| Lifetime Maximum Limit |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
$5,000,000
lifetime per individual |
$8,000,000
lifetime per individual |
|
| Deductible (Per Period of Coverage) |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| $250 to $10,000 |
$100 to $10,000 |
|
| Family Deductible |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| 3 times the individual deductible |
2 times the individual deductible |
|
| Treatment Outside the U.S. and Canada |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
Subject to Deductible
No coinsurance |
|
| Treatment Inside the U.S. (Out-Patient/In-Patient Emergency) |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| PPO Network - Deductible 50% Waived (to a $2,500 Maximum). No coinsurance. |
|
| Treatment Inside the U.S. (In-Patient Non-Emergency)) |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
Medical Concierge - deductible 50% waived (to a $2,500 maximum). No coinsurance.
PPO Network - subject to deductible. No coinsurance. |
|
| Treatment inside the U.S.- Non-PPO Network and Canada |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
Subject to deductible.
Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage |
Subject to deductible Plan pays 90% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage |
|
| Hospitalization / Room & Board |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| In U.S./Canada - URC of average semi-private room rate. Outside of U.S./Canada - URC of private room rate (not to exceed 150% of semi-private room rate). All subject to $600 per day - 240 day max. |
In U.S./Canada – URC of average semip-rivate room rate. Outside of U.S./ Canada - URC of private room rate (not to exceed 150% of semi-private room rate) |
Up to a limit of $2,250 per day - semi-private room rate |
In U.S./Canada – URC of average semiprivate room rate. Outside of U.S./ Canada - URC of private room rate (not to exceed 150% of semi-private room rate) |
Private room rate |
|
| Intensive Care Unit |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| $1,500 per day - 180 day per event |
URC |
Up to a limit of $4,500 per day |
URC |
URC |
|
| Surgery |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| URC |
URC |
URC |
URC |
URC |
|
| Anesthetist's Charges Associated with Surgery |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| 20% of surgery benefit |
URC |
20% of surgery benefit |
URC |
URC |
|
| Transplants |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
$250,000
per transplant |
$1,000,000
lifetime maximum |
$500,000
lifetime maximum |
$1,000,000
lifetime maximum |
$2,000,000
lifetime maximum |
|
| Out-patient |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| 25 visits: $70 doctor/specialist; $60 psychiatrist; $50 chiropractor; $250 X-ray per exam maximum limit; $500 surgery intervention consultation; $300 lab tests per exam maximum limit |
URC |
Physician Charges - limit of $150 per visit; Hospital Charge - $100 co-pay unless admitted; Urgent Care Facility - $25 copay; Diagnostic Lab and X-Rays limited to $5,000 per certificate period |
URC |
URC |
|
| Emergency Room Illness (Additional $250 deductible if not admitted) |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| URC |
URC |
URC |
URC |
URC |
|
| Emergency Room Accident |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| URC |
URC |
URC |
URC |
URC |
|
| Supplemental Accident |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
$300
per occurrence |
$300
per occurrence |
$300
per occurrence |
$500
per occurrence |
|
| Local Ambulance |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
$1,500
per covered event - not subject to deductible or coinsurance |
URC |
$100 per event - not subject to deductible or coinsurance |
URC |
URC |
|
| Mental/Nervous |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| Outpatient only after 12 months of continuous coverage |
$10,000 per period - $50,000 maximum - Available after 12 months of continuous coverage |
$2,500 maximum per certificate period; In-patient limited to 25 days per certificate period; Out-patient limited to max of 20 visits per certificate period at 70% eligible expenses, up to $75 maximum per visit; Lifetime maximum of $30,000 |
$10,000 per period - $50,000 maximum - Available after 12 months of continuous coverage |
SAAI - $50,000 lifetime maximum - Available after 12 months of continuous coverage |
|
| Emergency Evacuation |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
$50,000
per period of coverage - not subject to deductible or coinsurance |
Up to maximum limit - not subject to deductible or coinsurance |
$250,000 limit per person per certificate period |
Up to maximum limit - not subject to deductible or coinsurance |
|
| Emergency Reunion |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
$10,000 lifetime maximum |
|
| Return of Mortal Remains |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
$25,000
lifetime maximum per insured - not subject to deductible or coinsurance |
$15,000
lifetime maximum per insured - not subject to deductible or coinsurance |
$25,000
lifetime maximum per insured - not subject to deductible or coinsurance |
$50,000
lifetime maximum per insured -not subject to deductible or coinsurance |
|
| Remote Transportation |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
NA |
NA |
NA |
Limited to $5,000 per certificate period up to a $20,000 lifetime maximum |
|
| Political Evacuation and Repatriation |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
NA |
NA |
NA |
Limited to $10,000 lifetime maximum |
|
| Child Wellness (Under 18 years of age) |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| 3 visits per period of coverage - $70 maximum per period - Available after 12 months of continuous coverage |
$200 maximum per period of coverage - not subject to deductible or coinsurance - Available after 12 months of continuous coverage |
$400 maximum per period of coverage - not subject to deductible or coinsurance - Available after 6 months of continuous coverage |
|
| Adult Wellness |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
$250 per period of coverage - not subject to deductible or coinsurance - Available for those 30 years of age and over after 12 months of continuous coverage |
$500 per period of coverage - not subject to deductible or coinsurance - Available for those 18 years of age and over after 6 months of continuous coverage |
|
| Rx Coverage |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| URC |
URC |
$5,000 per certificate period for each insured person, out-patient only |
URC |
Outside U.S. - URC. Inside U.S. - Rx drug card co-pay: $20 for generic / $40 for brand name where generic is not available (Certain monthly per prescription amount limits may apply and require pre-approval by the Company.) |
|
| Other Services |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| Extended care: first 30 days; Radiation: URC; Home nursing: 30 days per covered event; Hospice: 30 days; Prosthetic Devices: all URC |
URC |
URC - Radiation & Chemotherapy treatments (in and out-patient) limited to $10,000 per year; $50,000 lifetime maximum |
URC |
URC |
|
| Physical Therapy |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| Maximum $40 per visit - 30 visit maximum |
Maximum $50 per visit |
Maximum $50 per visit - $1,000 max per certificate period. $10,000 lifetime maximum |
Maximum $50 per visit |
Maximum $50 per visit |
|
| Complementary Medicine |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| URC |
Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period of coverage |
|
| Recreational Scuba |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
URC |
URC |
URC |
URC |
|
| Non-emergency Dental |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
NA |
NA |
NA |
Calendar year maximum - $750;
Individual deductible - $50
Schedule of benefits -
Class I: 90%; Class II: 70%;
Class III: 50%;
(6 month waiting period) |
|
| Emergency Dental due to Accident |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| $1,000 per period of coverage |
URC |
$500 per period of coverage |
URC |
URC |
|
| Emergency Dental due to Sudden Unexpected Pain |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
$100 per period of coverage |
$100 per period of coverage |
$100 per period of coverage |
See non-emergency dental benefits |
|
| High School Sports Injury |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
NA |
NA |
NA |
Up to $20,000 per certificate period |
|
| Vision |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| NA |
NA |
NA |
NA |
Exams - up to $100 Materials - up to $150 per 24 months |
|
Maternity
Delivery, wellness, new born care & congenital disorders, Family Matters Maternity Program (*not subject to deductible or coinsurance - available after 10 months of coverage) |
| Silver |
Gold
(1st 36 months of continuous coverage) |
Gold
(Beginning the 1st day of the 37th month) |
Gold Plus |
Platinum |
| Optional Rider* - $50,000 lifetime maximum, maximum of $5,000 for normal delivery, $7,500 for C-section - not subject to deductible or coinsurance, $200 child wellness benefit for the first 12 months, new born care & congenital disorders maximum of $250,000 for the first 31 days (Benefits reduced by 50% for births in that occur in the 11th or 12th month of continuous coverage) |
SAAI - $1,000 additional deductible, $50,000 lifetime maximum, $200 child wellness benefit for the first 12 months, new born care & congenital disorders maximum of $250,000 for the first 31 days |
|
