| |
Select Plan |
Budget Plan |
| Certificate Period Maximum |
| $300,000 (Participant) |
| $ 50,000 (Spouse) |
| $ 50,000 (Child) |
|
| $250,000 (Participant) |
| $ 50,000 (Spouse) |
| $ 50,000 (Child) |
|
| Maximum Benefit per Injury or Illness |
| $300,000 (Participant) |
| $ 50,000 (Spouse) |
| $ 50,000 (Child) |
|
| $250,000 (Participant) |
| $ 50,000 (Spouse) |
| $ 50,000 (Child) |
|
| Deductible |
| $100 per Injury or Illness |
| Reduced to $50 if treatment is from Student Health Center |
|
| Coinsurance Claims incurred in US |
| For the Certificate Period, Underwriters will pay 80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Certificate Period Maximum |
| For charges incurred within the PPO or at a Student Health Center, coinsurance will be waived. |
|
For the Certificate Period, Underwriters will pay 80% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit |
| Coinsurance Claims incurred oustide of US |
After the Deductible, Underwriters will pay 100% of Eligible Expenses to Certificate Period Maximum |
For the Certificate Period, Underwriters will pay 80% of the next $10,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit |
| Hospital Room & Board |
Average Semi-private room rate, including nursing services |
| Local Ambulance |
Up to $350 per Injury / Illness if Hospitalized as Inpatient |
| Intensive Care Unit |
Usual, Reasonable, and Customary charges |
| Hospital Pre-Notification Penalty |
50% of Eligible Medical Expenses |
| Outpatient Treatment |
Usual, Reasonable, and Customary charges |
| Outpatient Prescription Drugs |
50% of Actual Charge |
| Mental Health Disorders |
| Outpatient: $50 Maximum per day, $500 Maximum Lifetime |
| Inpatient: Usual, Reasonable, and Customary charges to $10,000 Maximum Lifetime |
| Treatment must be not obtained at a Student Health Center |
|
| Dental Treatment due to Accident |
| $250 Maximum per tooth |
| $500 Maximum per Certificate Period |
|
| Dental Treatment to alleviate pain |
$100 Maximum per Certificate Period |
| Maternity Care for a Covered Pregnancy |
Usual, Reasonable, and Customary Charges |
| Routine Nursery Care of Newborn |
$750 Maximum per Certificate Period |
$250 Maximum per Certificate Period |
| Therapeutic Termination of Pregnancy |
$500 Maximum per Certificate Period |
| Physical Therapy & Chiropractic Care |
| Maximum $50 per visit per day |
| Must be ordered in advance by a Physician and not obtained at a Student Health Center |
|
| Intercollegiate, interscholastic, intramural, or club sports |
| $5,000 Maximum per Injury / Illness |
| Medical Expenses only |
|
| Terrorism |
$50,000 Maximum Lifetime Limit, Medical Expenses Only |
| Benefit Period for coverage after Policy Termination Date |
60 days from date of Injury or Onset of Illness if Member is Hospitalized on the Termination Date |
| Emergency Medical Evacuation |
| $300,000 (Participant) |
| $ 50,000 (Spouse) |
| $ 50,000 (Child) |
|
| $250,000 (Participant) |
| $ 50,000 (Spouse) |
| $ 50,000 (Child) |
|
| Emergency Reunion |
$2,500 Lifetime |
$1,000 Lifetime |
| Accidental Death & Dismemberment |
| Principal Sum |
| $25,000 (Participant) |
| $10,000 (Spouse) |
| $ 5,000 (Child) |
|
|
| Repatriation of Remains |
$25,000 Maximum |
$15,000 Maximum |
|
