| 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 |
None |
| Non-Preferred Providers |
$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 reasonable charge (UCR) after a $500 deductible. |
| Inpatient Hospitalization Expenses |
100% of Negotiated Charge after a $500 per admission deductible. |
Plan pays 70% of Reasonable Charge after a $500 per admission deductible. |
| Inpatient Mental Health Expenses* |
100% of Negotiated Charge after a $500 per admission deductible. |
Plan pays 70% of Negotiated Charge after a $500 per admission deductible is met. |
| Emergency Room Expenses |
Plan pays 100% after a $50 per visit Copay, waived if admitted |
Plan pays 100% after a $50 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) |
