| Lifetime Maximum Limit |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | $5,000,000
lifetime per individual | $8,000,000
lifetime per individual | |
| Deductible (Per Period of Coverage) |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | $250 to $10,000 | $100 to $10,000 | |
| Treatment Outside the U.S. and Canada |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | Subject to Deductible
No coinsurance | |
| Treatment Inside the U.S. (Out-Patient/In-Patient Emergency) |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | PPO Network - Deductible 50% Waived (to a $2,500 Maximum). No coinsurance. | |
| Treatment Inside the U.S. (In-Patient Non-Emergency)) |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | Medical Concierge - deductible 50% waived (to a $2,500 maximum). No coinsurance.
PPO Network - subject to deductible. No coinsurance. | |
| Treatment inside the U.S.- Non-PPO Network and Canada |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | Subject to deductible.
Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage | Subject to deductible Plan pays 90% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage | |
| Hospitalization / Room & Board |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | In U.S./Canada - URC of average semi-private room rate. Outside of U.S./Canada - URC of private room rate (not to exceed 150% of semi-private room rate). All subject to $600 per day - 240 day max. | In U.S./Canada – URC of average semip-rivate room rate. Outside of U.S./ Canada - URC of private room rate (not to exceed 150% of semi-private room rate) | Up to a limit of $2,250 per day - semi-private room rate | In U.S./Canada – URC of average semiprivate room rate. Outside of U.S./ Canada - URC of private room rate (not to exceed 150% of semi-private room rate) | Private room rate | |
| Intensive Care Unit |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | $1,500 per day - 180 day per event | URC | Up to a limit of $4,500 per day | URC | URC | |
| Surgery |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | URC | URC | URC | URC | URC | |
| Anesthetist's Charges Associated with Surgery |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | 20% of surgery benefit | URC | 20% of surgery benefit | URC | URC | |
| Transplants |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | $250,000
per transplant | $1,000,000
lifetime maximum | $500,000
lifetime maximum | $1,000,000
lifetime maximum | $2,000,000
lifetime maximum | |
| Out-patient |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | 25 visits: $70 doctor/specialist; $60 psychiatrist; $50 chiropractor; $250 X-ray per exam maximum limit; $500 surgery intervention consultation; $300 lab tests per exam maximum limit | URC | Physician Charges - limit of $150 per visit; Hospital Charge - $100 co-pay unless admitted; Urgent Care Facility - $25 copay; Diagnostic Lab and X-Rays limited to $5,000 per certificate period | URC | URC | |
| Emergency Room Illness (Additional $250 deductible if not admitted) |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | URC | URC | URC | URC | URC | |
| Emergency Room Accident |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | URC | URC | URC | URC | URC | |
| Supplemental Accident |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | $300
per occurrence | $300
per occurrence | $300
per occurrence | $500
per occurrence | |
| Local Ambulance |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | $1,500
per covered event - not subject to deductible or coinsurance | URC | $100 per event - not subject to deductible or coinsurance | URC | URC | |
| Mental/Nervous |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | Outpatient only after 12 months of continuous coverage | $10,000 per period - $50,000 maximum - Available after 12 months of continuous coverage | $2,500 maximum per certificate period; In-patient limited to 25 days per certificate period; Out-patient limited to max of 20 visits per certificate period at 70% eligible expenses, up to $75 maximum per visit; Lifetime maximum of $30,000 | $10,000 per period - $50,000 maximum - Available after 12 months of continuous coverage | SAAI - $50,000 lifetime maximum - Available after 12 months of continuous coverage | |
| Amateur Sailboat Racing |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | URC | URC | URC | URC | URC | |
| Special Crew Member Return Benefit |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | Up to $2,500 per period of insurance - not subject to deductible or coinsurance | Up to $2,500 per period of insurance - not subject to deductible or coinsurance | Up to $2,500 per period of insurance - not subject to deductible or coinsurance | Up to $2,500 per period of insurance - not subject to deductible or coinsurance | Up to $2,500 per period of insurance - not subject to deductible or coinsurance | |
| Emergency Evacuation |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | $50,000
per period of coverage - not subject to deductible or coinsurance | Up to maximum limit - not subject to deductible or coinsurance | $250,000 limit per person per certificate period | Up to maximum limit - not subject to deductible or coinsurance | |
| Emergency Reunion |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | $10,000 lifetime maximum | |
| Return of Mortal Remains |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | $25,000
lifetime maximum per insured - not subject to deductible or coinsurance | $15,000
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 | |
| Remote Transportation |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | NA | NA | NA | Limited to $5,000 per certificate period up to a $20,000 lifetime maximum | |
| Political Evacuation and Repatriation |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | NA | NA | NA | Limited to $10,000 lifetime maximum | |
| Child Wellness (Under 18 years of age) |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | 3 visits per period of coverage - $70 maximum per period - Available after 12 months of continuous coverage | $200 maximum per period of coverage - not subject to deductible or coinsurance - Available after 12 months of continuous coverage | $400 maximum per period of coverage - not subject to deductible or coinsurance - Available after 6 months of continuous coverage | |
| Adult Wellness |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | 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 6 months of continuous coverage | |
| Rx Coverage |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | URC | URC | $5,000 per certificate period for each insured person, out-patient only | URC | Outside U.S. - URC. Inside U.S. - Rx drug card co-pay: $20 for generic / $40 for brand name where generic is not available (Certain monthly per prescription amount limits may apply and require pre-approval by the Company.) | |
| Other Services |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | Extended care: first 30 days; Radiation: URC; Home nursing: 30 days per covered event; Hospice: 30 days; Prosthetic Devices: all URC | URC | URC - Radiation & Chemotherapy treatments (in and out-patient) limited to $10,000 per year; $50,000 lifetime maximum | URC | URC | |
| Physical Therapy |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | Maximum $40 per visit - 30 visit maximum | Maximum $50 per visit | Maximum $50 per visit - $1,000 max per certificate period. $10,000 lifetime maximum | Maximum $50 per visit | Maximum $50 per visit | |
| Complementary Medicine |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | URC | Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period of coverage | |
| Recreational Scuba |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | URC | URC | URC | URC | |
| Non-emergency Dental |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | NA | NA | NA | Calendar year maximum - $750;
Individual deductible - $50
Schedule of benefits -
Class I: 90%; Class II: 70%;
Class III: 50%;
(6 month waiting period) | |
| Emergency Dental due to Accident |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | $1,000 per period of coverage | URC | $500 per period of coverage | URC | URC | |
| Emergency Dental due to Sudden Unexpected Pain |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | $100 per period of coverage | $100 per period of coverage | $100 per period of coverage | See non-emergency dental benefits | |
| High School Sports Injury |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | NA | NA | NA | Up to $20,000 per certificate period | |
| Vision |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | NA | NA | NA | NA | Exams - up to $100 Materials - up to $150 per 24 months | |
Maternity
Delivery, wellness, new born care & congenital disorders, Family Matters Maternity Program (*not subject to deductible or coinsurance - available after 10 months of coverage) |
| Silver | Gold
(1st 36 months of continuous coverage) | Gold
(Beginning the 1st day of the 37th month) | Gold Plus | Platinum | | Optional Rider* - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section - not subject to deductible or coinsurance, $200 child wellness benefit for the first 12 months, new born care & congenital disorders maximum of $250,000 for the first 31 days (Benefits reduced by 50% for births in that occur in the 11th or 12th month of continuous coverage) | SAAI - $1,000 additional deductible, $50,000 lifetime maximum, $200 child wellness benefit for the first 12 months, new born care & congenital disorders maximum of $250,000 for the first 31 days | |