Summary Of Benefits & Coverage (SBC).pdf

LaSalle University's 2014-2015 student/family health insurance plan is a PPO with a coverage period of 08/04/2014 - 08/03/2015. The plan has a deductible of $200 for preferred providers and $600 for out-of-network providers. The out-of-pocket limit is $5,000 for preferred providers and $15,000 for out-of-network providers. The plan does not have an overall annual limit on what it pays.

Services and costs include:
- Primary care visits: 20% coinsurance for preferred providers, 40% coinsurance for out-of-network providers
- Specialist visits: 20% coinsurance for preferred providers, 40% coinsurance for out-of-network providers
- Preventive care: no charge for preferred providers, not covered for out-of-network providers
- Diagnostic tests: 20% coinsurance for preferred providers, 40% coinsurance for out-of-network providers
- Prescription drugs: $15-$60 copay for preferred providers, not covered for out-of-network providers
- Outpatient surgery: 20% coinsurance for preferred providers, 40% coinsurance for out-of-network providers
- Emergency room services: 20% coinsurance and $150 copay for preferred providers, 20% coinsurance and $150 deductible for out-of-network providers
- Hospital stays: 20% coinsurance for preferred providers, 40% coinsurance for out-of-network providers

The plan does not require a referral to see a specialist, but some services may have limitations or exceptions. Services not covered by the plan are listed on page 5 of the policy document.