premier 1 silver - bupalatinamerica.com · zone 2 | bolivia, chile, haiti, peru deductiblesage...

PRE MIU M BOOKLET

PRE MIE R 1 S ILVE R

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.

• Maximum age to apply: 74 years old. No age limit for guaranteed renewability.

• Children 0-9 years old cannot be sole policyholders. The child will be registered with the same deductible as the insured parent with the highest deductible.

• Available payment modes: annual and semiannual.

• 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 and, solely with respect to the insurer, where otherwise prohibited by the laws in the United Kingdom and/or Denmark. Please contact USA Medical Services for more information about this restriction.

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

ZONE 1 | HONDURAS

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17Deductibles US$1,000 US$2,500 US$5,000 US$10,000

Age Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual

0-9 US$1,259.00 US$654.68 US$842.00 US$437.84 US$572.00 US$297.44 US$361.00 US$187.72

10-19 2,311.00 1,201.72 1,471.00 764.92 1,052.00 547.04 708.00 368.16

20-29 6,103.00 3,173.56 3,925.00 2,041.00 3,031.00 1,576.12 2,277.00 1,184.04

30-39 6,758.00 3,514.16 4,688.00 2,437.76 3,801.00 1,976.52 3,064.00 1,593.28

40-49 7,642.00 3,973.84 5,273.00 2,741.96 4,224.00 2,196.48 3,380.00 1,757.60

50-59 10,991.00 5,715.32 7,751.00 4,030.52 6,196.00 3,221.92 5,375.00 2,795.00

60 14,347.00 7,460.44 9,890.00 5,142.80 8,292.00 4,311.84 7,516.00 3,908.32

61 14,711.00 7,649.72 10,148.00 5,276.96 8,508.00 4,424.16 7,710.00 4,009.20

62 15,087.00 7,845.24 10,407.00 5,411.64 8,723.00 4,535.96 7,912.00 4,114.24

63 15,391.00 8,003.32 10,612.00 5,518.24 8,902.00 4,629.04 8,069.00 4,195.88

64 15,697.00 8,162.44 10,821.00 5,626.92 9,075.00 4,719.00 8,228.00 4,278.56

65 31,233.00 16,241.16 21,785.00 11,328.20 17,632.00 9,168.64 16,926.00 8,801.52

66 32,045.00 16,663.40 22,347.00 11,620.44 18,091.00 9,407.32 17,356.00 9,025.12

67 32,863.00 17,088.76 22,915.00 11,915.80 18,549.00 9,645.48 17,799.00 9,255.48

68 33,520.00 17,430.40 23,377.00 12,156.04 18,920.00 9,838.40 18,157.00 9,441.64

69 34,187.00 17,777.24 23,845.00 12,399.40 19,297.00 10,034.44 18,521.00 9,630.92

70 and up 39,421.00 20,498.92 27,074.00 14,078.48 21,043.00 10,942.36 20,309.00 10,560.68

Additional coverage

Air ambulance US$487.00 US$253.00 US$487.00 US$253.00 US$487.00 US$253.00 US$487.00 US$253.00

ZONE 2 | BOLIVIA, CHILE, HAITI, PERU

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10-19 2,250.00 1,170.00 1,431.00 744.12 1,025.00 533.00 689.00 358.28

20-29 5,941.00 3,089.32 3,821.00 1,986.92 2,946.00 1,531.92 2,213.00 1,150.76

30-39 6,578.00 3,420.56 4,562.00 2,372.24 3,696.00 1,921.92 2,980.00 1,549.60

40-49 7,438.00 3,867.76 5,130.00 2,667.60 4,109.00 2,136.68 3,287.00 1,709.24

50-59 10,699.00 5,563.48 7,542.00 3,921.84 6,025.00 3,133.00 5,228.00 2,718.56

60 13,966.00 7,262.32 9,624.00 5,004.48 8,065.00 4,193.80 7,312.00 3,802.24

61 14,317.00 7,444.84 9,877.00 5,136.04 8,274.00 4,302.48 7,499.00 3,899.48

62 14,685.00 7,636.20 10,128.00 5,266.56 8,484.00 4,411.68 7,695.00 4,001.40

63 14,983.00 7,791.16 10,325.00 5,369.00 8,657.00 4,501.64 7,849.00 4,081.48

64 15,279.00 7,945.08 10,532.00 5,476.64 8,826.00 4,589.52 8,004.00 4,162.08

65 30,406.00 15,811.12 21,197.00 11,022.44 17,150.00 8,918.00 16,465.00 8,561.80

66 31,194.00 16,220.88 21,745.00 11,307.40 17,598.00 9,150.96 16,883.00 8,779.16

67 31,990.00 16,634.80 22,299.00 11,595.48 18,045.00 9,383.40 17,313.00 9,002.76

68 32,630.00 16,967.60 22,745.00 11,827.40 18,403.00 9,569.56 17,662.00 9,184.24

69 33,280.00 17,305.60 23,200.00 12,064.00 18,773.00 9,761.96 18,014.00 9,367.28

70 and up 38,377.00 19,956.04 26,344.00 13,698.88 20,471.00 10,644.92 19,754.00 10,272.08

Additional coverage


ZONE 3 | COSTA RICA, DOMINICAN REPUBLIC, EL SALVADOR

Deductibles US$1,000 US$2,500 US$5,000 US$10,000



10-19 2,250.00 1,170.00 1,431.00 744.12 1,025.00 533.00 689.00 358.28

20-29 5,941.00 3,089.32 3,821.00 1,986.92 2,946.00 1,531.92 2,213.00 1,150.76

30-39 6,578.00 3,420.56 4,562.00 2,372.24 3,696.00 1,921.92 2,980.00 1,549.60

40-49 7,438.00 3,867.76 5,130.00 2,667.60 4,109.00 2,136.68 3,287.00 1,709.24

50-59 10,699.00 5,563.48 7,542.00 3,921.84 6,025.00 3,133.00 5,228.00 2,718.56

60 13,966.00 7,262.32 9,624.00 5,004.48 8,065.00 4,193.80 7,312.00 3,802.24

61 14,317.00 7,444.84 9,877.00 5,136.04 8,274.00 4,302.48 7,499.00 3,899.48

62 14,685.00 7,636.20 10,128.00 5,266.56 8,484.00 4,411.68 7,695.00 4,001.40

63 14,983.00 7,791.16 10,325.00 5,369.00 8,657.00 4,501.64 7,849.00 4,081.48

64 15,279.00 7,945.08 10,532.00 5,476.64 8,826.00 4,589.52 8,004.00 4,162.08

65 30,406.00 15,811.12 21,197.00 11,022.44 17,150.00 8,918.00 16,465.00 8,561.80

66 31,194.00 16,220.88 21,745.00 11,307.40 17,598.00 9,150.96 16,883.00 8,779.16

67 31,990.00 16,634.80 22,299.00 11,595.48 18,045.00 9,383.40 17,313.00 9,002.76

68 32,630.00 16,967.60 22,745.00 11,827.40 18,403.00 9,569.56 17,662.00 9,184.24

69 33,280.00 17,305.60 23,200.00 12,064.00 18,773.00 9,761.96 18,014.00 9,367.28

70 and up 38,377.00 19,956.04 26,344.00 13,698.88 20,471.00 10,644.92 19,754.00 10,272.08

Additional coverage


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ZONE 4 | BELIZE, ECUADOR, GUATEMALA, GUYANA, NICARAGUA, PUERTO RICO, SURINAME, UNITED STATES VIRGIN ISLANDS, URUGUAY, REST OF THE CARIBBEAN

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Deductibles US$1,000 US$2,500 US$5,000 US$10,000



10-19 2,270.00 1,180.40 1,444.00 750.88 1,035.00 538.20 695.00 361.40

20-29 5,996.00 3,117.92 3,855.00 2,004.60 2,973.00 1,545.96 2,234.00 1,161.68

30-39 6,639.00 3,452.28 4,604.00 2,394.08 3,731.00 1,940.12 3,008.00 1,564.16

40-49 7,507.00 3,903.64 5,178.00 2,692.56 4,147.00 2,156.44 3,317.00 1,724.84

50-59 10,798.00 5,614.96 7,612.00 3,958.24 6,081.00 3,162.12 5,276.00 2,743.52

60 14,095.00 7,329.40 9,713.00 5,050.76 8,140.00 4,232.80 7,379.00 3,837.08

61 14,449.00 7,513.48 9,968.00 5,183.36 8,351.00 4,342.52 7,569.00 3,935.88

62 14,821.00 7,706.92 10,221.00 5,314.92 8,561.00 4,451.72 7,766.00 4,038.32

63 15,122.00 7,863.44 10,420.00 5,418.40 8,737.00 4,543.24 7,921.00 4,118.92

64 15,420.00 8,018.40 10,629.00 5,527.08 8,907.00 4,631.64 8,077.00 4,200.04

65 30,686.00 15,956.72 21,392.00 11,123.84 17,308.00 9,000.16 16,617.00 8,640.84

66 31,482.00 16,370.64 21,945.00 11,411.40 17,760.00 9,235.20 17,039.00 8,860.28

67 32,284.00 16,787.68 22,504.00 11,702.08 18,211.00 9,469.72 17,473.00 9,085.96

68 32,930.00 17,123.60 22,955.00 11,936.60 18,573.00 9,657.96 17,824.00 9,268.48

69 33,586.00 17,464.72 23,414.00 12,175.28 18,947.00 9,852.44 18,181.00 9,454.12

70 and up 38,730.00 20,139.60 26,587.00 13,825.24 20,659.00 10,742.68 19,936.00 10,366.72

Additional coverage


ZONE 5 | VENEZUELA

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10-19 2,062.00 1,072.24 1,307.00 679.64 936.00 486.72 631.00 328.12

20-29 5,445.00 2,831.40 3,499.00 1,819.48 2,699.00 1,403.48 2,026.00 1,053.52

30-39 6,028.00 3,134.56 4,177.00 2,172.04 3,383.00 1,759.16 2,728.00 1,418.56

40-49 6,819.00 3,545.88 4,699.00 2,443.48 3,760.00 1,955.20 3,009.00 1,564.68

50-59 9,807.00 5,099.64 6,906.00 3,591.12 5,515.00 2,867.80 4,786.00 2,488.72

60 12,800.00 6,656.00 8,813.00 4,582.76 7,383.00 3,839.16 6,693.00 3,480.36

61 13,124.00 6,824.48 9,041.00 4,701.32 7,572.00 3,937.44 6,866.00 3,570.32

62 13,461.00 6,999.72 9,274.00 4,822.48 7,767.00 4,038.84 7,043.00 3,662.36

63 13,731.00 7,140.12 9,454.00 4,916.08 7,924.00 4,120.48 7,183.00 3,735.16

64 14,004.00 7,282.08 9,644.00 5,014.88 8,080.00 4,201.60 7,326.00 3,809.52

65 27,865.00 14,489.80 19,412.00 10,094.24 15,697.00 8,162.44 15,072.00 7,837.44

66 28,586.00 14,864.72 19,912.00 10,354.24 16,105.00 8,374.60 15,451.00 8,034.52

67 29,320.00 15,246.40 20,419.00 10,617.88 16,515.00 8,587.80 15,843.00 8,238.36

68 29,904.00 15,550.08 20,829.00 10,831.08 16,844.00 8,758.88 16,167.00 8,406.84

69 30,501.00 15,860.52 21,245.00 11,047.40 17,181.00 8,934.12 16,489.00 8,574.28

70 and up 35,170.00 18,288.40 24,125.00 12,545.00 18,736.00 9,742.72 18,080.00 9,401.60

Additional coverage


ZONE 6 | ARGENTINA, COLOMBIA, PANAMA, PARAGUAY

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10-19 2,169.00 1,127.88 1,379.00 717.08 988.00 513.76 664.00 345.28

20-29 5,727.00 2,978.04 3,683.00 1,915.16 2,840.00 1,476.80 2,134.00 1,109.68

30-39 6,341.00 3,297.32 4,398.00 2,286.96 3,563.00 1,852.76 2,873.00 1,493.96

40-49 7,170.00 3,728.40 4,946.00 2,571.92 3,961.00 2,059.72 3,168.00 1,647.36

50-59 10,314.00 5,363.28 7,271.00 3,780.92 5,808.00 3,020.16 5,040.00 2,620.80

60 13,463.00 7,000.76 9,277.00 4,824.04 7,775.00 4,043.00 7,048.00 3,664.96

61 13,801.00 7,176.52 9,521.00 4,950.92 7,976.00 4,147.52 7,229.00 3,759.08

62 14,156.00 7,361.12 9,763.00 5,076.76 8,178.00 4,252.56 7,417.00 3,856.84

63 14,443.00 7,510.36 9,953.00 5,175.56 8,345.00 4,339.40 7,566.00 3,934.32

64 14,729.00 7,659.08 10,152.00 5,279.04 8,508.00 4,424.16 7,716.00 4,012.32

65 29,311.00 15,241.72 20,433.00 10,625.16 16,532.00 8,596.64 15,871.00 8,252.92

66 30,070.00 15,636.40 20,961.00 10,899.72 16,964.00 8,821.28 16,275.00 8,463.00

67 30,837.00 16,035.24 21,495.00 11,177.40 17,395.00 9,045.40 16,689.00 8,678.28

68 31,454.00 16,356.08 21,925.00 11,401.00 17,740.00 9,224.80 17,026.00 8,853.52

69 32,081.00 16,682.12 22,364.00 11,629.28 18,097.00 9,410.44 17,365.00 9,029.80

70 and up 36,994.00 19,236.88 25,394.00 13,204.88 19,733.00 10,261.16 19,042.00 9,901.84

Additional coverage


ZONE 7

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10-19 2,396.00 1,245.92 1,495.00 777.40 1,041.00 541.32 704.00 366.08

20-29 6,327.00 3,290.04 3,994.00 2,076.88 3,002.00 1,561.04 2,261.00 1,175.72

30-39 7,005.00 3,642.60 4,774.00 2,482.48 3,769.00 1,959.88 3,043.00 1,582.36

40-49 7,918.00 4,117.36 5,368.00 2,791.36 4,189.00 2,178.28 3,356.00 1,745.12

50-59 11,391.00 5,923.32 7,891.00 4,103.32 6,140.00 3,192.80 5,335.00 2,774.20

60 14,868.00 7,731.36 10,071.00 5,236.92 8,220.00 4,274.40 7,459.00 3,878.68

61 15,245.00 7,927.40 10,335.00 5,374.20 8,432.00 4,384.64 7,651.00 3,978.52

62 15,637.00 8,131.24 10,598.00 5,510.96 8,645.00 4,495.40 7,850.00 4,082.00

63 15,952.00 8,295.04 10,806.00 5,619.12 8,822.00 4,587.44 8,005.00 4,162.60

64 16,268.00 8,459.36 11,020.00 5,730.40 8,995.00 4,677.40 8,165.00 4,245.80

65 32,370.00 16,832.40 22,182.00 11,534.64 17,477.00 9,088.04 16,796.00 8,733.92

66 33,209.00 17,268.68 22,754.00 11,832.08 17,932.00 9,324.64 17,221.00 8,954.92

67 34,058.00 17,710.16 23,335.00 12,134.20 18,387.00 9,561.24 17,660.00 9,183.20

68 34,738.00 18,063.76 23,803.00 12,377.56 18,753.00 9,751.56 18,018.00 9,369.36

69 35,430.00 18,423.60 24,282.00 12,626.64 19,125.00 9,945.00 18,378.00 9,556.56

70 and up 40,856.00 21,245.12 27,572.00 14,337.44 20,858.00 10,846.16 20,150.00 10,478.00

Additional coverage


ZONE 8 | MEXICO

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10-19 2,564.00 1,333.28 1,630.00 847.60 1,167.00 606.84 785.00 408.20

20-29 6,770.00 3,520.40 4,353.00 2,263.56 3,358.00 1,746.16 2,522.00 1,311.44

30-39 7,500.00 3,900.00 5,199.00 2,703.48 4,210.00 2,189.20 3,396.00 1,765.92

40-49 8,477.00 4,408.04 5,845.00 3,039.40 4,685.00 2,436.20 3,746.00 1,947.92

50-59 12,192.00 6,339.84 8,596.00 4,469.92 6,869.00 3,571.88 5,961.00 3,099.72

60 15,916.00 8,276.32 10,968.00 5,703.36 9,193.00 4,780.36 8,332.00 4,332.64

61 16,318.00 8,485.36 11,254.00 5,852.08 9,428.00 4,902.56 8,548.00 4,444.96

62 16,736.00 8,702.72 11,542.00 6,001.84 9,669.00 5,027.88 8,770.00 4,560.40

63 17,076.00 8,879.52 11,764.00 6,117.28 9,866.00 5,130.32 8,945.00 4,651.40

64 17,414.00 9,055.28 12,003.00 6,241.56 10,060.00 5,231.20 9,121.00 4,742.92

65 34,652.00 18,019.04 24,157.00 12,561.64 19,545.00 10,163.40 18,764.00 9,757.28

66 35,550.00 18,486.00 24,779.00 12,885.08 20,052.00 10,427.04 19,239.00 10,004.28

67 36,458.00 18,958.16 25,411.00 13,213.72 20,563.00 10,692.76 19,729.00 10,259.08

68 37,188.00 19,337.76 25,922.00 13,479.44 20,974.00 10,906.48 20,128.00 10,466.56

69 37,929.00 19,723.08 26,442.00 13,749.84 21,393.00 11,124.36 20,531.00 10,676.12

70 and up 43,735.00 22,742.20 30,023.00 15,611.96 23,328.00 12,130.56 22,512.00 11,706.24

Additional coverage


ZONE 9 | CANADA, UNITED STATES OF AMERICA

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10-19 2,585.00 1,344.20 1,624.00 844.48 1,154.00 600.08 780.00 405.60

20-29 6,824.00 3,548.48 4,339.00 2,256.28 3,324.00 1,728.48 2,498.00 1,298.96

30-39 7,558.00 3,930.16 5,185.00 2,696.20 4,168.00 2,167.36 3,363.00 1,748.76

40-49 8,545.00 4,443.40 5,830.00 3,031.60 4,633.00 2,409.16 3,707.00 1,927.64

50-59 12,293.00 6,392.36 8,570.00 4,456.40 6,795.00 3,533.40 5,897.00 3,066.44

60 16,043.00 8,342.36 10,938.00 5,687.76 9,098.00 4,730.96 8,245.00 4,287.40

61 16,450.00 8,554.00 11,222.00 5,835.44 9,332.00 4,852.64 8,459.00 4,398.68

62 16,873.00 8,773.96 11,510.00 5,985.20 9,568.00 4,975.36 8,680.00 4,513.60

63 17,212.00 8,950.24 11,730.00 6,099.60 9,765.00 5,077.80 8,852.00 4,603.04

64 17,552.00 9,127.04 11,968.00 6,223.36 9,957.00 5,177.64 9,029.00 4,695.08

65 34,927.00 18,162.04 24,089.00 12,526.28 19,344.00 10,058.88 18,569.00 9,655.88

66 35,834.00 18,633.68 24,711.00 12,849.72 19,846.00 10,319.92 19,040.00 9,900.80

67 36,748.00 19,108.96 25,342.00 13,177.84 20,352.00 10,583.04 19,524.00 10,152.48

68 37,484.00 19,491.68 25,846.00 13,439.92 20,755.00 10,792.60 19,921.00 10,358.92

69 38,231.00 19,880.12 26,367.00 13,710.84 21,172.00 11,009.44 20,320.00 10,566.40

70 and up 44,081.00 22,922.12 29,940.00 15,568.80 23,088.00 12,005.76 22,278.00 11,584.56

Additional coverage


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

BINS_PB_P1S_eng_V17.01

Bupa Insurance LimitedBupa House, 15-19 Bloomsbury Way, London, WC1A 2BA, UK

Registered in England No. 3956433.Bupa Insurance Limited is authorizedby the Prudential RegulationAuthority and regulated by theFinancial Conduct Authority and thePrudential Regulation Authority. TheFinancial Conduct Authority doesnot regulate the activities of BupaInsurance Limited that take placeoutside of the United Kingdom.

Administration:17901 Old Cutler Road, Suite 400Palmetto Bay, Florida 33157Tel. +1 (305) 270 3944Fax +1 (305) 270 [email protected]

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