The following is a summary schedule of benefits for eligible medical expenses. Benefits are subject to maximums, deductible and coinsurance unless otherwise noted. NA (Not Applicable).
| Summary of Benefits |
| Benefit | Bronze | Silver | Gold | Platinum |
|---|---|---|---|---|
| Lifetime Maximum Limit | $1,000,000 per individual | $5,000,000 per individual | $5,000,000 per individual | $8,000,000 per individual |
| Deductible (Per period of coverage) | $250 to $10,000 | $250 to $10,000 | $250 to $25,000 | $100 to $25,000 |
| Treatment Outside the U.S. | 50% of deductible waived, up to a maximum of $2,500. No coinsurance. | 50% of deductible waived, up to a maximum of $2,500. No coinsurance. | 50% of deductible waived, up to a maximum of $2,500. No coinsurance. | 50% of deductible waived, up to a maximum of $2,500. No coinsurance. |
| Treatment inside the U.S. using Medical Concierge | 50% of deductible waived, up to a maximum of $2,500. No coinsurance. | 50% of deductible waived, up to a maximum of $2,500. No coinsurance. | 50% of deductible waived, up to a maximum of $2,500. No coinsurance. | 50% of deductible waived, up to a maximum of $2,500. No coinsurance. |
| Treatment inside the U.S. - PPO Network | Subject to deductible. No coinsurance. | Subject to deductible. No coinsurance. | Subject to deductible. No coinsurance. | Subject to deductible. No coinsurance. |
| Treatment inside the U.S. - Non-PPO Network | Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. | Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. | Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. | Subject to deductible. Plan pays 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage. |
| Coinsurance | International – 100% U.S. in-network – 100% U.S. out-of-network – 80% | International – 100% U.S. in-network – 100% U.S. out-of-network – 80% | International – 100% U.S. in-network – 100% U.S. out-of-network – 80% | International – 100% U.S. in-network – 100% U.S. out-of-network – 80% |
| Outpatient | $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 | $300 maximum per visit – lab tests; $250 maximum per visit – diagnostic x-rays
25 combined maximum visits Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance |
| Mental/Nervous | N/A | Outpatient after 12 months of continuous coverage. | $10,000 maximum per period of coverage with a $50,000 lifetime maximum - Available after 12 months of continuous coverage. | $50,000 lifetime maximum - Available after 12 months of continuous coverage |
| Hospital Emergency Room Injury | Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance |
| Hospital Emergency Room Illness | Subject to deductible and coinsurance. Covered only if admitted as inpatient | Subject to deductible and coinsurance. Additional $250 deductible if not admitted as an inpatient | Subject to deductible and coinsurance. Additional $250 deductible if not admitted as an inpatient | Subject to deductible and coinsurance. Additional $250 deductible if not admitted as an inpatient |
| Hospitalization / Room & Board | Subject to deductible and coinsurance for average semi-private room rate | Subject to deductible and coinsurance for average semi-private room rate. All subject to $600 per day/240 day maximum | Subject to deductible and coinsurance for average semi-private room rate | Subject to deductible and coinsurance for average private room rate |
| Intensive Care Unit | Subject to deductible and coinsurance | Subject to deductible and coinsurance. $1,500 limit per day – 180 days of coverage per event | Subject to deductible and coinsurance | Subject to deductible and coinsurance |
| CAT Scans, MRI, Echocardiography, Endoscopy, Gastroscopy, Cystoscopy | Subject to deductible and coinsurance. $600 maximum per examination | Subject to deductible and coinsurance. $600 maximum per examination | Subject to deductible and coinsurance | Subject to deductible and coinsurance |
| Surgery | Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance |
| Assistant Surgeon | 20% of primary surgeon’s charge | 20% of primary surgeon’s charge | 20% of primary surgeon’s charge | 20% of primary surgeon’s charge |
| Chemotherapy or Radiation Therapy | Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance |
|
Maternity Delivery, preventative, newborn care & congenital disorders, Family Matters Maternity Program (available after 10 months of coverage) | N/A | N/A | N/A | $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 | N/A | N/A | $750 maximum limit | $750 maximum limit |
| Physical Therapy | Subject to deductible and coinsurance. $40 maximum per visit – 10 visit limit per event. Available for 90 days following inpatient treatment or outpatient surgery | Subject to deductible and coinsurance. $40 maximum per visit – 30 visit limit | Subject to deductible and coinsurance. $50 maximum per visit | Subject to deductible and coinsurance. $50 maximum per visit |
| Transplants | $250,000 lifetime maximum | $250,000 lifetime maximum | $1,000,000 lifetime maximum | $2,000,000 lifetime maximum |
| Prescription Drugs, Dressings, and Durable Medical Equipment | Subject to deductible and coinsurance. Available for 90 days following related inpatient treatment or outpatient surgery. $600 outpatient maximum limit per event | Subject to deductible and coinsurance. 90-day supply per prescription following related covered event.
U.S. Retail Pharmacy | Subject to deductible and coinsurance. 90-day supply per prescription.
U.S. Retail Pharmacy | U.S. Retail Pharmacy: prescription drug card required. Copay 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 Program | N/A | N/A | N/A | Copay per 30-day supply: $20 for generic/$40 for non-preferred brand name. Must enroll via provider website: www.expatps.com Dispensing maximum: 180 days |
|
Orphan or Biologic Drugs (Available when all conditions are met)
| Inpatient Treatment maximum limit: $250,000. Outpatient Surgery: up to the maximum limit. Subject to deductible and coinsurance. Does not apply to maximum limit per event | Outpatient and Emergency Department Treatment maximum limit: $250,000. Subject to deductible and coinsurance | Inpatient & Outpatient Treatment maximum limit: $250,000. Subject to deductible and coinsurance | 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 |
$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 |
$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 |
$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 |
$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 | Optional Rider | Optional Rider | Optional Rider | $100 maximum per 24 months for exams. $150 per 24 months for materials |
|
Emergency Local Ambulance (Injury or illness resulting in an inpatient hospital admission) | $1,500 maximum limit per event - not subject to deductible or coinsurance. | $1,500 maximum limit per event - not subject to deductible or coinsurance. | Subject to deductible and coinsurance | Not subject to deductible and coinsurance |
| Emergency Evacuation |
$50,000 maximum per period of coverage. Not subject to deductible or coinsurance. |
$50,000 maximum per period of coverage. Not subject to deductible or coinsurance. |
Up to lifetime maximum limit. Not subject to deductible or coinsurance. |
Up to lifetime maximum limit. Not subject to deductible or coinsurance. |
| Emergency Reunion | $10,000 lifetime maximum. Not subject to deductible or coinsurance | N/A | $10,000 lifetime maximum. Not subject to deductible or coinsurance | $10,000 lifetime maximum. Not subject to deductible or coinsurance |
| Interfacility Ambulance Transfer (Transfer from one licensed health care Facility to another licensed health care Facility) | $1,500 maximum limit per event. Not subject to deductible or coinsurance. U.S. only | $1,500 maximum limit per event. Not subject to deductible or coinsurance. U.S. only |
Subject to deductible and coinsurance. U.S. only | Not subject to deductible or coinsurance. U.S. only |
| Political Evacuation and Repatriation | N/A | N/A | N/A | $10,000 lifetime maximum |
| Remote Transportation | N/A | N/A | N/A | $5,000 per period of coverage up to $20,000 lifetime maximum. Not subject to deductible or coinsurance |
| Return of Mortal Remains | $10,000 lifetime maximum - not subject to deductible or coinsurance. | $25,000 lifetime maximum - not subject to deductible or coinsurance. | $25,000 lifetime maximum - not subject to deductible or coinsurance. | $50,000 lifetime maximum - not subject to deductible or coinsurance. |
| Complementary Medicine | N/A | N/A | $500 maximum limit per period of coverage | $500 maximum limit per period of coverage |
| Traumatic Dental Injury Treatment at a hospital facility | $1,000 per period of coverage | $1,000 per period of coverage | Up to the lifetime maximum limit | Up to the lifetime maximum limit |
| Treatment Due to Unexpected Pain to Sound, Natural Teeth | N/A | N/A | $100 per period of coverage | 100% |
| Non-Emergency Treatment at a Dental Provider due to an Accident | N/A | N/A | $500 per period of coverage | See Non-Emergency Dental benefit |
| Non-emergency Dental | Optional Rider | Optional Rider | Optional Rider | $750 maximum per period of coverage; $50 individual deductible, applies to minor restorative and major restorative services |
| Hospital Indemnity (Inpatient hospitalization outside the U.S. only) |
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage. Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage. |
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage. Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage. |
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage. Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage. |
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage. Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage. |
| Supplemental Accident | N/A | N/A |
$300 of Eligible Medical Expenses following an accident. Not subject to deductible or coinsurance |
$500 of Eligible Medical Expenses following an accident. Not subject to deductible or coinsurance |
| Amateur Saliboat Racing | Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance | Subject to deductible and coinsurance |
| Crew Member Return | $2,500 maximum limit. Not subject to deductible or coinsurance | $2,500 maximum limit. Not subject to deductible or coinsurance | $2,500 maximum limit. Not subject to deductible or coinsurance | $2,500 maximum limit. Not subject to deductible or coinsurance |
| Adult Preventative Care (Age 19 or older) | N/A | N/A |
$250 per period of coverage. Not subject to deductible or coinsurance |
$500 per period of coverage. Not subject to deductible or coinsurance |
| Pre-Existing Conditions Limitation** | Excluded | $50,000 lifetime maximum; $5,000 per period of coverage for unknown conditions. Available after 24 months of continuous coverage.** | $50,000 lifetime maximum; $5,000 per period of coverage for unknown conditions. Available after 24 months of continuous coverage.** | Covered if disclosed and not excluded by rider |
**If applicants can verify their prior health insurance, with no significant break in coverage (63 days), IMG may accept this as Creditable Coverage and provide a pre-existing conditions waiver (final decision is subject to Underwriters approval). Creditable Coverage is defined as a group health plan provided by a U.S. employer or Health Insurance Issuer, individual major medical health insurance provided by a Health Insurance Issuer, or other Public Health Plan (any health plan established or maintained by a State or the U.S. government).
* This Web page contains only a consolidated and summary description of all current benefits, conditions, limitations and exclusions. A certificate containing the complete Certificate Wording with all terms, conditions and exclusions will be included in the fulfillment kit. IMG reserves the right to issue the most current Certificate Wording for this insurance plan in the event this Web page, application, and/or brochure has expired, is modified, or is replaced with a newer version. Current Certificate Wordings are available upon request.