| |
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 |
| Preventive and Office Visits |
Deductible is not applicable |
| 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% |
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% |
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% |
| 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 |
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
Plan 1,2,3,4,5 |
Deductible |
Out-of-Pocket
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 |
-
Copay waived when visiting an HTH Worldwide contracted
provider.
-
Deductibles are Per Person per Policy Period.
-
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.
-
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.
-
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.
-
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 |
|
