Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London
| Benefits | Limit |
|
Certificate Period Maximum (including all
benefits):
|
$250,000 per member |
| Deductible – Claims incurred inside the PPO |
$50 per incident for expenses occurred within the PPO network or if
treatment is from a Student Health Center
|
| Deductible – Claims incurred outside PPO Network | $150 per incident for expenses occurred outside of the PPO network |
| ER Deductible | $250 additional deductible per incident unless admitted as inpatient |
|
Coinsurance – Claims incurred within PPO
Network
|
80% of Eligible Expenses after the Deductible up to$25,000, then
100% up to the Certificate Period Maximum
|
|
Coinsurance – Claims incurred outside PPO
Network
|
70% of Eligible Expenses after the Deductible up $25,000, then
100% up to the Certificate Period Maximum
|
| Hospital Room and Board | Average Semi-Private room rate, including nursing services |
| Local Ambulance |
$350 per Injury or Illness, when covered Illness or Injury results in
Inpatient hospitalization
|
| Intensive Care Unit | Usual, Reasonable and Customary charges |
| Hospital Pre-certification Penalty | 50% of Eligible Medical Expenses |
| Outpatient Treatment | Usual, Reasonable and Customary charges |
| Outpatient Prescription Drugs |
$10 copay for generic drugs
$20 copay for brand name
|
| Maternity Care for a Covered Pregnancy | Usual, Reasonable, and Customary charges |
| Routine Nursery Care of Newborn | $750 Maximum per Certificate Period |
| Therapeutic Termination of Pregnancy | $500 Maximum per Certificate Period |
| Wellness |
100% of one Routine Physical Exam per member per Certificate
Period
|
| Physical Therapy and Chiropractic Care |
Maximum $50 per visit per day
Must be ordered in advance by a Physician and not obtained at a
Student Health Center.
|
|
Intercollegiate Interscholastic, Intramural or club
sports
|
$5,000 maximum per injury or illness.
Medical Expenses Only
|
| Mental Health Disorders |
90% of Usual, Reasonable and Customary Charges up to $10,000
for outpatient and/or inpatient treatment of Mental Health Disorders
per certificate period
Treatment must not be provided at a Student Health Center
|
| Dental Treatment due to Accident | $1,000 Maximum per Certificate Period |
| Emergency Medical Evacuation |
$500,000 Maximum Lifetime per Member
Not subject to Deductible or Coinsurance
|
| Repatriation of Remains |
$100,000 Maximum Lifetime per Member
Not subject to Deductible or Coinsurance
|
| Emergency Reunion |
$2,500 Lifetime Maximum for up to 15 days
Not subject to deductible or coinsurance
|
| Terrorism |
$50,000 Maximum Lifetime Limit
Eligible Medical Expenses only
|
| Accidental Death and Dismemberment |
$25,000 lifetime maximum
Not subject to Deductible or Coinsurance
Death – Principal Sum
Loss of 2 Limbs – Principal Sum
Loss of 1 Limb – One half Principal Sum
|