Trail Blazer Basic

 

  • Rates Starting at $57 per month
    $500,000 Medical Maximum per Accident or Sickness
    $150 Deductible per Policy Period
    $25 Office Copay (Waived at Student Health Center)

Rates (per month)

$57

Benefits

Coverage

Annual/Lifetime Maximum

Unlimited

Maximum per Covered Accident or Sickness

$500,000

Treatment Period

First Charges must occur within 30 days after the date of the Covered Accident or Sickness

Deductible

$150 per Policy Period

In Network Coinsurance

Single:  80% of Preferred Allowance up to $15,000; 100% of Preferred Provider Charges thereafter

 
Family:  80% of Preferred Allowance up to $35,000; 100% of Preferred Provider Charges thereafter

Out of Network Coinsurance

70% of Usual and Customary

Maximum Out of Pocket (In Network Only)

$3,000 Single/ $7,000 Family                                          Max out of Pocket Excludes Copays/Deductibles and Non Covered Charges

Copays/Deductible per Visit:

 

Dr's Office Visit

$25 (Waived at Student Health Center)

Emergency Room

$75

Hospital room and Board

$75

MRI/CAT Scans

$100

Prescription Drugs

$25 Generic

$15 Oral Contraceptives   

$50 All Other                     

(per prescription)

Benefit Period

From the date of the Covered Accident or Sickness to the Policy Termination Date

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 as any other condition.  Conception must occur while covered under the policy

Maximum for Dental Treatment (made necessary by Injury to Sound, Natural teeth only)

$2,500 Injury Only

Max. for Physiotherapy (Outpatient)

40 Visits

Max. for Psychotherapy (Inpatient)

40 Days

Max. for Psychotherapy (Outpatient)

40 Visits

Max. for Braces & Appliances

$5,000

Emergency Evacuation/Repatriation of Remains

100% of Actual Cost

Accidental Death and Dismemberment    Principal Sum

$10,000

Emergency Reunion

$2,500

*This Coverage contains a Pre-Existing condition limitation.  Out of Country Medical Maximum benefit of $50,000 may be applicable 

This is a brief summary of the ISP plan contained within and is not a contract of insurance. The terms and conditions of coverage are set forth in the Plan issued to the Participating Organization. If any conflict should arise between this summary and the respective Plan, the terms of the Plan will govern in all cases.