Patriot Exchange ProgramSM
Patriot Exchange ProgramSM

Summary of Benefits
Plan Maximum Choice of $50,000, $100,000, $250,000 or $500,000 per illness or injury with a lifetime maximum of $5,000,000
Deductible $100 per illness or injury
Coinsurance No coinsurance
Treatment Period Maximum 60 days for chronic conditions
Inpatient/Outpatient Benefits
Hospital Room and Board Up to average semi-private room rate
Hospital Intensive Care URC*
Physical Therapy URC* - 1 visit per day
Physician Visit URC* - 1 visit per day
Student Health Center $5 co-pay per visit (Not subject to deductible)
Prescription Drugs URC*
Eligible Medical Expenses URC*
Emergency Room visit with In-patient Admission URC*
Emergency Room visit without In-patient Admission Additional $250 deductible
Injury due to covered Accident - $500 maximum
Sudden & Unexpected Pain to natural teeth - $350 maximum
Evacuation Benefits
Emergency Medical Evacuation $50,000 lifetime maximum
Emergency Reunion $15,000 lifetime maximum
Return of Mortal Remains or Cremation/Burial $25,000 maximum for Return of Mortal Remains or $5,000 for Cremation/Burial
Political Evacuation $10,000 lifetime maximum
Accidental Death & Dismemberment $25,000 ($25,000 two limbs; $12,500 one limb)
Terrorism $50,000 lifetime maximum
Sudden & Unexpected Recurrence of a Pre-existing Condition (U.S. Citizens plan only)
Pre-Existing Conditions For conditions existing within 36 months before effective date, charges excluded after 12 months of coverage and then $500 maximum per period of coverage and $50,000 lifetime maximum
Incidental Trip Coverage Up to a cumulative 14 days
Lost Personal Property $250 maximum
Legal Assistance $500 maximum
Personal Liability
High School Sports URC*