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Patriot Exchange ProgramSM
Patriot Exchange ProgramSM

Summary of Benefits - Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Maximum Limit $5,000,000
Deductible Options $0, $100, $250 or $500 per illness or injury available
Maximum Limit Per Illness or Injury Choice of $50,000, $100,000, $250,000 or $500,000
Coinsurance Company pays 100%
Inpatient/Outpatient Benefits
Hospital Room and Board Up to average semi-private room rate
Intensive Care Unit Company pays 100% after deductible is met
Physical Therapy Company pays 100% after deductible is met; one visit per day (Medical order or treatment plan required)
Bedside Visit $1,500 maximum limit. Must be hospitalized in an intensive care unit. Not subject to deductible
Physician Visit Company pays 100% after deductible is met; one visit per day
Student Health Center $5 copay per visit. Not subject to deductible
Prescription Drugs Company pays 100% after deductible is met
90 day dispensing maximum
Urgent Care $50 copay. Not subject to deductible.
Copay is not applicable if you choose a $0 Deductible
Walk-in Clinic $20 copay. Not subject to deductible.
Copay is not applicable if you choose a $0 Deductible
Eligible Medical Expenses Company pays 100% after deductible is met
Emergency Room visit with In-patient Admission Company pays 100% after deductible is met
Emergency Room visit without In-patient Admission Additional $250 deductible
Interfacility Ambulance Transfer
(For Services Rendered in the U.S. )
Company pays 100%. Transfer must be a result of an inpatient hospital admission
Not subject to deductible
Dental Non-emergency treatment at a dental provider due to an accident: $500 period of coverage limit per injury; Treatment due to unexpected pain to sound, natural teeth: $350 period of coverage limit
Mental or Nervous / Substance Abuse Not covered if incurred in student health center
Inpatient: $10,000 maximum limit
Outpatient: $50 maximum limit per day. $500 maximum limit
Evacuation Benefits (Not subject to deductible)
Emergency Medical Evacuation $50,000 maximum limit
Emergency Reunion $15,000 maximum limit
Return of Mortal Remains or Cremation/Burial $25,000 maximum limit for return of mortal remains or $5,000 maximum limit for cremation/burial
Political Evacuation $10,000 maximum limit
ADDITIONAL BENEFITS
Accidental Death & Dismemberment $25,000 principal sum; Not subject to deductible
Terrorism $50,000 maximum limit; Not subject to deductible
Sudden & Unexpected Recurrence of a Pre-existing Condition Eligible medical expenses: $5,000 maximum limit
Emergency medical evacuation: $25,000 maximum limit
Pre-Existing Conditions For conditions existing within 36 months before effective date, charges excluded until after 12 months of coverage and then $500 per period of coverage and $1,500 maximum limit
Incidental Trip Coverage
(Available for non-U.S. residents only)
Up to a cumulative 14 days
OPTIONAL ADD-ON Riders
Lost Personal Property $250 per period of coverage limit
Legal Assistance $500 per period of coverage limit
Personal Liability - Injury to third party
Personal Liability - Damage to third party’s property
$2,000 per period of coverage limit after $100 deductible
$500 per period of coverage limit after $100 deductible
Limited High School and College Sports Company pays 100% after deductible is met