Benefits	Smart	Budget	Select	Elite
Overall Maximum Limit	$200,000$200k	$500,000$500k	$600,000$600k	$5,000,000$5M
MaximumMax. per injury/ illness	$100,000$100k	$250,000$250k	$300,000$300k	$500,000$500k
Deductible per injury/ illness Inside PPO Network, Outside USA or at Student Health Center (Except Emergency Room)	$50	$45	$35	$25
Deductible per injury/ illness All other locations (Except Emergency Room)	$100	$90	$70	$50
ER Deductible per visit claims incurred in the USA	$350	$350	$200	$100
Provider Network	Doctor/Hospital Search
Coinsurance — In Network, Inside the USA	80% of eligible expenses after the deductible up to the overall maximum	80% of the next $25,000 of eligible expenses after the deductible, then 100% to the overall maximum	80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum	100% of eligible expenses after the deductible to the overall maximum
Coinsurance — Out of Network, Inside the USA	Usual, Reasonable, and Customary (URC)
Coinsurance — Outside the USA	100% of Eligible Expenses, up to the Overall Maximum Limit, after the Deductible
Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.
Hospital Room & Board	Average Semi-Private Room Rate, including nursing services
Intensive Care Unit	Up to Overall Maximum Limit
Local Ambulance per injury/ illness if hospitalized as Inpatient Not subject to coinsurance	Up to $300	Up to $500	Up to $750	Up to $750
Outpatient Treatment	Up to Overall Maximum Limit
Outpatient Prescription Medication Not subject to deductible or coinsurance	50% of Actual Charge	50% of Actual Charge	50% of Actual Charge	100% coverage for generic 50% coverage for brand Specialty Drugs: No coverage
	For those members with a US destination, you will be automatically enrolled into the VantageAmerica Drug Discount program — further details below
Vaccination Not subject to deductible or coinsurance	No Coverage	No Coverage	No Coverage	$150 maximum see plan wording for list of covered vaccinations
Sports & Activities Leisure, Recreational, Entertainment, or Fitness	Up to the Overall Maximum Limit
Mental Health — Outpatient Treatment must not be obtained at the Student Health Center	Up to $50 per day $500 maximum	Maximum of 30 visits. Coverage includes drug and alcohol abuse.	Maximum of 30 visits. Coverage includes drug and alcohol abuse.	Maximum of 30 visits. Coverage includes drug and alcohol abuse.
Mental Health — Inpatient Treatment must not be obtained at the Student Health Center	Up to $5,000	Maximum of 30 days. Coverage includes drug and alcohol abuse.	Maximum of 30 days. Coverage includes drug and alcohol abuse.	Maximum of 30 days. Coverage includes drug and alcohol abuse.
Maternity Maternity care for a covered pregnancy	No Coverage	Up to $5,000	Up to $10,000	Up to $25,000
Newborn Care Routine nursery care of newborn Not subject to coinsurance	No Coverage	$250 MaximumMax.	$750 MaximumMax.	$750 MaximumMax.
Therapeutic Termination of Pregnancy Not subject to coinsurance	$500 MaximumMax.
Outpatient Physical Therapy & Chiropractic Care Not subject to coinsurance	$25 per day	$50 per day	$50 per day	$75 per day
	Must be ordered in advance by a physician and not obtained at a student health center
Dental treatment due to accident Not subject to coinsurance	$250 per tooth / $500 MaximumMax.
Dental treatment to alleviate pain Not subject to coinsurance	$100 MaximumMax.
Pre-existing Condition	No Coverage	12-monthmo. waiting period	6-monthmo. waiting period	6-monthmo. waiting period
Acute Onset of Pre-existing Condition (See benefit description)	Up to $25,000 lifetime maximum for eligible medical expenses
Terrorism Medical expenses only	No CoverageN/A	$50,000$50k MaximumMax.	$50,000$50k MaximumMax.	$50,000$50k MaximumMax.
All other Eligible Medical Expenses	Up to the Overall Maximum
Emergency Medical Evacuation Not subject to deductible coinsurance, or overall maximum limit	$50,000$50k lifetime maximum	$250,000$250k lifetime maximum	$300,000$300k lifetime maximum	$500,000$500k lifetime maximum
Repatriation of Remains Not subject to deductible coinsurance, or overall maximum limit	$25,000$25k lifetime maximum	$25,000$25k lifetime maximum	$50,000$50k lifetime maximum	$50,000$50k lifetime maximum
Emergency Reunion Not subject to deductible coinsurance, or overall maximum limit	Up to $1,000, subject to a maximum of 15 days	Up to $1,000, subject to a maximum of 15 days	Up to $5,000, subject to a maximum of 15 days	Up to $5,000, subject to a maximum of 15 days
Accidental Death & Dismemberment AD&D Not subject to deductible coinsurance, or overall maximum limit	No CoverageN/A	No CoverageN/A	Lifetime Maximum — $25,000 Death or Loss of 2 Limbs — $25,000 Loss of 1 Limb — $12,500	Lifetime Maximum — $25,000 Death or Loss of 2 Limbs — $25,000 Loss of 1 Limb — $12,500
Personal Liability Not subject to deductible coinsurance, or overall maximum limit	No CoverageN/A	No CoverageN/A	No CoverageN/A	Up to $250,000 lifetime maximum
Add-Ons:
Optional Sports Add-On Intercollegiate, Intramural, Interscholastic, Club sports Medical expenses only	No CoverageN/A	$3,000 per injury/illness	$5,000 per injury/illness	$5,000 per injury/illness

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Incidental Home Country Coverage

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