| Lifetime maximum | Unlimited |
| Maximum per sickness/injury | $100,000 |
| Co-insurance in network | 80% |
| Co-insurance out-of-network | 60% |
| Deductible in network | $500 |
| Deductible in non-network | $500 |
| Out of pocket in network | Unlimited |
| Co-pay in ER (waived if admitted) | $250 |
| Co-pay in SHC | $5 |
| Co-pay hospitalization | $0 |
| Pre-existing condition waiting period | 12 months |
| Medical evacuation | $50,000 |
| Repatriation | $25,000 |