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BENEFIT ATLAS TRAVEL ATLAS ESSENTIAL ATLAS PREMIUM
Deductibles
Overall Maximum Limit Per Certificate Period $0, $100, $250, $500, $1,000, $2,500, or $5,000 per certificate period. Age 80 or older- $20,000; Age 70 to 79- $50,000, $100,000, or
$250,000; All others- $50,000, $100,000, $250,000, $500,000,
Coinsurance Age 80 or older- $10,000; Age 70 to 79- $50,000, Age 80 or older- $10,000; Age 70 to 79 $1,000,000 or $2,000,000.

$100,000, or $250,000; All others- $50,000, $100,000, - $50,000, $100,000, or $250,000; All others We will pay 100% of eligible expenses after the deductible up to the
overall maximum limit.
$250,000, $500,000,$1,000,000, or $2,000,000 - $50,000, $100,000, $250,000, $500,000, or

$1,000,000

We will pay 100% of eligible expenses after the Within the PPO: We will pay 75% of eligible

deductible up to the overall maximum limit. expenses after the deductible to the overall

maximum limit

Outside the PPO: Usual, reasonable, and

customary. You may be responsible for any

charges exceeding the payable amount.

Eligible expenses are subject to deductible, coinsurance, overall maximum limit, and are per certificate period unless specifically indicated otherwise.

BENEFIT ATLASTRAVEL LIMITS ATLAS ESSENTIAL LIMITS ATLAS PREMIUM LIMITS

Hospital Room and Board Average semi-private room rate, including nursing services.

Local Ambulance Usual, reasonable and customary charges, when covered illness or injury results in hospitalization as inpatient.

Intensive Care Unit Up to the overall maximum limit.

Emergency Room Co-payment Claims incurred in U.S.

The member shall be responsible for a $200 co-payment for each use of emergency room for an Illness unless the member is admitted to the hospital.

There will be no co-payment for emergency room treatment of an injury.

Claims incurred outside the U.S.

No co-payment

Urgent Care Center Co-payment Claims incurred in U.S. Claims incurred in U.S. Claims incurred in U.S.

For each visit, you shall be responsible for a $15 For each visit, the member shall be For each visit, you shall be responsible for a $15 co-payment

co-payment responsible for a $15 co-payment, after which – Co-payment is waived for members with a $0 deductible.

– Co-payment is waived for members with a $0 coinsurance will apply. – not subject to deductible

deductible. -Co-payment waived if $0 deductible elected.

– not subject to deductible -Not subject to deductible. Claims incurred outside the U.S.

No co-payment

Claims incurred outside the U.S. Claims incurred outside the U.S.

No co-payment No co-payment

Hospital Indemnity $100 per day of inpatient hospitalization (not subject to No benefit $100 per day of inpatient hospitalization (not subject to deductible ).
deductible ). No benefit
Acute Onset of Pre-existing Condition Age 70 to 79: Up to the overall maximum limit or Age 70 to 79: Up to the overall maximum limit or $100,000,
(Excludes chronic and congenital conditions. $100,000, whichever is lower whichever is lower
Only available to members under age 80.) Under age 70: Up to the overall maximum limit
Under age 70: Up to the overall maximum limit

Up to $25,000 lifetime maximum for Emergency Medical Up to $25,000 lifetime maximum for Emergency Medical Evacuation

Evacuation Up to $250 (not subject to deductible ).
Up to $150. $50 deductible per occurrence (plan deductible is
Terrorism Up to $50,000 lifetime maximum, eligible medical expenses only. waived).
Emergency Dental (acute onset of pain) Up to $50 maximum per day. Must be ordered in advance by a
Emergency Eye Exam for a Covered Loss Up to $250 (not subject to deductible ). No benefit physician.

Outpatient Physical Therapy and Chiropractic Up to $150. $50 deductible per occurrence (plan No benefit ATLAS PREMIUM LIMITS
Care Up to $1,000,000 lifetime maximum, except as provided under
All Other Eligible Medical Expenses deductible is waived). acute onset of pre-existing condition (not subject to deductible or
EMERGENCYTRAVEL BENEFITS overall maximum limit).
Emergency Medical Evacuation Up to $50 maximum per day. Must be ordered in advance No benefit Up to $50,000 (not subject to deductible ).
Up to $1,000 (not subject to deductible ).
Return of Minor Children by a physician. Up to the overall maximum limit (not subject to deductible ).
Pet Return
Repatriation of Remains Up to the overall maximum limit. Up to $150,000, subject to a maximum of 15 days (not subject to
deductible ).
Emergency Reunion ATLASTRAVEL LIMITS ATLAS ESSENTIAL LIMITS Up to $500 a day for 5 days (not subject to deductible ).

Natural Disaster – Replacement Up to $1,000,000 lifetime maximum, except as provided Up to $500,000 lifetime maximum (not Up to $15,000 (not subject to deductible ).
Accommodations Up to $200 a day after a 12-hour delay period requiring an unplanned
Trip Interruption under acute onset of pre-existing condition (not subject to subject to deductible or coinsurance). overnight stay (2 days maximum. Not subject to deductible ).
Trip Delay
deductible or overall maximum limit). Up to $1,000 (not subject to deductible ).
Lost Checked Luggage Up to $150,000 lifetime maximum (not subject to deductible ).
Political Evacuation Up to $50,000 (not subject to deductible ). No benefit
Not subject to deductible, or overall maximum limit $250,000
Accidental Death and Dismember- carrier Up to $1,000 (not subject to deductible ). No benefit maximum benefit for any one family or group.
accident) Lifetime max.- $5,000; Death- $5,000; Loss of 2 limbs- $5,000; Loss
Up to the overall maximum limit (not subject to Up to $25,000 lifetime maximum (not subject of 1 limb- $2,500.
Members up to age 18 deductible ). to deductible ). Lifetime max.- $100,000; Death- $100,000; Loss of 2 limbs-
Up to $100,000, subject to a maximum of 15 days (not No benefit $100,000; Loss of 1 limb- $50,000.
Members age 18 through 69 subject to deductible ).
Up to $250 a day for 5 days (not subject to deductible ). No benefit Lifetime max.- $12,500; Death- $12,500; Loss of 2 limbs- $12,500;
Members age 70 through 74 Loss of 1 limb- $6,250.
Up to $10,000 (not subject to deductible ). No benefit Lifetime max.- $6,250; Death- $6,250; Loss of 2 limbs- $6,250; Loss
Members age 75 and older Up to $100 a day after a 12-hour delay period requiring an No benefit of 1 limb- $3,125.
unplanned overnight stay (2 days maximum. Not subject No benefit Not subject to deductible, or overall maximum limit. Up to age
Common Carrier Accidental Death ($250,000 to deductible ). No benefit 18- $25,000 per member; Age 18 to 69- $50,000 per member; Age
maximum benefit per any one family or Up to $500 (not subject to deductible ). No benefit 70 to 74- $12,500 per member; Age 75 and older- $6,250.
group) Up to $100,000 lifetime maximum (not subject to
deductible ). No benefit Up to $100,000 per certificate period, with $10,000 maximum for
Crisis Response- Ransom, Personal Not subject to deductible, or overall maximum limit. No benefit Natural Disaster Evacuation (not subject to deductible, or overall
Belongings, and Crisis Response Fees and $250,000 maximum benefit per any one family or group. No benefit maximum limit).
Expenses Lifetime max.- $5,000; Death- $5,000; Loss of 2 limbs-
$5,000; Loss of 1 limb- $2,500. No benefit Up to:
Personal Liability Lifetime max.- $50,000; Death- $50,000; Loss of 2 limbs $100,000 lifetime maximum
- $50,000; Loss of 1 limb- $25,000. Optional Accidental $100,000 third person injury
Border Entry Protection Death & Dismemberment buy-up of $50,000 to lifetime $100,000 third person property
maximum $100,000. $2,500 related third person property
Lifetime max.- $12,500; Death- $12,500; Loss of 2 - not subject to deductible, or overall maximum limit
limbs- $12,500; Loss of 1 limb- $6,250.
Lifetime max.- $6,250; Death- $6,250; Loss of 2 limbs- Up to $500 if traveling on a valid B-2 visa and denied entrance at the
$6,250; Loss of 1 limb- $3,125. U.S. border (not subject to deductible )
Not subject to deductible, or overall maximum limit. Up
to age 18- $25,000 per member; Age 18 to 69- $50,000
per member; Age 70 to 74- $12,500 per member; Age 75
and older- $6,250.
Up to $10,000 (not subject to deductible, or overall
maximum limit). Optional buy-up to $100,000 per certifi-
cate period, with $10,000 maximum for Natural Disaster
Evacuation
Up to:
$10,000 lifetime maximum
$10,000 third person injury
$10,000 third person property
$2,500 related third person property
- not subject to deductible, or overall maximum limit.
Optional buy-up to $90,000 lifetime maximum.
Up to $500 if traveling on a valid B-2 visa and denied
entrance at the U.S. border (not subject to deductible )

Bedside Visit Up to $1,500 (not subject to deductible ) No benefit Up to $1,500 (not subject to deductible )
Local Burial or Cremation Up to $5,000 lifetime maximum (not subject to Up to $5,000 lifetime maximum (not subject Up to $5,000 lifetime maximum (not subject to deductible).
deductible). to deductible or coinsurance).
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