| Hospital Room and Board
||Average semi-private room rate, including nursing services
| Local Ambulance
||Usual, reasonable, and customary charges when covered illness or injury results in hospitalization as inpatient
|Intensive Care Unit
||Up to the overall maximum limit.
|Emergency Room Co-payment – claims incurred in U.S.
||You shall be responsible for a $200 co-payment for each use of emergency room for an illness unless you are admitted to the hospital. There will be no co-payment for emergency room treatment of an injury.
|Urgent Care Center – claims incurred in U.S.
||For each visit, you shall be responsible for a $15 co-payment, after which coinsurance will apply.
- co-payment waived for members with a $0 deductible
- not subject to deductible
||Up to $50,000 lifetime maximum, eligible medical expenses only.
|Emergency Medical Evacuation
||Up to $500,000 lifetime maximum, not subject to deductible or coinsurance
|Repatriation of Remains
Up to $25,000 lifetime maximum, not subject to deductible or coinsurance
|Local Burial or Cremation
Up to $5,000 lifetime maximum, not subject to deductible or coinsurance