Premium rates ($) Aetna International Healthcare Plan www.mitraaca.com Effective 1 st October 2015 This schedule contains information on your premiums for the International Healthcare Plan in US$ Dollars. Simply decide which level of cover best suits your needs, choose your geographic area from the list in the next section, find your premium from the tables listed on the following pages, then contact Aetna using the details on this page or apply online at www.aetnainternational.com. There are five geographic areas and you should choose the country/area in which you will be resident at the time of inception of the policy. You will be covered worldwide, but if you wish to include elective treatment in the USA, this is available for an extra premium and is shown in Area 5. (Please note that for Areas 1 to 4, cover in the USA is for accident and emergency treatment only). All premiums quoted is for annual cover and is per person, unless otherwise stated. Contact details Indonesia PT Aetna Global Benefits Sentral Senayan 2 Building, 16th Floor Jl. Asia Afrika No. 8 Gelora Bung Karno Jakarta 10270 Indonesia T: +6221 40308999 Hp: 0851 051 88 999 0813840 38848 hadi@mitraaca.com www.mitraaca.com hadi@konsulasuransi.com www.konsulasuransi.com 46.02.425.1-APID E (10/15)
Area 2 Changed to Worldwide Excluding USA Excluding USA elective treatment Premiums shown in US$ Major Medical Nil Excess 1,000 Excess 5000 Excess Age Band 0-17 887 798 665 18-20 1,065 959 799 21-24 1,192 1,073 894 25-29 1,292 1,163 969 30-34 1,388 1,249 1,041 35-39 1,523 1,371 1,142 40-44 1,753 1,578 1,315 45-49 1,968 1,771 1,476 50-54 2,809 2,528 2,107 55-59 3,620 3,258 2,715 60-64 4,973 4,476 3,730 65-69* 7,665 6,898 5,749 70-74* 8,718 7,846 6,539 75-79* 10,041 9,036 7,530 80+* 11,341 10,207 8,506 Foundation Age Band 0-17 18-20 21-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69* 70-74* 75-79* 80+* 1,359 1,639 1,833 1,990 2,131 2,345 2,696 3,030 4,325 5,567 7,651 11,793 13,416 15,447 17,454 1,848 2,230 2,493 2,706 2,898 3,189 3,667 4,121 5,882 7,572 10,405 16,038 18,246 21,007 23,737 1,495 1,803 2,016 2,189 2,344 2,579 2,966 3,333 4,757 6,124 8,416 12,972 14,758 16,991 19,199 1,155 1,393 1,558 1,691 1,811 1,993 2,292 2,576 3,676 4,732 6,503 10,024 11,404 13,130 14,836 2
Foundation 500 Excess 1,000 Excess 2,000 Excess 5,000 Excess Age Band 0-17 1,087 1,019 883 679 18-20 1,312 1,230 1,066 820 21-24 1,466 1,375 1,191 916 25-29 1,592 1,492 1,293 995 30-34 1,705 1,598 1,385 1,065 35-39 1,876 1,758 1,524 1,172 40-44 2,157 2,022 1,752 1,348 45-49 2,424 2,273 1,970 1,515 50-54 3,460 3,244 2,811 2,162 55-59 4,454 4,176 3,619 2,784 60-64 6,121 5,738 4,973 3,825 65-69* 9,434 8,845 7,665 5,896 70-74* 10,733 10,062 8,720 6,708 75-79* 12,357 11,585 10,040 7,723 80+* 13,963 13,090 11,345 8,727 Lifestyle Age Band 0-17 1,630 2,135 1,776 1,434 18-20 1,966 2,576 2,143 1,730 21-24 2,198 2,880 2,396 1,935 25-29 2,384 3,123 2,599 2,098 30-34 2,561 3,354 2,791 2,253 35-39 2,817 3,690 3,070 2,479 40-44 3,235 4,237 3,526 2,847 45-49 3,939 5,160 4,293 3,466 50-54 5,621 7,364 6,127 4,947 55-59 7,238 9,482 7,889 6,369 60-64 9,943 13,025 10,838 8,750 65-69* 15,330 20,082 16,709 13,490 70-74* 17,440 22,846 19,009 15,347 75-79* 20,079 26,303 21,886 17,669 80+* 22,692 29,727 24,734 19,969 Lifestyle Plus Age Band 0-17 2,197 2,703 2,351 2,000 18-20 2,649 3,258 2,834 2,410 21-24 3,036 3,734 3,248 2,763 25-29 3,298 4,057 3,529 3,001 30-34 3,531 4,344 3,779 3,214 35-39 3,882 4,775 4,154 3,532 40-44 4,360 5,363 4,665 3,968 45-49 4,897 6,023 5,239 4,456 50-54 6,990 8,597 7,479 6,361 55-59 9,006 11,078 9,637 8,196 60-64 12,373 15,219 13,239 11,260 65-69* 18,398 22,629 19,685 16,742 70-74* 20,924 25,736 22,388 19,041 75-79* 24,093 29,634 25,779 21,925 80+* 27,225 33,487 29,131 24,775 3
Area 5 Worldwide including USA elective treatment Premiums including USA shown in US$ Foundation Age Band 0-17 2,411 3,279 2,652 2,050 18-20 2,733 3,716 3,006 2,323 21-24 3,459 4,705 3,805 2,940 25-29 3,773 5,132 4,151 3,207 30-34 4,041 5,496 4,445 3,435 35-39 4,485 6,099 4,933 3,812 40-44 5,447 7,408 5,992 4,630 45-49 6,151 8,366 6,766 5,228 50-54 7,195 9,785 7,914 6,116 55-59 9,483 12,896 10,431 8,060 60-64 13,644 18,556 15,008 11,597 65-69* 18,191 24,740 20,010 15,462 70-74* 20,501 27,882 22,551 17,426 75-79* 23,579 32,068 25,937 20,042 80+* 26,737 36,363 29,411 22,727 Foundation Age Band 0-17 18-20 21-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69* 70-74* 75-79* 80+* 500 Excess 1,000 Excess 2,000 Excess 5,000 Excess 1,929 2,186 2,767 3,019 3,233 3,588 4,358 4,921 5,756 7,586 10,915 14,553 16,401 18,863 21,390 1,808 2,049 2,595 2,830 3,031 3,364 4,085 4,613 5,396 7,112 10,233 13,643 15,376 17,684 20,053 1,567 1,776 2,249 2,453 2,627 2,915 3,541 3,998 4,677 6,164 8,869 11,824 13,326 15,326 17,379 1,206 1,366 1,730 1,887 2,020 2,242 2,724 3,076 3,597 4,741 6,822 9,096 10,251 11,790 13,369 4
Lifestyle Age Band 0-17 2,896 3,794 3,157 2,549 18-20 3,281 4,298 3,576 2,887 21-24 4,151 5,437 4,524 3,653 25-29 4,529 5,933 4,937 3,985 30-34 4,846 6,348 5,282 4,265 35-39 5,380 7,048 5,865 4,735 40-44 6,536 8,562 7,124 5,752 45-49 7,994 10,472 8,713 7,034 50-54 9,353 12,252 10,194 8,230 55-59 12,324 16,144 13,433 10,845 60-64 17,732 23,229 19,328 15,604 65-69* 23,647 30,977 25,775 20,809 70-74* 26,647 34,908 29,045 23,449 75-79* 30,648 40,149 33,407 26,970 80+* 34,757 45,532 37,885 30,586 Lifestyle Plus Age Band 0-17 3,763 5,230 4,026 3,424 18-20 4,267 5,931 4,565 3,883 21-24 5,527 7,682 5,913 5,029 25-29 6,032 8,384 6,454 5,489 30-34 6,452 8,968 6,904 5,871 35-39 7,167 9,962 7,669 6,522 40-44 8,496 11,809 9,090 7,731 45-49 9,593 13,335 10,265 8,730 50-54 11,225 15,603 12,011 10,215 55-59 14,788 20,555 15,823 13,457 60-64 21,282 29,582 22,771 19,366 65-69* 28,376 39,442 30,362 25,822 70-74* 31,978 44,449 34,216 29,100 75-79* 36,779 51,123 39,354 33,469 80+* 41,707 57,972 44,626 37,953 Additional Options Please note that all persons to be covered under this policy must select the same level of cover. USA Elective Treatment Area 5 rates apply. Direct Settlement Network 1 Additional load applies. Area/ Plan Foundation Lifestyle Lifestyle Plus Area 2, 5 10% 9% 7% Extended Evacuation Please contact Aetna for additional loading. 1 Available in certain countries. Please check with your local sales centre. 5
Stay connected to Aetna International: AetnaInternational Countries Country Area Canada 4 Gabon 1 Lithuania 3 Palau 2 Switzerland 3 Afghanistan 1 Cape Verde 1 Gambia 1 Luxembourg 3 Panama 2 Taiwan 4 Albania 3 Cayman Islands 4 Georgia 4 Macau 4 Papua New Tajikistan 4 Algeria 1 Central African Germany 3 Macedonia 3 Guinea 2 Tanzania (United American Samoa 2 Republic 1 Ghana 1 Madagascar 1 Paraguay 2 Republic of) 1 Andorra 3 Chad 1 Gibraltar 3 Malawi 1 Peru 2 Thailand 2 Angola 1 Chile 2 Greece 3 Malaysia 2 Philippines 2 Togo 1 Antigua and China 4 Grenada 4 Maldives 1 Poland 3 Tonga 2 Barbuda 4 Colombia 2 Guatemala 2 Mali 1 Portugal 3 Trinidad & Argentina 2 Comoros 1 Guinea 1 Malta 3 Qatar 1 Tobago 4 Armenia 4 Congo 1 Guinea-Bissau 1 Marshall Islands 2 Romania 3 Tunisia 1 Australia 4 Costa Rica 2 Guyana 2 Mauritania 1 Russia 4 Turkey 3 Austria 3 Croatia 3 Haiti 4 Mauritius 1 Rwanda 1 Turkenistan 4 Azerbaijan 4 Cyprus 3 Honduras 2 Mexico 2 Samoa 2 Turks & Caicos 4 Bahamas 4 Czech Republic 3 Hong Kong 4 Micronesia San Marino 3 Tuvalu 2 Bahrain 1 Democratic Hungary 3 (Federated Sao Tome and Uganda 1 Bangladesh 1 Republic of the Iceland 3 States of) 2 Principe 1 Ukraine 3 Barbados 4 Congo 1 India 1 Moldova 3 Saudi Arabia 1 United Arab Belarus 3 Denmark 3 Indonesia 2 Monaco 3 Senegal 1 Emirates 1 Belgium 3 Djibouti 1 Italy 3 Mongolia 2 Seychelles 1 United Kingdom 3 Belize 4 Dominica 4 Ivory Coast 1 Montenegro 3 Sierra Leone 1 Uruguay 2 Benin 1 Dominican Jamaica 4 Morocco Singapore 4 Uzbekistan 4 Bhutan 1 Republic 4 Japan 4 Mozambique 1 Slovakia 3 Vanuatu 2 Bolivia 2 East Timor 2 Jordan 1 Namibia 1 Slovenia 3 Vatican City 3 Bosnia & Ecuador 2 Kazakhstan 4 Nauru 2 Solomon Islands 2 Venezuela 2 Herzegovina 3 Egypt 1 Kenya 1 Nepal 2 South Africa 1 Vietnam 2 Botswana 1 El Salvador 2 Kiribati 2 Netherlands 3 Spain 3 Western Sahara 1 Brazil 2 Equatorial Korea, Netherlands Sri Lanka1 Yemen 1 British Virgin Guinea 1 South 2 Antilles 4 St Kitts & Nevis 4 Zambia 1 Islands 4 Eritrea 1 Kuwait 1 New Zealand 4 St Lucia 4 Zimbabwe 1 Brunei 2 Estonia 3 Kyrgyzstan 4 Nicaragua 2 St Martin 4 Bulgaria 3 Ethiopia 1 Laos 2 Niger 1 St Vincent & Burkina Faso 1 Fiji 2 Latvia 3 Nigeria 2 Grenadines 4 Burundi 1 Finland 3 Lesotho 1 Norway 3 Suriname 1 Cambodia 2 France 3 Libya 1 Oman 1 Swaziland 1 Cameroon 1 French Polynesia 2 Lichtenstein 3 Pakistan 1 Sweden 3 Aetna is a trademark of Aetna Inc. and is protected throughout the world by trademark registrations and treaties. Policies issued and underwritten by PT Asuransi Central Asia. Registered Address: Mall Ambassador Ruko 2 & 3, Jl. Prof. Dr. Satrio, Jakarta 12940, Indonesia. Aetna does not provide care or guarantee access to health services. Not all health services are covered. Health information programmes provide general health information and are not a substitute for diagnosis or treatment by a health care professional. See plan documents for a complete description of benefits, exclusions, limitations and conditions of cover. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna International plans, refer to www.aetnainternational.com. Whenever coverage provided by any insurance policy is in violation of any U.S, U.N or EU economic or trade sanctions, such coverage shall be null and void. For example, Aetna companies cannot pay for health care services provided in a country under sanction by the United States unless permitted under a written Office of Foreign Asset Control (OFAC) license. Learn more on the US Treasury s website at: www.treasury.gov/resource-center/sanctions. 2015 Aetna Inc. 46.02.425.1-APID E (10/15)