GeoBlue Xplorer Premier

Detail

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.

Benefit

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
Other Benefits		Limits
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

Exclusion

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.

Acute Pre-Ex Coverage

The pre-existing condition exclusion can be waived with proof of prior creditable insurance.

Pre-existing conditions

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.

Creditable coverage

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.

Renew

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

Cancel

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.

Claim

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 globalhealth@geo-blue.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.

Scenario	Coverage Under Full Pre-Existing Plan
My father had a heart attack a few years ago. After his travel to the US, he started experiencing heart pain. I took him to the cardiologist. Is this covered?	Yes. Cardiologist visits are covered underneath a Full Pre-Existing coverage plan.
My mother-in-law has been experiencing heart pain for last few days, and had a heart attack on the last day. Is this covered?	Yes. Under a Full Pre-Existing Plan, there is not time limitation between symptoms and seeking care.
My uncle had cancer a few years ago. He is on a Green Card and has been living in the US. Recently, the cancer has come back. Is this covered?	Yes. Chemotherapy & Radiation treatment are covered under this plan. One note- the recurring cancer diagnosis must occur after the effective date.
My cousin had a back injury a few years back. He recently starting feeling back pain and went to seek the advise of a Chiropractor & get physical therapy. Is this covered?	Yes. Chiropractic care & physical therapy regarding pre-existing conditions are covered underneath full pre-existing plans.
My aunt had a sudden heart attack. After staying a few days in the hospital, she needs prescription drugs, follow up blood tests, and doctors visits. Are these covered?	Yes. Any sudden medical event, along with any follow up visits, i.e. blood tests, x-rays, EKG, etc., will be covered by full pre-existing plans.
My mother is diabetic. She was prescribed medication but often forgets to take it often. She experienced a diabetic shock and needed to visit the emergency room. Will this emergency visit be covered?	Yes. Our plans cover you no matter whether your visitor was taking their prescribed medication or not. Full pre-existing plans will cover no matter what happens.

Scenario	Coverage Under INF Acute Onset Plan
My father had a heart attack a few years ago. After his travel to the US, he started experiencing heart pain. I took him immediately to the emergency room. Is this covered?	Yes. Cardiologist visits are covered underneath a Full Pre-Existing coverage plan.
My mother-in-law had a sudden drop in blood sugar. I took her to the Urgent Care clinic. Is this covered?	Yes, as long as you seek medical attention within 12 hours you are covered.
My uncle was playing a game of cricket in the neighborhood and started to experience chest pain. He was hospitalized for 3 days and required several blood tests, and heart scans. Will this be covered?	Yes. Our plans will cover any sudden recurrence caused by a pre-existing conditions. Our plans have no pre-authorization, meaning the hospital can get the treatment your visitors needs faster.
My father-in-law had several kidney issues over the past few years. After several hours of pain, we took him to the hospital to have kidney stones removed. Is this covered?	Yes. As long as the treatment is sought within the first 12 hours of first exhibiting symptoms, any pre-existing condition will be covered. Our plans have no look back period for pre-existing conditions.
My cousin has diabetes. After a few days in the US, she contracted a Urinary Tract Infection which required hospitalization. Is this covered?	Yes. Under our plans, Urinary Tract Infections are considered new sicknesses and are covered by Acute Onset coverage plans.
My mother is a heart patient. She was prescribed medication but often forgets to take it often. She experienced a sudden heart attack and needed to visit the emergency room. Will this emergency visit be covered?	Yes, our plans cover any incident regardless if your visitor was taking their prescribed medication.