Seguro Internacional | Full
Silver 5000- Worldwide
Deductible: 5.000 USD and Max. Coverage: 5.000.000 USD/Lifetime
From
US$ 100 . 08
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 .
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
8
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Vision 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
Routine Eye Examination N/A N/A N/A Maximum Limit every 24 months: $100
Contact Lenses, Contacts, Frames N/A N/A N/A Maximum Limit every 24 months: $150
Other Services
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
Complementary Medicine N/A N/A N/A
Maximum Limit: $500
Services include Acupuncture,
Aromatherapy, Herbal Therapy,
Magnetic Therapy, Massage Therapy
and Vitamin Therapy
Dental Treatment N/A N/A
Max limit: $100
(Treatment due to unexpected pain to
sound natural teeth)
Max limit: $500
(Non-emergency Treatment at a
Dental Provider’s office due to an
Accident)
$750 per period of coverage $50
deductible (max. 2 per family)
Routine services-90% (deductible
waived)
Minor restorative- 70%
Major restorative- 50%
6 month waiting period
Traumatic Dental Injury Maximum Limit: $1,000 Maximum Limit: $1,000
High School Sports N/A N/A N/A Lifetime Maximum: $20,000
Includes Collision Sports
Healthy Travel Preventative Coverage
Vaccinations and preventative prescription drugs administered by a
Physician within 30 days prior to th eInsured Person’s Initial Effective Date
and before departing to any destination
Lifetime Maximum: $250 Lifetime Maximum: $250 Lifetime Maximum: $250 Lifetime Maximum: $250
Supplemental Accident N/A N/A Maximum Limit per Accident: $300 Maximum Limit per Accident: $500
Optional Coverage
Terrorism
Platinum option only N/A N/A N/A $50,000 lifetime maximum
Sports Rider
Gold and Platinum options N/A N/A
$10,000 lifetime maximum for amateur
athletics
Adventure Sports:
Through age 49 years: $50,000 lifetime
maximum
Age 50 years through age 59 years:
$30,000 lifetime maximum
Age 60 years through age 64 years:
$15,000 lifetime maximum
$10,000 lifetime maximum for amateur
athletics
Adventure Sports:
Through age 49 years: $50,000 lifetime
maximum
Age 50 years through age 59 years:
$30,000 lifetime maximum
Age 60 years through age 64 years:
$15,000 lifetime maximum
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
Vision 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
Routine Eye Examination N/A N/A N/A Maximum Limit every 24 months: $100
Contact Lenses, Contacts, Frames N/A N/A N/A Maximum Limit every 24 months: $150
Other Services
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
Complementary Medicine N/A N/A N/A
Maximum Limit: $500
Services include Acupuncture,
Aromatherapy, Herbal Therapy,
Magnetic Therapy, Massage Therapy
and Vitamin Therapy
Dental Treatment N/A N/A
Max limit: $100
(Treatment due to unexpected pain to
sound natural teeth)
Max limit: $500
(Non-emergency Treatment at a
Dental Provider’s office due to an
Accident)
$750 per period of coverage $50
deductible (max. 2 per family)
Routine services-90% (deductible
waived)
Minor restorative- 70%
Major restorative- 50%
6 month waiting period
Traumatic Dental Injury Maximum Limit: $1,000 Maximum Limit: $1,000
High School Sports N/A N/A N/A Lifetime Maximum: $20,000
Includes Collision Sports
Healthy Travel Preventative Coverage
Vaccinations and preventative prescription drugs administered by a
Physician within 30 days prior to th eInsured Person’s Initial Effective Date
and before departing to any destination
Lifetime Maximum: $250 Lifetime Maximum: $250 Lifetime Maximum: $250 Lifetime Maximum: $250
Supplemental Accident N/A N/A Maximum Limit per Accident: $300 Maximum Limit per Accident: $500
Optional Coverage
Terrorism
Platinum option only N/A N/A N/A $50,000 lifetime maximum
Sports Rider
Gold and Platinum options N/A N/A
$10,000 lifetime maximum for amateur
athletics
Adventure Sports:
Through age 49 years: $50,000 lifetime
maximum
Age 50 years through age 59 years:
$30,000 lifetime maximum
Age 60 years through age 64 years:
$15,000 lifetime maximum
$10,000 lifetime maximum for amateur
athletics
Adventure Sports:
Through age 49 years: $50,000 lifetime
maximum
Age 50 years through age 59 years:
$30,000 lifetime maximum
Age 60 years through age 64 years:
$15,000 lifetime maximum
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
9
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Mental or Nervous Counseling
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
Mental or Nervous
After 12 months of continuous coverage; no waiting period for Platinum N/A Outpatient after 12 months of
continuous coverage
Maximum Limit: $10,000
Lifetime Maximum: $50,000 Lifetime Maximum: $50,000
Bereavement Counseling N/A Lifetime Max: $300 Lifetime Max: $300 Lifetime Max: $300
Remote Mental Health Service
(Non-Insurance Benefit) N/A N/A N/A
Dental
Dental Rider
Bronze, Silver and Gold plan options
$750 per period of coverage
$50 deductible (max. 2 per family)
Routine services-90% (deductible
waived)
Minor restorative- 70%
Major restorative- 50%
6 month waiting period
$750 per period of coverage
$50 deductible (max. 2 per family)
Routine services-90% (deductible
waived)
Minor restorative- 70%
Major restorative- 50%
6 month waiting period
$750 per period of coverage
$50 deductible (max. 2 per family)
Routine services-90% (deductible
waived)
Minor restorative- 70%
Major restorative- 50%
6 month waiting period
Dental Treatment benefit already
included; no rider required
Vision
Vision Rider
Bronze, Silver and Gold plan options
Exams-up to $100 per 24 months
Materials-up to $150 per 24 months
Exams-up to $100 per 24 months
Materials-up to $150 per 24 months
Exams-up to $100 per 24 months
Materials-up to $150 per 24 months
Vision Care benefit already included;
no rider required
Services
Universal Rx Drug Card Copayments N/A N/A N/A
Generic: $20
Brand: (when Generic is unavailable):
$40
Copayments are per 30-day supply
Dispensing maximum per prescription:
90 days
The Family Matters Program N/A N/A N/A
Provides educational information on
pregnancy and provides suggestions
for a healthy lifestyle
Emergency Services
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
Emergency Local Ambulance
Injury/Illness resulting in an Inpatient Hospital admission Maximum Limit per incident: $1,500 Maximum Limit per incident: $1,500
Emergency Medical Evacuation Maximum Limit: $50,000 Maximum Limit: $50,000 Maximum Limit: $50,000 Up to the Lifetime Maximum
Emergency Reunion
Lifetime Maximum: $10,000
Maximum days: 15
Meal Maximum Limit per day: $25
N/A
Lifetime Maximum: $10,000
Maximum days: 15
Meal Maximum Limit per day: $25
Lifetime Maximum: $10,000
Maximum days: 15
Meal Maximum Limit per day: $25
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.
M E N T A L H E A L T HP H Y S I C A L H E A L T HC R I S I S S U P P O R T
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Mental or Nervous Counseling
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
Mental or Nervous
After 12 months of continuous coverage; no waiting period for Platinum N/A Outpatient after 12 months of
continuous coverage
Maximum Limit: $10,000
Lifetime Maximum: $50,000 Lifetime Maximum: $50,000
Bereavement Counseling N/A Lifetime Max: $300 Lifetime Max: $300 Lifetime Max: $300
Remote Mental Health Service
(Non-Insurance Benefit) N/A N/A N/A
Dental
Dental Rider
Bronze, Silver and Gold plan options
$750 per period of coverage
$50 deductible (max. 2 per family)
Routine services-90% (deductible
waived)
Minor restorative- 70%
Major restorative- 50%
6 month waiting period
$750 per period of coverage
$50 deductible (max. 2 per family)
Routine services-90% (deductible
waived)
Minor restorative- 70%
Major restorative- 50%
6 month waiting period
$750 per period of coverage
$50 deductible (max. 2 per family)
Routine services-90% (deductible
waived)
Minor restorative- 70%
Major restorative- 50%
6 month waiting period
Dental Treatment benefit already
included; no rider required
Vision
Vision Rider
Bronze, Silver and Gold plan options
Exams-up to $100 per 24 months
Materials-up to $150 per 24 months
Exams-up to $100 per 24 months
Materials-up to $150 per 24 months
Exams-up to $100 per 24 months
Materials-up to $150 per 24 months
Vision Care benefit already included;
no rider required
Services
Universal Rx Drug Card Copayments N/A N/A N/A
Generic: $20
Brand: (when Generic is unavailable):
$40
Copayments are per 30-day supply
Dispensing maximum per prescription:
90 days
The Family Matters Program N/A N/A N/A
Provides educational information on
pregnancy and provides suggestions
for a healthy lifestyle
Emergency Services
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
Emergency Local Ambulance
Injury/Illness resulting in an Inpatient Hospital admission Maximum Limit per incident: $1,500 Maximum Limit per incident: $1,500
Emergency Medical Evacuation Maximum Limit: $50,000 Maximum Limit: $50,000 Maximum Limit: $50,000 Up to the Lifetime Maximum
Emergency Reunion
Lifetime Maximum: $10,000
Maximum days: 15
Meal Maximum Limit per day: $25
N/A
Lifetime Maximum: $10,000
Maximum days: 15
Meal Maximum Limit per day: $25
Lifetime Maximum: $10,000
Maximum days: 15
Meal Maximum Limit per day: $25
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.
M E N T A L H E A L T HP H Y S I C A L H E A L T HC R I S I S S U P P O R T
10
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Interfacility Ambulance Transfer
(United States Only) Maximum Limit per incident: $1,500 Maximum Limit per incident: $1,500
Political Evacuation and Repatriation N/A N/A N/A Lifetime Maximum: $10,000
Remote Transportation N/A N/A N/A Maximum Limit: $5,000
Lifetime Maximum: $20,000
Return of Mortal Remains Maximum Limit: $25,000 Maximum Limit: $25,000 Maximum Limit: $25,000 Maximum Limit: $50,000
Services
Global Concierge N/A N/A N/A Emergency travel assistance services
Travel Intelligence App
Optional Coverage
Global Term Life Insurance
Age 31 days -18 years
Age 19-29 years
Age 30-39 years
Age 40-44 years
Age 45-49 years
Age 50-54 years
Age 55-59 years
Age 60-64 years
Age 65-69 years
$5,000
$75,000
$50,000
$35,000
$25,000
$20,000
$15,000
$10,000
$7,500
$5,000
$75,000
$50,000
$35,000
$25,000
$20,000
$15,000
$10,000
$7,500
$5,000
$75,000
$50,000
$35,000
$25,000
$20,000
$15,000
$10,000
$7,500
$5,000
$75,000
$50,000
$35,000
$25,000
$20,000
$15,000
$10,000
$7,500
AD&D
included with Term Life
Accidental Loss of Life: Principal Sum*
Accidental Total Loss of 2 Members**: Principal Sum*
Accidental Total Loss of 1 Member**: 50%*
(*Benefit based on age at time of death** “Member” means hand, foot or eye)
F I N A N C I A L P R O T E C T I O N
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.
C R I S I S S U P P O R T
M y I M G S M M e m b e r P o r t a l
It’s easy to access and manage your IMG accounts any time, from anywhere and any
device, via MyIMG.
MyIMG features include:
» Claims submission and management
» ID Card and insurance documents
access
» Precertification process initiation
» Explanation of Benefit (EOB) access
» Customer Care live chat and contact
information
» Find a Doctor locator
PLAN DETAILS BRONZE SILVER GOLD PLATINUM
Interfacility Ambulance Transfer
(United States Only) Maximum Limit per incident: $1,500 Maximum Limit per incident: $1,500
Political Evacuation and Repatriation N/A N/A N/A Lifetime Maximum: $10,000
Remote Transportation N/A N/A N/A Maximum Limit: $5,000
Lifetime Maximum: $20,000
Return of Mortal Remains Maximum Limit: $25,000 Maximum Limit: $25,000 Maximum Limit: $25,000 Maximum Limit: $50,000
Services
Global Concierge N/A N/A N/A Emergency travel assistance services
Travel Intelligence App
Optional Coverage
Global Term Life Insurance
Age 31 days -18 years
Age 19-29 years
Age 30-39 years
Age 40-44 years
Age 45-49 years
Age 50-54 years
Age 55-59 years
Age 60-64 years
Age 65-69 years
$5,000
$75,000
$50,000
$35,000
$25,000
$20,000
$15,000
$10,000
$7,500
$5,000
$75,000
$50,000
$35,000
$25,000
$20,000
$15,000
$10,000
$7,500
$5,000
$75,000
$50,000
$35,000
$25,000
$20,000
$15,000
$10,000
$7,500
$5,000
$75,000
$50,000
$35,000
$25,000
$20,000
$15,000
$10,000
$7,500
AD&D
included with Term Life
Accidental Loss of Life: Principal Sum*
Accidental Total Loss of 2 Members**: Principal Sum*
Accidental Total Loss of 1 Member**: 50%*
(*Benefit based on age at time of death** “Member” means hand, foot or eye)
F I N A N C I A L P R O T E C T I O N
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.
C R I S I S S U P P O R T
M y I M G S M M e m b e r P o r t a l
It’s easy to access and manage your IMG accounts any time, from anywhere and any
device, via MyIMG.
MyIMG features include:
» Claims submission and management
» ID Card and insurance documents
access
» Precertification process initiation
» Explanation of Benefit (EOB) access
» Customer Care live chat and contact
information
» Find a Doctor locator
11
C R I S I S S U P P O R T
Available with Select GMI Plans
*Teleconsultations will not support a diagnosis for Mental or Nervous Disorders. Coverage for a Teleconsultation is not a determination that any specific condition discussed, raised
or identified during such Consultation is covered under this insurance. We reserve the right to decline future claims relating to or arising from any condition discussed, raised or
identified during a Teleconsultation where the illness or injury is directly or indirectly related to any Pre-existing Condition or is otherwise excluded under this Policy.
BRONZESILVERGOLDPLATINUM
P H Y S I C A L
H E A L T H F I N A N C I A L P R O T E C T I O N
U n i v e r s a l R X P h a r m a c y D i s c o u n t S a v i n g s (All plan levels)
This discount savings program allows you to purchase prescriptions at one of
over 35,000 participating pharmacies in the U.S. and receive the lower of 1)
Universal Rx contract price or 2) the pharmacy regular retail price. This program
is not insurance coverage. It is purely a discount program.
M e d i c a l C o n c i e r g e (All plan levels)
Whether you are seeking care at a local facility or in an unfamiliar location, quality
of care is a primary concern. IMG’s Medical Concierge program (available in the
U.S.) is designed to provide you with critical information and to assist you in
making the right decision for treatment. Your personal Medical Concierge will
review your specific non-emergency medical condition and provide you with
information on provider ratings, past outcomes, and general costs—all in the
area where you are planning treatment.
You will be entitled to receive a reduction in your deductible for utilizing this
unique medical service while in the United States. This level of individualized
service is unmatched in the international arena.
T e l e c o n s u l t a t i o n * (Gold & Platinum)
Online and telephonic access to a network of medical professionals available
to diagnose, treat and prescribe for non-emergency medical issues. The best
medicine brought to you and your family 24 hours a day, seven days a week.
T r a v e l I n t e l l i g e n c e (All plan levels)
A vital companion that provides access to dynamic alerts and country intelligence
to help you prepare for and stay safe while away from home.
» Travel Intelligence - Trustworthy and timely intelligence, professional advice
and support
» Safety Alerts - Alert notifications of high-risk events, including health, terrorism,
civil unrest, severe weather risks, in or near your current location
» Travel Essentials - Emergency hotline, access to travel documents, important
itinerary information
» Location Awareness - View and receive notifications of proximity threats based
on your current and last shared location
» Destination/Location Tips - Advice based on travel itinerary or countries of
interest
» Friends and Family Sharing - Add additional users to your account so they can
be notified in case of an emergency or a potential threat
C R I S I S S U P P O R T
Available with Select GMI Plans
*Teleconsultations will not support a diagnosis for Mental or Nervous Disorders. Coverage for a Teleconsultation is not a determination that any specific condition discussed, raised
or identified during such Consultation is covered under this insurance. We reserve the right to decline future claims relating to or arising from any condition discussed, raised or
identified during a Teleconsultation where the illness or injury is directly or indirectly related to any Pre-existing Condition or is otherwise excluded under this Policy.
BRONZESILVERGOLDPLATINUM
P H Y S I C A L
H E A L T H F I N A N C I A L P R O T E C T I O N
U n i v e r s a l R X P h a r m a c y D i s c o u n t S a v i n g s (All plan levels)
This discount savings program allows you to purchase prescriptions at one of
over 35,000 participating pharmacies in the U.S. and receive the lower of 1)
Universal Rx contract price or 2) the pharmacy regular retail price. This program
is not insurance coverage. It is purely a discount program.
M e d i c a l C o n c i e r g e (All plan levels)
Whether you are seeking care at a local facility or in an unfamiliar location, quality
of care is a primary concern. IMG’s Medical Concierge program (available in the
U.S.) is designed to provide you with critical information and to assist you in
making the right decision for treatment. Your personal Medical Concierge will
review your specific non-emergency medical condition and provide you with
information on provider ratings, past outcomes, and general costs—all in the
area where you are planning treatment.
You will be entitled to receive a reduction in your deductible for utilizing this
unique medical service while in the United States. This level of individualized
service is unmatched in the international arena.
T e l e c o n s u l t a t i o n * (Gold & Platinum)
Online and telephonic access to a network of medical professionals available
to diagnose, treat and prescribe for non-emergency medical issues. The best
medicine brought to you and your family 24 hours a day, seven days a week.
T r a v e l I n t e l l i g e n c e (All plan levels)
A vital companion that provides access to dynamic alerts and country intelligence
to help you prepare for and stay safe while away from home.
» Travel Intelligence - Trustworthy and timely intelligence, professional advice
and support
» Safety Alerts - Alert notifications of high-risk events, including health, terrorism,
civil unrest, severe weather risks, in or near your current location
» Travel Essentials - Emergency hotline, access to travel documents, important
itinerary information
» Location Awareness - View and receive notifications of proximity threats based
on your current and last shared location
» Destination/Location Tips - Advice based on travel itinerary or countries of
interest
» Friends and Family Sharing - Add additional users to your account so they can
be notified in case of an emergency or a potential threat
Request contact
Apply and/or receive advice from a specialized executive