Carnegie Mellon University Policy #02424 Benefits at a Glance Effective Date: January 1, 2014

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1 Carnegie Mellon University is offering Medical, Dental, Vision, Pharmacy, Medical Evacuation and Repatriation benefits through Cigna Global Health Benefits to our employees. This comprehensive international healthcare program allows our employees and their families to access quality healthcare anywhere in the world. The following pages will provide a general overview of the plan designs for our employees on international assignment. International Medical Plan Lifetime Maximum Benefit Unlimited Deductible Individual Family $350 $700 Out of Pocket Maximum - Excludes Deductible Individual Family $2,350 $4,700 Deductible/Out of Pocket Cross applies between International, In network and Out of network U.S. Accumulation Coinsurance (Cigna Pays) Inpatient Hospital Services Facility Physician Outpatient Facility Services Hospital Emergency Room (except if not a true emergency then 80% after Infertility (Procedures directly related to diagnosis are covered. Treatment, prescription drugs, and/or other method to bypass, i.e. In-vitro, are not covered) Family Planning Women s Services -Inpatient hospital facility -Outpatient hospital facility -Surgical services such as tubal ligation are covered (excluding reversals) -Includes contraceptive devices as ordered or prescribed by a physician Family Planning Men s Services -Inpatient hospital facility -Outpatient hospital facility -Surgical services such as vasectomy are covered (excluding reversals) deductible) Maternity Care Services Lab & Radiology Facility 1

2 International Medical Plan Short Term Rehabilitation (60 day maximum per calendar year for all therapies combined) Includes Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab and Cognitive Therapy Physician Visit Prescription Refer to the Prescription Drug Benefits Schedule Refer to the Prescription Drug Benefits Schedule Mental Illness and Substance Abuse Inpatient Outpatient Skilled Nursing Facility (60 day maximum per calendar year) Home Health Care (120 day Maximum per calendar year) Chiropractic Services (20 day maximum per calendar year) Hospice TMJ ($1000 maximum per lifetime) Diabetes Equipment & Supplies (Prescribed and recommended in writing by a physician. Equipment included are: insulin pumps, blood glucose meters and strips, urine testing strips, insulin, syringes, lancets, alcohol swabs and pharmacological agents for controlling blood sugar) External Prosthetic Appliances Durable Medical Equipment Dental Accident (Limited to a continuous course of treatment started within six months of accidental injury to sound natural teeth) 2

3 International Medical Plan Women s Preventive Services (As defined by PPACA including Annual well-woman visits, Screening for gestational diabetes, FDAapproved contraception methods and contraceptive counseling; including birth control and sterilization, HPV DNA testing for women 30 years and older, Sexuallytransmitted infection counseling, HIV screening and counseling, Domestic violence screening and counseling) Breast-feeding equipment and supplies (Limited to one rental of one breast pump per birth as ordered or prescribed by a physician. Includes related supplies and counseling) Delaware Mandated Autism Spectrum Disorders Coverage (Coverage for the screening, diagnosis and treatment of autism spectrum disorder and medications as prescribed by licensed providers) Carnegie Mellon University Well Child Care Immunizations (For children birth to age 18) Includes diphtheria, hepatitis A, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, Haemophilus influenza B) Adult Preventive Care Travel Immunizations (Employee and Dependent immunizations required for travel are included.) 3

4 International Medical Plan Papanicolaou Screening Test (One test per calendar year for females over age 18) Prostate Cancer Screening (One test per calendar year for males over age 50) Mammograms (One baseline exam for asymptomatic women ages 35-39; one exam every two years for asymptomatic women ages 40-49; one exam annually for women age 50 and over and whenever prescribed) Lead Poisoning Screening (For children at or around 12 months and children under age 6 who are considered to be high risk) Colorectal Cancer Screening (Age 50 and older or any person deemed as high risk of colon cancer) Carnegie Mellon University Allergy Testing / Treatment Routine Eye Exam Exam: One every 12 months Hardware: $200 maximum every 12 months not subject to deductible Hearing Exam: One every 24 months Hardware: Limited to dependent children under age 24, maximum of $1,000 per hearing aid unit necessary for each ear, every three years. 4

5 Direct Access to Obstetricians and Gynecologists You do not need prior authorization from the plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit or contact customer service at the phone number listed on the back of your ID card. Selection of a Primary Care Provider This plan generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. For children, you may designate a pediatrician as the primary care provider. Global Wellness Programs Pre-Assignment Assistance Program Health and Well-Being Assessment (HA) Cigna's Pre-Assignment Assistance is a unique clinical program that offers comprehensive case management, care coordination, inpatient management, evacuation assistance, and online expert second opinions for employees and dependents either in the U.S. or abroad. The tool can be accessed prior to or during assignment through Cigna's secure web portal Cigna Envoy. Employees that utilize the Pre-Assignment Assistance Program are more likely to have a successful assignment. The HA is a short, online assessment that is core to our wellness solutions and the first step to identifying personal health risks. Those who complete the HA, immediately receive a personalized health risk profile report. The HA is medically validated by the World Health Organization. 5

6 Pharmacy Management Purchased Inside the United States Only Prescription Drugs Pharmacy Participating Pharmacy Non-Participating Pharmacy Generic Brand Mail Order Drugs Generic Brand Your plan will cover of the approved Your plan will cover of the approved Your plan will cover of the approved Your plan will cover of the approved 20% coinsurance after plan deductible 20% coinsurance after plan deductible In-network coverage only In-network coverage only Emergency Medical Evacuation/Repatriation Emergency Evacuation Family Travel Arrangements Return of Dependent Children Repatriation of Mortal Remains Return of Traveling Companion coverage not subject to the deductible for services approved by International SOS Economy round-trip airfare to the place of hospitalization for one family member for hospitalizations in excess of 7 days One-way Economy airfare to return dependent children to their country of residence coverage not subject to the deductible In the event of hospitalization or evacuation, and a traveling companion s air ticket is no longer usable, one-way economy airfare will be provided to the original point of departure. 6

7 International Dental Plan Calendar Year Maximum (for Class I, II, III) Lifetime Maximum (for Class IV) Deductible (waived for Class I) $1,000 $1,500 $50 Individual / $150 Family Aggregate Class I Class II Class III Preventive Services Diagnostic General Preventive Basic Services Restorative (Basic) Endodontics Periodontics Prosthodontics Removable (Maintenance) Prosthodontics Fixed Bridge (Maintenance) Oral Surgery Major Services Restorative (Major) Prosthodontics Removable (Installation) Prosthodontics Fixed Bridge (Installation), not subject to deductible after deductible 50% after deductible Class IV Orthodontia (for dependent children under age 19) after a $50 lifetime deductible subject to a $1,500 lifetime maximum 50% after lifetime deductible 7

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