•   High School International Student 


Required Coverage Dates Gold Plan
$0.0   Deductible Option
Platinum Plan
$0.0   Deductible Option
24 & Under 25-29 30 & Above 24 & Under 25-29 30 & Above
ANNUAL 2016-17 $694 $694 $694 $980 $980 $980
PER MONTH (30-DAY RATE) $58 $58 $58 $81 $81 $81
No Lifetime Limits On Benefits Unlimited Max Benefit of per Person per Policy Year
$2,000,000 per Person per Policy Year Out-of-Pocket Maximum $6350 / policy year
Coinsurance: 80% In-Network, 70% Out-Network Coinsurance: 80% In-Network, 70% Out-Network
Preventive Care Services per ACA - 100% In-Network Preventive Care Services per ACA - 100% In-Network
Mental Illness & Substance Use Disorder Treatment Mental Illness & Substance Use Disorder Treatment
Prescription Drug Card: $20/$40/$60 copay Prescription Drug Card: $20/$40/$60 copay
Urgent Care Facilities - $50 copay Coverage for Intramural, Club, & Recreational Sports
Pre-existing Conditions - $2500 benefit; No exclusion after 6-mos Pre-existing Conditions – No Limitations or Exclusions
Evacuation & Repatriation - Pays 100% for services provided Evacuation & Repatriation - Pays 100% for services provided
Review Gold Plan Policy Brochure Review Platinum Plan Policy Brochure
All charges shown include premium, credit card transaction fees, ACH processing fees and other cost associated with offering this health plan. The programs offered here are underwritten by Student Resources (SPC) Ltd. A UnitedHealth Group Company. This plan can only be enrolled through www.psiservice.com.



Disclaimer:

"PSI gathered this information as a resource for students, and this does not intend to imply a relationship between your school and our website or company. We advise you to double-check directly with your school to ensure that these Student Plans meet your school's insurance requirements." "We gathered this information as a resource for students, and this does not intend to imply a relationship between your school and our website or company. We advise you to double-check directly with your school to ensure that these Student Plans meet your school's insurance requirements. PSI."