| |
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 |
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. |
Underwriters will pay 80% of the next $5,000 of Eligible
Expenses after the Deductible, then 100% to the Certificate Period
Maximum |
Coinsurance
Claims incurred oustide
of US |
After the Deductible, Underwriters
will pay 100% of Eligible Expenses to Certificate Period
Maximum |
Underwriters will pay 80% of the next $5,000 of Eligible
Expenses after the Deductible, then 100% to the Certificate Period
Maximum |
| 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 |
| 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 Lifetime (Participant)
$50,000 Lifetime (Spouse)
$50,000 Lifetime (Child) |
$250,000 Lifetime (Participant)
$50,000 Lifetime (Spouse)
$50,000 Lifetime (Child) |
| Emergency Reunion |
$2,500 Lifetime |
$1,000 Lifetime |
| Accidental Death & Dismemberment |
| Principal Sum |
| $25,000 (Participant) |
| $10,000 (Spouse) |
| $ 5,000 (Child) |
|
No coverage |
| Repatriation of Remains |
$25,000 Maximum |
$15,000 Maximum |