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treatment for mental or nervous disorders during hospital confinement, up to a maximum of $5,000 per Policy Year.

Outpatient

We will pay 100% for In-Network and 50% for Out-of-Network, both with a $20 copay for the Covered Expenses incurred when an Covered Person requires treatment for a mental or nervous disorder while not hospital confined up to a maximum of 15 visits per Policy Year, limited to one visit per day.

Physician Expense - care and treatment by a Physician, both in and out of the hospital, for non-surgical services, limited to one visit per day.

Surgical Expense - the Usual, Customary and Reasonable Expenses for the surgical fee based upon the MDR (Medical Data Research) survey of surgical fees, valued at the 80th percentile. If in connection with a surgery and the Covered Person requires the services of an anesthetist or assistant surgeon, We will pay the Usual, Customary and Reasonable Expense incurred.

Taxi Service Expense - We will ONLY reimburse an Insured Student who utilizes a taxi service when it is recommended by the Student Health Center or approved by the school representative in the residence hall. We will pay the taxi fares for transporting students to off-campus medical providers for the treatment of a Covered Charge or Expense.

We will pay the Usual, Customary and Reasonable charges for the following benefits as mandated by the State of Pennsylvania:

Alcohol and Drug Abuse Expense

Inpatient

We will pay 80% of network allowable or 50% of Usual, Customary and Reasonable charges for the Covered Charges incurred when a Covered Person requires treatment for detoxification or rehabilitation services for alcohol or drug abuse, during hospital confinement, not to exceed 7 days per hospital admission. The Lifetime maximum is 4 hospital admissions. When an Insured Person requires confinement in a non-hospital facility, We will pay for at least 30 days per year. However, there is a lifetime limit, for any Covered Person, of 90 days.

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Outpatient

We will pay 50% for the Covered Charges incurred when an Covered Person requires treatment for alcohol or drug abuse while not hospital confined up to a maximum of $70 per visit, limited to one visit per day, 30 visits per year. The 30 separate visits per year may be exchanged on a two for one basis to secure up to 15 additional non-hospital residential alcohol treatment days. Outpatient benefits are subject to a lifetime limitation of 120 visits.

C h i l d h o o d I m m u n i z a t i o n s B e n e f i t - B e n e f i t s f o r C o v e r e d P e r s o n s l e s s t h a n a g e 2 1 w i l l b e p a i d i n a c c o r d a n c e w i t h t h e P e n n s y l v a n i a D e p a r t m e n t o f H e a l t h c h i l d h o o d i m m u n i z a t i o n l a w . N o d e d u c t i b l e , o r d o l l a r l i m i t s h a l l a p p l y .

D i a b e t e s E x p e n s e B e n e f i t W e c o v e r e x p e n s e s i n c u r r e d f o r - e q u i p m e n t , s u p p l i e s a n d o u t p a t i e n t s e l f - m a n a g e m e n t t r a i n i n g a n d e d u c a t i o n , i n c l u d i n g m e d i c a l n u t r i t i o n t h e r a p y f o r t h e t r e a t m e n t o f d i a b e t e s , i f p r e s c r i b e d b y t h e C o v e r e d P e r s o n s P h y s i c i a n . E q u i p m e n t a n d s u p p l i e s i n c l u d e , b u t a r e n o t l i m i t e d t o t h e f o l l o w i n g : l a n c e t s a n d a u t o m a t i c l a n c i n g d e v i c e s ; g l u c o s e t e s t s t r i p s ; b l o o d g l u c o s e m o n i t o r s ; b l o o d g l u c o s e m o n i t o r s f o r t h e v i s u a l l y i m p a i r e d ; c o n t r o l s o l u t i o n s u s e d i n b l o o d g l u c o s e m o n i t o r s ; d i a b e t e s d a t a m a n a g e m e n t s y s t e m s f o r m a n a g e m e n t o f b l o o d g l u c o s e ; u r i n e t e s t i n g p r o d u c t s f o r g l u c o s e ; o r a l a n t i - d i a b e t i c a g e n t s u s e d t o r e d u c e b l o o d s u g a r l e v e l s ; a l c o h o l s w a b s ; s y r i n g e s ; i n j e c t i o n a i d s ; c a r t r i d g e s f o r t h e v i s u a l l y i m p a i r e d ; d i s p o s a l i n s u l i n c a r t r i d g e s a n d p e n c a r t r i d g e s ; i n s u l i n p r e p a r a t i o n s ; i n s u l i n p u m p s ; i n s u l i n i n f u s i o n d e v i c e s ; o r a l a g e n t s f o r t r e a t i n g h y p o g l y c e m i a ; g l u c a g o n f o r i n j e c t i o n t o i n c r e a s e b l o o d g l u c o s e c o n c e n t r a t i o n . C o v e r a g e i s p r o v i d e d f o r M e d i c a l l y N e c e s s a r y d i a b e t e s s e l f - m a n a g e m e n t e d u c a t i o n a n d e d u c a t i o n r e l a t i n g t o d i e t . D i a b e t e s o u t p a t i e n t s e l f - m a n a g e m e n t t r a i n i n g a n d e d u c a t i o n s h a l l b e p r o v i d e d u n d e r t h e s u p e r v i s i o n o f a l i c e n s e d h e a l t h c a r e p r o f e s s i o n a l w i t h e x p e r t i s e i n d i a b e t e s t o e n s u r e t h a t p e r s o n s w i t h d i a b e t e s a r e e d u c a t e d a s t o t h e p r o p e r s e l f - m a n a g e m e n t a n d t r e a t m e n t o f t h e i r d i a b e t e s , i n c l u d i n g i n f o r m a t i o n o n p r o p e r d i e t s . C o v e r a g e f o r s e l f - m a n a g e m e n t e d u c a t i o n a n d e d u c a t i o n r e l a t i n g t o d i e t a n d p r e s c r i b e d b y a P h y s i c i a n i n c l u d e s : ( 1 ) v i s i t s M e d i c a l l y N e c e s s a r y u p o n t h e d i a g n o s i s o f d i a b e t e s ; ( 2 ) v i s i t s u n d e r c i r c u m s t a n c e s w h e r e b y a P h y s i c i a n i d e n t i f i e s o r d i a g n o s e s a s i g n i f i c a n t c h a n g e i n t h e p a t i e n t ' s s y m p t o m s o r c o n d i t i o n s t h a t n e c e s s i t a t e s c h a n g e s i n a p a t i e n t ' s s e l f - m a n a g e m e n t ; a n d ( 3 ) w h e r e a n e w m e d i c a t i o n o r t h e r a p e u t i c p r o c e s s r e l a t i n g t o t h e C o v e r e d P e r s o n ' s t r e a t m e n t a n d / o r m a n a g e m e n t o f d i a b e t e s h a s b e e n i d e n t i f i e d a s M e d i c a l l y N e c e s s a r y b y a l i c e n s e d D o c t o r . W e c o v e r s u c h c h a r g e s t h e W e t r e a t C o v e r e d E x p e n s e s f o r a n y o t h e r S i c k n e s s . same way

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