Benefit Description
Subject to deductible and coinsurance unless otherwise noted | Silver | Gold | Platinum |
| Coverage Area | Two options: worldwide or worldwide excluding the U.S. and Canada | Two options: worldwide or worldwide excluding the U.S. and Canada | Two options: worldwide or worldwide excluding the U.S. and Canada |
| Policy Maximum | $5,000,000
lifetime per individual | $5,000,000
lifetime per individual | $8,000,000
lifetime per individual |
| Deductible | Ranges from $250 to $10,000 per period of coverage, 50% reduction within PPO | Ranges from $250 to $10,000 per period of coverage, 50% reduction within PPO, Carry forward deductible - last 30 days of certificate year | Ranges from $100 to $10,000 per period of coverage, 50% reduction within PPO, Carry forward deductible - last 30 days of certificate year |
| Family Deductible | Three times the individual deductible | Three times the individual deductible | Two times the individual deductible |
| Coinsurance within the U.S. and Canada | 80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage | 80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage | 90% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum per period of coverage |
| Coinsurance within the PPO network and outside the U.S. and Canada | 100% | 100% | 100% |
| Hospitalization / Room & Board | $600 per day (maximum of 240 consecutive days per covered event) | Average semi-private room rate | Private room rate |
| Intensive Care Unit | $1,500 per day (maximum of 180 consecutive days per covered event) | Usual, Reasonable and Customary (URC) | Usual, Reasonable and Customary (URC) |
| Surgery | URC | URC | URC |
| Anesthetist's Charges Associated with Surgery | 20% of surgery benefit | URC | URC |
| Transplants | $250,000
per transplant | $1,000,000
lifetime maximum | $2,000,000
lifetime maximum |
| Outpatient | Visits/Exams - 25 visits per insured person per period of coverage to the maximum limit as outlined: physician $70; specialist $70; psychiatrist $60; chiropractor $50; surgical intervention consultation $500; X-rays - $250 per exam maximum limit; Lab Tests - $300 per exam maximum limit | URC | URC |
| Rx Coverage | URC | URC | Prescription drug card - Copay: $20 for generic / $40 for brand name when a generic is not available |
| Emergency Room Illness | URC -
subject to an additional $250 deductible if not admitted | URC -
subject to an additional $250 deductible if not admitted | URC -
subject to an additional $250 deductible if not admitted |
| Emergency Room Accident | URC | URC | URC |
| Local Ambulance | $1,500
per covered event - not subject to deductible or coinsurance | URC | URC |
| Emergency Evacuation | $50,000
per period of coverage - not subject to deductible or coinsurance | Limited to policy maximum - not subject to deductible or coinsurance | Limited to policy maximum - not subject to deductible or coinsurance |
| Emergency Reunion | NA
(Not Applicable) | $10,000
lifetime maximum | $10,000
lifetime maximum |
| Return of Mortal Remains | $25,000
lifetime maximum per insured - not subject to deductible or coinsurance | $25,000
lifetime maximum per insured -not subject to deductible or coinsurance | $50,000
lifetime maximum per insured -not subject to deductible or coinsurance |
| Maternity | Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section, $200 child wellness benefit for first 12 months - not subject to deductible or coinsurance. Available after 10 months of coverage benefits reduced by 50% for births that occur in11th or 12th month of continuous coverage | Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section, $200 child wellness benefit for first 12 months - not subject to deductible or coinsurance. Available after 10 months of coverage benefits reduced by 50% for births that occur in11th or 12th month of continuous coverage | Same As Any Illness (SAAI) $1,000 additional deductible, $50,000 lifetime maximum, $200 child wellness benefit for first 12 months. Available after 10 months of coverage |
| Supplemental Accident | NA | $300
per occurrence - not subject to deductible or coinsurance | $500
per occurrence - not subject to deductible or coinsurance |
| Mental/Nervous | Outpatient only - (see Outpatient) Available after 12 months of continuous coverage | $10,000
per period of coverage up to a $50,000 lifetime maximum. Available after 12 months of continuous coverage | SAAI
$50,000 lifetime maximum. Available after 12 months of continuous coverage |
| Adult Wellness | NA | $250 per period of coverage - not subject to deductible or coinsurance Available for those 30 years of age and over after 12 months of continuous coverage | $500 per period of coverage - not subject to deductible or coinsurance Available for those 18 years of age and over after 12 months of continuous coverage |
| Child Wellness | Three visits per period of coverage -maximum $70 per visit. Available for children under 18 years of age after 12 months of continuous coverage | $200 maximum per period of coverage -not subject to deductible or coinsurance Available for children under 18 years of age after 12 months of continuous coverage | $400 maximum per period of coverage - not subject to deductible or coinsurance Available for children under 18 years of age after 12 months of continuous coverage |
| Other Services | Extended Care - limited to first 30 days of confinement
Radiation Treatment - URC
Home Nursing Care - limited 30 days per covered event
Hospice Care - limited 30 days per covered event
Prosthetic Devices - all URC | URC | URC |
| Physical Therapy | Maximum $40 per visit 30 visit maximum per period of coverage | Maximum $50 per visit | Maximum $50 per visit |
| High School Sports Injury | NA | NA | Up to $20,000 per certificate period |
| Recreational SCUBA | NA | URC | URC |
| Remote Transportation | NA | NA | Limited to $5,000 per certificate period up to a $20,000 lifetime maximum |
| Political Evacuation and Repatriation | NA | NA | Limited to $10,000 lifetime maximum |
| Complementary Medicine | NA | Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period of coverage | Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period of coverage |
| Non-emergency Dental | NA | NA | Calendar year maximum - $750
Individual deductible - $50
Schedule of benefits -
Class I: 90% Class II: 70%
Class III: 50% Ortho 0%
(6 month waiting period) |
Emergency Dental due to Accident | $1,000 per period of coverage | URC | URC |
| Emergency Dental due to Sudden Unexpected Pain | NA | $100 per period of coverage | See non-emergency dental benefits |
| Vision | NA | NA | Exams - up to $100 per 24 months
Materials - up to $150 per 24 months |
| Global Concierge & Assistance Services | NA | NA | Included |
| Pre-existing Conditions | $5,000 per period of coverage up to a $50,000 lifetime maximum. Available after 24 months of continuous coverage | $5,000 per period of coverage up to a $50,000 lifetime maximum. Available after 24 months of continuous coverage | SAAI |
NA (Not Applicable) / URC (Usual, Reasonable and Customary) / SAAI (Same As Any Illness) |
