Cruise Line International Insurance

• Non-emergency services only

The Medical Concierge Service is a proprietary service of IMG that helps an insured person navigate the United States healthcare system to identify the highest quality providers for scheduled inpatient and certain outpatient treatments.

Refer to the MEDICAL CONCIERGE provision for further details.

• Maximum 3 deductibles per family

• In addition to deductible

• Transplants: No coverage if precertification requirements are not met.
• Interfacility Ambulance Transfer: No coverage if precertification requirements are not met.
• Emergency Medical Evacuation: No coverage if precertification requirements are not met. Refer to the EMERGENCY MEDICAL EVACUATION provision for further details and requirements.
• Maternity and Newborn Care: 50% reduction of eligible medical expenses if precertification requirements are not met.
• All other Treatments & Supplies: 50% reduction of eligible medical expenses if precertification requirements are not met.
• Deductible is taken after reduction.
• Coinsurance is applied to remainder of the reduced amount.
• Refer to PRECERTIFICATION REQUIREMENTS provision for a complete list of services that require precertification.

• Injury: Not subject to emergency room deductible
• Illness: Subject to a $250 deductible for each emergency room visit for treatment that does not result in a direct hospital admission

• Average semi-private room rate
• Includes nursing, miscellaneous and ancillary services

• Payable at 100% if requested by the Company
• 50% reduction of eligible medical expenses for failure to obtain a second surgical opinion when required by the Company

• Surgery is incidental to and follows surgery that was covered under the plan

• 20% of the primary surgeon’s eligible fee

• After 10 months of continuous coverage
• Result of natural insemination

• After 10 months of continuous coverage

•  Eligible if pregnancy is covered under the plan

• Maximum Limit: $750

• Maximum limit per visit: $75
• Maximum visits: 20
• Medical order or treatment plan required
• Not subject to deductible

• Maximum limit per outpatient visit: $75
• Medical order or treatment plan required
• Inpatient physical therapy is not subject to the visit maximum

• Upon direct transfer from acute care facility

• Provided by a home health care agency
• Upon direct transfer from an acute care facility

• Lifetime maximum: $1,000,000
• Per period of coverage transplant maximum limit: 1
• Organ procurement & harvesting costs lifetime maximum: $10,000
• Travel & lodging lifetime maximum expense: $5,000
• Covered transplants: cornea, heart, heart/lung, lung, kidney, kidney/pancreas, liver, allogeneic or autologous bone marrow
• Subject to the TRANSPLANT PRECERTIFICATION provision and only when treatment is provided within the Company’s approved independent Managed Transplant System Network

• Maximum limit: $500
• Refer to the PREVENTATIVE CARE provision for further details and requirements

• Not subject to Deductible and Coinsurance
• Copayments are per 30-day supply
• Dispensing Maximum per prescription: 90 days
• Prescriptions $3,000 and higher will require Universal RX (URX) to obtain prior authorization from the Company

Universal RX (URX) prescription drug card MUST be utilized for all outpatient prescription drugs in the United States.

Retail Pharmacy Copayments:
Generic: $5
Higher cost generic and brand: $15
Non-preferred brand name: $30

• Subject to deductible and coinsurance
• Dispensing maximum per prescription: 90 days

• Copayments are per 30-day supply
• Dispensing maximum per prescription: 180 days
• Prescriptions $3,000 and higher will require Universal RX (URX) to obtain prior authorization from the company

• Enroll via the provider’s website: www.expatps.com
• Prescription submission:
  • Email (scan prescription): epsmanager@universalrx.com Fax: +1.540.777.7184

• Phone number: +1.540.777.1450
• Email: epsmanager@universalrx.com

• After 12 months of continuous coverage
• Maximum limit: $10,000

• After 12 months of continuous coverage
• Maximum limit per visit: $100
• Maximum visits: 52

• Subject to deductible and coinsurance
• Injury
• Illness resulting in an inpatient hospital admission

• Maximum limit as indicated on the declaration
• Insured persons under 65 years of age
• Approved in advance and coordinated by the company

• Transfer from one licensed health care facility to another licensed health care Facility resulting in an inpatient hospital admission

• Maximum limit: $25,000
• Local burial/Cremation maximum limit: $10,000
• Return of insured person’s mortal remains to home country
• Approved in advance by the Company

• Subject to deductible and coinsurance
• Accident related

• Up to the maximum limit
• Subject to deductible and coinsurance
• Treatment at a hospital facility due to an accident
• Additional treatment for the same injury rendered by a dental provider will be paid at 100%

• International only
• Inpatient hospitalization only
• Benefit is not available when the inpatient hospital treatment is part of the Medical Travel Management benefit

• Overnight maximum limit: $100
• Calendar year maximum limit: $2,000

• Overnight maximum limit: $400
• Calendar year maximum limit: $8,000

Treatment received by the insured person at a public hospital and no charges are incurred by the insured person or the company will be subject to the public hospital maximum limit.

Treatment received by the insured person at a public hospital and charges are submitted to the company for reimbursement will be subject to the private hospital maximum limit.

• Coverage for a consultation is not a determination that any specific condition discussed, raised, or identified during such consultation is covered under this insurance. The company reserves the right to decline future claims relating to or arising from any condition discussed, raised or identified during a consultation where the illness or injury is directly or indirectly related to any pre-existing condition or is otherwise excluded under this Certificate of Insurance

• Must be approved in advance by the company

• Medically necessary non-emergency treatment, including hospitalization and surgery for approved procedures, the company will offer medical travel as a means to manage the costs.
• If medical travel is approved, the company will reimburse 10% of the cost savings, up to a maximum of $7,500 back to the insured person where such savings arise from treatment outside of their host country and excluding the United States.
• Meal allowance maximum: $100
• Refer to the MEDICAL TRAVEL MANAGEMENT provision for further details and requirements.

• Applies to minor restorative, major restorative, and orthodontia services

• Maximum 3 deductibles per family

• Maximum visits per calendar year: 2
• Maximum visits: 1 every 6 months
• Radiographic examinations (including posterior bitewings): 1 every 6 months
• Fluoride treatment: once per calendar year for children under age 19

• Maximum limit: 1 every 3 years
• Full mouth x-rays including panographic x-rays

• Root planning: 1 every 2 years
• Periodontal surgery: 1 every 3 years

• Crowns, jackets, inlays on same tooth: 1 every 5 years
• Limitations for children under age 12

• Dentures/bridges: 1 every 5 years
• Replacement of denture base material or reline limit: 1 every 3 years

• Children under age 19