Colorado School of Mines Visiting Students and Scholars

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World Class Coverage Designed for Colorado School of Mines Visiting Students and Scholars

Participant & Dependent rates
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.

TO SECURE COVERAGE SIGN UP HERE

Coverage Summary for Policy #CC000808


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


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