Xplorer Health Plan Insurance | Benefits

GeoBlue's Xplorer Health Plan provides worldwide, comprehensive health insurance to international students coming to the US or US citizens going overseas. This plan offers concierge-level medical assistance and direct payment to any doctor, hospital, or clinic in the Blue Cross Blue Shield network in the US or in their extensive, yet carefully selected provider network outside the U.S. This plan can be purchased for as little as 6 months up to a year.

Doctor/Hospital Search

Benefits	Premier			Essential
	U.S. In-Network	U.S. Outside Network	Outside the US	Outside the US Only
Lifetime Maximum Limit	Unlimited
Annual Maximum Limit	Unlimited
Preventative and Office Visits — Insurer Waives Deductible
Physician Office Visits (Adults)	All except a $30 copay per visit	60% to Out-of-Pocket Maximum then 100%	All except a $10 copay per visit
Physician Office Visits (Children 0-18)	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Unlimited Well Baby Visit (Birth to Age 18)	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Child Immunizations, Labs and X-rays	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Women (19+) Routine Pap Smears, Annual Mammogram	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
PSA (Prostate-Specific Antigen) for Men	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Immunizations as recommended by the Center for Disease Control (CDC)	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
One Routine Physical Per Year	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Travel Vaccinations	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100% up to $500 per Calendar Yea
Professional Services — Insurer Pays After the Deductible is Met
Surgery, Anesthesia, Radiation Therapy, In-hospital Doctor V\isits, Diagnostic X-ray and Lab Work	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Inpatient Hospital Services — Insurer Pays After the Deductible is Met
Surgery, X-ray, In-hospital Doctor Visits, Organ/Tissue Transplants	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Inpatient Medical Emergency	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Inpatient Drugs	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Ambulatory and Therapeutic Services — Insurer Pays After the Deductible is Met
Ambulatory Surgical Center	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Ambulance Service	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Accidental Dental	$1,000 per year, $200 per tooth
Acupuncture and Chiropractic Services	80% up to $2,000	60% up to $2,000	100% up to $2,000
Durable Medical Equipment	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Infusion Therapy	80% to Coinsurance Maximum then 100%	60% to Out-of-Pocket Maximum then 100%	100%
Physical/Occupational Therapy	$50 max each visit, 12 visits per year Deductible is waived.
Inpatient Mental Health	80% up to 60 days	60% to Out-of-Pocket Maximum then 100%	100%
Outpatient Mental Health	75% up too 40 visits/ 60% thereafter
Inpatient Substance Abuse	80% up to 60 days detox	60% up to 60 days detox	100% up to 60 days detox
Outpatient Substance Abuse	75% up too 40 visits/ 60% thereafter
Prescription Drug Benefit Options — Insurer Waives Deductible
Basic Prescription Drug Benefit	100% of actual charges up to $1,000 Maximum per Insured Person per Coverage Period (Pay and claim benefit only)
Global Travel Benefits — Insurer Waives Deductible
Emergency Medical Transportation	N/A		Up to $250,000
Repatriation of Mortal Remains	N/A		Up to $250,000
Accidental Death and Dismemberment	Up to $50,000
Other Benefits — Insurer Pays After the 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

Geoblue Xplorer Premier Options
Plan	Deductible			Coinsurance Maximum
	U.S. In-Network	U.S. Out-of-Network	Outside U.S.
Elite	$0	$1,000	$0	$2,000
1000	$1,000	$2,000	$500	$4,000
2000	$2,000	$4,000	$1,000	$8,000
5000	$5,000	$10,000	$2,500	$10,000

Geoblue Xplorer Essential Options
Plan	Deductible
	U.S. In-Network	U.S. Out-of-Network	Outside U.S.
Elite	N/A	N/A	$0
1000	N/A	N/A	$1,000
2000	N/A	N/A	$2,500
5000	N/A	N/A	$5,000

Benefit	Optional Riders
Enhanced Prescriptions Rider Premier Plan Only	Includes the US: Subject to $25,000 Maximum per Insured Person per Policy Period. Max 90 day supply. Generics: 100% after $10 copay Brand name: 100% after $10 copay Injectables: 70%	Excludes the US: Subject to $25,000 Maximum per Insured Person per Policy Period. Max 90 day supply. 100% of actual charges up to $25,000
Dental and Vision Rider Available only for Elite or $1,000 Deductible	Dental Benefits Not subject to Deductible Annual Max — $1,500 Diagnostic and Preventative Dental Services — 100% Basic Dental Services — 80% Major Dental Services — 50% Orthodontic Dental Care (Under age 19 only) — 50% up to $1,000 Lifetime Max Vision Benefits Not subject to Deductible Annual Max — $250 Vision Examination — 70% Frames or Lenses — 70%
Optional Basic U.S. Benefits Essential Plan Only Basic travel accident and sickness coverage inside the U.S. for short trips to the U.S. Covers incidental illness and injury. Not designed to cover preventive, elective care or extended stays in the U.S.	N/A	100%, 80%, or 60% (depending upon services received) of actual charges up to $1,000,000/$500 maximum for pre-existing conditions Subject to Deductible

Benefit

Optional Riders

Enhanced Prescriptions Rider
Premier Plan Only

Includes the US: Subject to $25,000 Maximum per Insured Person per Policy Period. Max 90 day supply.
Generics: 100% after $10 copay
Brand name: 100% after $10 copay
Injectables: 70%

Excludes the US: Subject to $25,000 Maximum per Insured Person per Policy Period. Max 90 day supply.

100% of actual charges up to $25,000

Dental and Vision Rider
Available only for Elite or $1,000 Deductible

Dental Benefits Not subject to Deductible

Annual Max — $1,500
Diagnostic and Preventative Dental Services — 100%
Basic Dental Services — 80%
Major Dental Services — 50%
Orthodontic Dental Care (Under age 19 only) — 50% up to $1,000 Lifetime Max

Vision Benefits Not subject to Deductible

Annual Max — $250
Vision Examination — 70%
Frames or Lenses — 70%

Optional Basic U.S. Benefits
Essential Plan Only
Basic travel accident and sickness coverage inside the U.S. for short trips to the U.S. Covers incidental illness and injury. Not designed to cover preventive, elective care or extended stays in the U.S.

N/A

100%, 80%, or 60% (depending upon services received) of actual charges up to $1,000,000/$500 maximum for pre-existing conditions Subject to Deductible

Please note: The benefit table listed above is a consolidated version of the full plan benefits. Please view the plan certificate for the full benefits and limitations of the plan. Limits apply to all benefits.

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