GeoBlue Xplorer Premier
GeoBlue Xplorer is designed for extended living abroad. You can choose to enroll in a new plan when your existing plan expires. When you do, there are no medical questions and premium rates do not change based on your individual claims history. Your new rate will be the same as all persons covered in your rating class.
All U.S. citizens living abroad who are 74 or younger at the time of application are eligible to apply for coverage or; All legal residents of the U.S. (citizens and foreign nationals) who are age 74 or younger at the time of application are eligible if they live in the U.S. or; An employee of a U.S. company, whereby the company is domiciled in the U.S. and the company pays the insurance premium.
|Benefits||Outside U.S.||U.S. (In-Network)||U.S. (Outside Network)|
|Preventive and Office Visits &ndash Insurer Waives Deductible|
|Physician Office Visits (Adult)||All exce a $10 copay per visit||All exce a $30 copay per visit||60% to Out-of-Pocket Maximum then 100%|
|Physician Office Visits (Children 0-18)||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Unlimited Well Baby Visits||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Child Immunizations, Lab and X-rays||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Women: (19 and Older) Routine Pap Smears, Annual Mammogram||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|PSA for Men||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|One Routine Physical Per Year||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Professional Services &ndash Insurer Pays After Deductible is Met|
|Surgery, Anesthesia, Radiation Therapy, In-hospi- tal Doctor Visits, Diagnostic X-ray and Lab Work||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Inpatient Hospital Services - Insurer Pays After Deductible is Met|
|Surgery, X-rays, In-hospital Doctor Visits, Organ/ Tissue Transplant||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Inpatient Medical Emergency||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Inpatient Drugs||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Ambulatory and Therapeutic Services &ndash Insurer Pays After Deductible is Met|
|Ambulatory Surgical Center||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Ambulance Service||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Accidental Dental||$1,000 per year, $200 per tooth||$1,000 per year, $200 per tooth||$1,000 per year, $200 per tooth|
|Acupuncture and Chiropractic Services||100% up to $2,000||80% up to $2,000||60% up to $2,000|
|Durable Medical Equipment||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Infusion Therapy||100%||80% to Out-of-Pocket Maximum then 100%||60% to Out-of-Pocket Maximum then 100%|
|Physical/Occupational Therapy*||$50 max each visit, 12 visits per year||$50 max each visit, 12 visits per year||$50 max each visit, 12 visits per year|
|Inpatient Mental Health||100% up to 60 days||80% up to 60 days||60% up to 60 days|
|Outpatient Mental Health||75% up to 40 visits/60% thereafter||75% up to 40 visits/60% thereafter||75% up to 40 visits/60% thereafter|
|Inpatient Substance Abuse||100% up to 60 days detox||80% up to 60 days detox||60% up to 60 days detox|
|Outpatient Substance Abuse||75% up to 40 visits/60% thereafter||75% up to 40 visits/60% thereafter||75% up to 40 visits/60% thereafter|
|Prescriion Drug Benefit Oions &ndash Insurer Waives Deductible|
|Basic Prescriion Drug Benefit Subject to $1000 Maximum per Insured Person per Coverage Period||100% of actual charges||Generics: 100% after $10 copay Brandname: 100% after $25 copay Injectables: 70%||Generics: 100% after $10 copay Brandname: 100% after $25 copay Injectables: 70%|
|Oional rider, subject to $25,000 Maximum Benefit per Insured Person per Coverage Period.||100% of actual charges||Generics: 100% after $10 copay Brand- name: 100% after $25 copay Injectables: 70%||Generics: 100% after $10 copay Brandname: 100% after $25 copay Injectables: 70%|
|Global Travel Benefits &ndash Insurer Waives Deductible|
|Emergency Medical Transportation||Up to $250,000||n/a||n/a|
|Repatriation of Mortal Remains||Up to $25,000||n/a||n/a|
|Accidental Death and Dismemberment||$50,000||$50,000||$50,000|
|Home Health Care||100% Covered Expenses, as many as 30 visits per year|
|Skilled Nursing Facilities||100% with a maximum Covered Expense of $250 per day, as many as 50 days per year|
|Hospice||100% with a maximum Covered Expense of $5,000 per lifetime|
Xplorer Excluded Services
The plan does not provide benefits for:
1. Hospitalization, services and supplies that are not Medically Necessary.
2. Services or supplies that are not specifically mentioned in this Certificate.
3. Services or supplies for any illness or injury arising out of or in the course of employment for which benefits are available under any Worker's Compensation Law or other similar laws whether or not you make a claim for such compensation or receive such benefits.
4. Services or supplies that are furnished to you by the local, state or federal government and for any services or supplies to the extent payment or benefits are provided or available from the local, state or federal government whether or not that payment or benefits are received.
5. Conditions caused by or contributed by: (a) An act of war; (b) The inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) An Insured Person participating in the military service of any country; (d) An Insured Person participating in an insurrection, rebellion, or riot; (e) Services received for any condition caused by an Insured Person's commission of, or attempt to commit a felony or to which a contributing cause was the Insured Person being engaged in an illegal occupation; (f) An Insured Person voluntarily using illegal drugs; intentionally taking over the counter medication not in accordance with recommended dosage and warning instructions; and intentionally misusing prescription drugs.
6. Services or supplies that do not meet accepted standards of medical and/or dental practice.
7. Investigational Services and Supplies and all related services and supplies.
8. Custodial Care Service.
9. Routine physical examinations, unless otherwise specified in this Certificate.
10. Services or supplies received during an Inpatient stay when the stay is primarily related to behavioral, social maladjustment, lack of discipline or other antisocial actions that are not specifically the result of Mental Illness.
11. Cosmetic Surgery and related services and supplies, whether or not for psychological purposes, except for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors or diseases that occur after your Coverage Date.
12. Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar coverage.
13. Charges for failure to keep a scheduled visit or charges for completion of a Claim form.
14. Personal hygiene, comfort or convenience items commonly used for other than medical purposes, such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones.
15. Special braces, splints, specialized equipment, appliances, ambulatory apparatus, battery implants, except as specifically mentioned in this Certificate.
16. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
17. Blood derivatives that are not classified as drugs in the official formularies.
18. Eyeglasses, contact lenses or cataract lenses and the examination for prescribing or fitting of glasses or contact lenses or for determining the refractive state of the eye, except as specifically mentioned in this Certificate.
19. Treatment to change the refraction of one or both eyes (laser eye correction), including refractive keratectomy (RK) and photorefractive keratectomy (PRK).
20. Vision care services unless elected by your Group
21. Treatment of flat foot conditions and the prescription of supportive devices for such conditions and the treatment of subluxations of the foot.
22. Routine foot care, except for persons diagnosed with diabetes, including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet.
23. Immunizations, unless otherwise specified in this Certificate.
24. Maintenance Occupational Therapy, Maintenance Physical Therapy and Maintenance Speech Therapy.
25. Hearing aids or examinations for the prescription or fitting of hearing aids unless otherwise specified in this Certificate.
26. Services and supplies to the extent benefits are duplicated because the spouse, parent and/or child are employees of the Group and each is covered separately under this Certificate.
27. Diagnostic Service as part of routine physical examinations or check-ups, premarital examinations, determination of the refractive errors of the eyes, auditory problems, surveys, casefinding, research studies, screening, or similar procedures and studies, or tests which are Investigational unless otherwise specified in this Certificate.
28. Procurement or use of prosthetic devices, special appliances and surgical implants which are for cosmetic purposes, the comfort and convenience of the patient, or unrelated to the treatment of a disease or injury.
29. Services and supplies rendered or provided for human organ or tissue transplants other than those specifically named in this Certificate.
30. Investigational or experimental organ transplantation including animal to human organ transplants.
31. Consultations performed by you, your spouse, parents or children.
32. Charges for the services of a standby Physician.
33. Treatment for overweight conditions other than for morbid obesity.
34. Treatment for hair loss.
35. Growth Hormone treatment.
36. Dental treatment, dental surgery, dental prostheses and orthodontic treatment unless otherwise specified in this Certificate.
37. Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
38. Medical aids unless otherwise specified in this Certificate.
39. Services and treatment related to elective abortions.
40. Sterilization or the reversal of sterilization, unless otherwise specified in this Certificate.
41. All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization.
42. Cryopreservation of sperm or eggs.
43. Sex change operations.
44. Treatment of sexual dysfunction or inadequacy.
45. Non-prescription drugs.
46. Educational services except as specifically provided or arranged by the Insurer.
47. Nutritional counseling or food supplements, except for treatment of Phenylketonuria (PKU) and other inherited metabolic diseases and diabetes.
48. Charges by a provider for telephone consultations.
The pre-existing condition exclusion can be waived with proof of prior creditable insurance.
The GeoBlue Xplorer plan does not cover services for treatment of a medical condition for which medical advice, diagnosis, care, or treatment was recommended or received during 180 days immediately preceding the member’s eligibility date.
The 180-day pre-existing conditions period can be reduced or eliminated if you have been covered by a creditable group or individual health insurance plan.
If you were previously covered by a U.S. health plan that issues you a Certificate of Creditable Coverage, GeoBlue will credit you for this prior coverage. The number of months of coverage shown on the Certificate will reduce or eliminate the six-month pre-existing condition waiting period. If you have six or more months of creditable coverage, your waiting period will be eliminated. If you have less than six months creditable coverage, your waiting period will be reduced by the number of months you had creditable coverage. For example, if you have two months of creditable coverage, your waiting period will be reduced from six months to four months.
You can enroll in a Xplorer plan up to age 84. The policy does not automatically renew upon your request. You will be notified of your new plan rate at least 30 days prior to your policy expiration date. You must confirm your new policy rate in writing or by accepting the rate when logged in to our secure website. Plan rates are based on age at time of enrollment and are impacted by medical inflation. You will not be asked any medical questions and your personal health history will not determine your new rate. Xplorer rates are standard rates for all members re-enrolling
Coverage is not guaranteed until approved in writing by GeoBlue. Do not cancel your current insurance coverage until you have been notified of approval by GeoBlue that your GeoBlue Xplorer coverage is effective.
Any cancellation requests must come from the insured subscriber and be received by GeoBlue in writing via email, fax or regular mail. There are no cancellation fees or penalties. However, GeoBlue does not refund premium for a partial month. Retroactive cancellations are also not permitted.
GeoBlue's Global Health and Safety services help members identify, access, and pay for quality healthcare all over the world. This includes a contracted community of elite providers in 180 countries. Members can access these carefully selected providers and arrange for the bills to be sent directly to GeoBlue for payment as follows: go to www.geobluetravelinsurance.com. GeoBlue will automatically arrange for direct settlement of the bill for this visit. Please note, direct billing may not be available everywhere.
Direct billing can also be requested by calling the assistance telephone number listed on your member ID card, or by emailing email@example.com Please note that in the U.S. a member can simply show their ID card at time of service and participating providers will only bill the member for any required deductible or co-payment.
A claims instruction page is available online and can be accessed by visiting www.geobluetravelinsurance.com and selecting "Contact Us" from the top right navigation bar. Claim forms are downloadable from this section of the site as well.