Page 3 - StudentsSecure_Brochure
P. 3
®
BENEFIT ELITE SELECT BUDGET SMART
Certificate period maximum $5,000,000 $600,000 $500,000 $200,000
Maximum benefit per injury or illness $500,000 $300,000 $250,000 $100,000
Deductible (Except Emergency Room) $25 per injury or illness within the PPO $35 per injury or illness within the $45 per injury or illness within the $50 per injury or illness within the
network, outside the U.S. or at a student PPO network, outside the U.S. or at PPO network, outside the U.S. or PPO network, outside the U.S. or
health center; otherwise $50 per injury or a student health center; otherwise student health center; otherwise student health center; otherwise
illness $70 per injury or illness $90 per injury or illness $100 per injury or illness
Emergency Room Deductible (Claims incurred $100 for treatment received in an emer- $200 for treatment received in an $350 for treatment received in an emergency room
emergency room
in the U.S. only) gency room
Coinsurance- claims incurred inside U.S. Within the PPO: We will pay 100% of Within the PPO: We will pay 80% of Within the PPO: We will pay 80% of Within the PPO: We will pay 80% of
eligible expenses, after the deductible, up the next $5,000 of eligible expenses the next $25,000 of eligible expens- eligible expenses after the deductible
to the overall maximum limit. after deductible, then 100% to the es after deductible, then 100% to up to the overall maximum limit.
overall maximum limit. the overall maximum limit.
Outside the PPO: Usual, reasonable, and Outside the PPO: Usual, reasonable, Outside the PPO: Usual, reason- Outside the PPO: Usual, reasonable,
Coinsurance- claims incurred outside of U.S. customary.You may be responsible for any
charges exceeding the payable amount. and customary.You may be respon- able, and customary.You may be re- and customary.You may be respon-
sible for any charges exceeding the sponsible for any charges exceeding sible for any charges exceeding the
payable amount. the payable amount. payable amount.
After the deductible, 100% of eligible expenses to the certificate period maximum.
Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.
BENEFIT ELITE Limit SELECT Limit BUDGET Limit SMART Limit
Hospital room & board Up to $300 per injury / illness if
Local ambulance (Not subject to coinsurance) Average semi-private room rate, including nursing services Up to $500 per injury / illness if hospitalized as inpatient
hospitalized as inpatient
Intensive care unit Up to $750 per injury / illness if hospitalized as inpatient
Outpatient treatment Outpatient: $50 maximum per day,
Outpatient prescription drugs Up to the overall maximum limit $500 maximum. Inpatient: Up to
Up to the overall maximum limit $5,000.
Generic Drugs: 100% coinsurance 50% of actual charge (not subject to deductible or coinsurance)
Vaccinations
Brand Name Drugs: 50% coinsurance.
Specialty Drugs: No coverage. No coverage
(not subject to deductible)
Mental health disorders (Treatment must not Up to $150.
be provided at a student health center) Covered vaccinations and testing are:
Measles, Mumps, Rubella (MMR);Tetanus/
Diphtheria/Pertussis (TDAP); Chicken Pox
(Varicella); Hepatitis B; and Meningitis
(Meningococcal MCV4 and B)
(not subject to deductible or coinsurance)
Outpatient: Maximum of 30 visits. Inpatient: Maximum of 30 days.
Dental treatment due to accident Up to $250 maximum per tooth; $500 maximum per certificate period. Not subject to coinsurance.
Emergency dental (Acute onset of pain) Up to $100. Not subject to coinsurance.
Pre-existing condition 6-month waiting period 12-month waiting period No coverage
Acute onset of pre-existing condition (excludes $25,000 lifetime maximum for eligible expenses No coverage
chronic and congenital conditions) No coverage
Maternity care for a covered pregnancy Up to $25,000. Up to $10,000. Up to $5,000.
Nursery care of newborn (not subject to Up to $750. Up to $250.
coinsurance)
Therapeutic termination of pregnancy Up to $500. Not subject to coinsurance.
Outpatient Physical therapy & chiropractic care Up to $75 per visit per day Up to $50 per visit per day Up to $25 per visit per day
(Not subject to coinsurance. Must be ordered
in advance by a physician and not obtained at a
student health center.)
Intercollegiate, interscholastic, intramural, or Up to $5,000 maximum per injury or illness; medical expenses only Up to $3,000 maximum per injury No coverage
club sports or illness; medical expenses only
No coverage
Terrorism Up to $50,000 lifetime maximum. Eligible medical expenses only. BUDGET Limit SMART Limit
Up to $250,000 lifetime maximum Up to $50,000 lifetime maximum
EMERGENCYTRAVEL BENEFIT ELITE Limit SELECT Limit
Emergency medical evacuation (Not subject to Up to $500,000 lifetime maximum Up to $300,000 lifetime maximum
deductible or coinsurance.)
Emergency reunion Up to $5,000, subject to a maximum of 15 days Up to $1,000, subject to a maximum of 15 days
(Not subject to deductible or coinsurance.
Accidental death & dismemberment Lifetime Maximum- $25,000 No coverage
(Not subject to deductible or coinsurance.) Death- $25,000
Loss of 2 Limbs- $25,000
Loss of 1 Limb- $12,500
Repatriation of remains (not subject to deduct- Up to $50,000 lifetime maximum Up to $25,000 lifetime maximum
ible, coinsurance, or overall maximum limit)
Personal Liability Up to $250,000 lifetime maximum. No coverage
(Not subject to deductible or coinsurance.) Up to $250,000 third person injury or
property.
Up to $2,500 related third person property.
BENEFIT ELITE SELECT BUDGET SMART
Certificate period maximum $5,000,000 $600,000 $500,000 $200,000
Maximum benefit per injury or illness $500,000 $300,000 $250,000 $100,000
Deductible (Except Emergency Room) $25 per injury or illness within the PPO $35 per injury or illness within the $45 per injury or illness within the $50 per injury or illness within the
network, outside the U.S. or at a student PPO network, outside the U.S. or at PPO network, outside the U.S. or PPO network, outside the U.S. or
health center; otherwise $50 per injury or a student health center; otherwise student health center; otherwise student health center; otherwise
illness $70 per injury or illness $90 per injury or illness $100 per injury or illness
Emergency Room Deductible (Claims incurred $100 for treatment received in an emer- $200 for treatment received in an $350 for treatment received in an emergency room
emergency room
in the U.S. only) gency room
Coinsurance- claims incurred inside U.S. Within the PPO: We will pay 100% of Within the PPO: We will pay 80% of Within the PPO: We will pay 80% of Within the PPO: We will pay 80% of
eligible expenses, after the deductible, up the next $5,000 of eligible expenses the next $25,000 of eligible expens- eligible expenses after the deductible
to the overall maximum limit. after deductible, then 100% to the es after deductible, then 100% to up to the overall maximum limit.
overall maximum limit. the overall maximum limit.
Outside the PPO: Usual, reasonable, and Outside the PPO: Usual, reasonable, Outside the PPO: Usual, reason- Outside the PPO: Usual, reasonable,
Coinsurance- claims incurred outside of U.S. customary.You may be responsible for any
charges exceeding the payable amount. and customary.You may be respon- able, and customary.You may be re- and customary.You may be respon-
sible for any charges exceeding the sponsible for any charges exceeding sible for any charges exceeding the
payable amount. the payable amount. payable amount.
After the deductible, 100% of eligible expenses to the certificate period maximum.
Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.
BENEFIT ELITE Limit SELECT Limit BUDGET Limit SMART Limit
Hospital room & board Up to $300 per injury / illness if
Local ambulance (Not subject to coinsurance) Average semi-private room rate, including nursing services Up to $500 per injury / illness if hospitalized as inpatient
hospitalized as inpatient
Intensive care unit Up to $750 per injury / illness if hospitalized as inpatient
Outpatient treatment Outpatient: $50 maximum per day,
Outpatient prescription drugs Up to the overall maximum limit $500 maximum. Inpatient: Up to
Up to the overall maximum limit $5,000.
Generic Drugs: 100% coinsurance 50% of actual charge (not subject to deductible or coinsurance)
Vaccinations
Brand Name Drugs: 50% coinsurance.
Specialty Drugs: No coverage. No coverage
(not subject to deductible)
Mental health disorders (Treatment must not Up to $150.
be provided at a student health center) Covered vaccinations and testing are:
Measles, Mumps, Rubella (MMR);Tetanus/
Diphtheria/Pertussis (TDAP); Chicken Pox
(Varicella); Hepatitis B; and Meningitis
(Meningococcal MCV4 and B)
(not subject to deductible or coinsurance)
Outpatient: Maximum of 30 visits. Inpatient: Maximum of 30 days.
Dental treatment due to accident Up to $250 maximum per tooth; $500 maximum per certificate period. Not subject to coinsurance.
Emergency dental (Acute onset of pain) Up to $100. Not subject to coinsurance.
Pre-existing condition 6-month waiting period 12-month waiting period No coverage
Acute onset of pre-existing condition (excludes $25,000 lifetime maximum for eligible expenses No coverage
chronic and congenital conditions) No coverage
Maternity care for a covered pregnancy Up to $25,000. Up to $10,000. Up to $5,000.
Nursery care of newborn (not subject to Up to $750. Up to $250.
coinsurance)
Therapeutic termination of pregnancy Up to $500. Not subject to coinsurance.
Outpatient Physical therapy & chiropractic care Up to $75 per visit per day Up to $50 per visit per day Up to $25 per visit per day
(Not subject to coinsurance. Must be ordered
in advance by a physician and not obtained at a
student health center.)
Intercollegiate, interscholastic, intramural, or Up to $5,000 maximum per injury or illness; medical expenses only Up to $3,000 maximum per injury No coverage
club sports or illness; medical expenses only
No coverage
Terrorism Up to $50,000 lifetime maximum. Eligible medical expenses only. BUDGET Limit SMART Limit
Up to $250,000 lifetime maximum Up to $50,000 lifetime maximum
EMERGENCYTRAVEL BENEFIT ELITE Limit SELECT Limit
Emergency medical evacuation (Not subject to Up to $500,000 lifetime maximum Up to $300,000 lifetime maximum
deductible or coinsurance.)
Emergency reunion Up to $5,000, subject to a maximum of 15 days Up to $1,000, subject to a maximum of 15 days
(Not subject to deductible or coinsurance.
Accidental death & dismemberment Lifetime Maximum- $25,000 No coverage
(Not subject to deductible or coinsurance.) Death- $25,000
Loss of 2 Limbs- $25,000
Loss of 1 Limb- $12,500
Repatriation of remains (not subject to deduct- Up to $50,000 lifetime maximum Up to $25,000 lifetime maximum
ible, coinsurance, or overall maximum limit)
Personal Liability Up to $250,000 lifetime maximum. No coverage
(Not subject to deductible or coinsurance.) Up to $250,000 third person injury or
property.
Up to $2,500 related third person property.
