|Lifetime Maximum per Insured Person||Unlimited|
|Annual Maximum per Insured Person||Unlimited|
|Preventative and Primary Care||Insurer Waives Deductible|
|Preventative Care for Babies/Children: (Birth to Age 18)
Immunizations, Lab work & X-rays
|Preventative Care for Adults: (Age 19 and Older)
Routine Pap Smears, annual mammogram
PSA For Men
Annual Physical Examination/Health Screening
Diagnostic lab work & X-rays
|Primary Care Office Visits||All except a $10 copay per visit1|
|Professional Services||Insurer Pays After Deductible is Met|
|Surgery, anesthesia, radiation therapy, in-hospital doctor visits, diagnostic X-ray and lab work.||100%|
|Inpatient Hospital Services||Insurer Pays After Deductible is Met|
|Surgery, X-rays, in-hospital doctor visits, Organ/Tissue Transplant||100%|
|In-patient medical emergency2||100%|
|Ambulatory and Therapeutic Services||Insurer Pays After Deductible is Met, Unless Noted|
|Ambulatory Surgical Center||100%|
|Accidental Dental||$1,000 per year, $200 per tooth|
|Acupuncture and Chiropractic Services||100% up to $2,000|
|Durable Medical Equipment||100%|
deductible is waived
|$50 limit per visit, 12 visits per year|
|Rehabilitation and Therapy||Insurer Pays After Deductible is Met|
|a. Inpatient Mental Health||100% up to 60 days*|
|b. Outpatient Mental Health||75% up to 40 visits / 60% thereafter**|
|c. Inpatient Substance Abuse||100% up to 60 days detox|
|d. Outpatient Substance Abuse||75% up to 40 visits / 60% thereafter|
|Prescription Drug Benefit Options||Insurer Waives Deductible|
|Basic Prescription Drug Benefit||100% of actual charges up to $1,000|
|Optional Rider. Subject to $25,000 Maximum per Insured Person per Policy Period||100% of actual charges|
|Global Travel Benefits||Insurer Waives Deductible|
|Medical Evacuation||Up to $250,000|
|Repatriation of Remains||Up to $25,000|
|Accidental Death and Dismemberment||$50,000|
Plan Deductible Choices
GeoBlue Xplorer Essential1, 2
GeoBlue Xplorer Select1, 2
This is a summary benefit schedule and certain benefit levels may be higher based on your state of issuance. Visit state specific mandates for more information. Note, customers outside the United States are issued a Washington, DC policy.
- Copay waived when visiting an GeoBlue contracted provider.
- Emergency room visits that do not result in inpatient admissions will be subject to a $50 penalty.
- Deductibles are Per person per Calendar Year. A family is charged a maximum of 2.5 deductibles.
Insurer Pays after Deductible is Met
|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.|
* For residents of North Carolina - The insurer will pay 100% of the usual and customary fee.
** For residents of North Carolina - After a $10 copayment, the insurer will pay 100% of the usual and customary fee.
For Exclusions and Limitations see Plan Description
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