| Smart | Budget | Select | Elite | |
|---|---|---|---|---|
| Overall Max Limit | $200,000 | $500,000 | $1,000,000 | $5,000,000 |
| Max per injury/illness | $100,000 | $250,000 | $500,000 | $500,000 |
Deductible, Co-pays, and Coinsurance |
||||
|---|---|---|---|---|
| Smart | Budget | Select | Elite | |
| Deductible | $0 | $0 | $0 | $0 |
| Student Health Center Co-Pay | $25 | $25 | $10 | $10 |
| Physician Office Co-Pay | $75 in-network $150 out-of-network |
$50 in-network $100 out-of-network |
$50 in-network $100 out-of-network |
$20 in-network $40 out-of-network |
| Urgent Care/Walk-In Clinic Co-Pay | $100 in-network $200 out-of-network |
$75 in-network $150 out-of-network |
$50 in-network $100 out-of-network |
$30 in-network $60 out-of-network |
| Hospital Inpatient/Outpatient Co-Pay | $200 in-network $400 out-of-network |
$150 in-network $300 out-of-network |
$100 in-network $200 out-of-network |
$75 in-network $150 out-of-network |
|
Emergency Room Claims incurred in the USA |
$350 | $350 | $200 | $100 |
| Network | Click here to search the PPO Doctor/Hospital Network | |||
| Coinsurance Inside the USA |
In Network:
80% of the next $100,000 of eligible expenses after applicable co-pays, then 100% to the overall maximum. Out Network: Usual, Reasonable, and Customary (URC) |
In Network:
80% of the next $45,000 of eligible expenses after applicable co-pays, then 100% to the overall maximum. Out Network: Usual, Reasonable, and Customary (URC) |
In Network:
80% of the next $25,000 of eligible expenses after applicable co-pays, then 100% to the overall maximum. Out Network: Usual, Reasonable, and Customary (URC) |
In Network:
80% of the next $10,000 of eligible expenses after applicable co-pays, then 100% to the overall maximum. Out Network: Usual, Reasonable, and Customary (URC) |
| Coinsurance Outside the USA | 100% of Eligible Expenses, up to the Overall Maximum Limit, after applicable co-pays. | |||
Key Medical Benefits |
||||
|---|---|---|---|---|
| Smart | Budget | Select | Elite | |
| Hospital Room and Board | Average Semi-Private Room Rate, including nursing services | Average Semi-Private Room Rate, including nursing services | Average Semi-Private Room Rate, including nursing services | Average Semi-Private Room Rate, including nursing services |
| Outpatient Treatment | Up to Overall Maximum Limit | Up to Overall Maximum Limit | Up to Overall Maximum Limit | Up to Overall Maximum Limit |
| Prescription Medications | 50% of actual charge | 50% of actual charge | 50% of actual charge |
100% for generic 50% for brand 50% for oral contraceptives Specialty Drugs: No Coverage |
| Mental Health |
Outpatient:
$500 maximum Inpatient:Up to $5,000 |
Outpatient:
Maximum of 30 visits Inpatient:Maximum of 30 days Coverage includes drug and alcohol abuse. |
Outpatient:
Maximum of 30 visits Inpatient:Maximum of 30 days Coverage includes drug and alcohol abuse. |
Outpatient:
Maximum of 40 visits Inpatient:Maximum of 40 days Coverage includes drug and alcohol abuse. |
| Maternity | No coverage | Up to $5,000 | Up to $10,000 | Up to $15,000 |
| Preventative Care | No coverage | No coverage | No coverage | $200 after a 6-month waiting period |
| Vaccinations | No coverage | No coverage | No coverage | $150 maximum |
| Pre-existing Conditions | $25,000 for acute onset of a pre-existing condition only | 12-month waiting period during which the plan includes $25,000 for acute onset of a pre-existing condition | 6-month waiting period during which the plan includes $25,000 for acute onset of a pre-existing condition | 6-month waiting period during which the plan includes $25,000 for acute onset of a pre-existing condition |
| Medical Evacuation | $50,000 | $250,000 | $300,000 | $300,000 |
| Repatriation of Remains | $25,000 | $25,000 | $50,000 | $50,000 |
| Sports Coverage |
Leisure, recreational, entertainment and fitness sports included School sports — No Coverage |
Leisure, recreational, entertainment and fitness sports included School sports — No Coverage |
Leisure, recreational, entertainment and fitness sports included School sports — $5,000 per illness/injury |
Leisure, recreational, entertainment and fitness sports included School sports — $5,000 per illness/injury |
To view the full plan benefits and the complete table of benefits, please download a copy of the plan brochure:
This is a summary of a selection of the key plan benefits offered only as an illustration and does not supersede in any way the Certificate of Insurance and governing policy documents. The Certificate of Insurance is the only source of the actual benefits provided.