| Schedule of Benefits: |
| Coverage Area |
Worldwide |
| Maximum Lifetime Benefit Per Person |
$5,000,000 (Standard) |
| Deductible (Calendar Year) |
$100 - $25,000
The deductible is reduced 50% when using the U.S. independent Preferred Provider Organization (provided through The First Health Network) |
| Family Deductible (Calendar Year) |
Maximum of three (3)
deductibles per family |
| Deductible Carry Forward |
Expenses incurred during the last 3 months of a calendar year will be applied toward satisfaction of the deductible for the next calendar year, but only if the deductible was not met during the prior calendar year |
| Coinsurance Percentages |
|
| Adult Wellness Benefit |
Plan pays up to $500 per calendar year |
| Child Wellness Benefit |
Plan pays up to $500 per calendar year |
| Illness or Accident Benefit |
Subject to deductible and
applicable coinsurance |
| Physician Office Services |
|
| Medical expenses incurred outside the U.S., Canada, or Puerto Rico |
Plan pays 100% of eligible charges
after deductible |
| Medical expenses incurred in the U.S. using the PPO |
Plan pays 100% of eligible charges
after deductible |
| Medical expenses incurred in the U.S., Canada, or Puerto Rico outside the PPO |
Plan pays 80% up to $2,500 of eligible charges after deductible; thereafter the plan pays 100% of eligible charges |
Hospital Services
Inpatient & Outpatient
Emergency Room (injury or illness) |
Subject to deductible and
applicable coinsurance |
| Eligible Medical Expenses |
Subject to deductible and
applicable coinsurance |
| Local Ambulance |
Subject to deductible and coinsurance for emergency local transport deemed medically necessary |
| Emergency Medical Evacuation |
Up to the lifetime maximum benefit
per person |
| Emergency Reunion |
$10,000 per insured person
(return to home country) |
| Return of Mortal Remains |
$10,000 per insured person
(return to home country) |
| Maternity Coverage |
Covered as any other illness |
Pre-natal care; delivery of newborn;
post-natal care |
Subject to deductible &
coinsurance per person |
| Newborn baby care |
Routine care for first 31 days of life |
| Human Organ Covered Transplants |
$5,000,000 lifetime maximum inside transplant network facilities per person |
| Durable Medical Equipment |
$10,000 (lifetime maximum benefit) |
Home Health Care &
Extended Care Facility |
URC up to a maximum of
90 days coverage |
| Chiropractic Care |
$30 per visit, maximum of $1,000
per calendar year |
| Physical Therapy |
$50 maximum benefit per visit |
| Prescription Drugs |
Mail order and retail pharmacies Usual, reasonable, and customary charges |
| Supplemental Accident |
$300 benefit per accident, deductible
and coinsurance thereafter |
| Vision Benefit |
|
| Exams |
Plan pays up to $100 per 24 months |
| Materials (frames, lenses, contacts) |
Plan pays up to $150 per 24 months |
| Mental/Nervous, Alcohol & Substance Abuse Treatment |
| Inpatient |
Maximum of 30 days confinement |
| Outpatient |
Payable at 50% after deductible |
| Inpatient and outpatient |
$25,000 lifetime maximum |
| Family Counseling |
$500 lifetime maximum |
| Bereavement Counseling |
$100 benefit per person within 6 months of the covered insured person's death |
| Pre-Admission Certification |
Failure to pre-certify maternity, admissions, and surgeries could reduce benefits |
| Complementary Medicine Benefits |
Acupuncture - $150;
Aroma Therapy - $50;
Herbal Therapy - $50;
Magnetic Therapy - $75;
Massage Therapy - $150;
Vitamin Therapy - $100 |
| Hospice Care |
Up to the lifetime maximum limit |