GeoBlue Xplorer Premier

Plan Detail

Benefits


Benefits Outside U.S. U.S. (In-Network) U.S. (Outside Network)
Preventive and Office Visits – Insurer Waives Deductible
Physician Office Visits (Adult) All except a $10 copay per visit All except a $30 copay per visit 60% to Out-of-Pocket Maximum then 100%
Physician Office Visits (Children 0-18) 100% 80% to Out-of-Pocket Maximum then 100% 60% to Out-of-Pocket Maximum then 100%
Unlimited Well Baby Visits 100% 80% to Out-of-Pocket Maximum then 100% 60% to Out-of-Pocket Maximum then 100%
Child Immunizations, Lab and X-rays 100% 80% to Out-of-Pocket Maximum then 100% 60% to Out-of-Pocket Maximum then 100%
Women: (19 and Older) Routine Pap Smears, Annual Mammogram 100% 80% to Out-of-Pocket Maximum then 100% 60% to Out-of-Pocket Maximum then 100%
PSA for Men 100% 80% to Out-of-Pocket Maximum then 100% 60% to Out-of-Pocket Maximum then 100%
One Routine Physical Per Year 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%
Inpatient Medical Emergency 100% 80% to Out-of-Pocket Maximum then 100% 60% to Out-of-Pocket Maximum then 100%
Inpatient 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 $2,000 80% up to $2,000 60% up to $2,000
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* $50 max each visit, 12 visits per year $50 max each visit, 12 visits per year $50 max each visit, 12 visits per year
Inpatient Mental Health 100% up to 60 days 80% up to 60 days 60% up to 60 days
Outpatient Mental Health 75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter
Inpatient Substance Abuse 100% up to 60 days detox 80% up to 60 days detox 60% up to 60 days detox
Outpatient Substance Abuse 75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter 75% up to 40 visits/60% thereafter0
Prescription Drug Benefit Options – Insurer Waives Deductible
Basic Prescription Drug Benefit Subject to $1000
Maximum per Insured Person per Coverage 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%
Optional rider, subject to $25,000 Maximum
Benefit per Insured Person per Coverage 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
Emergency Medical Transportation Up to $250,000 n/a n/a
Repatriation of Mortal Remains Up to $250,000 n/a n/a
Accidental Death and Dismemberment $50,000 $50,000 $50,000
Other Benefits Limits
Home Health Care 100% Covered Expenses, as many as 30 visits per year
Skilled Nursing Facilities 100% with a maximum Covered Expense of $250 per day, as many as 50 days per year
Hospice 100% with a maximum Covered Expense of $5,000 per lifetime

GeoBlue Xplorer Premier has three tiers of coinsurance: 100% outside the U.S.; 80% in-network inside the U.S.; 60% out-of-network inside the U.S. All plans have an unlimited lifetime maximum and a $250,000 maximum benefit for emergency medical evacuation. The Out-of-Pocket Maximum is calculated by adding the deductible and coinsurance maximum together. Please refer to the chart on page 3 of the Brochure.

See other side for GeoBlue Xplorer Essential Benefit Schedule. This is intended to be a sample benefit schedule.

*Deductible is waived for this benefit.