ORBE Schedule of Benefits

Transcription

1 ORBE Schedule of Benefits

2 Schedule of Benefits

3 Coinsurance ORBE 90 ORBE 100 Worldwide Benefits Worldwide Benefits Worldwide Benefits WellAway s share of costs on a covered service Your share of costs on a covered service 20%* 20%* 90% 10%* 90% 10%* 100% 0% 100% 0% *Some out-of-pocket may apply Zone 1 Worldwide (including the USA) Zone 2 Worldwide (excluding the USA) Zone 3 Worldwide (excluding: USA, Bahamas, Bermuda, Brazil, Canada, China, Hong Kong, Japan, Panama, Singapore, Switzerland, and United Kingdom.) Zone 4 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 Bartholemy, 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.) Coinsurance maximums are capped to an annual limit depending on the chosen plan (, 90, 100). Please refer to page 8 for limits on caps per plan. This product features deductible options of $0, $100, $250, $500, $1,000, $2,000, $5,000, giving you control over your premium. Please contact your broker or a representative of WellAway Limited for more information. Coverage of pre-existing conditions may be available upon medical underwriting and application approval by WellAway Limited. All benefits are subject to Usual Customary and Reasonable Fee. USA Benefits Available with Zone 1 Maximum amounts apply to certain services. When going to out-of-network providers in the USA, 50% coinsurance will apply. You have access to special claims and administrative services within the USA. We provide you with access to more than 6 million facilities, doctors, osteopaths and outpatient services via our provider network. The USA is an expensive healthcare market. To help you keep your share of costs as low as possible, we endorse the use of in- network providers. When using outof-network providers, 50% coinsurance will apply. WellAway ORBE 3

4 WELLNESS PREVENTIVE (subject to 2 month waiting period, not applicable to newborns) Worldwide Benefits Zone 1, 2, 3 & 4 USA Benefits Zone 1 Adult female: Wellness physical examinations office visit, lab work, urinalysis & papanicolaou (PAP) screening Mammogram (eligible age: 40 years or above) Colonoscopy (eligible age: 50 years or above) Adult male: Wellness physical examinations office visit, lab work & urinalysis PSA screening test & colonoscopy (eligible age: 50 years or above) up to $500 up to $500 Children: Wellness physical examinations office visit, health history, development assessment, physical examination, age related diagnostic tests, vaccination and immunization in accordance with CDC recommendation for age Podiatry up to $100 per session 5 visit limit up to $100 per session 5 visit limit Alternative medicine (acupuncture, chiropractic, homeopathy, herbalism, dietetics) up to $100 per session limited to $500 Vaccination required for travel up to $100 Maximum amounts apply to certain services. When using out-of-network providers in the USA, 50% coinsurance will apply. All currency is reflected in USD. WellAway ORBE 4

5 HOSPITALIZATION AND SURGERY Hospitalization (inpatient) pre-authorization required (room & board, miscellaneous room services) In-hospital advanced diagnostic services (e.g., MRI, CT scans, nuclear imaging) Worldwide Benefits Zone 1, 2, 3 & 4 USA Benefits Zone 1 Private or semi-private room, up to $500 per day. up to $500 per day Routine x-ray and lab tests Intensive care unit (limited to 180 days ) Physician & osteopath services (inpatient) (limited to 1 per day, per specialty when medically necessary) Rehabilitation (inpatient) pre-authorization required Renal failure dialysis (inpatient) pre-authorization required Hospice 10 day limit 10 day limit up to $50,000 up to $50, day limit 30 day limit Pre-admission testing (must be performed 3-5 days in advance) Oncology treatment pre-authorization required (includes chemotherapy, radiation and breast reconstruction) Reconstructive surgery pre-authorization required (due to illness or injury) Surgical appliance and prosthesis (covered for devices which are an integral part of the surgical procedure when medically necessary) Surgeon fees pre-authorization required Miscellaneous equipment and supplies Organ transplant pre-authorization required (subject to 6 month waiting period) Inpatient psychiatric pre-authorization required (subject to 10 month waiting period) Ambulatory surgical facility pre-authorization required up to $150,000 lifetime 10 day limit up to $150,000 lifetime 10 day limit Maximum amounts apply to certain services. When using out-of-network providers in the USA, 50% coinsurance will apply. All currency is reflected in USD. WellAway ORBE 5

6 OUTPATIENT CARE Worldwide Benefits Zone 1, 2, 3 & 4 USA Benefits Zone 1 Outpatient psychiatric consultation & psychotherapist visit (subject to 10 month waiting period) 10 consultation limit 10 consultation limit Primary care visit only if medically necessary (includes physicians and osteopaths) up to $100 per consultation Specialist consultation only if medically necessary (includes physicians and osteopaths) up to $200 per consultation Durable medical equipment limited to $900 Allergy testing & treatment pre-authorization required (includes injections for allergies) up to $200 per year Basic diagnostic services (laboratory tests, x-rays, ultrasounds, EKG) Advanced diagnostic and imaging services pre-authorization required (when performed in a free-standing non hospital facility, e.g., MRI, CT scans, PET scans, MRA, nuclear imaging) up to $1,000 Outpatient therapeutic services (physical, occupational, speech, pulmonary & cardiac therapy - treatment plan must be provided) up to $100 per session, limited to 15 sessions per therapy type, max 45 sessions. up to $100 per session, limited to 15 sessions per therapy type, max 45 sessions. Home health care pre-authorization required (care must begin immediately following your hospital stay of no less than 3 days) Outpatient renal failure dialysis 15 day limit per post-hospital discharge. Max 30 days $10,000 limit 15 day limit per post-hospital discharge. Max 30 days per policy year $10,000 limit Maximum amounts apply to certain services. When using out-of-network providers in the USA, 50% coinsurance will apply. All currency is reflected in USD. WellAway ORBE 6

7 EMERGENCY AND URGENT CARE Worldwide Benefits Zone 1, 2, 3 & 4 USA Benefits Zone 1 Emergency ground ambulance (limited to one way trip) Emergency medical services/ emergency room Urgent care clinic/ facility Emergency dental treatment (due to accident or injury to sound natural teeth and treated within 24 hours of the event) up to $600 up to $600 PRESCRIPTION DRUGS Prescription drugs Generic dispensed when available: - Brand will only be dispensed if generic is not available and it is medically necessary. - In the USA, brand will be paid at the equivalent cost of generic. up to $5,000 up to $5,000 EVACUATION & REPATRIATION Emergency medical evacuation and repatriation pre-authorization required (members can return to their country of origin to be treated as long as they are physically and medically stable) Transfer to the nearest facility if the treatment needed is not available locally. Companion coverage/bedside visit (15 day limit ) up to $50,000 up to $50,000 limit per covered person, limit per covered person, Transportation (economy-class flight), hotel stay ($75 per day limit), car rental ($30 per day limit), daily meal allowance ($25) Repatriation of mortal remains pre-authorization required $25,000 maximum lifetime $25,000 maximum lifetime Maximum amounts apply to certain services. When using out-of-network providers in the USA, 50% coinsurance will apply. All currency is reflected in USD. WellAway ORBE 7

8 ORBE Optional Coverage MATERNITY (optional) (subject to 10 month waiting period) Maternity global period coverage (includes hospital, obstetrician and anesthesiologist) Complications of pregnancy (mother only) Non-healthy newborn infant care (baby must be added to the policy) Congenital disorder (baby must be added to the policy) Worldwide Benefits Zone 1, 2, 3 & 4 up to $8,000 up to $50,000 up to $50,000 up to $100,000 USA Benefits Zone 1 up to $8,000 up to $50,000 up to $50,000 up to $100,000 DENTAL AND VISION COVERAGE (optional) Dental & vision benefits are offered as a package and may not be purchased separately. Maximum benefit $3,500 Basic (routine) FIRST YEAR SECOND YEAR THIRD YEAR 65% 90% Deductible $100 lifetime Major restorative 25% 50% 65% Preventive (exams & cleanings, 2 per year) 100% 100% 100% Vision care (vision subject to 6 month waiting period) Routine vision exam $75, $10 copay (one vision exam per year - includes any fees for contact lens fittings) Orthodontic treatment (covered for children under the age of 19 - $1,200 lifetime maximum per child, $600 annual limit) Lenses (single vision, bifocal, trifocal) Frames (limited to one ) Contact lenses (in lieu of frames) 10% 25% 50% up to $200 (limited to one every 24 months) up to $225 up to $225 COINSURANCE MAXIMUM $6,300 individual $12,600 family Maximum amounts apply to certain services. When using out-of-network providers in the USA, 50% coinsurance will apply. All currency is reflected in USD. WellAway ORBE 8

9 This material is provided for informational purposes only and is subject to change. The information contained in this schedule of benefits does and will not affect, modify or supersede in any way the policy terms and conditions. This document shall not bind WellAway Limited or require WellAway Limited to offer or write any insurance at any particular rate or to any particular group or individual. The actual premium and benefits are governed by your policy documents. All benefits are subject to exclusions and limitations. To ensure you have all the information you need before purchasing one of our products, we recommend you consult with your independent medical, legal and/or tax advisors. 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 exclusions of coverage. Products and services may not be available in all jurisdictions and are expressly excluded where prohibited by applicable law. The contents of this material are the exclusive intellectual property of WellAway Limited. No reproduction, changes or copying is possible without the consent of WellAway Limited. The WellAway name, brand and logos are the registered marks of WellAway Limited and WellAway SA, Hamilton, Bermuda. WellAway ORBE 9

10 CONTACT US Bermuda: UK: France: Belgium: Skype: info@wellaway.com WellAway Limited Canon s Court, 22 Victoria Street Hamilton HM 12, Bermuda Rev. 08/2018