PART V SCHEDULE OF BENEFITS MEDICAL EXPENSE BENEFITS OAKLAND UNIVERSITY - STUDENT PLAN INJURY AND SICKNESS BENEFITS

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1 PART V SCHEDULE OF BENEFITS MEDICAL EXPENSE BENEFITS OAKLAND UNIVERSITY - STUDENT PLAN INJURY AND SICKNESS BENEFITS Maximum Benefit $100,000 (Per Insured Person) (Per Policy Year) Deductible Preferred Providers $300 (Per Insured Person) (Per Policy Year) Deductible Out of Network $600 (Per Insured Person) (Per Policy Year) (Deductible is waived when treatment is rendered at the Student Health Center.) Coinsurance Preferred Providers 80% except as noted below Coinsurance Out-of-Network 60% except as noted below The Preferred Provider for this plan is UnitedHealthcare Choice Plus. If care is received from a Preferred Provider any Covered Medical Expenses will be paid at the Preferred Provider level of benefits. If the Covered Medical Expense is incurred due to a Medical Emergency, benefits will be paid at the Preferred Provider level of benefits. In all other situations, reduced or lower benefits will be provided when an Out-of-Network provider is used. All benefit maximums are combined Preferred Provider and Out-of-Network, unless noted below. The benefits payable are as defined in and subject to all provisions of this policy and any endorsements thereto. Benefits will be paid up to the Maximum Benefit for each service as scheduled below. Preferred Provider Out-of-Pocket Maximum: After the Deductible of $300 per Insured Person has been satisfied, benefits will be paid for 80% of Covered Medical Expenses incurred up to a $5,000 out-of-pocket maximum for an Insured Person. After the Insured has paid $5,000 per Insured Person, payment will be made for 100% of additional Covered Medical Expenses incurred at a Preferred Provider, not to exceed $100,000 maximum. Out-of-Network Out-of-Pocket Maximum: After the Deductible of $600 per Insured Person has been satisfied, benefits will be paid for 60% of Covered Medical Expenses incurred up to a $10,000 out-of-pocket maximum for an Insured Person. After the Insured has paid $10,000 per Insured Person, payment will be made for 100% of additional Covered Medical Expenses incurred at an Out-of- Network Provider, not to exceed $100,000 maximum. A Student Health Center referral is required for expenses incurred for medical treatment rendered outside of the Student Health Center. Expenses for medical treatment rendered outside of the SHC for which no prior approval or referral is obtained will be subject to an additional $500 Deductible. SHC benefits are paid at 100% for Covered Medical Expenses incurred. The Policy Deductible is waived for expenses incurred at the SHC. Note: Per service Co-pays, Deductibles and non-covered Medical Expenses do not count towards meeting the Out-of-Pocket maximums. Nutrition programs listed as excluded in the Exclusions and Limitations section are paid at the Preferred Allowance level for Preferred Providers and the Usual and Customary level for Out of Network Providers. Inpatient Preferred Provider Out-of-Network Provider Room & Board: Preferred Allowance Hospital Miscellaneous: Preferred Allowance Routine Newborn Care: Paid as any other Sickness Paid as any other Sickness (4 days Hospital Confinement expense maximum) Physiotherapy: Preferred Allowance Surgery: Preferred Allowance (Specified Surgery based on data provided by FAIR Health, Inc.) Assistant Surgeon: No Benefits No Benefits Anesthetist: Preferred Allowance Registered Nurse's Services: Preferred Allowance Physician's Visits: Preferred Allowance COL-06-MI 9 (1) PPO

2 SCHEDULE OF BENEFITS (CONTINUED) MEDICAL EXPENSE BENEFITS OAKLAND UNIVERSITY - STUDENT PLAN INJURY AND SICKNESS BENEFITS Inpatient Preferred Provider Out-of-Network Provider Pre-admission Testing: Preferred Allowance Psychotherapy: Paid as any other Sickness Paid as any other Sickness (30 days maximum) Outpatient Preferred Provider Out-of-Network Provider Surgery: Preferred Allowance (Specified Surgery based on data provided by FAIR Health, Inc.) Day Surgery Miscellaneous: Preferred Allowance (Day Surgery Miscellaneous charges are based on the Outpatient Surgical Facility Charge Index.) Assistant Surgeon: No Benefits No Benefits Anesthetist: Preferred Allowance Physician's Visits: 100% of Preferred Allowance $25 copay per visit Physiotherapy: Preferred Allowance (Review of Medical Necessity will be performed after 12 visits per Injury or Sickness.) Medical Emergency: Preferred Allowance $150 copay per visit 80% of $150 Deductible per visit X-rays & Laboratory: Preferred Allowance Radiation Therapy & Preferred Allowance Chemotherapy: Tests & Procedures: Preferred Allowance Injections: Preferred Allowance *Prescription Drugs: UnitedHealthcare Network Pharmacy No Benefits (UHPS) $15 copay per prescription for Tier 1 $30 copay per prescription for Tier 2 $50 copay per prescription for Tier 3 up to a 31-day supply per prescription Psychotherapy: Paid as any other Sickness Paid as any other Sickness (50 visits maximum Per Policy Year) Other Preferred Provider Out-of-Network Provider Ambulance: Preferred Allowance 80% of Durable Medical Equipment: Preferred Allowance ($5,000 maximum Per Policy Year) (Durable Medical Equipment benefits payable under the $5,000 maximum Per Policy Year are not included in the $100,000 Maximum Benefit.) Consultant: 100% of Preferred Allowance $25 copay per visit Dental: Preferred Allowance 80% of ($5,000 maximum Per Policy Year) (Benefits paid on Injury to Sound, Natural Teeth only. Dental benefits are not subject to the $100,000 Maximum Benefit.) Alcoholism/Drug Abuse: Paid as any other Sickness Paid as any other Sickness Maternity: Paid as any other Sickness Paid as any other Sickness Elective Abortion: No Benefits No Benefits Complications of Pregnancy: Paid as any other Sickness Paid as any other Sickness Repatriation: Benefits provided by Scholastic Emergency Benefits provided by Scholastic Emergency Medical Evacuation: Benefits provided by Scholastic Emergency *AD&D: $1,250 - $5,000 maximum $1,250 - $5,000 maximum Intercollegiate Sports: No Benefits No Benefits Benefits provided by Scholastic Emergency COL-06-MI 9 (2) PPO

3 SCHEDULE OF BENEFITS (CONTINUED) MEDICAL EXPENSE BENEFITS OAKLAND UNIVERSITY - STUDENT PLAN INJURY AND SICKNESS BENEFITS Other Preferred Provider Out-of-Network Provider Infertility Testing: ($1,000 maximum Per Policy Year)(Infertility testing benefits are not subject to the $100,000 Maximum Benefit) Preferred Allowance Prosthetic Appliance/Orthotic Preferred Allowance Device: Preventive Care Services: 100% of Preferred Allowance No Benefits (No Deductible, copay or coinsurance will be applied to Preventive Care Services when treatment is received by a Preferred Provider. Preventive Care Services are limited to the following recommended preventive services: 1) U.S. Preventive Services Task Force (USPSTF) recommendations of "A" or "B"; 2) immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the CDC; 3) with respect to Insureds who are infants, children and adolescents, evidence-informed preventive care and screenings for infants, children, and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and 4) with respect to Insureds who are women, such additional preventive care and screenings provided for in comprehensive guidelines supported by the HSRA.) Maximum Benefit MAJOR MEDICAL No Benefits Maximum Benefit CATASTROPHIC MEDICAL No Benefits *SHC Referral Required: Yes (X) No ( ) Conversion Permitted: Yes ( ) No (X) ( ) 52 Week Benefit Period or (X) Extension of Benefits *Pre Admission Notification: Yes (X) No ( ) Other Insurance: (X) *Coordination of Benefits ( ) Excess Motor Vehicle ( ) Primary Insurance *If benefit is designated, see endorsement attached. COL-06-MI 9 (3) PPO

4 PART VIII EXCLUSIONS AND LIMITATIONS No benefits will be paid for: a) loss or expense caused by, contributed to, or resulting from; or b) treatment, services or supplies for, at, or related to: 1. Acupuncture; 2. Addiction, such as nicotine addiction; 3. Assistant Surgeon Fees; 4. Milieu therapy, learning disabilities, conceptual handicap, developmental delay or disorder or mental retardation, except as specifically provided in the policy; 5. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy or for newborn or adopted children; 6. Custodial care; care provided in: rest homes, health resorts, homes for the aged, halfway houses, college infirmaries or places mainly for domiciliary or custodial care; extended care in treatment or substance abuse facilities for domiciliary or custodial care; 7. Dental treatment, except for accidental Injury to Sound, Natural Teeth; 8. Elective Surgery or Elective Treatment; 9. Elective abortion; 10. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and problems; except when due to a disease process; 11. Foot care including: flat foot conditions, supportive devices for the foot, subluxations of the foot, care of corns, bunions (except capsular or bone surgery), calluses, toenails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet; 12. Health spa or similar facilities; strengthening programs; 13. Hearing examinations or hearing aids; or other treatment for hearing defects and problems. "Hearing defects" means any physical defect of the ear which does or can impair normal hearing, apart from the disease process; 14. Hirsutism; alopecia; 15. Hypnosis; 16. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury or as specifically provided in the policy; 17. Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 18. Injury sustained by reason of a motor vehicle accident to the extent that benefits are paid or payable by any other valid and collectible insurance; 19. Injury sustained while (a) participating in any intercollegiate or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participating in any practice or conditioning program for such sport, contest or competition; 20. Investigational services; 21. Lipectomy;

5 22. Organ transplants, including organ donation; EXCLUSIONS AND LIMITATIONS (Continued) 23. Participation in a riot or civil disorder; commission of or attempt to commit a felony; 24. Pre-existing Conditions in excess of $1,000, except for individuals who have been continuously insured under the school's policy for at least 6 consecutive months; The Pre-existing Condition exclusionary period will be reduced by the total number of months that the Insured provides documentation of continuous coverage under a prior health insurance policy which provided benefits similar to this policy; 25. Prescription Drugs, services or supplies as follows, except as specifically provided in the policy: a) Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other non-medical substances, regardless of intended use;(except as specifically provided in the Benefits for Diabetes Treatment) b) Immunization agents, biological sera, blood or blood products administered on an outpatient basis; c) Drugs labeled, Caution - limited by federal law to investigational use or experimental drugs; d) Products used for cosmetic purposes; e) Drugs used to treat or cure baldness;anabolic steroids used for body building; f) Anorectics - drugs used for the purpose of weight control; g) Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra; h) Growth hormones; or i) Refills in excess of the number specified or dispensed after one (1) year of date of the prescription. 26. Reproductive/Infertility services including but not limited to: family planning; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; tubal ligation; vasectomy; reversal of sterilization procedures; 27. Research or examinations relating to research studies, or any treatment for which the patient or the patient s representative must sign an informed consent document identifying the treatment in which the patient is to participate as a research study or clinical research study; 28. Routine Newborn Infant Care, well-baby nursery and related Physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery; 29. Routine physical examinations and routine testing; preventive testing or treatment; screening exams or testing in the absence of Injury or Sickness; except as specifically provided in the policy; 30. Services provided normally without charge by the Health Service of the Policyholder; or services covered or provided by the student health fee; 31. Skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia; temporomandibular joint dysfunction; deviated nasal septum, including submucous resection and/or other surgical correction thereof; nasal and sinus surgery, except for treatment of chronic purulent sinusitis; 32. Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any kind of aircraft, except while riding as a passenger on a regularly scheduled flight of a commercial airline; 33. Speech therapy; naturopathic services; 34. Supplies, except as specifically provided in the policy;

6 EXCLUSIONS AND LIMITATIONS (Continued) 35. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; 36. Treatment in a Government hospital, unless there is a legal obligation for the Insured Person to pay for such treatment; 37. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered); and 38. Weight management, weight reduction, treatment for obesity, surgery for removal of excess skin or fat.

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