PREMIUM BOOKLET B U PA CHOICE

PREMIUM BOOKLET B U PA CHOICE EFFECTIVE JANUARY 1, 2018

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 incountry 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.

CHOICE ZONE 2 Central America ZONE 3 Belize, Caribbean Islands, French Guiana, Guyana, Suriname ZONE 4 Bolivia, Colombia, Peru ECUADOR VENEZUELA Deductibles Plan Plan Plan Plan Plan In country of residence Out of country of residence US$500 US$500 US$500 US$500 US$500 US$2,500 US$2,500 US$2,500 US$2,500 US$2,500 Age Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual Annual Semiannual 1 child US$1,723.00 US$913.19 US$1,433.00 US$759.49 US$1,143.00 US$605.79 US$1,039.00 US$550.67 US$892.00 US$472.76 2 children 2,724.00 1,443.72 2,273.00 1,204.69 1,800.00 954.00 1,644.00 871.32 1,414.00 749.42 3 or more children 3,946.00 2,091.38 3,299.00 1,748.47 2,620.00 1,388.60 2,388.00 1,265.64 2,051.00 1,087.03 18-24 4,191.00 2,221.23 3,517.00 1,864.01 2,804.00 1,486.12 2,564.00 1,358.92 2,217.00 1,175.01 25-29 4,814.00 2,551.42 4,035.00 2,138.55 3,212.00 1,702.36 2,934.00 1,555.02 2,542.00 1,347.26 30-34 5,456.00 2,891.68 4,578.00 2,426.34 3,641.00 1,929.73 3,332.00 1,765.96 2,877.00 1,524.81 35-39 6,076.00 3,220.28 5,098.00 2,701.94 4,053.00 2,148.09 3,701.00 1,961.53 3,195.00 1,693.35 40-44 6,893.00 3,653.29 5,775.00 3,060.75 4,594.00 2,434.82 4,195.00 2,223.35 3,622.00 1,919.66 45-49 8,032.00 4,256.96 6,727.00 3,565.31 5,356.00 2,838.68 4,887.00 2,590.11 4,217.00 2,235.01 50-54 8,815.00 4,671.95 7,386.00 3,914.58 5,871.00 3,111.63 5,364.00 2,842.92 4,625.00 2,451.25 55-59 10,460.00 5,543.80 8,760.00 4,642.80 6,967.00 3,692.51 6,357.00 3,369.21 5,482.00 2,905.46 60-64 13,873.00 7,352.69 11,628.00 6,162.84 9,278.00 4,917.34 8,468.00 4,488.04 7,280.00 3,858.40 65-69 18,723.00 9,923.19 15,682.00 8,311.46 12,543.00 6,647.79 11,443.00 6,064.79 9,830.00 5,209.90 70-74 27,278.00 14,457.34 22,744.00 12,054.32 18,218.00 9,655.54 16,613.00 8,804.89 14,276.00 7,566.28 75-79 34,150.00 18,099.50 28,464.00 15,085.92 22,799.00 12,083.47 20,791.00 11,019.23 17,862.00 9,466.86 80 + 45,133.00 23,920.49 37,627.00 19,942.31 30,321.00 16,070.13 27,650.00 14,654.50 23,751.00 12,588.03 BUPA CHOICE PREMIUM BOOKLET, EFFECTIVE JANUARY 1, 2018 Additional coverage Private pilot US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25 Transplant procedures 250.00 132.50 250.00 132.50 250.00 132.50 250.00 132.50 250.00 132.50

CHOICE ZONA 2 Centroamérica ZONA 3 Belice, Guayana Francesa, Guyana, Islas del Caribe, Surinam ZONA 4 Bolivia, Colombia, Perú ECUADOR VENEZUELA Deducibles Plan Plan Plan Plan Plan Dentro del país de residencia Fuera del país de residencia US$500 US$500 US$500 US$500 US$500 US$2,500 US$2,500 US$2,500 US$2,500 US$2,500 Edad Anual Semestral Anual Semestral Anual Semestral Anual Semestral Anual Semestral 1 hijo US$1,723.00 US$913.19 US$1,433.00 US$759.49 US$1,143.00 US$605.79 US$1,039.00 US$550.67 US$892.00 US$472.76 2 hijos 2,724.00 1,443.72 2,273.00 1,204.69 1,800.00 954.00 1,644.00 871.32 1,414.00 749.42 3 hijos o más 3,946.00 2,091.38 3,299.00 1,748.47 2,620.00 1,388.60 2,388.00 1,265.64 2,051.00 1,087.03 18-24 4,191.00 2,221.23 3,517.00 1,864.01 2,804.00 1,486.12 2,564.00 1,358.92 2,217.00 1,175.01 25-29 4,814.00 2,551.42 4,035.00 2,138.55 3,212.00 1,702.36 2,934.00 1,555.02 2,542.00 1,347.26 30-34 5,456.00 2,891.68 4,578.00 2,426.34 3,641.00 1,929.73 3,332.00 1,765.96 2,877.00 1,524.81 35-39 6,076.00 3,220.28 5,098.00 2,701.94 4,053.00 2,148.09 3,701.00 1,961.53 3,195.00 1,693.35 40-44 6,893.00 3,653.29 5,775.00 3,060.75 4,594.00 2,434.82 4,195.00 2,223.35 3,622.00 1,919.66 45-49 8,032.00 4,256.96 6,727.00 3,565.31 5,356.00 2,838.68 4,887.00 2,590.11 4,217.00 2,235.01 50-54 8,815.00 4,671.95 7,386.00 3,914.58 5,871.00 3,111.63 5,364.00 2,842.92 4,625.00 2,451.25 55-59 10,460.00 5,543.80 8,760.00 4,642.80 6,967.00 3,692.51 6,357.00 3,369.21 5,482.00 2,905.46 60-64 13,873.00 7,352.69 11,628.00 6,162.84 9,278.00 4,917.34 8,468.00 4,488.04 7,280.00 3,858.40 65-69 18,723.00 9,923.19 15,682.00 8,311.46 12,543.00 6,647.79 11,443.00 6,064.79 9,830.00 5,209.90 70-74 27,278.00 14,457.34 22,744.00 12,054.32 18,218.00 9,655.54 16,613.00 8,804.89 14,276.00 7,566.28 75-79 34,150.00 18,099.50 28,464.00 15,085.92 22,799.00 12,083.47 20,791.00 11,019.23 17,862.00 9,466.86 80 + 45,133.00 23,920.49 37,627.00 19,942.31 30,321.00 16,070.13 27,650.00 14,654.50 23,751.00 12,588.03 BUPA CHOICE FOLLETO DE TARIFAS EFECTIVAS EL 1 DE ENERO DEL 2018 Cobertura adicional Piloto privado US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25 US$125.00 US$66.25 Procedimientos de trasplante 250.00 132.50 250.00 132.50 250.00 132.50 250.00 132.50 250.00 132.50

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 s Account # 2000037371881 ABA # 067006432 Account Name: Bupa Worldwide Premium Trust Reference: Policyholder Name and Policy Number Procedure for domestic wire transfers Account # 2000037371881 ABA # 121000248 Account Name: Bupa Worldwide Premium Trust Reference: Policyholder Name and Policy Number Procedure for international wire transfers Account # 2000037371881 ABA # 121000248 CHIPS # 0407 SWIFT # WFBIUS6S Account Name: Bupa Worldwide Premium Trust Reference: Policyholder Name and Policy Number

CÓMO PAGAR LA PRIMA Bupa 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) Número de cuenta: 2000037371881 ABA #: 067006432 Nombre de la cuenta: Bupa Worldwide Premium Trust Referencia: nombre del asegurado principal y número de póliza Transferencia bancaria doméstica Número de cuenta: 2000037371881 ABA #: 121000248 Nombre de la cuenta: Bupa Worldwide Premium Trust Referencia: nombre del asegurado principal y número de póliza Transferencia bancaria internacional Número de cuenta: 2000037371881 ABA #: 121000248 CHIPS # 0407 SWIFT # WFBIUS6S Nombre de la cuenta: Bupa Worldwide Premium Trust Referencia: nombre del asegurado principal y número de póliza

ZONE X COUNTRY 17901 Old Cutler Road, Suite 400 Palmetto Bay, Florida 33157 Tel. +1 (305) 398 7400 Fax +1 (305) 275 8484 www.bupasalud.com bupa@bupalatinamerica.com BUPA ADVANTAGE CARE PREMIUM BOOKLET, EFFECTIVE JANUARY 1, 2015 BIC_PB_CHO_V18.01