All amounts shown are in U.S. dollars.
Coverage Limit / Maximum Amount for Eligible Medical Expenses | |||
Benefits | In-Network | Out-of-Network | International |
Maximum Limit | Student: $1,000,000 Dependent: $100,000 | Student: $1,000,000 Dependent: $100,000 | Student: $1,000,000 Dependent: $100,000 |
Per Illness or Injury limit | Student: $500,000 Dependent: $100,000 | Student: $500,000 Dependent: $100,000 | Student: $500,000 Dependent: $100,000 |
Deductible Options
| $100 | $150 | $25 |
Coinsurance for Eligible Medical Expenses | |||
Benefits | In-Network | Out-of-Network | International |
Coinsurance
| 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 | |||
Benefits | 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 |
Maternity | 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 |
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 | |||
Benefits | In-Network | Out-of-Network | International |
Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded until the Insured Person has maintained 6 months of continuous coverage under this insurance. | |||
Student Health Center | |||
Benefits | In-Network | Out-of-Network | International |
Copayment per visit
| $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 | |||
Benefits | In-Network | Out-of-Network | International |
Eligible Medical Expenses | 90% | 80% | 100% |
Physician Visits/Services
| 90% | 80% | 100% |
Hospital Emergency Room
| 90% | 80% | 100% |
Teledoc Consultation (Groups only) |
| ||
Hospitalization / Room & Board
| 90% | 80% | 100% |
Intensive Care | 90% | 80% | 100% |
Outpatient Surgical / Hospital Facility | 90% | 80% | 100% |
Laboratory | 90% | 80% | 100% |
Radiology / X-ray | 90% | 80% | 100% |
Chemotherapy / Radiation Therapy | 90% | 80% | 100% |
Pre-admission Testing | 90% | 80% | 100% |
Surgery | 90% | 80% | 100% |
Reconstructive Surgery
| 90% | 80% | 100% |
Assistant Surgeon
| 90% | 80% | 100% |
Anesthesia | 90% | 80% | 100% |
Maternity and Newborn Care
| 80% | 60% | 100% |
Durable Medical Equipment | 90% | 80% | 100% |
Chiropractic Care
| 90% | 80% | 100% |
Physical Therapy
| 90% | 80% | 100% |
Extended Care Facility
| 90% | 80% | 100% |
Home Nursing Care
| 90% | 80% | 100% |
Prescription Drugs and Medication - The following Prescription Drugs and Medication Period of Coverage limit accumulates toward the Maximum Limit | |||
Benefits | In-Network | Out-of-Network | International |
Period of Coverage limit
|
|
|
|
Inpatient and Outpatient Surgery Prescription Drugs and Medication | 90% | 80% | 100% |
Emergency Room and Outpatient Office Visits Prescription Drugs and Medication | 90% | 80% | 100% |
Retail Pharmacy Prescripton Drugs and Medication
| N/A | 50% | 50% |
Mental or Nervous / Substance Abuse | |||
Benefits | In-Network | Out-of-Network | International |
Inpatient Mental or Nervous / Substance Abuse
| 90% | 80% | 100% |
Outpatient Mental or Nervous / Substance Abuse
| 90% | 80% | 100% |
Emergency Services | |||
Benefits | In-Network | Out-of-Network | International |
Emergency Local Ambulance
| 100% | 100% | 100% |
Emergency Medical Evacuation
| 100% | 100% | 100% |
Emergency Reunion
| 100% | 100% | 100% |
Interfacility Ambulance Transfer
| 100% | 100% | N/A |
Political Evacuation and Repatriation
| 100% | 100% | 100% |
Repatriation for Medical Treatment
| 100% | 100% | 100% |
Return of Mortal Remains
| 100% | 100% | 100% |
Other Services | |||||||||||||||||||||||
Benefits | In-Network | Out-of-Network | International | ||||||||||||||||||||
Terrorism
| 100% | 100% | 100% | ||||||||||||||||||||
Dental Treatment
| N/A | 90% | 100% | ||||||||||||||||||||
Traumatic Dental Injury
| 90% | 80% | 100% | ||||||||||||||||||||
Intercollegiate, Interscholastic, Intramural, or Club Sports
| 90% | 80% | 100% | ||||||||||||||||||||
Accidental Death & Dismemberment
|
| ||||||||||||||||||||||
Incidental Trip
| 90% | 80% | 100% | ||||||||||||||||||||
Personal Liability
|
Combined Maximum Limit: $10,000 Injury to Third Person: Per Injury Deductible: $100 Damage to Third Person’s property: Per damage Deductible: $100 |
Combined Maximum Limit: $10,000 Injury to Third Person: Per Injury Deductible: $100 Damage to Third Person’s property: Per damage Deductible: $100 |
Combined Maximum Limit: $10,000 Injury to Third Person: Per Injury Deductible: $100 Damage to Third Person’s property: Per damage Deductible: $100 |
* This Web page contains only a consolidated and summary description of all current benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate Wording for this insurance plan in the event this Web page, application, and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.