|
Age Eligibility |
14 days - 80+ years |
14 days - 69 years* |
|
Maximum Policy/Accident & Sickness Medical Coverage Limits |
$75,000
(ages 80+: $20,000) |
$200,000
(ages 65-69: $100,000) |
|
Deductible |
$0, $250, $500, or $1,000 per certificate |
$0, $520, $500, or $1,000 per certificate |
|
Coinsurance |
In-network: 100%; Out-of-network: Usual, Reasonable and Customary |
In-network: 100%; Out-of-network: Usual, Reasonable and Customary |
|
Provider Network |
GDPR residents: First Health Network
All others: UnitedHealthCare Network |
GDPR residents: First Health Network
All others: UnitedHealthCare Network |
|
Emergency Room Co-Payment |
Within the U.S.: $250 co-payment for illness unless you are admitted to the hospital. No co-payment for emergency room treatment of an injury. |
Within the U.S.: $250 co-payment for illness unless you are admitted to the hospital. No co-payment for emergency room treatment of an injury. |
|
Urgent Care Center Co-Payment |
Within the U.S.: $50 co-payment (Waived for members with $0 deductible) |
Within the U.S.: $50 co-payment (Waived for members with $0 deductible) |
|
Outpatient Physical Therapy and Chiropractic Care |
Usual, reasonable and customary charges. Must be ordered in advance by a physician. |
Usual, reasonable and customary charges. Must be ordered in advance by a physician. |
|
Emergency Dental Treatment due to Accident |
$1,000 |
$1,000 |
|
Emergency Dental (Acute Onset of Pain) |
$100 |
$100 |
Acute Onset of Pre-Existing Condition
(excludes chronic and congential conditions) |
$20,000 (ages 65 and above: $2,500) |
$20,000 (ages 65 and above: $2,500) |
|
Emergency Medical Evacuation |
$250,000 |
$250,000 |
|
COVID-19 Coverage |
Included |
Included |
|
Repatriation of Remains |
$50,000 |
$50,000 |
|
Emergency Reunion |
$15,000
(maximum 15 days) |
$15,000
(maximum 15 days) |
|
Terrorism |
$50,000 |
$50,000 |
|
Recreational Sports |
Coverage Included |
Coverage Included |
|
Personal Liability |
No Benefit |
No Benefit |
|
Accidental Death & Dismemberment |
$50,000 (ages 18-69)
$5,000 (under age 18)
$20,000 (ages 70-74)
$10,000 (ages 75 and older) |
$50,000 (ages 18-69)
$5,000 (under age 18)
$20,000 (ages 70-74)
$10,000 (ages 75 and older) |
|
Political Evacuation |
$25,000 |
$25,000 |
|
Crisis Response |
No Benefit |
No Benefit |
|
Trip Interruption |
$2,500 |
$2,500 |
|
24/7 Worldwide Assistance |
Included |
Included |
|
Optional Enhanced Accidental Death & Dismemberment |
$100,000 (ages 18-69) |
$100,000 (ages 18-69) |