DEPENDENT ENROLLMENT IS NOT AUTOMATICALLY RENEWED.
Please complete Dependent Enrollment Form if you wish to renew.
All adult dependents must receive their primary care through the Student Health Service.
Dependent Insurance At a Glance
| Type of Service or Supply |
Benefit Level |
| Lifetime Aggregate Maximum |
$250,000 |
| |
| Plan Deductible |
| Preferred Providers |
$100 per individual |
| Non-Preferred Providers |
$1,500 per Individual |
| |
| Annual Out of Pocket Limit |
| Preferred Providers |
$5,000 |
| Non-Preferred Providers |
$5,000 |
| |
| |
Preferred Care |
Non-Preferred Care |
| Physician Office Visit Expenses |
Plan pays 100% after $20 per visit Copay. |
Plan pays 70% of usual, customary & reasonable (UCR) after the $1500 deductible. |
| Inpatient Hospitalization Expenses |
Plan pays 80% of Negotiated Charge. |
Plan pays 50% of UCR after the deductible is met. |
| Inpatient Mental Health Expenses* |
Plan pays 80% of Negotiated Charge. |
Plan pays 50% of UCR after the deductible is met. |
| Emergency Room Expenses |
Plan pays 100% after a $50 per visit Copay, waived if admitted. |
Plan pays 100% after a $50 deductible, waived if admitted. |
| Prescription Drug Expenses** |
Plan pays 100% after designated Copay. (see below) |
Plan pays 70% after designated Copay. (see below) |
*Covered Medical Expenses are payable up to a maximum of 30 days per Policy Year
**Plan pays after a $15 copay/deductible (Preferred/Non-Preferred Care respectively) for each generic
prescription and a $35 copay/deductible (Preferred/Non-Preferred Care respectively) for each brand-name
prescription up to a maximum of $2,500 per Policy Year.
|
