|
Coverages |
VISIT®
ESSENTIAL |
VISIT® BASIC |
|
Accident & Sickness Medical |
$100,000 Medical Maximum per injury or illness
|
$500,000 Medical Maximum per injury or illness
|
Deductible
A Deductible is the
amount you pay to the doctor before the insurance pays
the rest
Copays |
$100 Deductible for Preferred Providers Per Insured
Person, Per Policy Year
Physician Visits: $35
Urgent Care: $50
Medical Emergency: $200
Lab: $20
X-Rays: $20 |
$100 Deductible for Preferred Providers Per Insured
Person, Per Policy Year
Physician Visits: $30
Medical Emergency: $200 |
|
Co-insurance |
After You pay the Deductible,
Preferred Providers are payable at 80% of Preferred
Allowance and Out of Network benefits are payable at 70%
of Usual and Customary charges. |
After You pay the Deductible,
Preferred Providers are payable at 80% of Preferred
Allowance and Out of Network benefits are payable at 70%
of Usual and Customary charges. |
|
Prescription Drug Benefit |
No Benefits
Out of Network - 70% of usual and
customary charge. $1000 maximum per policy year. |
$20 for Tier 1
30% Coinsurance for Tier 2
40%
Coinsurance for Tier 3
Up to a 31-day supply per
prescription filled at a UHC Pharmacy |
|
Emergency Medical Evacuation |
Unlimited |
Unlimited |
|
Repatriation of mortal remains |
Unlimited |
Unlimited |
|
Pre-existing condition coverage |
Pre-existing Conditions, in excess of $1,000, for a
period of 6 months. The Pre-existing Condition
exclusionary period will be reduced by the total number
of months that the Insured provides documentation of
continuous coverage under a prior health insurance
policy which provided benefits similar to this policy,
provided the coverage was continuous to a date within 63
days prior to the Insured’s effective date under this
policy.
|
6 months prior to Effective Date, waived after 6
consecutive months of coverage |
|
AD&D - Accidental Death & Dismemberment |
$25,000 per Insured/Spouse $5,000 per Dependent Child |
$25,000 per Insured/Spouse $5,000 per Dependent Child |
|
Maternity coverage |
No coverage |
Covered as any other Illness |
|
Preventive Care and Vaccinations |
No coverage
Some Vaccinations covered - please see
policy documents. |
100% of Preferred Allowance
$1,000 Maximum Benefit Per Policy Year |
|
Psychotherapy |
Paid as any other sickness |
Paid as any other sickness |
|
Home Country coverage |
No coverage provided unless traveling 100 miles or more
from your permanent residence. |
No coverage provided unless traveling 100 miles or more
from your permanent residence. |
|
Sports Coverage (non-interscholastic sports) |
Covered as any other illness.
No coverage for Team or Interscholastic sports.
Interscholastic/Intercollegiate coverage available
through the
SPORTS PLUS Plan. $10,000 per
injury.
|
Covered as any other illness.
No coverage for Team or Interscholastic sports.
Interscholastic/Intercollegiate coverage available
through the
SPORTS PLUS Plan. $10,000 per
injury.
|
|
Hazardous Sports coverage |
No
coverage |
No
coverage |
|
Trip Interruption |
No
coverage |
No
coverage |
|
Return of minor child |
We will coordinate and pay for one-way economy airfare
to send them back to your home country.
|
We will coordinate and pay for one-way economy airfare
to send them back to your home country.
|
|
Lost baggage |
No
coverage |
No
coverage |
|
View Policy Details |
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