Student Health Advantage Insurance

• Eligible medical expenses help	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Hospital room and board help	Average semi-private room rate, including nursing services In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Surgery help	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Intensive care unit help	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Student Health Center help	$5 co-pay per visit. Not subject to deductible.
  Mental/Nervous help	Not covered if incurred in student health center; Inpatient: $10K maximum limit; Outpatient: $50 maximum limit per day. $500 maximum limit In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum

• Coinsurance In addition to Deductible	In-Network: Plan pays 90%, insured pays 10% Out-Network: Plan pays 80%, insured pays 20% International: Plan pays 100%, insured pays 0%
  Out of Pocket Maximum	In-Network: $1K Out-Network: Up to the Maximum Limit International: $0

• Pre-Certification	50% reduction of eligible medical expenses if pre-certification provisions are not met
  Physician visits help	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Teladoc Consultation help	Company pays 100% within the U.S.; mental and nervous disorders not covered (Group plans only)
  Emergency Room and Outpatient Office Visits Prescription Drugs and Medication	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Radiology / X-ray help	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Laboratory help	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Assistant Surgeon help	20% of the primary surgeon’s eligible fee In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Anesthesia help	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Retail Pharmacy Prescription Drugs and Medication help	Dispensing maximum for Retail Pharmacy: 90 days per prescription In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Physical Therapy help	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Prescription Drugs and Medications help	Period of Coverage limit: $250K per person Spouse and Child: Up to the Maximum Limit ($100K)

• Emergency local ambulance help	Up to $350
  Hospital emergency room help	Injury: Not subject to Emergency Room Deductible Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission. In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Interfacility ambulance transfer help	Company pays 100%

• Emergency dental treatment help	Injury due to covered accident - $500 maximum; Sudden & unexpected pain to natural teeth - $350 maximum In-Network: Not Covered Out-Network: 90% up to policy maximum International: 100% up to policy maximum
  Traumatic Dental Injury	In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum

• Emergency medical evacuation help	$500K maximum limit
  Emergency reunion help	$50K lifetime maximum
  Repatriation for Medical Treatment	$100K maximum limit. Not subject to deductibley
  Return of mortal remains or cremation/burial help	$50K maximum limit for Return of Mortal Remains or $5K maximum limit for Cremation/Burial
  Political evacuation and repatriation help	$10K lifetime maximum

• Pre-Existing Condition help

  Standard:Covered after a waiting period of 12 months Platinum: Covered after a waiting period of 6 months

• Accidental death & dismemberment help

  $25K principal sum, Not subject to deductible

• Intercollegiate/interscholastic/intramural or club sports	$5K maximum per injury or illness
  Incidental Emergency in the U.S. help	Up to a cumulative 14 days (available for non-U.S. residents only) In-Network: 90% up to policy maximum Out-Network: 80% up to policy maximum International: 100% up to policy maximum
  Terrorism help	$50K maximum limit. Not subject to deductible

Student Health Advantage insurance can purchase an optional rider at the time of application. The optional riders provide additional coverage for a minimal charge.

• What is pre-certification requirements for Student Health Advantage medical insurance?
  Student Health Advantage Insurance Pre-Certification
  The following expenses must always be pre-certified in the U.S. only:
  
  1. Certain treatment and supplies including hospital admission, inpatient or outpatient surgery, and other procedures as noted in the certificate wording must be pre certified for medical necessity, which means the insured person or their attending physician must communicate with an IMG representative at the number listed on the IMG ID card prior to admission to a hospital, before receiving certain treatments and supplies or performance of a surgery.
  2. In case of an emergency admission, the precertification must be made within 48 hours of the admission, or as soon as reasonably possible.
  3. If a hospital admission or a surgery is not pre certified, eligible claims and expenses will be reduced by 50 percent.
  4. It is important to note that precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits, or a guarantee of payment. All medical expenses eligible for reimbursement must be medically necessary and will be paid or reimbursed at usual, reasonable, and customary rates.
  5. Routine physicals, inoculations, or other examinations or tests conducted when there is no objective indications or impairments in normal health;
  6. Please refer to the certificate wording for full details of the precertification requirements.
  7. The insured can begin the process of precertification by logging on to MyIMG Login To MyIMG - International Medical Group imglobal.com or the Client Resources section of imglobal.com. Look for the precertification option and submit the required information.
  8. Please note that this online service will only initiate the process for treatment and supplies outlined in the contract, and it should not be used to request precertification for emergency admissions, procedures or evacuations.
• Conditions of Coverage for Student Health Advantage
  
  1. Coverage and benefits are subject to the deductible and coinsurance, and all terms of the Certificate of Insurance and Master Policy
  2. Coverage under this plan is secondary to any other coverage
  3. Coverage and benefits are for medically necessary, usual, reasonable, and customary charges only
  4. Charges must be administered or ordered by a physician
  5. Charges must be incurred during the period of coverage or benefit period
  6. Claims must be presented to IMG for payment within ninety (90) days from the date the claim was incurred.