Coinsurance?
Restrictions| Benefits | Coverage |
| Hospital Room and Board | Average semi-private room rate, including nursing services |
| Intensive Care Unit | Up to the overall maximum limit. |
| Emergency Room Co-Payment |
Claims incurred in the 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. Claims incurred outside the U.S. - No co-payment |
| Urgent Care Center Co-Payment |
Claims incurred in the U.S. - For each visit, you shall be responsible for a $15 co-payment. Co-payment is waived for members with a $0 deductible. Not subject to deductible. Claims incurred outside the U.S. - No co-payment. |
| Coinsurance |
Inside the United States - In ppo network: Plan pays 100% of eligible expenses, after the deductible, to the overall maximum limit. Out of ppo network: Usual, reasonable, and customary. You may be responsible for any charges exceeding the payable amount. Outside the United States -Plan pays 100% of eligible expenses after the deductible up to the overall maximum limit. |
| Emergency Dental (acute onset of pain) | Up to $300. Not subject to deductible. |
| Hospital Indemnity | $100 per day of inpatient hospitalization. Not subject to deductible. |
| *Acute Onset of Pre-existing Condition (only available to members under age 80) | Under age 70: Covers up to overall maximum limit. Age 70 to 79: Covers up to overall maximum limit or $100,000, whichever is lower. (excludes chronic and congenital conditions) |
| Acute onset of pre-existing condition emergency medical evacuation | Covers up to $25,000 lifetime maximum (excludes chronic and congenital conditions). |
| Emergency Medical Evacuation | Up to $1,000,000 lifetime maximum, except as provided under *Acute Onset of Pre-existing Condition. Not subject to deductible or overall maximum limit. |
| Repatriation of Remains | Up to the overall maximum limit. |
| Local Burial or Cremation | Up to $5,000 lifetime maximum. |
| Local Ambulance | Usual, reasonable, and customary charges when covered illness or injury results in hospitalization as inpatient |
| Terrorism | Up to $50,000 lifetime maximum, eligible medical expenses only. |
| Accidental Death and Dismemberment (AD&D) (Excludes loss due to common carrier accident) |
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| Common Carrier Accidental Death |
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| Trip Interruption | Up to $15,000. Not subject to deductible. |
| Lost Checked Luggage | Up to $2,000. Not subject to deductible. |
| Travel Delay | Up to $200 a day after a 12-hour delay period requiring an unplanned overnight stay. Subject to a maximum of 2 days. Not subject to deductible. |
| Emergency Reunion | Up to $150,000, subject to a maximum of 15 days. Not subject to deductible. |
| Outpatient Physical Therapy and Chiropractic Care | Up to $50 maximum per day. Must be ordered in advance by a physician. (not subject to coinsurance) |
| Crisis Response - Ransom, Personal Belongings, Crisis Response Fees and Expenses, and Natural Disaster Evacuation | Up to $100,000 per certificate period, with $10,000 maximum for Natural Disaster Evacuation. Not subject to deductible or overall maximum limit. |
| Bedside Visit | Up to $1,500. Not subject to deductible. |
| Return of Minor Children | Up to $50,000. Not subject to deductible. |
| Pet Return | Up to $1,000. Not subject to deductible. |
| Political Evacuation | Up to $150,000 lifetime maximum. Not subject to deductible. |
| Natural Disaster – Replacement Accommodations | Up to $500 a day for 5 days. Not subject to deductible. |
| Personal Liability |
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| Border Entry Protection | Up to $500 if traveling on a valid B-2 visa and denied entrance at the U.S. border. Not subject to deductible. |
