BUPA CARE - bupalatinamerica.com€¦ · EXCLUSIVE CARE BUPA COMPLETE CARE PREMIUM RATES, EFFECTIVE...

PRE MIU M BOOKLET FOR PU E RTO R ICO

BU PA CARE

E F F E C TI V E JA N UA RY 1 , 2 01 6

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ADMINISTRATIVE NOTES

• Rates for Puerto Rico are in U.S. dollars. All applicable taxes are included.

• An annual $75 administration fee per policy applies.

• One deductible applies per insured, per policy year up to a maximum of the out-of-country deductible. If the in-country deductible has already been met, and treatment is later received out of country, the difference between both deductibles will be the insured’s responsibility. A maximum equivalent to two out-of-country deductibles per policy, per policy year applies.

• Maximum age to apply: 74 years old.

• Critical Care: for a quote, take the older person as the policyholder and refer to the rate sheet under the corresponding age group.

• Available payment modes: annually, semiannually, and quarterly.

• The insurer, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical Services for more information about this restriction.

• Approved and registered as surplus lines coverage under the Insurance Code of the Commonwealth of Puerto Rico. As surplus line, these policies do not provide coverage under the U.S. Patient Protection and Affordable Care Act of 2010 (PPACA).

• Bupa reserves the right to correct any errors or omissions.

NOTAS ADMINISTRATIVAS

• Las tarifas para Puerto Rico están expresadas en dólares de los Estados Unidos de América. Todos los impuestos correspondientes están incluidos.

• Se aplica una tarifa administrativa anual de US$75 por póliza.

• Se aplica un deducible por asegurado, por año póliza hasta el máximo del deducible fuera del país de residencia. Si ya se ha cubierto el deducible dentro del país de residencia, y luego el asegurado recibe tratamiento fuera de su país de residencia, la diferencia entre ambos deducibles será responsabilidad del asegurado. Se aplica un máximo equivalente a dos deducibles fuera del país de residencia por póliza, por año póliza.

• Edad máxima para solicitar cobertura: 74 años.

• Critical Care: para obtener una cotización, la persona de mayor edad es considerada como titular de la póliza. Busque la tarifa bajo el grupo de edad correspondiente.

• Opciones de pago disponibles: anual, semestral y trimestral.

• Ni la aseguradora, ni USA Medical Services, ni ninguna de sus filiales o subsidiarias pertinentes relacionadas participarán en transacciones con cualquier parte o país donde dichas transacciones estén prohibidas por las leyes de los Estados Unidos de América. Por favor comuníquese con USA Medical Services para obtener más información sobre esta restricción.

• Otorgadas y registradas como cubierta de líneas excedentes con arreglo al Código de Seguros del Estado Libre Asociado de Puerto Rico. Como cubierta de líneas excedentes, estas pólizas no proporcionan cobertura bajo la Ley de Protección al Paciente y Cuidado de Salud Asequible de 2010 (PPACA).

• Bupa se reserva el derecho de corregir cualquier error u omisión.

EXCLUSIVE CARE

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BUPA COMPLETE CARE PREMIUM RATES, EFFECTIVE JANUARY 1, 20122

Deductibles Plan 2 Plan 3 Plan 4 Plan 5 Plan 6

In country of residence US$1,000 US$2,000 US$5,000 US$10,000 US$20,000

Out of country of residence US$2,000 US$3,000 US$5,000 US$10,000 US$20,000

Age Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual

1 Child US$2,750.00 US$1,457.50 US$2,025.00 US$1,073.25 US$1,682.00 US$891.46 US$1,417.00 US$751.01 US$1,106.00 US$586.18

2 Children 4,375.00 2,318.75 3,228.00 1,710.84 2,678.00 1,419.34 2,251.00 1,193.03 1,753.00 929.09

3+ Children 6,410.00 3,397.30 4,731.00 2,507.43 3,919.00 2,077.07 3,302.00 1,750.06 2,573.00 1,363.69

18-24 7,913.00 4,193.89 5,227.00 2,770.31 3,759.00 1,992.27 2,663.00 1,411.39 2,096.00 1,110.88

25-29 8,298.00 4,397.94 5,776.00 3,061.28 4,164.00 2,206.92 2,957.00 1,567.21 2,322.00 1,230.66

30-34 8,633.00 4,575.49 6,195.00 3,283.35 4,662.00 2,470.86 3,541.00 1,876.73 2,792.00 1,479.76

35-39 9,668.00 5,124.04 6,938.00 3,677.14 5,228.00 2,770.84 3,971.00 2,104.63 3,127.00 1,657.31

40-44 11,213.00 5,942.89 7,589.00 4,022.17 5,802.00 3,075.06 4,370.00 2,316.10 3,437.00 1,821.61

45-49 12,535.00 6,643.55 8,485.00 4,497.05 6,490.00 3,439.70 4,882.00 2,587.46 3,845.00 2,037.85

50-54 16,043.00 8,502.79 11,142.00 5,905.26 8,468.00 4,488.04 6,900.00 3,657.00 5,441.00 2,883.73

55-59 17,070.00 9,047.10 11,854.00 6,282.62 9,012.00 4,776.36 7,345.00 3,892.85 5,791.00 3,069.23

60 18,600.00 9,858.00 12,937.00 6,856.61 10,369.00 5,495.57 8,848.00 4,689.44 7,198.00 3,814.94

61 19,985.00 10,592.05 13,898.00 7,365.94 11,139.00 5,903.67 9,514.00 5,042.42 7,733.00 4,098.49

62 21,878.00 11,595.34 15,223.00 8,068.19 12,201.00 6,466.53 10,413.00 5,518.89 8,468.00 4,488.04

63 23,265.00 12,330.45 16,184.00 8,577.52 12,971.00 6,874.63 11,075.00 5,869.75 9,005.00 4,772.65

64 25,165.00 13,337.45 17,519.00 9,285.07 14,037.00 7,439.61 11,983.00 6,350.99 9,744.00 5,164.32

65 32,902.00 17,438.06 22,849.00 12,109.97 17,750.00 9,407.50 15,987.00 8,473.11 13,751.00 7,288.03

66 38,226.00 20,259.78 26,553.00 14,073.09 20,624.00 10,930.72 18,584.00 9,849.52 15,979.00 8,468.87

67 41,752.00 22,128.56 28,999.00 15,369.47 22,531.00 11,941.43 20,289.00 10,753.17 17,452.00 9,249.56

68 46,233.00 24,503.49 32,110.00 17,018.30 24,949.00 13,222.97 22,479.00 11,913.87 19,326.00 10,242.78

69 50,868.00 26,960.04 35,330.00 18,724.90 27,454.00 14,550.62 24,731.00 13,107.43 21,267.00 11,271.51

70 62,609.00 33,182.77 43,023.00 22,802.19 32,318.00 17,128.54 28,819.00 15,274.07 25,019.00 13,260.07

71 65,071.00 34,487.63 44,712.00 23,697.36 33,588.00 17,801.64 29,953.00 15,875.09 26,005.00 13,782.65

72 66,912.00 35,463.36 45,975.00 24,366.75 34,534.00 18,303.02 30,799.00 16,323.47 26,741.00 14,172.73

73 69,372.00 36,767.16 47,671.00 25,265.63 35,805.00 18,976.65 31,935.00 16,925.55 27,725.00 14,694.25

74 70,598.00 37,416.94 48,510.00 25,710.30 36,441.00 19,313.73 32,500.00 17,225.00 28,212.00 14,952.36

75 and up 73,673.00 39,046.69 50,623.00 26,830.19 38,026.00 20,153.78 33,918.00 17,976.54 29,447.00 15,606.91

Additional coverageMaternity complications US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25

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Deducibles Plan 2 Plan 3 Plan 4 Plan 5 Plan 6

Dentro del país de residencia US$1,000 US$2,000 US$5,000 US$10,000 US$20,000

Fuera del país de residencia US$2,000 US$3,000 US$5,000 US$10,000 US$20,000

Edad Anual Semestral Anual Semestral Anual Semestral Anual Semestral Anual Semestral

1 hijo US$2,750.00 US$1,457.50 US$2,025.00 US$1,073.25 US$1,682.00 US$891.46 US$1,417.00 US$751.01 US$1,106.00 US$586.18

2 hijos 4,375.00 2,318.75 3,228.00 1,710.84 2,678.00 1,419.34 2,251.00 1,193.03 1,753.00 929.09

3 hijos o más 6,410.00 3,397.30 4,731.00 2,507.43 3,919.00 2,077.07 3,302.00 1,750.06 2,573.00 1,363.69

18-24 7,913.00 4,193.89 5,227.00 2,770.31 3,759.00 1,992.27 2,663.00 1,411.39 2,096.00 1,110.88

25-29 8,298.00 4,397.94 5,776.00 3,061.28 4,164.00 2,206.92 2,957.00 1,567.21 2,322.00 1,230.66

30-34 8,633.00 4,575.49 6,195.00 3,283.35 4,662.00 2,470.86 3,541.00 1,876.73 2,792.00 1,479.76

35-39 9,668.00 5,124.04 6,938.00 3,677.14 5,228.00 2,770.84 3,971.00 2,104.63 3,127.00 1,657.31

40-44 11,213.00 5,942.89 7,589.00 4,022.17 5,802.00 3,075.06 4,370.00 2,316.10 3,437.00 1,821.61

45-49 12,535.00 6,643.55 8,485.00 4,497.05 6,490.00 3,439.70 4,882.00 2,587.46 3,845.00 2,037.85

50-54 16,043.00 8,502.79 11,142.00 5,905.26 8,468.00 4,488.04 6,900.00 3,657.00 5,441.00 2,883.73

55-59 17,070.00 9,047.10 11,854.00 6,282.62 9,012.00 4,776.36 7,345.00 3,892.85 5,791.00 3,069.23

60 18,600.00 9,858.00 12,937.00 6,856.61 10,369.00 5,495.57 8,848.00 4,689.44 7,198.00 3,814.94

61 19,985.00 10,592.05 13,898.00 7,365.94 11,139.00 5,903.67 9,514.00 5,042.42 7,733.00 4,098.49

62 21,878.00 11,595.34 15,223.00 8,068.19 12,201.00 6,466.53 10,413.00 5,518.89 8,468.00 4,488.04

63 23,265.00 12,330.45 16,184.00 8,577.52 12,971.00 6,874.63 11,075.00 5,869.75 9,005.00 4,772.65

64 25,165.00 13,337.45 17,519.00 9,285.07 14,037.00 7,439.61 11,983.00 6,350.99 9,744.00 5,164.32

65 32,902.00 17,438.06 22,849.00 12,109.97 17,750.00 9,407.50 15,987.00 8,473.11 13,751.00 7,288.03

66 38,226.00 20,259.78 26,553.00 14,073.09 20,624.00 10,930.72 18,584.00 9,849.52 15,979.00 8,468.87

67 41,752.00 22,128.56 28,999.00 15,369.47 22,531.00 11,941.43 20,289.00 10,753.17 17,452.00 9,249.56

68 46,233.00 24,503.49 32,110.00 17,018.30 24,949.00 13,222.97 22,479.00 11,913.87 19,326.00 10,242.78

69 50,868.00 26,960.04 35,330.00 18,724.90 27,454.00 14,550.62 24,731.00 13,107.43 21,267.00 11,271.51

70 62,609.00 33,182.77 43,023.00 22,802.19 32,318.00 17,128.54 28,819.00 15,274.07 25,019.00 13,260.07

71 65,071.00 34,487.63 44,712.00 23,697.36 33,588.00 17,801.64 29,953.00 15,875.09 26,005.00 13,782.65

72 66,912.00 35,463.36 45,975.00 24,366.75 34,534.00 18,303.02 30,799.00 16,323.47 26,741.00 14,172.73

73 69,372.00 36,767.16 47,671.00 25,265.63 35,805.00 18,976.65 31,935.00 16,925.55 27,725.00 14,694.25

74 70,598.00 37,416.94 48,510.00 25,710.30 36,441.00 19,313.73 32,500.00 17,225.00 28,212.00 14,952.36

75 ó más 73,673.00 39,046.69 50,623.00 26,830.19 38,026.00 20,153.78 33,918.00 17,976.54 29,447.00 15,606.91

Cobertura adicionalComplicaciones de maternidad US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25

EXCLUSIVE CARE

PRIVILEGE CARE

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Deductibles Plan 2 Plan 3 Plan 4 Plan 5 Plan 6

In country of residence US$1,000 US$2,000 US$5,000 US$10,000 US$20,000

Out of country of residence US$2,000 US$3,000 US$5,000 US$10,000 US$20,000

Age Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual

1 Child US$2,309.00 US$1,223.77 US$1,688.00 US$894.64 US$1,331.00 US$705.43 US$1,121.00 US$594.13 US$830.00 US$439.90

2 Children 3,670.00 1,945.10 2,683.00 1,421.99 2,112.00 1,119.36 1,783.00 944.99 1,318.00 698.54

3+ Children 5,377.00 2,849.81 3,930.00 2,082.90 3,097.00 1,641.41 2,612.00 1,384.36 1,932.00 1,023.96

18-24 6,652.00 3,525.56 4,572.00 2,423.16 3,267.00 1,731.51 2,314.00 1,226.42 1,766.00 935.98

25-29 6,983.00 3,700.99 5,064.00 2,683.92 3,618.00 1,917.54 2,568.00 1,361.04 1,957.00 1,037.21

30-34 7,289.00 3,863.17 5,417.00 2,871.01 4,063.00 2,153.39 3,102.00 1,644.06 2,365.00 1,253.45

35-39 8,161.00 4,325.33 6,063.00 3,213.39 4,551.00 2,412.03 3,478.00 1,843.34 2,654.00 1,406.62

40-44 9,448.00 5,007.44 6,647.00 3,522.91 5,060.00 2,681.80 3,838.00 2,034.14 2,929.00 1,552.37

45-49 10,559.00 5,596.27 7,426.00 3,935.78 5,657.00 2,998.21 4,290.00 2,273.70 3,276.00 1,736.28

50-54 13,803.00 7,315.59 9,799.00 5,193.47 7,426.00 3,935.78 6,122.00 3,244.66 4,681.00 2,480.93

55-59 14,685.00 7,783.05 10,427.00 5,526.31 7,905.00 4,189.65 6,514.00 3,452.42 4,978.00 2,638.34

60 15,990.00 8,474.70 11,324.00 6,001.72 8,996.00 4,767.88 7,750.00 4,107.50 6,218.00 3,295.54

61 17,185.00 9,108.05 12,156.00 6,442.68 9,669.00 5,124.57 8,328.00 4,413.84 6,683.00 3,541.99

62 18,807.00 9,967.71 13,319.00 7,059.07 10,586.00 5,610.58 9,118.00 4,832.54 7,321.00 3,880.13

63 19,994.00 10,596.82 14,161.00 7,505.33 11,253.00 5,964.09 9,693.00 5,137.29 7,786.00 4,126.58

64 21,631.00 11,464.43 15,319.00 8,119.07 12,175.00 6,452.75 10,486.00 5,557.58 8,424.00 4,464.72

65 28,276.00 14,986.28 19,981.00 10,589.93 15,395.00 8,159.35 13,986.00 7,412.58 11,876.00 6,294.28

66 32,851.00 17,411.03 23,215.00 12,303.95 17,883.00 9,477.99 16,252.00 8,613.56 13,803.00 7,315.59

67 35,880.00 19,016.40 25,354.00 13,437.62 19,531.00 10,351.43 17,750.00 9,407.50 15,074.00 7,989.22

68 39,731.00 21,057.43 28,076.00 14,880.28 21,633.00 11,465.49 19,660.00 10,419.80 16,689.00 8,845.17

69 43,709.00 23,165.77 30,890.00 16,371.70 23,798.00 12,612.94 21,625.00 11,461.25 18,367.00 9,734.51

70 53,795.00 28,511.35 37,612.00 19,934.36 28,011.00 14,845.83 25,201.00 13,356.53 21,601.00 11,448.53

71 55,901.00 29,627.53 39,090.00 20,717.70 29,110.00 15,428.30 26,189.00 13,880.17 22,449.00 11,897.97

72 57,488.00 30,468.64 40,195.00 21,303.35 29,938.00 15,867.14 26,933.00 14,274.49 23,085.00 12,235.05

73 59,601.00 31,588.53 41,671.00 22,085.63 31,037.00 16,449.61 27,922.00 14,798.66 23,936.00 12,686.08

74 60,653.00 32,146.09 42,407.00 22,475.71 31,588.00 16,741.64 28,418.00 15,061.54 24,359.00 12,910.27

75 and up 63,294.00 33,545.82 44,254.00 23,454.62 32,964.00 17,470.92 29,651.00 15,715.03 25,422.00 13,473.66

Additional coverageMaternity complications US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25

PRIVILEGE CARE

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Deducibles Plan 2 Plan 3 Plan 4 Plan 5 Plan 6

Dentro del país de residencia US$1,000 US$2,000 US$5,000 US$10,000 US$20,000

Fuera del país de residencia US$2,000 US$3,000 US$5,000 US$10,000 US$20,000

Edad Anual Semestral Anual Semestral Anual Semestral Anual Semestral Anual Semestral

1 hijo US$2,309.00 US$1,223.77 US$1,688.00 US$894.64 US$1,331.00 US$705.43 US$1,121.00 US$594.13 US$830.00 US$439.90

2 hijos 3,670.00 1,945.10 2,683.00 1,421.99 2,112.00 1,119.36 1,783.00 944.99 1,318.00 698.54

3 hijos o más 5,377.00 2,849.81 3,930.00 2,082.90 3,097.00 1,641.41 2,612.00 1,384.36 1,932.00 1,023.96

18-24 6,652.00 3,525.56 4,572.00 2,423.16 3,267.00 1,731.51 2,314.00 1,226.42 1,766.00 935.98

25-29 6,983.00 3,700.99 5,064.00 2,683.92 3,618.00 1,917.54 2,568.00 1,361.04 1,957.00 1,037.21

30-34 7,289.00 3,863.17 5,417.00 2,871.01 4,063.00 2,153.39 3,102.00 1,644.06 2,365.00 1,253.45

35-39 8,161.00 4,325.33 6,063.00 3,213.39 4,551.00 2,412.03 3,478.00 1,843.34 2,654.00 1,406.62

40-44 9,448.00 5,007.44 6,647.00 3,522.91 5,060.00 2,681.80 3,838.00 2,034.14 2,929.00 1,552.37

45-49 10,559.00 5,596.27 7,426.00 3,935.78 5,657.00 2,998.21 4,290.00 2,273.70 3,276.00 1,736.28

50-54 13,803.00 7,315.59 9,799.00 5,193.47 7,426.00 3,935.78 6,122.00 3,244.66 4,681.00 2,480.93

55-59 14,685.00 7,783.05 10,427.00 5,526.31 7,905.00 4,189.65 6,514.00 3,452.42 4,978.00 2,638.34

60 15,990.00 8,474.70 11,324.00 6,001.72 8,996.00 4,767.88 7,750.00 4,107.50 6,218.00 3,295.54

61 17,185.00 9,108.05 12,156.00 6,442.68 9,669.00 5,124.57 8,328.00 4,413.84 6,683.00 3,541.99

62 18,807.00 9,967.71 13,319.00 7,059.07 10,586.00 5,610.58 9,118.00 4,832.54 7,321.00 3,880.13

63 19,994.00 10,596.82 14,161.00 7,505.33 11,253.00 5,964.09 9,693.00 5,137.29 7,786.00 4,126.58

64 21,631.00 11,464.43 15,319.00 8,119.07 12,175.00 6,452.75 10,486.00 5,557.58 8,424.00 4,464.72

65 28,276.00 14,986.28 19,981.00 10,589.93 15,395.00 8,159.35 13,986.00 7,412.58 11,876.00 6,294.28

66 32,851.00 17,411.03 23,215.00 12,303.95 17,883.00 9,477.99 16,252.00 8,613.56 13,803.00 7,315.59

67 35,880.00 19,016.40 25,354.00 13,437.62 19,531.00 10,351.43 17,750.00 9,407.50 15,074.00 7,989.22

68 39,731.00 21,057.43 28,076.00 14,880.28 21,633.00 11,465.49 19,660.00 10,419.80 16,689.00 8,845.17

69 43,709.00 23,165.77 30,890.00 16,371.70 23,798.00 12,612.94 21,625.00 11,461.25 18,367.00 9,734.51

70 53,795.00 28,511.35 37,612.00 19,934.36 28,011.00 14,845.83 25,201.00 13,356.53 21,601.00 11,448.53

71 55,901.00 29,627.53 39,090.00 20,717.70 29,110.00 15,428.30 26,189.00 13,880.17 22,449.00 11,897.97

72 57,488.00 30,468.64 40,195.00 21,303.35 29,938.00 15,867.14 26,933.00 14,274.49 23,085.00 12,235.05

73 59,601.00 31,588.53 41,671.00 22,085.63 31,037.00 16,449.61 27,922.00 14,798.66 23,936.00 12,686.08

74 60,653.00 32,146.09 42,407.00 22,475.71 31,588.00 16,741.64 28,418.00 15,061.54 24,359.00 12,910.27

75 ó más 63,294.00 33,545.82 44,254.00 23,454.62 32,964.00 17,470.92 29,651.00 15,715.03 25,422.00 13,473.66

Cobertura adicionalComplicaciones de maternidad US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25

ADVANTAGE CARE

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Deductibles Plan 1(*) Plan 2 Plan 3 Plan 4 Plan 5 Plan 6

In country of residence US$0 US$1,000 US$2,000 US$5,000 US$10,000 US$20,000

Out of country of residence

US$1,000 US$2,000 US$3,000 US$5,000 US$10,000 US$20,000

Age Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual

1 Child US$2,504.00 US$1,327.12 US$1,931.00 US$1,023.43 US$1,370.00 US$726.10 US$1,084.00 US$574.52 US$957.00 US$507.21 US$687.00 US$364.11

2 Children 3,856.00 2,043.68 3,146.00 1,667.38 2,165.00 1,147.45 1,714.00 908.42 1,520.00 805.60 1,014.00 537.42

3+ Children 5,636.00 2,987.08 4,606.00 2,441.18 3,165.00 1,677.45 2,504.00 1,327.12 2,205.00 1,168.65 1,544.00 818.32

18-24 6,093.00 3,229.29 4,349.00 2,304.97 3,267.00 1,731.51 2,499.00 1,324.47 1,914.00 1,014.42 1,517.00 804.01

25-29 6,814.00 3,611.42 4,837.00 2,563.61 3,644.00 1,931.32 2,779.00 1,472.87 2,136.00 1,132.08 1,678.00 889.34

30-34 7,958.00 4,217.74 5,602.00 2,969.06 4,282.00 2,269.46 3,306.00 1,752.18 2,535.00 1,343.55 1,952.00 1,034.56

35-39 8,989.00 4,764.17 6,210.00 3,291.30 4,770.00 2,528.10 3,677.00 1,948.81 2,888.00 1,530.64 2,167.00 1,148.51

40-44 10,178.00 5,394.34 7,009.00 3,714.77 5,408.00 2,866.24 4,175.00 2,212.75 3,229.00 1,711.37 2,454.00 1,300.62

45-49 11,754.00 6,229.62 8,147.00 4,317.91 6,229.00 3,301.37 4,704.00 2,493.12 3,675.00 1,947.75 2,854.00 1,512.62

50-54 13,298.00 7,047.94 8,923.00 4,729.19 7,003.00 3,711.59 5,483.00 2,905.99 4,128.00 2,187.84 3,128.00 1,657.84

55-59 15,415.00 8,169.95 10,544.00 5,588.32 8,086.00 4,285.58 6,068.00 3,216.04 4,783.00 2,534.99 3,701.00 1,961.53

60 16,401.00 8,692.53 11,649.00 6,173.97 8,955.00 4,746.15 6,672.00 3,536.16 5,274.00 2,795.22 4,099.00 2,172.47

61 18,456.00 9,781.68 13,113.00 6,949.89 10,077.00 5,340.81 7,512.00 3,981.36 5,938.00 3,147.14 4,614.00 2,445.42

62 20,513.00 10,871.89 14,574.00 7,724.22 11,204.00 5,938.12 8,351.00 4,426.03 6,611.00 3,503.83 5,131.00 2,719.43

63 22,572.00 11,963.16 16,036.00 8,499.08 12,322.00 6,530.66 9,188.00 4,869.64 7,273.00 3,854.69 5,650.00 2,994.50

64 24,622.00 13,049.66 17,497.00 9,273.41 13,449.00 7,127.97 10,029.00 5,315.37 7,937.00 4,206.61 6,164.00 3,266.92

65 27,051.00 14,337.03 18,919.00 10,027.07 14,637.00 7,757.61 10,930.00 5,792.90 8,641.00 4,579.73 7,021.00 3,721.13

66 28,643.00 15,180.79 20,033.00 10,617.49 15,499.00 8,214.47 11,577.00 6,135.81 9,155.00 4,852.15 7,435.00 3,940.55

67 31,834.00 16,872.02 22,264.00 11,799.92 17,225.00 9,129.25 12,869.00 6,820.57 10,172.00 5,391.16 8,261.00 4,378.33

68 35,020.00 18,560.60 24,494.00 12,981.82 18,954.00 10,045.62 14,158.00 7,503.74 11,198.00 5,934.94 9,092.00 4,818.76

69 36,614.00 19,405.42 25,611.00 13,573.83 19,814.00 10,501.42 14,801.00 7,844.53 11,705.00 6,203.65 9,508.00 5,039.24

70 37,388.00 19,815.64 25,940.00 13,748.20 20,130.00 10,668.90 15,027.00 7,964.31 11,928.00 6,321.84 9,636.00 5,107.08

71 42,069.00 22,296.57 29,190.00 15,470.70 22,654.00 12,006.62 16,912.00 8,963.36 13,422.00 7,113.66 10,842.00 5,746.26

72 46,748.00 24,776.44 32,435.00 17,190.55 25,174.00 13,342.22 18,797.00 9,962.41 14,919.00 7,907.07 12,049.00 6,385.97

73 51,426.00 27,255.78 35,686.00 18,913.58 27,698.00 14,679.94 20,676.00 10,958.28 16,413.00 8,698.89 13,260.00 7,027.80

74 56,108.00 29,737.24 38,933.00 20,634.49 30,213.00 16,012.89 22,559.00 11,956.27 17,911.00 9,492.83 14,467.00 7,667.51

75 and up 61,261.00 32,468.33 42,587.00 22,571.11 33,702.00 17,862.06 25,876.00 13,714.28 19,609.00 10,392.77 16,604.00 8,800.12

Additional coverageMaternity complications US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25

Transplant Procedures 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00

(*) Deductible Plan 1 (US$0/US$1,000) is only available for renewals of the same plan as of January 1, 2013.

ADVANTAGE CARE

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Deducibles Plan 1(*) Plan 2 Plan 3 Plan 4 Plan 5 Plan 6

Dentro del país de residencia US$0 US$1,000 US$2,000 US$5,000 US$10,000 US$20,000

Fuera del país de residencia US$1,000 US$2,000 US$3,000 US$5,000 US$10,000 US$20,000

Edad Anual Semestral Anual Semestral Anual Semestral Anual Semestral Anual Semestral Anual Semestral

1 hijo US$2,504.00 US$1,327.12 US$1,931.00 US$1,023.43 US$1,370.00 US$726.10 US$1,084.00 US$574.52 US$957.00 US$507.21 US$687.00 US$364.11

2 hijos 3,856.00 2,043.68 3,146.00 1,667.38 2,165.00 1,147.45 1,714.00 908.42 1,520.00 805.60 1,014.00 537.42

3 hijos o más 5,636.00 2,987.08 4,606.00 2,441.18 3,165.00 1,677.45 2,504.00 1,327.12 2,205.00 1,168.65 1,544.00 818.32

18-24 6,093.00 3,229.29 4,349.00 2,304.97 3,267.00 1,731.51 2,499.00 1,324.47 1,914.00 1,014.42 1,517.00 804.01

25-29 6,814.00 3,611.42 4,837.00 2,563.61 3,644.00 1,931.32 2,779.00 1,472.87 2,136.00 1,132.08 1,678.00 889.34

30-34 7,958.00 4,217.74 5,602.00 2,969.06 4,282.00 2,269.46 3,306.00 1,752.18 2,535.00 1,343.55 1,952.00 1,034.56

35-39 8,989.00 4,764.17 6,210.00 3,291.30 4,770.00 2,528.10 3,677.00 1,948.81 2,888.00 1,530.64 2,167.00 1,148.51

40-44 10,178.00 5,394.34 7,009.00 3,714.77 5,408.00 2,866.24 4,175.00 2,212.75 3,229.00 1,711.37 2,454.00 1,300.62

45-49 11,754.00 6,229.62 8,147.00 4,317.91 6,229.00 3,301.37 4,704.00 2,493.12 3,675.00 1,947.75 2,854.00 1,512.62

50-54 13,298.00 7,047.94 8,923.00 4,729.19 7,003.00 3,711.59 5,483.00 2,905.99 4,128.00 2,187.84 3,128.00 1,657.84

55-59 15,415.00 8,169.95 10,544.00 5,588.32 8,086.00 4,285.58 6,068.00 3,216.04 4,783.00 2,534.99 3,701.00 1,961.53

60 16,401.00 8,692.53 11,649.00 6,173.97 8,955.00 4,746.15 6,672.00 3,536.16 5,274.00 2,795.22 4,099.00 2,172.47

61 18,456.00 9,781.68 13,113.00 6,949.89 10,077.00 5,340.81 7,512.00 3,981.36 5,938.00 3,147.14 4,614.00 2,445.42

62 20,513.00 10,871.89 14,574.00 7,724.22 11,204.00 5,938.12 8,351.00 4,426.03 6,611.00 3,503.83 5,131.00 2,719.43

63 22,572.00 11,963.16 16,036.00 8,499.08 12,322.00 6,530.66 9,188.00 4,869.64 7,273.00 3,854.69 5,650.00 2,994.50

64 24,622.00 13,049.66 17,497.00 9,273.41 13,449.00 7,127.97 10,029.00 5,315.37 7,937.00 4,206.61 6,164.00 3,266.92

65 27,051.00 14,337.03 18,919.00 10,027.07 14,637.00 7,757.61 10,930.00 5,792.90 8,641.00 4,579.73 7,021.00 3,721.13

66 28,643.00 15,180.79 20,033.00 10,617.49 15,499.00 8,214.47 11,577.00 6,135.81 9,155.00 4,852.15 7,435.00 3,940.55

67 31,834.00 16,872.02 22,264.00 11,799.92 17,225.00 9,129.25 12,869.00 6,820.57 10,172.00 5,391.16 8,261.00 4,378.33

68 35,020.00 18,560.60 24,494.00 12,981.82 18,954.00 10,045.62 14,158.00 7,503.74 11,198.00 5,934.94 9,092.00 4,818.76

69 36,614.00 19,405.42 25,611.00 13,573.83 19,814.00 10,501.42 14,801.00 7,844.53 11,705.00 6,203.65 9,508.00 5,039.24

70 37,388.00 19,815.64 25,940.00 13,748.20 20,130.00 10,668.90 15,027.00 7,964.31 11,928.00 6,321.84 9,636.00 5,107.08

71 42,069.00 22,296.57 29,190.00 15,470.70 22,654.00 12,006.62 16,912.00 8,963.36 13,422.00 7,113.66 10,842.00 5,746.26

72 46,748.00 24,776.44 32,435.00 17,190.55 25,174.00 13,342.22 18,797.00 9,962.41 14,919.00 7,907.07 12,049.00 6,385.97

73 51,426.00 27,255.78 35,686.00 18,913.58 27,698.00 14,679.94 20,676.00 10,958.28 16,413.00 8,698.89 13,260.00 7,027.80

74 56,108.00 29,737.24 38,933.00 20,634.49 30,213.00 16,012.89 22,559.00 11,956.27 17,911.00 9,492.83 14,467.00 7,667.51

75 ó más 61,261.00 32,468.33 42,587.00 22,571.11 33,702.00 17,862.06 25,876.00 13,714.28 19,609.00 10,392.77 16,604.00 8,800.12

Cobertura adicionalComplicaciones de maternidad US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25

Procedimientosde trasplante 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00

(*) A partir del 1 de enero de 2013, el Plan 1 de deducible (US$0/US$1,000) solamente estará disponible para renovaciones del mismo plan de deducible.

SECURE CARE

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Out of country of residence

US$1,000 US$2,000 US$3,000 US$5,000 US$10,000 US$20,000


1 Child US$1,745.00 US$924.85 US$1,569.00 US$831.57 US$930.00 US$492.90 US$789.00 US$418.17 US$680.00 US$360.40 US$498.00 US$263.94

2 Children 2,861.00 1,516.33 2,647.00 1,402.91 1,379.00 730.87 1,243.00 658.79 1,070.00 567.10 795.00 421.35

3+ Children 4,192.00 2,221.76 3,885.00 2,059.05 1,986.00 1,052.58 1,810.00 959.30 1,555.00 824.15 1,150.00 609.50

18-24 3,844.00 2,037.32 3,246.00 1,720.38 2,541.00 1,346.73 1,950.00 1,033.50 1,689.00 895.17 1,280.00 678.40

25-29 4,268.00 2,262.04 3,583.00 1,898.99 2,871.00 1,521.63 2,176.00 1,153.28 1,882.00 997.46 1,425.00 755.25

30-34 4,927.00 2,611.31 4,104.00 2,175.12 3,370.00 1,786.10 2,533.00 1,342.49 2,191.00 1,161.23 1,653.00 876.09

35-39 5,452.00 2,889.56 4,524.00 2,397.72 3,776.00 2,001.28 2,816.00 1,492.48 2,430.00 1,287.90 1,829.00 969.37

40-44 6,152.00 3,260.56 5,072.00 2,688.16 4,309.00 2,283.77 3,182.00 1,686.46 2,753.00 1,459.09 2,070.00 1,097.10

45-49 7,128.00 3,777.84 5,839.00 3,094.67 5,049.00 2,675.97 3,706.00 1,964.18 3,204.00 1,698.12 2,403.00 1,273.59

50-54 7,802.00 4,135.06 6,378.00 3,380.34 5,561.00 2,947.33 4,065.00 2,154.45 3,515.00 1,862.95 2,630.00 1,393.90

55-59 9,214.00 4,883.42 7,492.00 3,970.76 6,641.00 3,519.73 4,824.00 2,556.72 4,164.00 2,206.92 3,115.00 1,650.95

60 9,713.00 5,147.89 7,842.00 4,156.26 7,095.00 3,760.35 5,108.00 2,707.24 4,408.00 2,336.24 3,292.00 1,744.76

61 10,935.00 5,795.55 8,832.00 4,680.96 7,990.00 4,234.70 5,755.00 3,050.15 4,962.00 2,629.86 3,715.00 1,968.95

62 12,158.00 6,443.74 9,816.00 5,202.48 8,880.00 4,706.40 6,396.00 3,389.88 5,519.00 2,925.07 4,132.00 2,189.96

63 13,376.00 7,089.28 10,802.00 5,725.06 9,772.00 5,179.16 7,040.00 3,731.20 6,076.00 3,220.28 4,548.00 2,410.44

64 14,596.00 7,735.88 11,791.00 6,249.23 10,668.00 5,654.04 7,684.00 4,072.52 6,638.00 3,518.14 4,965.00 2,631.45

65 14,656.00 7,767.68 11,802.00 6,255.06 10,771.00 5,708.63 7,728.00 4,095.84 6,671.00 3,535.63 4,986.00 2,642.58

66 14,710.00 7,796.30 11,815.00 6,261.95 10,868.00 5,760.04 7,776.00 4,121.28 6,706.00 3,554.18 5,002.00 2,651.06

67 16,352.00 8,666.56 13,132.00 6,959.96 12,082.00 6,403.46 8,644.00 4,581.32 7,461.00 3,954.33 5,560.00 2,946.80

68 17,997.00 9,538.41 14,451.00 7,659.03 13,296.00 7,046.88 9,512.00 5,041.36 8,207.00 4,349.71 6,125.00 3,246.25

69 18,809.00 9,968.77 15,108.00 8,007.24 13,901.00 7,367.53 9,950.00 5,273.50 8,581.00 4,547.93 6,406.00 3,395.18

70 18,946.00 10,041.38 15,137.00 8,022.61 14,136.00 7,492.08 10,047.00 5,324.91 8,664.00 4,591.92 6,439.00 3,412.67

71 21,320.00 11,299.60 17,035.00 9,028.55 15,908.00 8,431.24 11,314.00 5,996.42 9,752.00 5,168.56 7,250.00 3,842.50

72 23,696.00 12,558.88 18,936.00 10,036.08 17,680.00 9,370.40 12,578.00 6,666.34 10,841.00 5,745.73 8,060.00 4,271.80

73 26,073.00 13,818.69 20,834.00 11,042.02 19,448.00 10,307.44 13,839.00 7,334.67 11,930.00 6,322.90 8,866.00 4,698.98

74 28,446.00 15,076.38 22,736.00 12,050.08 21,225.00 11,249.25 15,100.00 8,003.00 13,019.00 6,900.07 9,676.00 5,128.28

75 and up 31,073.00 16,468.69 24,774.00 13,130.22 23,282.00 12,339.46 16,513.00 8,751.89 14,240.00 7,547.20 10,580.00 5,607.40




SECURE CARE

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1 hijo US$1,745.00 US$924.85 US$1,569.00 US$831.57 US$930.00 US$492.90 US$789.00 US$418.17 US$680.00 US$360.40 US$498.00 US$263.94

2 hijos 2,861.00 1,516.33 2,647.00 1,402.91 1,379.00 730.87 1,243.00 658.79 1,070.00 567.10 795.00 421.35

3 hijos o más 4,192.00 2,221.76 3,885.00 2,059.05 1,986.00 1,052.58 1,810.00 959.30 1,555.00 824.15 1,150.00 609.50

18-24 3,844.00 2,037.32 3,246.00 1,720.38 2,541.00 1,346.73 1,950.00 1,033.50 1,689.00 895.17 1,280.00 678.40

25-29 4,268.00 2,262.04 3,583.00 1,898.99 2,871.00 1,521.63 2,176.00 1,153.28 1,882.00 997.46 1,425.00 755.25

30-34 4,927.00 2,611.31 4,104.00 2,175.12 3,370.00 1,786.10 2,533.00 1,342.49 2,191.00 1,161.23 1,653.00 876.09

35-39 5,452.00 2,889.56 4,524.00 2,397.72 3,776.00 2,001.28 2,816.00 1,492.48 2,430.00 1,287.90 1,829.00 969.37

40-44 6,152.00 3,260.56 5,072.00 2,688.16 4,309.00 2,283.77 3,182.00 1,686.46 2,753.00 1,459.09 2,070.00 1,097.10

45-49 7,128.00 3,777.84 5,839.00 3,094.67 5,049.00 2,675.97 3,706.00 1,964.18 3,204.00 1,698.12 2,403.00 1,273.59

50-54 7,802.00 4,135.06 6,378.00 3,380.34 5,561.00 2,947.33 4,065.00 2,154.45 3,515.00 1,862.95 2,630.00 1,393.90

55-59 9,214.00 4,883.42 7,492.00 3,970.76 6,641.00 3,519.73 4,824.00 2,556.72 4,164.00 2,206.92 3,115.00 1,650.95

60 9,713.00 5,147.89 7,842.00 4,156.26 7,095.00 3,760.35 5,108.00 2,707.24 4,408.00 2,336.24 3,292.00 1,744.76

61 10,935.00 5,795.55 8,832.00 4,680.96 7,990.00 4,234.70 5,755.00 3,050.15 4,962.00 2,629.86 3,715.00 1,968.95

62 12,158.00 6,443.74 9,816.00 5,202.48 8,880.00 4,706.40 6,396.00 3,389.88 5,519.00 2,925.07 4,132.00 2,189.96

63 13,376.00 7,089.28 10,802.00 5,725.06 9,772.00 5,179.16 7,040.00 3,731.20 6,076.00 3,220.28 4,548.00 2,410.44

64 14,596.00 7,735.88 11,791.00 6,249.23 10,668.00 5,654.04 7,684.00 4,072.52 6,638.00 3,518.14 4,965.00 2,631.45

65 14,656.00 7,767.68 11,802.00 6,255.06 10,771.00 5,708.63 7,728.00 4,095.84 6,671.00 3,535.63 4,986.00 2,642.58

66 14,710.00 7,796.30 11,815.00 6,261.95 10,868.00 5,760.04 7,776.00 4,121.28 6,706.00 3,554.18 5,002.00 2,651.06

67 16,352.00 8,666.56 13,132.00 6,959.96 12,082.00 6,403.46 8,644.00 4,581.32 7,461.00 3,954.33 5,560.00 2,946.80

68 17,997.00 9,538.41 14,451.00 7,659.03 13,296.00 7,046.88 9,512.00 5,041.36 8,207.00 4,349.71 6,125.00 3,246.25

69 18,809.00 9,968.77 15,108.00 8,007.24 13,901.00 7,367.53 9,950.00 5,273.50 8,581.00 4,547.93 6,406.00 3,395.18

70 18,946.00 10,041.38 15,137.00 8,022.61 14,136.00 7,492.08 10,047.00 5,324.91 8,664.00 4,591.92 6,439.00 3,412.67

71 21,320.00 11,299.60 17,035.00 9,028.55 15,908.00 8,431.24 11,314.00 5,996.42 9,752.00 5,168.56 7,250.00 3,842.50

72 23,696.00 12,558.88 18,936.00 10,036.08 17,680.00 9,370.40 12,578.00 6,666.34 10,841.00 5,745.73 8,060.00 4,271.80

73 26,073.00 13,818.69 20,834.00 11,042.02 19,448.00 10,307.44 13,839.00 7,334.67 11,930.00 6,322.90 8,866.00 4,698.98

74 28,446.00

15,076.38 22,736.00 12,050.08 21,225.00 11,249.25 15,100.00 8,003.00 13,019.00 6,900.07 9,676.00 5,128.28

75 ó más 31,073.00 16,468.69 24,774.00 13,130.22 23,282.00 12,339.46 16,513.00 8,751.89 14,240.00 7,547.20 10,580.00 5,607.40




ESSENTIAL CARE

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Out of country of residence US$1,000 US$2,000 US$3,000 US$5,000 US$10,000 US$20,000


1 Child US$1,475.00 US$781.75 US$1,325.00 US$702.25 US$781.00 US$413.93 US$664.00 US$351.92 US$572.00 US$303.16 US$425.00 US$225.25

2 Children 2,418.00 1,281.54 2,231.00 1,182.43 1,163.00 616.39 1,049.00 555.97 906.00 480.18 669.00 354.57

3+ Children 3,533.00 1,872.49 3,276.00 1,736.28 1,674.00 887.22 1,528.00 809.84 1,313.00 695.89 970.00 514.10

18-24 3,233.00 1,713.49 2,728.00 1,445.84 2,137.00 1,132.61 1,640.00 869.20 1,417.00 751.01 1,072.00 568.16

25-29 3,591.00 1,903.23 3,013.00 1,596.89 2,413.00 1,278.89 1,829.00 969.37 1,583.00 838.99 1,196.00 633.88

30-34 4,151.00 2,200.03 3,451.00 1,829.03 2,839.00 1,504.67 2,125.00 1,126.25 1,838.00 974.14 1,385.00 734.05

35-39 4,593.00 2,434.29 3,805.00 2,016.65 3,172.00 1,681.16 2,365.00 1,253.45 2,047.00 1,084.91 1,539.00 815.67

40-44 5,178.00 2,744.34 4,267.00 2,261.51 3,625.00 1,921.25 2,678.00 1,419.34 2,311.00 1,224.83 1,735.00 919.55

45-49 6,004.00 3,182.12 4,919.00 2,607.07 4,252.00 2,253.56 3,124.00 1,655.72 2,695.00 1,428.35 2,018.00 1,069.54

50-54 6,572.00 3,483.16 5,369.00 2,845.57 4,683.00 2,481.99 3,423.00 1,814.19 2,958.00 1,567.74 2,214.00 1,173.42

55-59 7,761.00 4,113.33 6,309.00 3,343.77 5,596.00 2,965.88 4,061.00 2,152.33 3,502.00 1,856.06 2,617.00 1,387.01

60 8,184.00 4,337.52 6,604.00 3,500.12 5,977.00 3,167.81 4,298.00 2,277.94 3,709.00 1,965.77 2,772.00 1,469.16

61 9,215.00 4,883.95 7,438.00 3,942.14 6,734.00 3,569.02 4,848.00 2,569.44 4,179.00 2,214.87 3,126.00 1,656.78

62 10,242.00 5,428.26 8,275.00 4,385.75 7,482.00 3,965.46 5,385.00 2,854.05 4,648.00 2,463.44 3,475.00 1,841.75

63 11,271.00 5,973.63 9,102.00 4,824.06 8,236.00 4,365.08 5,935.00 3,145.55 5,119.00 2,713.07 3,828.00 2,028.84

64 12,303.00 6,520.59 9,936.00 5,266.08 8,989.00 4,764.17 6,475.00 3,431.75 5,587.00 2,961.11 4,180.00 2,215.40

65 12,351.00 6,546.03 9,947.00 5,271.91 9,074.00 4,809.22 6,514.00 3,452.42 5,618.00 2,977.54 4,195.00 2,223.35

66 12,395.00 6,569.35 9,953.00 5,275.09 9,159.00 4,854.27 6,553.00 3,473.09 5,646.00 2,992.38 4,212.00 2,232.36

67 13,784.00 7,305.52 11,070.00 5,867.10 10,187.00 5,399.11 7,286.00 3,861.58 6,282.00 3,329.46 4,683.00 2,481.99

68 15,167.00 8,038.51 12,176.00 6,453.28 11,209.00 5,940.77 8,017.00 4,249.01 6,911.00 3,662.83 5,154.00 2,731.62

69 15,855.00 8,403.15 12,736.00 6,750.08 11,719.00 6,211.07 8,383.00 4,442.99 7,228.00 3,830.84 5,396.00 2,859.88

70 15,971.00 8,464.63 12,759.00 6,762.27 11,917.00 6,316.01 8,469.00 4,488.57 7,298.00 3,867.94 5,422.00 2,873.66

71 17,972.00 9,525.16 14,356.00 7,608.68 13,410.00 7,107.30 9,537.00 5,054.61 8,219.00 4,356.07 6,107.00 3,236.71

72 19,976.00 10,587.28 15,962.00 8,459.86 14,906.00 7,900.18 10,598.00 5,616.94 9,139.00 4,843.67 6,787.00 3,597.11

73 21,979.00 11,648.87 17,561.00 9,307.33 16,400.00 8,692.00 11,662.00 6,180.86 10,053.00 5,328.09 7,472.00 3,960.16

74 23,982.00 12,710.46 19,164.00 10,156.92 17,897.00 9,485.41 12,725.00 6,744.25 10,972.00 5,815.16 8,156.00 4,322.68

75 and up 26,191.00 13,881.23 20,886.00 11,069.58 19,630.00 10,403.90 13,922.00 7,378.66 12,002.00 6,361.06 8,913.00 4,723.89




ESSENTIAL CARE

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1 hijo US$1,475.00 US$781.75 US$1,325.00 US$702.25 US$781.00 US$413.93 US$664.00 US$351.92 US$572.00 US$303.16 US$425.00 US$225.25

2 hijos 2,418.00 1,281.54 2,231.00 1,182.43 1,163.00 616.39 1,049.00 555.97 906.00 480.18 669.00 354.57

3 hijos o más 3,533.00 1,872.49 3,276.00 1,736.28 1,674.00 887.22 1,528.00 809.84 1,313.00 695.89 970.00 514.10

18-24 3,233.00 1,713.49 2,728.00 1,445.84 2,137.00 1,132.61 1,640.00 869.20 1,417.00 751.01 1,072.00 568.16

25-29 3,591.00 1,903.23 3,013.00 1,596.89 2,413.00 1,278.89 1,829.00 969.37 1,583.00 838.99 1,196.00 633.88

30-34 4,151.00 2,200.03 3,451.00 1,829.03 2,839.00 1,504.67 2,125.00 1,126.25 1,838.00 974.14 1,385.00 734.05

35-39 4,593.00 2,434.29 3,805.00 2,016.65 3,172.00 1,681.16 2,365.00 1,253.45 2,047.00 1,084.91 1,539.00 815.67

40-44 5,178.00 2,744.34 4,267.00 2,261.51 3,625.00 1,921.25 2,678.00 1,419.34 2,311.00 1,224.83 1,735.00 919.55

45-49 6,004.00 3,182.12 4,919.00 2,607.07 4,252.00 2,253.56 3,124.00 1,655.72 2,695.00 1,428.35 2,018.00 1,069.54

50-54 6,572.00 3,483.16 5,369.00 2,845.57 4,683.00 2,481.99 3,423.00 1,814.19 2,958.00 1,567.74 2,214.00 1,173.42

55-59 7,761.00 4,113.33 6,309.00 3,343.77 5,596.00 2,965.88 4,061.00 2,152.33 3,502.00 1,856.06 2,617.00 1,387.01

60 8,184.00 4,337.52 6,604.00 3,500.12 5,977.00 3,167.81 4,298.00 2,277.94 3,709.00 1,965.77 2,772.00 1,469.16

61 9,215.00 4,883.95 7,438.00 3,942.14 6,734.00 3,569.02 4,848.00 2,569.44 4,179.00 2,214.87 3,126.00 1,656.78

62 10,242.00 5,428.26 8,275.00 4,385.75 7,482.00 3,965.46 5,385.00 2,854.05 4,648.00 2,463.44 3,475.00 1,841.75

63 11,271.00 5,973.63 9,102.00 4,824.06 8,236.00 4,365.08 5,935.00 3,145.55 5,119.00 2,713.07 3,828.00 2,028.84

64 12,303.00 6,520.59 9,936.00 5,266.08 8,989.00 4,764.17 6,475.00 3,431.75 5,587.00 2,961.11 4,180.00 2,215.40

65 12,351.00 6,546.03 9,947.00 5,271.91 9,074.00 4,809.22 6,514.00 3,452.42 5,618.00 2,977.54 4,195.00 2,223.35

66 12,395.00 6,569.35 9,953.00 5,275.09 9,159.00 4,854.27 6,553.00 3,473.09 5,646.00 2,992.38 4,212.00 2,232.36

67 13,784.00 7,305.52 11,070.00 5,867.10 10,187.00 5,399.11 7,286.00 3,861.58 6,282.00 3,329.46 4,683.00 2,481.99

68 15,167.00 8,038.51 12,176.00 6,453.28 11,209.00 5,940.77 8,017.00 4,249.01 6,911.00 3,662.83 5,154.00 2,731.62

69 15,855.00 8,403.15 12,736.00 6,750.08 11,719.00 6,211.07 8,383.00 4,442.99 7,228.00 3,830.84 5,396.00 2,859.88

70 15,971.00 8,464.63 12,759.00 6,762.27 11,917.00 6,316.01 8,469.00 4,488.57 7,298.00 3,867.94 5,422.00 2,873.66

71 17,972.00 9,525.16 14,356.00 7,608.68 13,410.00 7,107.30 9,537.00 5,054.61 8,219.00 4,356.07 6,107.00 3,236.71

72 19,976.00 10,587.28 15,962.00 8,459.86 14,906.00 7,900.18 10,598.00 5,616.94 9,139.00 4,843.67 6,787.00 3,597.11

73 21,979.00 11,648.87 17,561.00 9,307.33 16,400.00 8,692.00 11,662.00 6,180.86 10,053.00 5,328.09 7,472.00 3,960.16

74 23,982.00 12,710.46 19,164.00 10,156.92 17,897.00 9,485.41 12,725.00 6,744.25 10,972.00 5,815.16 8,156.00 4,322.68

75 ó más 26,191.00 13,881.23 20,886.00 11,069.58 19,630.00 10,403.90 13,922.00 7,378.66 12,002.00 6,361.06 8,913.00 4,723.89




CRITICAL CARE

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Deducibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6

Dentro del país de residencia

US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000



Menos de 50 años

Tarifa individual US$1,599.00 US$847.47 US$1,291.00 US$684.23 US$1,128.00 US$597.84 US$891.00 US$472.23 US$667.00 US$353.51 US$426.00 US$225.78

Tarifa para dos personas 2,820.00 1,494.60 2,211.00 1,171.83 1,939.00 1,027.67 1,504.00 797.12 1,082.00 573.46 636.00 337.08

Tarifa familiar 4,034.00 2,138.02 3,129.00 1,658.37 2,755.00 1,460.15 2,116.00 1,121.48 1,498.00 793.94 840.00 445.20

50 años o más

Tarifa individual US$2,025.00 US$1,073.25 US$1,631.00 US$864.43 US$1,411.00 US$747.83 US$1,103.00 US$584.59 US$806.00 US$427.18 US$498.00 US$263.94

Tarifa para dos personas 3,239.00 1,716.67 2,548.00 1,350.44 2,226.00 1,179.78 1,715.00 908.95 1,224.00 648.72 706.00 374.18

Tarifa familiar 4,461.00 2,364.33 3,463.00 1,835.39 3,038.00 1,610.14 2,324.00 1,231.72 1,640.00 869.20 914.00 484.42

Deductibles Plan 1 Plan 2 Plan 3 Plan 4 Plan 5 Plan 6

In country of residence US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000

Out of country of residence US$2,000 US$3,500 US$5,000 US$10,000 US$20,000 US$50,000


Under 50

Single rate US$1,599.00 US$847.47 US$1,291.00 US$684.23 US$1,128.00 US$597.84 US$891.00 US$472.23 US$667.00 US$353.51 US$426.00 US$225.78

Two-party rate 2,820.00 1,494.60 2,211.00 1,171.83 1,939.00 1,027.67 1,504.00 797.12 1,082.00 573.46 636.00 337.08

Family rate 4,034.00 2,138.02 3,129.00 1,658.37 2,755.00 1,460.15 2,116.00 1,121.48 1,498.00 793.94 840.00 445.20

50 or older

Single rate US$2,025.00 US$1,073.25 US$1,631.00 US$864.43 US$1,411.00 US$747.83 US$1,103.00 US$584.59 US$806.00 US$427.18 US$498.00 US$263.94

Two-party rate 3,239.00 1,716.67 2,548.00 1,350.44 2,226.00 1,179.78 1,715.00 908.95 1,224.00 648.72 706.00 374.18

Family rate 4,461.00 2,364.33 3,463.00 1,835.39 3,038.00 1,610.14 2,324.00 1,231.72 1,640.00 869.20 914.00 484.42

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HOW IS THE PREMIUM PAID?Bupa must receive payment before the coverage can take effect. Please submit payment with your application. You can choose among the following payment options:

Online payment by credit card through our website www.bupasalud.com

Credit card MasterCard, VISA, American Express, or Diners Club

Personal check in U.S. dollars drawn on an American bank, cashier’s check, money order, traveler’s check

Bank transfer:

Procedure for ACH’sWells Fargo Bank200 South Biscayne Blvd, FL6011Miami, FL 33131Account # 2000037371881ABA # 067006432Account Name: Bupa Worldwide Premium TrustReference: Policyholder Name and Policy Number

Procedure for wire transfersWells Fargo Bank200 South Biscayne Blvd, FL6011Miami, FL 33131Account # 2000037371881ABA # 121000248Account Name: Bupa Worldwide Premium TrustReference: Policyholder Name and Policy Number

Procedure for international wire transfersWells Fargo Bank200 South Biscayne Blvd, FL6011Miami, FL 33131Account # 2000037371881ABA # 121000248CHIPS # 0407SWIFT # WFBIUS6SAccount Name: Bupa Worldwide Premium TrustReference: Policyholder Name and Policy Number

CÓMO PAGAR LA PRIMABupa debe recibir el pago de la prima para que la cobertura entre en vigencia. Por favor efectúe su pago al momento de presentar la solicitud. Usted puede elegir cualquiera de las siguientes opciones de pago:

Pago online mediante tarjeta de crédito a través de nuestro sitio web www.bupasalud.com

Tarjeta de crédito MasterCard, VISA, American Express, o Diners Club

Cheque personal en dólares de los Estados Unidos de América pagadero contra un banco estadounidense, cheque de caja, giro postal, cheque de viajero

Transferencia bancaria:

Cobranza de Cámara de Compensación Automatizada (CCA)Wells Fargo Bank200 South Biscayne Blvd, FL6011Miami, FL 33131Número de cuenta: 2000037371881ABA #: 067006432Nombre de la cuenta: Bupa Worldwide Premium TrustReferencia: nombre del asegurado principal y número de póliza

Transferencia bancaria domésticaWells Fargo Bank200 South Biscayne Blvd, FL6011Miami, FL 33131Número de cuenta: 2000037371881ABA #: 121000248Nombre de la cuenta: Bupa Worldwide Premium TrustReferencia: nombre del asegurado principal y número de póliza

Transferencia bancaria internacionalWells Fargo Bank200 South Biscayne Blvd, FL6011Miami, FL 33131Número de cuenta: 2000037371881ABA #: 121000248CHIPS # 0407SWIFT # WFBIUS6SNombre de la cuenta: Bupa Worldwide Premium TrustReferencia: nombre del asegurado principal y número de póliza

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PB-PR 2016 ENG-SPA

17901 Old Cutler Road, Suite 400Palmetto Bay, Florida 33157Tel. +1 (305) 398 7400Fax +1 (305) 275 [email protected]

BUPA CARE - bupalatinamerica.com€¦ · EXCLUSIVE CARE BUPA COMPLETE CARE PREMIUM RATES, EFFECTIVE...

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