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In-Patient Medical Benefits
| Hospital room and 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 private room rate PLATINUM: Subject to deductible and coinsurance for average private room rate |
| Surgery? | BRONZE: Up to the maximum limit SILVER: Up to the maximum limit GOLD: Subject to deductible and coinsurance PLATINUM: Subject to deductible and coinsurance |
| Intensive care unit? | BRONZE: Up to the overall maximum limit. SILVER: $1,500 limit per day - 180 days of coverage per event.Subject to deductible and coinsurance. GOLD: Subject to deductible and coinsurance PLATINUM: Subject to deductible and coinsurance |
| Physician visits? | Physician visits or services: Up to the maximum limit |
| Hospital indemnity(Inpatient hospitalization outside the U.S. only)? | Private Hospitals: $400 maximum limit per overnight and $4,000 maximum limit per period of coverage Public Hospitals: $500 maximum limit per overnight and $5,000 maximum limit per period of coverage. Not subject to deductible or coinsurance |
Out-Patient Medical Benefits
| Physical Therapy? | BRONZE: Subject to deductible and coinsurance. $40 maximum per visit - 10 visit limit per event. Available for 90 days following inpatient treatment or outpatient surgery SILVER: Subject to deductible and coinsurance.$40 maximum per visit - 30 visit limit per event. GOLD: Subject to deductible and coinsurance.$50 maximum per visit PLATINUM: Subject to deductible and coinsurance.$50 maximum per visit |
| Chemotherapy / 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 |
| Treatment Outside the U.S. | BRONZE: 50% of deductible waived, up to a maximum of $2,500. No coinsurance SILVER: 50% of deductible waived, up to a maximum of $2,500. No coinsurance GOLD: 50% of deductible waived, up to a maximum of $2,500. No coinsurance PLATINUM: 50% of deductible waived, up to a maximum of $2,500. No coinsurance |
| Treatment Inside the U.S. (using Medical Concierge) | BRONZE: 50% of deductible waived, up to a maximum of $2,500. No coinsurance SILVER: 50% of deductible waived, up to a maximum of $2,500. No coinsurance GOLD: 50% of deductible waived, up to a maximum of $2,500. No coinsurance PLATINUM: 50% of deductible waived, up to a maximum of $2,500. No coinsurance |
| Treatment Inside the U.S. (PPO Network) | BRONZE: Subject to deductible. No coinsurance SILVER: Subject to deductible. No coinsurance GOLD: Subject to deductible. No coinsurance PLATINUM: Subject to deductible. No coinsurance |
| Treatment Inside the U.S. (Non PPO Network)? | BRONZE: Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage SILVER: Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage GOLD: Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage PLATINUM: Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage |
| Office visits and Diagnostic/X-Ray | BRONZE: $300 maximum per visit - lab tests; $250 maximum per visit - diagnostic X-rays $500 maximum limit - specialists/physician charges (pre-inpatient / post-inpatient)Subject to deductible and coinsurance SILVER: $300 maximum per visit - lab tests; $250 maximum per visit - diagnostic X-rays $25 combined maximum visits $70 per visit/examination - specialists/physician charges$50 per visit/examination - chiropractor charges $500 maximum limit - surgery intervention consultation charges Subject to deductible and coinsurance GOLD: Subject to deductible and coinsurance PLATINUM: Subject to deductible and coinsurance |
| CAT 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 |
| Assistant Surgeon? | BRONZE: 20% of primary surgeon’s charge SILVER: 20% of primary surgeon’s charge GOLD: 20% of primary surgeon’s charge PLATINUM: 20% of primary surgeon’s charge |
| Transplants | BRONZE: $250,000 lifetime maximum SILVER: $250,000 lifetime maximum GOLD: $1,000,000 lifetime maximum PLATINUM: $2,000,000 lifetime maximum |
| Chiropractic Care? | Up to the maximum limit |
Emergency Services
| Emergency local ambulance? | BRONZE: $1,500 maximum limit per event.Not subject to deductible or coinsurance SILVER: $1,500 maximum limit per event.Not subject to deductible or coinsurance GOLD: Subject to deductible and coinsurance.U.S. only PLATINUM: subject to deductible or coinsurance |
| Emergency room accident | BRONZE: Up to the maximum limit SILVER: Up to the maximum limit GOLD: Up to the maximum limit PLATINUM: Up to the maximum limit |
| Emergency room illness | BRONZE: Subject to deductible and coinsurance. Covered only if admitted as inpatient SILVER: Subject to deductible and coinsurance. Covered only if admitted as inpatient GOLD: Subject to deductible and coinsurance.Additional $250 deductible if not admitted as an inpatient PLATINUM: Subject to deductible and coinsurance.Additional $250 deductible if not admitted as an inpatient |
Dental
| Non-Emergency Dental | BRONZE: Optional Rider SILVER: Optional Rider |
| Traumatic Dental InjuryTreatment at a hospital facility? | BRONZE: $1,000 per period of coverage SILVER: $1,000 per period of coverage GOLD: $100 per period of coverage PLATINUM: Up to the lifetime maximum limit |
| Treatment Due to Unexpected Pain to Sound, Natural Teeth | GOLD: 100% PLATINUM: 100% |
| Non-Emergency Dental | GOLD: $500 per period of coverage PLATINUM: $750 maximum per period of cov-erage; $50 individual deductible, applies to minor restorative and major restorative services |
Evacuation
| Emergency medical evacuation? | BRONZE: $50,000 maximum per period of coverage.Not subject to deductible or coinsurance SILVER: $50,000 maximum per period of coverage.Not subject to deductible or coinsurance GOLD: Up to maximum limit. Not subject to deductible or coinsurance PLATINUM: Up to maximum limit. Not subject to deductible or coinsurance |
| Return of mortal remains or cremation/burial? | BRONZE: $10,000 maximum limit. Not subject to deductible SILVER: $25,000 maximum limit. Not subject to deductible GOLD: $25,000 lifetime maximum. Not subject to deductible or coinsurance PLATINUM: $50,000 lifetime maximum. Not subject to deductible or coinsurance |
| Emergency reunion? | BRONZE: $10,000 maximum limit. Not subject to deductible SILVER: $10,000 maximum limit. Not subject to deductible GOLD: $10,000 maximum limit. Not subject to deductible PLATINUM: $10,000 maximum limit. Not subject to deductible |
Life
| Orphan or Biologic Drugs | BRONZE: Inpatient Treatment maximum limit: $250,000.Outpatient Surgery: up to the maximum limit.Subject to deductible and coinsurance.Does not apply to maximumlimit per event(Available when all conditions are met) » Approved in writing by company » Medically necessary » Not experimental or investigational Applies to period of coverage max. Max limit applies towards lifetime max. SILVER: Inpatient Treatment maximum limit: $250,000.Subject to deductible and coinsurance.(Available when all conditions are met) » Approved in writing by company » Medically necessary » Not experimental or investigational Applies to period of coverage max. Max limit applies towards lifetime max. GOLD: Inpatient & Outpatient Treatmentmaximum limit: $250,000. PLATINUM: Maximum limit $250,000. |
| 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. PLATINUM: $250 lifetime maximum. |
| Vision | BRONZE: Optional Rider SILVER: Optional Rider GOLD: Optional Rider PLATINUM: $100 maximum per 24 months for exams. $150 per 24 months for materials |
| Pre-Existing Conditions Limitation | BRONZE: Excluded SILVER: $50,000 lifetime maximum; $5,000 per period of coverage for unknown conditions.Available after 24 months of continuous coverage* GOLD: $50,000 lifetime maximum; $5,000 per period of coverage for unknown conditions. Available after 24 months of continuous coverage* PLATINUM: Covered if disclosed and not excluded by rider |
Other Benefits
| Prescription Coverage | BRONZE: Subject to deductible and coinsurance.Available for 90 days following related inpatient treatment or outpatient surgery.$600 maximum limit per event(includes dressings and durable medical equipment) SILVER: Subject to deductible and coinsurance.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: 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% |
Email: insurance@imglobal.com
Fax: 317-655-4505
1.800.628.4664
International Medical Group
P.O.Box 88500 Indianapolis,
IN 46208-0500
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