|
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
|
|
Preventive and
Office Visits
|
Insurer Waives
Deductible
|
|
Physician Office
Visits (Adult)
|
All except a $10
copay per visit1
|
All except a $30
copay per visit
|
60% to
Out-of-Pocket Maximum then 100%
|
|
Physician Office
Visits (Children 0-18)
|
100%
|
80% to
Out-of-Pocket Maximum then 100%
|
60% to
Out-of-Pocket Maximum then 100%
|
|
Child
Immunizations, Lab work & X-rays
|
100%
|
80% to
Out-of-Pocket Maximum then 100%
|
60% to
Out-of-Pocket Maximum then 100%
|
|
Women: (25 and
Older)
Routine Pap Smears, annual mammogram
|
100%
|
80% to
Out-of-Pocket Maximum then 100%
|
60% to
Out-of-Pocket Maximum then 100%
|
|
PSA for Men
|
100%
|
80% to
Out-of-Pocket Maximum then 100%
|
60% to
Out-of-Pocket Maximum then 100%
|
|
One Routine
Physical Per Year
|
100%
|
80% to
Out-of-Pocket Maximum then 100%
|
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
|
|
After 12 months of continuous coverage, Global Citizen
members may renew their coverage or apply for a new plan that
covers maternity costs in the same way as all other medical
conditions.
To be eligible for the maternity benefit, a member must not
be pregnant at the time of upgrade.
![[smlogo graphic]](../images/smlogo.gif)
