INTERNATIONAL STUDENT PLANS
Rates, Benefits, and Applications Included

Mountaineer is a high-end health plan for international students and scholars studying in the United States. Rates start at $70 per month for students age 25 and under. Mountaineer is an affordable alternative to MSU’s school insurance program.

If you have continuous coverage under a prior US insurance policy without interruption, you will receive credit toward Mountaineer’s six-month pre-existing condition limitation.

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Plan Highlights

High lifetime medical maximum
No copayment for treatment received at Student Health Center
$500,000 medical evacuation benefit
Dependent coverage available

Waiver Instructions

All summer session waiver requests must be completed by 5/12/12.
The waiver site will re-open in May for the fall semester waiver requests which must be completed between 5/12/12 and 8/14/12.
Make sure you have all necessary waiver information available BEFORE commencing the waiver process. Complete ALL necessary information before leaving the waiver site.

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Summary of Benefits (Policy #GLB 0009133488)

Benefits	In-Network*	Out-of-Network
Lifetime Medical Maximum	$2,000,000	$1,000,000
Maximum per Injury/Sickness	$300,000	$300,000
Maximum Out-of-pocket Expense	$2,000	No maximum
Coinsurance	Plan pays 80% of first $4,000 in expenses and 100% thereafter	Plan pays 75% of usual and customary charges
Copays**
Student Health Center	No copay	No copay
Elsewhere	$40	$60
Emergency Room (waived if admitted)	$100	$150
Hospital	$250	$250
X-ray and Lab Tests	$40	$60
Prescription Drugs	$20 (Generic)/ $30 (Other)	$20 (Generic)/ $30 (Other)
Home Country Coverage	$1,000	$1,000
Emergency Medical Evacuation	$500,000	$500,000
Emergency Medical Reunion	$2,000	$2,000
Repatriation of Remains	$100,000	$100,000
Accidental Death & Dismemberment Coverage	$20,000	$20,000

* You pay less for care received at the Student Health Center or from a doctor or hospital in the extensive Cofinity provider
network. If there are no Cofinity providers within 25 miles of where you are located, benefits will be paid at the In-Network level.

**Copays are waived if the participant is treated onsite at the Student Health Center and is not referred off campus:

In the case of a participant not being able to be treated at the Student Health Center and subsequently being referred to an
off-campus private doctor by a licensed general health practitioner at the Student Health Center, the copay will be half of the scheduled copay amount.
In the case of treatment not being possible at the Student Health Center and the participant being referred to the ER by a licensed general health practitioner at the Student Health Center, the copay will be half of the scheduled copay amount.
In the case of treatment not being available at the Student Health Center, or if there is not one, and the participant is referred to or forced to go the ER and then subsequently hospitalized, then the ER, doctor’s visit and hospitalization copays will be integrated to a maximum of $250.

For more information about the Mountaineer Plan, see the policy brochure.

Rates (Per Month)

Participant Only: Age 25 and under	$70
Participant Only: Age 26 or Over	$84
Participant with Spouse	$280
Participant with Spouse and 1 Child	$315
Participant with Spouse and Children	$385
Participant with 1 Child	$245
Participant with Children	$280