| CitizenSecureSM |
Benefits & Limits |
| Coverage Area |
Option 1 - Including the US and Canada
Option 2 - Excluding the US and Canada |
| Overall Policy Maximum |
$5,000,000 Lifetime |
| Deductibles Available |
$250, $500, $1,000, $2,500 or $5,000 per Member per Certificate Period. |
| Family Deductible |
Maximum of three Deductibles per family per Certificate Period |
| Coinsurance -- Claims incurred in US or Canada* |
80% of the next $5,000 of Eligible Medical Expenses after the Deductible, then 100% to the Overall Policy Maximum. The Coinsurance will be waived
if expenses are incurred within the PPOand expenses are submitted to Underwriters for
review and payment directly to the provider. |
| Coinsurance -- claims
incurred outside US or Canada |
After the Deductible, Underwriters will pay 100% of Eligible Expenses to the Overall
Maximum Limit |
| Family Coinsurance |
After $3,000 of Coinsurance has been paid per Family per Certificate Period, Underwriters
will pay 100% of Eligible Expenses to the Overall Maximum Limit |
| Hospital Room and Board -- In US or Canada* |
Average Semi-private room rate. |
| Hospital Room and Board
-- Outside US or Canada |
Average Private room rate. |
| Intensive Care Unit -- In US or Canada* |
Usual, Reasonable and Customary. |
| Intensive Care Unit --
Outside US or Canada |
Usual, Reasonable and Customary. |
| Prescription Drugs |
Usual, reasonable and customary
Subject to deductible and coinsurance |
| Mental Health Disorders |
$10,000 per Certificate Period ; $25,000 Lifetime Maximum, $50 maximum per visit per day for outpatient care (after 12 months of continuous coverage). |
| Maternity -- Normal or Complicated Delivery |
After the Deductible, Underwriters will pay 50% of the next $100,000
of Eligible Medical Expenses after the Deductible, then 100% to a Lifetime
Maximum of $250,000. Covered Maternity expenses include pre-natal, Delivery,
and post- natal care. (after 12 months of continuous coverage). |
| Maximum for Maternity |
$250,000 Lifetime |
| Newborn Care |
Included as part of Maternity benefits for maximum of 60 days. |
| Pre-existing Conditions |
Same as any other Injury or Illness if disclosed on Application and
not excluded or limited by Rider. |
| Local Ambulance |
Usual, Reasonable and Customary. |
| Physical Therapy |
$50 Maximum per visit. |
| Wellness |
All Wellness benefits are available after 12 months of continuous coverage and are not
subject to Deductible.
- Members under age 19: $50 per visit (including immunizations), maximum of three visits per
Certificate Period.
- Members age 30 and over: $250 per Member per Certificate Period
- Female Members age 40 and over (or qualifying Woman at Risk as herein defined): $100
per Member per Certificate Period for a screening mammogram
|
| Human Organ/Tissue Transplants** |
Same as any other Illness for Covered Transplants. |
| All Other Eligible Expenses |
Usual, Reasonable and Customary. |
| Emergency Medical Evacuation |
$50,000 Lifetime Maximum. |
| Repatriation of Remains |
$25,000 Limit |
| Emergency Reunion |
$10,000 Lifetime Maximum. |
| Pre-certification Penalty |
50% |
* Benefits within the US and Canada are not available to applicants electing Option 2 as their Coverage Area.
** Covered Transplants include Heart, Heart/Lung, Lung, Kidney, Kidney/Pancreas, Liver and Allogenic and
Autologous Bone Marrow. |
Atlas
