Benefit Schedule

Three tiers of coinsurance apply: 100% outside the U.S. , 80% in network in the U.S. , 60% out of network inside the U.S. All plan options have an Unlimited Lifetime Maximum and a $250,000 maximum benefit for emergency medical evacuation.

Features Outside U.S. U.S.(In Network) U.S.(Outside Network)
Lifetime Maximum per Insured Person Unlimited Unlimited Unlimited
Annual Maximum per Insured Person Unlimited Unlimited Unlimited
Preventative and Primary Care Insurer waives deductible
Preventative Care For Babies/Children: (Birth to Age 18)
  1. Office Visits/examination
  2. Immunizations, Lab work & X-rays
100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Preventative Care For Adults: (Age 19 and Older)
  1. Routine Pap Smears, annual mammogram
  2. PSA For Men
  3. Annual Physical Examination/Health Screening
  4. Diagnostic lab work & X-rays
100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Primary Care Office Visits All except a $10 copay per visit 1 All except a $30 copay per visit 60% to Coinsurance Maximum then 100%
Professional Services Insurer Pays After Deductible is Met
Surgery, anesthesia, radiation therapy, in-hospital doctor visits, diagnostic X-ray and lab work. 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Inpatient Hospital Services Insurer Pays After Deductible is Met
Surgery, X-rays, in-hospital doctor visits, Organ/Tissue Transplant 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
In-patient medical emergency 6 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
In-patient drugs 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Ambulatory and Therapeutic Services Insurer Pays After Deductible is Met; Unless Noted
Ambulatory Surgical Center 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Ambulance Service 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Accidental Dental $1,000 per year, $200 per tooth $1,000 per year, $200 per tooth $1,000 per year, $200 per tooth
Acupuncture and Chiropractic Services 100% up to $2000 80% up to $2000 60% up to $2000
Durable Medical Equipment 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Infusion Therapy 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Physical/Occupational Therapy
deductible is waived
$50 limit per visit, 12 visits per year $50 limit per visit, 12 visits per year $50 limit per visit, 12 visits per year
Rehabilitation and Therapy Insurer Pays After Deductible is Met
a. Inpatient Mental Health
100% up to 60 days 80% up to 60 days 60% up to 60 days
b. Outpatient Mental Health
75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter
c. Inpatient Substance Abuse
100% up to 60 days detox 80% up to 60 days detox 60% up to 60 days detox
d. Outpatient Substance Abuse
75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter
Prescription Drug Benefit Options Insurer Waives Deductible
Basic Prescription Drug Benefits 100% of actual charges up to $1,000 Generics: 100% after $10 copay
Brandname: 100% after $25 copay
Injectables: 70%
Generics: 100% after $10 copay
Brandname: 100% after $25 copay
Injectables: 70%
Optional Rider, subject to $25,000 maximum benefit per Insured Person per Policy Period. 100% of actual charges Generics: 100% after $10 copay
Brandname: 100% after $25 copay
Injectables: 70%
Generics: 100% after $10 copay
Brandname: 100% after $25 copay
Injectables: 70%
Global Travel Benefits Insurer Waives Deductible
Medical Evacuation Up to $250,000 n/a n/a
Repatriation of Remains Up to $25,000 n/a n/a
Accidental Death and Dismemberment $50,000 $50,000 $50,000
 
Plan Options
1,2,3,4,5,6
Deductible Coinsurance Maximum
Outside U.S. U.S.in Network U.S.out of Network
Elite $0 $0 $1,000 $2,000
1,000 $500 $1,000 $2,000 $4,000
2,000 $1,000 $2,000 $4,000 $8,000
5,000 $2,500 $5,000 $10,000 $10,000

1. Copay waived when visiting a contracted provider outside the U.S..
2. Deductibles are Per Person per Calendar Year.
3. The Out of Pocket Maximum is calculated by adding the deductible and coinsurance maximum together. A family is charged a maximum of 2.5 deductibles.
4. Amounts paid to satisfy a deductible are credited to all other deductibles, both inside and outside the U.S. For example, if you satisfy your Outside U.S. deductible, this amount is credited to the U.S. (In Network) and U.S. (Outside Network) deductible requirement.
5. An Insured Person only has to satisfy his/her Out of Pocket Maximum once a Year for all services received outside of the U.S. and in the U.S.
6. Emergency room visits that do not result in inpatient admissions will be subject to a $50 penalty

 
Other Benefits Limits
Skilled Nursing Facilities 100% with a maximum Covered Expense of $250 per day, as many as 50 days per year
Hospice 100% with a maximum Covered Expense of $5,000 per lifetime

Services provided in addition to the benefits above

 Ready access to quality care

  • Access to our global community of carefully selected, contracted hospitals, physicians, dentists and behavioral health professionals in over 180 countries.
  • Detailed provider profiles including medical training.
  • Personalized appointment scheduling and recruitment.
  • Fully profiled international treatment options.
  • Competitive U.S. PPO network and centers of excellence.
  • Emergency evacuation.
  • View More Details

 mPassport and Global Health and Safety Resources

  • Online and mobile assistance tools with full telephone support.
  • Daily email of health and security alerts
  • Detailed descriptions of health facilities and security issues by destination
  • Translation databases for brand name drugs and medical terms/phrases.
  • Web pages capturing key personalized Resources by destination.
  • View More Details

For Exclusions and Limitations see Plan Description.

Ten Day Money Back Guarantee
YOUR SATISFACTION IS GUARANTEED. We are so confident in our products that we offer the best guarantee in the business! If you are not completely satisfied with our product, simply return your Certificate or Policy of Insurance and Description of Emergency Medical Evacuation and Other Services within 10 days of receipt and include a letter indicating your desire to cancel. If you have not already left on your trip or incurred a claim, you will receive a full refund.