| Coverage Area | Worldwide |
| Maximum Lifetime Benefit Per Person | $5,000,000 (Standard) |
| Deductible (Calendar Year) | $100 - $25,000 |
| The deductible is reduced 50% when using the U.S. independent Preferred Provider Organization (provided through The First Health Network) |
| Family Deductible (Calendar Year) | Maximum of three (3) deductibles per family |
| Deductible Carry Forward |
| Expenses incurred during the last 3 months of a calendar year will be applied toward satisfaction of the deductible for the next calendar year, but only if the deductible was not met during the prior calendar year |
| Coinsurance Percentages |
| Medical expenses incurred outside the U.S., Canada, or Puerto Rico | Plan pays 100% of eligible charges after deductible | | Medical expenses incurred in the U.S. using the PPO | Plan pays 100% of eligible charges after deductible | | Medical expenses incurred in the U.S., Canada, or Puerto Rico outside the PPO | Plan pays 80% up to $2,500 of eligible charges after deductible; thereafter the plan pays 100% of eligible charges | |
| Physician Office Services |
| Adult Wellness Benefit | Plan pays up to $500 per calendar year | | Child Wellness Benefit | Plan pays up to $500 per calendar year | | Illness or Accident Benefit | Subject to deductible and applicable coinsurance | |
| Hospital Services | Subject to deductible and applicable coinsurance |
| Eligible Medical Expenses |
| Local Ambulance | Subject to deductible and coinsurance for emergency local transport deemed medically necessary |
| Subject to deductible and applicable coinsurance |
| Emergency Medical Evacuation | Up to the lifetime maximum benefit per person |
| Emergency Reunion | $10,000 per insured person (return to home country) |
| Return of Mortal Remains | $10,000 per insured person (return to home country) |
| Maternity Coverage | Covered as any other illness Subject to deductible & coinsurance per person |
| Pre-natal care; delivery of newborn; post-natal care Newborn baby care. Routine care for first 31 days of life |
| Human Organ Covered Transplants | $5,000,000 lifetime maximum inside transplant network facilities per person |
| Durable Medical Equipment | $10,000 (lifetime maximum benefit) |
| Home Health Care & Extended Care Facility | URC up to a maximum of 90 days coverage |
| Chiropractic Care | $30 per visit, maximum of $1,000 per calendar year |
| Physical Therapy | $50 maximum benefit per visit |
| Prescription Drugs - Mail order and retail pharmacies | Usual, reasonable, and customary charges |
| Supplemental Accident | $300 benefit per accident, deductible and coinsurance thereafter |
| Vision Benefit |
| Exams | Plan pays up to $100 per 24 months | | Materials (frames, lenses, contacts) | Plan pays up to $150 per 24 months | |
| Mental/Nervous, Alcohol & Substance Abuse Treatment |
Inpatient - Maximum of 30 days confinement
Outpatient - payable at 50% after deductible
Inpatient and outpatient - $25,000 lifetime maximum |
| Family Counseling | $500 lifetime maximum |
| Bereavement Counseling | $100 benefit per person within 6 months of the covered insured person's death |
| Pre-Admission Certification | Failure to pre-certify maternity, admissions, and surgeries could reduce benefits |
| Complementary Medicine Benefits | Failure to pre-certify maternity, admissions, and surgeries could reduce benefits |
| Acupuncture - $150; Aroma Therapy - $50; Herbal Therapy - $50; Magnetic Therapy - $75; Massage Therapy - $150; Vitamin Therapy - $100 |
| Hospice Care | Up to the lifetime maximum limit |