All adult dependents must receive their primary care through the Student Health Service.
Dependent Insurance At a Glance
| Type of Service or Supply |
Benefit Level |
| Lifetime Aggregate Maximum |
$250,000 |
| |
| Plan Deductible |
| Preferred Providers |
$100 per individual |
| Non-Preferred Providers |
$1,500 per Individual |
| |
| Annual Out of Pocket Limit |
| Preferred Providers |
$5,000 |
| Non-Preferred Providers |
No limit |
| |
| |
Preferred Care |
Non-Preferred Care |
| Physician Office Visit Expenses |
Plan pays 100% after $20 per visit Copay. |
Plan pays 70% of usual, customary & reasonable (UCR) after the $1500 deductible. |
| Inpatient Hospitalization Expenses |
Plan pays 80% of Negotiated Charge. |
Plan pays 50% of UCR after the deductible is met. |
| Inpatient Mental Health Expenses* |
Plan pays 80% of Negotiated Charge. |
Plan pays 50% of UCR after the deductible is met. |
| Emergency Room Expenses |
Plan pays 100% after a $50 per visit Copay, waived if admitted. |
Plan pays 100% after a $50 deductible, waived if admitted. |
| Prescription Drug Expenses** |
Plan pays 100% after designated Copay. (see below) |
Plan pays 70% after designated Copay. (see below) |
*Covered Medical Expenses are payable up to a maximum of 30 days per Policy Year
**Plan pays after a $15 copay/deductible (Preferred/Non-Preferred Care respectively) for each generic
prescription and a $35 copay/deductible (Preferred/Non-Preferred Care respectively) for each brand-name
prescription up to a maximum of $2,500 per Policy Year.
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