| Benefits | Economy | Choice | Elite |
|---|---|---|---|
| Lifetime Medical Maximum | $5,000,000 | ||
| Maximum Benefit options | |||
| Per injury/illness | $100,000; $250,000; $500,000; $1,000,000 | ||
| Deductible options | |||
| Per injury/illness | $0, $50, $100, $250, $500, $1,000 | ||
|
Student Health Center Copay per visit *not subject to the deductible |
$5 | ||
| Coinsurance | |||
| In-network, inside the US | 80% of expenses up to $5,000, then 100% up to the Medical Maximum | 90% of expenses up to $5,000, then 100% up to the Medical Maximum | 100% of expenses up to the Medical Maximum |
| Out-of-network, inside the US | 70% of expenses up to $5,000, then 100% up to the Medical Maximum | 80% of expenses up to $5,000, then 100% up to the Medical Maximum | 90% of expenses up to $5,000, then 100% up to the Medical Maximum |
| Outside the US | 100% up to the medical maximum | ||
|
Subject to deductible and coinsurance unless otherwise stated
|
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| Hospital Services | |||
| Hospital Room & Board | Up to Medical maximum | ||
| Inpatient | Up to Medical maximum | ||
| Outpatient | Up to Medical maximum | ||
| Emergency Room | Up to Medical maximum | ||
| Doctor Office Visits | Up to Medical maximum | ||
|
Coma Benefit *separate from the Medical Maximum |
$10,000 | $25,000 | $50,000 |
| Local Ambulance | |||
| Inside the US | $350 per Displacement | $500 per Displacement | $750 per Displacement |
| Outside the US | Up to Medical maximum | ||
| Prescription Drugs | |||
|
Inside the US *not subject to Deductible |
$10 Copay for generic; $20 Copay for brand name | $5 Copay for generic; $10 Copay for brand name | $0 Copay |
| Outside the US | $0 Copay, deductible applies | ||
| Vaccinations | |||
| In the US only, as required by school, University or Visa program | $100 per 364 days of continuous coverage | $150 per 364 days of continuous coverage | $200 per 364 days of continuous coverage |
| Mental Health Includes Alcohol & Substance Abuse |
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| Outpatient Treatment Maximum 45 days |
80% up to $500 | 80% up to $1,000 | 100% up to $2,000 |
| Inpatient Treatment Maximum 45 days |
Up to $5,000 | Up to $10,000 | Up to $20,000 |
| Emergency Dental Treatment | |||
| Due to an accident | $500 maximum | $1,000 maximum | $2,500 maximum |
| Alleviate onset of pain | $150 maximum | $250 maximum | $350 maximum |
| Pre-existing Conditions | |||
| Coverage for pre-existing conditions | Up to Medical Maximum After 12-month waiting period |
||
|
Acute Onset of a pre-existing condition Inside the US |
$5,000 maximum for eligible expenses for the acute onset of pre-existing condition only | $10,000 maximum for eligible expenses for the acute onset of pre-existing condition only | $25,000 maximum for eligible expenses for the acute onset of pre-existing condition only |
| Maternity 6-month waiting period |
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| In-network, inside the US | Up to $500 | 80% up to $10,000 | 80% up to $25,000 |
| Out-of-network, inside the US | Up to $500 | 60% up to $10,000 | 60% up to $25,000 |
| Outside the US | Up to $500 | 80% up to $10,000 | 100% up to $25,000 |
|
Benefits are reduced an additional 25% for failure to notify the company within the first 90
days of pregnancy
|
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| Newborn Care | |||
| Routine nursery care | $250 maximum | $500 maximum | $750 maximum |
| High School, Interscholastic, intercollegiate, intramural or club sports | |||
| Only available for an exclusive list of covered sports. Please refer to the certificate at the end of the page. | $2,500 | $5,000 | $10,000 |
| Physical Therapy and Chiropractic Care | |||
| Physical Therapy | $25 per day; 60 days max | $50 per day; 60 days max | $75 per day; 60 days max |
| Spinal Manipulation | $25 per day; 60 days max when prescribed by a Physician | $50 per day; 60 days max when prescribed by a Physician | $75 per day; 60 days max when prescribed by a Physician |
| Incidental Home Country Coverage | |||
| Incidental Trips to Home Country: minimum purchase of 30 days | $1,000 | $5,000 | $10,000 |
| Extension of Benefits | $1,000 | $5,000 | $10,000 |
| Motor Vehicle Accident | |||
| Inside the US | 50% up to $100,000 | 75% up to $100,000 | 100% up to $100,000 |
| Outside the US | Up to Medical Maximum | ||
| International Emergency Care | |||
| Emergency Medical Evacuation | $100,000 | $500,000 | $750,000 |
| Emergency Reunion | Up to $200 per day/ $15,000 maximum limit | Up to $200 per day/ $25,000 maximum limit | Up to $200 per day/ $50,000 maximum limit |
| Return of Child(ren) | $25,000 | $40,000 | $50,000 |
| Return of Mortal Remains | $50,000 | ||
| Political Evacuation and Repatriation | $10,000 | ||
| Local Burial or Cremation | $5,000 | ||
| Natural Disaster | |||
| Evacuation | $5,000 | $10,000 | $10,000 |
| Daily Benefit | $25 per day; 5 day limit | $50 per day; 5 day limit | $75 per day; 5 day limit |
| Accidental Death and Dismemberment | |||
| Primary Participant | $25,000 | ||
| Spouse | $10,000 | ||
| Child | $5,000 | ||
| Total for Insureds | $250,000 | ||
| Personal Liability | $25,000 | $50,000 | $100,000 |
| Additional Benefits | |||
| 24/7 Travel Assistant | Included | ||
| Non-contact Amateur Sports | $2,500 | $5,000 | $10,000 |
| Terrorism | $25,000 | $50,000 | $100,000 |
| Felonious Assault | $10,000 | $15,000 | $20,000 |
