Comprehensive benefit plan, including maternity coverage and access to providers in Latin America

Transcription

1 2018 Comprehensive benefit plan, including maternity coverage and access to providers in Latin America

2 Global Prime is tailored exclusively for individuals and families residing in Brazil who seek comprehensive health insurance with access to the highest quality medical providers in Brazil and Latin America. The plan offers a range of deductibles for members and provides coverage for inpatient care, outpatient care, preventive services, plus a pharmacy benefit and more. As with all GBG plans, Global Prime includes the world-class services of GBG Latin America for medical assistance and evacuations, if necessary, any time of day. GBG services include a vast network of medical facilities that will bill GBG directly, eliminating the need for a member to pay up-front for services. Global Prime also includes the GBG Personal Medical Advisor, one of the world s leading Medical Second Opinion services. Geographic Coverage Areas Global Prime provides Latin America coverage with access to a Preferred Provider Network in Brazil. This extensive geographic coverage area and use of provider networks allow GBG to provide first rate coverage while maintaining affordable rates.

3 Global Prime Schedule of Benefits Latin America (excluding Brazil): Free choice of Provider. HOSPITALIZATION BENEFITS Private/Semi-private room Intensive care unit Medical treatment, medicines, laboratory an diagnostic tests (including cancer treatment, chemotherapy/radiotherapy) Inpatient consultation by a physician or specialist Medical fees for Inpatient surgery Companion of hospitalized Insured Extended Care / Inpatient Rehabilitation (must be confined to facility immediately following a Hospital stay) Private duty nursing $300 per day; maximum of 10 days ; maximum 100 days Mental health Inpatient Physician/Specialist visit Mental health Outpatient OUTPATIENT BENEFITS ; maximum 30 visits ; maximum 50 visits per Policy Period Diagnostic exams including laboratory and imaging tests Outpatient surgery medical fees Therapeutic services: Chiropractic, Occupational Therapy, Vocational Speech Therapy, Homeopathy and Acupuncture Physical Therapy and Rehabilitation services Prescription Drugs following hospitalization or Outpatient surgery Prescription Drugs after consultation MAXIMUM BENEFIT Maximum $5,000,000 PROVIDER NETWORK Brazil: The Insurer maintains a Preferred Provider Network. In-network benefits are paid at. There is no coverage out-of-network. POLICY PERIOD DEDUCTIBLES Plan In Country of Residence Out of Country of Residence Plan In Country of Residence Out of Country of Residence Plan 1 N/A N/A Plan 4 $5,000 $5,000 Plan 2 N/A N/A Plan 5 $10,000 $10,000 Plan 3 $2,000 $2,000 Plan 6 $20,000 $20,000 Family Maximum Deductible: 2 x Individual Deductible ; maximum 30 combined visits ; maximum 50 combined visits per Policy Period ; for a maximum of 6 months; $3,000 thereafter ; maximum of $2,500 This is only a brief summary of key Plan provisions. Please refer to the Policy for complete details. Benefits are per person per Policy Period and are based upon medical necessity and Usual, Customary and Reasonable (UCR) charges, after Policy Period Deductible. Currency: USD

4 Serious Accident hospitalization (24 hours or more) EMERGENCIES ; Deductible waived for period of first hospitalization only Ground ambulance Air Ambulance ; $75,000 per event maximum; Deductible waived Emergency room and Emergency medical services Emergency dental Care - Limited to accidental injury of sound, natural teeth. Services must be completed within 120 days of Accident. Prophylactic surgery (only for gynecological cancer) Congenital and Hereditary Conditions Transplants procedures SPECIALIZED TREATMENTS PREVENTIVE CARE/ CHECK UP - Deductible Waived ; up to $5,000 Lifetime Maximum Covered according to the limits of this Policy ; $750,000 Lifetime Maximum per diagnosis, includes donor expenses Children up to 6 months of age (including immunizations, exams and consultation) ; maximum 5 visits Children 6 months or older and adults OTHER BENEFITS ; maximum $400 per person, Oncologic treatment Dialysis Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), AIDS Related Complex (ARC). A 24 month Waiting Period applies. Benefit is not covered if condition was diagnosed as Pre-existing Condition. GBG Personal Medical Advisor Medical Second Opinion service Home Health Benefits/ Home Care Special treatments (prosthesis, implants, appliances, orthotic devices and highly specialized drugs) Hospice Care Durable Medical Equipment Prosthetic limbs Repatriation of mortal remains, Lifetime maximum $15,000 Covered ; maximum 100 days ; maximum of 240 days ; maximum $30,000 $40,000 Policy Period maximum; $150,000 Lifetime Maximum $20,000 maximum per Insured War and Terrorism benefit MATERNITY BENEFITS (Covered on Plans 3 and 4 only) The Deductible is waived for this benefit only on Plan 3 ($2,000 Deductible) unless stated otherwise The Deductible applies for this benefit on Plan 4 ( $5,000 Deductible) A 10-month Waiting Period applies; no maternity related treatment for the mother or the newborn is covered during this period If only the mother is covered in the Policy (normal delivery or C-section) If both the mother and the father are covered in the Policy (normal delivery or C-section) Complications of Maternity and Perinatal (provided the child was born from a Covered Pregnancy). $7,000 benefit maximum per pregnancy $10,000 benefit maximum per pregnancy ; $500,000 Lifetime Maximum This is only a brief summary of key Plan provisions. Please refer to the Policy for complete details. Benefits are per person per Policy Period and are based upon medical necessity and Usual, Customary and Reasonable (UCR) charges, after Policy Period Deductible. Currency: USD

5 MATERNITY BENEFITS (Covered on Plans 3 and 4 only) (cont) Provisional coverage for newborn (for a maximum of 90 days); Covered Pregnancies only Optional Rider for Complications of Maternity and Perinatal (Plans 5 and 6). Coverage for Policyholder or spouse only. $5,000 benefit maximum per pregnancy $500,000 Lifetime Maximum, all pregnancies combined; Deductible applies Key Benefits Policy Period Maximum $5,000,000 Inpatient and Outpatient coverage Direct-bill network Emergency medical evacuation Online claims filing Live customer service Maternity and newborn care benefits Transplant procedure benefit THE FOLLOWING SERVICES REQUIRE PRE-AUTHORIZATION Hospitalization Exams or Outpatient procedures that requires more than local anesthesia Oncologic treatment in excess of $10,000 Home Health Benefits/ Home Care Organ, bone marrow, stem cell transplants, and other similar procedures Air Ambulance Air Ambulance service will be coordinated by Insurer s Air Ambulance Provider Specialty Treatments and Highly Specialized drugs Any condition that is expected to accumulate over $10,000 of medical treatment NOTE: Failure to pre-authorize a procedure that requires Pre-authorization will result in a 30% penalty. BRAZIL ONLY The following are non-preferred Providers: Hospital Israelita Albert Einstein Hospital Samaritano Rio de Janeiro Fleury Hospital Sírio-Libanês Copa Star There is no coverage in case of the use of a non-preferred Provider and the expenses incurred will be solely the Insured s responsability. NOTE: The Company retains the right to limit or prohibit the use of Providers, which significantly exceed Usual, Customary and Reasonable charges. This is only a brief summary of key Plan provisions. Please refer to the Policy for complete details. Benefits are per person per Policy Period and are based upon medical necessity and Usual, Customary and Reasonable (UCR) charges, after Policy Period Deductible. Currency: USD

6 LATAM_GPRIME_ENG_01FEB2018 Global Benefits Group Portola Parkway, Suite 110 Foothill Ranch, CA USA GBG Latin America 7600 Corporate Center Drive, Suite 500 Miami, FL USA latam.gbg.com