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PLAN BENEFITS - ADVANTAGE
Benefit
Certificate period maximum
Maximum benefit - per injury / illness
Deductible inside PPO network
Deductible all other locations
Student health center copay
Physician office copay
Urgent care copay
Inpatient/Outpatient Hospital copay
Co-insurance - In Network (inside USA)
Co-insurance - out of network (Inside USA)
Co-Insurance (Outside of USA)
Hospital room & board
Local ambulance if hospitalized as inpatient
Intensive care unit
Outpatient treatment
Outpatient prescriptions
Mental health (outpatient) excludes student health center
Mental health (inpatient) excludes student health center
Emergency Dental Treatment
Dental treatment due to accident
Pre-existing Conditions
Maternity (care for covered pregnancy)
Newborn care (routine nursery of newborn)
Therapeutic termination of pregnancy
Outpatient physiotherapy & chiropractic care
Sports cover
Intercollegiate, interscholastic, intramural & club sports
Leisure, recreational, entertainment of fitness
Terrorism (medical expenses only)
Emergency medical evacuation
Emergency reunion
Accidental death & dismemberment
Repatriation of remains
Personal liability
Vaccinations
Limit
$500,000
$300,000
$250 - per injury / illness
$250 - per injury / illness
$5 - per visit - not subject to coinsurance
$250 - Max 1 visit per day
$250 - per injury / illness
$150 - per visit in network ($300 out of network)
90% coverage - out of pocket max = $1,000
80% coverage- no out of pocket maximum
100% up to the maximum
Average semi-private room rate
$350 - not subject to co-insurance
Up to overall maximum
Up to overall maximum
50% coverage - Maximum 90 days per prescription
$50 per day - $500 maximum - includes drug & alcohol abuse
$10,000 - includes drug & alcohol abuse
$350 - treatment due to unexpected pain to sound natural teeth
$500 maximum
Excluded until 12 months continuous coverage
Not Covered
Not Covered
Not Covered
1 visit per day maximum - excludes student health center
$5,000 per injury
Up to overall maximum
$50,000 lifetime maximum
$500,000 lifetime maximum
$50,000 - maximum 15 days
$25,00 maximum - sub limits apply
$50,000 lifetime maximum
$10,000 maximum
Not insured
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