Chadron Pioneer Elite 5K

 

  • $5,000 Sports Benefit
    Reduced Copay for Treatment at Student Health Center
    Emergency Evacuation and Repatriation of Remains Covered at 100% of Actual Cost

Rates (per month)

$100
 

In                                                            Network

Out of Network
Annual/Lifetime Maximum Unlimited
Sport Benefit $5,000
Medical Maximum per Covered Accident or Sickness $500,000
First Treatment First Charge must occur within 30 days after the date of the Covered Accident or Sickness
Deductible   $200 per Policy Period 
Coinsurance Single:  80% of PPO Allowance for the first $25,000; 100% of Covered Expenses thereafter                                                        75% of Usual and Customary
  Family:  80% of PPO Allowance for the first $50,000; 100% of Covered Expenses thereafter                                                        75% of Usual and Customary
Maximum Out of Pocket $5,000 Single/ $10,000 Family N/A
  Max out of Pocket Excludes Copays/Deductibles/ Non Covered Charges  
Copays:    
Dr's Office Visit  $25 (Waived at SHC) $40
Emergency Room $150 $250
Hospital Room and Board** $150 $250
MRI/ CAT Scan** $100 $250
Prescription Drugs $25 Generic $50 All Other
Benefit Period Benefits Terminate when your policy ends
Extension of Benefits 3 Months if Hospitalized for a Covered Accident or Sickness at time of Coverage Expiration Date
Pre-Existing Condition Limitation 6 months (Prior Creditable coverage under an ISP Policy)*
Pregnancy Covered if Conception Occurs after coverage is in force
Maximum for Dental Treatment $2,500 (Injury Only)
Max. for Chiropractic Care $5,000
Max. for Physiotherapy (Outpatient) 30 Visits
Max. for Psychotherapy (Inpatient) 30 Days
Max. for Psychotherapy (Outpatient) 30 Visits
Max. for Braces & Appliances $5,000
Max. for Routine Newborn Hospital Nursery Care $3,000 $1,500
Emergency Evacuation 100% of Actual Cost
Repatriation of Remains 100% of Actual Cost
Accidental Death & Dismemberment $10,000
Emergency Reunion $2,500
Family Reunion $2,500
* This coverage contains a Pre-existing condition limitation.  Maximum benefit of $50,000 may be applicable.  The Pre-existing Conditions definitions are defined within the policy forms and may vary based on the state of issuance.
**Prior Notification Required  

View Chadron Pioneer Elite Policy