GeoBlue Xplorer Benefits

GeoBlue Brochure

PREMIER PLAN BENEFITS

Three tiers of coinsurance apply: 100% outside the U.S. , 80% in network in the U.S. , 60% out of network inside the U.S. All plan options have an Unlimited Lifetime Maximum and a $250,000 maximum benefit for emergency medical evacuation.

Features Outside U.S. U.S.(In Network) U.S.(Outside Network)
Lifetime Maximum per Insured Person Unlimited Unlimited Unlimited
Annual Maximum per Insured Person Unlimited Unlimited Unlimited
Preventative and Primary Care Insurer waives deductible
Preventative Care For Babies/Children: (Birth to Age 18)

  1. Office Visits/examination
  2. Immunizations, Lab work & X-rays
100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Preventative Care For Adults: (Age 19 and Older)

  1. Routine Pap Smears, annual mammogram
  2. PSA For Men
  3. Annual Physical Examination/Health Screening
  4. Diagnostic lab work & X-rays
100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Primary Care Office Visits All except a $10 copay per visit 1 All except a $30 copay per visit 60% to Coinsurance 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 Coinsurance Maximum then 100% 60% to Coinsurance 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 Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
In-patient medical emergency 6 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
In-patient drugs 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Ambulatory and Therapeutic Services Insurer Pays After Deductible is Met
Ambulatory Surgical Center 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Ambulance Service 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance 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 80% up to $2000 60% up to $2000
Durable Medical Equipment 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Infusion Therapy 100% 80% to Coinsurance Maximum then 100% 60% to Coinsurance Maximum then 100%
Physical/Occupational Therapy $30/visit, 12 visits per year $30/visit, 12 visits per year $30/visit, 12 visits per year
Rehabilitation and Therapy Insurer Pays After Deductible is Met
a.Inpatient Mental Health

100% up to 60 days 80% up to 60 days 60% up to 60 days
b.Outpatient Mental Health

75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter
c.Inpatient Substance Abuse

100% up to 60 days detox 80% up to 60 days detox 60% up to 60 days detox
d.Outpatient Substance Abuse

75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter
Prescription Drug Benefit Options Insurer Waives Deductible
Basic Prescription Drug Benefits 100% of actual charges up to $500 $0 $0
Optional Rider, subject to $25,000 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 $250,000 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
Plan Options
1,2,3,4,5,6
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 outside the U.S..
2. Deductibles are Per Person per Calendar Year.
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

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

Services provided in addition to the benefits above

 Ready access to quality care

  • Access to HTH Worldwide’s global community of carefully selected, contracted hospitals, physicians, dentists and behavioral health professionals in over 180 countries.
  • Detailed provider profiles including medical training.
  • Personalized appointment scheduling and recruitment.
  • Fully profiled international treatment options.
  • Competitive U.S. PPO network and centers of excellence.
  • Emergency evacuation.
  • View More Details

 mPassport and Global Health and Safety Resources

  • Online and mobile assistance tools with full telephone support.
  • Daily email of health and security alerts
  • Detailed descriptions of health facilities and security issues by destination
  • Translation databases for brand name drugs and medical terms/phrases.
  • Web pages capturing key personalized HTH Resources by destination.
  • View More Details

For Exclusions and Limitations see Plan Description.

Ten Day Money Back Guarantee
YOUR SATISFACTION IS GUARANTEED. We are so confident in our products that we offer the best guarantee in the business! If you are not completely satisfied with our Global Citizen Product, simply return your Certificate of Insurance and your ID Card to HTH within 10 days of your policy effective date. If you have not already used your insurance benefits, you will receive a full refund.

ESSENTIAL PLAN BENEFITS

Benefit Schedule

Offers 100% coverage across most benefits. All plan options have an Unlimited Lifetime Maximum and a $250,000 maximum benefit for emergency medical evacuation.

Features Benefits
Lifetime Maximum per Insured Person Unlimited
Annual Maximum per Insured Person Unlimited
Preventative and Primary Care Insurer waives deductible
Preventative Care For Babies/Children: (Birth to Age 18)

  1. Office Visits/examination
  2. Immunizations, Lab work & X-rays
100%
Preventative Care For Adults: (Age 19 and Older)

  1. Routine Pap Smears, annual mammogram
  2. PSA For Men
  3. Annual Physical Examination/Health Screening
  4. Diagnostic lab work & X-rays
100%
Primary Care Office Visits All except a $10 copay per visit 1
Professional Services Insurer Pays After Deductible is Met
Surgery, anesthesia, radiation therapy, in-hospital doctor visits, diagnostic X-ray and lab work. 100%
Inpatient Hospital Services Insurer Pays After Deductible is Met
Surgery, X-rays, in-hospital doctor visits, Organ/Tissue Transplant 100%
In-patient medical emergency 2 100%
In-patient drugs 100%
Ambulatory and Therapeutic Services Insurer Pays After Deductible is Met
Ambulatory Surgical Center 100%
Ambulance Service 100%
Accidental Dental $1,000 per year, $200 per tooth
Acupuncture and Chiropractic Services 100% up to $2,000
Durable Medical Equipment 100%
Infusion Therapy 100%
Physical/Occupational Therapy $30/visit, 12 visits per year
Rehabilitation and Therapy Insurer Pays After Deductible is Met
a.Inpatient Mental Health

100% up to 60 days
b.Outpatient Mental Health

75% up to 40 visits/60% thereafter
c.Inpatient Substance Abuse

100% up to 60 days detox
d.Outpatient Substance Abuse

75% up to 40 visits/60% thereafter
Prescription Drug Benefit Options Insurer Waives Deductible
Basic Prescription Drug Benefit 100% of actual charges up to $500
Optional Prescription Drug Benefit, Subject to $25,000 Maximum per Insured Person per Policy Period 80% of actual charges
Global Travel Benefits Insurer Waives Deductible
Medical Evacuation Up to $250,000
Repatriation of Remains Up to $25,000
Accidental Death and Dismemberment $50,000
Plan Options 1,2 Deductible 3
Elite $0
250 $250
500 $500
1,000 $1,000
2,500 $2,500
5,000 $5,000
10,000 $10,000

1. Copay waived when visiting an HTH Worldwide contracted provider.
2. Emergency room visits that do not result in inpatient admissions will be subject to a $50 penalty.
3. Deductibles are Per Person per Calendar Year. A family is charged a maximum of 2.5 deductibles.

Services provided in addition to the benefits above

 Ready access to quality care

  • Access to HTH Worldwide’s global community of carefully selected, contracted hospitals, physicians, dentists and behavioral health professionals in over 180 countries.
  • Detailed provider profiles including medical training.
  • Personalized appointment scheduling and recruitment.
  • Direct payment to providers.
  • Fully profiled international treatment options.
  • Emergency evacuation.
  • View More Details

 mPassport and Global Health and Safety Resources

  • Online and mobile assistance tools with full telephone support.
  • Daily email of health and security alerts
  • Detailed descriptions of health facilities and security issues by destination
  • Translation databases for brand name drugs and medical terms/phrases.
  • Web pages capturing key personalized HTH Resources by destination.
  • View More Details

For Exclusions and Limitations see Plan Description.

Ten Day Money Back Guarantee
YOUR SATISFACTION IS GUARANTEED. We are so confident in our products that we offer the best guarantee in the business! If you are not completely satisfied with our Global Citizen Product, simply return your Certificate of Insurance and your ID Card to HTH within 10 days of receipt and include a letter indicating your desire to cancel. If you have not already used your insurance benefits, you will receive a full refund.