| Plan 1 Coverage |
Participant
|
| Accident and Sickness Medical Maximums |
$ 250,000 per Occurance per Policy Year
$1,000,000 Lifetime Maximums |
|
Deductible - Per Injury or Illness |
$100 if not first treated by the Student Health Center (or if there is no Student Health Center) $ 50if first treated by the Student Health Center |
| Coinsurance |
80% to $10,000, then 100% to plan maximum |
| Co Pay - Per Written Prescription of Medicine |
$10 for Generic and $20 for Brand Name |
| Benefit Period |
Covered Expenses incurred during the Period of Coverage |
Maternity
|
Covered as any other illness |
| Mental Illness |
$5,000 payable at 80% up to max of 40 days |
| Alcohol and Drug Abuse Inpatient/Outpatient |
Inpatient/Outpatient: $1, 000 payable at 50% |
| Injuries from a Motor Vehicle Accident |
$10,000 |
| Sports-related Injuries |
$5,000 per injury |
| Dental (emergency) |
$250 per tooth to a maximum of $500 |
| Emergency Medical Evacuation |
$100,000 |
| Repatriation of Mortal Remains |
$25,000 |
| Emergency Reunion |
$5,000 |
| Accidental Death and Dismemberment |
$10,000 per Insured/ $5,000 Spouse/Dependent Child |
| Physiotherapy |
$500 |
| Spinal Manipulation |
$500 |
| Ambulance Service |
$350 |
Home Country Coverage -
Incidental trips to the Insured's Home Country |
$30 days of coverage up to a maximum of $1,000 |
| Home Country Extension of Benefits |
Up to $1,000, expenses must be incurred within 30 ays of returning to your Home Country |
| Assistance |
24 hours - Worldwide |
