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Patriot Exchange
Benefits

Benefits Coverage
Maximum Limit $5,000,000
Maximum Benefit per illness/injury Choice of $50,000, $100,000, $250,000, or $500,000
Deductible Options $0, $100, $250, $500 per illness or injury available
Student Health Center Copay
Not subject to the deductible
$5 per visit
Copay not applicable if you choose a $0 deductible
Urgent Care Center Copay
Not subject to the deductible
$50 per visit
Copay not applicable if you choose a $0 deductible
Walk-in Clinic Copay
Not subject to the deductible
$20 per visit
Copay not applicable if you choose a $0 deductible
Coinsurance 100% Coverage
Inpatient/Outpatient Benefits
Hospital Room & Board Up to the average semi-private room rate
Intensive Care Unit 100% after the deductible is met
Physical Therapy and Chiropractic Care
Medical order or treatment plan required
100% after the deductible is met
Maximum of one visit per day
Bedside Visit
Not subject to the deductible
$1,500 maximum. Must be hospitalized in an intensive care unit.
Physician Visit
100% after the deductible is met
Maximum of one visit per day
Prescription Medication
100% after the deductible is met
90-day dispensing maximum
Eligible Medical Expenses 100% after the deductible is met
Emergency Room visit with Inpatient Admission $250 if not admitted as an inpatient; waived if visit is the result of an injury
Emergency Room visit without Inpatient Admission Additional $250 deductible
Interfacility Ambulance Transfer (for services rendered in the US)
Not subject to the deductible
100%. Transfer must be a result of an inpatient hospital admissions.
Dental

Non-emergency treatment at a dental provider due to an accident: $500 period of coverage limit per injury

Treatment due to an unexpected pain to sound, natural teeth: $350 period of coverage limit
Mental or Nervous/Substance Abuse Outpatient: $50 maximum per day; $500 maximum limit
Inpatient: $10,000 maximum limit
Not covered if incurred in student health center
Evacuation Benefits (Not Subject to the Deductible)
Emergency Medical Evacuation $50,000 maximum
Return of Mortal Remains or Cremation/Burial $25,000 maximum limit for return of mortal remains
Or $5,000 maximum limit for cremation/burial
Emergency Reunion $15,000 maximum
Political Evacuation and Repatriation $10,000 maximum
Additional Benefits
Accidental Death and Dismemberment
Not subject to the deductible
$25,000 principal sum
Terrorism $50,000 maximum limit; not subject to deductible
Pre-existing Conditions For conditions existing within 36 months before effective date, charges excluded until after 12 months of coverage and then $500 per period of coverage and $1,500 maximum limit
Sudden & Unexpected Recurrence of a Pre-existing Condition Eligible medical expenses: $5,000 maximum limit
Emergency medical evacuation
Incidental Trip Coverage (Available to non-US Residents only) Up to a cumulative 14 days
Optional Add-On Riders
Lost Personal Property $250 per period of coverage limit
Legal Assistance $500 per period of coverage limit
Personal Liability Injury to a third party: $2,000 per period of coverage limit after $100 deductible
Damage to third party’s property: $500 per period of coverage limit after a $100 deductible
Limited High School and College Sports 100% after deductible is met
Adventure Sports 14 days–49 years old: $50,000 Maximum
50–59 years old: $30,000 Maximum
60–64 years old: $15,000 Maximum

Please Note: The benefit table listed above is a consolidated version of the full plan benefits. Please view the plan certificate for more details about benefits and limitations of the plan. Limits apply to all benefits.


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