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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.