| Company/Plan Name |
WorldCare Value Advantage PPO 70 |
| Deductible |
|
| In-Network |
$10,000
Per Person, Per Calendar Year |
| Out-Network |
$30,000
Per Person, Per Calendar Year |
| Maximum Family Deductible |
3 Deductibles Per Family, Per Calendar Year |
| Coinsurance |
|
| In-Network |
70/30% to $10,000 |
| Out-Network |
50/50% to $10,000 |
| Maximum Out-Of-Pocket Coinsurance |
|
| In-Network |
$3,000 excluding Deductible and any applicable Access Fees & copayments |
| Out-Network |
$5,000 excluding Deductible, Access Fees & copayments plus charges above usual & customary |
| Maximum Benefit |
$1,000,000 Lifetime (Optional $5,000,000 Lifetime not quoted) |
| Physician Office Visit |
|
| In-Network |
Subject to Deductible & CoInsurance (Optional Benefit Increase Option, not quoted)
|
| Out-Network |
Subject to Deductible & CoInsurance (Optional Benefit Increase Option, not quoted)
|
| Outpatient Lab & X-Ray |
|
| In-Network |
Deductible & CoInsurance Apply |
| Out-Network |
Deductible & CoInsurance Apply |
| Outpatient Preventive Care |
|
| In-Network |
Not covered (or subject to state mandate) |
| Out-Network |
Not covered (or subject to state mandate) |
| Prescription Drugs |
Optional RX Benefit Available (not quoted) |
| Generic |
Not covered (Discount Card only) |
| Brand Name(formulary) |
Not covered (Discount Card only) |
| Brand Name(Non-formulary) |
Not covered (Discount Card only) |
| Outpatient Surgery |
|
| In-Network |
$250 Per Day Access Fee (maximum of 4 Per Person, Per Calendar Year), then subject to Deductible & CoInsurance |
| Out-Network |
$250 Per Day Access Fee (maximum of 4 Per Person, Per Calendar Year), then subject to Deductible & CoInsurance |
| Emergency Room |
|
| In-Network |
$250 Access Fee (waived if admitted directly as Hospital Inpatient), then subject to Deductible & CoInsurance |
| Out-Network |
$250 Access Fee (waived if admitted directly as Hospital Inpatient), then subject to Deductible & CoInsurance |
| Maternity Prenatal/Post Natal |
|
| In-Network |
Not covered (see brochure for complications of pregnancy) |
| Out-Network |
Not covered (see brochure for complications of pregnancy) |
| Inpatient Benefits |
|
| Hospitalization |
|
| In-Network |
$500 Per Day Access Fee (maximum of 4 Per Person, Per Calendar Year), then subject to Deductible & CoInsurance |
| Out-Network |
$500 Per Day Access Fee (maximum of 4 Per Person, Per Calendar Year), then subject to Deductible & CoInsurance |
| Surgical |
|
| In-Network |
Deductible & CoInsurance Apply |
| Out-Network |
Deductible & CoInsurance Apply |
| Maternity |
|
| In-Network |
Not covered (see brochure for complications of pregnancy) |
| Out-Network |
Not covered (see brochure for complications of pregnancy) |
| Rate Guarantee |
Initial 12 month rate guarantee |
| Optional Benefits |
|
| Supplemental Accident |
Benefit of $500, $1,000, $1,500, $2,000, $2,500, $3,000, $5,000; pays full benefit for treatment of injuries on an OutPatient basis not to exceed the amount you choose per person, per calendar year(not all levels available in all states)(not quoted) |
| 24 Hour Coverage |
Included |
| Other |
Benefit Increase Option, provides coverage for Physician Office Visit ($40 CoPay in-network), Prescription Drugs (subject to a separate $500 Deductible Per Person, Per Calendar Year, maximum benefit $2,500 Per Person, Per Year) see brochure for details |
