International Student Insurance|AnyInsurance

#	Essential Plan	Plus Plan	Elite Plan
Maximum Benefit	$100,000 (For Each Injury or Sickness)	No Overall Maximum Dollar Limit	No Overall Maximum Dollar Limit
Deductible	$150/$500	$100/$500	$100/$500
Individual Out-of-Pocket Maximum	None	$6,850	$5,000
Physician's Visits	$35 Copay per visit	$30 Copay per visit	$25 Copay per visit
Medical Emergency	$250 Copay per visit and 20%	$250 Copay per visit and 20%	$200 Copay per visit and 10%
Ambulance	20% after deductible	20% after deductible	10% after deductible
Room and Board	$100 Copay per visit and 20%	20% after deductible	10% after deductible
Outpatient Surgery	$100 Copay per visit and 20%	20% after deductible	10% after deductible
X-rays & Lab	$25 Copay per visit and 20%	20%	10%
Prescription Drugs	None	$15 Copay per prescription Tier 1 30% Coinsurance per prescription Tier 2 45% Coinsurance per prescription Tier 3	$15 Copay per prescription Tier 1 30% Coinsurance per prescription Tier 2 45% Coinsurance per prescription Tier 3
Preventive Care	None	Free	Free
Plan detail information	PDF	PDF	PDF

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Essential Plan

Maximum Benefit
$100,000 (For Each Injury or Sickness)
Deductible
$150/$500
Individual Out-of-Pocket Maximum
None
Physician's Visits
$35 Copay per visit
Medical Emergency
$250 Copay per visit and 20%

Ambulance
20% after deductible
Room and Board
$100 Copay per visit and 20%
Outpatient Surgery
$100 Copay per visit and 20%
X-rays & Lab
$25 Copay per visit and 20%
Prescription Drugs
None
Preventive Care
None
Plan detail information
PDF

Plus Plan

Maximum Benefit
No Overall Maximum Dollar Limit
Deductible
$100/$500
Individual Out-of-Pocket Maximum
$6,850
Physician's Visits
$30 Copay per visit
Medical Emergency
$250 Copay per visit and 20%

Ambulance
20% after deductible
Room and Board
20% after deductible
Outpatient Surgery
20% after deductible
X-rays & Lab
20%
Prescription Drugs
$15 Copay per prescription Tier 1 30% Coinsurance per prescription Tier 2 45% Coinsurance per prescription Tier 3
Preventive Care
Free
Plan detail information
PDF

Elite Plan

Maximum Benefit
No Overall Maximum Dollar Limit
Deductible
$100/$500
Individual Out-of-Pocket Maximum
$5,000
Physician's Visits
$25 Copay per visit
Medical Emergency
$200 Copay per visit and 10%

Ambulance
10% after deductible
Room and Board
10% after deductible
Outpatient Surgery
10% after deductible
X-rays & Lab
10%
Prescription Drugs
$15 Copay per prescription Tier 1 30% Coinsurance per prescription Tier 2 45% Coinsurance per prescription Tier 3
Prescription Drugs
Free
Plan detail information
PDF

To file an appeal, please include the following information:

A letter requesting an appeal to your claim(s), including your: Name, Address, Phone number, UnitedHealthcare Student ID number, Date of service for your injury/sickness, Claim number(s) (located on the top of your Explanation of Benefits), and Email address
A copy of your Explanation of Benefits for the claim(s) in question.
Medical Records including all test results from all providers visited for the specific injury/sickness that you are appealing.

Once we receive the documentation, your appeal will be reviewed and a written response will be mailed to you. The response will include what the findings were, if the appeal was approved or denied, and the reason for the final decision.

International Student Insurance:OPT,ESL,F1/J1,Green card,U.S. citizen