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Benefit Description
Subject to deductible and coinsurance unless otherwise
noted
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Silver
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Gold
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Platinum
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Coverage Area
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Two options: worldwide or worldwide excluding the U.S. and Canada
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Two options: worldwide or worldwide excluding the U.S. and Canada
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Two options: worldwide or worldwide excluding the U.S. and Canada
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Policy Maximum
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$5,000,000
lifetime per individual
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$5,000,000
lifetime per individual
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$8,000,000
lifetime per individual
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Deductible
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Ranges from $250 to $10,000 per
period of coverage, 50% reduction within PPO
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Ranges from $250 to $10,000 per
period of coverage, 50% reduction within PPO, Carry
forward deductible - last 30 days of certificate year
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Ranges from $100 to $10,000 per
period of coverage, 50% reduction within PPO, Carry forward deductible - last
30 days of certificate year
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Family Deductible
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3x the single
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3x the single
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2x the single
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Coinsurance within the U.S.
and Canada
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80% of the next $5,000 of eligible
expenses after the deductible, then 100% to the overall maximum per period of
coverage
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80% of the next $5,000 of eligible
expenses after the deductible, then 100% to the overall maximum per period of
coverage
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90% of the next $5,000 of eligible
expenses after the deductible, then 100% to the overall maximum per period of
coverage
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Coinsurance within the PPO network and outside the U.S. and
Canada
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100%
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100%
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100%
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Hospitalization / Room & Board
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$600 per day (maximum of 240
consecutive days per covered event)
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Average semi-private room rate
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Private room rate
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Intensive Care Unit
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$1,500 per day (maximum of 180
consecutive days per covered event)
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Usual, Reasonable and Customary
(URC)
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Usual, Reasonable and Customary
(URC)
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Surgery
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URC
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URC
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URC
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Anesthetist's Charges Associated with Surgery
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20% of surgery benefit
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URC
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URC
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Transplants
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$250,000
per transplant
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$1,000,000
lifetime maximum
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$2,000,000
lifetime maximum
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Outpatient
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Visits/Exams - 25 visits per insured person per period of coverage to the
maximum limit as outlined: physician $70; specialist $70; psychiatrist
$60; chiropractor $50; surgical intervention consultation $500;
X-rays - $250 per exam maximum limit; Lab Tests - $300 per exam
maximum limit
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URC
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URC
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Rx Coverage
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URC
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URC
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URC
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Emergency Room Illness
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URC -
subject to an additional $250 deductible if not admitted
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URC -
subject to an additional $250 deductible if not admitted
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URC -
subject to an additional $250 deductible if not admitted
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Emergency Room Accident
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URC
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URC
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URC
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Local Ambulance
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$1,500
per covered event - not subject to deductible or coinsurance
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URC
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URC
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Emergency Evacuation
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$50,000
per period of coverage - not subject to deductible or coinsurance
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Limited to policy maximum - not
subject to deductible or coinsurance
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Limited to policy maximum - not
subject to deductible or coinsurance
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Emergency Reunion
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NA
(Not Applicable)
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$10,000
lifetime maximum
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$10,000
lifetime maximum
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Return of Mortal Remains
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$25,000
lifetime maximum per insured - not subject to deductible or coinsurance
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$25,000
lifetime maximum per insured -not subject to deductible
or coinsurance
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$50,000
lifetime maximum per insured -not subject to deductible or coinsurance
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Maternity
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Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal
delivery, $7,500 for C-section, $200 child wellness benefit for first 12
months - not subject to deductible or coinsurance. Available after 10
months of coverage benefits reduced by 50% for births that occur in11th or
12th month of continuous coverage
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Optional Rider - $50,000 lifetime maximum, maximum of $5,000 for normal
delivery, $7,500 for C-section, $200 child wellness benefit for first 12
months - not subject to deductible or coinsurance. Available after 10
months of coverage benefits reduced by 50% for births that occur in11th or
12th month of continuous coverage
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Same As Any Illness (SAAI) $1,000
additional deductible, $50,000 lifetime maximum, $200 child wellness benefit
for first 12 months. Available after 10 months of coverage
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Supplemental Accident
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NA
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$300
per occurrence - not subject to deductible or
coinsurance
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$500
per occurrence - not subject to deductible or
coinsurance
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Mental/Nervous
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Outpatient only - (see
Outpatient) Available after 12 months of continuous coverage
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$10,000
per period of coverage up to a $50,000 lifetime maximum. Available after
12 months of continuous coverage
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SAAI
$50,000 lifetime maximum. Available after 12 months of continuous coverage
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Adult Wellness
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NA
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$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
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$500 per period of coverage - not
subject to deductible or coinsurance Available for those 18 years of age
and over after 12 months of continuous coverage
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Child Wellness
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Three visits per period of
coverage -maximum $70 per visit. Available for children under 18 years of
age after 12 months of continuous coverage
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$200 maximum per period of
coverage -not subject to deductible or coinsurance Available for children
under 18 years of age after 12 months of continuous coverage
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$400 maximum per period of coverage
- not subject to deductible or coinsurance Available for children under 18
years of age after 12 months of continuous coverage
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Other Services
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Extended Care - limited to first 30 days of confinement
Radiation Treatment - URC
Home Nursing Care - limited 30 days per covered event
Hospice Care - limited 30 days per covered event
Prosthetic Devices - all URC
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URC
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URC
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Physical Therapy
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Maximum $40 per visit 30 visit
maximum per period of coverage
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Maximum $50 per visit
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Maximum $50 per visit
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High School Sports Injury
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NA
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NA
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Up to $5,000 maximum
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Recreational SCUBA
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NA
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URC
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URC
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Remote Transportation
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NA
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NA
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Limited to $5,000 per certificate
period up to a $20,000 lifetime maximum
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Political Evacuation and Repatriation
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NA
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NA
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Limited to $10,000 lifetime
maximum
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Complementary Medicine
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NA
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Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period of coverage
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Acupuncture $150
Aroma Therapy $50
Herbal Therapy $50
Magnetic Therapy $75
Massage Therapy $150
Vitamin Therapy $100
Each per period of coverage
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Non-emergency Dental
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NA
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NA
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Calendar year maximum - $750
Individual deductible - $50
Schedule of benefits -
Class I: 90% Class II: 70%
Class III: 50% Ortho 0%
(6 month waiting period)
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Emergency Dental due to Accident
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$1,000 per period of coverage
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URC
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URC
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Emergency Dental due to Sudden Unexpected Pain
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NA
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$100 per period of coverage
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See non-emergency dental benefits
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Vision
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NA
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NA
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Exams - up to $100 per 24 months
Materials - up to $150 per 24 months
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Global Concierge & Assistance Services
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NA
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NA
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Included
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Pre-existing Conditions
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$5,000 per period of coverage up
to a $50,000 lifetime maximum. Available after 24 months of continuous
coverage
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$5,000 per period of coverage up
to a $50,000 lifetime maximum. Available after 24 months of continuous
coverage
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SAAI
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NA (Not Applicable) / URC (Usual,
Reasonable and Customary) / SAAI (Same As Any Illness)
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