Benefit Summary

Executive Health Options

• Overall Maximum Limit $5,000,000 Lifetime
• Coverage Area  Including the US and Canada
• Deductibles Available $250, $500, $1,000, $2,500 or $5,000 per Member per Certificate Period
• Family Deductible Maximum of three Deductibles per Family per Certificate Period
• Coinsurance – Claims Incurred in US or Canada
  • After the Deductible, Underwriters will pay 80% of the next $5,000 of Eligible Expenses per Member per Certificate Period, then 100% to the Overall Maximum will be waived if expenses are incurred within the PPO and expenses are submitted to Underwriters for review and payment directly to the provider
• Coinsurance – Claims Incurred outside US or Canada
  • After the Deductible, Underwriters will pay 100% of Eligible Expenses to the Overall Maximum Limit
• Family Coinsurance
  • After the Deductible, Underwriters will pay 100% of Eligible Expenses per Member per Certificate Period to the Overall Maximum Limit
• Hospital Room and Board – In US or Canada Average Semi-private room rate
• Hospital Room and Board– Outside US or Canada Average Private room rate
• Intensive Care Unit Usual, Reasonable and Customary
• Prescription Drugs Usual, Reasonable and Customary; Subject to Deductible and Coinsurance
• Mental Health Disorders
  • $10,000 per Certificate Period, $25,000 Lifetime Maximum, $50 Maximum per visit per day for outpatient care (after 12 months of continuous coverage)
• Maternity – Normal or Complicated Delivery
  • After the Deductible, Underwriters will pay 50% of the next $100,000 of Eligible Medical Expenses, then 100% to a Lifetime Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery, and post-natal care (after 12 months of continuous coverage) Maximum for Maternity $250,000 Lifetime Newborn Care Included as part of Maternity benefits for a maximum of 60 days
• Pre-existing Conditions
  • Same as any other Injury or Illness if disclosed on Application and not excluded or limited by Rider
• Local Ambulance Usual, Reasonable and Customary
• Physical Therapy $50 Maximum per visit per day
• Wellness
  • All Wellness benefits are available after 12 months of continuous coverage and are not subject to Deductible. 
  • Members under age 19: $50 per visit (including immunizations), maximum of three visits per Certificate Period.
  • Members age 30 and over: $250 per Member per Certificate Period. Female Members age 40 and over (or qualifying Woman at Risk): $100 per Member per Certificate Period for a screening mammogram
• Human Organ/Tissue Transplants Same as any other Illness for Covered Transplants*
• All Other Eligible Expenses Usual, Reasonable and Customary
• Emergency Medical Evacuation $50,000 Lifetime Maximum
• Repatriation of Remains $25,000 Limit
• Emergency Reunion $10,000 Lifetime Maximum
• Pre-certification Penalty 50%
   

*Covered Transplants include Heart, Heart/Lung, Lung, Kidney, Kidney/Pancreas, Liver and Allogenic and
Autologous Bone Marrow