Lifetime Maximum

$5,000,000

Coverage Area

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Option1: Including the U.S.

Option2: Excluding the U.S.

Family Deductible

Maximum of three deductibles per Certificate Period

Coinsurance – Claims Incurred in US or Canada*

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Deductible, the Policy pays 80% of the next $5,000 of Eligible Expenses, per Member per Certificate Period, then 100% up to the Policy 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, the Policy pays 100% of Eligible Expenses to the Policy Maximum. Hospital Admissions must be Pre-Notified using Seven Corners’ Pre-Notification Program.

Family Coinsurance

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After $3,000 of Coinsurance has been paid per Family per Certificate Period, Underwriters will pay 100% of Eligible Expenses to the Overall Maximum Limit.

Hospital Room and Board – In US or Canada*

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Average Semi-Private room rate

Hospital Room and Board – Outside US or Canada*

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Average Private room rate

Intensive Care Unit

Usual, Reasonable

Prescription Drugs

URC, Subject to Deductible and Coinsurance

Mental Health Disorder

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$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

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After the Deductible, Underwriters will pay %50 percent 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

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

Pre-existing Conditions

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

Local Ambulance

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Usual, Reasonable and Customary

Physical Therapy

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$50 Maximum per visit per day

Wellness

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All Wellness benefits are avaialable after 12 months of continuous coverage and are not subject to Deductible. Members under age 19: $50 per visit per day (including immunizations), maximum of 3 visits per Certification period. Members age 30 and over: $250 per Member per Certification period. Female Members age 40 and over: $100 per Member per Certification period for a Screening Mammogrm.

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 Lifetime Maximum

Emergency Reunion

$10,000 Lifetime Maximum

Pre-Certification Penalty

50%