Care for Indonesia TOB

Table of Benefits

Care for Indonesia

International healthcare for you and your family
Valid from 1^st November 2026

This Table of Benefits provides an overview of the treatments and medical services you are covered for, as listed in this document. Your cover will also include the following member services, included in the cost of your plan.Contents

We provide our Care plans in three different levels, which offer from essential to premium cover:

Care Base

Care Enhanced

Care Signature

We provide our Care plans in three different levels, which offer from essential to premium cover: Care Base, Care Enhanced and Care Signature. Please see the tables in the next pages for a comparison of the three levels and choose the one that suits you. Under these cover levels, you will find three modules that cover different types of treatments: Core for in-patient and high-cost treatments, then Out-patient and Dental. You must select the type of Core plan you prefer, then you can add either an Out-patient plan or a Dental plan, or both. You cannot buy the Out-patient plan and the Dental plan separately, without a Core plan.

Please note that the type of Core plan you select will determine the type of the other modules, e.g. if you choose the Care Base Core Plan, then you must select the Care Base Out-patient Plan, and so on.

Policy terms and conditions

This Table of Benefits was designed for informational purposes and offers an overview of the cover we provide under each plan. All limits are per member, per Insurance Year, unless otherwise stated. Cover is subject to product availability and to our policy terms and conditions, as detailed in our Individual Benefit Guide available on our website: www.allianzcare.com

Key to Table of Benefits

√	Covered in full, up to the maximum plan limit
X	Not available

Core Plans

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Maximum plan limit	US$ 1,350,000	US$ 2,700,000	US$ 5,000,000
In-patient benefits
Hospital accommodation Pre-authorisation required	Private room	Private room	Private room
Intensive care Pre-authorisation required	√	√	√
Prescribed drugs and dressings In-patient and day-care treatment only Pre-authorisation required	√	√	√
Surgical fees, including anaesthesia and theatre charges Pre-authorisation required	√	√	√
Physician and therapist fees In-patient and day-care treatment only Pre-authorisation required	√	√	√
Surgical appliances and materials Pre-authorisation required	√	√	√

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Diagnostic tests In-patient and day-care treatment only Pre-authorisation required	√	√	√
Organ transplant In-patient treatment only Pre-authorisation required	√	√	√
Bariatric surgery In-patient, day-care and out-patient treatment 24-month waiting period applies Pre-authorisation required	X	70% up to US$ 20,250	80% up to US$ 27,000
Psychiatry and psychotherapy In-patient and day-care treatment only Pre-authorisation required	√	√	√
Accommodation costs for one parent staying in hospital with an insured child under 18 Pre-authorisation required	√	√	√
Emergency in-patient dental treatment	√	√	√

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Other benefits
Day-care treatment Pre-authorisation required	√	√	√
Kidney dialysis In-patient, day-care and out-patient treatment Pre-authorisation required	√	√	√
HIV/AIDS treatment In-patient, day-care and out-patient treatment Pre-authorisation required	√	√	√
Out-patient surgery Pre-authorisation required	√	√	√
Nursing at home or in a convalescent home Immediately after or instead of hospitalisation Pre-authorisation required	US$ 2,025, max 30 days	US$ 3,375, max 60 days	√ max. 90 days
Rehabilitation treatment In-patient, day-care and out-patient treatment; must commence within 14 days of discharge after the acute medical and/or surgical treatment ceases Pre-authorisation required	US$ 4,050, max 30 days	US$ 10,125, max 60 days	√ max. 90 days

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Pre-hospitalisation tests Covered when they are needed in the 72 hours before in-patient or day-care treatment	√	√	√
Post-hospitalisation treatment Covered when it is needed in the 90 days following discharge from in-patient or day-care treatment for the same acute medical condition	√	√	√
Local ambulance	√	√	√
Emergency treatment outside area of cover For trips of a maximum period of six weeks	US$ 135,000, max. 42 days	US$ 337,500, max. 42 days	√ max. 42 days
Medical evacuation and repatriation	√	√	√
Where necessary treatment is not available locally, we will evacuate the insured person to the nearest appropriate medical centre (or if the insured person’s home country is within their area of cover, they can choose to be medically repatriated to their home country). Pre-authorisation required	√	√	√
Where ongoing treatment is required, we will cover hotel accommodation costs. Pre-authorisation required	√	√	√
Evacuation in the event of unavailability of adequately screened blood. Pre-authorisation required	√	√	√

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
If medical necessity prevents an immediate return trip following discharge from an in-patient episode of care, we will cover hotel accommodation costs. Pre-authorisation required	Max. 7 days	Max. 7 days	Max. 7 days
Travel costs for one person accompanying an evacuated/repatriated person Pre-authorisation required	US$ 2,700	US$ 4,050	US$ 4,050
Travel costs of insured family members in the event of an evacuation/repatriation Pre-authorisation required	X	US$ 2,700 per event	US$ 2,700 per event
Travel costs of insured persons to be with a close relative who is at peril of death or who has died One round trip per insured person per Insurance Year	X	US$ 1,015	US$ 2,025
Repatriation of mortal remains or burial expenses Pre-authorisation required	√	√	√
Travel costs of insured family members in the event of the repatriation of mortal remains Pre-authorisation required	X	US$ 2,700 per event	US$ 2,700 per event
CT and MRI scans In-patient and out-patient treatment	√	√	√

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
PET and CT-PET scans In-patient and out-patient treatment Pre-authorisation required	√	√	√
Oncology In-patient, day-care and out-patient treatment Pre-authorisation required	√	√	√
Purchase of a wig, prosthetic bra or other external prosthetic device for cosmetic purposes	US$ 270	US$ 270	US$ 675
Congenital conditions In-patient, day-care and out-patient treatment Pre-authorisation required	US$ 20,250	US$ 33,750	US$ 54,000
Preventive surgery In-patient and out-patient treatment Pre-authorisation required	X	US$ 20,250	US$ 40,500
Routine maternity In-patient and out-patient treatment 12-month waiting period applies Pre-authorisation required	X	US$ 6,750 per pregnancy	US$ 13,500 per pregnancy
Complications of childbirth In-patient treatment 12-month waiting period applies Pre-authorisation required	X	US$ 13,500 per pregnancy	US$ 20,250 per pregnancy

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Complications of pregnancy In-patient and out-patient treatment 12-month waiting period applies Pre-authorisation required	X	√	√
Laser eye treatment	X	X	US$ 1,350
In-patient cash benefit at public hospitals Per night	US$ 205, max. 25 nights	US$ 205, max. 25 nights	US$ 205, max. 25 nights
Emergency out-patient treatment Where these benefit amounts are reached, any additional costs may be reimbursed within the terms of any separate Out-patient Plan	US$ 338	US$ 1,015	US$ 2,025
Emergency out-patient dental treatment Can also be reimbursed within the terms of any separate Dental Plan	X	US$ 400	US$ 1,015
Palliative care In-patient, day-care and out-patient treatment Pre-authorisation required	√	√	√
Long term care In-patient, day-care and out-patient treatment Pre-authorisation required	Max. 90 days per lifetime	Max. 90 days per lifetime	Max. 90 days per lifetime

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Additional Core Plan services
Expat Assistance Programme** Offers access to a range of 24/7 multilingual support services as follows: Confidential and professional counselling up to five sessions per issue, per calendar year (in-person, phone and video) Legal and financial referral services Wellness website access	√	√	√
Travel Security Services** Offers 24/7 access to personal security information and advice for all your travel safety queries. This includes: Emergency Security Assistance Hotline (not a free phone number) Country intelligence and security advice Daily security news and travel safety alerts	√	√	√
Olive** Our Health & Wellness support program includes, for example: Fitness app Access to wellness resources	√	√	√
Digital Health App** Reimbursement for one digital health app of your choice for the prevention, detection and management of a disease or condition.	US$ 70	US$ 70	US$ 70

Indonesia Care
Base

Indonesia Care Enhanced

Indonesia Care Signature

MyHealth Digital Services

Manage your cover online with our app or portal anytime, anywhere
Submit and track progress of claims
Access your policy documents, health services, payment details and more

√

Second Medical Opinion Service**

Offers access to expert help on the best treatment options available, if you have been diagnosed with a serious illness or had surgery recommended

√

Core Plan Deductibles

To reduce your Core Plan premium, simply select an optional deductible from the list below and read across to find the relevant premium discount. You can choose a Core Plan deductible AND/OR an Out-patient Plan co-payment (appearing further in this document, under the Out-patient Plan table). Where a deductible is selected, it is payable per person, per Insurance Year. Also, our premiums are expressed in whole numbers (i.e. without any cents or pence etc.), therefore, percentages may be slightly higher or lower than those stated below.

Optional Core Plan Deductibles	Premium discount
No deductible	0%
US$ 1,000	10%
US$ 4,000	20%
US$ 8,000	30%
US$ 15,000	40%

Out-patient Plans

You can select an Out-patient Plan together with the corresponding Core Plan. You cannot buy it separately.

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Maximum plan limit	US$ 6,750	US$ 11,780	No limit
Out-patient Plan benefits
Video consultation services** Accessed via our TeleHealth Hub	√	√	√
Medical practitioner fees	√	√	√
Prescribed drugs and dressings	√	√	√
Specialist fees	√	√	√
Diagnostic tests	√	√	√

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Vaccinations	US$ 150	US$ 400	US$ 700
Chiropractic treatment osteopathy, homeopathy, Chinese herbal medicine, acupuncture (including cupping and moxibustion) and podiatry	US$ 405	US$ 1,520	√
Prescribed physiotherapy Referral from doctor required After every 12 visits, your doctor or therapist needs to provide a progress report and a treatment plan for your condition	US$ 675	US$ 1,520	√
Prescribed speech therapy and occupational therapy Pre-authorisation required	US$ 675	US$ 1,520	√

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Health and wellbeing checks including screening for the early detection of illness or disease Checks are limited to: Physical examination Chest X-ray Blood tests (full blood count, biochemistry, lipid profile, thyroid function test, liver function test, kidney function test) Cardiovascular examination (physical examination, electrocardiogram, blood pressure) Neurological examination (physical examination) Bone densitometry (every five years for women aged 50+) Cancer screening Checks are limited to: Annual gynaecological exam Mammogram (every two years for women aged 45+, or younger where a family history exists) Annual prostate screening (yearly for men aged 50+, or younger where a family history exists) Colonoscopy (every five years for members aged 50+, or 40+ where a family history exists) Annual faecal occult blood test BRCA1 and BRCA2 genetic test (where a direct family history exists) Well child test (for children up to the age of six years)	US$ 200 X	US$ 810 15 visits	US$ 1,080 15 visits
Fertility treatment 12-month waiting period applies	X	X	US$ 9,450 per year
Psychiatry and psychotherapy Referral from doctor required for psychotherapy	5 visits	15 visits	30 visits

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Prescribed medical aids	US$ 675	US$ 2,025	√
Prescribed glasses and contact lenses including eye examination	X	X	US$ 245
Dietician fees	X	2 visits	4 visits
Hormone replacement therapy	US$ 540	US$ 1,015	US$ 1,620
Prescribed vitamins, minerals and supplements	X	US$ 150	US$ 150

Out-patient Plan co-payments

To reduce your Out-patient Plan premium, simply select an optional co-payment from the list below and read across to find the relevant premium discount. You can choose an Out-patient Plan co-payment AND/OR a Core Plan deductible. Also, our premiums are expressed in whole numbers (i.e. without any cent), therefore, percentages may be slightly higher or lower than those stated below.

Optional Out-patient Plan co-payment	Premium discount
No co-payment	0%
10%	12.5%
20%	25%
30%	36.5%

Dental Plans

You can select a Dental Plan together with the corresponding Core Plan. You cannot buy it separately.

	Indonesia Care Base	Indonesia Care Enhanced	Indonesia Care Signature
Maximum plan limit	US$ 750	US$ 1,500	US$ 2,500
Dental Plan benefits
Dental treatment	80% refund	80% refund	√
Dental surgery	80% refund	80% refund	√
Periodontics	80% refund	80% refund	√
Orthodontic treatment 10-month waiting period applies	X	50% refund	50% refund
Dental prostheses 10-month waiting period applies	X	50% refund	50% refund

Area of cover

We offer a choice of three different areas of cover:

Worldwide*

Worldwide excluding USA

Southeast Asia Select
(Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Thailand and Vietnam only)

The cost of your cover will vary depending on which region of cover you choose. The areas of cover are subject to our terms and conditions.

*For Worldwide cover, please see our Benefit Guide for details on how to navigate the US healthcare system ensuring access to care on a direct billing basis.

** Certain services that may be included in your plan are provided by third party providers. If included in your plan, these services will show in your Table of Benefits. These services are made available to you subject to your acceptance of your policy’s terms and conditions, as well as the service’s terms and conditions as set out by the relevant third party service provider. By accepting the third party service providers’ terms and conditions, you enter a separate contractual relationship directly with them. Their services may be subject to geographical restrictions. Full details of the third party service providers’ terms and conditions are available in their websites and in the relevant application and/or platform where services may be hosted. The third party service providers are independent data controllers, and we recommend that you review their privacy notices to understand how they process your personal data. The third party service providers offer non-insurance services that are not intended to be a substitute for in-person medical consultations, diagnosis, treatment, assessment or care. You understand and agree that the insurer, its reinsurer and their administrators are not responsible or liable for any claim, loss or damage, directly or indirectly resulting from your use of any of these third party services.

Request a callback

Medical Provider Access options

Comprehensive You have access to any medical provider of your choice within your area of cover. No medical provider co-payments apply.Standard You have access to any medical provider of your choice within your area of cover, same as per the ‘Comprehensive’ option. However,
in this case there will be a 20%
co-payment applicable to most
in-patient and day-care treatments and services covered under the Core Plan, when you receive them at the medical providers listed alongside. The selection of the ‘Standard’ option will also lower your premium.Singapore

Mount Elizabeth Hospital

Mount Elizabeth Novena Hospital

Gleneagles Hospital

Farrer Park Hospital

Parkway East Hospital

Hong Kong

Hong Kong Sanatorium & Hospital, HKSH Eastern Medical Centre and HKSH Cancer Centre

Hong Kong Adventist Hospital - Stubbs Road

Gleneagles Hong Kong Hospital

Matilda International Hospital

China

All locations of United Family Hospitals and Clinics, except all Shanghai United Family Hospitals and Clinics

All locations of Parkway Health Clinics, including the Gleneagles Medical and Surgical Centre and Shenton Clinics

Raffles Medical in Beijing, Tianjin, Nanjing, Chongqing

Thailand

Bumrungrad International Hospital, Bangkok

Bangkok Hospital, Bangkok

Indonesia

All locations of Pondok Indah Hospitals

All locations of Siloam Hospitals

Rumah Sakit Umum Siloam Lippo Village

Rumah Sakit Umum Syubbanul Wathon

BIMC Nusa Dua

BIMC Kuta

Malaysia

Prince Court Medical Centre

Pantai Hospital Kuala Lumpur

KPJ Ampang Puteri

Philippines

Asian Hospital and Medical Center

St. Luke's Medical Center - Quezon City

St. Luke's Medical Center - Global City

Vietnam

FV Hospital

Family Medical Practice District 1 - Ho Chi Minh City

Talk to us, we love to help!

If you have any queries, please get in touch:

Request a callback

Or contact us:

Helpline

Phone: 0018 0306 5171 (toll-free calling from inside Indonesia)
+ 60 3 92127820 (calling from outside Indonesia)

Toll free numbers: www.allianzcare.com/toll-free-numbers

If you are not able to access the toll-free numbers from a mobile phone, please dial the Helpline number listed above. Calls to our Helpline will be recorded and may be monitored for training, quality and regulatory purposes.

Email: individual.sales@allianzworldwidecare.com