| Benefit Description
| Silver
| Gold
(1st 36 months of continuous coverage)
| Gold
(Beginning the 1st day of the 37th month)
| Gold Plus
| Platinum
|
| Lifetime Maximum Limit
| $5,000,000 lifetime per individual |
$5,000,000 lifetime per individual |
$5,000,000 lifetime per individual |
$5,000,000 lifetime per individual |
$8,000,000 lifetime per individual |
Deductible
(Per Period of Coverage)
| $250 to $10,000
50% waived within PPO network |
$250 to $10,000
50% waived within PPO network |
$250 to $10,000
50% waived within PPO network |
$250 to $10,000
50% waived within PPO network |
$100 to $10,000
50% waived within PPO network |
| Family Deductible
| Three times the individual deductible |
Three times the individual deductible |
Three times the individual deductible |
Three times the individual deductible |
Two times the individual deductible |
| Coinsurance within the PPO network
| No coinsurance |
No coinsurance |
No coinsurance |
No coinsurance |
No coinsurance |
| Coinsurance outside the U.S. and Canada
| No coinsurance |
No coinsurance |
No coinsurance |
No coinsurance |
No coinsurance |
| Coinsurance inside 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 |
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 |
| Hospitalization / Room & Board
| $600 per day - 240 day maximum |
Average semi-private room rate |
Up to a limit of $2,250 per day |
Average semi-private room rate |
Private room rate |
| Intensive Care Unit
| $1,500 per day - 180 day per event |
URC |
Up to a limit of $4,500 per day |
URC |
URC |
| Surgery
| URC |
URC |
URC |
URC |
URC |
| Anesthetist's Charges Associated with Surgery
| 20% of surgery benefit |
URC |
20% of surgery benefit |
URC |
URC |
| Transplants
| $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
| 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; Physiotherapy - up to $75 per visit, $1,000 max per certificate period $10,000 lifetime maximum |
URC |
URC |
Emergency Room Illness
(Additional $250 deductible if not admitted)
| URC |
URC |
URC |
URC |
URC |
| Emergency Room Accident
| URC |
URC |
URC |
URC |
URC |
| Supplemental Accident
| NA |
$300 per occurrence |
$300 per occurrence |
$300 per occurrence |
$500 per occurrence |
| Local Ambulance
| $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
| Outpatient only after 12 months |
$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 |
| Child Wellness
| 3 visits per period of coverage - $70 maximum per period - Available after 12 months
of continuous coverage |
$200 maximum per period of coverage - Available after 12 months of continuous coverage |
$200 maximum per period of coverage - Available after 12 months of continuous coverage |
$200 maximum per period of coverage - Available after 12 months of continuous coverage |
$400 maximum per period of coverage - Available after 6 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 |
$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 |
$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 |
| Emergency Evacuation
| $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 |
Up to maximum limit - not subject to deductible or coinsurance |
| Emergency Reunion
| NA |
$10,000 lifetime maximum |
$10,000 lifetime maximum |
$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 |
$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
| NA |
NA |
NA |
NA |
Limited to $5,000 per certificate period up to a $20,000 lifetime maximum |
| Political Evacuation and Repatriation
| NA |
NA |
NA |
NA |
Limited to $10,000 lifetime maximum |
| Rx Coverage
| 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 |
| Other Services
| 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
| Maximum $40 per visit - 30 visit maximum |
Maximum $50 per visit |
Maximum $50 per visit |
Maximum $50 per visit |
Maximum $50 per visit |
| 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 |
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 |
| Recreational SCUBA
| NA |
URC |
URC |
URC |
URC |
| Non-emergency Dental
| NA |
NA |
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 |
$500 per period |
URC |
URC |
| Emergency Dental due to Sudden Unexpected Pain
| 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
| NA |
NA |
NA |
NA |
Up to $20,000 per certificate period |
| Vision
| NA |
NA |
NA |
NA |
Exams - up to $100 Materials - up to $150 per 24 months |
| Global Concierge & Assistance Services
| NA |
NA |
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 |
$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 |
Maternity
Delivery, wellness, new born care &
congenital disorders
(not subject to deductible or
coinsurance - available after 10
months of coverage
| Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for
normal delivery, $7,500 for C-section, $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) |
Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for
normal delivery, $7,500 for C-section, $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) |
Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for
normal delivery, $7,500 for C-section, $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) |
Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for
normal delivery, $7,500 for C-section, $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 illness maximum of $250,000
for the first 31 days |
| NA (Not Applicable) / URC (Usual, Reasonable and Customary) / SAAI (Same As Any Illness) |