Seguro Internacional | Full
Silver 1000- Worldwide
Deductible: 1.000 USD and Max. Coverage: 5.000.000 USD/Lifetime
From
US$ 146 . 33
G L O B A L M E D I C A L I N S U R A N C E ®
Bronze
Silver
Gold
Platinum
Plan Options:A W O R L D W I D E M E D I C A L I N S U R A N C E P R O G R A M F O R I N D I V I D UA L S A N D FA M I L I E S .
Bronze
Silver
Gold
Platinum
Plan Options:A W O R L D W I D E M E D I C A L I N S U R A N C E P R O G R A M F O R I N D I V I D UA L S A N D FA M I L I E S .
2
Being a global citizen can be an exciting
experience, but it also comes with potential
complications. Your health care should not be
one of those concerns. With Global Medical
Insurance, a revolutionary program from
International Medical Group® (IMG®), you will
receive the worldwide medical coverage you
need, backed by the world-class services you
expect.
Global Medical Insurance allows you to choose
from several plan options, areas of coverage,
multiple deductibles, and modes of payment.
With your medical history in mind, the program
provides different underwriting methods to
extend medical coverage to you that may be
declined by other companies. Quite simply, we
help you build the cover you need.
With IMG, you will rest assured knowing that
we have a dedicated department working to
keep your insurance as affordable as possible.
The costs of health care are rising, but we are
committed to controlling those costs.
You need the proper worldwide coverage,
provided by a company that’s there for you
when you need us most. When you select
Global Medical Insurance, you receive IMG’s
promise to deliver exceptional medical benefits,
medical assistance, and service—all designed to
give you Global Peace of Mind®.
G l o b a l M e d i c a l I n s u r a n c e ®
P l a n H i g h l i g h t s
» Flexibility - Multiple plan options and payment modes to fit your
budget
» Choice of Coverage Area - Worldwide or Worldwide Excluding the
U.S., Canada, China, Hong Kong, Japan, Macau, Singapore, and Taiwan
» Freedom to Choose - Select your own health care provider, no matter
where you are in the world
» Travel Intelligence - Receive location-specific alerts on health,
transportation, security, and weather
» Assistance Services - Available on all plans
» Preventative Care - No waiting period on wellness benefits
» Healthy Travel Preventative Coverage - Receive vaccinations and
preventative prescriptions prior to departure
» Pre-Existing Condition Waiver - For individuals with proof of
comprehensive health insurance and no significant break in coverage
(63 days)
Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and
governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
S A F E T Y S O L U T I O N S
No matter your reason for being a global citizen, we know your safety is important to you. IMG’s Global Medical Insurance has solutions designed to protect you and give you Global
Peace of Mind.
P H Y S I C A L H E A L T H
You can’t plan when you get sick, and unfortunately, it can happen anytime
and anywhere. Medical bills can be expensive, and IMG plans provide the
cross-border medical coverage you need for unexpected medical care and
routine visits.
M E N T A L W E L L N E S S
Being away from your support system can be challenging. IMG provides
access to mental health services, like virtual counseling, to help with the
transition as you adapt to cultural differences, adjust to a change in job or
education, and navigate new relationships while you’re away from loved
ones.
F I N A N C I A L P R O T E C T I O N
Costs can add up while seeking medical treatment. However, access
to IMG’s international physician and provider networks and pharmacy
discount programs can help you save on out-of-pocket medical expenses
and prescription medications.
C R I S I S S U P P O R T
Navigating an emergency in a foreign country is never easy. That’s why IMG
offers a travel intelligence app to warn you of imminent dangers and security
threats. Plus, a multilingual staff of nurses, doctors, and case managers
provide 24/7 assistance services to facilitate a response to urgent and
emergency situations, such as evacuations or search and rescue missions.
W o r l d w i d e C o v e r a g e . W o r l d - C l a s s S e r v i c e s .
Being a global citizen can be an exciting
experience, but it also comes with potential
complications. Your health care should not be
one of those concerns. With Global Medical
Insurance, a revolutionary program from
International Medical Group® (IMG®), you will
receive the worldwide medical coverage you
need, backed by the world-class services you
expect.
Global Medical Insurance allows you to choose
from several plan options, areas of coverage,
multiple deductibles, and modes of payment.
With your medical history in mind, the program
provides different underwriting methods to
extend medical coverage to you that may be
declined by other companies. Quite simply, we
help you build the cover you need.
With IMG, you will rest assured knowing that
we have a dedicated department working to
keep your insurance as affordable as possible.
The costs of health care are rising, but we are
committed to controlling those costs.
You need the proper worldwide coverage,
provided by a company that’s there for you
when you need us most. When you select
Global Medical Insurance, you receive IMG’s
promise to deliver exceptional medical benefits,
medical assistance, and service—all designed to
give you Global Peace of Mind®.
G l o b a l M e d i c a l I n s u r a n c e ®
P l a n H i g h l i g h t s
» Flexibility - Multiple plan options and payment modes to fit your
budget
» Choice of Coverage Area - Worldwide or Worldwide Excluding the
U.S., Canada, China, Hong Kong, Japan, Macau, Singapore, and Taiwan
» Freedom to Choose - Select your own health care provider, no matter
where you are in the world
» Travel Intelligence - Receive location-specific alerts on health,
transportation, security, and weather
» Assistance Services - Available on all plans
» Preventative Care - No waiting period on wellness benefits
» Healthy Travel Preventative Coverage - Receive vaccinations and
preventative prescriptions prior to departure
» Pre-Existing Condition Waiver - For individuals with proof of
comprehensive health insurance and no significant break in coverage
(63 days)
Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and
governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
S A F E T Y S O L U T I O N S
No matter your reason for being a global citizen, we know your safety is important to you. IMG’s Global Medical Insurance has solutions designed to protect you and give you Global
Peace of Mind.
P H Y S I C A L H E A L T H
You can’t plan when you get sick, and unfortunately, it can happen anytime
and anywhere. Medical bills can be expensive, and IMG plans provide the
cross-border medical coverage you need for unexpected medical care and
routine visits.
M E N T A L W E L L N E S S
Being away from your support system can be challenging. IMG provides
access to mental health services, like virtual counseling, to help with the
transition as you adapt to cultural differences, adjust to a change in job or
education, and navigate new relationships while you’re away from loved
ones.
F I N A N C I A L P R O T E C T I O N
Costs can add up while seeking medical treatment. However, access
to IMG’s international physician and provider networks and pharmacy
discount programs can help you save on out-of-pocket medical expenses
and prescription medications.
C R I S I S S U P P O R T
Navigating an emergency in a foreign country is never easy. That’s why IMG
offers a travel intelligence app to warn you of imminent dangers and security
threats. Plus, a multilingual staff of nurses, doctors, and case managers
provide 24/7 assistance services to facilitate a response to urgent and
emergency situations, such as evacuations or search and rescue missions.
W o r l d w i d e C o v e r a g e . W o r l d - C l a s s S e r v i c e s .
4
Summary Schedule of Benefits
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Carrier Sirius Specialty Insurance Corporation
Underwriting approach Full Medical Underwriting
Period of Coverage 12 months (Annually renewable)
Area of Coverage Area 2: Worldwide excluding United States, Canada, China, Hong Kong, Japan, Singapore and Taiwan
Area 3: Worldwide
Age Up to Age 74
Lifetime Maximum $1,000,000 per individual $5,000,000 per individual $5,000,000 per individual $8,000,000 per individual
Deductible
Medical Concierge and International: 50% of the deductible waived up to a
maximum of $2,500.
$250 to $10,000 $250 to $10,000 $250 to $25,000 $100 to $25,000
Coinsurance
Medical Concierge: 100%
U.S. in-network: 100%
U.S. out-of-network: 80% up to $5,000 then 100%
International:100%
Precertification Transplants, Interfacility Ambulance Transfer, Medical Evacuation, Orphan Drugs or BIologic Drugs: No coverage if pre-certification requirements are not met
All other Treatments and supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
Pre-existing Conditions
(only applicable when insured is not on a certificate with creditable coverage)
Known Disclosed Conditions N/A Covered the same as any illness or
injury unless excluded by a Rider
Covered the same as any illness or
injury unless excluded by a Rider
Covered if disclosed and not
excluded by rider
Non-disclosed Conditions N/A No Coverage No Coverage Covered if disclosed and not
excluded by rider
Unknown Conditions
After 24 months of continuous coverage N/A Period of Coverage: $5,000
Lifetime Maximum: $50,000
Period of Coverage: $5,000
Lifetime Maximum: $50,000
Covered if disclosed and not
excluded by rider
Inpatient
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable and Customary amounts
Maximum Limit per Period of Coverage or if indicated, Lifetime Maximum
Eligible Medical Expenses
Physician Visits
Hospitalization Room/Board $600 per day/ 240 day max
Ancillary Services Covered under Hospitalization room &
board/professional fees $400 per day Covered under Hospitalization room &
board/professional fees
Covered under Hospitalization room &
board/professional fees
Anesthesiologist & Anesthesia
This is a summary schedule of benefits that are subject to exclusions, limitations, maximums, deductible and coinsurance unless otherwise noted. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way
the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
Charges and expenses incurred by the Insured Person during the Period of Coverage with respect to an Illness or Injury suffered or sustained by the Insured Person during the Period of Coverage and while this Certificate is in effect, so long as the Charges are
Usual, Reasonable and Customary and are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”).
P L A N D E T A I L SP H Y S I C A L H E A L T H
Summary Schedule of Benefits
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Carrier Sirius Specialty Insurance Corporation
Underwriting approach Full Medical Underwriting
Period of Coverage 12 months (Annually renewable)
Area of Coverage Area 2: Worldwide excluding United States, Canada, China, Hong Kong, Japan, Singapore and Taiwan
Area 3: Worldwide
Age Up to Age 74
Lifetime Maximum $1,000,000 per individual $5,000,000 per individual $5,000,000 per individual $8,000,000 per individual
Deductible
Medical Concierge and International: 50% of the deductible waived up to a
maximum of $2,500.
$250 to $10,000 $250 to $10,000 $250 to $25,000 $100 to $25,000
Coinsurance
Medical Concierge: 100%
U.S. in-network: 100%
U.S. out-of-network: 80% up to $5,000 then 100%
International:100%
Precertification Transplants, Interfacility Ambulance Transfer, Medical Evacuation, Orphan Drugs or BIologic Drugs: No coverage if pre-certification requirements are not met
All other Treatments and supplies: 50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met.
Pre-existing Conditions
(only applicable when insured is not on a certificate with creditable coverage)
Known Disclosed Conditions N/A Covered the same as any illness or
injury unless excluded by a Rider
Covered the same as any illness or
injury unless excluded by a Rider
Covered if disclosed and not
excluded by rider
Non-disclosed Conditions N/A No Coverage No Coverage Covered if disclosed and not
excluded by rider
Unknown Conditions
After 24 months of continuous coverage N/A Period of Coverage: $5,000
Lifetime Maximum: $50,000
Period of Coverage: $5,000
Lifetime Maximum: $50,000
Covered if disclosed and not
excluded by rider
Inpatient
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable and Customary amounts
Maximum Limit per Period of Coverage or if indicated, Lifetime Maximum
Eligible Medical Expenses
Physician Visits
Hospitalization Room/Board $600 per day/ 240 day max
Ancillary Services Covered under Hospitalization room &
board/professional fees $400 per day Covered under Hospitalization room &
board/professional fees
Covered under Hospitalization room &
board/professional fees
Anesthesiologist & Anesthesia
This is a summary schedule of benefits that are subject to exclusions, limitations, maximums, deductible and coinsurance unless otherwise noted. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way
the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
Charges and expenses incurred by the Insured Person during the Period of Coverage with respect to an Illness or Injury suffered or sustained by the Insured Person during the Period of Coverage and while this Certificate is in effect, so long as the Charges are
Usual, Reasonable and Customary and are incurred for Treatment or supplies that are Medically Necessary (“Eligible Medical Expenses”).
P L A N D E T A I L SP H Y S I C A L H E A L T H
5
P H Y S I C A L H E A L T H
Summary Schedule of Benefits (Continued)
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Surgeon & Surgery
Reconstructive Surgery
Assistant Surgeon
20% of primary surgeon’s charges
Intensive Care Unit Maximum consecutive days: 180
Maximum Limit per day: $1500
Extended Care Facility Maximum days: 30
Hospice Maximum days: 30 (combined with
outpatient)
Laboratory
Radiology/X-ray
Physical Therapy $50 Maximum Limit per visit $50 Maximum Limit per visit
Chemotherapy or Radiation Therapy
Prescriptions Included in Ancillary Services $400 per
day limit
Transplants
$250,000 lifetime maximum
Organ procurement and harvesting
costs Lifetime Max: $10,000
Travel & Lodging Lifetime Maximum:
$5,000
$250,000 lifetime maximum
Organ procurement and harvesting
costs Lifetime Max: $10,000
Travel & Lodging Lifetime Maximum:
$5,000
$1,000,000 lifetime maximum
Organ procurement and harvesting
costs Lifetime Max: $10,000
Travel & Lodging Lifetime Maximum:
$5,000
$2,000,000 lifetime maximum
Organ procurement and harvesting
costs Lifetime Max: $20,000
Travel & Lodging Lifetime Maximum:
$10,000
Outpatient Services
Outpatient Services must follow Inpatient Treatment or Outpatient Surgery
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable and Customary amounts
Maximum Limit per Period of Coverage or if indicated, Lifetime Maximum
Eligible Medical Expenses
Physician/Specialist Visit
Maximum Limit: $500 (Prior to
Inpatient Treatment)
Maximum Limit: $500 (90 days
following Intpatient Treatment or
Outpatient Surgery)
Mental or Nervous disorders available
after 12 months of continuous
coverage
Combined maximum visits: 25
Physician/Specialist maximum per
visit: $70
Chiro max per visit: $50 (with referral
from physician)
Surgical Intervention Consultation
max: $500
Teleconsultation
(Non-Insurance Benefit) N/A N/A
This is a summary schedule of benefits that are subject to exclusions, limitations, maximums, deductible and coinsurance unless otherwise noted. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way
the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
P H Y S I C A L H E A L T H
Summary Schedule of Benefits (Continued)
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Surgeon & Surgery
Reconstructive Surgery
Assistant Surgeon
20% of primary surgeon’s charges
Intensive Care Unit Maximum consecutive days: 180
Maximum Limit per day: $1500
Extended Care Facility Maximum days: 30
Hospice Maximum days: 30 (combined with
outpatient)
Laboratory
Radiology/X-ray
Physical Therapy $50 Maximum Limit per visit $50 Maximum Limit per visit
Chemotherapy or Radiation Therapy
Prescriptions Included in Ancillary Services $400 per
day limit
Transplants
$250,000 lifetime maximum
Organ procurement and harvesting
costs Lifetime Max: $10,000
Travel & Lodging Lifetime Maximum:
$5,000
$250,000 lifetime maximum
Organ procurement and harvesting
costs Lifetime Max: $10,000
Travel & Lodging Lifetime Maximum:
$5,000
$1,000,000 lifetime maximum
Organ procurement and harvesting
costs Lifetime Max: $10,000
Travel & Lodging Lifetime Maximum:
$5,000
$2,000,000 lifetime maximum
Organ procurement and harvesting
costs Lifetime Max: $20,000
Travel & Lodging Lifetime Maximum:
$10,000
Outpatient Services
Outpatient Services must follow Inpatient Treatment or Outpatient Surgery
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable and Customary amounts
Maximum Limit per Period of Coverage or if indicated, Lifetime Maximum
Eligible Medical Expenses
Physician/Specialist Visit
Maximum Limit: $500 (Prior to
Inpatient Treatment)
Maximum Limit: $500 (90 days
following Intpatient Treatment or
Outpatient Surgery)
Mental or Nervous disorders available
after 12 months of continuous
coverage
Combined maximum visits: 25
Physician/Specialist maximum per
visit: $70
Chiro max per visit: $50 (with referral
from physician)
Surgical Intervention Consultation
max: $500
Teleconsultation
(Non-Insurance Benefit) N/A N/A
This is a summary schedule of benefits that are subject to exclusions, limitations, maximums, deductible and coinsurance unless otherwise noted. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way
the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
6
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Hospital Emergency Room: International
Surgery/Outpatient Surgical Facility & Surgeon
Anesthesiologist & Anesthesia
Reconstructive Surgery
20% of primary surgeon’s charges
Second Surgical Opinion
Laboratory Maximum Limit per visit: $300 (Prior to
and post Inpatient Treatment only) Maximum Limit per visit: $300
Radiology/X-ray
Maximum Limit per examination: $250
(Prior to and post Inpatient Treatment
only)
Maximum Limit per examination: $250
CAT Scans, MRI, Echocardiography, Endoscopy, Gastroscopy,
Cystoscopy
Maximum Limit per examination: $600
(Prior to Inpatient Treatment only) Maximum Limit per examination: $600
Chemotherapy or Radiation Therapy
Pre-Admin Testing
Durable Medical Equipment See above
Maternity N/A N/A N/A
Available after 10 months of
continuous coverage
Maternity Deductible: $2,500 (In
addition to plan Deductible)
Lifetime Maximum: $50,000
Newborn Care/Congenital Disorders N/A N/A N/A
Maximum Limit: $250,000
Eligible if the Pregnancy is covered
under the plan
Routine Care during the first 31 days
of life
Newborn Wellness N/A N/A N/A
Maximum Limit: $200
Eligible if the Pregnancy is covered
under the plan
Routine Care after 31 days of life
through 12 months
Podiatry Care N/A N/A Maximum Limit: $750 Maximum Limit: $750
Physical Therapy
Medical order required
Available for 90 days following
Inpatient Treatment or Outpatient
Surgery
Maximum Limit per visit: $40
Maximum visits: 10
Maximum Limit per visit: $40
Maximum visits per day: 1
Maximum visits: 30
Maximum Limit per visit: $50
Maximum visits per day: 1
Medical order required
Maximum Limit per visit: $50
Maximum visits per day: 1
Medical order required
Home Nursing Care Maximum days: 30
Maximum Limit per day: $150 Maximum days: 30
Summary Schedule of Benefits (Continued)
This is a summary schedule of benefits that are subject to exclusions, limitations, maximums, deductible and coinsurance unless otherwise noted. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way
the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
P H Y S I C A L H E A L T H
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Hospital Emergency Room: International
Surgery/Outpatient Surgical Facility & Surgeon
Anesthesiologist & Anesthesia
Reconstructive Surgery
20% of primary surgeon’s charges
Second Surgical Opinion
Laboratory Maximum Limit per visit: $300 (Prior to
and post Inpatient Treatment only) Maximum Limit per visit: $300
Radiology/X-ray
Maximum Limit per examination: $250
(Prior to and post Inpatient Treatment
only)
Maximum Limit per examination: $250
CAT Scans, MRI, Echocardiography, Endoscopy, Gastroscopy,
Cystoscopy
Maximum Limit per examination: $600
(Prior to Inpatient Treatment only) Maximum Limit per examination: $600
Chemotherapy or Radiation Therapy
Pre-Admin Testing
Durable Medical Equipment See above
Maternity N/A N/A N/A
Available after 10 months of
continuous coverage
Maternity Deductible: $2,500 (In
addition to plan Deductible)
Lifetime Maximum: $50,000
Newborn Care/Congenital Disorders N/A N/A N/A
Maximum Limit: $250,000
Eligible if the Pregnancy is covered
under the plan
Routine Care during the first 31 days
of life
Newborn Wellness N/A N/A N/A
Maximum Limit: $200
Eligible if the Pregnancy is covered
under the plan
Routine Care after 31 days of life
through 12 months
Podiatry Care N/A N/A Maximum Limit: $750 Maximum Limit: $750
Physical Therapy
Medical order required
Available for 90 days following
Inpatient Treatment or Outpatient
Surgery
Maximum Limit per visit: $40
Maximum visits: 10
Maximum Limit per visit: $40
Maximum visits per day: 1
Maximum visits: 30
Maximum Limit per visit: $50
Maximum visits per day: 1
Medical order required
Maximum Limit per visit: $50
Maximum visits per day: 1
Medical order required
Home Nursing Care Maximum days: 30
Maximum Limit per day: $150 Maximum days: 30
Summary Schedule of Benefits (Continued)
This is a summary schedule of benefits that are subject to exclusions, limitations, maximums, deductible and coinsurance unless otherwise noted. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way
the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
P H Y S I C A L H E A L T H
7This is a summary schedule of benefits that are subject to exclusions, limitations, maximums, deductible and coinsurance unless otherwise noted. Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way
the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Hospice N/A Maximum days: 30
(combined with Inpatient)
Prescription Drugs and Medication
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable and Customary amounts
Maximum Limit per Period of Coverage or if indicated. Lifetime Maximum
Prescription Drugs, Dressings, and Durable Medical
Equipment
Available for 90 days following
Inpatient Treatment or Outpatient
Surgery
Maximum Limit per event: $600
(Orphan Drugs or Biologic Drugs do
not apply to the Maximum Limit per
event)
Subject to deductible and coinsurance.
90-day supply per prescription
following related covered event.
U.S. Retail Pharmacy
out-of-network: 80%
International Retail Phamacy: 100%
Subject to deductible and coinsurance.
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.
Copay 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 N/A N/A N/A
Copay per 30-day supply:
$20 for generic/$40 for
non-preferred brand name.
Must enroll via provider website: www.
expatps.com
Dispensing maximum: 180 days
Orphan or Biologic Drugs (Available when all conditions are met)
» Approved in writing by company
» Medically necessary
» Not experimental or investigational
Applies to period of coverage max.
Max limit applies towards lifetime max.
Inpatient Treatment
maximum limit: $250,000.
Outpatient Surgery:
up to the maximum limit.
Subject to deductible and coinsurance.
Does not apply to maximum
limit per event
Outpatient and Emergency
Department Treatment
maximum limit: $250,000.
Subject to deductible and coinsurance
Inpatient & Outpatient Treatment
maximum limit: $250,000.
Subject to deductible and coinsurance
Maximum limit $250,000.
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
Preventative Care
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable and Customary amounts
Maximum Limit per Period of Coverage or if indicated. Lifetime Maximum
Child Preventative Care
Ages 18 years and younger N/A Maximum Limit per visit: $70
Maximum visits: 3 Maximum Limit: $200 Maximum Limit: $400
Adult Preventative Care N/A N/A Maximum Limit: $250 Maximum Limit: $500
Summary Schedule of Benefits (Continued)
P H Y S I C A L H E A L T H
the Certificate of Insurance and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Hospice N/A Maximum days: 30
(combined with Inpatient)
Prescription Drugs and Medication
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable and Customary amounts
Maximum Limit per Period of Coverage or if indicated. Lifetime Maximum
Prescription Drugs, Dressings, and Durable Medical
Equipment
Available for 90 days following
Inpatient Treatment or Outpatient
Surgery
Maximum Limit per event: $600
(Orphan Drugs or Biologic Drugs do
not apply to the Maximum Limit per
event)
Subject to deductible and coinsurance.
90-day supply per prescription
following related covered event.
U.S. Retail Pharmacy
out-of-network: 80%
International Retail Phamacy: 100%
Subject to deductible and coinsurance.
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.
Copay 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 N/A N/A N/A
Copay per 30-day supply:
$20 for generic/$40 for
non-preferred brand name.
Must enroll via provider website: www.
expatps.com
Dispensing maximum: 180 days
Orphan or Biologic Drugs (Available when all conditions are met)
» Approved in writing by company
» Medically necessary
» Not experimental or investigational
Applies to period of coverage max.
Max limit applies towards lifetime max.
Inpatient Treatment
maximum limit: $250,000.
Outpatient Surgery:
up to the maximum limit.
Subject to deductible and coinsurance.
Does not apply to maximum
limit per event
Outpatient and Emergency
Department Treatment
maximum limit: $250,000.
Subject to deductible and coinsurance
Inpatient & Outpatient Treatment
maximum limit: $250,000.
Subject to deductible and coinsurance
Maximum limit $250,000.
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
Preventative Care
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable and Customary amounts
Maximum Limit per Period of Coverage or if indicated. Lifetime Maximum
Child Preventative Care
Ages 18 years and younger N/A Maximum Limit per visit: $70
Maximum visits: 3 Maximum Limit: $200 Maximum Limit: $400
Adult Preventative Care N/A N/A Maximum Limit: $250 Maximum Limit: $500
Summary Schedule of Benefits (Continued)
P H Y S I C A L H E A L T H