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Student Health Advantage Platinum Benefits
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Maximum Limits
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Student: $1,000,000 Dependent: $100,000
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Deductible- Outside U.S.
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$100 per illness/injury
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Deductible- Inside U.S.
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PPO Provider: $100 per illness/injury
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NON PPO Provider: $150 per illness/injury
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Coinsurance Outside the U.S.
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No coinsurance
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In U.S.
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In PPO: No Coinsurance
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Out of PPO: 80% of eligible medical expenses up to $5,000 then 100% thereafter
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Hospital Room & Board
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Average semi-private room rate, including nursing service
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Intensive Care
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After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.)
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Maternity and Newborn Care
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$5,000 max limit. Benefit includes newborn routine care during the first 31 days of life
After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.)
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Emergency Room Injury
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After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally
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Emergency Room Illness with In-patient admission
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After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally
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Emergency Room without In-patient admission
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After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally. Subject to additional $250 Deductible
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Mental & Nervous Disorders
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Out-Patient: $50 per day; $500 lifetime maximum
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In-Patient: After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally to $10,000 lifetime maximum
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Prescription Drugs
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In-Patient: After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally Out-Patient: 50% of actual charges
90-day dispensing maximum
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Physical Therapy
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After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally. Limit once per day
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Local Ambulance
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Up to $750 per illness resulting in hospitalization or injury.
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Dental
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Injury due to covered Accident: $500
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Sudden & Unexpected Pain to natural teeth: $350
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Eligible Medical Expenses
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After deductible is met, company pays 80% of expenses out-of-network (U.S.) or 100% in-network (U.S.) and internationally
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Emergency Medical Evacuation
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$500,000 lifetime maximum
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Emergency Reunion
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$50,000 lifetime maximum
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Return of Mortal Remains
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$50,000 lifetime maximum
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Intercollegiate/Interscholastic/Intramural or Club Sports
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$5,000 maximum per injury/illness
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Pre-Existing Conditions
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Charges excluded after 6 months of continuous coverage
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