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The Company will pay for the expenses listed below, up to the
following limits:
Maximum Aggregate Benefit: $250,000 maximum aggregate benefit per Injury or Sickness,
including Repatriation and Medical Evacuation Deductible: $100 Deductible per policy year. The Deductible is waived for the Covered
Student if the Covered Student
first utilizes and/or is
referred by the approved Student Health Services or if Student Health
Services is closed.
The Covered Person is responsible for paying the Deductible
amount listed before the Company will begin paying benefits.
Coinsurance: the Company will pay 100%
of Allowable Charges if a PPO
is utilized or 70% of R&C if
a non-PPO is utilized, except
as specified herein. When a Covered Person has incurred
$5,000 of out-of-pocket Eligible Expenses per policy year,
the Company payment
will increase to 100% of
R&C.
Eligible Expenses are limited to the following
Reasonable and Customary charges (R&C):
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Diagnosis and treatment by a legally qualified Doctor
All
Doctor visits are subject to a $25 Copay
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After a $25 Copay per visit, 100% of Allowable Charges for PPO
or
70% of
R&C for non-PPO
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Physiotherapy—includes chiropractic treatment
All
Doctor visits are subject to a $25 Copay
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100% of Allowable Charges for PPO or 70% of R&C for non-PPO; up to a maximum of $500 per Sickness or Injury
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Acupuncture
All
Doctor visits are subject to a $25 Copay
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100% of Allowable Charges for PPO or 70% of R&C for non-PPO; up to a maximum of $500 per Sickness or
Injury
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Diagnosis and
treatment by a
legally qualified surgeon, registered nurse,
professional anesthetist, radiologist
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100% of Allowable Charges for PPO or 70% of R&C for
non-PPO
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Hospital room and board, up to average semi-private room rate
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100% of Allowable Charges for PPO or 70% of R&C for
non-PPO
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Laboratory, diagnostic and x-ray examinations
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100% of Allowable Charges for PPO or 70% of R&C for
non-PPO
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Prescription drugs and medicines administered as an inpatient
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100% of Allowable Charges for PPO or 70% of R&C for
non-PPO
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Payment
for outpatient prescription drugs (including prescription contraceptives)
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50% of actual charge
The Covered
Person must pay for prescription drugs at the time of pick up, then
submit a claim for reimbursement for the amount the Company
is responsible for paying.
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Treatment of an Emergency Medical Condition in an emergency care facility, including all licensed Doctors, laboratory and radiology treatments
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100% of R&C
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Outpatient
treatment of Mental or Nervous Disorders*, including alcohol and substance
abuse treatment
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After
a $25 Copay (waived if referred by SMC Psychological Ser- vices), 50% of
Eligible Expenses incurred, to a maximum of 20 visits per policy year for
outpatient treatment
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Inpatient
treatment of Mental or Nervous Disorders*, including alcohol and substance
abuse treatment
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100% of expenses incurred up to 10 continuous days; 50% thereafter, to a maximum of 35 additional days (100% if certified by the Utilization
Review Organization--see page 5)
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Pregnancy and Maternity
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Paid as any other
Sickness; up to 48 hours
after birth (96 hours for cesarean delivery)
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Complications of Pregnancy
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Paid as any other Sickness
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Expenses
and supplies normally provided for an elective termination of pregnancy
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Up to a maximum of $500
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Rental charge
for durable medical
equipment, or the purchase of this
equipment, whichever is less
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100% of Allowable Charges for PPO or 70% of R&C for
non-PPO
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Professional ambulance service to the nearest Hospital
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100% of R&C
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Repair of Injury to sound natural teeth
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Up to maximum of $100 per tooth, $500 per Injury
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Repair
of eye glasses, contact lens or hearing aids when required as a direct result
of an Injury
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100% of Allowable Charges for PPO or 70% of R&C for
non-PPO
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Rehabilitative services Medically Necessary to restore
bodily function lost due to Sickness or Injury. These
services are subject
to review and approval by the Plan Administrator and Utilization Review
Organization (see page 5).
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100% of Allowable Charges for PPO or 70% of R&C for
non-PPO
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Specific Disease Waiver: The following
Pre-Existing Conditions and diseases, and only
these conditions and
diseases, will be considered a Sickness under the plan even though manifested before coverage began.
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Up to
a maximum of $500 per year
Includes: malaria, dysentery, tuberculosis, cholera, shigellosis, typhoid fever, typhus, diphtheria, yellow fever schistosomiasis, and mosquito borne
viral encephalitis.
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* Treatment of Severe Mental Illness is paid the same as any other condition. Please see the definition on page
18.
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