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Plan Detail

Plan Administrator: USI Affinity Travel Insurance Services | AM Best Rating: A+ "Superior" | Underwriter: Lloyd's of London

Benefits


 

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