Lifetime maximum Unlimited Unlimited Unlimited Unlimited Unlimited Claim submission Provider files Provider files Provider files You file You file Hospital benefits Inpatient Pre-registration required 100 per cent 100 per cent 100 per cent 100 per cent United States: 80 per cent after deductible International: 100 per cent Outpatient 100 per cent 100 per cent 100 per cent 100 per cent United States: 80 per cent after deductible International: 100 per cent Emergency room (initial visit) 100 per cent accidental injury; sudden and serious medical condition 100 per cent after $75 co-pay (waived if admitted within 24 hours) 100 per cent after $75 co-pay (waived if admitted within 24 hours) 100 per cent after $75 co-pay (waived if admitted within 24 hours) 100 per cent after $75 co-pay (waived if admitted within 24 hours) Emergency room visit (for non-emergency care) Not covered but 100 per cent after $35 co-pay at urgent care centres in the United States 80 per cent Not covered 80 per cent after deductible Not covered Medical benefits Office/home visits 100 per cent 100 per cent after $15/$20 primary care physician/ specialist 100 per cent after $15/$20 primary care physician/ specialist co-pay 80 per cent after deductible 80 per cent after deductible Routine physical 100 per cent once every 12 months 100 per cent after $15 co-pay once every 12 months 100 per cent after $15 co-pay once every 12 months 80 per cent after deductible once every 12 months 80 per cent after deductible once every 12 months
Surgery 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Prescription drugs Pharmacy $5.00 for generic/brand per 30-day supply 20 per cent copay up to $20 per 30-day supply for generic 25 per cent copay up to $30 per 30-day supply for brand name 20 per cent copay up to $20 per 30-day supply for generic 25 per cent copay up to $30 per 30-day supply for brand name United States: 60 per cent after deductible International: 80 per cent after deductible United States: 60 per cent after deductible International: 80 per cent after deductible Mail order $2.50 for generic/brand per 30-day supply 100 per cent after $15 co-pay per 90day supply 100 per cent after $15 co-pay per 90day supply Not applicable Not applicable Behavioural health-care benefits (must be pre-certified; benefit maximum for in-network and combined) Inpatient mental health care 100 per cent 100 per cent 100 per cent 100 per cent after deductible 80 per cent after deductible Outpatient mental health care 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Inpatient alcohol and substance abuse care 100 per cent 100 per cent 100 per cent 100 per cent after deductible 80 per cent after deductible Outpatient alcohol and substance abuse care 100 per cent 100 per cent 100 per cent 80 per cent after deductible 80 per cent after deductible Vision care Eye exam 100 per cent 1 exam every 12 months 100 per cent after $20 co-pay 1 exam every 12 months 100 per cent after $15 co-pay 1 exam every 12 months 80 per cent 1 exam every 12 months $40 allowance 1 exam every 12 months network
(non-surgical) Telemedicine 100 per cent after $15 primary care physician co-pay 80 per cent after deductible Maternity (includes voluntary sterilization and voluntary abortion, see family planning) 100 per cent after $15 co-pay 80 per cent after deductible Physician in-hospital services 100 per cent 80 per cent after deductible Other in-hospital physician services (e.g. attending/independent physician who does not bill through hospital) 100 per cent 80 per cent after deductible Surgery (in hospital or office) 100 per cent 80 per cent after deductible Second surgical opinion 100 per cent 100 per cent after deductible Anaesthesia 100 per cent (if participating hospital) 80 per cent after deductible Allergy testing and treatment (given by a physician) 100 per cent after $20 specialist co-pay 80 per cent after deductible Allergy injections (not given by a physician) 100 per cent 80 per cent after deductible Preventive care Routine physicals and immunizations – Children age 7+ and adults: 1 routine exam every 12 months 100 per cent after $15 co-pay 80 per cent after deductible Well-child care and immunizations Well-child care to age 7: – 6 visits per year age 0-1 year – 2 visits per year age 1-2 years – 1 visit per year age 2-7 years 100 per cent Routine OB/GYN exam 1 routine exam per calendar year, including 1 Pap smear 100 per cent after $15 co-pay 80 per cent after deductible Family planning – Office visits, including tests and counselling 100 per cent after $20 specialist co-pay 80 per cent after deductible – Surgical sterilization procedures for 100 per cent 80 per cent (deductible waived)
Fertility treatments (in vitro fertilization not covered) 100 per cent Doctors’ fees at 80 per cent plus MMBP Note: For chemo and radiotherapy and haemodialysis received in the United States, benefits are subject to prior approval (see below), and failure to comply will result in a penalty. General cover — hospitalizations (subject to prior approval) Benefits Remarks Bed and board 100 per cent up to a maximum per day The maximum per day varies depending on the region Cover restricted to 100 per cent of a semi-private room or ward for specific areas See details in the plan description on our website Other hospital expenses 100 per cent Doctors’ fees 80 per cent plus MMBP Personal expenses Not covered Covered expenses incurred in the United States of America Benefits Remarks Increased deductible $5,000 per person per calendar year or $15,000 per family per calendar year, except for tele-psychiatry which falls under the regular $200/$600 individual/family deductible No BMIP or MMBP, except for telepsychiatry which has a $200/$600 individual/family deductible Strict enforcement of prior approval for: 80 per cent (yearly deductible of $5,000 per person per calendar year or $15,000 per family per calendar year) No MMBP – Planned hospitalization – Selected outpatient treatments (chemo and radiotherapy, haemodialysis) For more information, please check the website. General cover — benefits with ceilings Benefits Ceiling Dental 80 per cent – $1,000 per person per calendar year – carry over from previous year’s balance Optical 80 per cent $250 per period of 24 months (counted as of date of purchase) Medical check-up 100 per cent $750 per person per calendar year Home hospitalization 100 per cent $5,000 per illness