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Patriot Exchange
Benefits

Benefits Coverage
Overall Maximum Limit $5,000,000
Maximum Limit per illness/injury $50,000, $100,000, $250,000, or $500,000
Deductible per illness/injury $0, $100, $250, or $500
Student Health Center Copay Not subject to the deductible $5 per visit
Coinsurance 100% coverage, after the deductible, up to the maximum limit
Inpatient/Outpatient Benefits Subject to Deductible unless otherwise noted.
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless Stated as Maximum Limit
Eligible Medical Expenses Up to the maximum limit
Physician/Specialist Visit Up to the maximum limit 1 visit per day, unless visit is for different medical/surgical specialty
Urgent Care Not subject to deductible. $50 copay. Copay is not applicable when the $0 deductible is selected.
Walk-in Clinic Not subject to deductible. $20 copay. Copay is not applicable when the $0 deductible is selected.
Hospital Emergency Room

Up to the maximum limit

Illness: Subject to a $250 deductible for each ER visit for treatment that does not result in direct inpatient hospital admission.

Injury: Not subject to emergency room deductible.
Hospitalization / Room & Board Average semi-private room rate up to the maximum limit. Includes nursing service, miscellaneous and Ancillary services.
Intensive Care Unit Up to the maximum limit
Bedside Visit Not subject to the deductible $1,500 maximum. Must be hospitalized in an intensive care unit.
Outpatient Surgical / Hospital Facility Up to the maximum limit
Laboratory Up to the maximum limit
Radiology / X-ray Up to the maximum limit
Pre-admission Testing Up to the maximum limit
Surgery Up to the maximum limit
Reconstructive Surgery Up to the maximum limit Surgery is incidental to and follows surgery that was covered under the plan
Assistant Surgeon 20% of the primary surgeon’s eligible fee
Anesthesia Up to the maximum limit
Durable Medical Equipment Up to the maximum limit Standard basic hospital bed and/or a standard basic wheelchair
Chiropractic Care Up to the maximum limit Medical order or treatment plan required
Physical Therapy Up to the maximum limit 1 visit per day
Medical order or treatment plan required
Extended Care Facility Up to the maximum limit Upon direct transfer from an acute care facility
Home Nursing Care Up to the maximum limit Provided by a Home Health Care Agency
Upon direct transfer from an acute care facility
COVID-19 Coverage COVID-19/SARD-CoV-2 shall be considered the same as any other illness or injury, subject to all other terms and conditions
Prescription Drugs and Medication Inpatient and Outpatient Up to the maximum limit, may not exceed $250,000 Dispensing limit per prescription: 90 days
Mental or Nervous / Substance Abuse

Outpatient: $10,000 maximum limit

Inpatient: $50 limit per day, $500 maximum limit Not covered if incurred at the Student Health Center
Emergency Services NOT subject to Deductible unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless Stated as Maximum Limit
Emergency Local Ambulance Subject to deductible

Up to the maximum limit

Injury

Illness: must result in an inpatient hospital admission
Emergency Medical Evacuation $50,000 maximum limit Must be approved and coordinated in advance by the company
Emergency Reunion

$15,000 maximum limit

15 day maximum, $25 per day meal maximum Must be approved in advance by the company
Interfacility Ambulance Transfer Services rendered in the United States Up to the maximum limit Transfer must be a result of an Inpatient Hospital admission
Political Evacuation and Repatriation $10,000 maximum limit Must be approved in advance by the company
Return of Mortal Remains or Cremation/Burial

$25,000 maximum limit for Return of Mortal Remains

$5,000 maximum limit for Cremation/Burial Must be approved in advance by the company
Other Services NOT subject to Deductible unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless Stated as Maximum Limit
Accidental Death and Dismemberment $25,000 principal sum Death must occur within 90 days of the accident
Dental Treatment

Treatment due to Unexpected Pain to Sound Natural Teeth: $350 limit

Non-emergency Treatment due to Accident: $500 maximum
Traumatic Dental Injury Subject to deductible Up to the maximum limit Additional treatment for the same injury rendered by a dental provider will be paid at 100%.
Incidental Trip 14 day maximum Country of Residence is outside the United States
Terrorism $50,000 maximum limit
Pre-existing Conditions $500 per period of coverage, $1,500 maximum limit Available after 12 months of continuous coverage
Sudden and Unexpected Reoccurrence of a Pre-Existing Condition Available on Patriot Exchange International (no U.S. coverage) only

Maximum limit: $5,000

Emergency Medical Evacuation maximum limit: $25,000
Optional Add-On Rider NOT subject to Deductible unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless Stated as Maximum Limit
Interscholastic Athletics, Intramural Sports and Club Sports Subject to deductible Up to the maximum limit
Baggage

Lost or Stolen Baggage: $250 limit

Lost or Stolen Valuables: $250 limit

Lost or Stolen Personal Papers: $250 limit
Legal Assistance $500 limit for initial consultation When the Insured Person receives a legal summons, threat of lawsuit, or other notice of a third-party claim regarding a personal Injury or property damage liability
Personal Liability Secondary to any other insurance

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 No coverage for injury to a related third party or damage to related third person’s property.
Optional Adventure Sports Rider Subject to Deductible unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless Stated as Maximum Limit
Adventure Sports per Injury or Illness

Through age 49: $50,000 maximum limit

Ages 50 through age 59: $30,000 maximum limit

Ages 60 through age 64: $15,000 maximum limit

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


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