Medical Maximum | In Network: $300,000 per Injury or Sickness, to an overall $500,000 Maximum Out Network: $300,000 per Injury or Sickness, to an overall $500,000 Maximum |
Lifetime Maximum | In Network: Unlimited Out Network: Unlimited |
Deductible at Student Health Center | In Network:$25 Out Network: $25 |
Deductible Options | In Network:$150 Out Network: $150 |
Office Visit Deductible | In Network: $40 per Occurrence Out Network: $40 per Occurrence |
Emergency Room Deductible | In Network: $300 per Occurrence (waived if admitted) Out Network: $300 per Occurrence (waived if admitted) |
Hospital Room & Board | In Network: 80% of the Preferred Allowance Out Network: 70% of of the Semi-Private Room Rate |
Intensive Care | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Hospital Misc. Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Surgeon | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Pre-Admission Testing | In Network: 80% of the Preferred Allowance Out Network: 70% of URC( |
Anesthesia | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Day Surgery Misc | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Diagnostic X-Ray and Lab | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Ambulance | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Physician Visit | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Consult Physician | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Radiation/Chemotherapy | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Emergency Room (50% Coinsurance for Non-Emergency Use) | In Network: 80% of the Preferred Allowance(subject to a $300 Deductible per visit, waived if admitted) Out Network: 70% of URC(subject to a $300 Deductible per visit, waived if admitted) |
Maternity & Pre-Natal Care Expense (Conception must occur while covered under the Policy) | In Network: 100% of the Preferred Allowance($5,000 Maximum Benefit for normal delivery,
$10,000 Max Benefit for C-Section) Out Network: 70% of URC($5,000 Maximum Benefit for normal delivery, $10,000 Max Benefit for C-Section) |
Elective/ Therapuetic Termination of Pregnancy (Conception must occur while covered under the Policy) | In Network: 80% of the Preferred Allowance (Up to $500 Max) Out Network: 70% of URC(Up to $500 Max) |
In-Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Out -Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URCC |
Alcohol & Drug Abuse Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Pre-Existing Conditions(Covered after 6 months) | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Sports Activities (Injuries arising from Interscholastic, Intramural, Leisure, and Club Sports) | In Network: 80% of the Preferred Allowance (up to $5,000 Max) Out Network: 70% of URC (up to $5,000 Max) |
In-Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Out -Patient Expense | In Network: 80% of the Preferred Allowance Out Network: 70% of URC |
Motor Vehicle Accident | In Network: 80% of the Preferred Allowance(up to $10,000 Max) Out Network: 70% of URC(up to $10,000 Max) |
Emergency Dental Expense | In Network: 80% of the Preferred Allowance(up to $250 per tooth to a $500 Max) Out Network: 70% of URC(up to $250 per tooth to a $500 Max) |
Durable Medical Equipment Expense | In Network: 80% of the Preferred Allowance(up to $1,000 Max) Out Network: 70% of URC(up to $1,000 Max) |
Extension of Home Country Sickness | $1000 Max Benefit |
Emergency Medical Evacuation | 100% of Actual Expense up to $60,000 |
Emergency Medical Repatriation | 100% of Actual Expense up to $60,000 |
Return of Mortal Remains | 100% of Actual Expense up to $60,000 |
Accidental Death & Dismemberment | $10,000 |
Prescription Drug Co-Payment (per prescription) (Oral Contraceptives are included) | In Network:80% of the Preferred Allowance
based on a 30-day supply per
prescription Non-Network Provider:70% of URC based on a 30-day supply per prescription |
Travel Assistance Services | 24-hour travel assistance services are provided by GBG Assist |
Trawick International Covid19 travel insurance by Collegiate Care Enhanced Student Insurance for coronavirus coverage will cover eligible medical expenses resulting from COVID-19/SARS-CoV-2. Eligible medical expenses are medically necessary expenses that are not subject to another plan exclusion.
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