| Pre-existing Conditions Waiting Period |
| No Coverage |
$500 maximum per certificate period; 12 months waiting period |
12 months waiting period |
6 months waiting period |
| Maximum per injury or illness |
| $100,000 |
$100,000 |
$300,000 |
$500,000 |
| Deductible (except emergency room) |
| $100 in network / $150 out of network |
$50 in network / $150 out of network |
$45 in network / $90 out of network |
$25 in network / $50 out of network |
| ER Deductible |
| $500 per incident |
$350 per incident |
$250 per incident |
$100 per incident |
| Coinsurance inside the U.S. |
In network: 80% after deductible, up to overall maximum limit
Out of Network: Plan pays 100% |
In network: 80% after deductible, up to $25,000, then overall maximum limit
Out of Network: Plan pays 100% |
In network: 80% after deductible, up to $25,000, then overall maximum limit
Out of Network: Plan pays 100% |
In network: 80% after deductible, up to $25,000, then overall maximum limit
Out of Network: Plan pays 100% |
| Coinsurance outside the U.S. |
| Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
| Local Ambulance |
| $300 per injury or illness |
$350 per injury or illness |
$350 per injury or illness |
$350 per injury or illness |
| Prescription Drugs |
| For outpatient prescription 50% of actual charges |
$10 deductible for generic drugs
$20 deductible for brand name |
$10 deductible for generic drugs
$20 deductible for brand name |
$10 deductible for generic drugs
$20 deductible for brand name |
| Wellness |
| Not Avaliable |
100% of one routine physical exam per member |
100% of one routine physical exam per member |
100% of one routine physical exam per member |
| Physical Therapy & Chiropractic Care |
| Up to $25 per visit per day |
Up to $50 per visit per day |
Up to $50 per visit per day |
Up to $75 per visit per day |
| Dental Treatment due to Accident |
| Not Available |
Not Available |
$1,000 maximum per certificate period |
$1,000 maximum per certificate period |
| Dental Treatment due to Alleviate pain |
| Not Available |
Not Available |
$100 |
$100 |
| Intercollegiate Interscholastic, Intramural or club sports |
| Not Available |
$2,500 maximum per injury or illness. Medical Expenses Only |
$5,000 maximum per injury or illness. Medical Expenses Only |
$5,000 maximum per injury or illness. Medical Expenses Only |
| Mental Health Disorders |
Outpatient $50 max per day, $500 max;
Inpatient Up to $5,000 (excludes drug and alcohol abuse).
No treatment at student health center |
Outpatient $50 max per day, $500 max;
Inpatient Up to $5,000 (excludes drug and alcohol abuse).
No treatment at student health center |
Outpatient $50 max per day, $500 max;
Inpatient Up to $10,000 (includes drug and alcohol abuse).
No treatment at student health center |
Within PPO 80% of eligible expenses; Outside PPO up to overall maximum limit
Outside U.S. 100% coinsurance
No treatment at student health center (includes drug and alcohol abuse). |
| Maternity care for covered pregnancy |
| Not Avaliable |
IN PPO NETWORK: 80% of eligible expenses; OUT OF PPO NETWORK: Up to the overall maximum.
Outside US: 100% coinsurance up to overall maximum |
IN PPO NETWORK: 80% of eligible expenses; OUT OF PPO NETWORK: Up to the overall maximum.
Outside US: 100% coinsurance up to overall maximum |
IN PPO NETWORK: 80% of eligible expenses; OUT OF PPO NETWORK: Up to the overall maximum.
Outside US: 100% coinsurance up to overall maximum |
| Repatriation of Remains |
| $25,000 lifetime maximum |
$25,000 lifetime maximum |
$25,000 lifetime maximum |
$25,000 lifetime maximum |
| Terrorism |
| Up to $50,000 lifetime maximum |
Up to $50,000 lifetime maximum |
Up to $50,000 lifetime maximum |
Up to $50,000 lifetime maximum |
| Accidental Death and Dismemberment |
| Up to $10,000 lifetime maximum |
Up to $25,000 lifetime maximum |
Up to $25,000 lifetime maximum |
Up to $25,000 lifetime maximum |
| Emergency Reunion |
| Up to $1,500, maximum of 15 days |
Up to $2,500, maximum of 15 days |
Up to $2,500, maximum of 15 days |
Up to $5,000, maximum of 15 days |
