Lifetime Maximum |
Student |
$500,000 |
$1,000,000 |
Dependent |
$100,000 |
$100,000 |
Per Illness/Injury Maximum |
Student |
$300,000 |
$500,000 |
Each eligible dependent |
$100,000 |
$100,000 |
Deductible |
For Treatment received outside the US |
$100 per Illness or Injury |
$25 per Illness or Injury |
For Treatment received inside the US |
$100 per Illness or Injury |
PPO: $25 per Illness or Injury Non-PPO: $50 per Illness or Injury
|
Emergency Room |
|
An additional Deductible of $250 will be applied for each Emergency Room visit for Treatment
of
an Illness which does not result in a direct hospital admission.
|
Student Health Center |
|
$5 co-pay per visit if Treatment received in Student Health Center (not subject to deductible)
|
Coinsurance |
For Treatment received outside the US |
The plan pays 100% of eligible expenses up to Maximum Limit |
For Treatment received within the US |
In the PPO Network or Student Health Center:
The plan pays 100% of eligible expenses up to Maximum Limit
Outside of the PPO Network:
The plan pays 80% of eligible expenses up to $5,000, then 100% up to Maximum Limit
Provider Network
|
Medical Benefits |
Hospital Room & Board |
Average semi-private room rate |
Intensive Care Unit (ICU) |
After deductible is met, the plan pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.)
and internationally.
|
Maternity |
If incurred outside the US |
Not eligible for coverage |
After the deductible is met, the plan pays 100% of expenses up to $5,000 |
If incurred within the PPO network (in the US) |
Not eligible for coverage |
After the deductible is met, the plan pays 80% of expenses up to $5,000 |
If incurred outside of the PPO network (in the US) |
Not eligible for coverage |
After the deductible is met, the plan pays 60% of expenses up to $5,000 |
Routine Newborn Care |
Not eligible for coverage |
Included in Maternity Benefit during the first 31 days of life |
Physical Therapy
|
After deductible is met, the plan pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.)
and internationally, limit one visit per day.
|
Mental & Nervous Treatment |
Student Health Center |
Not eligible for coverage |
Outpatient Treatment |
$50 per day; $500 Lifetime Maximum |
Inpatient Treatment |
After deductible is met, plan pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and
internationally up to $10,00 maximum limit.
|
Local Ambulance |
Per Injury |
$350 |
$750 |
Per Illness (only if admitted inpatient) |
$350 |
$750 |
Prescription Drugs |
Inpatient |
After deductible is met, the plan pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.)
and internationally.
|
Outpatient |
50% of actual charges |
Dental |
Injury due to covered accident |
$500 period of coverage limit per injury |
Sudden & Unexpected Pain |
$350 period of coverage limit (to sound, natural teeth) |
Additional Benefits |
Intercollegiate, Interscholastic, Intramural or Club |
$5,000 per Injury or Illness |
Incidental Trip Coverage |
Up to a cumulative 14 days (available for non-U.S. residents only) |
Pre-existing Conditions |
After 12 months of continuous coverage |
After 6 months of continuous coverage |
Terrorism Coverage |
$50,000 Lifetime Maximum |
Personal Liability |
$10,000 combined maximum limit |
Injury to third person |
Subject to a $100 per injury deductible |
Damage to third person’s property |
Subject to a $100 per damage deductible |
Accidental Death & Dismemberment (AD&D) |
Eligible Participant |
$25,000 |
Spouse |
$10,000 |
Dependent Child |
$5,000 |
Dismemberment Levels |
Scheduled |
International Emergency Care |
Medical Evacuation |
$500,000 Lifetime Maximum |
Emergency Reunion |
$50,000 Lifetime Maximum |
Return of Mortal Remains |
$50,000 Lifetime Maximum |
Political Evacuation And Repatriation |
$10,000 Lifetime Maximum |