	Standard	Platinum
Lifetime Maximum
Student	$500,000	$1,000,000
Dependent Spouse and Child	$100,000	$100,000
Per Illness/Injury Maximum
Student	$300,000	$500,000
Each eligible dependent Spouse and Child	$100,000	$100,000
Deductible
For Treatment received outside the US	$100 per Illness or Injury	$25 per Illness or Injury
For Treatment received inside the US	$100 per Illness or Injury	PPO: $25 per Illness or Injury Non-PPO: $50 per Illness or Injury
Student Health Center
	$5 co-pay per visit if Treatment received in Student Health Center (not subject to deductible)
Coinsurance
For Treatment received outside the US	After the deductible, the plan pays 100% of eligible expenses up to Maximum Limit.
For Treatment received within the US	In the PPO Network or Student Health Center: After the deductible, the plan pays 100% of eligible expenses up to Maximum Limit Outside of the PPO Network: After the deductible, the plan pays 80% of eligible expenses up to $1,000, then 100% up to Maximum Limit Provider Network
Inpatient or Outpatient Services Subject to Deductible and Coinsurance unless otherwise noted. Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Eligible Medical Expenses	Up to the maximum limit
Physician Visits / Services	Up to the maximum limit 1 visit per day Surgery is not subject to the maximum visit limit
Hospital Emergency Room	Up to the maximum limit. Illness: Subject to a $250 deductible for each ER visit for treatment that does not result in direct inpatient hospital admission. Injury: Not subject to emergency room deductible.
Hospitalization / Room & Board	Average semi-private room rate up to the maximum limit. Includes nursing service, miscellaneous and Ancillary services.
Intensive Care Unit (ICU)	Up to the maximum limit
Outpatient Surgical / Hospital Facility	Up to the maximum limit
Laboratory	Up to the maximum limit
Radiology / X-ray	Up to the maximum limit
Chemotherapy / Radiation Therapy	Up to the maximum limit
Pre-admission Testing	Up to the maximum limit
Surgery	Up to the maximum limit
Reconstructive Surgery Surgery is incidental to and follows surgery that was covered under the plan	Up to the maximum limit
Assistant Surgeon	20% of the primary surgeon’s eligible fee
Anesthesia	Up to the maximum limit
Durable Medical Equipment	Up to the maximum limit Standard basic hospital bed and/or a standard basic wheelchair
Chiropractic Care	Up to the maximum limit Medical order or treatment plan required
Physical Therapy	Up to the maximum limit Medical order or treatment plan required 1 visit per day
Pre-Existing Conditions	Eligible expenses covered after 12 continuous months of coverage	Eligible expenses covered after 6 continuous months of coverage
Maternity Pre-natal care, delivery of a Newborn, and post-natal care of an Insured Person, including complications	No Coverage	In the US: In-Network: 80% up to $5,000 Out-of-Network: 60% up to $5,000 Outside the US: 100% up to $5,000
Routine Newborn Care	No Coverage	Included in Maternity Benefit during the first 31 days of life
Extended Care Facility	Up to the maximum limit Upon direct transfer from an acute care facility
Home Nursing Care	Up to the maximum limit Provided by a Home Health Care Agency Upon direct transfer from an acute care facility
COVID-19 Coverage	COVID-19/SARS-CoV-2 shall be considered the same as any other illness or injury, subject to all other terms and conditions.
Prescription Medication	Period of Coverage Limit: Primary Insured Person: $250,000 maximum Spouse and Child: $100,000 maximum Inpatient and Outpatient Surgery, Emergency Room, and Outpatient Office Visits Prescription Drugs and Medication: Up to the Period of Coverage Limit Retail Pharmacy Prescription Drugs and Medication: 50% coverage, 90 day dispensing maximum
Mental or Nervous / Substance Abuse	Inpatient: $10,000 maximum Outpatient: $50 limit per day, $500 maximum limit Not covered if incurred at Student Health Center
Emergency Services NOT subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Emergency Local Ambulance	Per Injury: $350 Per Illness resulting in Inpatient Hospitalization: $350	Per Injury: $750 Per Illness resulting in Inpatient Hospitalization: $750
Emergency Medical Evacuation	$500,000 lifetime maximum Must be approved in advance and coordinated by the Company
Emergency Reunion	$50,000 lifetime maximum 15 day maximum, $25 per day meal maximum Must be approved in advance by the Company
Interfacility Ambulance Transfer	Up to the maximum limit Transfer must be a result of an Inpatient Hospital admission Services rendered in the United States
Political Evacuation and Repatriation	$10,000 lifetime maximum Must be approved in advance by the Company
Return of Mortal Remains	$50,000 lifetime maximum Local Burial/Cremation: $5,000 maximum Must be approved in advance by the Company
Other Services Subject to Deductible and Coinsurance unless otherwise noted Eligible Medical Expenses are limited to Usual, Reasonable and Customary Limits per Period of Coverage unless stated as Maximum Limit
Accidental Death & Dismemberment Death must occur within 90 days of the accident	Principal Sum: Insured Person: $25,000 Spouse: $10,000 Child: $5,000 Not subject to deductible or coinsurance
Dental Treatment	Treatment due to Unexpected Pain to Sound, Natural Teeth: $350 maximum Non-Emergency Treatment due to an Accident: $500 maximum
Traumatic Dental Injury	Up to the maximum limit. Additional treatment for the same injury rendered by a dental provider will be paid at 100%. Subject to deductible and coinsurance.
Incidental Trip	Up to a cumulative 14 days Insured Person’s Country of Residence is not the United States
Intercollegiate, Interscholastic, Intramural, and Club Sports	$5,000 per injury or illness
Personal Liability Secondary to any other insurance	$10,000 combined maximum limit. Injury to a third person: $100 per injury deductible. Damage to a third person’s property: $100 per damage deductible. No coverage for injury to a related third party or damage to related third person’s property.
Terrorism	$50,000 Lifetime Maximum Not subject to deductible or coinsurance

Adventure Sports Rider (Available to insureds up to age 64)
Certain activities designated as adventure sports can be covered up to the maximums listed below if the optional rider is purchased. Certain activities are never covered, regardless of whether the Adventure Sports Rider is purchased. For a list of activities considered to be adventure sports, please contact us.
Age	Lifetime Maximum
0–49	$50,000
50–59	$30,000
60–64	$15,000

Age	Student	Spouse	Dep. Child
Under 19	$53	$310	$64
19–23	$59	$310	$64
24–30	$78	$339	$64
31–40	$119	$452	$64
41–50	$192	$463	$64
51–64	$257	$452	$64

Age	Student	Spouse	Dep. Child
Under 19	$68	$356	$85
19–23	$89	$356	$85
24–30	$104	$394	$85
31–40	$187	$525	$85
41–50	$303	$542	$85
51–64	$405	$525	$85

Age	Student	Spouse	Dep. Child
Under 19	$163	$959	$176
19–23	$180	$959	$176
24–30	$237	$1,049	$176
31–40	$259	$1,398	$176
41–50	$584	$1,436	$176
51–64	$774	$1,398	$176

Age	Student	Spouse	Dep. Child
Under 19	$207	$1,103	$234
19–23	$272	$1,103	$234
24–30	$314	$1,218	$234
31–40	$563	$1,622	$234
41–50	$921	$1,676	$234
51–64	$1,229	$1,622	$234

Wisconsin Lutheran High School

Highlights of the Student Health Advantage plan include:

US Healthcare System Video

Sexual Assault Awareness Video

Mental Health Awareness