Gold 2

The most affordable option to take care of your health

The Gold 2 Plan offers you balanced medical coverage, set copayments, and services within the preferred network.

Hospitalization within the network

X-rays and laboratory tests covered

Provider and pharmacy network

Renewable life insurance included

Summary of Benefits:

Click any category to see detailed copays and coverage.

Benefit / Service Category

Annual Medical Deductible / MOOP

Annual limit on the member’s medical expenses

Individual

N/A

Family

N/A

Annual Prescription Drug Deductible

Annual amount before prescriptions are covered

Individual

$250

Family

$250
Per subscriber

Combined MOOP (medical and prescriptions)

Total maximum out-of-pocket expenses per year

Individual

$6,350

Family

$12,700

Emergency Services

Immediate emergency care

Accident / Illness

$0 / $75 Out-of-Network

Outpatient Services

Consultations and treatments without hospitalization

Primary Care Physician

$10

Specialist

$15

Sub-specialist

$20

Psychiatrist

$15

Psychologist

$15

Podiatrist

$15

Chiropractor

$15

Audiologist

$15

Optometrist

$15

Ambulatory Surgery Center

$0 / $250 Out-of-Network

In-office diagnostic / surgical procedures

50%

Endoscopic procedures

50%

Laboratory and X-Ray Services

Diagnostic tests and medical studies

Laboratory

$0 / 50% Out-of-Network

X-Ray

$0 / 50% Out-of-Network

Ultrasound

$0 / 50% Out-of-Network

PET Scan, CT Scan, MRI, or PET CT (1 per year)

50%

Hospitalization

Hospital stays and inpatient care

Partial (including Mental Health)

$150

With preauthorization (including Mental Health)

$0 / $250 Out-of-Network

Without preauthorization (including Mental Health)

$250

Skilled nursing care

50%

Surgical assistant

Subscriber pays 50%

Rehabilitation and Medical Equipment

Therapies and necessary medical equipment

Physical therapy

$15

Respiratory therapy

$15

Home health care

50%

Durable medical equipment

50% up to $5,000; excess 80%

Chiropractic Manipulations

$15

Mental Health

Group therapy and emotional support

Group therapy

$15

Collateral visits

$15

Pharmacy

Covered prescription medications

Generic Bioequivalent – Level 1

$5

Preferred Brand – Level 2

25% ($251-$1,000); over $1,001:
80% Generic First Option

Non-Preferred Brand – Level 3

50% ($251-$1,000); over $1,001:
80% Generic First Option

Specialty Drugs – Level 4

50% ($251-$1,000); over $1,001:
80% Generic First Option

Over-the-Counter (OTC) medications

$1

Prevention, Wellness, and Chronic Conditions

Preventive care and ongoing management

Preventive services including women’s services

0%

Preventive vaccines

0%

Respiratory Syncytial Virus vaccine

50%

Vision Services

Exams, lenses, and vision benefits

Adult refraction exam

$15

Adult reimbursement coverage

100% reimbursement up to $125
for lenses and frames

Pediatric refraction exam

0%

Pediatric vision – corrective lenses

20% coinsurance up to $250
for lenses and frames

Other Services

Air ambulance and U.S. coverage

Air ambulance in Puerto Rico

$15

Emergency services in the U.S.

20% coinsurance

Services in the U.S. (not available in PR)

20% coinsurance

Bariatric Surgery for Morbid Obesity

Procedure for severe obesity management

Bariatric surgery procedure

$0 / $250 Out-of-Network

Included Programs

Nutritionist and support programs

Nutritionist

Reimbursement up to $20 per visit
(max. 4 per year)

Dental Coverage

Diagnosis, prevention, and dental treatments

Preventive Diagnostics

0%

Minor Restorative

20%

Major Restorative

50%

Space maintainers

Not covered

Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.

Benefit / Service Category

Annual Medical Deductible / MOOP

Annual limit on the member’s medical expenses

Individual	N/A
Family	N/A

Annual Prescription Drug Deductible

Annual amount before prescriptions are covered

Individual	$250
Family	$250 per subscriber

Combined MOOP (medical and prescriptions)

Total maximum out-of-pocket expenses per year

Individual	$6,350
Family	$12,700

Emergency Services

Immediate emergency care

Accident / Illness

$0 / $75 Out-of-Network

Outpatient Services

Consultations and treatments without hospitalization

Primary Care Physicial	$10
Especialist	$15
Sub-Especialist	$20
Psychiatrist	$15
Psychologist	$15
Podiatrist	$15
Chiropractor	$15
Audiólogo	$15
Audiologist	$15
Ambulatory Surgery Center	$0 / $250 Out-of-Network
In-office diagnostic / surgical procedures	50%
Endoscopic procedures	50%

Laboratory and X-Ray Services

Diagnostic tests and medical studies

Laboratory	$0 / 50% Out-of-Network
X-Ray	$0 / 50% Out-of-Network
Ultrasound	$0 / 50% Out-of-Network
PET Scan, CT Scan, MRI o PET CT (1 año)	50%

Hospitalization

Hospital stays and inpatient care

Partial (including Mental Health)	$150
With preauthorization (including Mental Health)	$0 / $250 Out-of-Network
Without preauthorization (including Mental Health)	$250
Skilled nursing care	50%
Surgical assistant	Subscriber pays 50%

Rehabilitation and Medical Equipment

Therapies and necessary medical equipment

Physical therapy	$15
Respiratory therapy	$15
Home health care	50%
Durable medical equipment	50% up to $5,000, Excess 80%
Chiropractic Manipulations	$15

Mental Health

Group therapy and emotional support

Group therapy	$15
Collateral visits	$15

Pharmacy

Covered prescription medications

Generic Bioequivalent – Level 1	$5
Preferred Brand – Level 2	25% ($251-$1,000) over $1,001: 80% Generic First Option
Non-Preferred Brand – Level 3	50% ($251-$1,000) over $1,001: 80% Generic First Option
Specialty Drugs – Level 4	50% ($251-$1,000); over $1,001: 80% Generic First Option
Over-the-Counter (OTC) medications	$1

Prevention, Wellness, and Chronic Conditions

Preventive care and ongoing management

Preventive services including women’s services	0%
Preventive vaccines	0%
Respiratory Syncytial Virus vaccine	50%

Vision Services

Exams, lenses, and vision benefits

Adult refraction exam	$15
Adult reimbursement coverage	100% reimbursement up to $125 for lenses and frames.
Pediatric refraction exam	0%
Pediatric vision – corrective lenses	20% coinsurance up to $250 for lenses and frames.

Other Services

Air ambulance and U.S. coverage

Air ambulance in Puerto Rico	$15
Emergency services in the U.S.	20% coinsurance
Services in the U.S. (not available in PR)	20% coinsurance

Bariatric Surgery for Morbid Obesity

Procedure for severe obesity management

Bariatric surgery procedure

$0 / $250 Out-of-Network

Included Programs

Nutritionist and support programs

Nutritionist

Reimbursement up to $20 per visit (max. 4 per year)

Dental Coverage

Diagnosis, prevention, and dental treatments

Preventive Diagnostics	0%
Minor Restorative	20%
Major Restorative	50%
Space maintainers	Not covered

Note: This is a summary of benefits. Consult your plan documents for complete information. Copayments and coinsurance are subject to the annual maximum limit.

Other benefits

Choose additional benefits that suit your needs. You can add an Extended Dental Plan or Life Insurance for greater peace of mind.

Extended Dental Plan

Extensive dental coverage including crowns.

Preventive Diagnostics

Coinsurance

Dental Exam (1 every 3 years)

Dental Exam Periodic

Dental Preventive - adult (1 every 6 months)

Fluoride Treatment (1 every 6 months) (up 19 yr)

Sealant (under 14 yrs)

20%

Dental Spacer (up 14 yr) (1 per lifetime)

Dental X-ray Complete Series (1 every 3 years)

Dental Periapical Film-Initial (1 per year)

Dental Periapical Films (5 per year)

Dental Bitewings

Dental X-ray (panoramic every 3 years)

Minor Restorative

Dental Restorative (every 3 years)

20%

Sedative Filling (every 5 years per tooth) (1 piece per day)

20%

Simple Extraction

20%

Emergency Dental Visit (every 6 months)

20%

Major Restorative

Dental Endodontics (every 5 years per tooth)

20%

Dental Periodontics (per quadrant)

20%

Dental Oral Surgery

20%

Extended Dental (Optional)

Dental Crowns Restoration (every 5 years)

50%

Cost: $10.00 Individual, $20.00 Couple, $22 Family

Personal Protective Equipment for the Dentist

20%

Life Insurance

Includes life insurance for your peace of mind.

Annually Renewable Term Life Insurance

The company will pay the designated beneficiary in effect on the date of the insured subscriber's death, the amount of $5,000 for death.

Accidental Death Insurance

The company will pay an additional $5,000 to the life insurance benefit to the designated beneficiary, should the insured subscriber die due to an accident.

Accidental Death and Dismemberment

The amount indicated in the following table will be paid to the designated beneficiary in case of accidental death and to the insured in case of dismemberment when, within a period of ninety (90) days from the date of the accident, one of the following losses occurs:

For the Loss of:

The amount of: will be paid

Life

$5,000

Both hands or both feet

$5,000

Sight of both eyes

$5,000

One hand and one foot

$5,000

One hand and the sight of one eye

$5,000

One foot and the sight of one eye

$5,000

Loss of speech

$5,000

Hearing in both ears

$5,000

One hand, one foot, or the sight of one eye

$2,500

Hearing in one ear

$5,000

Thumb and index finger of the same hand

$1,250

Accelerated Death Benefit Endorsement for Early Payment

This Accelerated Death Benefit Endorsement for early payment is an excellent benefit available to all insureds who qualify for the insurance. The endorsement provides for the advance payment of 50% of the basic coverage amount (life insurance) in the event that the insured is diagnosed with a terminal illness and a physician certifies that the insured's life expectancy is 12 months or less.

The 50% advance of the insurance amount may only be requested once. The advance is not a loan and does not incur a penalty on the remaining life insurance amount. The endorsement has a cost that is calculated at the time the advance is requested.

Subscriber's Insurance Reduction by Age

The insurance amount will be reduced according to the following table:

Age

Insurance Amount
(% of Principal Insurance Amount)

65-69

65%

70-74

45%

75-79

30%

80-84

30%

85-89

15%

90 or more

10%

Life and Accidental Death Insurance

In the event that death was caused by an accident, the insurance would pay the basic amount of $5,000 plus the accidental death insurance of $5,000, for a total of $10,000.

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Gold 2

Summary of Benefits:

Benefit / Service Category

Individual

N/A

Family

N/A

Individual

$250

Family

$250Per subscriber

Individual

$6,350

Family

$12,700

Accident / Illness

$0 / $75 Out-of-Network

Primary Care Physician

$10

Specialist

$15

Sub-specialist

$20

Psychiatrist

$15

Psychologist

$15

Podiatrist

$15

Chiropractor

$15

Audiologist

$15

Optometrist

$15

Ambulatory Surgery Center

$0 / $250 Out-of-Network

In-office diagnostic / surgical procedures

50%

Endoscopic procedures

50%

Laboratory

$0 / 50% Out-of-Network

X-Ray

$0 / 50% Out-of-Network

Ultrasound

$0 / 50% Out-of-Network

PET Scan, CT Scan, MRI, or PET CT (1 per year)

50%

Partial (including Mental Health)

$150

With preauthorization (including Mental Health)

$0 / $250 Out-of-Network

Without preauthorization (including Mental Health)

$250

Skilled nursing care

50%

Surgical assistant

Subscriber pays 50%

Physical therapy

$15

Respiratory therapy

$15

Home health care

50%

Durable medical equipment

50% up to $5,000; excess 80%

Chiropractic Manipulations

$15

Group therapy

$15

Collateral visits

$15

Generic Bioequivalent – Level 1

$5

Preferred Brand – Level 2

25% ($251-$1,000); over $1,001: 80% Generic First Option

Non-Preferred Brand – Level 3

50% ($251-$1,000); over $1,001: 80% Generic First Option

Specialty Drugs – Level 4

$250
Per subscriber

25% ($251-$1,000); over $1,001:
80% Generic First Option

50% ($251-$1,000); over $1,001:
80% Generic First Option

50% ($251-$1,000); over $1,001:
80% Generic First Option

100% reimbursement up to $125
for lenses and frames

20% coinsurance up to $250
for lenses and frames

Reimbursement up to $20 per visit
(max. 4 per year)