| Rates | Participant (Student/Faculty/Staff) |
Per Dependent (Spouse/Child) |
|---|---|---|
| Monthly | $140.35 | $309.00 |
IMPORTANT: To enroll your dependent(s), please complete the dependent enrollment form posted on the left-side bar and submit it to enrollments@mycisi.com. You must be enrolled in this coverage in order for your dependent(s) to be enrolled.
| Coverages and Services | Maximum Limits |
|---|---|
| Accidental Death and Dismemberment Per Insured Person | $10,000 |
| Benefit Maximum | $2,000,000 |
| Annual Deductible | $100 In-Network / $250 Out-of-Network |
| Coinsurance | 80% In-Network / 60% Out-of-Network |
| Out-of-Pocket Expense Maximum | $2,000 In-Network / $4,000 Out-of-Network |
| Student Health Center Copay | $0 |
| Office Visit Copay | $25 In-Network / $50 Out-of-Network |
| Hospital Copay | $100 In-Network / $200 Out-of-Network |
| Emergency Room Copay** | $250 In-Network / $500 Out-of-Network |
| MRI/Cat Scan Copay | $100 In-Network / $200 Out-of-Network |
| Extension of Benefits | 30 days (up to $10,000) |
| Emergency Medical Reunion | (incl. hotel/meals, max $100/day) $2,500 |
| Emergency Medical Evacuation | $100,000 |
| Repatriation/Return of Mortal Remains | $100,000 |
| Team Assist Plan (TAP): 24/7 medical, travel, technical assistance | |
| **The Emergency Room Copay will be waived if the Insured Person is admitted to the Hospital as an inpatient or if the illness is life threatening. Life threatening means the illness will likely cause the death of the Insured Person. | |
Please contact the Team Assist line by phone at (877) 714-8179 (toll free) or email mail@oncallinternational.com. The Team Assist Emergency Assistance Provider is On Call International.
Non-Emergency questions may be directed to CISI at 203-399-5130 (toll free 800-303-8120).
To locate an In-Network provider near you, use the Aetna Preferred Provider Network website: https://www.culturalinsurance.com/aetna-provider-search
All content copyright © Cultural Insurance Services International (CISI) | 1 High Ridge Park | Stamford, CT 06905 | USA
