| Features |
Outside U.S. |
U.S.(In Network) |
U.S.(Outside Network) |
| Lifetime Maximum per Insured Person |
$5,000,000 |
$5,000,000 |
$5,000,000 |
| Preventative and Primary Care – Deductible is not applicable |
Preventative Care For Babies/Children: (Birth to Age 18)
- Office Visits/examination
- Immunizations, Lab work & X-rays
|
100% |
80% to Out-of-Pocket Maximum then 100%s |
60% to Out-of-Pocket Maximum then 100% |
Preventative Care For Adults: (Age 19 and Older)
- Routine Pap Smears, annual mammogram
- PSA For Men
- Annual Physical Examination/Health Screening
- Diagnostic lab work & X-rays
|
100% |
80% to Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket Maximum then 100% |
| Primary Care Office Visits |
All except a $10 copay per visit1 |
All except a $30 copay per visit |
60% to Out-of-Pocket 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 Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket 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 Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket Maximum then 100% |
| In-patient medical emergency6 |
100% |
80% to Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket Maximum then 100% |
| In-patient drugs |
100% |
80% to Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket Maximum then 100% |
| Ambulatory and Therapeutic Services |
Insurer Pays After Deductible is Met |
| Ambulatory Surgical Center |
100% |
80% to Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket Maximum then 100% |
| Ambulance Service |
100% |
80% to Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket 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 |
100% up to $2000 |
100% up to $2000 |
| Durable Medical Equipment |
100% |
80% to Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket Maximum then 100% |
| Infusion Therapy |
100% |
80% to Out-of-Pocket Maximum then 100% |
60% to Out-of-Pocket Maximum then 100% |
| Physical/Occupational Therapy |
$30/visit, 12 visits per year |
$30/visit, 12 visits per year |
$30/visit, 12 visits per year |
| Basic Prescription Drug Benefit |
50% of actual charges up to $500 |
$0 |
$0 |
| Optional Prescription Drug Benefit |
Insurer Waives Deductible |
| Subject to $5,000 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 $100,000 |
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 |
| |
Global Citizen
Plan 1,2,3,4,5 |
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.
2. Deductibles are Per Person per Policy Period.
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
|
| Participating and Non-Participating Providers |
Inpatient Benefit |
Outpatient Benefit |
| Mental Health |
100% up to 20 days per year |
80% up to 30 visits per year |
| Substance Abuse |
100% up to 12 days of detox |
80% up to 30 visits per year |
|
| 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 |
|
