Patriot Exchange Program - Basic

Plan Detail

Plan Administrator: International Medical Group | AM Best Rating: A "Excellent" | Underwriter: Sirius International

Benefits


Maximum Limit $5,000,000
Deductible Options $0, $100, $250 or $500 per illness or injury available
Maximum Limit Per Illness or Injury Choice of $50,000, $100,000, $250,000 or $500,000
Coinsurance Company pays 100%
  INPATIENT/OUTPATIENT BENEFITS
Hospital Room and Board Up to the average semi-private room rate
Intensive Care Unit Company pays 100% after deductible is met
Physical Therapy Company pays 100% after deductible is met; one visit per day (Medical order or treatment plan required)
Bedside Visit $1,500 maximum limit. Must be hospitalized in an intensive care unit. Not subject to deductible
Physician Visit Company pays 100% after deductible is met; one visit per day
Student Health Center $5 copay per visit. Not subject to deductible
Prescription Drugs Company pays 100% after deductible is met
90 day dispensing maximum
Urgent Care $50 copay. Not subject to deductible.
Copay is not applicable if you choose a $0 Deductible
Walk-in Clinic $20 copay. Not subject to deductible.
Copay is not applicable if you choose a $0 Deductible
Eligible Medical Expenses Company pays 100% after deductible is met
Emergency Room visit with In-patient Admission Company pays 100% after deductible is met
Emergency Room visit without In-patient Admission Additional $250 deductible
Interfacility Ambulance Transfer
(For Services Rendered in the U.S. )
Company pays 100%. Transfer must be a result of an inpatient hospital admission
Not subject to deductible
Dental Non-emergency treatment at a dental provider due to an accident: $500 period of coverage limit per injury; Treatment due to unexpected pain to sound, natural teeth: $350 period of coverage limit
Mental or Nervous / Substance Abuse Not covered if incurred in student health center
Inpatient: $10,000 maximum limit
Outpatient: $50 maximum limit per day. $500 maximum limit
EVACUATION BENEFITS (Not subject to deductible)
Emergency Medical Evacuation $50,000 maximum limit
Emergency Reunion $15,000 maximum limit
Return of Mortal Remains or Cremation/Burial $25,000 maximum limit for return of mortal remains
or $5,000 maximum limit for cremation/burial
Political Evacuation and Repatriation $10,000 maximum limit
  ADDITIONAL BENEFITS
Accidental Death & Dismemberment $25,000 principal sum; Not subject to deductible
Terrorism $50,000 maximum limit; Not subject to deductible
Sudden & Unexpected Recurrence of a Pre-existing Condition Eligible medical expenses: $5,000 maximum limit
Emergency medical evacuation: $25,000 maximum limit
Pre-existing Conditions For conditions existing within 36 months before effective date, charges excluded until after 12 months of coverage and then $500 per period of coverage and $1,500 maximum limit
Incidental Trip Coverage (Available for non-U.S. residents only) Up to a cumulative 14 days
  OPTIONAL ADD-ON RIDER
Lost Personal Property $250 per period of coverage limit
Legal Assistance $500 per period of coverage limit
Personal Liability - Injury to third party
Personal Liability - Damage to third party’s property
$2,000 per period of coverage limit after $100 deductible
$500 per period of coverage limit after $100 deductible
Limited High School and College Sports Company pays 100% after deductible is met

Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.