Xplorer Plan Benefits – GeoBlue Xplorer Coverage
Benefits, limitations, and exclusions overview:
| Benefit Maximums | Outside the U.S. | U.S. (In Network) | U.S. (Outside Network) |
|---|---|---|---|
| Lifetime Maximum per Insured Person | Unlimited | Unlimited | Unlimited |
| Annual Maximum per Insured Person | Unlimited | Unlimited | Unlimited |
| Preventative and Primary Care | Insurer Waives Deductible | ||
| Preventative Care For Babies/Children: (Birth to Age 18) a. Office Visits/examination b. Immunizations, Lab work & X-rays |
100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Preventative Care for Adults: (Age 19 and Older) a. Routine Pap Smears, annual mammogram b. PSA For Men c. Annual Physical Examination Health Screening d. Diagnostic lab work & X-rays |
100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Primary Care Office Visits | All except a $10 copay per visit1 | All except a $30 copay per visit | 60% to Coinsurance Maximum then 100% |
| Professional Services | Insurer Pays After Deductible is Met | ||
| Surgery, anesthesia, radiation therapy, in-hospital doctor visits, diagnostic X-ray and lab work. | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance 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 Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| In-patient medical emergency6 | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| In-patient drugs | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Ambulatory and Therapeutic Services | Insurer Pays After Deductible is Met, Unless Noted. | ||
| Ambulatory Surgical Center | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Ambulance Service | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance 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 $2000 | 80% up to $2000 | 60% up to $2000 |
| Durable Medical Equipment | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Infusion Therapy | 100% | 80% to Coinsurance Maximum then 100% | 60% to Coinsurance Maximum then 100% |
| Physical/Occupational Therapy, the deductible is waived. |
$30/visit, 12 visits per year | $30/visit, 12 visits per year | $30/visit, 12 visits per year |
| Rehabilitation and Therapy | Insurer Pays After Deductible is Met | ||
| a. Inpatient Mental Health | 100% up to 60 days | 80% up to 60 days | 60% up to 60 days |
| b. Outpatient Mental Health | 75% up to 40 visits / 60% thereafter | 75% up to 40 visits / 60% thereafter | 75% up to 40 visits / 60% thereafter |
| c. Inpatient Substance Abuse | 100% up to 60 days detox | 80% up to 60 days detox | 60% up to 60 days detox |
| d. Outpatient Substance Abuse | 75% up to 40 visits / 60% thereafter | 75% up to 40 visits / 60% thereafter | 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 | $0 | $0 |
| Optional Rider. Subject to $25,000 Maximum per Insured Person per Policy 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% |
| Global Travel Benefits | Insurer Waives Deductible | ||
| Medical Evacuation | Up to $250,000 | n/a | n/a |
| Repatriation of Remains | Up to $25,000 | n/a | n/a |
| Accidental Death and Dismemberment | $50,000 | $50,000 | $50,000 |
| Plan Deductible Choices 1, 2, 3, 4, 5, 6 |
Deductible | Coinsurance Maximum | ||
|---|---|---|---|---|
| Outside U.S. | U.S. In Network | U.S. Out of Network | ||
| Elite | $0 | $0 | $1,000 | $2,000 |
| 1,000 | $500 | $1,000 | $2,000 | $4,000 |
| 2,000 | $1,000 | $2,000 | $4,000 | $8,000 |
| 5,000 | $2,500 | $5,000 | $10,000 | $10,000 |
| 10,000 | $10,000 | $10,000 | $10,000 | $10,000 |
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 a GeoBlue contracted provider is located outside the U.S.
- Deductibles are Per person per Calendar Year.
- The Out of Pocket Maximum is calculated by adding the deductible and coinsurance maximum together. A family is charged a maximum of 2.5 deductibles.
- Amounts paid to satisfy a deductible are credited to all other deductibles, both inside and outside the U.S. For example if you satisfy your Outside U.S deductible, this amount is credited to the U.S. (In Network) and U.S. (Outside Network) deductible requirement.
- An Insured Person only has to satisfy his/her Coinsurance Maximum once a year for all services received outside of the U.S. and in the U.S.
- Emergency room visits that do not result in inpatient admissions will be subject to a $50 penalty
| Other Benefits | 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 complete Xplorer policy terms and conditions, including exclusions and limitations see
- Xplorer Certificate and Plan Description
- Compare GeoBlue Expat Coverage Options in the U.S.
- Optional Basic U.S. Benefits – Available to Xplorer Essential Members
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Xplorer Global Medical: Generate a Free Quote / Apply Online
Geo Blue International Plans are the trade name of Worldwide Insurance Services, LLC (Worldwide Services Insurance Agency, LLC in California and New York), an independent licensee of the Blue Cross and Blue Shield Association. GeoBlue is the administrator of coverage provided under international health insurance policies issued by 4 Ever Life International Limited, Bermuda, an independent licensee of the Blue Cross Blue Shield Association.
