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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 At a Glance

Type of Service or Supply Benefit Level
Lifetime Aggregate Maximum No lifetime maximum
Policy Year Maximum $1.25 million per condition per policy year
Preventive Care Services Coverage provided for most services at Student Health Services. Coverage also available for preventive services from community providers. See Plan Brochure for details.
 
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 $25 per visit Copay. Plan pays 70% of usual, customary & reasonable  (UCR) after the $1500 deductible.
Inpatient Hospitalization Expenses 100% of Negotiated Charge after a $500 per admission deductible. Plan pays 70% of UCR after a $500 per admission deductible.
Inpatient Mental Health Expenses* 100% of Negotiated Charge after a $500 per admission deductible. Plan pays 70% of UCR after a $500 per admission deductible.
Emergency Room Expenses Plan pays 100% of Negotiated Charge after a $100 per visit Copay, (waived if admitted). Plan pays 100% of reasonable charge after a $100 per visit copay, (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 $45 copay/deductible (Preferred/Non-Preferred Care respectively).

  

  
     
        
  
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