|
Features |
Outside U.S.
|
U.S.(In Network)
|
U.S.(Outside
Network) |
| Lifetime
Maximum per Insured Person |
$5,000,000
|
$5,000,000
|
$5,000,000
|
|
Preventative and Primary Care – Deductible is not applicable
|
Preventative
Care For Babies/Children: (Birth to Age 18)
- Office Visits/examination
- Immunizations, Lab work & X-rays
|
100% |
80% to Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
Preventative
Care For Adults: (Age 19 and Older)
- Routine Pap Smears, annual mammogram
- PSA For Men
- Annual Physical Examination/Health
Screening
- Diagnostic lab work & X-rays
|
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
| Primary Care
Office Visits |
All except a
$10 copay per visit1 |
All except a
$30 copay per visit |
60% to
Out-of-Pocket Maximum then 100% |
|
Professional Services - Insurer Pays After Deductible is Met
|
| Surgery,
anesthesia, radiation therapy, in-hospital doctor visits, diagnostic
X-ray and lab work. |
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
| Inpatient
Hospital Services |
Insurer Pays After Deductible is Met |
| Surgery,
X-rays, in-hospital doctor visits, Organ/Tissue Transplant |
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
| In-patient
medical emergency6 |
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
| In-patient
drugs |
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
| Ambulatory
and Therapeutic Services |
Insurer Pays After Deductible is Met |
| Ambulatory
Surgical Center |
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
| Ambulance
Service |
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
| Accidental
Dental |
$1,000 per
year, $200 per tooth |
$1,000 per
year, $200 per tooth |
$1,000 per
year, $200 per tooth |
| Acupuncture
and Chiropractic Services |
100% up to
$2000 |
100% up to
$2000 |
100% up to
$2000 |
| Durable
Medical Equipment |
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
| Infusion
Therapy |
100% |
80% to
Out-of-Pocket Maximum then 100% |
60% to
Out-of-Pocket Maximum then 100% |
|
Physical/Occupational Therapy |
$30/visit,
12 visits per year |
$30/visit,
12 visits per year |
$30/visit,
12 visits per year |
| Basic
Prescription Drug Benefit |
50% of
actual charges up to $500 |
$0 |
$0 |
| Optional
Prescription Drug Benefit |
Insurer Waives Deductible |
|
Subject to $5,000 Maximum Benefit per Insured Person per Policy
Period. |
100% of actual charges |
Generics: 100% after $10 copay
Brandname: 100% after $25 copay
Injectables: 70% |
Generics: 100% after $10 copay
Brandname: 100% after $25 copay
Injectables: 70% |
| Global
Travel Benefits |
Insurer Waives Deductible |
| Medical
Evacuation |
Up to
$100,000 |
n/a |
n/a |
| Repatriation
of Remains |
Up to
$25,000 |
n/a |
n/a |
| Accidental
Death and Dismemberment |
$50,000 |
$50,000 |
$50,000 |
| |
Global Citizen
Plan 1,2,3,4,5 |
Deductible
|
Coinsurance Maximum
|
|
Outside U.S.
|
U.S.in Network
|
U.S.out of
Network |
| Elite
|
$0 |
$0 |
$1,000 |
$2,000 |
| 500
|
$250 |
$500 |
$1,000 |
$3,000 |
| 1,000
|
$500 |
$1,000 |
$2,000 |
$4,000 |
| 2,000
|
$1,000 |
$2,000 |
$4,000 |
$8,000 |
| 5,000
|
$2,500 |
$5,000 |
$10,000 |
$10,000 |
| 10,000
|
$10,000 |
$10,000 |
$10,000 |
$10,000 |
| 25,000
|
$25,000 |
$25,000 |
$25,000 |
$10,000 |
1. Copay waived when
visiting an HTH Worldwide contracted provider.
2. Deductibles are Per Person per Policy Period.
3. The Out of Pocket Maximum is calculated by
adding the deductible and coinsurance maximum together. A family
is charged a maximum of 2.5 deductibles.
4. Amounts paid to satisfy a deductible are
credited to all other deductibles, both inside and outside the
U.S. For example, if you satisfy your Outside U.S. deductible,
this amount is credited to the U.S. (In Network) and U.S. (Outside
Network) deductible requirement.
5. An Insured Person only has to satisfy his/her
Out of Pocket Maximum once a Year for all services received
outside of the U.S. and in the U.S.
6. Emergency room visits that do not result in
inpatient admissions will be subject to a $50 penalty
|
|
Participating and
Non-Participating Providers |
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 |
| |
|
Other Benefits |
Limits |
| Home
Health Care |
100% Covered Expenses, as many as 30
visits per year |
| Skilled
Nursing Facilities |
100% with a maximum Covered Expense of
$250 per day, as many as 50 days per year |
| Hospice |
100% with a maximum Covered Expense of
$5,000 per lifetime |
|
