| Benefits |
Outside the U.S.
|
In Network, U.S.
|
Out-of-Network, U.S.
|
|
Preventative and Primary Care - Deductible is not applicable
|
|
Primary Care Office Visits - as many as 4 visits per Calendar Year
|
All except a $10 copay per visit |
All except a $30 copay per visit |
60% to Coinsurance Maximum then 100% |
Preventative Care for Babies/Children: (Birth to Age 18)
- Office Visits/examination
- Immunizations, Lab work & X-rays
|
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
Preventative Care For Adults: (Age 19 and Older)
- Routine Pap Smears, annual mammogram
- PSA For Men
|
100% |
80% to Coinsurance Maximum then 100% |
80% to Coinsurance Maximum then 100% |
| Annual Physical Examination/Health Screening |
100%
Maximum Covered Expense of $250 and limited to one per Calendar Year. |
80% to Coinsurance Maximum then 100%
Maximum Covered Expense of $250 and limited to one per Calendar Year.
|
60% to Coinsurance Maximum then 100%
Maximum Covered Expense of $250 and limited to one per Calendar Year.
|
|
Outpatient Services - Insurer pays after the Deductible is Met
|
|
Outpatient Medical Care |
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
|
Inpatient Hospital Services - Insurer pays after the Deductible is Met
|
| Surgery, X-rays, In-hospital doctor visits, Organ/Tissue Transplant |
The Insurer will pay 100% of Covered Expenses. |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
| In-patient medical emergency |
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
Professional Services
Surgery, anesthesia, radiation therapy, in-hospital doctor visits, diagnostic X-ray and lab work |
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
| Other Services - Insurer pays after the Deductible is Met, unless noted
|
| Ambulatory Surgical Center |
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
| Physical/Occupational
Therapy/Medicine
|
Deductible is waived. Covered Expenses up to $50 per visit, and as many as 6 visits per Calendar Year |
| Ambulance Service |
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
| Durable Medical Equipment |
100% |
80% to Coinsurance Maximum then 100% |
80% to Coinsurance Maximum then 100% |
| Mental, Emotional or Functional Nervous Disorders, Alcoholism or Drug Abuse |
|
|
a. Mental, Emotional or Functional Nervous Disorders - Inpatient: Up to 20 days of inpatient confinement per Calendar Year
|
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
|
b. Mental, Emotional or Functional Nervous Disorders - Outpatient: First 10 visits per Calendar Year
|
50% |
50% |
50% |
|
c. Alcoholism or Drug Abuse - Inpatient in a Hospital, Non-hospital Residential Treatment Center or Day Care Center Up to 10 days per Calendar Year
|
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
|
c. Alcoholism or Drug Abuse - Outpatient: Up to 10 visits per Calendar Year
|
100% |
80% to Coinsurance Maximum then 100% |
60% to Coinsurance Maximum then 100% |
| Outpatient prescription drugs |
100% of actual charge up to an annual maximum of $1,000.
Maximum 90 - day supply |
| Dental Care required due to an Injury |
100% of Covered Expenses up to $500 per Calendar Year maximum |
| Accidental Death and Dismemberment |
Maximum Benefit: Principal Sum up to $10,000 |
| Repatriation of Remains |
Maximum Benefit up to $25,000 |
| Medical Evacuation |
Maximum Lifetime Benefit for all Evacuations up to $250,000 |
