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   Dependent Insurance Coverage
  

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 Coverage

Effective August 17, 2014


Plan Features

In-Network

Out-of-Network

Deductible per individual

$150

$500

Annual Out-of-Pocket Max (Integrated maximum for Preferred Care only.  Includes Preferred $150 deductible, Preferred copays, Preferred coinsurance, Preferred Rx copays)

$5000 (In-Network only)

$6000 (Non- preferred only)

Coinsurance

20%

30%

Maximum coverage per condition 

None

None

Lifetime Max

None

None

Office Visit

In-Network

Out-of-Network

Preventive

$0

30% after deductible

Physician

$40*

30% after deductible

Testing

In-Network

Out-of-Network

Lab/Diagnostic Test/preadmission testing

20% after deductible

30% after deductible

High Cost Imaging copay/coinsurance

20% after deductible

30% after deductible

ADD testing/treatment

20% after deductible

30% after deductible

Inpatient

In-Network

Out-of-Network

Inpatient Hospital Stay Facility fee

20% after deductible

30% after deductible

Inpatient Hospital Stay Physician fee

20% after deductible

30% after deductible

Emergency/Urgent

In-Network

Out-of-Network

Emergency Room - inclusive of Facility and physician fees (copay waived if admitted to hospital)

$100

$100

Ambulance

20% after deductible

30% after deductible

Urgent care center

$40

30% after deductible

Outpatient/Other

In-Network

Out-of-Network

Outpatient surgery facility fee

20% after deductible

30% after deductible

Outpatient surgery physician fee

20% after deductible

30% after deductible

Acupuncture Outpatient

$40

30% after deductible

Acupuncture as anesthesia

20% after deductible

30% after deductible

Chiropractor

$40

30% after deductible

Physical Therapy Outpatient

$40

30% after deductible

Outpatient chemotherapy

$40

30% after deductible

Home Health

20% after deductible

30% after deductible

Rehabilitation/Habilitation - Inpatient

20% after deductible

30% after deductible

Rehabilitation/Habilitation - Outpatient

$40

30% after deductible

Skilled nursing

20% after deductible

30% after deductible

Durable medical equipment

20% after deductible

30% after deductible

Hospice

20% after deductible

30% after deductible

Termination of Pregnancy

20%

30% after deductible

ICU

20% after deductible

30% after deductible

Removal of Impacted Wisdom Teeth

20% after deductible

30% after deductible

Dental injury only

20% after deductible

30% after deductible

Behavioral Health

In-Network

Out-of-Network

Mental Health- Outpatient

$20

30% after deductible

Mental health- Inpatient

20% after deductible

30% after deductible

Mental Health Visits

No limit

None

Mental Health days

No limit

None

Substance abuse inpatient student

20% after deductible

30% after deductible

Substance abuse inpatient dependent 

20% after deductible

30% after deductible

Substance abuse outpatient student

$20

30% after deductible

Substance abuse outpatient dependent

$20

30% after deductible

Prescription Coverage

In-Network

Out-of-Network

Contraceptives: Generics and Brands without a generic equivalent or alternative

$0

$20, $50, $75/30%

Generic Drugs

$20

$20/30%

Preferred Brand drugs

$50

$50/30%

Non-Preferred Brand drugs

$75

$75/30%

Specialty Drugs copay/coinsurance

$75

$75/30%

 

*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 $45 copay/deductible (Preferred/Non-Preferred Care respectively).

  

  
     
        
  
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