bupa essential care€¦ · de los estados unidos y puerto rico. • opciones de pago disponibles:...

FOLLETO DE TARIFAS

BU PA ESSE NTIAL CARE

E F E C TI VA S E L 1 D E E N E R O D E 2 014

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 UsUs$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.

•Edad máxima para solicitar cobertura: 74 años.

•Las tarifas están basadas en el país de residencia. Por favor consulte folletos de tarifas separados para las islas vírgenes de los Estados Unidos y Puerto rico.

•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.

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

ZoNa 1MÉXICO

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BUPA COMPLETE CARE PrEmiUm ratEs, EFFECtivE JaNUarY 1, 20122

Deducibles Plan1(a) Plan2 Plan3 Plan4 Plan5 Plan6

Dentrodelpaísderesidencia US$0 US$1,000 US$2,000 US$5,000 US$10,000 US$20,000

Fueradelpaísderesidencia US$1,000 US$2,000 US$3,000 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$1,168.00 Us$619.04 Us$1,051.00 Us$557.03 Us$619.00 Us$328.07 Us$530.00 Us$280.90 Us$457.00 Us$242.21 Us$338.00 Us$179.14

2 hijos 1,917.00 1,016.01 1,775.00 940.75 924.00 489.72 837.00 443.61 719.00 381.07 537.00 284.61

3 hijos o más 2,804.00 1,486.12 2,602.00 1,379.06 1,327.00 703.31 1,210.00 641.30 1,047.00 554.91 774.00 410.22

18-24 2,578.00 1,366.34 2,175.00 1,152.75 1,710.00 906.30 1,312.00 695.36 1,138.00 603.14 863.00 457.39

25-29 2,861.00 1,516.33 2,400.00 1,272.00 1,924.00 1,019.72 1,463.00 775.39 1,267.00 671.51 959.00 508.27

30-34 3,305.00 1,751.65 2,752.00 1,458.56 2,259.00 1,197.27 1,703.00 902.59 1,473.00 780.69 1,111.00 588.83

35-39 3,656.00 1,937.68 3,030.00 1,605.90 2,532.00 1,341.96 1,892.00 1,002.76 1,635.00 866.55 1,230.00 651.90

40-44 4,125.00 2,186.25 3,400.00 1,802.00 2,891.00 1,532.23 2,140.00 1,134.20 1,851.00 981.03 1,392.00 737.76

45-49 4,781.00 2,533.93 3,916.00 2,075.48 3,386.00 1,794.58 2,492.00 1,320.76 2,153.00 1,141.09 1,616.00 856.48

50-54 5,228.00 2,770.84 4,272.00 2,264.16 3,728.00 1,975.84 2,731.00 1,447.43 2,362.00 1,251.86 1,771.00 938.63

55-59 6,176.00 3,273.28 5,023.00 2,662.19 4,452.00 2,359.56 3,242.00 1,718.26 2,798.00 1,482.94 2,093.00 1,109.29

60 6,509.00 3,449.77 5,255.00 2,785.15 4,759.00 2,522.27 3,432.00 1,818.96 2,962.00 1,569.86 2,214.00 1,173.42

61 7,330.00 3,884.90 5,916.00 3,135.48 5,359.00 2,840.27 3,864.00 2,047.92 3,332.00 1,765.96 2,497.00 1,323.41

62 8,147.00 4,317.91 6,581.00 3,487.93 5,959.00 3,158.27 4,295.00 2,276.35 3,708.00 1,965.24 2,776.00 1,471.28

63 8,965.00 4,751.45 7,240.00 3,837.20 6,557.00 3,475.21 4,728.00 2,505.84 4,082.00 2,163.46 3,056.00 1,619.68

64 9,784.00 5,185.52 7,903.00 4,188.59 7,156.00 3,792.68 5,162.00 2,735.86 4,457.00 2,362.21 3,335.00 1,767.55

65 9,822.00 5,205.66 7,912.00 4,193.36 7,225.00 3,829.25 5,192.00 2,751.76 4,481.00 2,374.93 3,351.00 1,776.03

66 9,860.00 5,225.80 7,918.00 4,196.54 7,291.00 3,864.23 5,222.00 2,767.66 4,506.00 2,388.18 3,361.00 1,781.33

67 10,959.00 5,808.27 8,802.00 4,665.06 8,105.00 4,295.65 5,807.00 3,077.71 5,009.00 2,654.77 3,737.00 1,980.61

68 12,057.00 6,390.21 9,686.00 5,133.58 8,920.00 4,727.60 6,392.00 3,387.76 5,513.00 2,921.89 4,114.00 2,180.42

69 12,610.00 6,683.30 10,128.00 5,367.84 9,322.00 4,940.66 6,684.00 3,542.52 5,762.00 3,053.86 4,306.00 2,282.18

70 12,699.00 6,730.47 10,144.00 5,376.32 9,479.00 5,023.87 6,751.00 3,578.03 5,820.00 3,084.60 4,321.00 2,290.13

71 14,290.00 7,573.70 11,419.00 6,052.07 10,666.00 5,652.98 7,600.00 4,028.00 6,549.00 3,470.97 4,867.00 2,579.51

72 15,880.00 8,416.40 12,688.00 6,724.64 11,857.00 6,284.21 8,445.00 4,475.85 7,281.00 3,858.93 5,413.00 2,868.89

73 17,470.00 9,259.10 13,962.00 7,399.86 13,047.00 6,914.91 9,291.00 4,924.23 8,011.00 4,245.83 5,958.00 3,157.74

74 19,061.00 10,102.33 15,236.00 8,075.08 14,239.00 7,546.67 10,141.00 5,374.73 8,742.00 4,633.26 6,500.00 3,445.00

75 ó más 20,824.00 11,036.72 16,603.00 8,799.59 15,614.00 8,275.42 11,092.00 5,878.76 9,563.00 5,068.39 7,107.00 3,766.71

CoberturaadicionalComplicaciones de maternidad Us$225.00 Us$119.25 Us$225.00 Us$119.25 Us$225.00 Us$119.25 Us$225.00 Us$119.25 Us$225.00 Us$119.25 Us$225.00 Us$119.25

Procedimientosde trasplante 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00 300.00 159.00

(a) a partir del 1 de enero de 2013, el Plan 1 de deducible (Us$0/Us$1,000) solamente estará disponible para renovaciones del mismo plan de deducible.

ZoNa 2ChILE, hAITí, hONDURAS

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2 hijos 1,927.00 1,021.31 1,786.00 946.58 925.00 490.25 838.00 444.14 724.00 383.72 535.00 283.55

3 hijos o más 2,820.00 1,494.60 2,620.00 1,388.60 1,334.00 707.02 1,218.00 645.54 1,049.00 555.97 776.00 411.28

18-24 2,586.00 1,370.58 2,185.00 1,158.05 1,710.00 906.30 1,312.00 695.36 1,137.00 602.61 861.00 456.33

25-29 2,872.00 1,522.16 2,410.00 1,277.30 1,928.00 1,021.84 1,464.00 775.92 1,269.00 672.57 957.00 507.21

30-34 3,316.00 1,757.48 2,757.00 1,461.21 2,269.00 1,202.57 1,701.00 901.53 1,473.00 780.69 1,110.00 588.30

35-39 3,672.00 1,946.16 3,042.00 1,612.26 2,544.00 1,348.32 1,895.00 1,004.35 1,636.00 867.08 1,233.00 653.49

40-44 4,139.00 2,193.67 3,412.00 1,808.36 2,900.00 1,537.00 2,144.00 1,136.32 1,853.00 982.09 1,391.00 737.23

45-49 4,796.00 2,541.88 3,928.00 2,081.84 3,402.00 1,803.06 2,498.00 1,323.94 2,157.00 1,143.21 1,618.00 857.54

50-54 5,251.00 2,783.03 4,289.00 2,273.17 3,745.00 1,984.85 2,738.00 1,451.14 2,364.00 1,252.92 1,772.00 939.16

55-59 6,201.00 3,286.53 5,044.00 2,673.32 4,472.00 2,370.16 3,247.00 1,720.91 2,805.00 1,486.65 2,095.00 1,110.35

60 6,536.00 3,464.08 5,281.00 2,798.93 4,780.00 2,533.40 3,438.00 1,822.14 2,970.00 1,574.10 2,216.00 1,174.48

61 7,359.00 3,900.27 5,940.00 3,148.20 5,383.00 2,852.99 3,871.00 2,051.63 3,343.00 1,771.79 2,501.00 1,325.53

62 8,181.00 4,335.93 6,606.00 3,501.18 5,983.00 3,170.99 4,310.00 2,284.30 3,719.00 1,971.07 2,781.00 1,473.93

63 9,005.00 4,772.65 7,273.00 3,854.69 6,583.00 3,488.99 4,742.00 2,513.26 4,094.00 2,169.82 3,063.00 1,623.39

64 9,823.00 5,206.19 7,938.00 4,207.14 7,188.00 3,809.64 5,175.00 2,742.75 4,468.00 2,368.04 3,344.00 1,772.32

65 9,865.00 5,228.45 7,946.00 4,211.38 7,254.00 3,844.62 5,207.00 2,759.71 4,493.00 2,381.29 3,356.00 1,778.68

66 9,901.00 5,247.53 7,954.00 4,215.62 7,321.00 3,880.13 5,240.00 2,777.20 4,515.00 2,392.95 3,368.00 1,785.04

67 11,007.00 5,833.71 8,841.00 4,685.73 8,139.00 4,313.67 5,820.00 3,084.60 5,021.00 2,661.13 3,745.00 1,984.85

68 12,112.00 6,419.36 9,730.00 5,156.90 8,959.00 4,748.27 6,406.00 3,395.18 5,526.00 2,928.78 4,124.00 2,185.72

69 12,664.00 6,711.92 10,173.00 5,391.69 9,364.00 4,962.92 6,700.00 3,551.00 5,779.00 3,062.87 4,313.00 2,285.89

70 12,756.00 6,760.68 10,187.00 5,399.11 9,520.00 5,045.60 6,769.00 3,587.57 5,835.00 3,092.55 4,335.00 2,297.55

71 14,354.00 7,607.62 11,469.00 6,078.57 10,717.00 5,680.01 7,621.00 4,039.13 6,569.00 3,481.57 4,880.00 2,586.40

72 15,950.00 8,453.50 12,748.00 6,756.44 11,911.00 6,312.83 8,473.00 4,490.69 7,304.00 3,871.12 5,427.00 2,876.31

73 17,551.00 9,302.03 14,026.00 7,433.78 13,105.00 6,945.65 9,321.00 4,940.13 8,037.00 4,259.61 5,977.00 3,167.81

74 19,150.00 10,149.50 15,303.00 8,110.59 14,297.00 7,577.41 10,171.00 5,390.63 8,773.00 4,649.69 6,517.00 3,454.01

75 ó más 20,923.00 11,089.19 16,678.00 8,839.34 15,688.00 8,314.64 11,126.00 5,896.78 9,591.00 5,083.23 7,123.00 3,775.19




ZoNa 3COSTA RICA, EL SALVADOR

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2 hijos 1,842.00 976.26 1,702.00 902.06 887.00 470.11 798.00 422.94 687.00 364.11 514.00 272.42

3 hijos o más 2,692.00 1,426.76 2,499.00 1,324.47 1,273.00 674.69 1,164.00 616.92 1,000.00 530.00 740.00 392.20

18-24 2,467.00 1,307.51 2,084.00 1,104.52 1,543.00 817.79 1,256.00 665.68 1,085.00 575.05 821.00 435.13

25-29 2,738.00 1,451.14 2,300.00 1,219.00 1,750.00 927.50 1,401.00 742.53 1,211.00 641.83 915.00 484.95

30-34 3,166.00 1,677.98 2,633.00 1,395.49 2,073.00 1,098.69 1,627.00 862.31 1,406.00 745.18 1,060.00 561.80

35-39 3,503.00 1,856.59 2,903.00 1,538.59 2,333.00 1,236.49 1,808.00 958.24 1,565.00 829.45 1,176.00 623.28

40-44 3,952.00 2,094.56 3,259.00 1,727.27 2,676.00 1,418.28 2,045.00 1,083.85 1,767.00 936.51 1,329.00 704.37

45-49 4,580.00 2,427.40 3,751.00 1,988.03 3,154.00 1,671.62 2,384.00 1,263.52 2,058.00 1,090.74 1,543.00 817.79

50-54 5,010.00 2,655.30 4,094.00 2,169.82 3,482.00 1,845.46 2,614.00 1,385.42 2,257.00 1,196.21 1,692.00 896.76

55-59 5,917.00 3,136.01 4,815.00 2,551.95 4,177.00 2,213.81 3,101.00 1,643.53 2,677.00 1,418.81 2,003.00 1,061.59

60 6,242.00 3,308.26 5,038.00 2,670.14 4,469.00 2,368.57 3,285.00 1,741.05 2,833.00 1,501.49 2,118.00 1,122.54

61 7,023.00 3,722.19 5,673.00 3,006.69 5,042.00 2,672.26 3,697.00 1,959.41 3,189.00 1,690.17 2,386.00 1,264.58

62 7,811.00 4,139.83 6,307.00 3,342.71 5,620.00 2,978.60 4,113.00 2,179.89 3,550.00 1,881.50 2,654.00 1,406.62

63 8,595.00 4,555.35 6,940.00 3,678.20 6,194.00 3,282.82 4,525.00 2,398.25 3,907.00 2,070.71 2,921.00 1,548.13

64 9,380.00 4,971.40 7,575.00 4,014.75 6,765.00 3,585.45 4,944.00 2,620.32 4,266.00 2,260.98 3,193.00 1,692.29

65 9,418.00 4,991.54 7,583.00 4,018.99 6,832.00 3,620.96 4,971.00 2,634.63 4,288.00 2,272.64 3,206.00 1,699.18

66 9,453.00 5,010.09 7,591.00 4,023.23 6,896.00 3,654.88 4,998.00 2,648.94 4,312.00 2,285.36 3,215.00 1,703.95

67 10,509.00 5,569.77 8,439.00 4,472.67 7,678.00 4,069.34 5,559.00 2,946.27 4,791.00 2,539.23 3,577.00 1,895.81

68 11,559.00 6,126.27 9,287.00 4,922.11 8,458.00 4,482.74 6,116.00 3,241.48 5,275.00 2,795.75 3,935.00 2,085.55

69 12,090.00 6,407.70 9,708.00 5,145.24 8,847.00 4,688.91 6,398.00 3,390.94 5,518.00 2,924.54 4,116.00 2,181.48

70 12,173.00 6,451.69 9,730.00 5,156.90 8,995.00 4,767.35 6,464.00 3,425.92 5,571.00 2,952.63 4,140.00 2,194.20

71 13,702.00 7,262.06 10,946.00 5,801.38 10,133.00 5,370.49 7,277.00 3,856.81 6,271.00 3,323.63 4,658.00 2,468.74

72 15,225.00 8,069.25 12,167.00 6,448.51 11,277.00 5,976.81 8,087.00 4,286.11 6,971.00 3,694.63 5,182.00 2,746.46

73 16,755.00 8,880.15 13,391.00 7,097.23 12,416.00 6,580.48 8,897.00 4,715.41 7,669.00 4,064.57 5,701.00 3,021.53

74 18,282.00 9,689.46 14,611.00 7,743.83 13,557.00 7,185.21 9,710.00 5,146.30 8,371.00 4,436.63 6,224.00 3,298.72

75 ó más 19,968.00 10,583.04 15,922.00 8,438.66 14,879.00 7,885.87 10,619.00 5,628.07 9,155.00 4,852.15 6,799.00 3,603.47

Coberturaadicional

Complicaciones de maternidad Us$225.00 Us$119.25 Us$225.00 Us$119.25 Us$225.00 Us$119.25 Us$225.00 Us$119.25 Us$225.00 Us$119.25 Us$225.00 Us$119.25



ZoNa 4BELICE, GUATEMALA, GUyANA, NICARAGUA, PERÚ, SURINAM, URUGUAy, RESTO DEL CARIBE(b)

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1 hijo Us$1,040.00 Us$551.20 Us$936.00 Us$496.08 Us$555.00 Us$294.15 Us$472.00 Us$250.16 Us$405.00 Us$214.65 Us$299.00 Us$158.47

2 hijos 1,707.00 904.71 1,578.00 836.34 822.00 435.66 740.00 392.20 637.00 337.61 474.00 251.22

3 hijos o más 2,498.00 1,323.94 2,317.00 1,228.01 1,182.00 626.46 1,079.00 571.87 926.00 490.78 685.00 363.05

18-24 2,290.00 1,213.70 1,934.00 1,025.02 1,517.00 804.01 1,163.00 616.39 1,005.00 532.65 764.00 404.92

25-29 2,540.00 1,346.20 2,133.00 1,130.49 1,709.00 905.77 1,299.00 688.47 1,125.00 596.25 849.00 449.97

30-34 2,936.00 1,556.08 2,445.00 1,295.85 2,007.00 1,063.71 1,508.00 799.24 1,304.00 691.12 982.00 520.46

35-39 3,248.00 1,721.44 2,696.00 1,428.88 2,250.00 1,192.50 1,676.00 888.28 1,450.00 768.50 1,093.00 579.29

40-44 3,666.00 1,942.98 3,022.00 1,601.66 2,567.00 1,360.51 1,894.00 1,003.82 1,639.00 868.67 1,233.00 653.49

45-49 4,245.00 2,249.85 3,480.00 1,844.40 3,009.00 1,594.77 2,211.00 1,171.83 1,909.00 1,011.77 1,432.00 758.96

50-54 4,647.00 2,462.91 3,799.00 2,013.47 3,315.00 1,756.95 2,424.00 1,284.72 2,096.00 1,110.88 1,567.00 830.51

55-59 5,488.00 2,908.64 4,461.00 2,364.33 3,960.00 2,098.80 2,874.00 1,523.22 2,480.00 1,314.40 1,855.00 983.15

60 5,789.00 3,068.17 4,671.00 2,475.63 4,230.00 2,241.90 3,044.00 1,613.32 2,627.00 1,392.31 1,963.00 1,040.39

61 6,514.00 3,452.42 5,261.00 2,788.33 4,763.00 2,524.39 3,427.00 1,816.31 2,958.00 1,567.74 2,213.00 1,172.89

62 7,245.00 3,839.85 5,851.00 3,101.03 5,293.00 2,805.29 3,812.00 2,020.36 3,289.00 1,743.17 2,462.00 1,304.86

63 7,969.00 4,223.57 6,440.00 3,413.20 5,826.00 3,087.78 4,195.00 2,223.35 3,621.00 1,919.13 2,710.00 1,436.30

64 8,696.00 4,608.88 7,024.00 3,722.72 6,356.00 3,368.68 4,580.00 2,427.40 3,954.00 2,095.62 2,959.00 1,568.27

65 8,734.00 4,629.02 7,033.00 3,727.49 6,420.00 3,402.60 4,610.00 2,443.30 3,976.00 2,107.28 2,970.00 1,574.10

66 8,764.00 4,644.92 7,040.00 3,731.20 6,480.00 3,434.40 4,637.00 2,457.61 3,996.00 2,117.88 2,983.00 1,580.99

67 9,742.00 5,163.26 7,828.00 4,148.84 7,202.00 3,817.06 5,153.00 2,731.09 4,444.00 2,355.32 3,316.00 1,757.48

68 10,721.00 5,682.13 8,611.00 4,563.83 7,926.00 4,200.78 5,670.00 3,005.10 4,890.00 2,591.70 3,652.00 1,935.56

69 11,210.00 5,941.30 9,005.00 4,772.65 8,285.00 4,391.05 5,931.00 3,143.43 5,114.00 2,710.42 3,817.00 2,023.01

70 11,288.00 5,982.64 9,021.00 4,781.13 8,427.00 4,466.31 5,992.00 3,175.76 5,163.00 2,736.39 3,838.00 2,034.14

71 12,706.00 6,734.18 10,150.00 5,379.50 9,484.00 5,026.52 6,742.00 3,573.26 5,814.00 3,081.42 4,323.00 2,291.19

72 14,120.00 7,483.60 11,285.00 5,981.05 10,538.00 5,585.14 7,495.00 3,972.35 6,463.00 3,425.39 4,800.00 2,544.00

73 15,534.00 8,233.02 12,414.00 6,579.42 11,593.00 6,144.29 8,248.00 4,371.44 7,110.00 3,768.30 5,286.00 2,801.58

74 16,952.00 8,984.56 13,550.00 7,181.50 12,651.00 6,705.03 8,999.00 4,769.47 7,760.00 4,112.80 5,768.00 3,057.04

75 ó más 18,518.00 9,814.54 14,764.00 7,824.92 13,875.00 7,353.75 9,844.00 5,217.32 8,486.00 4,497.58 6,304.00 3,341.12

Coberturaadicional



(a) a partir del 1 de enero de 2013, el Plan 1 de deducible (Us$0/Us$1,000) solamente estará disponible para renovaciones del mismo plan de deducible. • (b) Excluye Trinidad & Tobago

ZoNa 5VENEzUELA

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1 hijo Us$658.00 Us$348.74 Us$593.00 Us$314.29 Us$350.00 Us$185.50 Us$299.00 Us$158.47 Us$259.00 Us$137.27 Us$191.00 Us$101.23

2 hijos 1,080.00 572.40 1,000.00 530.00 520.00 275.60 469.00 248.57 407.00 215.71 301.00 159.53

3 hijos o más 1,583.00 838.99 1,467.00 777.51 747.00 395.91 682.00 361.46 591.00 313.23 436.00 231.08

18-24 1,445.00 765.85 1,221.00 647.13 956.00 506.68 735.00 389.55 637.00 337.61 482.00 255.46

25-29 1,603.00 849.59 1,345.00 712.85 1,079.00 571.87 818.00 433.54 713.00 377.89 537.00 284.61

30-34 1,855.00 983.15 1,543.00 817.79 1,271.00 673.63 952.00 504.56 826.00 437.78 621.00 329.13

35-39 2,052.00 1,087.56 1,701.00 901.53 1,420.00 752.60 1,059.00 561.27 919.00 487.07 691.00 366.23

40-44 2,314.00 1,226.42 1,910.00 1,012.30 1,622.00 859.66 1,197.00 634.41 1,040.00 551.20 780.00 413.40

45-49 2,682.00 1,421.46 2,200.00 1,166.00 1,902.00 1,008.06 1,395.00 739.35 1,210.00 641.30 908.00 481.24

50-54 2,938.00 1,557.14 2,398.00 1,270.94 2,096.00 1,110.88 1,531.00 811.43 1,328.00 703.84 994.00 526.82

55-59 3,472.00 1,840.16 2,822.00 1,495.66 2,503.00 1,326.59 1,815.00 961.95 1,576.00 835.28 1,176.00 623.28

60 3,660.00 1,939.80 2,954.00 1,565.62 2,675.00 1,417.75 1,924.00 1,019.72 1,668.00 884.04 1,245.00 659.85

61 4,120.00 2,183.60 3,327.00 1,763.31 3,011.00 1,595.83 2,167.00 1,148.51 1,880.00 996.40 1,405.00 744.65

62 4,583.00 2,428.99 3,699.00 1,960.47 3,348.00 1,774.44 2,409.00 1,276.77 2,091.00 1,108.23 1,564.00 828.92

63 5,042.00 2,672.26 4,071.00 2,157.63 3,685.00 1,953.05 2,654.00 1,406.62 2,301.00 1,219.53 1,722.00 912.66

64 5,501.00 2,915.53 4,445.00 2,355.85 4,022.00 2,131.66 2,896.00 1,534.88 2,512.00 1,331.36 1,880.00 996.40

65 5,524.00 2,927.72 4,448.00 2,357.44 4,061.00 2,152.33 2,912.00 1,543.36 2,527.00 1,339.31 1,887.00 1,000.11

66 5,546.00 2,939.38 4,454.00 2,360.62 4,097.00 2,171.41 2,931.00 1,553.43 2,539.00 1,345.67 1,891.00 1,002.23

67 6,165.00 3,267.45 4,949.00 2,622.97 4,555.00 2,414.15 3,258.00 1,726.74 2,825.00 1,497.25 2,105.00 1,115.65

68 6,785.00 3,596.05 5,449.00 2,887.97 5,013.00 2,656.89 3,584.00 1,899.52 3,110.00 1,648.30 2,318.00 1,228.54

69 7,094.00 3,759.82 5,694.00 3,017.82 5,242.00 2,778.26 3,750.00 1,987.50 3,248.00 1,721.44 2,426.00 1,285.78

70 7,144.00 3,786.32 5,707.00 3,024.71 5,331.00 2,825.43 3,790.00 2,008.70 3,282.00 1,739.46 2,438.00 1,292.14

71 8,040.00 4,261.20 6,423.00 3,404.19 5,999.00 3,179.47 4,265.00 2,260.45 3,696.00 1,958.88 2,744.00 1,454.32

72 8,936.00 4,736.08 7,138.00 3,783.14 6,670.00 3,535.10 4,742.00 2,513.26 4,107.00 2,176.71 3,053.00 1,618.09

73 9,833.00 5,211.49 7,858.00 4,164.74 7,338.00 3,889.14 5,217.00 2,765.01 4,521.00 2,396.13 3,359.00 1,780.27

74 10,728.00 5,685.84 8,573.00 4,543.69 8,008.00 4,244.24 5,693.00 3,017.29 4,934.00 2,615.02 3,668.00 1,944.04

75 ó más 11,720.00 6,211.60 9,345.00 4,952.85 8,783.00 4,654.99 6,229.00 3,301.37 5,398.00 2,860.94 4,009.00 2,124.77




ZoNa 6ARGENTINA, COLOMBIA, PANAMÁ, PARAGUAy

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2 hijos 1,495.00 792.35 1,381.00 731.93 715.00 378.95 648.00 343.44 561.00 297.33 414.00 219.42

3 hijos o más 2,186.00 1,158.58 2,029.00 1,075.37 1,033.00 547.49 944.00 500.32 812.00 430.36 601.00 318.53

18-24 2,003.00 1,061.59 1,694.00 897.82 1,329.00 704.37 1,018.00 539.54 880.00 466.40 668.00 354.04

25-29 2,224.00 1,178.72 1,867.00 989.51 1,496.00 792.88 1,136.00 602.08 981.00 519.93 742.00 393.26

30-34 2,570.00 1,362.10 2,139.00 1,133.67 1,760.00 932.80 1,321.00 700.13 1,141.00 604.73 863.00 457.39

35-39 2,843.00 1,506.79 2,358.00 1,249.74 1,970.00 1,044.10 1,468.00 778.04 1,270.00 673.10 955.00 506.15

40-44 3,206.00 1,699.18 2,643.00 1,400.79 2,247.00 1,190.91 1,662.00 880.86 1,436.00 761.08 1,079.00 571.87

45-49 3,716.00 1,969.48 3,046.00 1,614.38 2,633.00 1,395.49 1,935.00 1,025.55 1,670.00 885.10 1,254.00 664.62

50-54 4,068.00 2,156.04 3,323.00 1,761.19 2,902.00 1,538.06 2,121.00 1,124.13 1,833.00 971.49 1,373.00 727.69

55-59 4,804.00 2,546.12 3,908.00 2,071.24 3,467.00 1,837.51 2,517.00 1,334.01 2,171.00 1,150.63 1,623.00 860.19

60 5,068.00 2,686.04 4,089.00 2,167.17 3,703.00 1,962.59 2,666.00 1,412.98 2,300.00 1,219.00 1,718.00 910.54

61 5,703.00 3,022.59 4,606.00 2,441.18 4,169.00 2,209.57 3,000.00 1,590.00 2,591.00 1,373.23 1,937.00 1,026.61

62 6,339.00 3,359.67 5,119.00 2,713.07 4,638.00 2,458.14 3,340.00 1,770.20 2,880.00 1,526.40 2,156.00 1,142.68

63 6,976.00 3,697.28 5,634.00 2,986.02 5,104.00 2,705.12 3,674.00 1,947.22 3,171.00 1,680.63 2,374.00 1,258.22

64 7,615.00 4,035.95 6,147.00 3,257.91 5,567.00 2,950.51 4,010.00 2,125.30 3,462.00 1,834.86 2,591.00 1,373.23

65 7,644.00 4,051.32 6,155.00 3,262.15 5,622.00 2,979.66 4,034.00 2,138.02 3,482.00 1,845.46 2,602.00 1,379.06

66 7,676.00 4,068.28 6,163.00 3,266.39 5,674.00 3,007.22 4,058.00 2,150.74 3,500.00 1,855.00 2,610.00 1,383.30

67 8,529.00 4,520.37 6,848.00 3,629.44 6,308.00 3,343.24 4,511.00 2,390.83 3,891.00 2,062.23 2,903.00 1,538.59

68 9,385.00 4,974.05 7,537.00 3,994.61 6,939.00 3,677.67 4,965.00 2,631.45 4,284.00 2,270.52 3,196.00 1,693.88

69 9,814.00 5,201.42 7,880.00 4,176.40 7,255.00 3,845.15 5,194.00 2,752.82 4,480.00 2,374.40 3,343.00 1,771.79

70 9,882.00 5,237.46 7,895.00 4,184.35 7,378.00 3,910.34 5,247.00 2,780.91 4,521.00 2,396.13 3,358.00 1,779.74

71 11,122.00 5,894.66 8,887.00 4,710.11 8,303.00 4,400.59 5,904.00 3,129.12 5,091.00 2,698.23 3,782.00 2,004.46

72 12,360.00 6,550.80 9,876.00 5,234.28 9,231.00 4,892.43 6,566.00 3,479.98 5,660.00 2,999.80 4,206.00 2,229.18

73 13,599.00 7,207.47 10,869.00 5,760.57 10,155.00 5,382.15 7,225.00 3,829.25 6,225.00 3,299.25 4,630.00 2,453.90

74 14,839.00 7,864.67 11,859.00 6,285.27 11,079.00 5,871.87 7,881.00 4,176.93 6,796.00 3,601.88 5,053.00 2,678.09

75 ó más 16,209.00 8,590.77 12,925.00 6,850.25 12,153.00 6,441.09 8,621.00 4,569.13 7,434.00 3,940.02 5,521.00 2,926.13

Coberturaadicional




ZoNa 7

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2 hijos 2,625.00 1,391.25 2,424.00 1,284.72 1,240.00 657.20 1,015.00 537.95 875.00 463.75 650.00 344.50

3 hijos o más 3,840.00 2,035.20 3,559.00 1,886.27 1,779.00 942.87 1,475.00 781.75 1,273.00 674.69 942.00 499.26

18-24 3,505.00 1,857.65 2,955.00 1,566.15 2,273.00 1,204.69 1,588.00 841.64 1,373.00 727.69 1,039.00 550.67

25-29 3,892.00 2,062.76 3,263.00 1,729.39 2,559.00 1,356.27 1,771.00 938.63 1,533.00 812.49 1,156.00 612.68

30-34 4,498.00 2,383.94 3,743.00 1,983.79 3,012.00 1,596.36 2,060.00 1,091.80 1,782.00 944.46 1,340.00 710.20

35-39 4,977.00 2,637.81 4,122.00 2,184.66 3,378.00 1,790.34 2,293.00 1,215.29 1,981.00 1,049.93 1,488.00 788.64

40-44 5,618.00 2,977.54 4,629.00 2,453.37 3,854.00 2,042.62 2,594.00 1,374.82 2,243.00 1,188.79 1,682.00 891.46

45-49 6,513.00 3,451.89 5,337.00 2,828.61 4,521.00 2,396.13 3,022.00 1,601.66 2,612.00 1,384.36 1,959.00 1,038.27

50-54 7,126.00 3,776.78 5,820.00 3,084.60 4,982.00 2,640.46 3,313.00 1,755.89 2,863.00 1,517.39 2,143.00 1,135.79

55-59 8,419.00 4,462.07 6,845.00 3,627.85 5,954.00 3,155.62 3,938.00 2,087.14 3,396.00 1,799.88 2,536.00 1,344.08

60 8,878.00 4,705.34 7,165.00 3,797.45 6,358.00 3,369.74 4,164.00 2,206.92 3,593.00 1,904.29 2,686.00 1,423.58

61 10,001.00 5,300.53 8,070.00 4,277.10 7,165.00 3,797.45 4,693.00 2,487.29 4,048.00 2,145.44 3,028.00 1,604.84

62 11,116.00 5,891.48 8,977.00 4,757.81 7,968.00 4,223.04 5,219.00 2,766.07 4,503.00 2,386.59 3,367.00 1,784.51

63 12,234.00 6,484.02 9,876.00 5,234.28 8,769.00 4,647.57 5,745.00 3,044.85 4,960.00 2,628.80 3,708.00 1,965.24

64 13,355.00 7,078.15 10,780.00 5,713.40 9,571.00 5,072.63 6,272.00 3,324.16 5,413.00 2,868.89 4,049.00 2,145.97

65 13,406.00 7,105.18 10,793.00 5,720.29 9,661.00 5,120.33 6,309.00 3,343.77 5,442.00 2,884.26 4,066.00 2,154.98

66 13,458.00 7,132.74 10,805.00 5,726.65 9,752.00 5,168.56 6,347.00 3,363.91 5,473.00 2,900.69 4,080.00 2,162.40

67 14,963.00 7,930.39 12,010.00 6,365.30 10,843.00 5,746.79 7,057.00 3,740.21 6,084.00 3,224.52 4,539.00 2,405.67

68 16,460.00 8,723.80 13,221.00 7,007.13 11,936.00 6,326.08 7,768.00 4,117.04 6,697.00 3,549.41 4,996.00 2,647.88

69 17,214.00 9,123.42 13,823.00 7,326.19 12,478.00 6,613.34 8,124.00 4,305.72 7,001.00 3,710.53 5,228.00 2,770.84

70 17,338.00 9,189.14 13,850.00 7,340.50 12,686.00 6,723.58 8,204.00 4,348.12 7,073.00 3,748.69 5,252.00 2,783.56

71 19,512.00 10,341.36 15,591.00 8,263.23 14,278.00 7,567.34 9,239.00 4,896.67 7,962.00 4,219.86 5,916.00 3,135.48

72 21,688.00 11,494.64 17,327.00 9,183.31 15,870.00 8,411.10 10,268.00 5,442.04 8,852.00 4,691.56 6,575.00 3,484.75

73 23,860.00 12,645.80 19,067.00 10,105.51 17,466.00 9,256.98 11,300.00 5,989.00 9,742.00 5,163.26 7,240.00 3,837.20

74 26,037.00 13,799.61 20,805.00 11,026.65 19,060.00 10,101.80 12,334.00 6,537.02 10,631.00 5,634.43 7,902.00 4,188.06

75 ó más 28,446.00 15,076.38 22,674.00 12,017.22 20,904.00 11,079.12 13,490.00 7,149.70 11,628.00 6,162.84 8,634.00 4,576.02




ZoNa 8TRINIDAD & TOBAGO

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2 hijos 1,566.00 829.98 1,448.00 767.44 754.00 399.62 679.00 359.87 585.00 310.05 435.00 230.55

3 hijos o más 2,292.00 1,214.76 2,125.00 1,126.25 1,084.00 574.52 990.00 524.70 850.00 450.50 629.00 333.37

18-24 2,100.00 1,113.00 1,774.00 940.22 1,392.00 737.76 1,067.00 565.51 922.00 488.66 701.00 371.53

25-29 2,330.00 1,234.90 1,957.00 1,037.21 1,568.00 831.04 1,191.00 631.23 1,031.00 546.43 779.00 412.87

30-34 2,694.00 1,427.82 2,244.00 1,189.32 1,842.00 976.26 1,383.00 732.99 1,197.00 634.41 901.00 477.53

35-39 2,979.00 1,578.87 2,474.00 1,311.22 2,064.00 1,093.92 1,538.00 815.14 1,330.00 704.90 1,003.00 531.59

40-44 3,364.00 1,782.92 2,773.00 1,469.69 2,354.00 1,247.62 1,738.00 921.14 1,503.00 796.59 1,131.00 599.43

45-49 3,895.00 2,064.35 3,193.00 1,692.29 2,760.00 1,462.80 2,028.00 1,074.84 1,751.00 928.03 1,314.00 696.42

50-54 4,264.00 2,259.92 3,485.00 1,847.05 3,041.00 1,611.73 2,224.00 1,178.72 1,923.00 1,019.19 1,438.00 762.14

55-59 5,035.00 2,668.55 4,093.00 2,169.29 3,632.00 1,924.96 2,637.00 1,397.61 2,275.00 1,205.75 1,702.00 902.06

60 5,311.00 2,814.83 4,286.00 2,271.58 3,881.00 2,056.93 2,792.00 1,479.76 2,410.00 1,277.30 1,801.00 954.53

61 5,977.00 3,167.81 4,827.00 2,558.31 4,370.00 2,316.10 3,145.00 1,666.85 2,713.00 1,437.89 2,030.00 1,075.90

62 6,647.00 3,522.91 5,368.00 2,845.04 4,856.00 2,573.68 3,497.00 1,853.41 3,018.00 1,599.54 2,258.00 1,196.74

63 7,311.00 3,874.83 5,908.00 3,131.24 5,346.00 2,833.38 3,849.00 2,039.97 3,322.00 1,760.66 2,487.00 1,318.11

64 7,978.00 4,228.34 6,444.00 3,415.32 5,832.00 3,090.96 4,203.00 2,227.59 3,628.00 1,922.84 2,715.00 1,438.95

65 8,012.00 4,246.36 6,453.00 3,420.09 5,890.00 3,121.70 4,229.00 2,241.37 3,647.00 1,932.91 2,724.00 1,443.72

66 8,041.00 4,261.73 6,458.00 3,422.74 5,945.00 3,150.85 4,254.00 2,254.62 3,666.00 1,942.98 2,736.00 1,450.08

67 8,937.00 4,736.61 7,182.00 3,806.46 6,607.00 3,501.71 4,727.00 2,505.31 4,077.00 2,160.81 3,042.00 1,612.26

68 9,836.00 5,213.08 7,900.00 4,187.00 7,271.00 3,853.63 5,201.00 2,756.53 4,486.00 2,377.58 3,351.00 1,776.03

69 10,284.00 5,450.52 8,262.00 4,378.86 7,600.00 4,028.00 5,441.00 2,883.73 4,691.00 2,486.23 3,502.00 1,856.06

70 10,357.00 5,489.21 8,276.00 4,386.28 7,732.00 4,097.96 5,497.00 2,913.41 4,737.00 2,510.61 3,522.00 1,866.66

71 11,657.00 6,178.21 9,312.00 4,935.36 8,701.00 4,611.53 6,186.00 3,278.58 5,335.00 2,827.55 3,966.00 2,101.98

72 12,954.00 6,865.62 10,353.00 5,487.09 9,668.00 5,124.04 6,877.00 3,644.81 5,929.00 3,142.37 4,404.00 2,334.12

73 14,251.00 7,553.03 11,389.00 6,036.17 10,636.00 5,637.08 7,566.00 4,009.98 6,523.00 3,457.19 4,849.00 2,569.97

74 15,552.00 8,242.56 12,430.00 6,587.90 11,606.00 6,151.18 8,255.00 4,375.15 7,120.00 3,773.60 5,292.00 2,804.76

75 ó más 16,989.00 9,004.17 13,545.00 7,178.85 12,729.00 6,746.37 9,032.00 4,786.96 7,785.00 4,126.05 5,784.00 3,065.52




ZoNa 9ECUADOR

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2 hijos 1,183.00 626.99 1,095.00 580.35 569.00 301.57 514.00 272.42 446.00 236.38 330.00 174.90

3 hijos o más 1,733.00 918.49 1,606.00 851.18 818.00 433.54 747.00 395.91 647.00 342.91 477.00 252.81

18-24 1,582.00 838.46 1,337.00 708.61 1,047.00 554.91 805.00 426.65 698.00 369.94 528.00 279.84

25-29 1,755.00 930.15 1,473.00 780.69 1,182.00 626.46 896.00 474.88 781.00 413.93 588.00 311.64

30-34 2,031.00 1,076.43 1,690.00 895.70 1,392.00 737.76 1,042.00 552.26 904.00 479.12 680.00 360.40

35-39 2,247.00 1,190.91 1,863.00 987.39 1,555.00 824.15 1,160.00 614.80 1,006.00 533.18 757.00 401.21

40-44 2,534.00 1,343.02 2,091.00 1,108.23 1,776.00 941.28 1,311.00 694.83 1,139.00 603.67 854.00 452.62

45-49 2,937.00 1,556.61 2,409.00 1,276.77 2,083.00 1,103.99 1,528.00 809.84 1,325.00 702.25 994.00 526.82

50-54 3,217.00 1,705.01 2,626.00 1,391.78 2,295.00 1,216.35 1,676.00 888.28 1,454.00 770.62 1,088.00 576.64

55-59 3,802.00 2,015.06 3,090.00 1,637.70 2,741.00 1,452.73 1,987.00 1,053.11 1,726.00 914.78 1,288.00 682.64

60 4,008.00 2,124.24 3,235.00 1,714.55 2,929.00 1,552.37 2,107.00 1,116.71 1,826.00 967.78 1,363.00 722.39

61 4,511.00 2,390.83 3,643.00 1,930.79 3,297.00 1,747.41 2,373.00 1,257.69 2,059.00 1,091.27 1,538.00 815.14

62 5,018.00 2,659.54 4,050.00 2,146.50 3,666.00 1,942.98 2,638.00 1,398.14 2,290.00 1,213.70 1,713.00 907.89

63 5,521.00 2,926.13 4,458.00 2,362.74 4,035.00 2,138.55 2,906.00 1,540.18 2,520.00 1,335.60 1,886.00 999.58

64 6,024.00 3,192.72 4,867.00 2,579.51 4,404.00 2,334.12 3,171.00 1,680.63 2,751.00 1,458.03 2,059.00 1,091.27

65 6,049.00 3,205.97 4,871.00 2,581.63 4,447.00 2,356.91 3,189.00 1,690.17 2,767.00 1,466.51 2,066.00 1,094.98

66 6,073.00 3,218.69 4,877.00 2,584.81 4,486.00 2,377.58 3,209.00 1,700.77 2,780.00 1,473.40 2,071.00 1,097.63

67 6,751.00 3,578.03 5,419.00 2,872.07 4,988.00 2,643.64 3,568.00 1,891.04 3,093.00 1,639.29 2,305.00 1,221.65

68 7,430.00 3,937.90 5,967.00 3,162.51 5,489.00 2,909.17 3,924.00 2,079.72 3,405.00 1,804.65 2,538.00 1,345.14

69 7,768.00 4,117.04 6,235.00 3,304.55 5,740.00 3,042.20 4,106.00 2,176.18 3,557.00 1,885.21 2,656.00 1,407.68

70 7,823.00 4,146.19 6,249.00 3,311.97 5,837.00 3,093.61 4,150.00 2,199.50 3,594.00 1,904.82 2,670.00 1,415.10

71 8,804.00 4,666.12 7,033.00 3,727.49 6,569.00 3,481.57 4,670.00 2,475.10 4,047.00 2,144.91 3,005.00 1,592.65

72 9,785.00 5,186.05 7,816.00 4,142.48 7,304.00 3,871.12 5,192.00 2,751.76 4,497.00 2,383.41 3,343.00 1,771.79

73 10,767.00 5,706.51 8,605.00 4,560.65 8,035.00 4,258.55 5,713.00 3,027.89 4,950.00 2,623.50 3,678.00 1,949.34

74 11,747.00 6,225.91 9,387.00 4,975.11 8,769.00 4,647.57 6,234.00 3,304.02 5,403.00 2,863.59 4,016.00 2,128.48

75 ó más 12,833.00 6,801.49 10,233.00 5,423.49 9,617.00 5,097.01 6,821.00 3,615.13 5,911.00 3,132.83 4,390.00 2,326.70




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CómoPagarlaPrimaBupa 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:

CobranzadeCámaradeCompensaciónautomatizada(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

TransferenciabancariadomésticaWells 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

TransferenciabancariainternacionalWells 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

17901 old Cutler road, suite 400Palmetto Bay, Florida 33157tel. +1 (305) 398 7400Fax +1 (305) 275 [email protected]

PB-Ess 2014 EsP

bupa essential care€¦ · de los estados unidos y puerto rico. • opciones de pago disponibles:...

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