|
BASIC PLAN |
EXTENDED PLAN (Students) |
HOSPITAL BENEFITS |
|
|
Semi-Private Room & Board |
3 Days @ *75%/60% |
*75%/60% |
Hospital extras during covered hospitalization |
3 Days @ *75%/60% $2500 max |
*75%/60% |
Ambulance Service |
to $100.00 max |
*75% R&C |
SPECIAL NURSING (R.N.)
When prescribed by the attending physician,
during covered hospitalization, up to $30 per day. |
Not Covered |
up to 10 days *75%/60% |
PRESCRIPTIONS ** |
Not Covered |
100% R&C, $20 co-pay deducted once student
pays in full and submits claim. $150 yearly Rx deductable |
PHYSICIAN BENEFITS |
|
|
Office Visits |
$20.00 each
5 max per condition |
*75%/60% |
Consultation when requested by attending Physician |
up to $50.00 |
*75%/60% |
Hospital Visits, during covered hospitalization, one/day |
5 visits @ $20.00 |
25 visits @ $20.00 |
SURGICAL BENEFITS |
|
|
Surgeon Fees |
50% of Allowable Charges $2500 max |
*75%/60% |
Assistant Surgeon |
20% of Surgery allowance |
*75%/60% |
Anesthetist |
20% of Surgery allowance |
*75%/60% |
DIAGNOSTIC X-RAY & LAB BENEFITS/condition
(includes allergy testing when ordered by a doctor; annual mammogram, pap smear, etc..)
|
up to $150.00 |
*75%/60% |
RADIATION THERAPY & CHEMOTHERAPY |
*75%/60% up to $300.00 |
*75%/60% |
SUPPLEMENTARY INJURY BENEFIT |
up to $150.00 |
up to $150.00 |
STERILIZATION EXPENSE BENEFIT |
50% of allowable charges |
Not covered |
*EXTENDED PLAN BENEFITS
Aggregate Lifetime Maximum, per condition |
N/A |
up to $50,000.00 lifetime per condition |
Out-Patient Mental/Nervous conditions, $5000 annual max per person |
$20.00 per visit, 5 visits max |
*75%/60% up to $75.00 per visit |
Percentage Payable |
|
|
1. For other inpatient Mental/Nervous conditions |
$20.00 per visit,5 visits max |
*75%/60% |
2. For Outpatient Psychiatric Prescriptions (RX limited to 30 day supply at a time) |
N/A |
100% R&C, $20 co-pay deducted once student
pays in full and submits claim. $150 yearly Rx deductable. |
Cash Deductible, per policy year |
N/A |
$500.00 |
Intensive Care |
N/A |
*75%/60% Up to 2 1/2 times the semi-private rate |
Cancer Screening, related to sickness only |
$20.00 per visit, 5 visits max |
*75%/60% |
ACCIDENTAL DEATH & DISMEMBERMENT |
Not covered |
$1000.00 max |
PREGNANCY EXPENSE BENEFITS |
|
|
Maternity |
$20.00 per visit, 5 visits max |
*75%/60% |
Routine Newborn Care (up to 4 days hospital confinement) |
N/A |
*75%/60% |
MEDICAL EVACUATION, WORLD WIDE ASSISTANCE & REPATRIATION |
Provided by Assist America.
Included in the PSU International Student Plan only. |
*75%/60% - 75% of preferred allowance when a First Health Provider is used,
60% of R&C (Reasonable & Customary) when out-of-network provider is used. There is a deductible of $500 per
policy year before extended benefits are paid out, and a separate prescription
deductible of $150 per year. The deductible can be made up of many covered expenses
such as hospital, X-ray, and office visit fees. Please refer to the brochure for details,
as the grid above is for the most common issues seen by PSU students.
**You may fill your prescriptions at any pharmacy. You will need to pay out of pocket
then submit your prescription receipt (not cash register receipt) to the claims
company for reimbursement. Separate Rx deductible of $150 per year.
