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As specified under The Health Insurance Act 1970 and its regulations, orders and rules |
| Ancillary Hospital Services Bermuda Hospitals Board Fee Schedule |
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| Surgical, Obstetrical, Anaesthetic, Diagnostic and Medical Care Bermuda Fee Schedule |
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| Ground Ambulance to Home As specified under The Health Insurance Act |
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| Chronic Disease Management Programme 80% | $2,880 maximum per policy year |
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| Medical Alarm Device 80% | $200 maximum per policy year |
Asthmatic, Audiologic, Allergy & Chronic Obstructive Pulmonary Disease (COPD) Counselling:
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Medical Nutritional Therapy (Provider must be a registered Dietitian approved by Argus):
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| Weight Loss Management Programme (Programme & provider must be pre-approved by Argus): $127, 26 visits per policy year |
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Diabetes Prevention Programme (Programme & provider must be pre-approved by Argus):
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Diabetes Reversal Programme:
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Annual Foot Exam: $150, maximum 1 exam per policy year For persons with type I or II diabetes or diabetic neuropathy |
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| Allergy testing: Our Fee Schedule, $600 per lifetime |
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| Allergy Injections: $20 per injection and serum combined |
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| Annual Health Exam: Maximum 1 exam per policy year
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Annual Specialist / Gynaecologist Exam (all ages): $325, 1 exam per policy year |
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| Routine Diagnostic Testing in conjunction with Annual Exams: Bermuda Fee Schedule |
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| Well-Baby Routine Health exam (under 2 years): $107 |
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| Annual Eye Exam: $115, maximum 1 exam per policy year Routine Diagnostic Testing in conjunction with Annual Eye Exam (Provider must be approved by the Bermuda Health Council): $200 per policy year |
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| Immunisations and Injections: $30 per injection |
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| Diagnostic Services in Private Testing Facilities: Includes Genetic Testing and Sleep Studies (These services must be pre-certified by Argus): Bermuda Fee Schedule |
General Practitioner
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Specialist
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Telemedicine Office Visit (Services must be pre-certified by Argus) $125 |
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In Office Medical / Surgical Treatment Bermuda Fee Schedule |
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| Physical Medicine and Supplementary Therapies: Manipulations, Speech Therapy, Chiropractic, Osteopathy:
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| Chiropody / Podiatry: $75, maximum 12 visits per policy year |
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| Behavioural Therapies for Autism Spectrum & Attention Deficit Disorders (Services must be pre-certified by Argus): Individual and family applied behavioural therapies 100% of billed charges, $2,500 maximum per policy year |
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Complementary Alternative Therapies:
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| Psychiatrist: $190 Clinical Psychologist/Group Therapy Session: $140 Counselling:
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| Sclerotherapy: Bermuda Fee Schedule $1,000 per policy year |
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| Lymphedema Treatment: $110, 28 visits policy year |
| Major Medical Benefits are applicable to overseas treatment and services. Eligible Expenses are payable at a percentage of the lesser of Usual and Customary Charges, claim amounts reduced by the Argus claims editing process or Discounted Rates. |
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| Maximum benefit for Active Employees, Dependents other than Dependent Children noted below and eligible Retirees: Unlimited |
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| Dependent Children age 19 and under age 26 who are not fulltime students: Unlimited per one 12-month period |
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| Emergency Treatment: Insured calls Argus Health within 48 hours of incident: 100% Coinsurance Insured does not contact Argus Health within 48 hours of incident: 80% Coinsurance |
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| All Other Treatment not specified below: Insured must call Argus in advance and treatment must be pre-certified by Argus and obtained within the Argus Network in order to receive 100% coinsurance; otherwise, benefits are payable at 80% |
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| Neonatal Treatment, Congenital Birth Defects & High-Risk Pregnancy: Charges related to neonatal, congenital birth defects and high-risk pregnancy will only be payable at 100% if they are pre-certified by Argus and treatment is obtained within the Argus Canada Network; otherwise, benefits are payable at 80% |
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| Spinal Treatment: Charges related to spinal care, services and treatment will only be payable at 100% if they are pre-certified by Argus and obtained within the Argus Spinal Care Network; otherwise, benefits are payable at 50%. Spinal care, services and treatment are subject to a mandatory second opinion review. |
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| Paediatric Assessment of Autism Spectrum & Attention Deficit Disorders: Charges related to paediatric assessment of autism spectrum and attention deficit disorders will only be payable at 100% if they are pre-certified by Argus and obtained within the Argus Preferred Provider Network; otherwise, benefits are payable at 80% |
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| Specialty Prescription Drugs: Physician and facility charges related to the administration of specialty prescription drugs will only be payable at 100% if they are tier one drugs, pre-certified by Argus and obtained within the Argus Specialty Prescription Drug Network; otherwise, benefits are payable at 50% |
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| Psychiatric Disorders & Substance Abuse Disorders: Charges related to psychiatric and substance abuse disorders will only be payable at 100% if they are pre-certified by Argus and obtained within the Argus Psychiatric & Substance Abuse Disorders Network; otherwise, benefits are payable at 80% |
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The following services are payable at a percentage of the lesser of Usual & Customary charges, claim amounts reduced by the Argus claims editing process or Discounted Rates, and must be pre-certified by Argus in order to receive maximum reimbursement: |
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| Inpatient Care: Semi-private accommodation |
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| Intensive Care, Outpatient and Emergency Care: Unlimited |
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| Surgical, Obstetrical, Anaesthetic, Diagnostic and Medical Care: Unlimited |
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| Physician Services - Home or Office Visit: Unlimited |
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| Rehabilitation / Skilled Nursing Facility: Semi-private up to 60 days per policy year |
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| Home Health Care: Unlimited |
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| Transplant Services: Unlimited |
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| Psychiatric & Substance Abuse Disorders (Must be pre-certified by Argus in order to be eligible and receive maximum reimbursement): Inpatient Care: Unlimited Psychiatric Professional Services: Unlimited |
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Hotel or Rental Accommodation are only eligible for services indicated in the chart above and must be pre-certified by Argus in order to be eligible:
Commercial Economy Airfare (Excludes preferred/priority seating and baggage fees): Combined Maximum with Hotel or Rental Accommodation: $35,000 per policy year |
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| *Benefits for one travelling companion are approved for one episode of care in the following circumstances: When the Insured Person is a minor Dependent Child, or has surgery or mental incapacity or otherwise requires a travelling companion due to medical necessity, subject to medical documentation and pre-approval by Argus. |
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The following services must be pre-certified by Argus in order to be eligible: |
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| Ground Ambulance and Air Ambulance: Unlimited (if Medically Necessary) |
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| Air Ambulance Return to Bermuda: Unlimited (if Medically Necessary) |
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| Behavioural Therapies for Autism Spectrum & Attention Deficit Disorders: Individual and family applied behavioural therapies 100% of billed charges, $2,500 maximum per policy year |
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| Genetic Testing: Unlimited |
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| Telemedicine Office Visit: Unlimited |
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| Repatriation of remains (inclusive of cremation): Unlimited for return of remains or ashes |
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The following services are payable at 100% of the lesser of Usual and Customary charges, claim amounts reduced by the Argus claims editing process or Discounted Rates. Airfare and accommodation do not apply to these services, consultations and second opinions. Pre-certification of these services is not required. |
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| Annual Health Exam and related Diagnostic Testing: $2,000 per policy year |
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| Physical Medicine and Supplementary Therapies: (Nutritional/Diabetic, Asthmatic, Audiologic and Allergy Counselling Services, Well-baby Care, Immunisations and Injections, Allergy Testing, Annual Eye Exam, Physical and Occupational Therapy, Chiropractic, Osteopathy, Chiropody, Podiatry, Speech Therapy) $3,360 combined maximum per policy year |
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| Complementary Alternative Therapies: (Massage and Acupuncture) $350 combined maximum per policy year |
| Supplementary Miscellaneous Benefits are applicable Worldwide.** Hearing Aids, Surgical Support Hose, Surgical Brassieres, Wigs, Orthotics: 80% | $4,000 combined maximum every 5 policy years |
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| Prosthetic Devices and Appliances: 80% | $25,000 maximum per lifetime |
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| Durable Medical Equipment, Accidental Dental Services and Cardiac Rehabilitation/Exercise Programme, Medical/Surgical Supplies: 80% of usual and customary charges **Airfare and accommodation do not apply to Worldwide Treatment and Services |
| Vision Care Benefits are applicable Worldwide.** Prescription Eye Glasses or Contact Lenses: $400 per policy year payable at 100% |
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| Elective Surgical Treatment for Vision Correction: $2,000 per lifetime payable at 100% **Airfare and accommodation do not apply to Worldwide Treatment and Services |
| Benefits are payable in accordance with the Bermuda Dental Fee Schedule. Amounts charged by a provider which exceed the scheduled amounts are your responsibility. Please obtain a pre-estimate of benefits from your dentist prior to undergoing extensive dental procedures. Basic Dental Services (DE01): Preventive and Diagnostic: 100% of Fee Schedule Policy Year: Unlimited Lifetime: Unlimited |
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| Exams, Consultations, Polishing, Scaling or Root Planing, Fluoride: 100% of Fee Schedule Policy Year: $1,400 Lifetime: Unlimited |
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| Surgical and Minor Restorative: 100% of Fee Schedule Policy Year: Unlimited Lifetime: Unlimited |
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| Endodontics: 100% of Fee Schedule Policy Year: Unlimited Lifetime: Unlimited |
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| Periodontics: 50% of Fee Schedule Policy Year: $2,000 Lifetime: Unlimited |
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Major Restorative Services (DE02): 50% or 80% of Fee Schedule Policy Year: $5,000 Lifetime: Unlimited |
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Orthodontic Services (DE03): Only Insured Persons up to age 19 are covered 50% of Fee Schedule Policy Year: N/A Lifetime: $4,000 **Airfare and accommodation do not apply to Worldwide Treatment and Services |
| Prescription Benefits are applicable Worldwide.** Prescription Drugs, Birth Control, Medicines and Sera available only by prescription: 80% for brand name drugs 100% for generic drugs **Airfare and accommodation do not apply to Worldwide Treatment and Services |
| Specialty Prescription Drugs (Must be pre-certified by Argus) (High cost drugs, biologic and biosimilar drugs and specialty drugs approved by Argus to treat complex or chronic medical conditions) 100% for tier one drugs 50% for tier two drugs |
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