| Medical Maximum |
In Network: $150,000 per Injury or Sickness, to an overall $300,000 Maximum
Out Network: $150,000 per Injury or Sickness, to an overall $300,000 Maximum |
| Lifetime Maximum |
In Network: Unlimited
Out Network: Unlimited |
| Deductible at Student Health Center |
In Network:$35
Out Network: $35 |
| Deductible Options |
In Network:$250
Out Network: $250 |
| Office Visit Deductible |
In Network: $40 per Occurrence
Out Network: $40 per Occurrence |
| Emergency Room Deductible |
In Network: $300 per Occurrence
Out Network: $300 per Occurrence |
| Hospital Room & Board |
In Network: 100% of the Preferred Allowance
Out Network: 75% of of the Semi-Private Room Rate
|
| Intensive Care |
In Network: 100% of the Preferred Allowance(up to $1,525/day)
Out Network: 75% of URC(up to $1,525/day) |
| Hospital Misc. Expense |
In Network: 100% of the Preferred Allowance(up to $500 Max Benefit)
Out Network: 75% of URC(up to $500 Max Benefit) |
| Surgeon |
In Network: 00% of the Preferred Allowance
Out Network: 75% of URC |
| Pre-Admission Testing |
In Network: 100% of the Preferred Allowance(up to $900 Max)
Out Network: 75% of URC(up to $900 Max) |
| Anesthesia |
In Network: 100% of the Preferred Allowance
Out Network: 75% of URC |
| Day Surgery Misc |
In Network: 100% of the Preferred Allowance
Out Network: 75% of URC |
| Diagnostic X-Ray and Lab |
In Network: 100% of the Preferred Allowance
Out Network: 75% of URC |
| Ambulance |
In Network: 100% of the Preferred Allowance
Out Network: 75% of URC |
| Physician Visit |
In Network: 100% of the Preferred Allowance
Out Network: 75% of URC |
| Consult Physician |
In Network: 100% of the Preferred Allowance
Out Network: 75% of URC |
| Extended Care/ Inpatient Rehabilitation |
In Network: 100% of the Preferred Allowance
Out Network: 75% of URC |
| Emergency Room (50% Coinsurance for Non-Emergency Use) |
In Network: 80% of the Preferred Allowance(subject to a $300 Deductible per visit, waived if admitted)
Out Network: 70% of URC(subject to a $300 Deductible per visit, waived if admitted) |
| Maternity & Pre-Natal Care Expense (Conception must occur while covered under the Policy) |
In Network: 100% of the Preferred Allowance($5,000 Maximum Benefit for normal delivery,
$7,500 Max Benefit for C-Section)
Out Network: 75% of URC($5,000 Maximum Benefit for normal delivery,
$7,500 Max Benefit for C-Section) |
| Elective/ Therapuetic Termination of Pregnancy (Conception must occur while covered under the Policy) |
In Network: 100% of the Preferred Allowance (Up to $500 Max)
Out Network: 75% of URC(Up to $500 Max) |
