| |
Outside U.S. |
| Lifetime Maximum per Insured Person |
$5,000,000 |
| Preventive and Office Visits |
Insurer Waives Deductible |
| Physician Office Visits (Adult) |
All except a $10 copay per visit1 |
| Physician Office Visits (Children 0-18) |
100% |
| Child Immunizations, Lab work & X-rays |
100% |
Women: (25 and Older)
Routine Pap Smears, annual mammogram |
100% |
| PSA for Men |
100% |
| One Routine Physical Per Year |
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 $2000 |
| Durable Medical Equipment |
100% |
| Infusion Therapy |
100% |
| Physical/Occupational Therapy |
$30/visit, 12 visits per year |
| Basic Prescription Drug Benefit |
50% of actual charges up to $500 |
| Optional Prescription Drug Benefit |
Insurer Pays After Deductible
is Met |
| Subject to $3,000 Maximum
Benefit per Insured Person per Policy Period. |
80% of actual charges |
| Global Travel Benefits |
Insurer Pays Without a Deductible |
| Medical Evacuation |
Up to $100,000 |
| Repatriation of Remains |
Up to $25,000 |
| Accidental Death and Dismemberment |
$50,000 |
Maternity Benefits
After 12 months of continuous coverage, Global Citizen members may renew their coverage or apply for a new plan that covers maternity costs in the same way as all other medical conditions.
To be eligible for the maternity benefit, a member must not be pregnant at the time of upgrade. |
|
| Global Citizen EXP
Plan 1,2,3 |
Deductible |
| Elite |
$0 |
| 500 |
$250 |
| 1,000 |
$500 |
| 2,000 |
$1,000 |
| 5,000 |
$2,500 |
| 10,000 |
$10,000 |
| 25,000 |
$25,000 |
- Copay waived when visiting an HTH Worldwide contracted
provider.
- Emergency room visits that do not result in inpatient admissions will be subject to a $50 penalty.
- Out of Pocket Maximums exclude the Deductible.
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