Patriot Group Exchange ProgramSM
Patriot Group Exchange ProgramSM

Coverage Limit / Maximum Amount for Eligible Medical Expenses - All amounts shown are in U.S. dollars.
Plan Details In-Network Out-of-Network International
Maximum Limit $5,000,000 $5,000,000 $5,000,000
Deductible Options $0, $100, $250, or $500 per illness or injury available $0, $100, $250, or $500 per illness or injury available $0, $100, $250, or $500 per illness or injury available
Coinsurance for Eligible Medical Expenses
Plan Details In-Network Out-of-Network International
Coinsurance
  • In addition to Deductible
Plan pays 90%
Insured pays 10%
Plan pays 80%
Insured pays 20%
Plan pays 100%
Insured pays 0%
Out of Pocket Maximum $1,000 Up to the Maximum Limit $0
Precertification
Plan Details In-Network Out-of-Network International
Interfacility Ambulance Transfer, Emergency Medical Evacuation No coverage if Pre-certification requirements are not met No coverage if Pre-certification requirements are not met No coverage if Pre-certification requirements are not met
All other Treatments & supplies 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met
Pre-existing Conditions
Plan Details In-Network Out-of-Network International
Pre-existing conditions
  • Charges resulting directly or indirectly from or relating to any Pre-existing Condition that existed within 36 months prior to the Effective Date are excluded until the Insured Person has maintained 12 months of continuous coverage under this insurance.
Period of Coverage Limit (after 12 months): $500 Maximum Limit: $1,500 Period of Coverage Limit (after 12 months): $500 Maximum Limit: $1,500 Period of Coverage Limit (after 12 months): $500 Maximum Limit: $1,500
Student Health Center
Plan Details In-Network Out-of-Network International
Copayment per visit
  • Not subject to the per Illness or Injury Deductible
  • Copayment is not applicable if the Declaration states a $0 Deductible
$5 $5 $5
Coinsurance Plan pays 100%
Insured pays 0%
Plan pays 100%
Insured pays 0%
Plan pays 100%
Insured pays 0%
Inpatient/Outpatient Benefits
Plan Details In-Network Out-of-Network International
Eligible Medical Expenses 90% 80% 100%
Physician / Specialist Visit
  • Maximum Visits per day: 1
(unless visit is for a different medical/surgical specialty)
90% 80% 100%
Urgent Care
  • Not subject to Deductible
  • Copayment: $50
  • Copayment is not applicable if the Declaration states a $0 Deductible
90% 80% 100%
Walk-in Clinic
  • Not subject to Deductible
  • Copayment: $20
  • Copayment is not applicable if the Declaration states a $0 Deductible
90% 80% 100%
Hospital Emergency Room
  • Injury: Not subject to Emergency Room Deductible
  • Illness: Subject to a $500 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission.
90% 80% 100%
Hospitalization / Room & Board
  • Average semi-private room rate
  • Includes nursing, miscellaneous and Ancillary Services
90% 80% 100%
Intensive Care 90% 80% 100%
Bedside Visit
  • Not subject to Deductible
  • Maximum Limit: $1,500
  • Hospitalized in an Intensive Care Unit
  • Refer to the BEDSIDE VISIT provision for further details
90% 80% 100%
Outpatient Surgical / Hospital Facility 90% 80% 100%
Laboratory 90% 80% 100%
Radiology / X-ray 90% 80% 100%
Pre-admission Testing 90% 80% 100%
Surgery 90% 80% 100%
Pre-admission Testing 90% 80% 100%
Surgery 90% 80% 100%
Reconstructive Surgery
  • Surgery is incidental to and follows Surgery that was covered under the plan
90% 80% 100%
Assistant Surgeon
  • 20% of the primary surgeon’s eligible fee
90% 80% 100%
Anesthesia 90% 80% 100%
Durable Medical Equipment 90% 80% 100%
Chiropractic Care
  • Medical order or Treatment plan required
90% 80% 100%
Physical Therapy
  • Maximum Visits per day: 1
  • Medical order or Treatment plan required
90% 80% 100%
Extended Care Facility
  • Upon direct transfer from an acute care Hospital
90% 80% 100%
Home Nursing Care
  • Provided by a Home Health Care Agency
  • Upon direct transfer from an acute care Hospital
90% 80% 100%
Prescription Drugs and Medication - The following Prescription Drugs and Medication Period of Coverage limit accumulates toward the Maximum Limit
Plan Details In-Network Out-of-Network International
Prescription Drugs and Medication
  • Period of Coverage limit: $250,000 per person
  • Obtained through Retail Pharmacy, Inpatient and Outpatient Surgery, Emergency Room and Outpatient Office Visits
  • Dispensing maximum for Retail Pharmacy: 90 days per prescription
N/A 90% 100%
Mental or Nervous / Substance Abuse
Plan Details In-Network Out-of-Network International
Inpatient Mental or Nervous / Substance Abuse
  • Maximum Limit: $10,000
  • Not covered if incurred at the Student Health Center
90% 80% 100%
Outpatient Mental or Nervous / Substance Abuse
  • Maximum Limit per day: $50
  • Maximum Limit: $500
  • Not covered if incurred at the Student Health Center
90% 80% 100%
Emergency Services
Plan Details In-Network Out-of-Network International
Emergency Local Ambulance
  • Subject to Deductible
  • Injury
  • Illness resulting in a Hospitalization admission
100% 100% 100%
Emergency Medical Evacuation
  • Maximum Limit: $50,000
  • Must be approved in advance and coordinated by the Company
100% 100% 100%
Emergency Reunion
  • Maximum Limit: $15,000
  • Maximum Days: 15
  • Meal Maximum per day: $25
  • Reasonable and necessary travel costs and accommodations
  • Must be approved in advance by the Company
100% 100% 100%
Interfacility Ambulance Transfer
  • Up to the per Injury or Illness limit
  • Services rendered in the United States
  • Transfer must be a result of an Inpatient Hospital admission
100% 100% N/A
Political Evacuation and Repatriation
  • Maximum Limit: $10,000
  • Must be approved in advance by the Company
100% 100% 100%
Repatriation for Medical Treatment
  • Maximum Benefit: $100,000
  • Approved in advance and coordinated by the Company
  • Refer to the REPATRIATION FOR MEDICAL TREATMENT provision for further details
100% 100% 100%
Return of Mortal Remains
  • Maximum Limit: $25,000
  • Local Burial / Cremation at place of death
  • Maximum Limit: $5,000
  • Return of Insured Person’s Mortal Remains to Country of Residence
  • Must be approved in advance by the Company
100% 100% 100%
Other Services
Plan Details In-Network Out-of-Network International
Terrorism
  • Maximum Limit: $50,000
100% 100% 100%
Dental Treatment
  • Period of Coverage Limit: $350
  • (Treatment due to Unexpected pain to sound, natural teeth)
  • Period of Coverage Limit per Injury: $500
(Non-emergency Treatment at a Dental Provider due to an Accident)
N/A 90% 100%
Traumatic Dental Injury
  • Subject to Deductible and Coinsurance
  • Up to the Maximum Limit
  • Treatment at a Hospital Facility due to an Accident
  • Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%
90% 80% 100%
Accidental Death & Dismemberment
  • Principal Sum Maximum: $25,000
  • Death must occur within 90 days of the Accident
Accidental Death: 100% of Principal Sum
Accidental Dismemberment:
Loss Percent of Principal Sum
Sight of 1 eye 50%
1 hand or 1 foot 50%
1 hand and loss of sight of 1 eye 100%
1 foot and loss of sight of 1 eye 100%
1 hand and 1 foot 100%
Both hands or both feet 100%
Sight of both eyes 100%
Incidental Trip
  • Maximum days: 14
  • Country of Residence is outside the United States
  • Refer to the INCIDENTAL TRIP provision for further details
90% 80% 100%
Optional Add-On Rider
Plan Details In-Network Out-of-Network International
Personal Liability
  • Injury to third party: $2,000 per period of coverage limit after $100 deductible
  • Damage to third party’s property: $500 per period of coverage limit after $100 deductible
100% 100% 100%
Lost Personal Property
  • $250 per period of cover age limit
100% 100% 100%
Limited High School and College Sports
  • Company pays 100% after deductible is met
100% 100% 100%
Legal Assistance $500 period of coverage limit $500 period of coverage limit $500 period of coverage limit