ONEWORLD Summary of Benefits

Transcription

1 ONEWORLD Summary of Benefits

2 ZONE 1 Benefits in the USA Summary of Benefits

3 ZONE 1 BENEFITS IN THE USA ANNUAL LIMIT 5,000,000 SILVER PLATINUM In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Deductible The amount you owe for covered health care services before your health plan begins to pay. None 2,000 4,000 None 1,000 2,000 None 500 1,000 Coinsurance Your share of costs on a covered service. WellAway s share of costs on a covered service, after deductible and copay. 30% 20% 70% 10% 90% Out-of-Pocket Maximum (OOP) The maximum you will pay each benefit period. Deductibles, coinsurance and co-payments are included in reaching your OOP. 6,300 12,600 N/A 3,500 7,000 N/A 1,500 3,000 N/A In-Network (applicable to USA only) Refers to a group of physicians, hospitals and other health care facilities that have entered into an argument with WellAway to provide medical care to its members. Health care providers that have no entered into an agreement with WellAway are called Out-of-Network Provider. Out-of-Network services carry financial penalties. Zone 1 Zone 2 Zone 3 Zone 4 Worldwide (including the USA) Worldwide (excluding the USA) Worldwide excluding: USA, Bahamas, Bermuda, Brazil, Canada, China, Hong Kong, Japan, Panama, Singapore, Switzerland, and United Kingdom. Rest of the world excluding: USA, Angola, Argentina, Australia, Austria, Azerbaijan, Bahamas, Bahrain, Barbados,Belgium,Bermuda, Bolivia, Bosnia and Herzegovina, Brazil, Bulgaria, Canada, Chile, China, Cyprus, Colombia, Costa Rica, Croatia,Czech Republic, Denmark, Djibouti, Dominican Republic, Ecuador, Finland, France, Georgia, Germany, Greece, Guatemala, Hong Kong, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kazakhstan, Kuwait, Lebanon, Lithuania, Liechtenstein, Luxembourg, Malaysia, Mexico, Monaco, Mozambique, Netherlands, New Zealand, Nigeria, Norway, Oman, Panama, Peru, Portugal, Qatar, Russia, Saint Bathelemy, Saint Martin, Saint Pierre and Miquelon, Saudi Arabia, Slovakia, Spain, Singapore, South Africa, Sweden, Switzerland, Taiwan, Thailand, Turkey, UAE, United Kingdom, Ukraine, Uruguay, Venezuela, Vietnam, Wallis and Futuna Islands. IMPORTANT NOTE: If you decide to purchase a WellAway product, you will be provided with a member package that contains a complete description of benefits, conditions, limitations and exclusion of coverage. All Benefits are subject to Usual Customary and Reasonable Fees (UCR) All Benefits reflected in USD. WellAway ONEWORLD 9

4 ZONE 1 BENEFITS IN THE USA HOSPITALIZATION AND SURGERY In-Network Out-of-Network Hospitalization (inpatient) Pre-authorization required Semi-private room & board, miscellaneous services (eg. x-ray, lab test, anesthesia, MRI, CT scans.) Limited to 180 days per Benefit Period. 450 copay then 950 copay then Intensive care unit (limited to 180 days per Benefit Period) Physician services (inpatient) (limited to one (1) per day, per specialty when medically necessary) Rehabilitation (inpatient) Pre-authorization required 45 day limit per Benefit Period 45 day limit per Benefit Period Renal failure dialysis (inpatient) Pre-authorization required (limited to six (6) weeks per Benefit Period) 450 copay then 800 copay then Hospice 60 day Lietime limit 60 day Lifetime limit Pre-admission testing (must be performed 3-5 days in advance) Ambulatory/outpatient surgical facility Pre-authorization required 400 copay then 750 copay then Oncology treatment Pre-authorization required (includes chemotherapy, radiation, and breast reconstruction) Reconstructive surgery Pre-authorization required (due to illness or injury first sustained while under the plan and performed within 12 months from date of accident) Surgical appliance and prosthesis (covered for devices which are integral part of the surgical procedure when medically necessary) 400 copay then 750 copay then Anesthesiologist (inpatient/outpatient) 30% of approved fees** 30% of approved fees** Surgeon fees (inpatient/outpatient) (multiple surgery guidelines apply) Assistant surgeon fees (inpatient/outpatient when medically necessary and per-authorized) 20% of approved fees** 20% of approved fees** Diabetic equipment and supplies Home health care Pre-authorization required 30 day limit per Benefit Period 30 day limit per Benefit Period Organ transplant Pre-authorization required (subject to six (6) month waiting period) Outpatient renal failure dialysis up to 200,000 Lifetime limit 15,000 limit per Benefit Period Not covered 15,000 limit per Benefit Period IMPORTANT NOTE: Some services require pre-authorization. Contact us immediately about any serious illness or accident where you have to go into a hospital or emergency room. If you are unable to contact us because the condition is life, limb, sight, or organ threatening, please do so within 48 hours of the incident. Planned treatment requires a minimum of 5 days prior notice. **Approved fees means the amount approved to be paid by insurance company to the principal surgeon, after deductible and coinsurance WellAway ONEWORLD 10

5 ZONE 1 BENEFITS IN THE USA WELLNESS & OUTPATIENT CARE In-Network Out-of-Network Inpatient psychiatric Pre-authorization required Outpatient psychiatric consultation Primary care consultation 200 copay then 15 day limit per Benefit Period 80 copay then 15 visit limit per Benefit Period 50 copay then 45 visit limit per Benefit Period 500 copay then 15 day limit per Benefit Period 120 copay then 15 visit limit per Benefit Period 120 copay then 45 visit limit per Benefit Period Specialist consultation Chiropractic services 60 copay then 45 visit limit per Benefit Period 35 copay then 5 session limit per Benefit period up to 90 per session 145 copay then 45 visit limit per Benefit Period 60 copay then 5 session limit per Benefit Period up to 90 per session Podiatry Durable medical equipment Outpatient therapeutic services - rehabilitation: Physical, occupational, speech, pulmonary & cardiac therapy (treatment plan must be provided) 60 copay then limited to 600 per Benefit limited to 1,000 per Benefit Period 40 copay then limited to 20 sessions per therapy type per Benefit Period 120 copay then limited to 600 per Benefit Period limited to 1,000 per Benefit Period 60 copay then limited to 20 sessions per therapy type per Benefit Period Injections/allergy treatment 20 copay then 40 copay then Basic diagnostic services (laboratory tests, x-rays, ultrasounds, EKG) Advanced diagnostic services/imaging Pre-authorization required (including but not limited to: MRI, CT scans, MRA, nuclear imaging) 350 copay then 700 copay then Routine physical examinations Adult female: Routine physical examinations office visit, routine physical exam, routine lab work, urinalysis, routine mammogram, papanicolaou (PAP) screening, colonoscopy based on medical history. Adult male: Office visit, routine physical exam, routine lab work, urinalysis, PSA screening test, colonoscopy based on medical history. Children: (subject to 2 months waiting period except newborns) Wellness physical examinations office visit, health history, development assessment, physical examination, age related diagnostic tests, vaccination and immunizations in accordance with CDC recommendation for age. up to 300 per Benefit Period up to 300 per Benefit Period WellAway ONEWORLD 11

6 PRESCRIPTION DRUGS ZONE 1 BENEFITS IN THE USA In-Network Out-of-Network Tier 1 preferred generic 30* Not covered Tier 2 preferred generic brand name 60* Not covered Tier 3 non preferred brand 80* Not covered Tier 4 specialty medication 150* Not covered EMERGENCY & URGENT CARE Emergency ground ambulance (limited to one way trip) Emergency medical services/emergency room (if admitted to hospital, inpatient co-payment would apply in lieu of emergency room co-payment) Urgent care facility Emergency dental treatment (due to accident or injury to sound natural teeth and treated within 24 hours of the event) 100 copay then 300 copay then 60 copay then 700 limit per Benefit Period 100 copay then 300 copay then 120 copay then 700 limit per Benefit Period EVACUATION & REPATRIATION Emergency medical evacuation Pre-authorization required Transfer to the nearest medical facility if the treatment needed is not available locally. up to 20,000 limit per covered person, per Benefit Period up to 20,000 limit per covered person, per Benefit Period Medical repatriation Pre-authorization required Members can return to their country of origin to be treated as long as they are physically and medically stable. Companion coverage/bedside visit (15 day limit per Benefit Period) Cost of transportation (economy-class flight) 15,000 Lifetime maximum Transportation (economy-class flight) hotel stay (75 per day limit) Economy car rental (30 per day limit), Daily meal allowance (25) Repatriation of mortal remains Pre-authorization required 10,000 maximum lifetime 10,000 maximum lifetime IMPORTANT NOTE: if you decide to purchase a WellAway product, you will be provided a member package that contains a complete description of benefits, conditions, limitations and exclusions of coverage. All Benefits are subject to Usual Customary and reasonable Fees (UCR). All Benefits reflected in USD *Dollar () amount refers to copay portion of the insured WellAway ONEWORLD 12

7 ZONE 1 BENEFITS IN THE USA ONEWORLD Optional Coverage MATERNITY (OPTIONAL) In-Network Out-of-Network Maternity global period coverage up to 9,500 up to 9,500 Complications of pregnancy up to 75,000 up to 75,000 Newborn infant care up to 100,000 up to 100,000 Congenital / Hereditary up to 250,000 up to 250,000 DENTAL AND VISION COVERAGE (OPTIONAL) FIRST YEAR SECOND YEAR THIRD YEAR Maximum benefit 3,500 per policy year Basic (routine) 65% 90% Deductible 100 lifetime Major restorative 25% 65% Preventive (exams & cleanings, 2 per year) 100% 100% 100% Orthodontic treatment (covered for children under the age of 19-1,200 lifetime maximum per child, 600 annual limit) 10% 25% Vision Care Routine vision exam 75, 10 copay (one vision exam per year - includes any fees for contact lense fittings) Lenses (single vision, bifocal, trifocal) Frames (limited to one per benefit period) Contact lenses (in lieu of frames) up to 225 (limited to one every 24 months) up to 200 up to 100 WellAway ONEWORLD 13

8 ZONE 1 Worldwide benefits outside the USA Summary of Benefits

9 ZONE 1 Worldwide Benefits outside the USA Summary of Benefits

10 ZONE 1 BENEFITS OUTSIDE THE USA ANNUAL LIMIT 5,000,000 SILVER PLATINUM One of the highest limits on the market. Deductible The amount you owe for covered health care services before your health plan begins to pay. None None None Coinsurance Your share of costs on a covered service. 30% 20% 10% WellAway s share of costs on a covered service, after deductible and copay. 70% 90% Out-of-Pocket Maximum (OOP) The maximum you will pay each benefit period. Deductibles, coinsurance and co-payments are included in reaching your OOP. 6,300 12,600 3,500 7,000 1,500 3,000 Zone 1 Zone 2 Zone 3 Zone 4 Worldwide (including the USA) Worldwide (excluding the USA) Worldwide excluding: USA, Bahamas, Bermuda, Brazil, Canada, China, Hong Kong, Japan, Panama, Singapore, Switzerland, and United Kingdom. Rest of the world excluding: USA, Angola, Argentina, Australia, Austria, Azerbaijan, Bahamas, Bahrain, Barbados,Belgium,Bermuda, Bolivia, Bosnia and Herzegovina, Brazil, Bulgaria, Canada, Chile, China, Cyprus, Colombia, Costa Rica, Croatia,Czech Republic, Denmark, Djibouti, Dominican Republic, Ecuador, Finland, France, Georgia, Germany, Greece, Guatemala, Hong Kong, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kazakhstan, Kuwait, Lebanon, Lithuania, Liechtenstein, Luxembourg, Malaysia, Mexico, Monaco, Mozambique, Netherlands, New Zealand, Nigeria, Norway, Oman, Panama, Peru, Portugal, Qatar, Russia, Saint Bathelemy, Saint Martin, Saint Pierre and Miquelon, Saudi Arabia, Slovakia, Spain, Singapore, South Africa, Sweden, Switzerland, Taiwan, Thailand, Turkey, UAE, United Kingdom, Ukraine, Uruguay, Venezuela, Vietnam, Wallis and Futuna Islands. IMPORTANT NOTE: If you decide to purchase a WellAway product, you will be provided with a member package that contains a complete description of benefits, conditions, limitations and exclusion of coverage. All Benefits are subject to Usual Customary and Reasonable Fees (UCR) All Benefits reflected in USD.

11 ZONE 1 BENEFITS OUTSIDE THE USA HOSPITALIZATION AND SURGERY Hospitalization (inpatient) Pre-authorization required Semi-private room & board, miscellaneous services (eg. x-ray, lab test, anesthesia, MRI, CT scans.) Limited to 180 days per Benefit Period. Intensive care unit (limited to 180 days per Benefit Period) Physician services (inpatient) (limited to one (1) per day, per specialty when medically necessary) Rehabilitation (inpatient) Pre-authorization required 45 day limit per Benefit Period Renal failure dialysis (inpatient) Pre-authorization required (limited to six (6) weeks per Benefit Period) Hospice Pre-admission testing (must be performed 3-5 days in advance) 60 day Lifetime limit Ambulatory/outpatient surgical facility Pre-authorization required Oncology treatment Pre-authorization required (includes chemotherapy, radiation, and breast reconstruction) Reconstructive surgery Pre-authorization required (due to illness or injury first sustained while under the plan and performed within 12 months from date of accident) Surgical appliance and prosthesis (covered for devices which are integral part of the surgical procedure when medically necessary) Anesthesiologist (inpatient/outpatient) 30% of approved fees** Surgeon Fees (inpatient/outpatient) (multiple surgery guidelines apply) Assistant surgeon fees (inpatient/outpatient when medically necessary and per-authorized) 20% of approved fees** Diabetic equipment and supplies Home health care Pre-authorization required Organ transplant Pre-authorization required (subject to six (6) month waiting period) Outpatient renal failure dialysis (30 day limit per Benefit Period) up to 200,000 Lifetime limit 15,000 limit per Benefit Period IMPORTANT NOTE: Some services require pre-authorization. Contact us immediately about any serious illness or accident where you have to go into a hospital or emergency room. If you are unable to contact us because the condition is life, limb, sight, or organ threatening, please do so within 48 hours of the incident. Planned treatment requires a minimum of 5 days prior notice. **Approved fees means the amount approved to be paid by insurance company to the principal surgeon, after deductible and coinsurance WellAway ONEWORLD 29

12 ZONE 1 BENEFITS OUTSIDE THE USA WELLNESS & OUTPATIENT CARE Inpatient psychiatric Pre-authorization required Outpatient psychiatric consultation limited to 15 days per Benefit Period limited to 15 visits per Benefit Period Primary care consultation limited to 45 visits per Benefit Period Specialist consultation Chiropractic services Podiatry Durable medical equipment Outpatient therapeutic services - rehabilitation: Physical, occupational, speech, pulmonary & cardiac therapy (treatment plan must be provided) limited to 45 visits per Benefit Period limited to 5 sessions per Benefit period up to 90 per session limited to 600 per Benefit Period limited to 1,000 per Benefit Period limited to 20 sessions per therapy type per Benefit Period Injections/allergy treatment Basic diagnostic services (laboratory tests, x-rays, ultrasounds, EKG) Advanced diagnostic services/imaging Pre-authorization required (including but not limited to: MRI, CT scans, MRA, nuclear imaging) Routine physical examinations Adult female: Routine physical examinations office visit, routine physical exam, routine lab work, urinalysis, routine mammogram, papanicolaou (PAP) screening, colonoscopy based on medical history. Adult male: Office visit, routine physical exam, routine lab work, urinalysis, PSA screening test, colonoscopy based on medical history. limited to 300 per Benefit Period Children: (subject to 2 months waiting period except newborns) Wellness physical examinations office visit, health history, development assessment, physical examination, age related diagnostic tests, vaccination and immunizations in accordance with CDC recommendation for age. WellAway ONEWORLD 30

13 ZONE 1 BENEFITS OUTSIDE THE USA PRESCRIPTION DRUGS Tier 1 preferred generic Tier 2 preferred generic brand name * Tier 3 non preferred brand Tier 4 specialty medication * * *up to 7,000 limit per Benefit Period EMERGENCY & URGENT CARE Emergency ground ambulance (limited to one way trip) Emergency medical services/emergency room (if admitted to hospital, inpatient co-payment would apply in lieu of emergency room co-payment) Urgent care facility Emergency dental treatment (due to accident or injury to sound natural teeth and treated within 24 hours of the event) limited to 700 per Benefit Period EVACUATION & REPATRIATION Emergency medical evacuation Pre-authorization required Transfer to the nearest medical facility if the treatment needed is not available locally. Medical repatriation Pre-authorization required Members can return to their country of origin to be treated as long as they are physically and medically stable. Companion coverage/bedside visit (15 day limit per Benefit Period) Repatriation of mortal remains Pre-authorization required up to 20,000 limit per covered person, per Benefit Period Cost of transportation (economy-class flight) 15,000 Lifetime maximum Transportation (economy-class flight) hotel stay (75 per day limit) Economy car rental (30 per day limit), Daily meal allowance (25) 10,000 maximum lifetime IMPORTANT NOTE: if you decide to purchase a WellAway product, you will be provided a member package that contains a complete description of benefits, conditions, limitations and exclusions of coverage. All Benefits are subject to Usual Customary and reasonable Fees (UCR). All Benefits reflected in USD *Dollar () amount refers to copay portion of the insured WellAway ONEWORLD 31

14 ZONE 1 BENEFITS OUTSIDE THE USA ONEWORLD Optional Coverage MATERNITY (OPTIONAL) Maternity global period coverage up to 9,500 Complications of pregnancy up to 75,000 Newborn infant care up to 100,000 Congenital / Hereditary up to 250,000 DENTAL AND VISION COVERAGE (OPTIONAL) FIRST YEAR SECOND YEAR THIRD YEAR Maximum benefit 3,500 per policy year Basic (routine) 65% 90% Deductible 100 lifetime Major restorative 25% 65% Preventive (exams & cleanings, 2 per year) 100% 100% 100% Orthodontic treatment (covered for children under the age of 19-1,200 lifetime maximum per child, 600 annual limit) 10% 25% Vision Care Routine vision exam 75, 10 copay (one vision exam per year - includes any fees for contact lense fittings) Lenses (single vision, bifocal, trifocal) Frames (limited to one per benefit period) Contact lenses (in lieu of frames) up to 225 (limited to one every 24 months) up to 200 up to 100 WellAway ONEWORLD 32

15 ZONE 2, 3 & 4 Worldwide Excluding USA Summary of Benefits

16 ZONE 2, 3 & 4 Worldwide Excluding USA Summary of Benefits

17 ZONE 2, 3 & 4 WORLDWIDE EXCLUDING USA ANNUAL LIMIT 5,000,000 SILVER PLATINUM One of the highest limits on the market. Deductible The amount you owe for covered health care services before your health plan begins to pay. None None None Coinsurance Your share of costs on a covered service. 30% 20% 10% WellAway s share of costs on a covered service, after deductible and copay. 70% 90% Out-of-Pocket Maximum (OOP) The maximum you will pay each benefit period. Deductibles, coinsurance and co-payments are included in reaching your OOP. 6,300 12,600 3,500 7,000 1,500 3,000 Zone 1 Zone 2 Zone 3 Zone 4 Worldwide (including the USA) Worldwide (excluding the USA) Worldwide excluding: USA, Bahamas, Bermuda, Brazil, Canada, China, Hong Kong, Japan, Panama, Singapore, Switzerland, and United Kingdom. Rest of the world excluding: USA, Angola, Argentina, Australia, Austria, Azerbaijan, Bahamas, Bahrain, Barbados,Belgium,Bermuda, Bolivia, Bosnia and Herzegovina, Brazil, Bulgaria, Canada, Chile, China, Cyprus, Colombia, Costa Rica, Croatia,Czech Republic, Denmark, Djibouti, Dominican Republic, Ecuador, Finland, France, Georgia, Germany, Greece, Guatemala, Hong Kong, Hungary, Iceland, Ireland, Israel, Italy, Japan, Kazakhstan, Kuwait, Lebanon, Lithuania, Liechtenstein, Luxembourg, Malaysia, Mexico, Monaco, Mozambique, Netherlands, New Zealand, Nigeria, Norway, Oman, Panama, Peru, Portugal, Qatar, Russia, Saint Bathelemy, Saint Martin, Saint Pierre and Miquelon, Saudi Arabia, Slovakia, Spain, Singapore, South Africa, Sweden, Switzerland, Taiwan, Thailand, Turkey, UAE, United Kingdom, Ukraine, Uruguay, Venezuela, Vietnam, Wallis and Futuna Islands. IMPORTANT NOTE: If you decide to purchase a WellAway product, you will be provided with a member package that contains a complete description of benefits, conditions, limitations and exclusion of coverage. All Benefits are subject to Usual Customary and Reasonable Fees (UCR) All Benefits reflected in USD.

18 ZONE 2, 3 & 4 WORLDWIDE EXCLUDING USA HOSPITALIZATION AND SURGERY Hospitalization (inpatient) Pre-authorization required Semi-private room & board, miscellaneous services (eg. x-ray, lab test, anesthesia, MRI, CT scans.) Limited to 180 days per Benefit Period. Intensive care unit (limited to 180 days per Benefit Period) Physician services (inpatient) (limited to one (1) per day, per specialty when medically necessary) Rehabilitation (inpatient) Pre-authorization required 45 day limit per Benefit Period Renal failure dialysis (inpatient) Pre-authorization required (limited to six (6) weeks per Benefit Period) Hospice Pre-admission testing (must be performed 3-5 days in advance) 60 day Lifetime limit Ambulatory/outpatient surgical facility Pre-authorization required Oncology treatment Pre-authorization required (includes chemotherapy, radiation, and breast reconstruction) Reconstructive surgery Pre-authorization required (due to illness or injury first sustained while under the plan and performed within 12 months from date of accident) Surgical appliance and prosthesis (covered for devices which are integral part of the surgical procedure when medically necessary) Anesthesiologist (inpatient/outpatient) 30% of approved fees** Surgeon Fees (inpatient/outpatient) (multiple surgery guidelines apply) Assistant surgeon fees (inpatient/outpatient when medically necessary and per-authorized) 20% of approved fees** Diabetic equipment and supplies Home health care Pre-authorization required Organ transplant Pre-authorization required (subject to six (6) month waiting period) Outpatient renal failure dialysis (30 day limit per Benefit Period) up to 200,000 Lifetime limit 15,000 limit per Benefit Period IMPORTANT NOTE: Some services require pre-authorization. Contact us immediately about any serious illness or accident where you have to go into a hospital or emergency room. If you are unable to contact us because the condition is life, limb, sight, or organ threatening, please do so within 48 hours of the incident. Planned treatment requires a minimum of 5 days prior notice. **Approved fees means the amount approved to be paid by insurance company to the principal surgeon, after deductible and coinsurance WellAway ONEWORLD 48

19 ZONE 2, 3 & 4 WORLDWIDE EXCLUDING USA WELLNESS & OUTPATIENT CARE Inpatient psychiatric Pre-authorization required Outpatient psychiatric consultation limited to 15 days per Benefit Period limited to 15 visits per Benefit Period Primary care consultation limited to 45 visits per Benefit Period Specialist consultation Chiropractic services Podiatry Durable medical equipment Outpatient therapeutic services - rehabilitation: Physical, occupational, speech, pulmonary & cardiac therapy (treatment plan must be provided) limited to 45 visits per Benefit Period limited to 5 sessions per Benefit period up to 90 per session limited to 600 per Benefit Period limited to 1,000 per Benefit Period limited to 20 sessions per therapy type per Benefit Period Injections/allergy treatment Basic diagnostic services (laboratory tests, x-rays, ultrasounds, EKG) Advanced diagnostic services/imaging Pre-authorization required (including but not limited to: MRI, CT scans, MRA, nuclear imaging) Routine physical examinations Adult female: Routine physical examinations office visit, routine physical exam, routine lab work, urinalysis, routine mammogram, papanicolaou (PAP) screening, colonoscopy based on medical history. Adult male: Office visit, routine physical exam, routine lab work, urinalysis, PSA screening test, colonoscopy based on medical history. limited to 300 per Benefit Period Children: (subject to 2 months waiting period except newborns) Wellness physical examinations office visit, health history, development assessment, physical examination, age related diagnostic tests, vaccination and immunizations in accordance with CDC recommendation for age. WellAway ONEWORLD 49

20 ZONE 2, 3 & 4 WORLDWIDE EXCLUDING USA PRESCRIPTION DRUGS Tier 1 preferred generic Tier 2 preferred generic brand name * Tier 3 non preferred brand Tier 4 specialty medication * * *up to 7,000 limit per Benefit Period EMERGENCY & URGENT CARE Emergency ground ambulance (limited to one way trip) Emergency medical services/emergency room (if admitted to hospital, inpatient co-payment would apply in lieu of emergency room co-payment) Urgent care facility Emergency dental treatment (due to accident or injury to sound natural teeth and treated within 24 hours of the event) limited to 700 per Benefit Period EVACUATION & REPATRIATION Emergency medical evacuation Pre-authorization required Transfer to the nearest medical facility if the treatment needed is not available locally. Medical repatriation Pre-authorization required Members can return to their country of origin to be treated as long as they are physically and medically stable. Companion coverage/bedside visit (15 day limit per Benefit Period) Repatriation of mortal remains Pre-authorization required up to 20,000 limit per covered person, per Benefit Period Cost of transportation (economy-class flight) 15,000 Lifetime maximum Transportation (economy-class flight) hotel stay (75 per day limit) Economy car rental (30 per day limit), Daily meal allowance (25) 10,000 maximum lifetime IMPORTANT NOTE: if you decide to purchase a WellAway product, you will be provided a member package that contains a complete description of benefits, conditions, limitations and exclusions of coverage. All Benefits are subject to Usual Customary and reasonable Fees (UCR). All Benefits reflected in USD *Dollar () amount refers to copay portion of the insured WellAway ONEWORLD 50

21 ZONE 2, 3 & 4 WORLDWIDE EXCLUDING USA ONEWORLD Optional Coverage MATERNITY (OPTIONAL) Maternity global period coverage up to 9,500 Complications of pregnancy up to 75,000 Newborn infant care up to 100,000 Congenital / Hereditary up to 250,000 DENTAL AND VISION COVERAGE (OPTIONAL) FIRST YEAR SECOND YEAR THIRD YEAR Maximum benefit 3,500 per policy year Basic (routine) 65% 90% Deductible 100 lifetime Major restorative 25% 65% Preventive (exams & cleanings, 2 per year) 100% 100% 100% Orthodontic treatment (covered for children under the age of 19-1,200 lifetime maximum per child, 600 annual limit) 10% 25% Vision Care Routine vision exam 75, 10 copay (one vision exam per year - includes any fees for contact lense fittings) Lenses (single vision, bifocal, trifocal) Frames (limited to one per benefit period) Contact lenses (in lieu of frames) up to 225 (limited to one every 24 months) up to 200 up to 100 WellAway ONEWORLD 51

22 CONTACT US Bermuda: Denmark: Skype: WellAway Limited Canon s Court, 22 Victoria Street Hamilton HM 12, Bermuda THANK YOU! Rev WellAway ONEWORLD 58