Benefits 7C-PLAN 1 7C-PLAN 2 HTH PLANS HTH PLANS HCC PLAN-5 HCC-PLAN-6 SUSA-PLAN-7 SUSA-PLAN-8
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Maximum per Accident or Sickness         $250,000 $300,000  N/A  N/A
Annual Maximum         $250,000 $300,000 $250,000 $300,000
Lifetime Maximum         Cert Period Max $250,000 Cert Period Max $300,000 $250,000 $300,000
Deductible per Accident or Sickness         $100 per injury/sickness, $50 if at SHC $100 per injury/sickness, $50 if at SHC $50 per injury or sickness in network or outside the US & $150 for out of network providers, deductible is waived if student uses SHC. Deductible will not exceed $250 per covered person per policy year. If there is no SHC available deductible is waived if student sees in network provider. $50 per injury or sickness in network or outside the US & $150 for out of network providers, deductible is waived if student uses SHC. Deductible will not exceed $250 per covered person per policy year. If there is no SHC available deductible is waived if student sees in network provider.
Co-Insurance         Inside the US-80% to $10,000 then 100% to max; Outside the US-80% to $10,000 then 100% to max Inside the US-80% to $5,000 then 100% to max; Within the PPO or at the SHC co-isurance is waived; Outside the US-100% to max 80% in network or outside the US or 70% out of network up to $25,000, After $25,000 100 % in network or 70% out of network to max 80% in network or outside the US or 70% out of network up to $25,000, After $25,000 100 % in network or 70% out of network to max
Network (PPO Provider)         CMN CMN First Health First Health
Inpatient Hospital Services         Inside the US-80% to $10,000 then 100% to max; Outside the US-80% to $10,000 then 100% to max Inside the US-80% to $5,000 then 100% to max; Within the PPO or at the SHC co-isurance is waived; Outside the US-100% to max 80% in network or outside the US or 70% out of network up to $25,000, After $25,000 100 % in network or 70% out of network to max 80% in network or outside the US or 70% out of network up to $25,000, After $25,000 100 % in network or 70% out of network to max
Outpatient Services         Inside the US-80% to $10,000 then 100% to max; Outside the US-80% to $10,000 then 100% to max Inside the US-80% to $5,000 then 100% to max; Within the PPO or at the SHC co-isurance is waived; Outside the US-100% to max 80% in network or outside the US or 70% out of network up to $25,000, After $25,000 100 % in network or 70% out of network to max 80% in network or outside the US or 70% out of network up to $25,000, After $25,000 100 % in network or 70% out of network to max
Inpatient Mental & Nervous, Substance Abuse         UC&R up to $10,000 Maximum Lifetime UC&R up to $10,000 Maximum Lifetime The program pays the lesser of U & C for the first 30 days of confinement per policy year or 90% of U&C up to to a limit of $10,000 in the US, $5,000 outside the US The program pays the lesser of U & C for the first 30 days of confinement per policy year or 90% of U&C up to to a limit of $10,000 in the US, $5,000 outside the US
Outpatient Mental & Nervous, Substance Abuse         $50 per day, $500 Maximum Lifetime $50 per day, $500 Maximum Lifetime The program pays the lesser of U & C for the first 30 days of confinement per policy year or 90% of U&C up to to a limit of $10,000 in the US, $5,000 outside the US The program pays the lesser of U & C for the first 30 days of confinement per policy year or 90% of U&C up to to a limit of $10,000 in the US, $5,000 outside the US
Prescriptions         50% 50% $10 co-pay Generic and $20 for Brand Name $10 co-pay Generic and $20 for Brand Name
Medical Evacuation         Up to $250,000 lifetime Up to $300,000 lifetime $500,000 $500,000
Repatriation         Up to $15,000 Up to $25,000 $100,000 $100,000
Bedside Visit         $1,000 Lifetime $2,500 Lifetime Up to $2,500 Up to $2,500
Home County Coverage         15 Days 15 Days 30 Days of Coverage up to $1,000 max 30 Days of Coverage up to $1,000 max
Travel Assistance         Yes Yes Yes Yes
Maternity         Usual, Reasonable & Customary Charges Usual, Reasonable & Customary Charges
Accidental
Death & Dismemberment		         No Coverage $25,000 Particiapant $5,000 $5,000
          All Hospitalizations, Surgeries, Pregnancies, Emergency Medical Evacs, Reunions, Rep, CAT Scans, MRI's must be pre-certified or benefits are reduces to 50% All Hospitalizations, Surgeries, Pregnancies, Emergency Medical Evacs, Reunions, Rep, CAT Scans, MRI's must be pre-certified or benefits are reduces to 50%
Offers Coverage for Dependents         Yes Yes Yes Yes
Monthly Rates Monthly Rates Monthly Rates Monthly Rates Monthly Rates Monthly Rates Monthly Rates Monthly Rates Monthly Rates
Under 19 Rates are dependent on age and deductible. Rates are dependent on age and deductible. Rates are dependent on age and deductible. Rates are dependent on age and deductible. $39 $59

Under 25    $60.30

50-54          $408

Under 25   $67.50

50-54         $444.30
19-23         $45 $67

25-29         $90.30

 25-29          $98.40 
24-30         $67 $89 30-34         $114.60 30-34         $124.80
31-40         $99 $149 35-39         $162.00 35-39         $176.40
41-50         $249 $350 40-44         $204.00 40-44         $222.30
51-64         $338 $450 45-49        $220.80 45-49        $240.60
  7C-PLAN 1 7C-PLAN 2 HTH PLANS HTH PLANS HCC PLAN-5 HCC PLAN-6 SUSA-PLAN-7  SUSA-PLAN-8 
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