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.
