Health Insurance:
Plan Highlights
2013-2014 BENEFIT SUMMARY
(effective 8/1/13 - 7/31/14)
Medical Calendar Year Deductible
|
Student/Subscriber Pays
|
Medical Calendar-Year Deductible |
$150 |
Annual Out-of-Pocket Maximum Individual/Family |
$3,000/$6,000 |
Outpatient Care
|
Office Visits |
$40 Copay (deductible waived) |
Preventive Exams |
No Charge (deductible waived) |
Maternity/Prenatal Care |
No Charge (deductible waived) |
Well-Child Preventative Care Visits |
No Charge (deductible waived) |
Vaccines (Immunizations) |
No Charge (deductible waived) |
Allergy Injections |
$5 Copay |
Occupational, Physical, and Speech Therapy |
$40 Copay |
Most Labs and Imaging |
$10 Copay |
MRI, CT and PET Scans |
$50 Copay |
Outpatient Surgery |
20% Coinsurance |
Emergency Services
|
Emergency Department Visits (waived if admitted directly to hospital) |
20% Coinsurance |
Ambulance Services |
$150 Copay |
Prescriptions
|
Generic (Up to a 30-Day Supply) |
$10 Copay (Deductible Waived) |
Brand Name (Up to a 30-Day Supply) |
$30 Copay (Deductible Waived) |
Generic Mail Order Incentive (Up to a 100-Day Supply) |
$20 Copay (Deductible Waived) |
Brand Name Mail Order Incentive (Up to a 100-Day Supply) |
$60 Copay (Deductible Waived) |
Hospice Care
|
Physician Services, Room and Board, Tests, Medications, Supplies and Therapies |
20% Coinsurance |
Skilled Nursing Facility Care (Up to 100 Days) |
20% Coinsurance |
Mental Health Services
|
Outpatient Visits |
$40 copay (Individual Therapy, Deductible Waived) |
|
$20 copay (Group Therapy, Deductible Waived) |
Inpatient Psychiatric Hospitalization & Intensive Psychiatric Treatment Programs |
20% Coinsurance |
Chemical Dependency Services
|
Outpatient Visits |
$40 copay (Individual Therapy, Deductible Waived) |
|
$5 copay (Group Therapy, Deductible Waived) |
Inpatient Detoxification |
20% Coinsurance |
Other
|
Certain Durable Medical Equipment (DME) |
20% Coinsurance (Deductible Waived) |
Vision Exam |
No Charge (Deductible Waived) |
Optical (Eyewear) |
Not Covered |
Home Health Care (Up to 100 Two-Hour Visits Per Calendar Year) |
No Charge (Deductible Waived) |
Hospice Care |
No Charge (Deductible Waived) |
This is only a summary of plan features. Please consult the GGU Student Health Insurance Brochure for a more detailed description of plan features, including benefits, exclusions
and limitations.