BUPA ESSENTIAL CARE · 2016-10-11 · ZONE 1 | MEXICO BUPA ESSENTIAL CARE PREMIUM BOOKLET,...

PRE MIU M BOOKLET

BU PA ESSE NTIAL CARE

E F F E C TI V E JA N UA RY 1 , 2 017

ADMINISTRATIVE NOTES• Rates are in U.S. dollars and don’t include taxes.

• An annual US$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.

• Premium rates are based on the country of residence. See separate premium rates for Puerto Rico and the U.S. Virgin Islands.

• 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.

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

ZONE 1 | MEXICO

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

Deductibles Plan 1 (a) 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$1,743.00 US$923.79 US$1,567.00 US$830.51 US$924.00 US$489.72 US$790.00 US$418.70 US$682.00 US$361.46 US$505.00 US$267.65

2 Children 2,859.00 1,515.27 2,648.00 1,403.44 1,379.00 730.87 1,248.00 661.44 1,073.00 568.69 800.00 424.00

3+ Children 4,184.00 2,217.52 3,882.00 2,057.46 1,979.00 1,048.87 1,805.00 956.65 1,562.00 827.86 1,154.00 611.62

18-24 3,846.00 2,038.38 3,245.00 1,719.85 2,551.00 1,352.03 1,957.00 1,037.21 1,698.00 899.94 1,288.00 682.64

25-29 4,268.00 2,262.04 3,581.00 1,897.93 2,870.00 1,521.10 2,183.00 1,156.99 1,889.00 1,001.17 1,431.00 758.43

30-34 4,931.00 2,613.43 4,105.00 2,175.65 3,370.00 1,786.10 2,541.00 1,346.73 2,198.00 1,164.94 1,657.00 878.21

35-39 5,453.00 2,890.09 4,520.00 2,395.60 3,777.00 2,001.81 2,822.00 1,495.66 2,439.00 1,292.67 1,835.00 972.55

40-44 6,154.00 3,261.62 5,073.00 2,688.69 4,312.00 2,285.36 3,192.00 1,691.76 2,762.00 1,463.86 2,076.00 1,100.28

45-49 7,132.00 3,779.96 5,842.00 3,096.26 5,052.00 2,677.56 3,717.00 1,970.01 3,212.00 1,702.36 2,411.00 1,277.83

50-54 7,800.00 4,134.00 6,373.00 3,377.69 5,562.00 2,947.86 4,074.00 2,159.22 3,523.00 1,867.19 2,642.00 1,400.26

55-59 9,213.00 4,882.89 7,494.00 3,971.82 6,641.00 3,519.73 4,836.00 2,563.08 4,175.00 2,212.75 3,122.00 1,654.66

60 9,710.00 5,146.30 7,840.00 4,155.20 7,100.00 3,763.00 5,119.00 2,713.07 4,418.00 2,341.54 3,303.00 1,750.59

61 10,936.00 5,796.08 8,826.00 4,677.78 7,995.00 4,237.35 5,764.00 3,054.92 4,971.00 2,634.63 3,725.00 1,974.25

62 12,153.00 6,441.09 9,818.00 5,203.54 8,890.00 4,711.70 6,407.00 3,395.71 5,532.00 2,931.96 4,141.00 2,194.73

63 13,374.00 7,088.22 10,801.00 5,724.53 9,781.00 5,183.93 7,054.00 3,738.62 6,089.00 3,227.17 4,559.00 2,416.27

64 14,597.00 7,736.41 11,790.00 6,248.70 10,675.00 5,657.75 7,700.00 4,081.00 6,649.00 3,523.97 4,975.00 2,636.75

65 14,652.00 7,765.56 11,803.00 6,255.59 10,778.00 5,712.34 7,746.00 4,105.38 6,684.00 3,542.52 4,999.00 2,649.47

66 14,710.00 7,796.30 11,813.00 6,260.89 10,877.00 5,764.81 7,790.00 4,128.70 6,722.00 3,562.66 5,014.00 2,657.42

67 16,349.00 8,664.97 13,130.00 6,958.90 12,091.00 6,408.23 8,662.00 4,590.86 7,473.00 3,960.69 5,574.00 2,954.22

68 17,986.00 9,532.58 14,450.00 7,658.50 13,307.00 7,052.71 9,535.00 5,053.55 8,225.00 4,359.25 6,137.00 3,252.61

69 18,812.00 9,970.36 15,109.00 8,007.77 13,906.00 7,370.18 9,972.00 5,285.16 8,596.00 4,555.88 6,424.00 3,404.72

70 18,945.00 10,040.85 15,134.00 8,021.02 14,141.00 7,494.73 10,071.00 5,337.63 8,682.00 4,601.46 6,446.00 3,416.38

71 21,319.00 11,299.07 17,035.00 9,028.55 15,912.00 8,433.36 11,338.00 6,009.14 9,770.00 5,178.10 7,261.00 3,848.33

72 23,691.00 12,556.23 18,929.00 10,032.37 17,688.00 9,374.64 12,599.00 6,677.47 10,861.00 5,756.33 8,076.00 4,280.28

73 26,063.00 13,813.39 20,828.00 11,038.84 19,464.00 10,315.92 13,861.00 7,346.33 11,951.00 6,334.03 8,889.00 4,711.17

74 28,436.00 15,071.08 22,729.00 12,046.37 21,242.00 11,258.26 15,128.00 8,017.84 13,041.00 6,911.73 9,697.00 5,139.41

75 and up 31,067.00 16,465.51 24,770.00 13,128.10 23,293.00 12,345.29 16,547.00 8,769.91 14,267.00 7,561.51 10,602.00 5,619.06

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

Transplantprocedures 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00

ZONE 2 | CHILE, HAITI, HONDURAS

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2 Children 2,827.00 1,498.31 2,620.00 1,388.60 1,356.00 718.68 1,229.00 651.37 1,062.00 562.86 785.00 416.05

3+ Children 4,137.00 2,192.61 3,843.00 2,036.79 1,957.00 1,037.21 1,787.00 947.11 1,539.00 815.67 1,138.00 603.14

18-24 3,793.00 2,010.29 3,206.00 1,699.18 2,509.00 1,329.77 1,924.00 1,019.72 1,668.00 884.04 1,262.00 668.86

25-29 4,213.00 2,232.89 3,536.00 1,874.08 2,828.00 1,498.84 2,148.00 1,138.44 1,862.00 986.86 1,403.00 743.59

30-34 4,865.00 2,578.45 4,044.00 2,143.32 3,329.00 1,764.37 2,496.00 1,322.88 2,161.00 1,145.33 1,628.00 862.84

35-39 5,387.00 2,855.11 4,464.00 2,365.92 3,731.00 1,977.43 2,780.00 1,473.40 2,400.00 1,272.00 1,809.00 958.77

40-44 6,073.00 3,218.69 5,006.00 2,653.18 4,254.00 2,254.62 3,145.00 1,666.85 2,718.00 1,440.54 2,041.00 1,081.73

45-49 7,035.00 3,728.55 5,763.00 3,054.39 4,990.00 2,644.70 3,665.00 1,942.45 3,164.00 1,676.92 2,374.00 1,258.22

50-54 7,703.00 4,082.59 6,292.00 3,334.76 5,493.00 2,911.29 4,016.00 2,128.48 3,468.00 1,838.04 2,600.00 1,378.00

55-59 9,097.00 4,821.41 7,399.00 3,921.47 6,560.00 3,476.80 4,763.00 2,524.39 4,115.00 2,180.95 3,074.00 1,629.22

60 9,588.00 5,081.64 7,747.00 4,105.91 7,013.00 3,716.89 5,043.00 2,672.79 4,356.00 2,308.68 3,250.00 1,722.50

61 10,796.00 5,721.88 8,715.00 4,618.95 7,896.00 4,184.88 5,678.00 3,009.34 4,904.00 2,599.12 3,669.00 1,944.57

62 12,002.00 6,361.06 9,691.00 5,136.23 8,777.00 4,651.81 6,322.00 3,350.66 5,456.00 2,891.68 4,079.00 2,161.87

63 13,211.00 7,001.83 10,669.00 5,654.57 9,657.00 5,118.21 6,956.00 3,686.68 6,006.00 3,183.18 4,494.00 2,381.82

64 14,411.00 7,637.83 11,645.00 6,171.85 10,544.00 5,588.32 7,591.00 4,023.23 6,555.00 3,474.15 4,905.00 2,599.65

65 14,472.00 7,670.16 11,657.00 6,178.21 10,641.00 5,639.73 7,639.00 4,048.67 6,590.00 3,492.70 4,923.00 2,609.19

66 14,525.00 7,698.25 11,668.00 6,184.04 10,741.00 5,692.73 7,686.00 4,073.58 6,624.00 3,510.72 4,940.00 2,618.20

67 16,147.00 8,557.91 12,969.00 6,873.57 11,941.00 6,328.73 8,538.00 4,525.14 7,365.00 3,903.45 5,493.00 2,911.29

68 17,768.00 9,417.04 14,274.00 7,565.22 13,143.00 6,965.79 9,397.00 4,980.41 8,107.00 4,296.71 6,050.00 3,206.50

69 18,578.00 9,846.34 14,924.00 7,909.72 13,736.00 7,280.08 9,830.00 5,209.90 8,478.00 4,493.34 6,328.00 3,353.84

70 18,713.00 9,917.89 14,944.00 7,920.32 13,967.00 7,402.51 9,929.00 5,262.37 8,560.00 4,536.80 6,360.00 3,370.80

71 21,058.00 11,160.74 16,826.00 8,917.78 15,722.00 8,332.66 11,179.00 5,924.87 9,637.00 5,107.61 7,159.00 3,794.27

72 23,398.00 12,400.94 18,702.00 9,912.06 17,473.00 9,260.69 12,429.00 6,587.37 10,715.00 5,678.95 7,961.00 4,219.33

73 25,747.00 13,645.91 20,576.00 10,905.28 19,225.00 10,189.25 13,674.00 7,247.22 11,790.00 6,248.70 8,768.00 4,647.04

74 28,093.00 14,889.29 22,450.00 11,898.50 20,974.00 11,116.22 14,922.00 7,908.66 12,870.00 6,821.10 9,560.00 5,066.80

75 and up 30,694.00 16,267.82 24,467.00 12,967.51 23,015.00 12,197.95 16,323.00 8,651.19 14,071.00 7,457.63 10,449.00 5,537.97



ZONE 3 | COSTA RICA, EL SALVADOR

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2 Children 2,703.00 1,432.59 2,497.00 1,323.41 1,301.00 689.53 1,171.00 620.63 1,007.00 533.71 755.00 400.15

3+ Children 3,949.00 2,092.97 3,666.00 1,942.98 1,867.00 989.51 1,707.00 904.71 1,467.00 777.51 1,086.00 575.58

18-24 3,618.00 1,917.54 3,057.00 1,620.21 2,263.00 1,199.39 1,843.00 976.79 1,591.00 843.23 1,205.00 638.65

25-29 4,016.00 2,128.48 3,374.00 1,788.22 2,567.00 1,360.51 2,055.00 1,089.15 1,776.00 941.28 1,342.00 711.26

30-34 4,644.00 2,461.32 3,862.00 2,046.86 3,041.00 1,611.73 2,387.00 1,265.11 2,062.00 1,092.86 1,555.00 824.15

35-39 5,139.00 2,723.67 4,259.00 2,257.27 3,423.00 1,814.19 2,652.00 1,405.56 2,296.00 1,216.88 1,724.00 913.72

40-44 5,798.00 3,072.94 4,781.00 2,533.93 3,926.00 2,080.78 3,000.00 1,590.00 2,592.00 1,373.76 1,949.00 1,032.97

45-49 6,719.00 3,561.07 5,502.00 2,916.06 4,627.00 2,452.31 3,497.00 1,853.41 3,019.00 1,600.07 2,263.00 1,199.39

50-54 7,351.00 3,896.03 6,006.00 3,183.18 5,109.00 2,707.77 3,834.00 2,032.02 3,311.00 1,754.83 2,481.00 1,314.93

55-59 8,680.00 4,600.40 7,064.00 3,743.92 6,127.00 3,247.31 4,549.00 2,410.97 3,927.00 2,081.31 2,938.00 1,557.14

60 9,158.00 4,853.74 7,391.00 3,917.23 6,556.00 3,474.68 4,818.00 2,553.54 4,156.00 2,202.68 3,106.00 1,646.18

61 10,303.00 5,460.59 8,321.00 4,410.13 7,397.00 3,920.41 5,423.00 2,874.19 4,678.00 2,479.34 3,501.00 1,855.53

62 11,459.00 6,073.27 9,252.00 4,903.56 8,244.00 4,369.32 6,034.00 3,198.02 5,207.00 2,759.71 3,893.00 2,063.29

63 12,609.00 6,682.77 10,181.00 5,395.93 9,086.00 4,815.58 6,638.00 3,518.14 5,732.00 3,037.96 4,285.00 2,271.05

64 13,760.00 7,292.80 11,112.00 5,889.36 9,925.00 5,260.25 7,252.00 3,843.56 6,258.00 3,316.74 4,684.00 2,482.52

65 13,817.00 7,323.01 11,124.00 5,895.72 10,022.00 5,311.66 7,293.00 3,865.29 6,291.00 3,334.23 4,703.00 2,492.59

66 13,867.00 7,349.51 11,136.00 5,902.08 10,117.00 5,362.01 7,333.00 3,886.49 6,326.00 3,352.78 4,715.00 2,498.95

67 15,417.00 8,171.01 12,380.00 6,561.40 11,264.00 5,969.92 8,155.00 4,322.15 7,029.00 3,725.37 5,247.00 2,780.91

68 16,958.00 8,987.74 13,623.00 7,220.19 12,407.00 6,575.71 8,972.00 4,755.16 7,739.00 4,101.67 5,773.00 3,059.69

69 17,736.00 9,400.08 14,241.00 7,547.73 12,978.00 6,878.34 9,386.00 4,974.58 8,094.00 4,289.82 6,038.00 3,200.14

70 17,857.00 9,464.21 14,274.00 7,565.22 13,195.00 6,993.35 9,483.00 5,025.99 8,173.00 4,331.69 6,074.00 3,219.22

71 20,100.00 10,653.00 16,058.00 8,510.74 14,865.00 7,878.45 10,675.00 5,657.75 9,199.00 4,875.47 6,833.00 3,621.49

72 22,336.00 11,838.08 17,849.00 9,459.97 16,543.00 8,767.79 11,863.00 6,287.39 10,227.00 5,420.31 7,602.00 4,029.06

73 24,580.00 13,027.40 19,645.00 10,411.85 18,213.00 9,652.89 13,052.00 6,917.56 11,250.00 5,962.50 8,364.00 4,432.92

74 26,819.00 14,214.07 21,435.00 11,360.55 19,888.00 10,540.64 14,245.00 7,549.85 12,281.00 6,508.93 9,130.00 4,838.90

75 and up 29,293.00 15,525.29 23,357.00 12,379.21 21,827.00 11,568.31 15,578.00 8,256.34 13,430.00 7,117.90 9,975.00 5,286.75



ZONE 4 | BELIZE, GUATEMALA, GUYANA, NICARAGUA, PERU, SURINAME, URUGUAY, REST OF THE CARIBBEAN(c)

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(a) Deductible Plan 1 (US$0/US$1,000) is only available for renewals of the same plan as of January 1, 2013. • (c) Excluding Trinidad & Tobago






2 Children 2,505.00 1,327.65 2,315.00 1,226.95 1,206.00 639.18 1,086.00 575.58 935.00 495.55 695.00 368.35

3+ Children 3,665.00 1,942.45 3,399.00 1,801.47 1,733.00 918.49 1,583.00 838.99 1,359.00 720.27 1,005.00 532.65

18-24 3,359.00 1,780.27 2,837.00 1,503.61 2,225.00 1,179.25 1,706.00 904.18 1,475.00 781.75 1,120.00 593.60

25-29 3,727.00 1,975.31 3,130.00 1,658.90 2,507.00 1,328.71 1,905.00 1,009.65 1,650.00 874.50 1,246.00 660.38

30-34 4,306.00 2,282.18 3,587.00 1,901.11 2,944.00 1,560.32 2,213.00 1,172.89 1,913.00 1,013.89 1,441.00 763.73

35-39 4,764.00 2,524.92 3,955.00 2,096.15 3,301.00 1,749.53 2,459.00 1,303.27 2,128.00 1,127.84 1,602.00 849.06

40-44 5,378.00 2,850.34 4,433.00 2,349.49 3,766.00 1,995.98 2,779.00 1,472.87 2,405.00 1,274.65 1,809.00 958.77

45-49 6,227.00 3,300.31 5,104.00 2,705.12 4,414.00 2,339.42 3,244.00 1,719.32 2,800.00 1,484.00 2,101.00 1,113.53

50-54 6,817.00 3,613.01 5,573.00 2,953.69 4,864.00 2,577.92 3,556.00 1,884.68 3,075.00 1,629.75 2,298.00 1,217.94

55-59 8,051.00 4,267.03 6,544.00 3,468.32 5,809.00 3,078.77 4,216.00 2,234.48 3,637.00 1,927.61 2,722.00 1,442.66

60 8,492.00 4,500.76 6,852.00 3,631.56 6,206.00 3,289.18 4,466.00 2,366.98 3,853.00 2,042.09 2,879.00 1,525.87

61 9,556.00 5,064.68 7,717.00 4,090.01 6,987.00 3,703.11 5,027.00 2,664.31 4,339.00 2,299.67 3,246.00 1,720.38

62 10,629.00 5,633.37 8,583.00 4,548.99 7,764.00 4,114.92 5,592.00 2,963.76 4,825.00 2,557.25 3,613.00 1,914.89

63 11,690.00 6,195.70 9,447.00 5,006.91 8,546.00 4,529.38 6,154.00 3,261.62 5,312.00 2,815.36 3,975.00 2,106.75

64 12,757.00 6,761.21 10,304.00 5,461.12 9,324.00 4,941.72 6,719.00 3,561.07 5,800.00 3,074.00 4,341.00 2,300.73

65 12,813.00 6,790.89 10,317.00 5,468.01 9,417.00 4,991.01 6,763.00 3,584.39 5,832.00 3,090.96 4,356.00 2,308.68

66 12,856.00 6,813.68 10,327.00 5,473.31 9,506.00 5,038.18 6,803.00 3,605.59 5,861.00 3,106.33 4,375.00 2,318.75

67 14,291.00 7,574.23 11,483.00 6,085.99 10,564.00 5,598.92 7,560.00 4,006.80 6,519.00 3,455.07 4,865.00 2,578.45

68 15,727.00 8,335.31 12,632.00 6,694.96 11,628.00 6,162.84 8,318.00 4,408.54 7,173.00 3,801.69 5,357.00 2,839.21

69 16,446.00 8,716.38 13,211.00 7,001.83 12,154.00 6,441.62 8,700.00 4,611.00 7,502.00 3,976.06 5,600.00 2,968.00

70 16,560.00 8,776.80 13,233.00 7,013.49 12,362.00 6,551.86 8,790.00 4,658.70 7,573.00 4,013.69 5,631.00 2,984.43

71 18,639.00 9,878.67 14,890.00 7,891.70 13,913.00 7,373.89 9,891.00 5,242.23 8,529.00 4,520.37 6,342.00 3,361.26

72 20,714.00 10,978.42 16,555.00 8,774.15 15,458.00 8,192.74 10,995.00 5,827.35 9,482.00 5,025.46 7,041.00 3,731.73

73 22,789.00 12,078.17 18,211.00 9,651.83 17,007.00 9,013.71 12,099.00 6,412.47 10,430.00 5,527.90 7,754.00 4,109.62

74 24,869.00 13,180.57 19,878.00 10,535.34 18,559.00 9,836.27 13,202.00 6,997.06 11,384.00 6,033.52 8,461.00 4,484.33

75 and up 27,165.00 14,397.45 21,658.00 11,478.74 20,355.00 10,788.15 14,441.00 7,653.73 12,448.00 6,597.44 9,248.00 4,901.44



ZONE 5 | VENEZUELA

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1 Child US$765.00 US$405.45 US$690.00 US$365.70 US$407.00 US$215.71 US$347.00 US$183.91 US$301.00 US$159.53 US$223.00 US$118.19

2 Children 1,256.00 665.68 1,163.00 616.39 605.00 320.65 545.00 288.85 473.00 250.69 350.00 185.50

3+ Children 1,840.00 975.20 1,706.00 904.18 868.00 460.04 792.00 419.76 687.00 364.11 506.00 268.18

18-24 1,679.00 889.87 1,420.00 752.60 1,112.00 589.36 855.00 453.15 741.00 392.73 560.00 296.80

25-29 1,864.00 987.92 1,563.00 828.39 1,255.00 665.15 951.00 504.03 829.00 439.37 625.00 331.25

30-34 2,158.00 1,143.74 1,793.00 950.29 1,477.00 782.81 1,107.00 586.71 961.00 509.33 722.00 382.66

35-39 2,387.00 1,265.11 1,978.00 1,048.34 1,651.00 875.03 1,232.00 652.96 1,069.00 566.57 804.00 426.12

40-44 2,690.00 1,425.70 2,220.00 1,176.60 1,887.00 1,000.11 1,392.00 737.76 1,209.00 640.77 906.00 480.18

45-49 3,118.00 1,652.54 2,557.00 1,355.21 2,211.00 1,171.83 1,622.00 859.66 1,406.00 745.18 1,056.00 559.68

50-54 3,415.00 1,809.95 2,789.00 1,478.17 2,437.00 1,291.61 1,780.00 943.40 1,544.00 818.32 1,156.00 612.68

55-59 4,037.00 2,139.61 3,281.00 1,738.93 2,910.00 1,542.30 2,109.00 1,117.77 1,832.00 970.96 1,367.00 724.51

60 4,256.00 2,255.68 3,435.00 1,820.55 3,110.00 1,648.30 2,237.00 1,185.61 1,939.00 1,027.67 1,447.00 766.91

61 4,790.00 2,538.70 3,868.00 2,050.04 3,500.00 1,855.00 2,520.00 1,335.60 2,185.00 1,158.05 1,633.00 865.49

62 5,328.00 2,823.84 4,301.00 2,279.53 3,892.00 2,062.76 2,800.00 1,484.00 2,432.00 1,288.96 1,819.00 964.07

63 5,862.00 3,106.86 4,733.00 2,508.49 4,285.00 2,271.05 3,086.00 1,635.58 2,676.00 1,418.28 2,003.00 1,061.59

64 6,395.00 3,389.35 5,168.00 2,739.04 4,676.00 2,478.28 3,367.00 1,784.51 2,920.00 1,547.60 2,185.00 1,158.05

65 6,423.00 3,404.19 5,171.00 2,740.63 4,721.00 2,502.13 3,385.00 1,794.05 2,938.00 1,557.14 2,194.00 1,162.82

66 6,448.00 3,417.44 5,178.00 2,744.34 4,763.00 2,524.39 3,408.00 1,806.24 2,952.00 1,564.56 2,198.00 1,164.94

67 7,168.00 3,799.04 5,753.00 3,049.09 5,297.00 2,807.41 3,788.00 2,007.64 3,285.00 1,741.05 2,447.00 1,296.91

68 7,888.00 4,180.64 6,335.00 3,357.55 5,828.00 3,088.84 4,168.00 2,209.04 3,615.00 1,915.95 2,695.00 1,428.35

69 8,247.00 4,370.91 6,620.00 3,508.60 6,094.00 3,229.82 4,360.00 2,310.80 3,775.00 2,000.75 2,821.00 1,495.13

70 8,305.00 4,401.65 6,635.00 3,516.55 6,198.00 3,284.94 4,406.00 2,335.18 3,815.00 2,021.95 2,835.00 1,502.55

71 9,347.00 4,953.91 7,468.00 3,958.04 6,975.00 3,696.75 4,959.00 2,628.27 4,297.00 2,277.41 3,190.00 1,690.70

72 10,389.00 5,506.17 8,299.00 4,398.47 7,755.00 4,110.15 5,513.00 2,921.89 4,775.00 2,530.75 3,550.00 1,881.50

73 11,432.00 6,058.96 9,136.00 4,842.08 8,531.00 4,521.43 6,066.00 3,214.98 5,257.00 2,786.21 3,905.00 2,069.65

74 12,473.00 6,610.69 9,967.00 5,282.51 9,310.00 4,934.30 6,619.00 3,508.07 5,736.00 3,040.08 4,265.00 2,260.45

75 and up 13,627.00 7,222.31 10,864.00 5,757.92 10,210.00 5,411.30 7,242.00 3,838.26 6,276.00 3,326.28 4,660.00 2,469.80



ZONE 6 | ARGENTINA, COLOMBIA, PANAMA(1), PARAGUAY

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






2 Children 1,990.00 1,054.70 1,837.00 973.61 952.00 504.56 863.00 457.39 747.00 395.91 551.00 292.03

3+ Children 2,909.00 1,541.77 2,700.00 1,431.00 1,374.00 728.22 1,257.00 666.21 1,081.00 572.93 799.00 423.47

18-24 2,665.00 1,412.45 2,255.00 1,195.15 1,768.00 937.04 1,356.00 718.68 1,172.00 621.16 888.00 470.64

25-29 2,960.00 1,568.80 2,485.00 1,317.05 1,991.00 1,055.23 1,512.00 801.36 1,305.00 691.65 987.00 523.11

30-34 3,421.00 1,813.13 2,847.00 1,508.91 2,342.00 1,241.26 1,757.00 931.21 1,518.00 804.54 1,149.00 608.97

35-39 3,783.00 2,004.99 3,138.00 1,663.14 2,621.00 1,389.13 1,953.00 1,035.09 1,691.00 896.23 1,271.00 673.63

40-44 4,267.00 2,261.51 3,517.00 1,864.01 2,990.00 1,584.70 2,212.00 1,172.36 1,911.00 1,012.83 1,437.00 761.61

45-49 4,946.00 2,621.38 4,054.00 2,148.62 3,504.00 1,857.12 2,575.00 1,364.75 2,223.00 1,178.19 1,669.00 884.57

50-54 5,414.00 2,869.42 4,423.00 2,344.19 3,863.00 2,047.39 2,822.00 1,495.66 2,440.00 1,293.20 1,826.00 967.78

55-59 6,394.00 3,388.82 5,201.00 2,756.53 4,614.00 2,445.42 3,350.00 1,775.50 2,889.00 1,531.17 2,159.00 1,144.27

60 6,744.00 3,574.32 5,441.00 2,883.73 4,929.00 2,612.37 3,548.00 1,880.44 3,062.00 1,622.86 2,286.00 1,211.58

61 7,591.00 4,023.23 6,131.00 3,249.43 5,548.00 2,940.44 3,992.00 2,115.76 3,448.00 1,827.44 2,578.00 1,366.34

62 8,437.00 4,471.61 6,813.00 3,610.89 6,174.00 3,272.22 4,445.00 2,355.85 3,834.00 2,032.02 2,870.00 1,521.10

63 9,285.00 4,921.05 7,499.00 3,974.47 6,793.00 3,600.29 4,890.00 2,591.70 4,220.00 2,236.60 3,160.00 1,674.80

64 10,134.00 5,371.02 8,181.00 4,335.93 7,410.00 3,927.30 5,337.00 2,828.61 4,608.00 2,442.24 3,448.00 1,827.44

65 10,174.00 5,392.22 8,192.00 4,341.76 7,482.00 3,965.46 5,369.00 2,845.57 4,634.00 2,456.02 3,462.00 1,834.86

66 10,216.00 5,414.48 8,202.00 4,347.06 7,551.00 4,002.03 5,402.00 2,863.06 4,659.00 2,469.27 3,473.00 1,840.69

67 11,351.00 6,016.03 9,115.00 4,830.95 8,395.00 4,449.35 6,004.00 3,182.12 5,179.00 2,744.87 3,864.00 2,047.92

68 12,491.00 6,620.23 10,031.00 5,316.43 9,235.00 4,894.55 6,608.00 3,502.24 5,702.00 3,022.06 4,254.00 2,254.62

69 13,061.00 6,922.33 10,488.00 5,558.64 9,656.00 5,117.68 6,913.00 3,663.89 5,963.00 3,160.39 4,450.00 2,358.50

70 13,152.00 6,970.56 10,508.00 5,569.24 9,820.00 5,204.60 6,983.00 3,700.99 6,017.00 3,189.01 4,469.00 2,368.57

71 14,803.00 7,845.59 11,827.00 6,268.31 11,051.00 5,857.03 7,858.00 4,164.74 6,776.00 3,591.28 5,034.00 2,668.02

72 16,450.00 8,718.50 13,144.00 6,966.32 12,286.00 6,511.58 8,739.00 4,631.67 7,534.00 3,993.02 5,599.00 2,967.47

73 18,099.00 9,592.47 14,466.00 7,666.98 13,516.00 7,163.48 9,615.00 5,095.95 8,285.00 4,391.05 6,163.00 3,266.39

74 19,749.00 10,466.97 15,783.00 8,364.99 14,746.00 7,815.38 10,489.00 5,559.17 9,046.00 4,794.38 6,725.00 3,564.25

75 and up 21,573.00 11,433.69 17,202.00 9,117.06 16,175.00 8,572.75 11,473.00 6,080.69 9,893.00 5,243.29 7,347.00 3,893.91



ZONE 7

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1 Child US$1,941.00 US$1,028.73 US$1,746.00 US$925.38 US$1,007.00 US$533.71 US$782.00 US$414.46 US$673.00 US$356.69 US$499.00 US$264.47

2 Children 3,188.00 1,689.64 2,943.00 1,559.79 1,506.00 798.18 1,232.00 652.96 1,063.00 563.39 789.00 418.17

3+ Children 4,663.00 2,471.39 4,321.00 2,290.13 2,160.00 1,144.80 1,791.00 949.23 1,545.00 818.85 1,144.00 606.32

18-24 4,256.00 2,255.68 3,588.00 1,901.64 2,759.00 1,462.27 1,928.00 1,021.84 1,667.00 883.51 1,261.00 668.33

25-29 4,725.00 2,504.25 3,962.00 2,099.86 3,107.00 1,646.71 2,150.00 1,139.50 1,862.00 986.86 1,404.00 744.12

30-34 5,461.00 2,894.33 4,544.00 2,408.32 3,657.00 1,938.21 2,501.00 1,325.53 2,163.00 1,146.39 1,627.00 862.31

35-39 6,043.00 3,202.79 5,004.00 2,652.12 4,101.00 2,173.53 2,784.00 1,475.52 2,405.00 1,274.65 1,806.00 957.18

40-44 6,821.00 3,615.13 5,620.00 2,978.60 4,680.00 2,480.40 3,149.00 1,668.97 2,723.00 1,443.19 2,042.00 1,082.26

45-49 7,908.00 4,191.24 6,479.00 3,433.87 5,489.00 2,909.17 3,669.00 1,944.57 3,172.00 1,681.16 2,378.00 1,260.34

50-54 8,652.00 4,585.56 7,066.00 3,744.98 6,048.00 3,205.44 4,023.00 2,132.19 3,476.00 1,842.28 2,602.00 1,379.06

55-59 10,222.00 5,417.66 8,310.00 4,404.30 7,229.00 3,831.37 4,781.00 2,533.93 4,123.00 2,185.19 3,079.00 1,631.87

60 10,779.00 5,712.87 8,699.00 4,610.47 7,719.00 4,091.07 5,056.00 2,679.68 4,362.00 2,311.86 3,261.00 1,728.33

61 12,142.00 6,435.26 9,798.00 5,192.94 8,699.00 4,610.47 5,698.00 3,019.94 4,915.00 2,604.95 3,676.00 1,948.28

62 13,496.00 7,152.88 10,899.00 5,776.47 9,674.00 5,127.22 6,337.00 3,358.61 5,467.00 2,897.51 4,087.00 2,166.11

63 14,854.00 7,872.62 11,991.00 6,355.23 10,647.00 5,642.91 6,975.00 3,696.75 6,022.00 3,191.66 4,502.00 2,386.06

64 16,215.00 8,593.95 13,088.00 6,936.64 11,620.00 6,158.60 7,615.00 4,035.95 6,572.00 3,483.16 4,916.00 2,605.48

65 16,276.00 8,626.28 13,104.00 6,945.12 11,730.00 6,216.90 7,659.00 4,059.27 6,607.00 3,501.71 4,936.00 2,616.08

66 16,339.00 8,659.67 13,119.00 6,953.07 11,840.00 6,275.20 7,706.00 4,084.18 6,645.00 3,521.85 4,953.00 2,625.09

67 18,167.00 9,628.51 14,581.00 7,727.93 13,164.00 6,976.92 8,568.00 4,541.04 7,387.00 3,915.11 5,510.00 2,920.30

68 19,984.00 10,591.52 16,052.00 8,507.56 14,491.00 7,680.23 9,432.00 4,998.96 8,131.00 4,309.43 6,065.00 3,214.45

69 20,900.00 11,077.00 16,782.00 8,894.46 15,150.00 8,029.50 9,863.00 5,227.39 8,500.00 4,505.00 6,347.00 3,363.91

70 21,050.00 11,156.50 16,815.00 8,911.95 15,402.00 8,163.06 9,961.00 5,279.33 8,587.00 4,551.11 6,376.00 3,379.28

71 23,690.00 12,555.70 18,929.00 10,032.37 17,335.00 9,187.55 11,217.00 5,945.01 9,667.00 5,123.51 7,182.00 3,806.46

72 26,331.00 13,955.43 21,037.00 11,149.61 19,268.00 10,212.04 12,467.00 6,607.51 10,747.00 5,695.91 7,983.00 4,230.99

73 28,968.00 15,353.04 23,149.00 12,268.97 21,205.00 11,238.65 13,719.00 7,271.07 11,828.00 6,268.84 8,791.00 4,659.23

74 31,611.00 16,753.83 25,260.00 13,387.80 23,140.00 12,264.20 14,975.00 7,936.75 12,907.00 6,840.71 9,594.00 5,084.82

75 and up 34,536.00 18,304.08 27,528.00 14,589.84 25,380.00 13,451.40 16,379.00 8,680.87 14,118.00 7,482.54 10,483.00 5,555.99



ZONE 8 | TRINIDAD & TOBAGO

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2 Children 2,111.00 1,118.83 1,952.00 1,034.56 1,016.00 538.48 915.00 484.95 788.00 417.64 586.00 310.58

3+ Children 3,089.00 1,637.17 2,865.00 1,518.45 1,461.00 774.33 1,334.00 707.02 1,145.00 606.85 848.00 449.44

18-24 2,831.00 1,500.43 2,391.00 1,267.23 1,876.00 994.28 1,438.00 762.14 1,243.00 658.79 945.00 500.85

25-29 3,139.00 1,663.67 2,638.00 1,398.14 2,113.00 1,119.89 1,605.00 850.65 1,390.00 736.70 1,050.00 556.50

30-34 3,631.00 1,924.43 3,024.00 1,602.72 2,482.00 1,315.46 1,864.00 987.92 1,614.00 855.42 1,214.00 643.42

35-39 4,014.00 2,127.42 3,334.00 1,767.02 2,781.00 1,473.93 2,073.00 1,098.69 1,793.00 950.29 1,351.00 716.03

40-44 4,534.00 2,403.02 3,736.00 1,980.08 3,173.00 1,681.69 2,342.00 1,241.26 2,026.00 1,073.78 1,524.00 807.72

45-49 5,249.00 2,781.97 4,303.00 2,280.59 3,720.00 1,971.60 2,733.00 1,448.49 2,360.00 1,250.80 1,771.00 938.63

50-54 5,747.00 3,045.91 4,696.00 2,488.88 4,099.00 2,172.47 2,997.00 1,588.41 2,592.00 1,373.76 1,938.00 1,027.14

55-59 6,786.00 3,596.58 5,517.00 2,924.01 4,895.00 2,594.35 3,554.00 1,883.62 3,066.00 1,624.98 2,294.00 1,215.82

60 7,158.00 3,793.74 5,776.00 3,061.28 5,231.00 2,772.43 3,762.00 1,993.86 3,248.00 1,721.44 2,428.00 1,286.84

61 8,056.00 4,269.68 6,505.00 3,447.65 5,889.00 3,121.17 4,239.00 2,246.67 3,656.00 1,937.68 2,736.00 1,450.08

62 8,957.00 4,747.21 7,235.00 3,834.55 6,544.00 3,468.32 4,713.00 2,497.89 4,068.00 2,156.04 3,044.00 1,613.32

63 9,854.00 5,222.62 7,962.00 4,219.86 7,205.00 3,818.65 5,188.00 2,749.64 4,477.00 2,372.81 3,352.00 1,776.56

64 10,752.00 5,698.56 8,684.00 4,602.52 7,860.00 4,165.80 5,664.00 3,001.92 4,890.00 2,591.70 3,659.00 1,939.27

65 10,798.00 5,722.94 8,696.00 4,608.88 7,939.00 4,207.67 5,699.00 3,020.47 4,914.00 2,604.42 3,672.00 1,946.16

66 10,837.00 5,743.61 8,704.00 4,613.12 8,012.00 4,246.36 5,733.00 3,038.49 4,941.00 2,618.73 3,688.00 1,954.64

67 12,044.00 6,383.32 9,679.00 5,129.87 8,905.00 4,719.65 6,371.00 3,376.63 5,495.00 2,912.35 4,100.00 2,173.00

68 13,255.00 7,025.15 10,648.00 5,643.44 9,799.00 5,193.47 7,009.00 3,714.77 6,045.00 3,203.85 4,516.00 2,393.48

69 13,859.00 7,345.27 11,135.00 5,901.55 10,243.00 5,428.79 7,333.00 3,886.49 6,323.00 3,351.19 4,721.00 2,502.13

70 13,958.00 7,397.74 11,154.00 5,911.62 10,421.00 5,523.13 7,408.00 3,926.24 6,384.00 3,383.52 4,747.00 2,515.91

71 15,710.00 8,326.30 12,550.00 6,651.50 11,726.00 6,214.78 8,337.00 4,418.61 7,190.00 3,810.70 5,346.00 2,833.38

72 17,459.00 9,253.27 13,954.00 7,395.62 13,029.00 6,905.37 9,268.00 4,912.04 7,990.00 4,234.70 5,935.00 3,145.55

73 19,206.00 10,179.18 15,349.00 8,134.97 14,334.00 7,597.02 10,197.00 5,404.41 8,792.00 4,659.76 6,535.00 3,463.55

74 20,959.00 11,108.27 16,752.00 8,878.56 15,642.00 8,290.26 11,125.00 5,896.25 9,595.00 5,085.35 7,133.00 3,780.49

75 and up 22,896.00 12,134.88 18,255.00 9,675.15 17,154.00 9,091.62 12,172.00 6,451.16 10,492.00 5,560.76 7,794.00 4,130.82



ZONE 9 | ECUADOR

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1 Child US$1,044.00 US$553.32 US$940.00 US$498.20 US$555.00 US$294.15 US$473.00 US$250.69 US$411.00 US$217.83 US$303.00 US$160.59

2 Children 1,713.00 907.89 1,585.00 840.05 824.00 436.72 745.00 394.85 645.00 341.85 478.00 253.34

3+ Children 2,510.00 1,330.30 2,326.00 1,232.78 1,185.00 628.05 1,083.00 573.99 938.00 497.14 690.00 365.70

18-24 2,291.00 1,214.23 1,936.00 1,026.08 1,516.00 803.48 1,166.00 617.98 1,011.00 535.83 765.00 405.45

25-29 2,541.00 1,346.73 2,132.00 1,129.96 1,711.00 906.83 1,297.00 687.41 1,130.00 598.90 851.00 451.03

30-34 2,940.00 1,558.20 2,448.00 1,297.44 2,016.00 1,068.48 1,509.00 799.77 1,310.00 694.30 984.00 521.52

35-39 3,254.00 1,724.62 2,697.00 1,429.41 2,252.00 1,193.56 1,679.00 889.87 1,457.00 772.21 1,096.00 580.88

40-44 3,669.00 1,944.57 3,028.00 1,604.84 2,572.00 1,363.16 1,898.00 1,005.94 1,649.00 873.97 1,237.00 655.61

45-49 4,252.00 2,253.56 3,488.00 1,848.64 3,017.00 1,599.01 2,213.00 1,172.89 1,919.00 1,017.07 1,438.00 762.14

50-54 4,658.00 2,468.74 3,802.00 2,015.06 3,322.00 1,760.66 2,427.00 1,286.31 2,106.00 1,116.18 1,575.00 834.75

55-59 5,504.00 2,917.12 4,475.00 2,371.75 3,970.00 2,104.10 2,877.00 1,524.81 2,500.00 1,325.00 1,865.00 988.45

60 5,804.00 3,076.12 4,684.00 2,482.52 4,241.00 2,247.73 3,051.00 1,617.03 2,644.00 1,401.32 1,974.00 1,046.22

61 6,533.00 3,462.49 5,275.00 2,795.75 4,774.00 2,530.22 3,435.00 1,820.55 2,981.00 1,579.93 2,226.00 1,179.78

62 7,266.00 3,850.98 5,865.00 3,108.45 5,308.00 2,813.24 3,819.00 2,024.07 3,317.00 1,758.01 2,480.00 1,314.40

63 7,994.00 4,236.82 6,455.00 3,421.15 5,842.00 3,096.26 4,208.00 2,230.24 3,649.00 1,933.97 2,731.00 1,447.43

64 8,722.00 4,622.66 7,047.00 3,734.91 6,378.00 3,380.34 4,591.00 2,433.23 3,983.00 2,110.99 2,981.00 1,579.93

65 8,759.00 4,642.27 7,053.00 3,738.09 6,440.00 3,413.20 4,617.00 2,447.01 4,006.00 2,123.18 2,991.00 1,585.23

66 8,793.00 4,660.29 7,061.00 3,742.33 6,495.00 3,442.35 4,647.00 2,462.91 4,025.00 2,133.25 2,999.00 1,589.47

67 9,775.00 5,180.75 7,847.00 4,158.91 7,222.00 3,827.66 5,166.00 2,737.98 4,478.00 2,373.34 3,338.00 1,769.14

68 10,758.00 5,701.74 8,639.00 4,578.67 7,947.00 4,211.91 5,682.00 3,011.46 4,930.00 2,612.90 3,675.00 1,947.75

69 11,248.00 5,961.44 9,028.00 4,784.84 8,311.00 4,404.83 5,945.00 3,150.85 5,151.00 2,730.03 3,845.00 2,037.85

70 11,327.00 6,003.31 9,048.00 4,795.44 8,451.00 4,479.03 6,009.00 3,184.77 5,204.00 2,758.12 3,866.00 2,048.98

71 12,749.00 6,756.97 10,184.00 5,397.52 9,512.00 5,041.36 6,762.00 3,583.86 5,860.00 3,105.80 4,352.00 2,306.56

72 14,168.00 7,509.04 11,317.00 5,998.01 10,577.00 5,605.81 7,518.00 3,984.54 6,512.00 3,451.36 4,841.00 2,565.73

73 15,589.00 8,262.17 12,459.00 6,603.27 11,634.00 6,166.02 8,273.00 4,384.69 7,168.00 3,799.04 5,326.00 2,822.78

74 17,010.00 9,015.30 13,592.00 7,203.76 12,698.00 6,729.94 9,026.00 4,783.78 7,823.00 4,146.19 5,815.00 3,081.95

75 and up 18,582.00 9,848.46 14,818.00 7,853.54 13,924.00 7,379.72 9,876.00 5,234.28 8,560.00 4,536.80 6,357.00 3,369.21



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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 domestic 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

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BIC_PB_ESS_eng_V17.01

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

BUPA ESSENTIAL CARE · 2016-10-11 · ZONE 1 | MEXICO BUPA ESSENTIAL CARE PREMIUM BOOKLET,...

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Transcript of BUPA ESSENTIAL CARE · 2016-10-11 · ZONE 1 | MEXICO BUPA ESSENTIAL CARE PREMIUM BOOKLET,...