|Deductibles||$0, $100, $250, $500, $1,000 or $2,500 per certiﬁcate period.|
|Coinsurance - Claims incurred in U.S. or Canada||For the certiﬁcate period, underwriters will pay 80% of the next $5,000 of eligible expenses after the deductible, then 100% to the overall maximum limit. Coinsurance will be waived if expenses are incurred within the PPO and are submitted to underwriters for review and payment directly to the provider.|
|Coinsurance - Claims incurred out- side U.S. or Canada||For the certiﬁcate period, underwriters will pay 100% of eligible expenses after the deductible up to the overall maximum limit.|
|Hospital Room and Board||Average semi-private room rate, including nursing services.|
|Local Ambulance||Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.|
|Intensive Care Unit||Usual, reasonable and customary charges.|
|Emergency Room Co-payment||In addition to coinsurance, the member shall be responsible for a $200 co-payment for each use of emergency room for an Illness unless the member is admitted to the hospital. There will be no copayment for emergency room treatment of an injury.|
|Urgent Care Center||For each visit, the member shall be responsible for a $50 co-payment, after which coinsurance will apply. Not subject to deductible.|
|Hospital Indemnity (in addition to medical expenses)||$100 per day of inpatient hospitalization for member's use to offset miscellaneous expenses (not subject to deductible or coinsurance).|
|Physical Therapy||$50 maximum per day.|
|All Other Eligible Medical Expenses||Usual, reasonable and customary charges.|
|Acute Onset of Pre-existing Condition (only available to members younger than 70)||Limited beneﬁt up to the medical coverage maximum (excludes chronic and congenital conditions). $25,000 lifetime maximum for emergency medical evacuation.|
|Emergency Dental (acute onset of pain)||$250 limit per certiﬁcate period (not subject to deductible or coinsurance).|
|Emergency Medical Evacuation||$1,000,000 lifetime maximum, except as provided under acute onset of pre-existing condition|
(not subject to deductible or coinsurance).
|Return of Minor Children||$50,000 per certiﬁcate period (not subject to deductible or coinsurance).|
|Pet Return||Up to $1,000 to return a traveling pet home if member is hospitalized.|
|Repatriation of Remains||Overall maximum limit (not subject to deductible or coinsurance).|
|Emergency Reunion||$50,000 limit per certiﬁcate period, subject to a maximum of 15 days|
(not subject to deductible or coinsurance).
|Natural Disaster||Maximum $100 a day for 5 days (not subject to deductible or coinsurance).|
|Trip Interruption||$5,000 limit per certiﬁcate period (not subject to deductible or coinsurance).|
|Trip Delay||$100 for a 12-hour delay requiring an unplanned overnight stay (2 days maximum).|
|Lost Checked Luggage||$500 limit per certiﬁcate period (not subject to deductible or coinsurance).|
|Political Evacuation||$10,000 lifetime maximum (not subject to deductible or coinsurance).|
|Terrorism||$50,000 maximum lifetime limit, eligible medical expenses only.|
|Accidental Death and Dismemberment (excludes loss due to common carrier accident; $250,000 maximum beneﬁt per one family or group)||Not subject to deductible or coinsurance.|
|Members up to age 18||Lifetime max. - $5,000; Death - $5,000; Loss of 2 limbs - $5,000; Loss of 1 limb - $2,500.|
|Members age 18 through 69||Lifetime max. - $50,000; Death - $50,000; Loss of 2 limbs - $50,000; Loss of 1 limb - $25,000.|
|Members age 70 through 74||Lifetime max. - $12,500; Death - $12,500; Loss of 2 limbs - $12,500; Loss of 1 limb - $6,250.|
|Members age 75 and older||Lifetime max. - $6,250; Death - $6,250; Loss of 2 limbs - $6,250; Loss of 1 limb - $3,125.|
|Common Carrier Accidental Death ($250,000 maximum beneﬁt per any one family or group)||Not subject to deductible or coinsurance.|
Up to age 18 - $25,000 per member; Age 18 to 69 - $50,000 per member;
Age 70 to 74 - $12,500 per member; Age 75 and older - $6,250.
|Hospital Pre-certiﬁcation Penalty||50% of eligible medical expenses.|
|Overall Maximum Limit Per Certiﬁcate Period||Age 80 or older - $10,000; Age 70 to 79 - $50,000, $100,000;|
All others - $50,000, $100,000, $200,000, $500,000 or $1,000,000.
|Crisis Response||$10,000 limit per certiﬁcate period;|
Includes access to Unity Crisis Group services.
|Personal Liability||$10,000 lifetime maximum.|
|Bedside Visit||$1,500 (economy ticket for family member to visit if member admitted to ICU).|