Medical Maximum | In Network: Unlimited Out Network: Unlimited |
Lifetime Maximum | In Network: Unlimited Out Network: Unlimited |
Deductible Options | In Network: $100 or $500 Out Network: $100 or $500 |
Office Visit Deductible | In Network: $25 per Occurrence
Out Network: $25 per Occurrence |
Urgent Care Deductible | In Network: $50 per Occurrence Out Network: $50 per Occurrence |
Emergency Room Deductible | In Network: $150 per Occurrence Out Network: $150 per Occurrence |
Hospital Room & Board | In Network: 80% of the Preferred Allowance Out Network: 70% of of the Semi-Private Room Rate |
Intensive Care | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Hospital Misc. Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Surgeon | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Pre-Admission Testing | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Anesthesia | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Day Surgery Misc | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Diagnostic X-Ray and Lab | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Ambulance | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Physician Visit | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Consult Physician | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Extended Care/ Inpatient Rehabilitation | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Emergency Room (70% Coinsurance for Non-Emergency Use) | In Network: 80% of the Preferred Allowance(subject to a $150 Deductible per visit, waived if admitted) Out Network: 70% of URC(subject to a $150 Deductible per visit, waived if admitted) |
Maternity & Pre-Natal Care Expense (Conception must occur while covered under the Policy) | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Elective/ Therapuetic Termination of Pregnancy (Conception must occur while covered under the Policy) | In Network: 80% of the Preferred Allowance (Up to $1,500 Max) Out Network: 70% of URC(Up to $1,500 Max) |
Radiation/Chemotherapy | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Wellness Medical | In Network: 100% of the Preferred Allowance
(deductible does not apply) 0-12 Months: Exam, Immunizations & Routine Eye & Hearing Exams Child/Adult: Annual Exam, Immunizations & Routine Eye & Hearing Exams Out Network: No Benefit |
In-Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Out -Patient Expense | In Network: 80% of the Preferred Allowance (subject to a $25 Co-Payment) Out Network: 70% of URC (subject to a $25 Co-Payment) |
In-Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Out -Patient Expense | In Network: 80% of the Preferred Allowance (subject to a $25 Co-Payment) Out Network: 70% of URC (subject to a $25 Co-Payment) |
Sports Activities (Injuries arising from Intercollegiate, Interscholastic, Intramural, Leisure, and Club Sports) | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
In-Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Out -Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Motor Vehicle Accident | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
AIDS, HIV, ARC, Sexually Transmitted Diseases & All Related Conditions | In Network: 100% of the Preferred Allowance Out Network: 70% of URC |
Diabetic Medical Supplies | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Pediatric Dental Care | In Network: 50% of the Preferred Allowance Out Network: 70% of URC |
Homeopathic Care & Acupuncture | In Network: 80% of the Preferred Allowance(up to $500 Max, subject to a $25 co-payment) Out Network: 70% of URC(up to $500 Max, subject to a $25 co-payment) |
Home Health Care | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
In-Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Out-Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Emergency Dental Expense | In Network: 80% of the Preferred Allowance(up to $250 per tooth to a $1,000 Max) Out Network: 70% of URC(up to $250 per tooth to a $1,000 Max) |
Durable Medical Equipment Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Emergency Medical Evacuation | In Network: 100% of Actual Expense Out Network: 100% of Actual Expense |
Return of Mortal Remains | In Network: 100% of Actual Expense Out Network: 100% of Actual Expense |
Extension of Home Country Sickness | In Network: $1,000 Out Network: $1,000 |
Accidental Death & Dismemberment | $30,000 |
Prescription Drug Co-Payment (per prescription) (Oral Contraceptives are included) | Network Provider: Tier 1: $10 Co-Pay Tier 2: $20 Co-Pay Tier 3: $40 Co-Pay(up to a 31-day supply per prescription) Non-Network Provider: No benefit if a non-network pharmacy is used. |
Travel Assistance Services | 24-hour travel assistance services are provided by GBG Assist |
Trawick International Covid19 travel insurance by Collegiate Care Elite Student Insurance for coronavirus coverage will cover eligible medical expenses resulting from COVID-19/SARS-CoV-2. Eligible medical expenses are medically necessary expenses that are not subject to another plan exclusion.
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