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Broadmoor Agency
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Patriot Exchange Program Medical Insurance
Please use this high level information as a guide only and do not make any decisions solely based on this information. If you have any concerns, doubts or questions, please refer to the individual policy details for complete information, as it is not possible to accurately represent all the details in concise information such as follows, or call us for further details. If there is any discrepancy between this information and the actual policy details, the policy details will override.
All the amounts are in U.S. dollars.
Vision (eyeglasses, etc.) is not covered in any of the plans.
General
Patriot Exchange Program℠
Within PPO network: After deductible, plan pays 90% up to $10,000, then 100% up to the policy maximum.
Outside PPO network: After deductible, plan pays 80% up to the policy maximum.
Outside US: After deductible, covers at 100% up to the policy maximum.
$5 copay, deductible waived
Medical - Outpatient
To policy maximum
1 visit per day.
US-Urgent Care: Deductible waived, $50 copay; unless $0 deductible.
US-Walk-in Clinic: Deductible waived, $20 copay; unless $0 deductible.
Co-insurance still applies.
To policy maximum
Extra $500 copay for illness that does not result in hospital admission.
To policy maximum, 90 day supply per prescription. Period of coverage limit: $250,000 per person.
To policy maximum
To policy maximum
To policy maximum
20% of primary surgeon charge. No standby availability coverage.
To policy maximum
To policy maximum
Medical - Inpatient
To policy maximum, average semi-private room including nursing services.
To policy maximum
To policy maximum
To policy maximum
20% of primary surgeon charge. No standby availability coverage.
To policy maximum
To policy maximum
Medical - Other Treatment And Services
-
Standard basic hospital bed and/or standard basic wheelchair
Optional: Adventure Sports, available for ages under 65. Add On, available for High School and College.
To policy maximum, for injury or if covered illness results in hospital admission.
-
$10,000. Cannot be provided at a Student Health Center.
$50 per day, $500 maximum. Cannot be provided at a Student Health Center.
Included in the Mental & Nervous Disorder benefit
Chiropractic Care: To policy maximum Physical Therapy: To policy maximum, 1 visit per day Must be ordered in advance by phyisician.
United Healthcare PPO
Network of physicians, hospitals, urgent cares, labs and other healthcare providers.
No network for pharmacies, dentists, ambulance.
After 12 month waiting period, $500 per period of coverage, $1,500 maximum.
US Citizens: Sudden & Unexpected Reoccurrence: Medical up to $5,000. Medical Evacuation up to $25,000.
-
-
-
50% reduction in benefits, $1,000 maximum penalty
Included
Dental
$350 for pain, $500 for non-emergency injury
To policy maximum
Travel
-
Optional: Add On, $250 maximum
-
$15,000, maximum of 15 days
$50,000. Medically Necessary Repatriation up to $100,000.
$25,000
$5,000
$10,000
Life
$25,000
$25,000
Other
-
Incidental: 14 days after 30 days of continuous coverage, non-US residents only.
-
-
-
Optional: Add On, $2,000 maximum for injury, $500 maximum for damage.
$50,000
Outside Country of Residence
Plan Features
Before effective date, full refund.
After effective date, pro-rated refund for whole months minus $50 cancellation fee, as long as no claims have been filed since the effective date; form required.
1 month up to 4 years
$0
Optional: Legal Assistance with Add On, $500 maximum
Optional: Cell phone coverage
Bedside Visit: $1,500
Email
Per Incident
$0 Up to 64
$100 Up to 64
$250 Up to 64
$500 Up to 64
Per Incident
$50,000 Up to 64
$100,000 Up to 64
$250,000 Up to 64
$500,000 Up to 64
International Medical Group (IMG)
SiriusPoint Specialty Insurance Corporation
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- For medical benefits, to policy maximum, refer to the Usual, Reasonable and Customary Charges. Deductible and coinsurance apply, unless otherwise noted.
- Whenever there is a difference in benefits levels within PPO network and outside PPO network, the benefits shown above are applicable when availing treatment within PPO network.
- Coverages shown are per person unless noted otherwise.
- The dash (-) in the fields above means Not Applicable (N/A).
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