| Student Lifetime Maximum | $250,000 |
| Deductible | $250 of covered Medical Expenses per Policy year per student |
| Deductible – Emergency Room |
$100 per visit (In addition to the $250 Policy year deductible) |
| Out of Pocket Maximum | $5,000 per policy year excluding deductible for services at Preferred Provider hospitals only (IP and OP) |
| Pre-existing Conditions | No benefits paid on pre-existing conditions except for students who have been continuously insured under the school’s plan for at least 12 consecutive months. |
| Hospital Benefits | Preferred Provider: 80% of preferred allowance Non-Preferred Provider: 60% of Usual & Customary Charges |
| Physician’s Benefits | Preferred Provider: 80% of preferred allowance Non-Preferred Provider: 80% of Usual & Customary Charges |
| Emergency Care - Medical Emergencies only |
Preferred Provider: 80% of preferred allowance Non-Preferred Provider: 80% of Usual & Customary Charges |
| Diagnostic & Lab Services | Preferred Provider: 80% of preferred allowance Non-Preferred Provider: 80% of Usual & Customary Charges |
| Physical Therapy - $3,000 maximum/policy year | Preferred Provider: 80% of preferred allowance Non-Preferred Provider: 80% of Usual & Customary Charges |
| Prescription Drugs | Inpatient: 80% of actual charges Outpatient: Not Covered |
| Mental Health Care & Drug Abuse | Inpatient: 30 days maximum per policy year Outpatient: 25 visits maximum per policy year |
| Outpatient Preferred Provider: 80% of preferred allowance Outpatient Non-Preferred Provider: 80% of Usual & Customary Charges | |
| Alcoholism Care | Benefits are subject to Hospital benefits levels shown above |
| Inpatient Preferred or Non-preferred: Paid as any other sickness Outpatient Preferred Provider: 80% of preferred allowance Outpatient Non-Preferred Provider: 80% of Usual & Customary Charges | |
| Skilled Nursing Facility | Limited to a maximum of 120 days of confinement per Policy Year |
| Preferred Provider: 80% of preferred allowance Non-Preferred Provider: 80% of Usual & Customary Charges | |
| Home Health Care | Limited to a maximum of 40 visits per policy year |
| Preferred Provider: 80% of preferred allowance Non-Preferred Provider: 80% of Usual & Customary Charges | |
| Other Covered Medical Expenses | Preferred Provider: 80% of preferred allowance Non-Preferred Provider: 80% of Usual & Customary Charges |