| 每次受伤或生病最高保额 | $100,000 |
| 网络内共同保险 | 80% |
| 网络外共同保险 | 60% |
| 网络内自付上限 | Unlimited |
| 急诊室自付额 (若被纳入住院将免除) | $350 |
| 学生健康中心自付额 | $5 |
| 专科医生共付额 | $50 |
| 住院治疗共付额 | $0 |
| 原有疾病状况等待期 | 80% UCR-Up to $25,000 for emergency care and stabilization only |
| 预防保健 | N/A |
| 医疗运送和遗体送返 | 80% UCR-Up to $50,000 |
| 医疗运送 | 80% UCR-Up to $50,000 |
| 遗体送返 | 80% UCR-Up to $25,000 |