Business Travel Insurance Plans

• Non-emergency services only

• In addition to Deductible

• Transplants: No coverage if Precertification requirements are not met.
• Interfacility Ambulance Transfer: No coverage if Precertification requirements are not met.
• Maternity and Newborn care: 50% penalty if not Precertified within 60 days of delivery.
• Emergency Medical Evacuation: No coverage if Precertification requirements are not met. Refer to the EMERGENCY MEDICAL EVACUATION provision for complete requirements and coverage.
• All other Treatments & supplies: 50% reduction of Eligible Medical Expenses if Precertification requirements are not met.
• Deductible is taken after reduction.
• Coinsurance is applied to remainder of the reduced amount.
• Refer to Precertification REQUIREMENTS provision for a complete list of services that require Precertification .

• Injury: Not subject to Emergency Room Deductible
• Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does not result in a direct Hospital admission

• United States: Average private room rate
• International: Average private room rate up to a maximum of 150% of the average semi- private room rate
• Includes nursing services, miscellaneous and Ancillary Services

• Surgery is incidental to and follows Surgery that was covered under the plan

• 20% of the primary surgeon’s eligible fee

• After 10 consecutive months of coverage

• After 10 consecutive months of coverage

• Lifetime Maximum: $250,000
• First 31 days of life
• Eligible when the Newborn’s birth is covered under this plan

• Prescribed by a Physician

• Not subject to Deductible or Coinsurance
• Maximum per visit: $25
• Maximum visits: 20
• Prescribed by a Physician

• Maximum Charge per Visit: $50
• Prescribed by a Physician

• Upon direct transfer from an acute care Facility

• Provided by a Home Health Care Agency
• Upon direct transfer from an acute care Facility

• Terminally ill - 6 months to live
• Inpatient Hospice Facility
• Insured Person’s home

• Lifetime Maximum: $1,000,000
• Calendar Year Transplant Maximum: 1
• Organ procurement & harvesting costs Lifetime Maximum: $10,000
• Travel & lodging Lifetime Maximum expense: $5,000
• Covered Transplants: cornea, heart, heart/lung, lung, kidney, kidney/pancreas, liver, allogeneic or autologous bone marrow
• Subject to the TRANSPLANT Precertification provision and only when Treatment is provided within the Company’s approved independent Managed Transplant System Network

• Maximum Limit: $250
• Refer to the PREVENTATIVE CARE provision for further details and requirements

• Maximum Limit: $150
• Refer to the PREVENTATIVE CARE provision for further details and requirements

• All categories listed under the Prescription Drugs and Medication benefit accumulate toward the Lifetime Maximum Limit
• Routine inoculations and vaccinations are not subject to this limit and fall under the Preventative Care benefit

• Subject to Deductible and Coinsurance
• Received as part of a Treatment plan or general care
• Not obtained through a retail pharmacy

• Not subject to Deductible and Coinsurance
• Prescriptions $3,000 and higher will require Universal RX (URX) to obtain prior authorization from the Company

Generic $5
Higher cost Generic and Brand 30%
Non-Preferred Brand Name $50 plus 30%

• Prescriptions $3,000 and higher will require Universal RX (URX) to obtain prior authorization from the Company

Medication delivery to an international address when prescription is not available for purchase internationally.

Copayment is per 30-day supply
Dispensing maximum per prescription: 180

• Enroll: www.expatps.com
• Email scanned prescription to epsmanager@universalrx.com
• Fax: +1.540.777.7184
• Phone number: +1.540.777.1450
• Email: epsmanager@universalrx.com

• Maximum Limit: $10,000
• After 12 consecutive months of coverage

• Maximum per visit: $100
• Maximum visits: 52
• After 12 consecutive months of coverage

• Not subject to Deductible or Coinsurance
• Lifetime Maximum: $300
• Counseling 6 months before or after a Family member’s death

• Subject to Deductible and Coinsurance
• Injury
• Illness resulting in an Inpatient Hospital admission

• Maximum Limit: $1,000,000
• Insured persons under age 65
• Approved in advance and coordinated by the Company

• Subject to Deductible and Coinsurance
• Maximum Limit: $10,000
• Day Maximum: 15 days
• Meal Maximum: $25 per day
• Reasonable and necessary travel costs and accommodations
• Approved in advance by the Company

• Transfer from one licensed health care Facility to another licensed health care Facility resulting in an Inpatient Hospital admission

• Lifetime Maximum: $10,000
• Approved in advance by the Company

• Maximum Limit: $25,000
• Return of Insured Person’s Mortal Remains to Home Country
• Approved in advance by the Company

• Subject to Deductible and Coinsurance
• Maximum Limits are per Insured Person

• Subject to Deductible and Coinsurance
• Accident related

• International only
• Inpatient Hospitalization only

Private Hospital

• Overnight Maximum Limit: $400
• Maximum Limit: $4,000

Public Hospital (state, government or charitable Hospital)

• Overnight Maximum Limit: $500
• Maximum Limit: $5,000

Treatment received by the Insured Person at a Public Hospital and no Charges are incurred by the Insured Person or the Company will be subject to the Public Hospital Maximum Limit.

Treatment received by the Insured Person at a Public Hospital and Charges are submitted to the Company for reimbursement will be subject to the Private Hospital Maximum Limit.

• Maximum Limit per Accident: $300
• Once the Maximum Limit is satisfied, Charges will be subject to Deductible and Coinsurance and paid the same as any other Injury

• Benefit available every 24 months

• Routine Eye Examination Maximum Limit: $100
• Corrective Lenses (Contacts)/Frame Maximum Limit: $150

• Applies to Minor and Major Restorative Services

• Maximum Deductibles per Family: 3

• Preventative visits and cleanings: 2
  (1 every 6 months)
• Radiographic examinations: 2
  (including posterior bitewings; 1 every 6 months)
• Fluoride Treatment Maximum Limit: 1
  (Children under 19 years of age)

• Refer to the ELIGIBLE DENTAL EXPENSES provision for further details

• Root planning Maximum Limit: 1 every 2 years
• Periodontal Surgery Maximum Limit: 1 every 3 years

• Maximum Limit: 1 every 3 years
• Full mouth x-rays including panographic x-rays

• Crowns, Jackets, Inlays on same tooth Maximum Limit: 1 every 5 years
• Adults and Children older than 12 years of age
• Refer to the ELIGIBLE DENTAL EXPENSES provision for further details

• Dentures / Bridge Maximum Limit: 1 every 5 years
• Replacement of denture base material or reline Maximum Limit: 1 every 3 years
• Refer to the ELIGIBLE DENTAL EXPENSES provision for further details

• Children less than 19 years of age