Benefits 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. | In Network, U.S. | Out of Network, U.S. |
|---|---|---|---|
| Lifetime Maximum per Insured Person | Unlimited | Unlimited | Unlimited |
| Annual Maximum per Insured Person | Unlimited | Unlimited | Unlimited |
| Preventative and Primary Care | Insurer waives deductible | ||
| Primary Care Office Visits - as many as 8 visits per Calendar Year | All except a $10 copay per visit 1 | All except a $30 copay per visit | 60% to Coinsurance Maximum then 100% |
Preventative Care for Babies/Children: (Birth to Age 18)
|
100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
Preventative Care For Adults: (Age 19 and Older)
|
100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Travel Vaccinations | 100% Maximum Covered Expense of $500 per Calendar Year. | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Annual Physical Examination/Health Screening | 100% Maximum Covered Expense of $250 and limited to one per Calendar Year. |
80% to Coinsurance Maximum then 100% Maximum Covered Expense of $250 and limited to one per Calendar Year. |
60% to Coinsurance Maximum then 100% Maximum Covered Expense of $250 and limited to one per Calendar Year. |
| Outpatient Services | Insurer Pays After Deductible is Met | ||
| Outpatient Medical Care | 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 | The Insurer will pay 100% of Covered Expenses. | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| In-patient medical emergency | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Professional Services 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% |
| Other 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% |
| Physical/Occupational Therapy/Medicine | Deductible is waived. Covered Expenses up to $50 per visit, and as many as 6 visits per Calendar Year | ||
| Ambulance Service | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Durable Medical Equipment | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Rehabilitation and Therapy | Insurer Pays After Deductible is Met, unless noted | ||
| 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 |
| Outpatient prescription drugs | Insurer waives deductible 100% of actual charge up to an annual maximum of $5,000. Max 90-day supply |
||
| Dental Care required due to an Injury | 100% of Covered Expenses up to $500 per Calendar Year maximum | ||
| Global Travel Benefits | Insurer Waives Deductible | ||
| Medical Evacuation | Maximum Lifetime Benefit for all Evacuations up to $250,000 | ||
| Repatriation of Remains | Maximum Benefit up to $25,000 | ||
| Accidental Death and Dismemberment | Maximum Benefit: Principal Sum up to $10,000 | ||
DEDUCTIBLE OPTIONS
| Plan Options 1,2,3,4,5 | Deductible | Coinsurance Maximum | ||
|---|---|---|---|---|
| Outside U.S. | U.S.in Network | U.S. out of Network | ||
| 0 | $0 | $0 | $0 | $1,000 |
| 250 | $125 | $250 | $500 | $2,000 |
| 500 | $500 | $500 | $500 | $3,000 |
| 1,000 | $500 | $1,000 | $2,000 | $4,000 |
| 2,500 | $1,250 | $2,500 | $5,000 | $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 $100 penalty
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