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If a Covered Person incurs expenses while insured under the Policy due to an Injury or a Sickness, the Insurer will pay the Reasonable Expenses for the Covered Medical Expenses listed below. All Covered Medical Expenses incurred as a result of the same or related cause, including any Complications, shall be considered as resulting from on Sickness or Injury. The amount payable for any one Injury or Sickness will not exceed the Maximum Benefits of $1,000,000 per Lifetime, $250,000 per Policy Year, $250,000 per Injury or Sickness for the Eligible Participant and the Eligible Dependent. Benefits are subject to the Deductible Amount, Coinsurance and Maximum Benefits stated in the Schedule of Benefits, specified benefits and limitations set forth under Covered Medical Expenses, the General Policy Exclusions, the Pre Existing Condition Limitation, the Recognized Student Health Center Provision and to all other limitations and provisions of the Policy.
When using non-PPO health care providers, insured persons are responsible for any difference between the covered expenses and actual charges, as well as any percentage co-payment.
| MEDICAL BENEFITS LIMITS - COVERED MEMBER |
| |
PPO Plan In PPO Limit |
PPO Plan Outside PPO Limits |
| Physician Office Visits 1 |
100% of Negotiated Rates
after $20 Copayment per visit |
75% of Reasonable Expenses |
| Inpatient Hospital Services 2 |
100% of Negotiated Rates
after $50 Copayment per visit |
75% of Reasonable Expenses |
Hospital and Physician
Outpatient Services 2 |
100% of Negotiated Rates
after $50 Copayment per visit |
75% of Reasonable Expenses |
1 All Physician Visit Copayments for an Injury or Sickness are waived if treatment is received at Recognized Student Health Center or if the initial treatment for an Injury or Sickness is received at Recognized Student Health Center. If there is a charge for visits to, or medical services, treatments and supplies received from, a Recognized Student Health Center for an Injury or a Sickness, benefits for those visits, medical services, treatments and supplies will be paid at 100% of Reasonable Expenses with no Copayment or Deductible. If the Recognized Student Health Center is not able to treat the Covered Person, it will refer the Covered Person to a Preferred Provider. If the Covered Person uses the Preferred Provider, medical benefits are paid according to the “Inside PPO” schedule. If the Covered Person chooses not to use the Preferred Provider, medical benefits are paid according to the “Outside PPO” schedule.
2 Inpatient Hospital Services and Hospital and Physician Outpatient Services consist of the following: Hospital room and board, including general nursing services; medical and surgical treatment; medical services and supplies; Outpatient nursing services provided by an RN, LPN or LVN; local professional ground ambulance services to and from a local Hospital for Emergency Hospitalization and Emergency Medical Care, X-rays; laboratory tests, prescription medicines; artificial limbs or prosthetic appliances, including those which are functionally necessary; the rental or purchase, at the Insurer’s option, of durable medical equipment for therapeutic use, including repairs and necessary maintenance of purchased equipment not provided for under a manufacturer’s warranty or purchase agreement. The Insurer will not pay for Hospital room and board charges in excess of the prevailing semi private room rate unless the requirements of Medically Necessary treatment dictate accommodations other than a semi private room.
Benefits listed below are subject to Lifetime Maximum,
Annual Maximum, Maximums per Injury and Sickness, Co-Insurance,
and the above listed PPO Plan type limits. |
Maternity Care for a
Covered
Pregnancy 3 |
Reasonable Expenses |
Inpatient treatment of
mental and nervous
disorders
including drug or alcohol
abuse |
Reasonable Expenses up a maximum period of 30 days per lifetime |
Outpatient treatment of mental and
nervous
disorders
including drug or alcohol abuse |
Reasonable Expenses up to $1,000 Maximum per lifetime |
Outpatient back and spine treatment
(including modalities) |
Reasonable Expenses up to $1,000 Maximum per Policy Year with a $20 per visit Maximum and a Maximum of 3 visits per week |
Treatment of Specified
therapies, including
acupuncture and
Physiotherapy |
Reasonable Expenses up to $1,000 Maximum per Policy Year on an Inpatient basis. Reasonable Expenses up to $50 Maximum per visit subject to a Maximum of 20 visits on an Outpatient basis. This benefit is per Policy Year. PPO Limits will apply |
Therapeutic or Elective
termination of
pregnancy |
Reasonable Expenses up to $500 In PPO Maximum per Policy Year or up to $500 Outside PPO Maximum per Policy Year |
Routine nursery care of a
newborn child of a covered
pregnancy |
Reasonable Expenses up to $1,000 Maximum per Policy Year |
Annual cervical cytology
screening for women 18 and
older |
Reasonable Expenses |
Low dose mammography
screening, one
baseline
mammogram and one
mammogram per year |
Reasonable Expenses |
Medical treatment arising from
participation in intercollegiate,
interscholastic or club sports |
Reasonable Expenses up to $10,000 Maximum per Policy Year. Injuries from participation in intramural sports are covered as any other Injury |
Repairs to sound, natural teeth required due to an Injury |
100% of Reasonable Expenses up to $1,000 per Policy Year maximum, Maximum $200 per tooth |
Outpatient prescription drugs |
Prescription Drug Program with the Copayment stated below. Limited to a 31 day supply for initial fill or refill |
Generic Drugs |
All except a $10 Copayment per prescription |
Brand Name Drugs |
All except a $25 Copayment per prescription |
3 The Insurer will pay the actual expenses incurred as a result of pregnancy, childbirth, miscarriage, or any Complications resulting from any of these, except to the extent shown in the Schedule of Benefits. Conception must have occurred while the Covered Person was insured under the Policy.
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