| Lifetime Maximum Limit |
| $1 million/individual |
$1 million/individual |
$1 million/individual |
$1 million/individual |
| Deductible (Per Period of Coverage) |
| $250 to $10K |
$250 to $10K |
$250 to $10K |
$250 to $10K |
| Optional Coverage at additional cost |
| Global Term Life Insurance including Accidental Death & Dismemberment; Dental and Vision |
Global Term Life Insurance including Accidental Death & Dismemberment; Dental and Vision |
Global Term Life Insurance including Accidental Death & Dismemberment; Adventure Sports Rider; Dental and Vision |
Global Term Life Insurance including Accidental Death & Dismemberment; Terrorism; Adventure Sports Rider; |
| Treatment Outside the U.S. |
| 50% of deductible waived, up to a maximum of $2.5K. No coinsurance. |
| Treatment Inside the U.S. |
PPO Network: Subject to deductible. No coinsurance
Non-PPO Network: Subject to deductible. Plan pays 80% of the next $5K of eligible expenses, then 100% to the overall maximum limit. |
| Coinsurance |
| International - 100%; U.S. in-network - 100%; U.S out-of-network - 80% |
| Outpatient Treatments |
Diagnostic / X-Ray: $250 maximum per visit
Lab tests: $300 maximum per visit
Specialists / Physician charges: $500 maximum limit (pre-inpatient / post-inpatient) |
Diagnostic / X-Ray: $250 maximum per visit
Lab tests: $300 maximum per visit
Specialists / Physician charges: $70 per visit/examination (25 combined maximum visits)
Chiropractor charges: $50 per visit / examination
Surgery intervention consultation charges: $500 per consultation |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Mental/Nervous |
| Not Covered |
Outpatient after 12 months of continuous coverage |
$10K maximum. Avaliable after 12 months of continuous coverage |
$350 for treatment received in an emergency room |
| Hospital Emergency Room Injury |
| Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Hospital Emergency Room Illness |
| Covered only if admitted as inpatient |
Additional $250 deductible if not admitted as an inpatient |
Additional $250 deductible if not admitted as an inpatient |
Additional $250 deductible if not admitted as an inpatient |
| Hospital Room & Board |
| Subject to deductible and coinsurance for average semi-private room rate |
Subject to deductible and coinsurance for average semi-private room rate.All subject to $600 per day /240 day maximum |
Subject to deductible and coinsurance for average semi-private room rate |
Subject to deductible and coinsurance for average private room rate |
| Intensive care unit |
| Subject to deductible and coinsurance |
$1.5K limit per day - 180 days of coverage per event |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| CAT Scans, MRI, Echocardiography, Endoscopy, Gastroscopy, Cystoscopy |
Subject to deductible and coinsurance
$600 maximum limit per examination |
Subject to deductible and coinsurance
$600 maximum limit per examination |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Surgery |
| Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Assistant Surgeon |
| 20% of primary surgeon’s charge |
20% of primary surgeon’s charge |
20% of primary surgeon’s charge |
20% of primary surgeon’s charge |
| Chemotherapy or Radiation Therapy |
| Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Maternity |
| No Coverage |
No Coverage |
No Coverage |
$2.5K additional deductible per pregnancy.
$50K lifetime maximum.
$200 newborn preventative care benefit for the first 31 days -12 months after birth.
$250K maximum for newborn care & congenital disorders for the first 31 days after birth. |
| Podiatry Care |
| No Coverage |
No Coverage |
$750 per period of coverage |
$750 per period of coverage |
| Physical therapy |
| $40 maximum per visit - 10 visit limit per event. Available for 90 days following inpatient treatment or outpatient surgery |
$40 maximum per visit - 30 visit limit |
$50 maximum per visit |
$50 maximum per visit |
| Transplants |
| $250K lifetime maximum |
$250K lifetime maximum |
$1M lifetime maximum |
$2M lifetime maximum |
| Prescription Coverage |
Available for 90 days following related inpatient treatment or outpatient surgery.
$600 maximum limit per event(includes dressings and durable medical equipment) |
90-day supply per prescription following related covered event.U.S.
Retail Pharmacy out-of-network: 80%
International Retail Phamacy: 100% |
90-day supply per prescription.U.S. Retail Pharmacy out-of-network: 80%
International Retail Phamacy: 100% |
U.S. Retail Pharmacy: prescription drug card required.Co-pay per 30-day supply: $20 for generic / $40 for brand name where generic is not available.International Retail Pharmacy(subject to deductible): 100% |
| Expatriate Prescription Services Program |
| No Coverage |
No Coverage |
No Coverage |
Co-pay per 30-day supply: $20 for generic / $40 for non-preferred brand name.
Must enroll via provider website: www.expatps.comDispensing maximum: 180 days |
| Orphan or Biologic Drugs |
Inpatient Treatment maximum limit: $250K.
Outpatient Surgery: up to the maximum limit.
Subject to deductible and coinsuranceDoes not apply to maximum limit per event |
Inpatient & Outpatient Treatmentmaximum limit: $250K |
Inpatient & Outpatient Treatmentmaximum limit: $250K. |
Maximum limit $250K.U.S. Retail Pharmacy & expatriate prescription services program: Subject to copayments.
International retail pharmacy: Subject to deductible and coinsurance.
Inpatient/outpatient medical treatment: Subject to deductible and coinsurance |
| Healthy Travel Preventative Coverage |
| $250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
$250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
$250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
$250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
| Vision |
| Optional Rider |
Optional Rider |
Optional Rider |
$100 maximum per 24 months for exams. $150 per 24 months for materials |
| Local Ambulance (U.S. only) |
| $1.5K maximum limit per event |
$1.5K maximum limit per event |
Subject to deductible and coinsurance. |
Not subject to deductible or coinsurance |
| Emergency evacuation |
| Up to $50K maximum per period of coverage. Not subject to deductible or coinsurance. |
Up to $50K maximum per period of coverage. Not subject to deductible or coinsurance. |
Up to lifetime maximum limit. Not subject to deductible or coinsurance. |
Up to maximum limit. Not subject to deductible or coinsurance. |
| Emergency reunion |
| $10K lifetime maximum |
No Coverage |
$10K lifetime maximum |
$10K lifetime maximum |
| Interfacility Ambulance Transfer |
| $1.5K maximum limit per event. Not subject to deductible or coinsurance.U.S. only |
$1.5K maximum limit per event. Not subject to deductible or coinsurance. U.S. only |
Subject to deductible and coinsurance.U.S. only |
Not subject to deductible or coinsurance.U.S. only |
| Political Evacuation and Repatriation |
| No Coverage |
No Coverage |
No Coverage |
$10K lifetime maximum |
| Remote Transportation |
| No Coverage |
No Coverage |
No Coverage |
$5K per period of coverage up to $20K lifetime maximum. Not subject to deductible or coinsurance |
| Return of Mortal Remains (not subject to deductible or coinsurance) |
| $10K lifetime maximum |
$25K lifetime maximum |
$25K lifetime maximum |
$50K lifetime maximum |
| Complementary Medicine |
| No Coverage |
No Coverage |
$500 maximum limit per period of coverage |
$500 maximum limit per period of coverage |
| Traumatic Dental Injury |
| $1K per period of coverage |
$1K per period of coverage |
Up to lifetime maximum limit |
Up to lifetime maximum limit |
| Treatment Due to Unexpected Pain to Sound, Natural Teeth |
| No Coverage |
No Coverage |
$100 per period of coverage |
100% |
| Non Emergency Dental due to Accident |
| No Coverage |
No Coverage |
$500 per period of covergae |
$750 maximum per period of cov-erage; $50 individual deductible, applies to minor restorative and major restorative services |
| Non Emergency Dental |
| Optional Rider |
Optional Rider |
Optional Rider |
$750 maximum per calendar year; $50 individual deductible, applies to minor restorative and major restorative services. |
| Hospital Indemnity |
Private Hospitals: $400 per overnight and $4K maximum limit per calendar year.
Public Hospitals: $500 per overnight and $5K maximum limit per calendar year. |
| Supplemental Accident |
| No Coverage |
No Coverage |
$300 of eligible medical expenses following an accident . Not subject to deductible or coinsurance |
$500 maximum limit per accident. Not subject to deductible and coinsurance |
| Amateur Sailboat Racing |
| Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Crew Member Return |
| $2.5K maximum limit.Not subject to deductible or coinsurance |
$2.5K maximum limit.Not subject to deductible or coinsurance |
$2.5K maximum limit.Not subject to deductible or coinsurance |
$2.5K maximum limit.Not subject to deductible or coinsurance |
| Adult Preventative Care(Age 19 or older) |
| No Coverage |
No Coverage |
$250 per period of coverage |
$500 per period of coverage |
| Child Preventative Care( Through age 18) |
| No Coverage |
$70 maximum per visit, 3 visit per period of coverage |
$200 maximum per period of coverage |
$400 maximum per period of coverage |
| Pre-Existing Conditions Limitation |
| Excluded |
$50K lifetime maximum; $5K per period of coverage after 24 months |
$50K lifetime maximum; $5K per period of coverage after 24 months |
Covered if disclosed and not excluded by rider |
