Xplorer Essential Benefits
  Outside U.S.
Lifetime Maximum per Insured Person Unlimited
Annual Maximum per Insured Person Unlimited
Preventative and Primary Care Insurer Waives Deductible
Primary Care Office Visits All except a $10 copay per visit1

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%
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 emergency2 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
Inpatient Mental Health 100% up to 60 days
Outpatient Mental Health 75% up to 40 visits/60% thereafter
Inpatient Substance Abuse 100% up to 60 days detox
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 Pays Without a Deductible
Medical Evacuation Up to $250,000
Repatriation of Remains Up to $25,000
Accidental Death and Dismemberment $50,000
  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.

Patient Protection and Affordable Care Act (“PPACA”): This insurance is not subject to, and does not provide certain of the insurance benefits required by, the United States PPACA. PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney or tax professional to determine if PPACA’s requirements are applicable to you. The policy contains the plan benefits, including a lifetime maximum that you have selected. Please review your choices to ensure that you have sufficient coverage to meet your medical needs.