| Benefits | Economy |
|---|---|
| Certificate Period Maximum | $200,000$200k |
| Maximum Benefit per illness/Injury | $100,000$100k |
| Deductible | $0 |
| ER Co-Pay | $350 |
| Student Health Center/Teladoc Co-Pay | $35 (Coinsurance does not apply) |
| Physician office Co-Pay | $100 |
| Urgent Care/Walk-in Clinic Co-Pay | $75 |
| Provider Network | Doctor/Hospital Search |
|
Coinsurance In-network, Inside the US |
80% Coverage up to Maximum Benefit |
|
Coinsurance Out-of-network, inside the US |
60% Coverage up to Maximum Benefit |
|
Coinsurance Outside the US |
100% of Eligible Expenses |
| The following benefits are all subject to the deductible, copays, and coinsurance, unless otherwise stated: | |
| Hospital Room & Board | Usual, reasonable, and customary charges |
|
Local Ambulance Per Injury/Illness if hospitalized as Inpatient |
Up to $500 |
| Intensive Care Unit | Usual, reasonable, and customary charges |
| Outpatient Treatment | Usual, reasonable, and customary charges |
|
Outpatient Prescription Medication Not subject to Coinsurance |
$50 Co-Pay
Through the Magellan Rx Network |
|
Mental Health Outpatient |
Up to $50 per day; 5 visits maximum |
| Coverage includes drug and alcohol abuse | |
|
Mental Health Inpatient |
Up to $2,500 maximum |
| Dental Treatment |
Accident — $250 per tooth; maximum of $500 Onset of pain — $100 maximum (Certificate Period must be 30 or more days) |
| Therapeutic Termination of Pregnancy | $500 Maximum after 90 days of continuous coverage |
|
Outpatient Physical Therapy & Chiropractic Care Subject to coinsurance |
$75 Co-Pay |
| Terrorism | Usual, reasonable, and customary charges |
| Emergency Medical Evacuation | $50,000$50k |
| Emergency Reunion | $1,000 |
| Repatriation of Remains | $25,000$25k |
| COVID-19 including viral mutations |
Usual, reasonable, and customary charges |
| Incidental Trip Home | 15 days per 90 days of coverage |
| Radiology / X-rays / Labortory | Usual, reasonable, and customary charges |
| Professional fees by Physician including specialists, surgeons, anesthesiologists |
Usual, reasonable, and customary charges
assistant surgeon fees subject to a maximum of 20% of covered primary surgeon fees |
| Operating room, treatment room and/or recovery room | Usual, reasonable, and customary charges |
| Interfacility Ambulance Transfer | $500 |
| All other Eligible Medical Expenses | Usual, reasonable, and customary charges |
This plan is underwritten by Lloyd's.