|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.
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 $250. 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)
|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)
|Common Carrier Accidental Death||
|Trip Interruption||Up to $15,000. Not subject to deductible.|
|Lost Checked Luggage||Up to $1,000. 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.|
|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.|