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)
|