is provided.
Reconstructive Surgery Payable in accordance with the type of expense incurred and the place where service is provided.
Transgender Related Expense

Covered Medical Expenses include charges incurred by a covered person for medically necessary surgery, mental health, prescription drugs and other related services that are Covered Medical Expenses under this plan.

Surgical transgender services are limited to $50,000 per Policy Year.
Payable in accordance with the type of expense incurred and the place where service is provided.
Biofeedback Expense 80% of the Negotiated Charge 60% of the Recognized Charge
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