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| Medical Maximum Options (per person per disablement) |
Ages 14 days to 64 years
$50,000; $100,000; $250,000; $500,000; $1,000,000 |
Ages 14 days to 64 years
$50,000; $100,000; $250,000; $500,000; $1,000,000 |
Ages 14 days to 64 years
$50,000; $100,000; $250,000; $500,000; $1,000,000 |
| Hospital room and board |
| Usual, Reasonable and Customary to the medical maximum. |
Usual, Reasonable and Customary to the medical maximum. |
Usual, Reasonable and Customary to the medical maximum. |
| Prescription Drugs |
Inside the U.S - $10 copay for generic/$20 copay for brand name (not subject to the deductible)
Outside the U.S - $0 copay (deductible applies) |
Inside the U.S - $5 copay for generic/$10 copay for brand name (not subject to the deductible)
Outside the U.S - $0 copay (deductible applies) |
Inside the U.S - $10 copay for generic/$20 copay for brand name (not subject to the deductible)
Outside the U.S - $0 copay (deductible applies) |
| Vaccinations (in the U.S. only as required by school, university or visa program) |
| $100 per 364 days of continuous coverage |
$150 per 364 days of continuous coverage |
$200 per 364 days of continuous coverage |
| Physical Therapy |
| $25 per day to a max of 60 days |
$50 per day to a max of 60 days |
$75 per day to a max of 60 days |
|
Spinal Manipulation |
| $25 per day to a max of 60 days (if prescribed by a physician for pain relief) |
$50 per day to a max of 60 days (if prescribed by a physician for pain relief) |
$75 per day to a max of 60 days (if prescribed by a physician for pain relief) |
| Local Ambulance Benefit |
Inside the U.S - $350 per disablement (injury/illness)
Outside the U.S - Up to medical maximum |
Inside the U.S - $500 per disablement (injury/illness)
Outside the U.S - Up to medical maximum |
Inside the U.S - $750 per disablement (injury/illness)
Outside the U.S - Up to medical maximum |
| Coma Benefit |
| $10,000 (separate from the medical maximum) |
$25,000 (separate from the medical maximum) |
$50,000 (separate from the medical maximum) |
| Extension of Benefits to Home Country |
| $1,000 |
$5,000 |
$10,000 |
Incidental Trips to Home Country
(for minimum purchases of 30 days) |
| $1,000 |
$5,000 |
$10,000 |
| Waiver of Pre-existing Conditions |
| After a waiting period of 364 days of continuous coverage, pre-existing conditions are covered as any other disablement. |
After a waiting period of 364 days of continuous coverage, pre-existing conditions are covered as any other disablement. |
After a waiting period of 364 days of continuous coverage, pre-existing conditions are covered as any other disablement. |
Acute Onset of a Pre-existing Condition
(during the initial 364 days of coverage) |
| Medical covered expenses up to $5,000 |
Medical covered expenses up to $10,000 |
Medical covered expenses up to $25,000 |
| Mental Illness including Alcohol & Substance Abuse |
| Inpatient: $5,000 (45 days max), Outpatient: 80% of URC to $500 |
Inpatient: $10,000 (45 days max), Outpatient: 80% of URC to $1,000 |
Inpatient: $20,000 (45 days max), Outpatient: $2,000 |
| Motor Vehicle Accident |
Inside the U.S - 50% up to $100,000
Outside the U.S - Up to medical maximum |
Inside the U.S - 75% up to $100,000
Outside the U.S - Up to medical maximum |
Inside the U.S - 100% up to $100,000
Outside the U.S - Up to medical maximum |
| Non-contact Amateur Sports |
| $2,500 |
$5,000 |
$10,000 |
Maternity Care
For a pregnancy to be covered, conception must occur 180 days after coverage begins. |
$500
Benefits reduced 25% for failure to notify us within the first 90 days of pregnancy |
- Inside the U.S
- In ppo network: 80% up to $10,000
- Out of ppo network: 60% up to $10,000
- Outside the U.S - 80% up to $10,000
Benefits reduced 25% for failure to notify us within the first 90 days of pregnancy
|
- Inside the U.S
- In ppo network: 80% up to $25,000
- Out of ppo network: 60% up to $25,000
- Outside the U.S - 100% up to $25,000
Benefits reduced 25% for failure to notify us within the first 90 days of pregnancy
|
| Routine Newborn Care |
| $250 per newborn child |
$500 per newborn child |
$750 per newborn child |
Dental - Sudden Relief of Pain
(for minimum purchases of 30 days) |
| $150 |
$250 |
$350 |
| Dental - Accident |
| $500 |
$1,000 |
$2,500 |
| Emergency Medical Evacuation & Repatriation |
| $100,000 (separate from the medical maximum) |
$500,000 (separate from the medical maximum) |
$750,000 (separate from the medical maximum) |
| Emergency Medical Reunion |
| Up to $200 per day/$15,000 maximum |
Up to $200 per day/$25,000 maximum |
Up to $200 per day/$50,000 maximum |
| Return of Child(ren) |
| $25,000 |
$40,000 |
$25,000 |
| Return of Mortal Remains |
| $50,000 |
$50,000 |
$50,000 |
| Local Burial or Cremation |
| $5,000 |
$5,000 |
$5,000 |
| Natural Disaster Evacuation |
| $5,000 |
$10,000 |
$10,000 |
| Natural Disaster Daily Benefit |
| $25 per day, 5-day limit |
$50 per day, 5-day limit |
$75 per day, 5-day limit |
| Political Evacuation & Repatriation |
| $10,000 |
$10,000 |
$10,000 |
| Felonious Assault |
| $10,000 (separate from the medical maximum) |
$15,000 (separate from the medical maximum) |
$20,000 (separate from the medical maximum) |
| Terrorism |
| $25,000 |
$50,000 |
$100,000 |
| Accidental Death and Dismemberment (AD&D) |
- $25,000 for primary participant
- $10,000 for plan participant spouse
- $5,000 for plan participant child
- Aggregate limit of $250,000 for total number of insureds on plan
|
- $25,000 for primary participant
- $10,000 for plan participant spouse
- $5,000 for plan participant child
- Aggregate limit of $250,000 for total number of insureds on plan
|
- $25,000 for primary participant
- $10,000 for plan participant spouse
- $5,000 for plan participant child
- Aggregate limit of $250,000 for total number of insureds on plan
|
| Personal liability |
| $25,000 |
$50,000 |
$100,000 |
| Hazardous Activities |
| Up to medical maximum |
Up to medical maximum |
Up to medical maximum |
GEOGRAPHIC RESTRICTIONS