| Features |
Outside the U.S. |
In the U.S. |
| Preferred Benefits (In-Network) |
Non-Preferred Benefits (Out-of-Network) |
| Individual Deductible |
$0 per calendar year |
$700 per calendar year |
$1,350 per calendar year |
| Family Deductible |
$0 per calendar year |
$1,400 per calendar year |
$2,700 per calendar year |
| Prior Plan Credit |
Does not apply |
| Individual Coinsurance Limit |
$0 per calendar year |
$3,000 per calendar year |
$6,000 per calendar year |
| Does not include deductibles, copays, benefit penalties, 50% items, and Outpatient Prescription Drugs; includes Outpatient Prescription Drugs when outside the U.S. |
| Family Coinsurance Limit |
$0 per calendar year |
$6,000 per calendar year |
$12,000 per calendar year |
| Does not include deductibles, copays, benefit penalties, 50% items, and Outpatient Prescription Drugs; includes Outpatient Prescription Drugs when outside the U.S. |
| Lifetime Maximum |
Unlimited |
| Member Payment Percentages |
| Hospital Services |
| Inpatient |
No charge |
20% after deductible |
40% after deductible |
| Outpatient |
No charge |
20% after deductible |
40% after deductible |
| Private Room Limit |
The institution’s semiprivate rate |
| Pre-certification Penalty |
No penalty |
No penalty |
$400 |
| To avoid penalties and/or benefit reductions for non-preferred benefits received in the U.S., contact the service center to determine if precertification is needed for a procedure. |
| Non-Emergency Use of the Emergency Room |
No penalty |
50% after deductible |
50% after deductible |
| Emergency Room |
No charge |
20% after deductible |
20% after deductible |
| Non-Urgent Use of Urgent Care Provider |
No charge |
20% after deductible |
40% after deductible |
| Urgent Care |
No charge |
20% after deductible |
40% after deductible |
| Ambulance |
No charge |
20% after deductible |
40% after deductible |
| Physician Services |
| Physician Office Visit |
No charge |
20% after deductible |
40% after deductible |
| Specialist Office Visit |
No charge |
20% after deductible |
40% after deductible |
| Virtual Care and Virtual Primary Care |
Not covered |
No charge |
Not covered |
| Walk-in Clinics |
No charge |
20% after deductible |
40% after deductible |
| Designated Walk-in Clinics, no charge when outside the U.S. Walk-in Clinics are free-standing health care facilities that (a) may be located in or with a pharmacy, drug store, supermarket, or other retail store, and (b) provide limited medical care and services on a scheduled or unscheduled basis. Urgent care centers, emergency rooms, the outpatient department of a hospital, ambulatory surgical centers, and physician offices are not considered to be a Walk-in Clinic. |
| Mental Health Services* |
| Mental Health Inpatient Coverage
(Unlimited days per calendar year) |
No charge |
20% after deductible |
40% after deductible |
| Mental Health Outpatient Coverage
(Unlimited visits per calendar year) |
No charge |
20% after deductible |
40% after deductible |
| Alcohol/Drug Abuse Services* |
| Substance Abuse Inpatient Coverage
(Unlimited days per calendar year) |
No charge |
20% after deductible |
40% after deductible |
| Substance Abuse Outpatient Coverage
(Unlimited visits per calendar year) |
No charge |
20% after deductible |
40% after deductible |
| Other Services |
| Skilled Nursing Facility
(120 days per calendar year) |
No charge |
20% after deductible |
40% after deductible |
| Hospice Care Facility Inpatient
(60 days lifetime maximum) |
No charge |
20% after deductible |
40% after deductible |
| Hospice Care Facility Outpatient
(Unlimited lifetime maximum) |
No charge |
20% after deductible |
40% after deductible |
| Home Health Care
(120 visits per calendar year) |
No charge |
20% after deductible |
40% after deductible |
| Private Duty Nursing
(70 shifts per calendar year) |
No charge |
20% after deductible |
40% after deductible |
| Spinal Disorder Treatment
(Unlimited visits per calendar year) |
No charge |
20% after deductible |
25% after deductible |
| Short-Term Rehabilitation |
No charge |
20% after deductible |
25% after deductible |
| Includes coverage for Occupational and Physical Therapies; unlimited visits per calendar year. |
| Speech Therapy |
No charge |
20% after deductible |
40% after deductible |
| Includes coverage for Speech Therapies; 60 visits per calendar year. |
| Diagnostic Outpatient X-ray |
No charge |
20% after deductible |
40% after deductible |
| Diagnostic Outpatient Lab |
No charge |
20% after deductible |
40% after deductible |
| Bariatric Surgery (Unlimited per lifetime) |
No charge |
20% after deductible |
40% after deductible |
| Base Infertility Services |
No charge |
20% after deductible |
40% after deductible |
| Base plan coverage is limited to the testing and treatment of an underlying condition. |
| Other Services |
| Comprehensive Infertility Services |
No charge |
20% after deductible |
40% after deductible |
| Six cycles of Comprehensive plan coverage include coverage of Artificial Insemination and Ovulation Induction. |
| ART Infertility Services |
No charge |
20% after deductible |
40% after deductible |
| Six cycles per lifetime for Advanced Reproductive Technology (ART) coverage with cryopreservation, storage, and unlimited embryo transfers. |
| Autism |
Autism covered same as any other expenseMember cost sharing is based on the type of service performed and the place of service where it is rendered. |
| Payment for Non-Preferred Providers** |
Not applicable |
Not applicable |
Professional: 105% of MedicareFacility: 140% of Medicare |
| Routine Hearing Exam (Includes one routine exam every 12 months.) |
No charge |
No charge |
40% after deductible |
| Hearing Aids |
No charge |
20% after deductible |
40% after deductible |
| One hearing aid per ear, up to $1,000 maximum per ear every three years, for child to age 24. |
| Aetna Assistance Program (Unlimited calendar year maximum) |
No charge |
No charge |
No charge |
| Employee Assistance Program (EAP) |
Included |
Included |
Included |
| Includes up to five counseling sessions per issue, per year, per enrolled member. Access benefits by calling the member service number on ID card: 1-800-231-7729 or collect 1-813-775-0190. Services include: cultural adjustment assistance, marital/family stress, child care and behavioral concerns, social adaptation needs, alcohol/substance abuse, work/life balance, and depression. |
| Wellness Benefits |
| Routine Children Physical Exams |
No charge |
No charge |
No charge |
| Seven exams in the first 12 months of life, three exams in the second 12 months of life, three exams in the third 12 months of life, one exam per 12 months thereafter to age 22 (includes immunizations). |
| Routine Adult Physical Exams |
No charge |
No charge |
No charge up to a $1,000 calendar-year maximum (includes immunizations, X-rays, and labs) |
| Adults age 22+ & -65: one exam/12 months; Adults age 65+: one exam/12 months (includes immunizations). |
| Routine Gynecological Exams |
No charge |
No charge |
No charge |
| Includes one exam and pap smear per calendar year. |
| Mammograms
(Unlimited visits per calendar year) |
No charge |
No charge |
No charge |
| Prostate Specific Antigen (PSA)
(Unlimited visits per calendar year) |
No charge |
No charge |
No charge |
| Digital Rectal Exam (DRE)
(Unlimited visits per calendar year) |
No charge |
No charge |
No charge |
| Cancer Screening |
No charge |
No charge |
No charge |
| Recommended: Members age 45 and older. |
| Prescription Drug Coverage |
| Generic Drugs
(365-day maximum supply) |
No charge |
$10 copay per month supply (includes Mail Order Drugs) |
40% no deductible |
| Brand Name Drugs
(365-day maximum supply) |
No charge |
$20 copay per month supply (includes Mail Order Drugs) |
40% no deductible |
| Vision Expenses |
| Routine Eye Exam |
No charge |
No charge |
No charge up to a maximum of $35 after $10 per-visit deductible |
| Covered under medical. Includes one routine exam per calendar year. |
| Single, Bifocal, Trifocal & Lenticular Vision Lenses
(Two lenses, once every calendar year) |
No charge |
No charge |
No charge |
| Frames-Retail
(Once every other calendar year) |
No charge up to $100 |
No charge up to $100 |
No charge up to $100 |
| Contact Lenses
(In place of lens and frame allowances, once every calendar year) |
No charge up to $110 |
No charge up to $110 |
No charge up to $110 |
| Comprehensive Dental |
| Calendar Year Deductible |
$50 per calendar year |
| Family Deductible |
$150 per calendar year |
| Type A Expense
(Diagnostic & Preventative) |
No charge |
| Type B Expense
(Basic Restorative) |
20% after deductible |
| Type C Expense
(Major Restorative) |
50% after deductible |
| Type D Expense
(Major Restorative) |
50% after deductible |
| Orthodontic Treatment
(Dependent children only) |
50% after deductible |
| Calendar Year Maximum |
$2,000 |
| Orthodontic Lifetime Maximum |
$2,000 |
| TMJ Lifetime Maximum |
$1,200 |
| Implants Calendar Year Maximum |
$2,000 |
| Services and Programs Included in Quote |
| Informed Health Line (24-hour nurse line) |
International Maternity Management Program |
| International Case Management |
Well-Being Assessment |
| *This Plan includes coverage under the extent required in accordance with the Federal Mental Health Parity and Addiction Equity Act (MHPAEA), beginning with plan years starting on or after January 1, 2018.
** Payment for Non-Preferred Providers: We cover the cost of care differently based on whether health care providers, such as doctors and hospitals, are “in-network” or “out-of-network.” |
