Stevens Institute of Technology
Medical Expense Schedule of Benefits
Up to $75,000 Maximum Benefit Paid as Specified Below (For Each Injury or Sickness)
This Certificate provides benefits for 100% (except outpatient charges which are paid at 80%) of the Reasonable and Customary Charges incurred by an Insured Person for loss due to a covered Injury or Sickness up to the Basic Maximum Benefit of $2,000. After the Basic Maximum Benefit of $2,000 has been paid by the Company, the Major
Medical Benefit will pay 80% of the Reasonable and Customary Charges incurred in excess of $2,000 up to, but not exceeding $75,000 (including the Basic benefits) for Domestic Students and International Students and their Dependents. Benefits will be paid up to Maximum Benefit for each service as scheduled below. The student must use the services of the Student Health Center (SHC) first where treatment will be administered, or referral issued. Expenses incurred for medical treatment rendered outside of the SHC for which no prior approval or referral is obtained are excluded from coverage.
SHC referral for outside care is not necessary under certain conditions such as medical emergency. Please refer to page 7 of brochure for those conditions. Covered Medical Expenses include:
Stevens Institute of Technology б .
Insurance Provider |
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|
DBغ |
Life Maximum
|
$75,000 |
Unlimited |
Major Benefit
|
$75,000 |
$50,000 per Sickness or Injury |
Copayment
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|
80% of R&C Charges |
100% |
Prescription Drug
ప δ
|
$10 generic/$25 brand co-pay, up to a $250 Policy
Year Maximum for all conditions |
$0 |
Premium
(Annual)
|
Student:$838
Spouse:$2,568
Child:$1,071
|
Student:$480
Spouse:$480
Child:$480
|
|