Smart | Budget | Select | Elite | |
---|---|---|---|---|
Overall Max Limit | $200,000 | $500,000 | $600,000 | $5,000,000 |
Max per injury/illness | $100,000 | $250,000 | $300,000 | $500,000 |
Deductibles and Coinsurance |
||||
---|---|---|---|---|
Smart | Budget | Select | Elite | |
Deductible per injury/illness Inside PPO, Outside USA, Student Health Center, except ER | $50 | $45 | $35 | $25 |
Deductible per injury/illness All other locations, except ER | $100 | $90 | $70 | $50 |
ER Deductible Per visit, inside the USA only | $350 | $350 | $200 | $100 |
Network | Click here to search the PPO Doctor/Hospital Network | |||
Coinsurance Inside the USA |
In Network:
80% of eligible expenses after the deductible up to the overall maximum Out Network: Usual, Reasonable, and Customary (URC) |
In Network:
80% of the next $25,000 of eligible expenses after the deductible, then 100% to the overall maximum. $5,000 max out of pocket Out Network: Usual, Reasonable, and Customary (URC) |
In Network:
80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum. $1,000 max out of pocket Out Network: Usual, Reasonable, and Customary (URC) |
In Network:
100% of eligible expenses after the deductible to the overall maximum Out Network: Usual, Reasonable, and Customary (URC) |
Coinsurance Outside the USA | 100% of Eligible Expenses, up to the Overall Maximum Limit, after the Deductible. |
Key Medical Benefits |
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---|---|---|---|---|
Smart | Budget | Select | Elite | |
Hospital Room and Board | Average Semi-Private Room Rate, including nursing services | Average Semi-Private Room Rate, including nursing services | Average Semi-Private Room Rate, including nursing services | Average Semi-Private Room Rate, including nursing services |
Outpatient Treatment | Up to Overall Maximum Limit | Up to Overall Maximum Limit | Up to Overall Maximum Limit | Up to Overall Maximum Limit |
Prescription Medications | 50% of actual charge | 50% of actual charge | 50% of actual charge |
100% for generic 50% for brand Specialty Drugs: No Coverage |
Mental Health |
Outpatient:
Up to $50 per day, $500 max Inpatient:Up to $5,000 |
Outpatient:
Maximum of 30 visits Inpatient:Maximum of 30 days Coverage includes drug and alcohol abuse. |
Outpatient:
Maximum of 30 visits Inpatient:Maximum of 30 days Coverage includes drug and alcohol abuse. |
Outpatient:
Maximum of 30 visits Inpatient:Maximum of 30 days Coverage includes drug and alcohol abuse. |
Maternity | No coverage | Up to $5,000 | Up to $10,000 | Up to $25,000 |
Pre-existing Conditions | $25,000 for acute onset of a pre-existing condition only | 12 month waiting period during which the plan includes $25,000 for acute onset of a pre-existing condition | 6 month waiting period during which the plan includes $25,000 for acute onset of a pre-existing condition | 6 month waiting period during which the plan includes $25,000 for acute onset of a pre-existing condition |
Medical Evacuation | $50,000 | $250,000 | $300,000 | $500,000 |
Repatriation of Remains | $25,000 | $25,000 | $50,000 | $50,000 |
Sports Coverage |
Leisure, recreational, entertainment and fitness sports included School sports — No Coverage |
Leisure, recreational, entertainment and fitness sports included School sports — Optional Add-on |
Leisure, recreational, entertainment and fitness sports included School sports — Optional Add-on |
Leisure, recreational, entertainment and fitness sports included School sports — Optional Add-on |
To view the full plan benefits and the complete table of benefits, please download a copy of the plan brochure:
This is a summary of a selection of the key plan benefits offered only as an illustration and does not supersede in any way the Certificate of Insurance and governing policy documents. The Certificate of Insurance is the only source of the actual benefits provided.