BUPA WORLDWIDE - bupalatinamerica.com · hasta un máximo de US$5,000,000. Aplica un coaseguro por...

P R E M I U M B O O K L E T

BU PA WORLDWIDE

E F F E C TI V E JA N UA RY 1 , 2 01 8

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

• 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.

• For ages 65 and older, a Treating Physician Statement is required when applying for coverage.

• 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.

• Coinsurance: For Plans A, B and C, after meeting the deductible, 80% of the first US$5,000 in approved charges is covered; then 100% of approved charges up to US $5,000,000. One coinsurance per insured, per policy year applies. For Plans C Plus, D and E, no coinsurance applies.

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

NOTAS ADMINISTRATIVAS• Las tarifas están expresadas en dólares de los Estados

Unidos de América y no incluyen impuestos.

• 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.

• Para solicitantes de 65 o más, se requiere incluir el formulario Declaración del Médico Tratante al solicitar la cobertura.

• 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.

• Coaseguro: Para los Planes A, B y C, después de satisfacer el deducible, se cubre el 80% de los primeros US$5,000 en gastos aprobados; luego, el 100% de gastos aprobados hasta un máximo de US$5,000,000. Aplica un coaseguro por asegurado, por año póliza. Para los Planes C Plus, D y E, no se aplica coaseguro.

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

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18Deductibles Plan A Plan B Plan C Plan C Plus Plan D Plan E

In country ofresidence US$250 US$500 US$1,000 US$5,000 US$10,000 US$20,000

Out of countryof residence US$500 US$1,250 US$2,500 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$5,741.00 US$3,042.73 US$4,178.00 US$2,214.34 US$3,067.00 US$1,625.51 US$1,841.00 US$975.73 US$1,626.00 US$861.78 US$1,173.00 US$621.69

2 children 9,083.00 4,813.99 6,585.00 3,490.05 4,836.00 2,563.08 2,908.00 1,541.24 2,578.00 1,366.34 1,723.00 913.19

3 or more children 13,338.00 7,069.14 9,601.00 5,088.53 7,055.00 3,739.15 4,236.00 2,245.08 3,734.00 1,979.02 2,624.00 1,390.72

18-25 12,787.00 6,777.11 10,019.00 5,310.07 7,399.00 3,921.47 4,199.00 2,225.47 3,214.00 1,703.42 2,537.00 1,344.61

26-29 14,522.00 7,696.66 11,523.00 6,107.19 8,497.00 4,503.41 4,795.00 2,541.35 3,677.00 1,948.81 2,888.00 1,530.64

30-34 16,432.00 8,708.96 13,102.00 6,944.06 9,656.00 5,117.68 5,571.00 2,952.63 4,254.00 2,254.62 3,275.00 1,735.75

35-39 18,635.00 9,876.55 14,612.00 7,744.36 10,750.00 5,697.50 6,197.00 3,284.41 4,852.00 2,571.56 3,634.00 1,926.02

40-44 20,974.00 11,116.22 16,571.00 8,782.63 12,199.00 6,465.47 7,028.00 3,724.84 5,424.00 2,874.72 4,116.00 2,181.48

45-49 23,870.00 12,651.10 19,349.00 10,254.97 14,246.00 7,550.38 7,928.00 4,201.84 6,176.00 3,273.28 4,791.00 2,539.23

50-54 27,545.00 14,598.85 21,265.00 11,270.45 15,653.00 8,296.09 9,241.00 4,897.73 6,939.00 3,677.67 5,256.00 2,785.68

55-59 31,162.00 16,515.86 25,264.00 13,389.92 18,579.00 9,846.87 10,223.00 5,418.19 8,037.00 4,259.61 6,218.00 3,295.54

60-64 39,685.00 21,033.05 35,141.00 18,624.73 25,847.00 13,698.91 14,079.00 7,461.87 11,112.00 5,889.36 8,628.00 4,572.84

65-69 61,610.00 32,653.30 54,048.00 28,645.44 39,716.00 21,049.48 21,701.00 11,501.53 17,120.00 9,073.60 13,900.00 7,367.00

70-74 90,443.00 47,934.79 79,024.00 41,882.72 58,061.00 30,772.33 31,707.00 16,804.71 25,109.00 13,307.77 20,278.00 10,747.34

75-79 112,322.00 59,530.66 98,972.00 52,455.16 72,713.00 38,537.89 41,578.00 22,036.34 31,430.00 16,657.90 26,612.00 14,104.36

80 + 158,366.00 83,933.98 139,542.00 73,957.26 102,507.00 54,328.71 58,606.00 31,061.18 44,277.00 23,466.81 37,523.00 19,887.19

Additional coverageMaternitycomplications US$225.00 US$119.25 US$225.00 US$119.25 US$225.00 US$119.25

Private pilot 125.00 66.25 125.00 66.25 125.00 66.25 US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25

Deducibles Plan A Plan B Plan C Plan C Plus Plan D Plan E

Dentro del país de residencia US$250 US$500 US$1,000 US$5,000 US$10,000 US$20,000

Fuera del país de residencia US$500 US$1,250 US$2,500 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$5,741.00 US$3,042.73 US$4,178.00 US$2,214.34 US$3,067.00 US$1,625.51 US$1,841.00 US$975.73 US$1,626.00 US$861.78 US$1,173.00 US$621.69

2 hijos 9,083.00 4,813.99 6,585.00 3,490.05 4,836.00 2,563.08 2,908.00 1,541.24 2,578.00 1,366.34 1,723.00 913.19

3 hijos o más 13,338.00 7,069.14 9,601.00 5,088.53 7,055.00 3,739.15 4,236.00 2,245.08 3,734.00 1,979.02 2,624.00 1,390.72

18-25 12,787.00 6,777.11 10,019.00 5,310.07 7,399.00 3,921.47 4,199.00 2,225.47 3,214.00 1,703.42 2,537.00 1,344.61

26-29 14,522.00 7,696.66 11,523.00 6,107.19 8,497.00 4,503.41 4,795.00 2,541.35 3,677.00 1,948.81 2,888.00 1,530.64

30-34 16,432.00 8,708.96 13,102.00 6,944.06 9,656.00 5,117.68 5,571.00 2,952.63 4,254.00 2,254.62 3,275.00 1,735.75

35-39 18,635.00 9,876.55 14,612.00 7,744.36 10,750.00 5,697.50 6,197.00 3,284.41 4,852.00 2,571.56 3,634.00 1,926.02

40-44 20,974.00 11,116.22 16,571.00 8,782.63 12,199.00 6,465.47 7,028.00 3,724.84 5,424.00 2,874.72 4,116.00 2,181.48

45-49 23,870.00 12,651.10 19,349.00 10,254.97 14,246.00 7,550.38 7,928.00 4,201.84 6,176.00 3,273.28 4,791.00 2,539.23

50-54 27,545.00 14,598.85 21,265.00 11,270.45 15,653.00 8,296.09 9,241.00 4,897.73 6,939.00 3,677.67 5,256.00 2,785.68

55-59 31,162.00 16,515.86 25,264.00 13,389.92 18,579.00 9,846.87 10,223.00 5,418.19 8,037.00 4,259.61 6,218.00 3,295.54

60-64 39,685.00 21,033.05 35,141.00 18,624.73 25,847.00 13,698.91 14,079.00 7,461.87 11,112.00 5,889.36 8,628.00 4,572.84

65-69 61,610.00 32,653.30 54,048.00 28,645.44 39,716.00 21,049.48 21,701.00 11,501.53 17,120.00 9,073.60 13,900.00 7,367.00

70-74 90,443.00 47,934.79 79,024.00 41,882.72 58,061.00 30,772.33 31,707.00 16,804.71 25,109.00 13,307.77 20,278.00 10,747.34

75-79 112,322.00 59,530.66 98,972.00 52,455.16 72,713.00 38,537.89 41,578.00 22,036.34 31,430.00 16,657.90 26,612.00 14,104.36

80 + 158,366.00 83,933.98 139,542.00 73,957.26 102,507.00 54,328.71 58,606.00 31,061.18 44,277.00 23,466.81 37,523.00 19,887.19

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

Piloto privado 125.00 66.25 125.00 66.25 125.00 66.25 US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25

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ZONE 2: CENTRAL AMERICA

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1 child US$5,160.00 US$2,734.80 US$3,779.00 US$2,002.87 US$2,697.00 US$1,429.41 US$1,727.00 US$915.31 US$1,520.00 US$805.60 US$1,102.00 US$584.06

2 children 8,148.00 4,318.44 5,965.00 3,161.45 4,253.00 2,254.09 2,730.00 1,446.90 2,413.00 1,278.89 1,618.00 857.54

3 or more children 11,978.00 6,348.34 8,692.00 4,606.76 6,194.00 3,282.82 3,983.00 2,110.99 3,488.00 1,848.64 2,469.00 1,308.57

18-25 11,494.00 6,091.82 9,081.00 4,812.93 6,502.00 3,446.06 3,943.00 2,089.79 3,003.00 1,591.59 2,387.00 1,265.11

26-29 13,045.00 6,913.85 10,438.00 5,532.14 7,470.00 3,959.10 4,506.00 2,388.18 3,444.00 1,825.32 2,718.00 1,440.54

30-34 14,765.00 7,825.45 11,868.00 6,290.04 8,488.00 4,498.64 5,224.00 2,768.72 3,983.00 2,110.99 3,076.00 1,630.28

35-39 16,745.00 8,874.85 13,227.00 7,010.31 9,458.00 5,012.74 5,815.00 3,081.95 4,537.00 2,404.61 3,417.00 1,811.01

40-44 18,835.00 9,982.55 15,000.00 7,950.00 10,722.00 5,682.66 6,596.00 3,495.88 5,076.00 2,690.28 3,865.00 2,048.45

45-49 21,437.00 11,361.61 17,517.00 9,284.01 12,519.00 6,635.07 7,446.00 3,946.38 5,782.00 3,064.46 4,504.00 2,387.12

50-54 24,729.00 13,106.37 19,246.00 10,200.38 13,753.00 7,289.09 8,682.00 4,601.46 6,497.00 3,443.41 4,940.00 2,618.20

55-59 27,984.00 14,831.52 22,869.00 12,120.57 16,326.00 8,652.78 9,604.00 5,090.12 7,521.00 3,986.13 5,840.00 3,095.20

60-64 33,958.00 17,997.74 30,316.00 16,067.48 21,646.00 11,472.38 12,599.00 6,677.47 9,913.00 5,253.89 7,724.00 4,093.72

65-69 55,173.00 29,241.69 48,789.00 25,858.17 34,803.00 18,445.59 20,327.00 10,773.31 15,975.00 8,466.75 13,020.00 6,900.60

70-74 80,613.00 42,724.89 70,995.00 37,627.35 50,640.00 26,839.20 29,556.00 15,664.68 23,324.00 12,361.72 18,905.00 10,019.65

75-79 100,106.00 53,056.18 88,920.00 47,127.60 63,421.00 33,613.13 38,761.00 20,543.33 29,193.00 15,472.29 24,804.00 13,146.12

80 + 141,138.00 74,803.14 125,364.00 66,442.92 89,405.00 47,384.65 54,629.00 28,953.37 41,129.00 21,798.37 34,979.00 18,538.87







1 hijo US$5,160.00 US$2,734.80 US$3,779.00 US$2,002.87 US$2,697.00 US$1,429.41 US$1,727.00 US$915.31 US$1,520.00 US$805.60 US$1,102.00 US$584.06

2 hijos 8,148.00 4,318.44 5,965.00 3,161.45 4,253.00 2,254.09 2,730.00 1,446.90 2,413.00 1,278.89 1,618.00 857.54

3 hijos o más 11,978.00 6,348.34 8,692.00 4,606.76 6,194.00 3,282.82 3,983.00 2,110.99 3,488.00 1,848.64 2,469.00 1,308.57

18-25 11,494.00 6,091.82 9,081.00 4,812.93 6,502.00 3,446.06 3,943.00 2,089.79 3,003.00 1,591.59 2,387.00 1,265.11

26-29 13,045.00 6,913.85 10,438.00 5,532.14 7,470.00 3,959.10 4,506.00 2,388.18 3,444.00 1,825.32 2,718.00 1,440.54

30-34 14,765.00 7,825.45 11,868.00 6,290.04 8,488.00 4,498.64 5,224.00 2,768.72 3,983.00 2,110.99 3,076.00 1,630.28

35-39 16,745.00 8,874.85 13,227.00 7,010.31 9,458.00 5,012.74 5,815.00 3,081.95 4,537.00 2,404.61 3,417.00 1,811.01

40-44 18,835.00 9,982.55 15,000.00 7,950.00 10,722.00 5,682.66 6,596.00 3,495.88 5,076.00 2,690.28 3,865.00 2,048.45

45-49 21,437.00 11,361.61 17,517.00 9,284.01 12,519.00 6,635.07 7,446.00 3,946.38 5,782.00 3,064.46 4,504.00 2,387.12

50-54 24,729.00 13,106.37 19,246.00 10,200.38 13,753.00 7,289.09 8,682.00 4,601.46 6,497.00 3,443.41 4,940.00 2,618.20

55-59 27,984.00 14,831.52 22,869.00 12,120.57 16,326.00 8,652.78 9,604.00 5,090.12 7,521.00 3,986.13 5,840.00 3,095.20

60-64 33,958.00 17,997.74 30,316.00 16,067.48 21,646.00 11,472.38 12,599.00 6,677.47 9,913.00 5,253.89 7,724.00 4,093.72

65-69 55,173.00 29,241.69 48,789.00 25,858.17 34,803.00 18,445.59 20,327.00 10,773.31 15,975.00 8,466.75 13,020.00 6,900.60

70-74 80,613.00 42,724.89 70,995.00 37,627.35 50,640.00 26,839.20 29,556.00 15,664.68 23,324.00 12,361.72 18,905.00 10,019.65

75-79 100,106.00 53,056.18 88,920.00 47,127.60 63,421.00 33,613.13 38,761.00 20,543.33 29,193.00 15,472.29 24,804.00 13,146.12

80 + 141,138.00 74,803.14 125,364.00 66,442.92 89,405.00 47,384.65 54,629.00 28,953.37 41,129.00 21,798.37 34,979.00 18,538.87



ZONA 2: CENTROAMÉRICA

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ZONE 3: BELIZE, CARIBBEAN ISLANDS, FRENCH GUIANA, GUYANA, SURINAME

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1 child US$4,173.00 US$2,211.69 US$3,055.00 US$1,619.15 US$2,179.00 US$1,154.87 US$1,405.00 US$744.65 US$1,236.00 US$655.08 US$897.00 US$475.41

2 children 6,590.00 3,492.70 4,823.00 2,556.19 3,438.00 1,822.14 2,218.00 1,175.54 1,959.00 1,038.27 1,317.00 698.01

3 or more children 9,690.00 5,135.70 7,026.00 3,723.78 5,011.00 2,655.83 3,229.00 1,711.37 2,835.00 1,502.55 2,003.00 1,061.59

18-25 9,303.00 4,930.59 7,353.00 3,897.09 5,270.00 2,793.10 3,217.00 1,705.01 2,449.00 1,297.97 1,946.00 1,031.38

26-29 10,563.00 5,598.39 8,453.00 4,480.09 6,055.00 3,209.15 3,668.00 1,944.04 2,810.00 1,489.30 2,218.00 1,175.54

30-34 11,950.00 6,333.50 9,606.00 5,091.18 6,880.00 3,646.40 4,262.00 2,258.86 3,245.00 1,719.85 2,504.00 1,327.12

35-39 13,553.00 7,183.09 10,714.00 5,678.42 7,661.00 4,060.33 4,734.00 2,509.02 3,699.00 1,960.47 2,786.00 1,476.58

40-44 15,247.00 8,080.91 12,140.00 6,434.20 8,685.00 4,603.05 5,370.00 2,846.10 4,133.00 2,190.49 3,150.00 1,669.50

45-49 17,347.00 9,193.91 14,177.00 7,513.81 10,137.00 5,372.61 6,056.00 3,209.68 4,707.00 2,494.71 3,666.00 1,942.98

50-54 20,011.00 10,605.83 15,579.00 8,256.87 11,134.00 5,901.02 7,062.00 3,742.86 5,289.00 2,803.17 4,022.00 2,131.66

55-59 22,640.00 11,999.20 18,510.00 9,810.30 13,217.00 7,005.01 7,808.00 4,138.24 6,119.00 3,243.07 4,755.00 2,520.15

60-64 27,491.00 14,570.23 24,544.00 13,008.32 17,528.00 9,289.84 10,247.00 5,430.91 8,064.00 4,273.92 6,287.00 3,332.11

65-69 44,628.00 23,652.84 39,466.00 20,916.98 28,153.00 14,921.09 16,517.00 8,754.01 12,980.00 6,879.40 10,582.00 5,608.46

70-74 65,177.00 34,543.81 57,402.00 30,423.06 40,947.00 21,701.91 23,999.00 12,719.47 18,944.00 10,040.32 15,354.00 8,137.62

75-79 80,936.00 42,896.08 71,887.00 38,100.11 51,277.00 27,176.81 31,467.00 16,677.51 23,702.00 12,562.06 20,141.00 10,674.73

80 + 114,099.00 60,472.47 101,346.00 53,713.38 72,278.00 38,307.34 44,346.00 23,503.38 33,388.00 17,695.64 28,398.00 15,050.94







1 hijo US$4,173.00 US$2,211.69 US$3,055.00 US$1,619.15 US$2,179.00 US$1,154.87 US$1,405.00 US$744.65 US$1,236.00 US$655.08 US$897.00 US$475.41

2 hijos 6,590.00 3,492.70 4,823.00 2,556.19 3,438.00 1,822.14 2,218.00 1,175.54 1,959.00 1,038.27 1,317.00 698.01

3 hijos o más 9,690.00 5,135.70 7,026.00 3,723.78 5,011.00 2,655.83 3,229.00 1,711.37 2,835.00 1,502.55 2,003.00 1,061.59

18-25 9,303.00 4,930.59 7,353.00 3,897.09 5,270.00 2,793.10 3,217.00 1,705.01 2,449.00 1,297.97 1,946.00 1,031.38

26-29 10,563.00 5,598.39 8,453.00 4,480.09 6,055.00 3,209.15 3,668.00 1,944.04 2,810.00 1,489.30 2,218.00 1,175.54

30-34 11,950.00 6,333.50 9,606.00 5,091.18 6,880.00 3,646.40 4,262.00 2,258.86 3,245.00 1,719.85 2,504.00 1,327.12

35-39 13,553.00 7,183.09 10,714.00 5,678.42 7,661.00 4,060.33 4,734.00 2,509.02 3,699.00 1,960.47 2,786.00 1,476.58

40-44 15,247.00 8,080.91 12,140.00 6,434.20 8,685.00 4,603.05 5,370.00 2,846.10 4,133.00 2,190.49 3,150.00 1,669.50

45-49 17,347.00 9,193.91 14,177.00 7,513.81 10,137.00 5,372.61 6,056.00 3,209.68 4,707.00 2,494.71 3,666.00 1,942.98

50-54 20,011.00 10,605.83 15,579.00 8,256.87 11,134.00 5,901.02 7,062.00 3,742.86 5,289.00 2,803.17 4,022.00 2,131.66

55-59 22,640.00 11,999.20 18,510.00 9,810.30 13,217.00 7,005.01 7,808.00 4,138.24 6,119.00 3,243.07 4,755.00 2,520.15

60-64 27,491.00 14,570.23 24,544.00 13,008.32 17,528.00 9,289.84 10,247.00 5,430.91 8,064.00 4,273.92 6,287.00 3,332.11

65-69 44,628.00 23,652.84 39,466.00 20,916.98 28,153.00 14,921.09 16,517.00 8,754.01 12,980.00 6,879.40 10,582.00 5,608.46

70-74 65,177.00 34,543.81 57,402.00 30,423.06 40,947.00 21,701.91 23,999.00 12,719.47 18,944.00 10,040.32 15,354.00 8,137.62

75-79 80,936.00 42,896.08 71,887.00 38,100.11 51,277.00 27,176.81 31,467.00 16,677.51 23,702.00 12,562.06 20,141.00 10,674.73

80 + 114,099.00 60,472.47 101,346.00 53,713.38 72,278.00 38,307.34 44,346.00 23,503.38 33,388.00 17,695.64 28,398.00 15,050.94



ZONA 3: BELICE, GUAYANA FRANCESA, GUYANA, ISLAS DEL CARIBE, SURINAM

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1 child US$3,605.00 US$1,910.65 US$2,621.00 US$1,389.13 US$1,850.00 US$980.50 US$1,199.00 US$635.47 US$1,052.00 US$557.56 US$757.00 US$401.21

2 children 5,695.00 3,018.35 4,134.00 2,191.02 2,917.00 1,546.01 1,894.00 1,003.82 1,666.00 882.98 1,111.00 588.83

3 or more children 8,365.00 4,433.45 6,024.00 3,192.72 4,252.00 2,253.56 2,762.00 1,463.86 2,413.00 1,278.89 1,693.00 897.29

18-25 8,040.00 4,261.20 6,311.00 3,344.83 4,486.00 2,377.58 2,751.00 1,458.03 2,091.00 1,108.23 1,656.00 877.68

26-29 9,130.00 4,838.90 7,249.00 3,841.97 5,150.00 2,729.50 3,139.00 1,663.67 2,398.00 1,270.94 1,881.00 996.93

30-34 10,323.00 5,471.19 8,246.00 4,370.38 5,849.00 3,099.97 3,644.00 1,931.32 2,766.00 1,465.98 2,130.00 1,128.90

35-39 11,711.00 6,206.83 9,190.00 4,870.70 6,516.00 3,453.48 4,050.00 2,146.50 3,155.00 1,672.15 2,364.00 1,252.92

40-44 13,176.00 6,983.28 10,411.00 5,517.83 7,380.00 3,911.40 4,595.00 2,435.35 3,526.00 1,868.78 2,670.00 1,415.10

45-49 14,988.00 7,943.64 12,161.00 6,445.33 8,612.00 4,564.36 5,180.00 2,745.40 4,012.00 2,126.36 3,107.00 1,646.71

50-54 17,288.00 9,162.64 13,363.00 7,082.39 9,463.00 5,015.39 6,036.00 3,199.08 4,507.00 2,388.71 3,410.00 1,807.30

55-59 19,558.00 10,365.74 15,871.00 8,411.63 11,231.00 5,952.43 6,680.00 3,540.40 5,213.00 2,762.89 4,029.00 2,135.37

60-64 23,797.00 12,612.41 21,091.00 11,178.23 14,923.00 7,909.19 8,778.00 4,652.34 6,885.00 3,649.05 5,341.00 2,830.73

65-69 38,741.00 20,532.73 34,013.00 18,026.89 24,033.00 12,737.49 14,182.00 7,516.46 11,116.00 5,891.48 9,001.00 4,770.53

70-74 56,829.00 30,119.37 49,688.00 26,334.64 35,108.00 18,607.24 20,695.00 10,968.35 16,285.00 8,631.05 13,116.00 6,951.48

75-79 70,573.00 37,403.69 62,231.00 32,982.43 43,956.00 23,296.68 27,137.00 14,382.61 20,377.00 10,799.81 17,205.00 9,118.65

80 + 99,488.00 52,728.64 87,726.00 46,494.78 61,956.00 32,836.68 38,242.00 20,268.26 28,700.00 15,211.00 24,256.00 12,855.68







1 hijo US$3,605.00 US$1,910.65 US$2,621.00 US$1,389.13 US$1,850.00 US$980.50 US$1,199.00 US$635.47 US$1,052.00 US$557.56 US$757.00 US$401.21

2 hijos 5,695.00 3,018.35 4,134.00 2,191.02 2,917.00 1,546.01 1,894.00 1,003.82 1,666.00 882.98 1,111.00 588.83

3 hijos o más 8,365.00 4,433.45 6,024.00 3,192.72 4,252.00 2,253.56 2,762.00 1,463.86 2,413.00 1,278.89 1,693.00 897.29

18-25 8,040.00 4,261.20 6,311.00 3,344.83 4,486.00 2,377.58 2,751.00 1,458.03 2,091.00 1,108.23 1,656.00 877.68

26-29 9,130.00 4,838.90 7,249.00 3,841.97 5,150.00 2,729.50 3,139.00 1,663.67 2,398.00 1,270.94 1,881.00 996.93

30-34 10,323.00 5,471.19 8,246.00 4,370.38 5,849.00 3,099.97 3,644.00 1,931.32 2,766.00 1,465.98 2,130.00 1,128.90

35-39 11,711.00 6,206.83 9,190.00 4,870.70 6,516.00 3,453.48 4,050.00 2,146.50 3,155.00 1,672.15 2,364.00 1,252.92

40-44 13,176.00 6,983.28 10,411.00 5,517.83 7,380.00 3,911.40 4,595.00 2,435.35 3,526.00 1,868.78 2,670.00 1,415.10

45-49 14,988.00 7,943.64 12,161.00 6,445.33 8,612.00 4,564.36 5,180.00 2,745.40 4,012.00 2,126.36 3,107.00 1,646.71

50-54 17,288.00 9,162.64 13,363.00 7,082.39 9,463.00 5,015.39 6,036.00 3,199.08 4,507.00 2,388.71 3,410.00 1,807.30

55-59 19,558.00 10,365.74 15,871.00 8,411.63 11,231.00 5,952.43 6,680.00 3,540.40 5,213.00 2,762.89 4,029.00 2,135.37

60-64 23,797.00 12,612.41 21,091.00 11,178.23 14,923.00 7,909.19 8,778.00 4,652.34 6,885.00 3,649.05 5,341.00 2,830.73

65-69 38,741.00 20,532.73 34,013.00 18,026.89 24,033.00 12,737.49 14,182.00 7,516.46 11,116.00 5,891.48 9,001.00 4,770.53

70-74 56,829.00 30,119.37 49,688.00 26,334.64 35,108.00 18,607.24 20,695.00 10,968.35 16,285.00 8,631.05 13,116.00 6,951.48

75-79 70,573.00 37,403.69 62,231.00 32,982.43 43,956.00 23,296.68 27,137.00 14,382.61 20,377.00 10,799.81 17,205.00 9,118.65

80 + 99,488.00 52,728.64 87,726.00 46,494.78 61,956.00 32,836.68 38,242.00 20,268.26 28,700.00 15,211.00 24,256.00 12,855.68



ZONA 4: BOLIVIA, COLOMBIA, PERÚ

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2 children 6,880.00 3,646.40 5,020.00 2,660.60 3,574.00 1,894.22 2,305.00 1,221.65 2,037.00 1,079.61 1,367.00 724.51

3 or more children 10,116.00 5,361.48 7,315.00 3,876.95 5,207.00 2,759.71 3,359.00 1,780.27 2,947.00 1,561.91 2,082.00 1,103.46

18-25 9,712.00 5,147.36 7,645.00 4,051.85 5,479.00 2,903.87 3,339.00 1,769.67 2,543.00 1,347.79 2,020.00 1,070.60

26-29 11,025.00 5,843.25 8,786.00 4,656.58 6,287.00 3,332.11 3,805.00 2,016.65 2,918.00 1,546.54 2,305.00 1,221.65

30-34 12,469.00 6,608.57 9,988.00 5,293.64 7,152.00 3,790.56 4,420.00 2,342.60 3,369.00 1,785.57 2,596.00 1,375.88

35-39 14,140.00 7,494.20 11,135.00 5,901.55 7,961.00 4,219.33 4,916.00 2,605.48 3,843.00 2,036.79 2,894.00 1,533.82

40-44 15,911.00 8,432.83 12,624.00 6,690.72 9,023.00 4,782.19 5,573.00 2,953.69 4,296.00 2,276.88 3,270.00 1,733.10

45-49 18,106.00 9,596.18 14,748.00 7,816.44 10,534.00 5,583.02 6,293.00 3,335.29 4,885.00 2,589.05 3,804.00 2,016.12

50-54 20,886.00 11,069.58 16,206.00 8,589.18 11,574.00 6,134.22 7,339.00 3,889.67 5,497.00 2,913.41 4,184.00 2,217.52

55-59 23,633.00 12,525.49 19,248.00 10,201.44 13,732.00 7,277.96 8,111.00 4,298.83 6,366.00 3,373.98 4,946.00 2,621.38

60-64 28,697.00 15,209.41 25,534.00 13,533.02 18,220.00 9,656.60 10,646.00 5,642.38 8,389.00 4,446.17 6,536.00 3,464.08

65-69 46,586.00 24,690.58 41,052.00 21,757.56 29,270.00 15,513.10 17,158.00 9,093.74 13,499.00 7,154.47 11,007.00 5,833.71

70-74 67,733.00 35,898.49 59,446.00 31,506.38 42,380.00 22,461.40 24,832.00 13,160.96 19,615.00 10,395.95 15,898.00 8,425.94

75-79 84,115.00 44,580.95 74,456.00 39,461.68 53,069.00 28,126.57 32,563.00 17,258.39 24,551.00 13,012.03 20,856.00 11,053.68

80 + 118,584.00 62,849.52 104,965.00 55,631.45 74,807.00 39,647.71 45,891.00 24,322.23 34,584.00 18,329.52 29,406.00 15,585.18








2 hijos 6,880.00 3,646.40 5,020.00 2,660.60 3,574.00 1,894.22 2,305.00 1,221.65 2,037.00 1,079.61 1,367.00 724.51

3 hijos o más 10,116.00 5,361.48 7,315.00 3,876.95 5,207.00 2,759.71 3,359.00 1,780.27 2,947.00 1,561.91 2,082.00 1,103.46

18-25 9,712.00 5,147.36 7,645.00 4,051.85 5,479.00 2,903.87 3,339.00 1,769.67 2,543.00 1,347.79 2,020.00 1,070.60

26-29 11,025.00 5,843.25 8,786.00 4,656.58 6,287.00 3,332.11 3,805.00 2,016.65 2,918.00 1,546.54 2,305.00 1,221.65

30-34 12,469.00 6,608.57 9,988.00 5,293.64 7,152.00 3,790.56 4,420.00 2,342.60 3,369.00 1,785.57 2,596.00 1,375.88

35-39 14,140.00 7,494.20 11,135.00 5,901.55 7,961.00 4,219.33 4,916.00 2,605.48 3,843.00 2,036.79 2,894.00 1,533.82

40-44 15,911.00 8,432.83 12,624.00 6,690.72 9,023.00 4,782.19 5,573.00 2,953.69 4,296.00 2,276.88 3,270.00 1,733.10

45-49 18,106.00 9,596.18 14,748.00 7,816.44 10,534.00 5,583.02 6,293.00 3,335.29 4,885.00 2,589.05 3,804.00 2,016.12

50-54 20,886.00 11,069.58 16,206.00 8,589.18 11,574.00 6,134.22 7,339.00 3,889.67 5,497.00 2,913.41 4,184.00 2,217.52

55-59 23,633.00 12,525.49 19,248.00 10,201.44 13,732.00 7,277.96 8,111.00 4,298.83 6,366.00 3,373.98 4,946.00 2,621.38

60-64 28,697.00 15,209.41 25,534.00 13,533.02 18,220.00 9,656.60 10,646.00 5,642.38 8,389.00 4,446.17 6,536.00 3,464.08

65-69 46,586.00 24,690.58 41,052.00 21,757.56 29,270.00 15,513.10 17,158.00 9,093.74 13,499.00 7,154.47 11,007.00 5,833.71

70-74 67,733.00 35,898.49 59,446.00 31,506.38 42,380.00 22,461.40 24,832.00 13,160.96 19,615.00 10,395.95 15,898.00 8,425.94

75-79 84,115.00 44,580.95 74,456.00 39,461.68 53,069.00 28,126.57 32,563.00 17,258.39 24,551.00 13,012.03 20,856.00 11,053.68

80 + 118,584.00 62,849.52 104,965.00 55,631.45 74,807.00 39,647.71 45,891.00 24,322.23 34,584.00 18,329.52 29,406.00 15,585.18



ZONA 5: ARGENTINA, CHILE, PARAGUAY, URUGUAY

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2 children 6,726.00 3,564.78 4,908.00 2,601.24 3,492.00 1,850.76 2,254.00 1,194.62 1,994.00 1,056.82 1,338.00 709.14

3 or more children 9,887.00 5,240.11 7,145.00 3,786.85 5,089.00 2,697.17 3,285.00 1,741.05 2,882.00 1,527.46 2,040.00 1,081.20

18-25 9,490.00 5,029.70 7,472.00 3,960.16 5,350.00 2,835.50 3,260.00 1,727.80 2,485.00 1,317.05 1,971.00 1,044.63

26-29 10,770.00 5,708.10 8,588.00 4,551.64 6,145.00 3,256.85 3,721.00 1,972.13 2,854.00 1,512.62 2,247.00 1,190.91

30-34 12,188.00 6,459.64 9,762.00 5,173.86 6,983.00 3,700.99 4,317.00 2,288.01 3,293.00 1,745.29 2,537.00 1,344.61

35-39 13,820.00 7,324.60 10,883.00 5,767.99 7,780.00 4,123.40 4,803.00 2,545.59 3,752.00 1,988.56 2,824.00 1,496.72

40-44 15,555.00 8,244.15 12,337.00 6,538.61 8,819.00 4,674.07 5,448.00 2,887.44 4,199.00 2,225.47 3,194.00 1,692.82

45-49 17,695.00 9,378.35 14,415.00 7,639.95 10,294.00 5,455.82 6,154.00 3,261.62 4,779.00 2,532.87 3,720.00 1,971.60

50-54 20,413.00 10,818.89 15,836.00 8,393.08 11,311.00 5,994.83 7,173.00 3,801.69 5,372.00 2,847.16 4,087.00 2,166.11

55-59 23,099.00 12,242.47 18,818.00 9,973.54 13,425.00 7,115.25 7,936.00 4,206.08 6,223.00 3,298.19 4,833.00 2,561.49

60-64 28,051.00 14,867.03 24,960.00 13,228.80 17,811.00 9,439.83 10,410.00 5,517.30 8,202.00 4,347.06 6,388.00 3,385.64

65-69 45,540.00 24,136.20 40,132.00 21,269.96 28,614.00 15,165.42 16,788.00 8,897.64 13,206.00 6,999.18 10,762.00 5,703.86

70-74 66,218.00 35,095.54 58,116.00 30,801.48 41,431.00 21,958.43 24,295.00 12,876.35 19,190.00 10,170.70 15,550.00 8,241.50

75-79 82,232.00 43,582.96 72,788.00 38,577.64 51,882.00 27,497.46 31,855.00 16,883.15 24,016.00 12,728.48 20,397.00 10,810.41

80 + 115,931.00 61,443.43 102,619.00 54,388.07 73,133.00 38,760.49 44,896.00 23,794.88 33,832.00 17,930.96 28,768.00 15,247.04








2 hijos 6,726.00 3,564.78 4,908.00 2,601.24 3,492.00 1,850.76 2,254.00 1,194.62 1,994.00 1,056.82 1,338.00 709.14

3 hijos o más 9,887.00 5,240.11 7,145.00 3,786.85 5,089.00 2,697.17 3,285.00 1,741.05 2,882.00 1,527.46 2,040.00 1,081.20

18-25 9,490.00 5,029.70 7,472.00 3,960.16 5,350.00 2,835.50 3,260.00 1,727.80 2,485.00 1,317.05 1,971.00 1,044.63

26-29 10,770.00 5,708.10 8,588.00 4,551.64 6,145.00 3,256.85 3,721.00 1,972.13 2,854.00 1,512.62 2,247.00 1,190.91

30-34 12,188.00 6,459.64 9,762.00 5,173.86 6,983.00 3,700.99 4,317.00 2,288.01 3,293.00 1,745.29 2,537.00 1,344.61

35-39 13,820.00 7,324.60 10,883.00 5,767.99 7,780.00 4,123.40 4,803.00 2,545.59 3,752.00 1,988.56 2,824.00 1,496.72

40-44 15,555.00 8,244.15 12,337.00 6,538.61 8,819.00 4,674.07 5,448.00 2,887.44 4,199.00 2,225.47 3,194.00 1,692.82

45-49 17,695.00 9,378.35 14,415.00 7,639.95 10,294.00 5,455.82 6,154.00 3,261.62 4,779.00 2,532.87 3,720.00 1,971.60

50-54 20,413.00 10,818.89 15,836.00 8,393.08 11,311.00 5,994.83 7,173.00 3,801.69 5,372.00 2,847.16 4,087.00 2,166.11

55-59 23,099.00 12,242.47 18,818.00 9,973.54 13,425.00 7,115.25 7,936.00 4,206.08 6,223.00 3,298.19 4,833.00 2,561.49

60-64 28,051.00 14,867.03 24,960.00 13,228.80 17,811.00 9,439.83 10,410.00 5,517.30 8,202.00 4,347.06 6,388.00 3,385.64

65-69 45,540.00 24,136.20 40,132.00 21,269.96 28,614.00 15,165.42 16,788.00 8,897.64 13,206.00 6,999.18 10,762.00 5,703.86

70-74 66,218.00 35,095.54 58,116.00 30,801.48 41,431.00 21,958.43 24,295.00 12,876.35 19,190.00 10,170.70 15,550.00 8,241.50

75-79 82,232.00 43,582.96 72,788.00 38,577.64 51,882.00 27,497.46 31,855.00 16,883.15 24,016.00 12,728.48 20,397.00 10,810.41

80 + 115,931.00 61,443.43 102,619.00 54,388.07 73,133.00 38,760.49 44,896.00 23,794.88 33,832.00 17,930.96 28,768.00 15,247.04



ZONA 6

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18Deductibles Plan C Plan C Plus Plan D Plan E

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

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

Age Anual Semestral Anual Semestral Anual Semestral Anual Semestral

1 child US$2,419.00 US$1,282.07 US$1,558.00 US$825.74 US$1,372.00 US$727.16 US$1,000.00 US$530.00

2 children 3,814.00 2,021.42 2,462.00 1,304.86 2,172.00 1,151.16 1,464.00 775.92

3 or more children 5,690.00 3,015.70 3,706.00 1,964.18 3,265.00 1,730.45 2,335.00 1,237.55

18-25 5,860.00 3,105.80 3,572.00 1,893.16 2,724.00 1,443.72 2,168.00 1,149.04

26-29 6,727.00 3,565.31 4,079.00 2,161.87 3,123.00 1,655.19 2,471.00 1,309.63

30-34 7,642.00 4,050.26 4,732.00 2,507.96 3,605.00 1,910.65 2,788.00 1,477.64

35-39 8,510.00 4,510.30 5,261.00 2,788.33 4,109.00 2,177.77 3,100.00 1,643.00

40-44 9,647.00 5,112.91 5,964.00 3,160.92 4,594.00 2,434.82 3,495.00 1,852.35

45-49 11,259.00 5,967.27 6,729.00 3,566.37 5,225.00 2,769.25 4,076.00 2,160.28

50-54 12,365.00 6,553.45 7,847.00 4,158.91 5,871.00 3,111.63 4,466.00 2,366.98

55-59 14,680.00 7,780.40 8,675.00 4,597.75 6,797.00 3,602.41 5,282.00 2,799.46

60-64 19,464.00 10,315.92 11,379.00 6,030.87 8,957.00 4,747.21 6,986.00 3,702.58

65-69 31,257.00 16,566.21 18,334.00 9,717.02 14,419.00 7,642.07 11,756.00 6,230.68

70-74 45,457.00 24,092.21 26,641.00 14,119.73 21,028.00 11,144.84 17,047.00 9,034.91

75-79 56,918.00 30,166.54 34,935.00 18,515.55 26,313.00 13,945.89 22,364.00 11,852.92

80 + 80,232.00 42,522.96 49,229.00 26,091.37 37,065.00 19,644.45 31,526.00 16,708.78

Additional coverage

Maternity complications US$225.00 US$119.25

Private pilot 125.00 66.25 US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25

Deducibles Plan C Plan C Plus Plan D Plan E

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

Fuera del país de residencia US$2,500 US$5,000 US$10,000 US$20,000

Edad Anual Semestral Anual Semestral Anual Semestral Anual Semestral

1 hijo US$2,419.00 US$1,282.07 US$1,558.00 US$825.74 US$1,372.00 US$727.16 US$1,000.00 US$530.00

2 hijos 3,814.00 2,021.42 2,462.00 1,304.86 2,172.00 1,151.16 1,464.00 775.92

3 hijos o más 5,690.00 3,015.70 3,706.00 1,964.18 3,265.00 1,730.45 2,335.00 1,237.55

18-25 5,860.00 3,105.80 3,572.00 1,893.16 2,724.00 1,443.72 2,168.00 1,149.04

26-29 6,727.00 3,565.31 4,079.00 2,161.87 3,123.00 1,655.19 2,471.00 1,309.63

30-34 7,642.00 4,050.26 4,732.00 2,507.96 3,605.00 1,910.65 2,788.00 1,477.64

35-39 8,510.00 4,510.30 5,261.00 2,788.33 4,109.00 2,177.77 3,100.00 1,643.00

40-44 9,647.00 5,112.91 5,964.00 3,160.92 4,594.00 2,434.82 3,495.00 1,852.35

45-49 11,259.00 5,967.27 6,729.00 3,566.37 5,225.00 2,769.25 4,076.00 2,160.28

50-54 12,365.00 6,553.45 7,847.00 4,158.91 5,871.00 3,111.63 4,466.00 2,366.98

55-59 14,680.00 7,780.40 8,675.00 4,597.75 6,797.00 3,602.41 5,282.00 2,799.46

60-64 19,464.00 10,315.92 11,379.00 6,030.87 8,957.00 4,747.21 6,986.00 3,702.58

65-69 31,257.00 16,566.21 18,334.00 9,717.02 14,419.00 7,642.07 11,756.00 6,230.68

70-74 45,457.00 24,092.21 26,641.00 14,119.73 21,028.00 11,144.84 17,047.00 9,034.91

75-79 56,918.00 30,166.54 34,935.00 18,515.55 26,313.00 13,945.89 22,364.00 11,852.92

80 + 80,232.00 42,522.96 49,229.00 26,091.37 37,065.00 19,644.45 31,526.00 16,708.78

Cobertura adicional

Complicaciones de maternidad US$225.00 US$119.25

Piloto privado 125.00 66.25 US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25

PUERTO RICO

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1 child US$3,282.00 US$1,739.46 US$2,387.00 US$1,265.11 US$1,683.00 US$891.99 US$1,093.00 US$579.29 US$958.00 US$507.74 US$690.00 US$365.70

2 children 5,194.00 2,752.82 3,770.00 1,998.10 2,661.00 1,410.33 1,724.00 913.72 1,517.00 804.01 1,013.00 536.89

3 or more children 7,625.00 4,041.25 5,489.00 2,909.17 3,879.00 2,055.87 2,519.00 1,335.07 2,199.00 1,165.47 1,545.00 818.85

18-25 7,337.00 3,888.61 5,761.00 3,053.33 4,095.00 2,170.35 2,520.00 1,335.60 1,920.00 1,017.60 1,523.00 807.19

26-29 8,333.00 4,416.49 6,617.00 3,507.01 4,703.00 2,492.59 2,869.00 1,520.57 2,193.00 1,162.29 1,723.00 913.19

30-34 9,421.00 4,993.13 7,525.00 3,988.25 5,336.00 2,828.08 3,328.00 1,763.84 2,531.00 1,341.43 1,951.00 1,034.03

35-39 10,685.00 5,663.05 8,383.00 4,442.99 5,944.00 3,150.32 3,703.00 1,962.59 2,886.00 1,529.58 2,165.00 1,147.45

40-44 12,018.00 6,369.54 9,503.00 5,036.59 6,739.00 3,571.67 4,196.00 2,223.88 3,223.00 1,708.19 2,444.00 1,295.32

45-49 13,671.00 7,245.63 11,093.00 5,879.29 7,860.00 4,165.80 4,726.00 2,504.78 3,662.00 1,940.86 2,842.00 1,506.26

50-54 15,766.00 8,355.98 12,184.00 6,457.52 8,630.00 4,573.90 5,511.00 2,920.83 4,117.00 2,182.01 3,120.00 1,653.60

55-59 17,837.00 9,453.61 14,478.00 7,673.34 10,243.00 5,428.79 6,098.00 3,231.94 4,760.00 2,522.80 3,682.00 1,951.46

60-64 21,704.00 11,503.12 19,232.00 10,192.96 13,609.00 7,212.77 8,008.00 4,244.24 6,285.00 3,331.05 4,872.00 2,582.16

65-69 35,321.00 18,720.13 31,010.00 16,435.30 21,917.00 11,616.01 12,937.00 6,856.61 10,140.00 5,374.20 8,212.00 4,352.36

70-74 51,807.00 27,457.71 45,302.00 24,010.06 32,011.00 16,965.83 18,872.00 10,002.16 14,854.00 7,872.62 11,965.00 6,341.45

75-79 64,338.00 34,099.14 56,731.00 30,067.43 40,074.00 21,239.22 24,743.00 13,113.79 18,581.00 9,847.93 15,693.00 8,317.29

80 + 90,693.00 48,067.29 79,970.00 42,384.10 56,480.00 29,934.40 34,863.00 18,477.39 26,169.00 13,869.57 22,116.00 11,721.48







1 hijo US$3,282.00 US$1,739.46 US$2,387.00 US$1,265.11 US$1,683.00 US$891.99 US$1,093.00 US$579.29 US$958.00 US$507.74 US$690.00 US$365.70

2 hijos 5,194.00 2,752.82 3,770.00 1,998.10 2,661.00 1,410.33 1,724.00 913.72 1,517.00 804.01 1,013.00 536.89

3 hijos o más 7,625.00 4,041.25 5,489.00 2,909.17 3,879.00 2,055.87 2,519.00 1,335.07 2,199.00 1,165.47 1,545.00 818.85

18-25 7,337.00 3,888.61 5,761.00 3,053.33 4,095.00 2,170.35 2,520.00 1,335.60 1,920.00 1,017.60 1,523.00 807.19

26-29 8,333.00 4,416.49 6,617.00 3,507.01 4,703.00 2,492.59 2,869.00 1,520.57 2,193.00 1,162.29 1,723.00 913.19

30-34 9,421.00 4,993.13 7,525.00 3,988.25 5,336.00 2,828.08 3,328.00 1,763.84 2,531.00 1,341.43 1,951.00 1,034.03

35-39 10,685.00 5,663.05 8,383.00 4,442.99 5,944.00 3,150.32 3,703.00 1,962.59 2,886.00 1,529.58 2,165.00 1,147.45

40-44 12,018.00 6,369.54 9,503.00 5,036.59 6,739.00 3,571.67 4,196.00 2,223.88 3,223.00 1,708.19 2,444.00 1,295.32

45-49 13,671.00 7,245.63 11,093.00 5,879.29 7,860.00 4,165.80 4,726.00 2,504.78 3,662.00 1,940.86 2,842.00 1,506.26

50-54 15,766.00 8,355.98 12,184.00 6,457.52 8,630.00 4,573.90 5,511.00 2,920.83 4,117.00 2,182.01 3,120.00 1,653.60

55-59 17,837.00 9,453.61 14,478.00 7,673.34 10,243.00 5,428.79 6,098.00 3,231.94 4,760.00 2,522.80 3,682.00 1,951.46

60-64 21,704.00 11,503.12 19,232.00 10,192.96 13,609.00 7,212.77 8,008.00 4,244.24 6,285.00 3,331.05 4,872.00 2,582.16

65-69 35,321.00 18,720.13 31,010.00 16,435.30 21,917.00 11,616.01 12,937.00 6,856.61 10,140.00 5,374.20 8,212.00 4,352.36

70-74 51,807.00 27,457.71 45,302.00 24,010.06 32,011.00 16,965.83 18,872.00 10,002.16 14,854.00 7,872.62 11,965.00 6,341.45

75-79 64,338.00 34,099.14 56,731.00 30,067.43 40,074.00 21,239.22 24,743.00 13,113.79 18,581.00 9,847.93 15,693.00 8,317.29

80 + 90,693.00 48,067.29 79,970.00 42,384.10 56,480.00 29,934.40 34,863.00 18,477.39 26,169.00 13,869.57 22,116.00 11,721.48



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1 child US$2,923.00 US$1,549.19 US$2,128.00 US$1,127.84 US$1,499.00 US$794.47 US$976.00 US$517.28 US$852.00 US$451.56 US$612.00 US$324.36

2 children 4,619.00 2,448.07 3,354.00 1,777.62 2,368.00 1,255.04 1,538.00 815.14 1,352.00 716.56 902.00 478.06

3 or more children 6,793.00 3,600.29 4,887.00 2,590.11 3,451.00 1,829.03 2,240.00 1,187.20 1,957.00 1,037.21 1,374.00 728.22

18-25 6,541.00 3,466.73 5,140.00 2,724.20 3,656.00 1,937.68 2,250.00 1,192.50 1,718.00 910.54 1,363.00 722.39

26-29 7,426.00 3,935.78 5,902.00 3,128.06 4,200.00 2,226.00 2,562.00 1,357.86 1,964.00 1,040.92 1,546.00 819.38

30-34 8,390.00 4,446.70 6,708.00 3,555.24 4,763.00 2,524.39 2,973.00 1,575.69 2,263.00 1,199.39 1,746.00 925.38

35-39 9,519.00 5,045.07 7,474.00 3,961.22 5,305.00 2,811.65 3,306.00 1,752.18 2,574.00 1,364.22 1,937.00 1,026.61

40-44 10,707.00 5,674.71 8,469.00 4,488.57 6,010.00 3,185.30 3,745.00 1,984.85 2,879.00 1,525.87 2,181.00 1,155.93

45-49 12,177.00 6,453.81 9,887.00 5,240.11 7,010.00 3,715.30 4,221.00 2,237.13 3,270.00 1,733.10 2,540.00 1,346.20

50-54 14,047.00 7,444.91 10,859.00 5,755.27 7,697.00 4,079.41 4,918.00 2,606.54 3,672.00 1,946.16 2,784.00 1,475.52

55-59 15,885.00 8,419.05 12,899.00 6,836.47 9,130.00 4,838.90 5,435.00 2,880.55 4,248.00 2,251.44 3,283.00 1,739.99

60-64 19,324.00 10,241.72 17,130.00 9,078.90 12,125.00 6,426.25 7,141.00 3,784.73 5,602.00 2,969.06 4,347.00 2,303.91

65-69 31,486.00 16,687.58 27,646.00 14,652.38 19,540.00 10,356.20 11,536.00 6,114.08 9,045.00 4,793.85 7,327.00 3,883.31

70-74 46,134.00 24,451.02 40,345.00 21,382.85 28,514.00 15,112.42 16,815.00 8,911.95 13,233.00 7,013.49 10,662.00 5,650.86

75-79 57,292.00 30,364.76 50,521.00 26,776.13 35,691.00 18,916.23 22,039.00 11,680.67 16,550.00 8,771.50 13,980.00 7,409.40

80 + 80,764.00 42,804.92 71,212.00 37,742.36 50,302.00 26,660.06 31,053.00 16,458.09 23,308.00 12,353.24 19,700.00 10,441.00







1 hijo US$2,923.00 US$1,549.19 US$2,128.00 US$1,127.84 US$1,499.00 US$794.47 US$976.00 US$517.28 US$852.00 US$451.56 US$612.00 US$324.36

2 hijos 4,619.00 2,448.07 3,354.00 1,777.62 2,368.00 1,255.04 1,538.00 815.14 1,352.00 716.56 902.00 478.06

3 hijos o más 6,793.00 3,600.29 4,887.00 2,590.11 3,451.00 1,829.03 2,240.00 1,187.20 1,957.00 1,037.21 1,374.00 728.22

18-25 6,541.00 3,466.73 5,140.00 2,724.20 3,656.00 1,937.68 2,250.00 1,192.50 1,718.00 910.54 1,363.00 722.39

26-29 7,426.00 3,935.78 5,902.00 3,128.06 4,200.00 2,226.00 2,562.00 1,357.86 1,964.00 1,040.92 1,546.00 819.38

30-34 8,390.00 4,446.70 6,708.00 3,555.24 4,763.00 2,524.39 2,973.00 1,575.69 2,263.00 1,199.39 1,746.00 925.38

35-39 9,519.00 5,045.07 7,474.00 3,961.22 5,305.00 2,811.65 3,306.00 1,752.18 2,574.00 1,364.22 1,937.00 1,026.61

40-44 10,707.00 5,674.71 8,469.00 4,488.57 6,010.00 3,185.30 3,745.00 1,984.85 2,879.00 1,525.87 2,181.00 1,155.93

45-49 12,177.00 6,453.81 9,887.00 5,240.11 7,010.00 3,715.30 4,221.00 2,237.13 3,270.00 1,733.10 2,540.00 1,346.20

50-54 14,047.00 7,444.91 10,859.00 5,755.27 7,697.00 4,079.41 4,918.00 2,606.54 3,672.00 1,946.16 2,784.00 1,475.52

55-59 15,885.00 8,419.05 12,899.00 6,836.47 9,130.00 4,838.90 5,435.00 2,880.55 4,248.00 2,251.44 3,283.00 1,739.99

60-64 19,324.00 10,241.72 17,130.00 9,078.90 12,125.00 6,426.25 7,141.00 3,784.73 5,602.00 2,969.06 4,347.00 2,303.91

65-69 31,486.00 16,687.58 27,646.00 14,652.38 19,540.00 10,356.20 11,536.00 6,114.08 9,045.00 4,793.85 7,327.00 3,883.31

70-74 46,134.00 24,451.02 40,345.00 21,382.85 28,514.00 15,112.42 16,815.00 8,911.95 13,233.00 7,013.49 10,662.00 5,650.86

75-79 57,292.00 30,364.76 50,521.00 26,776.13 35,691.00 18,916.23 22,039.00 11,680.67 16,550.00 8,771.50 13,980.00 7,409.40

80 + 80,764.00 42,804.92 71,212.00 37,742.36 50,302.00 26,660.06 31,053.00 16,458.09 23,308.00 12,353.24 19,700.00 10,441.00



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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

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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BIC_PB_AWW_V18.01

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

BUPA WORLDWIDE - bupalatinamerica.com · hasta un máximo de US$5,000,000. Aplica un coaseguro por...

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