Liaison Student Plan Benefits- Non-US Citizens
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Lifetime Medical Maximum
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Economy: $5,000,000 Participant
Choice: $5,000,000 Participant
Elite: $5,000,000 Participant
$100,000 Spouse/Dependent
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Per Injury/Illness Maximum (up to age 64)
Economy, Choice & Elite
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Options of $50,000; $100,000; $250,000; $500,000; $1,000,000
$100,000 Spouse/Dependent
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Deductible per Injury/Illness
Economy, Choice & Elite
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$0, $50, $100, $250, $500, $1,000
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Copay per Prescription Medication
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$10 Generic
$20 Brand name
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Coinsurance
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Economy: In PPO Network 80% of the first $5,000, then 100% to the medical maximum
Out of PPO Network 70% of the first $5,000 then 100% to medical maximum
Choice: In PPO Network 90% of the first $5,000 then 100% to medical maximum
Out of PPO Network 80% of the first $5,000 then 100% to medical maximum
Elite: In PPO Network 100% to the medical maximum
Out of PPO Network 90% of the first $5,000 then 100% to medical maximum
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Dental Accident Coverage
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Economy: $500
Choice: $1,000
Elite: $2,500
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Dental Sudden Relief of Pain
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Economy: $150
Choice: $250
Elite: $350
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Emergency Medical Evacuation & Repatriation
(Separate from Medical Max)
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Economy: $100,000
Choice: $500,000
Elite: $750,000
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Return of Mortal Remains
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$50,000
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Emergency Medical Reunion
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Economy: $15,000
Choice: $25,000
Elite: $50,000
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Political Evacuation
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$10,000 Lifetime
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Terrorism
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Economy: $:25,000
Choice: $50,000
Elite: $100,000
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Ambulance Service (per injury/illness)
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Economy: $350
Choice: $500
Elite: $750
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Maternity Care
For a pregnancy to be covered, conception must occur 180 days after coverage begins
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Economy: $500
Choice: In PPO 80% up to $10,000
Out of PPO 60% up to $10,000
Elite: In PPO 80% up to 25,000
Out of PPO 60% up to $25,000
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Routine Newborn Care
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Economy: $250
Choice: $500
Elite: $750
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Mental Illness including Alcohol and Substance Abuse
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Inpatient
Economy: $5,000
Choice: $10,000
Elite: $20,000
Outpatient
Economy: 80% of URC to $500
Choice: 80% of URC to $1,000
Elite: $2,000
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Noncontact Amateur Sports**
(Please see below for list of covered sports)
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Economy: $2,500
Choice: $5,000
Elite: $10,000
(Includes high school, interscholastic, intramural or club sports)
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Home Country Coverage
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Economy: $1,000
Choice: $5,000
Elite: $10,000
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Personal Liability
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$25,000- $100,000
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Accidental Death & Dismemberment (AD&D)
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$25,000 principal sum for Participant
$10,000 principal sum per spouse
$5,000 principal sum per dependent
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Pre-Existing Condition Waiver
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Waiting period of 364 days of continuous coverage, then covered as any other disablement.
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