| 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 |
