Overall Maximum Limit

$5,000,000 Lifetime

Coverage Area

Option 1 - Including the U.S. and Canada, Option 2 - Excluding the U.S. and Canada

Deductibles Available

$250, $500, $1,000, $2,500 or $5,000 per Member per Certificate Period

Family Deductible

Maximum of three Deductibles per Family per Certificate Period

Coinsurance – Claims Incurred in US or Canada*

More Information

After the Deductible, Underwriters will pay 80% of the next $5,000 of Eligible Expenses per Member per Certificate Period, then 100% to the Overall Maximum Limit. The Coinsurance will be waived if expenses are incurred within the PPO and expenses are submitted to Underwriters for review and payment directly to the provider

Coinsurance – Claims Incurred outside US or Canada

More Information

After the Deductible, Underwriters will pay 100% of Eligible Expenses to the Overall Maximum Limit

Family Coinsurance

More Information

After the Deductible, Underwriters will pay 100% of Eligible Expenses per Member per Certificate Period to the Overall Maximum Limit

Hospital Room and Board – In US or Canada*

Average Semi-private room rate

Hospital Room and Board – Outside US or Canada*

Average Private room rate

Intensive Care Unit

Usual, Reasonable and Customary

Prescription Drugs

Usual, Reasonable and Customary Subject to Deductible and Coinsurance

Mental Health Disorders

More Information

$10,000 per Certificate Period, $25,000 Lifetime Maximum, $50 Maximum per visit per day for outpatient care (after 12 months of continuous coverage)

Maternity – Normal or Complicated Delivery

More Information

After the Deductible, Underwriters will pay 50% of the next $100,000 of Eligible Medical Expenses, then 100% to a Lifetime Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery, and post-natal care (after 12 months of continuous coverage)

Maximum for Maternity

$250,000 Lifetime

Newborn Care

Included as part of Maternity benefits for a maximum of 60 days

Pre-existing Conditions

More Information

Same as any other Injury or Illness if disclosed on Application and not excluded or limited by Ride

Local Ambulance

Usual, Reasonable and Customary

Physical Therapy

$50 Maximum per visit per day

Wellness

More Information

All Wellness benefits are available after 12 months of continuous coverage and are not subject to Deductible. Members under age 19: $50 per visit (including immunizations), maximum of three visits per Certificate Period. Members age 30 and over: $250 per Member per Certificate Period. Female Members age 40 and over (or qualifying Woman at Risk): $100 per Member per Certificate Period for a screening mammogram

Human Organ/Tissue Transplants

Same as any other Illness for Covered Transplants**

All Other Eligible Expenses

Usual, Reasonable and Customary

Emergency Medical Evacuation

$50,000 Lifetime Maximum

Repatriation of Remains

$25,000 Limit

Emergency Reunion

$10,000 Lifetime Maximum

Pre-certification Penalty

50%

* Benefits within the US and Canada are not available to applicants electing Option 2 as their Coverage Area.

** Covered Transplants include Heart, Heart/Lung, Lung, Kidney, Kidnet/Pancreas, Liver, and Allogenic and Autologous Bone Marrow.