| BENEFIT |
ELITE |
SELECT |
BUDGET |
SMART |
| Certificate Period Maximum |
$1,000,000 |
$600,000 |
$500,000 |
$200,000 |
| Maximum Benefit per Injury or Illness |
$500,000 |
$300,000 |
$250,000 |
$100,000 |
| Deductible(Except Emergency Room) |
$25 per injury or illness within the PPO network, outside the U.S. or at a student health center; otherwise $50 per injury or illness
|
$35 per injury or illness within the PPO network, outside the U.S. or at a student health center; otherwise $70 per injury or illness
|
$45 per injury or illness within the PPO network, outside the U.S. or student health center; otherwise $90 per injury or illness
|
$50 per injury or illness within the PPO network, outside the U.S. or student health center; otherwise $100 per injury or illness
|
| Emergency Room Deductible (Claims incurred in the U.S. only) |
$100 for treatment received in an emergency room
|
$200 for treatment received in an emergency room
|
$350 for treatment received in an emergency room
|
Coinsurance -
claims incurred inside the U.S. |
Within the PPO: We will pay 100% of eligible expenses, after the deductible, up to the overall maximum limit.
Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
Within the PPO: We will pay 80% of the next $5,000 of eligible expenses after deductible, then 100% to the overall maximum limit.
Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
Within the PPO: We will pay 80% of the next $25,000 of eligible expenses after deductible, then 100% to the overall maximum limit.
Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
Within the PPO: We will pay 80% of eligible expenses after the deductible up to the overall maximum limit.
Outside the PPO: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. |
Coinsurance -
claims incurred outside the U.S. |
After the deductible, 100% of eligible expenses to the certificate period maximum. |
| Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise. |
| BENEFIT |
ELITE Limit |
SELECT Limit |
BUDGET Limit |
SMART Limit |
| Hospital room & board |
Average semi-private room rate, including nursing services. |
Local ambulance
(Not subject to coinsurance) |
Up to $750 per injury / illness if hospitalized as inpatient |
Up to $500 per injury / illness if hospitalized as inpatient |
Up to $300 per injury / illness if hospitalized as inpatient |
| Intensive care unit |
Up to the overall maximum limit |
| Outpatient treatment |
Up to the overall maximum limit |
| Outpatient prescription drugs |
Generic Drugs: 100% coinsurance
Brand Name Drugs: 50% coinsurance.
Specialty Drugs: No coverage.(not subject to deductible) |
50% of actual charge (not subject to deductible or coinsurance) |
| Vaccinations |
Up to $150.Covered vaccinations and testing are: Measles, Mumps, Rubella (MMR); Tetanus/Diphtheria/Pertussis (TDAP); Chicken Pox (Varicella); Hepatitis B; and Meningitis (Meningococcal MCV4 and B) (not subject to deductible or coinsurance) |
No coverage |
| Mental health disorders (Treatment must not be provided at a student health center) |
Outpatient: Maximum of 30 visits. Inpatient: Maximum of 30 days. |
Outpatient: $50 maximum per day, $500 maximum. Inpatient: Up to $10,000 maximum. |
Outpatient: $50 maximum per day, $500 maximum. Inpatient: Up to $5,000. |
| Dental treatment due to accident |
Up to $250 maximum per tooth; $500 maximum per certificate period. Not subject to coinsurance. |
| Emergency dental (Acute onset of pain) |
Up to $100. Not subject to coinsurance. |
| Pre-existing condition |
6-month waiting period |
12-month waiting period |
No coverage |
| Acute onset of pre-existing condition (excludes chronic and congenital conditions) |
$25,000 lifetime maximum for eligible expenses |
| Maternity care for a covered pregnancy |
Up to $25,000. |
Up to $10,000. |
Up to $5,000. |
No coverage. |
| Nursery care of newborn (not subject to coinsurance) |
Up to $750. |
Up to $250. |
No coverage. |
| Therapeutic termination of pregnancy |
Up to $500. Not subject to coinsurance. |
| Outpatient Physical therapy & chiropractic care (Not subject to coinsurance. Must be ordered in advance by a physician and not obtained at a student health center.) |
Up to $75 per visit per day |
Up to $50 per visit per day |
Up to $25 per visit per day |
| Intercollegiate, interscholastic, intramural, or club sports |
Up to $5,000 maximum per injury or illness; medical expenses only |
Up to $3,000 maximum per injury or illness; medical expenses only |
No coverage. |
| Terrorism |
Up to $50,000 lifetime maximum. Eligible medical expenses only. |
No coverage. |
| EMERGENCY TRAVEL BENEFIT |
ELITE Limit |
SELECT Limit |
BUDGET Limit |
SMART Limit |
| Emergency medical evacuation (Not subject to deductible or coinsurance.) |
Up to $500,000 lifetime maximum |
Up to $300,000 lifetime maximum |
Up to $250,000 lifetime maximum |
Up to $50,000 lifetime maximum |
| Emergency reunion(Not subject to deductible or coinsurance.) |
Up to $5,000, subject to a maximum of 15 days |
Up to $1,000, subject to a maximum of 15 days |
| Accidental death & dismemberment(Not subject to deductible or coinsurance.) |
Lifetime Maximum - $25,000
Death - $25,000
Loss of 2 Limbs - $25,000
Loss of 1 Limb - $12,500
|
No coverage. |
| Repatriation of remains (not subject to deductible, coinsurance, or overall maximum limit) |
Up to $50,000 lifetime maximum |
Up to $25,000 lifetime maximum |
| Personal Liability(Not subject to deductible or coinsurance.) |
Up to $250,000 lifetime maximum.
Up to $250,000 third person injury or property.
Up to $2,500 related third person property. |
No coverage. |
