Insurance Provider
|
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SHIPÇ÷£ |
LIG¼ÕÇØº¸Çè |
Lifetime Maximum
|
|
Unlimited |
Benefit
|
$200,000 |
$100,000 per Sickness or Injury
|
Deductible
°í°´ ºÎ´ã±Ý |
$75 per quarter per insured person up to a maximum deductible of $300 per policy year |
|
$0 |
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|
the plan pays 80% after you pay a $300 • copay per admission; you pay the other 20% |
|
100% |
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|
Out-of-Network
Provider:
the plan pays 60% after you pay a $400 copay • per admission; you pay the other 40%
|
100% º¸»ó |
Prescription Drug
(¾à°ª°í°´ºÎ´ã±Ý)
|
Rubenstein Pharmacy
(on campus at Hall Health) |
You pay the higher of:
Generic: 20% or $15 copay•
Brand formulary: 30% or $25 copay• Non-formulary: 40% or $30 copay• Maximum copay/coinsurance of up to $200/prescription |
.
|
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You pay the higher of:
Generic: 30% or $15copay•
Brand formulary: 40% or $25 copay• Non-formulary: 50% or $30 copay• Maximum copay/coinsurance of up to $200/prescription | |
Out-of-network pharmacies |
You pay:
Generic: 50%
Brand formulary: 50%
Non-formulary: 50%
Maximum copay/coinsurance of up to $200/prescription | |
Premium
(Annual)
|
Student: $1,840
Spouse: $2,744
Child(ren): $2,320 |
Student: $981
Spouse: $981
Child: $981 |