|
Features
|
Benefits
|
| Preventive and Office Visits |
Insurer Waives Deductible |
| Physician Office Visits (Adult) |
All except a $10 copay per visit1 |
| Physician Office Visits (Children 0-18) |
100% |
| Child Immunizations, Lab work & X-rays |
100% |
Women: (25 and Older)
Routine Pap Smears, annual mammogram |
100% |
| PSA for Men |
100% |
| One Routine Physical Per Year |
100% |
| Professional Services |
Insurer Pays After Deductible is Met |
| Surgery, anesthesia, radiation therapy, in-hospital
doctor visits, diagnostic X-ray and lab work. |
100% |
| Maternity |
100% |
| Inpatient Hospital Services |
Insurer Pays After Deductible is Met |
| Surgery, X-rays, in-hospital doctor visits, Organ/Tissue Transplant |
100% |
| In-patient medical emergency2 |
100% |
| In-patient drugs |
100% |
| Ambulatory and Therapeutic Services |
Insurer Pays After Deductible is Met |
| Ambulatory Surgical Center |
100% |
| Ambulance Service |
100% |
| Accidental Dental |
$1,000 per year, $200 per tooth |
| Acupuncture and Chiropractic Services |
100% up to $2,000 |
| Durable Medical Equipment |
100% |
| Infusion Therapy |
100% |
| Physical/Occupational Therapy |
$30/visit, 12 visits per year |
| Basic Prescription Drug Benefit |
50% of actual charges up to $500 |
| Optional Prescription Drug Benefit |
Insurer Waives Deductible |
| Subject to $3,000 Maximum Benefit per
Insured Person per Policy Period |
80% of actual charges |
| Global Travel Benefits |
Insurer Pays Without a Deductible |
| Medical Evacuation |
Up to $100,000 |
| Repatriation of Remains |
Up to $25,000 |
| Accidental Death and Dismemberment |
$50,000 |
| Other |
Inpatient Benefit |
Outpatient Benefit |
| Mental Health |
100% up to 20 days per year |
80% up to 30 visits per year |
| Substance Abuse |
100% up to 12 days of detox |
80% up to 30 visits per year |
| |
| Global Citizen EXP Plan 1.2.3 |
Deductible |
| Elite |
$0 |
| 250 |
$250 |
| 500 |
$500 |
| 1000 |
$1,000 |
| 2500 |
$2,500 |
1. Copay waived when visiting an
HTH Worldwide contracted provider.
2. Emergency room visits
that do not result in inpatient admissions will be subject to a $50
penalty.
3. Out of Pocket Maximums exclude the Deductible.
|
|
