Lifetime Maximum

$300,000

$500,000

$250,000

$500,000

Maximum for Interscholastic Sports

N/A

N/A

$5,000

Maximum Benefit Limit per Sickness or Injury

$150,000

$250,000

$125,000

$300,000

Deductible per Person per Sickness or Injury

*Reduced to $50 per event if first rendered at School Student Health Facility

*Reduced to $45 per event if first rendered at School Student Health Facility

*Reduced to $20 per event if first rendered at School Student Health Facility. Combined maximum $600

*Reduced to $20 per event if first rendered at School Student Health Facility. Combined maximum $400

Copayments ER Visit (waived if admitted)

$0

$300

Coinsurance

The plan pays 100%
of covered medical expenses

The Plan pays 80% of the 1st $6,000;
100% thereafter to a maximum of $125,000

The Plan pays 70% of the 1st $6,000; 100% thereafter to a maximum of $125,000

The Plan pays 80% of the 1st $4,000; 100% thereafter to a maximum of $300,000

The Plan pays 70% of the 1st $4,000; 100% thereafter to a maximum of $300,000

Pre-Existing Condition Exclusion

6 months (credit is applied
for prior continuous coverage)

Covered with no waiting period

Prescription Drugs

$1000 Maximum

$750

$1,000

Prescription Copay

$25
*Not subject to deductible or co-insurance

N/A

Diagnostic X-rays and Lab Services

$1000

Additional $250 one CAT scan,
PET scan or MRI

Covered as any other medical benefit

Maternity (conception must occur while coverage is in force)

$5,000 for
natural delivery

$7,500 for
C-section delivery

$7,500 for
natural delivery

$10,000 for
C-section delivery

Covered as any other sickness

Mental and Nervous Disorder and Substance Abuse

Covered as any other sickness

Covered as any other sickness

Emergency Evacuation

$50,000

$100,000

100% of covered expenses

Repatriation of Remains

$25,000

$50,000

100% of covered expenses

Accidental Death and Dismemberment Coverage

$15,000

$15,000

$25,000

Paralysis

Included

Included

Coma

Included

Not included

Assistance Provider

Travel Guard

Europe Assistance

Home Country Coverage

$500

Not included

Emergency Medical Reunion

$1,000
lifetime maximum

$1,500
lifetime maximum

$2,500

Surgical Treatment

$25,000

$50,000

$25,000

$50,000

Physician’s Non-Surgical Visit

$50/visit, 1 visit/day,
30 visits maximum

$60/visit, 1 visit/day,
30 visits maximum

$50/initial visit,
$40 each follow up visit

$70/initial visit,
$50 each follow up visit

Hospital Room and Board

$1,000/day,
to 30 days maximum

$700/day,
to 30 days maximum

$1,000/day,
to 30 days maximum

Hospital Miscellaneous

$500/day, to 30 days maximum

$3,000

Covered as any other medical expense

Hospital Intensive Care Unit

Additional $525/day,
to 8 days maximum

Daily room rates

Anesthetist

25% of surgical benefit

Covered as any other medical expense

Assistant Surgeon

25% of surgical benefit

Covered as any other medical expense

Consultant Physician, when Requested by Attending Physician

$400

$200

$250

Pre-Admission Tests within 7 Days before Hospital Admission

$900

Covered as any other medical expense

Inpatient Private Duty Nurse

$500

Not included

Day Surgery Miscellaneous
Related to outpatient scheduled surgery performed at a Hospital or licensed outpatient surgery center; including the cost of operating room, anesthesia, drugs and medicines and medical supplies.

$2,000

$2,500

$5,000

$7,500

Hospital Emergency Room

75% of usual and customary
to $10,000 maximum

Covered as any other medical expense

Ambulance Services

$400

Covered as any other medical expense

Initial Orthopedic Prosthesis or Brace

$1,000

Covered as any other medical expense

Dental Treatment for Injury to Sound, Natural Teeth

$500

$250 per tooth

$300 per tooth

Chemotherapy and/or Radiation Therapy

$5,000

Covered as any other medical expense

Physiotherapy (Inpatient and Outpatient)

$35/visit, 1 visit/day,
12 visits maximum

$40 per visit

$60 per visit

Lost Baggage

Not covered

$250/bag, 2 bag maximum

Trip Interruption

Not covered

$2,000

$5,000

Age 29 and under

$32

$41

Age 25 and Under

$30

$37

30 – 40

$102

$115

26 – 29

$59

$69

41 – 50

$118

$163

30 – 65

$99

$120

51 – 65

$137

$181

Spouse

$235

$290

Dependent

$186

$276

Each Child

$90

$130

Participants Lifetime Medical Maximum

$2,000,000

$1,000,000

Participants Maximum Benefit Limit per Sickness or Injury

$300,000

$300,000

Deductible per Person per Sickness or Injury

N/A

N/A

• Hospitalization

$250

$250

Coinsurance

80% of the first $4,000—100% thereafter to a maximum of $300,000

75% of usual and customary charges up to a maximum of $300,000

Maximum Out-of-Pocket Expense

$2,000
(not Including copayment)

No maximum

Pre-Existing Condition Exclusion

6 months
(credit is provided for prior continuous coverage)

Prescription Drugs

$2,000 maximum

Diagnostic X-rays and Lab Services

$2,000 maximum

Maternity (conception must occur while coverage is in force)

Covered as any other sickness

Mental and Nervous Disorder and Substance Abuse

Limited to 1 visit per day to maximum of 35 visits per year

Emergency Medical Evacuation

$500,000

Repatriation of Remains

$100,000

Accidental Death & Dismemberment Coverage

$20,000

Paralysis

Included

Coma

Included

Chartis Solutions (Personal Security Assistance, Live Travel/Medical Assistance, Worldwide Travel Assist, Concierge Services)

Included

Home Country Coverage

$1,000 Maximum

$2,000 Lifetime Maximum

Dependents Medical maximum

$250,000 Lifetime/ $100,000 per sickness or injury

Participant (age 25 and under)

$60

Participant (over age 25)

$74

Participant and Spouse

$208

Participant and Dependent Child(ren)

$208

Participant, Spouse and Dependent Child(ren)

$326