| Benefit |
Bronze |
Silver |
Gold |
Platinum |
| Lifetime Maximum Limit |
$1,000,000 per individual |
$5,000,000 per individual |
$5,000,000 per individual |
$8,000,000 per individual |
Deductible (Per Period of Coverage) |
$250 to $10,000 |
$250 to $10,000 |
$250 to $25,000 |
$100 to $25,000 |
| Deductible Carry Forward |
included |
included |
included |
included |
| Treatment outside the U.S. |
50% of deductible waived, up to a maximum of $2,500. No coinsurance |
50% of deductible waived, up to a maximum of $2,500. No coinsurance |
50% of deductible waived, up to a maximum of $2,500. No coinsurance |
50% of deductible waived, up to a maximum of $2,500. No coinsurance |
| Treatment inside the U.S. using Medical Concierge |
50% of deductible waived, up to a maximum of $2,500. No coinsurance |
50% of deductible waived, up to a maximum of $2,500. No coinsurance |
50% of deductible waived, up to a maximum of $2,500. No coinsurance |
50% of deductible waived, up to a maximum of $2,500. No coinsurance |
| Treatment inside the U.S. - PPO Network |
Subject to Deductible. No coinsurance |
Subject to Deductible. No coinsurance |
Subject to Deductible. No coinsurance |
Subject to Deductible. No coinsurance |
| Treatment inside the U.S.- Non-PPO Network |
Subject to Deductible.Plan pay 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage |
Subject to Deductible.Plan pay 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage |
Subject to Deductible.Plan pay 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage |
Subject to Deductible.Plan pay 80% of the next $5,000 of eligible expenses, then 100% to the overall maximum per period of coverage |
| Coinsurance |
International - 100% U.S. in-network – 100% U.S. out-of-network - 80% |
International - 100% U.S. in-network – 100% U.S. out-of-network - 80% |
International - 100% U.S. in-network – 100% U.S. out-of-network - 80% |
International - 100% U.S. in-network – 100% U.S. out-of-network - 80% |
| Outpatient |
$500 maximum limit - specialists/physician charges (pre-inpatient / post-inpatient)
$300 maximum per visit - lab tests; $250 maximum per visit - diagnostic x-rays
Subject to deductible and coinsurance |
$70 maximum limit; 25 visit limit - specialists/physician charges $50 maximum limit - chiropractor charges $500 maximum limit - surgery intervention consultation charges $300 maximum per visit - lab tests; $250 maximum per visit - diagnostic x-rays
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Mental/Nervous |
N/A |
Subject to deductible and coinsurance. Outpatient after 12 months of continuous coverage |
Subject to deductible and coinsurance. $10,000 maximum. |
Subject to deductible and coinsurance. $50,000 lifetime maximum. |
| Hospital Emergency Room Injury |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Hospital Emergency Room Illness |
Subject to deductible and coinsurance. Covered only if admitted as inpatient |
Subject to deductible and coinsurance. Additional $250 deductible if not admitted as an inpatient |
Subject to deductible and coinsurance. Additional $250 deductible if not admitted as an inpatient |
Subject to deductible and coinsurance. Additional $250 deductible if not admitted as an inpatient |
| Hospitalization / Room & Board |
Subject to deductible and coinsurance for average semi-private room rate |
Subject to deductible and coinsurance for average semi-private room rate. All subject to $600 per day /240 day maximum |
Subject to deductible and coinsurance for average semi-private room rate |
Subject to deductible and coinsurance for average semi-private room rate |
| Intensive Care Unit |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance. $1,500 limit per day - 180 days of coverage per event |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| CAT Scans, MRI, Echocardiography, Endoscopy, Gastroscopy, Cystoscopy |
Subject to deductible and coinsurance $600 maximum limit per examination |
Subject to deductible and coinsurance $600 maximum limit per examination |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Surgery |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
| Assistant Surgeon |
20% of primary surgeon’s charge |
20% of primary surgeon’s charge |
20% of primary surgeon’s charge |
20% of primary surgeon’s charge |
| Chemotherapy or Radiation Therapy |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Subject to deductible and coinsurance |
Maternity (Delivery, preventative care, newborn care & congenital disorders, Family Matters Maternity Program (available after 10 months of coverage) |
N/A |
N/A |
N/A |
$2,500 additional deductible per pregnancy. $50,000 lifetime maximum. $200 newborn preventative care benefit for the first 31 days -12 months after birth. $250,000 maximum for newborn care & congenital disorders for the first 31 days after birth |
Podiatry Care (Additional $250 deductible if not admitted) |
N/A |
N/A |
$750 maximum limit |
$750 maximum limit |
| Physical Therapy |
Subject to deductible and coinsurance. $40 maximum per visit - 10 visit limit per event. Available for 90 days following inpatient treatment or outpatient surgery |
Subject to deductible and coinsurance. $40 maximum per visit - 30 visit limit |
Subject to deductible and coinsurance. $50 maximum per visit |
Subject to deductible and coinsurance. $50 maximum per visit |
| Transplants |
$250,000 lifetime maximum |
$250,000 lifetime maximum |
$1,000,000 lifetime maximum |
$2,000,000 lifetime maximum |
| Prescription Coverage |
Subject to deductible and coinsurance. Available for 90 days following related inpatient treatment or outpatient surgery. $600 outpatient maximum limit per event |
Subject to deductible and coinsurance. 90-day supply per prescription following related covered event |
Subject to deductible and coinsurance. 90-day supply per prescription. Outpatient only |
International - 100% Inside U.S. - Prescription drug card co-pay: $20 for generic / $40 for brand name where generic is not available. 90-day supply per prescription |
| Healthy Travel Preventive coverage |
$250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
$250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
$250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
$250 lifetime maximum. Not subject to deductible or coinsurance. Applies to vaccinations and preventative prescription drugs administered by a physician within 30 days prior to the insured person’s initial effective date and before departing to any destination |
| Vision |
Optional Rider |
Optional Rider |
Optional Rider |
$100 maximum per 24 months for exams. $150 per 24 months for materials |
| Local Ambulance due to Injury or Illness resulting in Hospitalization |
$1,500 maximum limit per event. Not subject to deductible or coinsurance |
$1,500 maximum limit per event. Not subject to deductible or coinsurance |
Subject to deductible and coinsurance |
Not subject to deductible or coinsurance |
| Emergency Evacuation |
$50,000 maximum per period of coverage. Not subject to deductible or coinsurance |
$50,000 maximum per period of coverage. Not subject to deductible or coinsurance |
Up to lifetime maximum limit. Not subject to deductible or coinsurance |
Up to maximum limit. Not subject to deductible or coinsurance |
| Emergency Reunion |
$10,000 lifetime maximum. Not subject to deductible or coinsurance |
N/A |
$10,000 lifetime maximum. Not subject to deductible or coinsurance |
$10,000 lifetime maximum. Not subject to deductible or coinsurance |
Interfacility Ambulance Transfer (Transfer from one licensed health care Facility to another licensed health care Facility) |
$1,500 maximum limit per event. Not subject to deductible or coinsurance. U.S. only |
$1,500 maximum limit per event. Not subject to deductible or coinsurance. U.S. only |
Subject to deductible and coinsurance. U.S. only |
Not subject to deductible or coinsurance. U.S. only |
| Political Evacuation and Repatriation |
N/A |
N/A |
N/A |
$10,000 lifetime maximum |
| Remote Transportation |
N/A |
N/A |
N/A |
$5,000 per period of coverage up to $20,000 lifetime maximum. Not subject to deductible or coinsurance |
| Return of Mortal Remains |
$10,000 lifetime maximum. Not subject to deductible or coinsurance |
$25,000 lifetime maximum. Not subject to deductible or coinsurance |
$25,000 lifetime maximum. Not subject to deductible or coinsurance |
$50,000 lifetime maximum. Not subject to deductible or coinsurance |
| Complementary Medicine |
N/A |
N/A |
$500 maximum limit per period of coverage |
$500 maximum limit per period of coverage |
| Traumatic Dental InjuryTreatment at a hospital facility |
$1,000 per period of coverage |
$1,000 per period of coverage |
Up to the lifetime maximum limit |
Up to the lifetime maximum limit |
| Treatment Due to Unexpected Pain to Sound, Natural Teeth |
N/A |
N/A |
$100 per period of coverage |
100% |
| Non-Emergency Treatment at a Dental Provider due to an Accident |
N/A |
N/A |
$500 per period of coverage |
See Non-Emergency Dental benefit |
| Non-Emergency Dental |
Optional Rider |
Optional Rider |
Optional Rider |
$750 maximum per period of coverage; $50 individual deductible, applies to minor restorative and major restorative services |
| Hospital Indemnity(Outside the U.S. only) |
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage. Not subject to deductible or coinsurance |
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage. Not subject to deductible or coinsurance |
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage. Not subject to deductible or coinsurance |
Private Hospitals: $400 per overnight and $4,000 maximum limit per period of coverage.
Public Hospitals: $500 per overnight and $5,000 maximum limit per period of coverage. Not subject to deductible or coinsurance |
| Supplemental Accident |
N/A |
N/A |
$300 of eligible medical expenses following an accident . Not subject to deductible or coinsurance |
$500 of eligible medical expenses following an accident . Not subject to deductible or coinsurance |
Adult Preventative Care (Age 19 or older) |
N/A |
N/A |
$250 per period of coverage. Not subject to deductible or coinsurance. |
$500 per period of coverage. Not subject to deductible or coinsurance. |
Child Preventative Care (Through age 18) |
N/A |
$70 maximum per visit, 3 visit limit per period of coverage. Not subject to deductible or coinsurance. |
$200 maximum per period of coverage. Not subject to deductible or coinsurance. |
$400 maximum per period of coverage. Not subject to deductible or coinsurance. |
Pre-Existing Conditions Limitation (Outside the U.S. only) |
Excluded |
$50,000 lifetime maximum; $5,000 per period of coverage for unknown conditions. Available after 24 months of continuous coverage* |
$50,000 lifetime maximum; $5,000 per period of coverage for unknown conditions. Available after 24 months of continuous coverage* |
Covered if disclosed and not excluded by rider |
| *If applicants can verify their prior comprehensive health insurance, with no significant break in coverage (63 days), IMG may accept this as Creditable Coverage and provide a pre-existing conditions waiver (final decision is subject to Underwriters approval). Creditable Coverage is defined as a group health plan provided by a U.S. employer or Health Insurance Issuer, individual major medical health insurance provided by a Health Insurance Issuer, or other Public Health Plan (any comprehensive health plan established or maintained by a State or the U.S. government) |
| Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy documents (together the "Insurance Contract"). The Insurance Contract is the only source of the actual benefits provided |