| Coverages |
SMART |
BUDGET |
SELECT |
ELITE |
Accident & Sickness
Medical
Routine physical
exams and vaccinations are
not
covered |
100,000 per injury or illness medical maximum |
250,000 per injury or illness medical maximum |
$300,000 per injury or illness maximum
|
$500,000 per injury or illness maximum |
| Deductible |
$50 per injury or illness
In-Network
$100 per injury or illness Out-of-Network
$350
per injury or illness ER |
$45 per injury or illness In-Network
$90 per injury or illness
Out-of-Network
$350 per injury or illness ER
|
$25 per injury or illness In-Network
$50 per injury or illness
Out-of-Network
$100 per injury or illness ER |
$25 per injury or illness In-Network
$50 per injury or illness
Out-of-Network
$100 per injury or illness ER |
| Co-insurance |
80% to the
certificate period maximum limit. |
Underwriters
will pay 80% of the next $25,000 of eligible expenses after the
deductible, then 100% to the certificate period maximum. |
Underwriters
will pay 80% of the next $5,000 of eligible expenses after the
deductible, then 100% to the certificate period maximum. |
Within the PPO
network, underwriters will pay 100% of eligible expenses after the
deductible to the certificate period maximum (80% of eligible
expenses outside the PPO network). |
| Medical Maximum |
$200,000
Certificate Period |
$250,000
Certificate period |
$300,000
Certificate period |
$500,000
Certificate Period |
| Emergency Medical
Evacuation |
$50,000 |
$250,000 |
$300,000 |
$500,000 |
| Repatriation of mortal
remains |
$25,000 |
$25,000 |
$25,000 |
$50,000 |
| Pre-existing condition
coverage |
After deductible and coinsurance, $25,000 lifetime maximum for acute
onset of pre-existing conditions. |
Covered after 12-month waiting period. |
Covered after 6-month waiting period. |
Covered after 6-month waiting period. |
| AD&D - Accidental Death &
Dismemberment |
No coverage |
No coverage |
$25,000 |
$25,000 |
| Maternity coverage |
No coverage |
$5,000 Maximum. After deductible, eligible expenses will be paid at 80% within the
PPO or 60% outside the PPO up to a certificate period maximum of
$5,000. |
$10,000 Maximum.
After deductible, eligible expenses will be paid at 80% up to the
certificate period maximum within the PPO or 60% outside the PPO. |
$15,000 Maximum. After deductible, eligible expenses will be paid at 80% up to the
certificate period maximum within the PPO or 60% outside the PPO. |
|
Mental Health |
|
Outpatient: $50
maximum per day, $500 maximum per certificate period; |
| Inpatient:
Usual, reasonable, and customary charges up to $5,000
maximum per certificate period; |
| Drug or
Alcohol Abuse: No
coverage. |
|
|
Outpatient: $50
maximum per day, $500 maximum per certificate period; |
| Inpatient:
Usual, reasonable, and customary charges up to $10,000
maximum per certificate period; |
| Drug or
Alcohol Abuse:
Included. |
|
|
Outpatient: After
deductible, eligible expenses will be paid at 80% up to the
certificate period maximum within the PPO or 60% outside the
PPO for a maximum of 30 visits per certificate period; |
| Inpatient:After
deductible, eligible expenses will be paid at 80% up to the
certificate period maximum within the PPO or 60% outside the
PPO for a maximum of 30 days per certificate period; |
| Drug or
Alcohol Abuse:
Included. |
|
|
Outpatient: After
deductible, eligible expenses will be paid at 80% up to the
certificate period maximum within the PPO or 60% outside the
PPO for a maximum of 30 visits per certificate period; |
| Inpatient:After
deductible, eligible expenses will be paid at 80% up to the
certificate period maximum within the PPO or 60% outside the
PPO for a maximum of 30 days per certificate period; |
| Drug or
Alcohol Abuse:
Included. |
|
|
Intercollegiate, Interscholastic Sports |
no coverage |
$3,000 maximum
per injury |
$5,000 maximum
per injury |
$5,000 maximum
per injury |
| View Policy
Details |
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|
|
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