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*

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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

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

Acute Onset of Pre-existing Condition

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$1,000 during the first Certificate Period and $2,500 during the second Certificate Period

Pre-existing Conditions

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$5,000 per Certificate Period subject to a Lifetime Maximum of $50,000 (including Acute Onset claims) after 24 months of continuous coverage under the plan

Maternity

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$5,000 per Pregnancy after 12 months of continuous coverage under the plan, including Inpatient, Outpatient and other benefits provided under the plan. Not subject to Coinsurance

Newborn Care

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$15,000 per covered Pregnancy, including Inpatient, Outpatient and other benefits as provided under the plan, during the first 60 days of life

Organ Transplants

$250,000 Lifetime Maximum for Covered Transplants**

INPATIENT BENEFITS (All Subject to Deductible and Coinsurance)

Hospital Room and Board

$600 per day, maximum of 240 days per Hospitalization (including ICU days)

Intensive Care Unit (ICU)

$1,500 per day, maximum of 240 days per Hospitalization (including non-ICU days)

Lab, x-rays and other covered Inpatient services & supplies

Usual, Reasonable and Customary Charges (except as limited under the plan)

OUTPATIENT BENEFITS (All Subject to Deductible and Coinsurance)

Office Visits (Including Physician, Specialist Physician, Psychiatrist, Chiropractor, Surgical Consultant, Physical or Occupational Therapist)

25 visits per Certificate Period per person as provided under the plan

Physician

$70 per visit

Specialist Physician

$70 per visit

Psychiatrist

$60 per visit, after 12 months of continuous coverage under the plan

Chiropractor

$50 per visit (must be prescribed by another non-Chiropractor Physician)

Surgical Consultant

$500 per consultation prior to Surgery

Physical or Occupational Therapy

$50 per visit (must be prescribed by a Physician who is not affiliated with the Physical Therapy practice)

X-rays

$250 per exam (includes Sonograms, Ultrasounds and diagnostic Mammograms)

Laboratory

$300 per exam (includes all procedures carried out on one specimen)

Emergency Room

Usual, Reasonable and Customary for covered Illnesses if hospitalized as Inpatient and for covered Injuries

Local Ambulance

$1,500 per Certificate Period per person

INPATIENT or OUTPATIENT BENEFITS (All Subject to Deductible and Coinsurance)

Prescription Medications

Usual, Reasonable and Customary

Surgery

Usual, Reasonable and Customary

Assistant Surgeon

20% of Surgeon benefit

Anesthesiologist

20% of Surgeon benefit

Midwife Services

$500 per covered Pregnancy

MRI, CAT Scan, Echocardiography, Endoscopy, Gastroscopy, Colonoscopy and Cystoscopy

$600 per exam

Chemotherapy and Radiation Therapy

Usual, Reasonable and Customary

WELLNESS BENEFITS (Not Subject to Deductible or Coinsurance)

Well Child (under age 19)

$50 per visit for a maximum of 3 visits per Certificate Period (included in Office Visit limit), after 12 months of continuous coverage under the plan

Wellness (Adult 19+)

$250 per Certificate Period, after 24 months of continuous coverage under the plan, including Office Visit for $70 and X-Ray and Lab for $180

OTHER BENEFITS (All Subject to Deductible and Coinsurance)

Durable Medical Equipment

Usual, Reasonable and Customary charges for Wheelchair, Hospital Bed, and/or Toilet

Emergency Medical Evacuation

$50,000 per Certificate Period

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

Repatriation of Remains

$25,000 Maximum

Emergency Reunion

$5,000 Lifetime Maximum