| Plan benefits |
| Lifetime Maximum Limit |
BRONZE: $1 million/individual
SILVER: $5 million/individual
GOLD: $5 million/individual
PLATINUM: $8 million/individual |
| Deductible (Per Period of Coverage) |
BRONZE: $250 to $10,000
SILVER: $250 to $10,000
GOLD: $250 to $25,000
PLATINUM: $100 to $25,000 |
| Optional Coverage at additional cost |
BRONZE: Global Term Life Insurance including Accidental Death & Dismemberment; Dental and Vision
SILVER: Global Term Life Insurance including Accidental Death & Dismemberment; Dental and Vision
GOLD: Global Term Life Insurance including Accidental Death & Dismemberment; Adventure Sports Rider; Dental and Vision
PLATINUM: Global Term Life Insurance including Accidental Death & Dismemberment; Terrorism; Adventure Sports Rider |
| Mental/Nervous |
BRONZE: No Coverage
SILVER: Outpatient after 12 months of continuous coverage
GOLD: $10,000 maximum. Avaliable after 12 months of continuous coverage
PLATINUM: $50,000 lifetime maximum. Avaliable after 12 months of continuous coverage |
| Hospital Emergency Room Injury |
BRONZE: Subject to deductible and coinsurance
SILVER: Subject to deductible and coinsurance
GOLD: Subject to deductible and coinsurance
PLATINUM: Subject to deductible and coinsurance |
| Hospital Emergency Room Illness |
BRONZE: Covered only if admitted as inpatient
SILVER: Additional $250 deductible if not admitted as an inpatient
GOLD: Additional $250 deductible if not admitted as an inpatien
PLATINUM: Additional $250 deductible if not admitted as an inpatien |
| Hospital Room & Board |
BRONZE: Subject to deductible and coinsurance for average semi-private room rate
SILVER: Subject to deductible and coinsurance for average semi-private room rate.All subject to $600 per day /240 day maximum
GOLD: Subject to deductible and coinsurance for average semi-private room rate
PLATINUM: Subject to deductible and coinsurance for average private room rate |
| Intensive care unit |
BRONZE: Subject to deductible and coinsurance
SILVER: $1,500 limit per day - 180 days of coverage per event
GOLD: Subject to deductible and coinsurance
PLATINUM: Subject to deductible and coinsurance |
| Scans, MRI, Echocardiography, Endoscopy, Gastroscopy, Cystoscopy |
BRONZE: Subject to deductible and coinsurance
$600 maximum limit per examination
SILVER: Subject to deductible and coinsurance
$600 maximum limit per examination
GOLD: Subject to deductible and coinsurance
PLATINUM: Subject to deductible and coinsurance |
| Surgeon |
BRONZE: Subject to deductible and coinsurance
SILVER: Subject to deductible and coinsurance
GOLD: Subject to deductible and coinsurance
PLATINUM: Subject to deductible and coinsurance |
| Assistant Surgeon |
BRONZE: 20% of primary surgeon’s charge
SILVER: 20% of primary surgeon’s charge
GOLD: 20% of primary surgeon’s chargel
PLATINUM: 20% of primary surgeon’s charge |
| Chemotherapy or Radiation Therapy |
BRONZE: Subject to deductible and coinsurance
SILVER: Subject to deductible and coinsurance
GOLD: Subject to deductible and coinsurance
PLATINUM: Subject to deductible and coinsurance |
| Maternity |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: No Coverage
PLATINUM: $2,500 additional deductible per pregnancy.
$50,000 lifetime maximum.
$200 newborn preventative care benefit for the first 31 days -12 months after birth.
$250,000 maximum for newborn care & congenital disorders for the first 31 days after birth. |
| Podiatry Care |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: $750 per period of coverage
PLATINUM: $750 per period of coverage |
| Physical therapy |
BRONZE: $40 maximum per visit - 10 visit limit per event. Available for 90 days following inpatient treatment or outpatient surgery
SILVER: $40 maximum per visit - 30 visit limit
GOLD: $50 maximum per visit
PLATINUM: $50 maximum per visit |
| Transplants |
BRONZE: $250,000 lifetime maximum
SILVER: $250,000 lifetime maximum
GOLD: $1,000,000 lifetime maximum
PLATINUM: $2,000,000 lifetime maximum |
| Prescription Coverage |
BRONZE: Available for 90 days following related inpatient treatment or outpatient surgery.
$600 maximum limit per event(includes dressings and durable medical equipment)
SILVER: 90-day supply per prescription following related covered event.U.S.
Retail Pharmacy out-of-network: 80%
International Retail Phamacy: 100%
GOLD: 90-day supply per prescription.U.S. Retail Pharmacy out-of-network: 80%
International Retail Phamacy: 100%
PLATINUM: U.S. Retail Pharmacy: prescription drug card required.Co-pay per 30-day supply: $20 for generic / $40 for brand name where generic is not available.International Retail Pharmacy(subject to deductible): 100% |
| Expatriate Prescription Services |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: No Coverage
PLATINUM: Co-pay per 30-day supply: $20 for generic / $40 for non-preferred brand name.
Must enroll via provider website: www.expatps.comDispensing maximum: 180 days |
| Orphan or Biologic Drugs |
BRONZE: Inpatient Treatment maximum limit: $250,000.
Outpatient Surgery: up to the maximum limit.
Subject to deductible and coinsuranceDoes not apply to maximum limit per event
SILVER: Inpatient & Outpatient Treatmentmaximum limit: $250,000
GOLD: Inpatient & Outpatient Treatmentmaximum limit: $250,000
PLATINUM: Maximum limit $250,000.U.S. Retail Pharmacy & expatriate prescription services program: Subject to copayments.
International retail pharmacy: Subject to deductible and coinsurance.
Inpatient/outpatient medical treatment: Subject to deductible and coinsurance |
| Healthy Travel Preventative Coverage |
BRONZE: $250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination
SILVER: $250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination
GOLD: $250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination
PLATINUM: $250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
| Vision |
BRONZE: Optional Rider
SILVER: Optional Rider
GOLD: Optional Rider
PLATINUM: $100 maximum per 24 months for exams. $150 per 24 months for materials |
| Local Ambulance (U.S. only) |
BRONZE: $1,500 maximum limit per event
SILVER: $1,500 maximum limit per event
GOLD: Subject to deductible and coinsurance.
PLATINUM: Not subject to deductible or coinsurance |
| Emergency evacuation |
BRONZE: Up to $50,000 maximum per period of coverage. Not subject to deductible or coinsurance.
SILVER: Up to $50,000 maximum per period of coverage. Not subject to deductible or coinsurance.
GOLD: Up to lifetime maximum limit. Not subject to deductible or coinsurance.
PLATINUM: Up to maximum limit. Not subject to deductible or coinsurance. |
| Emergency reunion |
BRONZE: $10,000 lifetime maximum
SILVER: No Coverage
GOLD: $10,000 lifetime maximum
PLATINUM: $10,000 lifetime maximum |
| Interfacility Ambulance Transfer |
BRONZE: $1,500 maximum limit per event. Not subject to deductible or coinsurance.U.S. only
SILVER: $1,500 maximum limit per event. Not subject to deductible or coinsurance.U.S. only
GOLD: Subject to deductible and coinsurance.U.S. only
PLATINUM: Not subject to deductible and coinsurance.U.S. only |
| Political Evacuation and Repatriation |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: No Coverage
PLATINUM: $10,000 lifetime maximum |
| Remote Transportation |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: No Coverage
PLATINUM: $5,000 per period of coverage up to $20,000 lifetime maximum. Not subject to deductible or coinsurance |
| Return of Mortal Remains (not subject to deductible or coinsurance) |
BRONZE: $10,000 lifetime maximum
SILVER: $25,000 lifetime maximum
GOLD: $25,000 lifetime maximum
PLATINUM: $50,000 lifetime maximum |
| Complementary Medicine |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: $500 maximum limit per period of coverage
PLATINUM: $500 maximum limit per period of coverage |
| Traumatic Dental Injury |
BRONZE: $1,000 per period of coverage
SILVER: $1,000 per period of coverage
GOLD: Up to lifetime maximum limit
PLATINUM: Up to lifetime maximum limit |
| Adult Preventative Care(Age 19 or older) |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: $250 per period of coverage
PLATINUM: $500 per period of coverage |
| Treatment Due to Unexpected Pain to Sound, Natural Teeth |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: $100 per period of coverage
PLATINUM: $100 |
| Non Emergency Dental due to Accident |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: $500 per period of coverage
PLATINUM: $750 maximum per period of coverage; $50 individual deductible, applies to minor restorative and major restorative services |
| Non Emergency Dental |
BRONZE: Optional Rider
SILVER: Optional Rider
GOLD: Optional Rider
PLATINUM: $750 maximum per calendar year; $50 individual deductible, applies to minor restorative and major restorative services. |
| Supplemental Accident |
BRONZE: No Coverage
SILVER: No Coverage
GOLD: $300 of eligible medical expenses following an accident . Not subject to deductible or coinsurance
PLATINUM: $500 maximum limit per accident. Not subject to deductible and coinsurance |
| Amateur Sailboat Racing |
BRONZE: Subject to deductible and coinsurance
SILVER: Subject to deductible and coinsurance
GOLD: Subject to deductible and coinsurance
PLATINUM: Subject to deductible and coinsurance |
| Crew Member Return |
BRONZE: $2,500 maximum limit.Not subject to deductible or coinsurance
SILVER: $2,500 maximum limit.Not subject to deductible or coinsurance
GOLD: $2,500 maximum limit.Not subject to deductible or coinsurance
PLATINUM: $2,500 maximum limit.Not subject to deductible or coinsurance |
| Child Preventative Care(Through age 18) |
BRONZE: No Coverage
SILVER: $70 maximum per visit, 3 visit per period of coverage
GOLD: $200 maximum per period of coverage
PLATINUM: $400 maximum per period of coverage |
| Pre-Existing Conditions Limitation |
BRONZE: Excluded
SILVER: $50,000 lifetime maximum; $5,000 per period of coverage after 24 months
GOLD: $50,000 lifetime maximum; $5,000 per period of coverage after 24 months
PLATINUM: Covered if disclosed and not excluded by rider |
