GLOBAL STUDENT FREEDOM

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1 Health Insurance Plan for INTERNATIONAL Students GLOBAL STUDENT FREEDOM Specially designed for International Students Academic Year

2 Experience and Expertise in the International Marketplace Global Benefits Group and TieCare International have been specializing in the international insurance market for more than 35 years, serving as leading underwriters, developers and distributors of products and services designed especially for the needs of overseas workers and international travelers. GBG underwrites health, life, disability, travel and other specialty insurances for groups and individuals who are expatriates, thirdcountry nationals or high net-worth local nationals. GBG STUDENT HEALTH INSURANCE Colleges and universities require international students to have health insurance plans while studying. GBG Student Health Insurance Plans offer international students an alternative to more expensive university plans; they provide health insurance which may meet health insurance waiver requirements of some U.S. higher education institutions. Coverage is available to all International Students studying outside their home country who are enrolled and actively attending an accredited college or university. Under our TieCare International brand, we are the leading provider of health insurance to the international educational community with customers in over 50 countries. As globalization of the world s economy has continued to accelerate, GBG has developed a specialized underwriting structure that is required to meet the needs of this select market niche. This structure is devoted to one business only: underwriting risks for organizations and individuals whose life and work transcend geographic boundaries. The GBG portfolio of products provides optimum security because it is supported by a world-class panel comprising some of the largest and most financially stable underwriters in the world: GBG Insurance Limited (rated B++ by A.M. Best Company) Chubb Insurance (rated A++) General Reinsurance Corporation (rated A++) Lloyd s of London (rated A) Additionally, GBG partners with a multitude of local insurance companies around the world when an admitted carrier is required to meet specific country regulations. TieCare also operates as a Lloyd s coverholder. We are proud to offer this exciting and innovative structure to our clients. It provides the international marketplace with an unprecedented and unique combination: International expertise Dedicated underwriting facility Financial security Responsive customer service 24JUL2015GSFreedom For more information visit

3 GLOBAL STUDENT FREEDOM Network ENTRY AGE Coventry/First Health Network in U.S Minimum 12, Maximum 65 INJURY, ACCIDENT AND SICKNESS This policy will pay benefits for Injury or Sickness to an Insured Person as a result of an Emergency stay in a Hospital or Emergency medical or therapeutic services as specifically listed below. It also includes Prescription drugs (including oral contraceptives), Mental Health, Travel-related benefits, Accidental Death and Dismemberment and Preventive Care. GENERAL FEATURES AND PLAN SPECIFICATIONS Benefit Maximum $150,000 per Injury or Sickness Annual Maximum $400,000 Deductible $100 per Injury or Sickness ($45 per Injury or Sickness at Student Health Center) Coinsurance 100% of Usual, Resalable & Customary (URC) Charges Medical Evacuation/ Repatriation $60,000 Repatriation of Remains $50,000 Home Country Coverage $500 maximum AD&D $10,000 COVERED MEDICAL BENEFITS Emergency Hospital Accommodations Semi-private room and board Hospital Miscellaneous Expenses: while Hospital Confined. Benefits will be paid for services and supplies such as: the cost of operating room; laboratory tests; X-ray examination; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies. Intensive Care (If medically necessary) Surgeon s Benefit (Inpatient or Outpatient) Physician s fees for surgery. Covered medical expenses will be paid under this Inpatient benefit; or under the Outpatient surgery benefit, but not for both. Assistant Surgeon (Inpatient or Outpatient) Day Surgery (Outpatient) In connection with Outpatient day surgery; excluding nonscheduled surgery and surgery performed in a Hospital emergency room, trauma center, Physician s office, or clinic. Benefits will be paid for services and supplies such as: the cost of the operating room, laboratory tests and X-ray examinations including professional fees, anesthesia, drugs or medicines, therapeutic services and supplies. $1,000 per day, Up to 30 Days Maximum $500 per day, Up to 30 days maximum. $1,525 per day to 8 days maximum, Payable in lieu of the Hospital Room and Board Expense. $3,000 Maximum Per Policy Period 25% of Surgeon s Benefit payable $1,000 Maximum Per Policy Period Pre-admission Testing $900 maximum 24JUL2015_GSFreedom

4 GLOBAL STUDENT FREEDOM COVERED MEDICAL EXPENSES (Continued) Anesthesia Benefit (Inpatient or Outpatient) Diagnostic X-rays & Lab services Ambulance Service Physician Visits (Inpatient or Outpatient): Benefits are limited to one Physician s visit per day. Benefits do not apply when related to surgery. Covered medical expenses will be paid under the Inpatient benefit or under the Outpatient benefit for Physician s Visits but not both. 25% of Surgeon s Benefit payable $500 maximum, Cat Scan, PET Scan or MRI up to $350 additional. $400 maximum $50 per visit, 1 visit per day, 30 visits maximum Consultant Physician Fees when requested and approved by the attending Physician $400 maximum Emergency Room Benefit Includes the attending Doctor s charges, X-rays, laboratory procedures, use of the emergency room and supplies. Subject to an additional copay/deductible of $300 per occurrence. If a Plan Participant is admitted to the hospital following visit to the emergency room, the additional deductible is waived. After the deductible has been satisfied the plan will pay 80% of Reasonable and Customary Charges. Maternity (conception must occur while this coverage is in effect) $5,000 maximum for normal delivery, $7,500 for C-section delivery Mental and Nervous Condition (Inpatient) Benefits are payable at 80%. Mental and Nervous Condition (Outpatient) Alcoholism/Drug Abuse Treatment Emergency Dental Expense 1) Performed by a Physician; and 2) made necessary by Injury to Natural Teeth. Routine dental care and treatment to the gums are not covered. Maximum of 40 visits per year, $5,000 maximum per policy year, payable at 80%. The benefits and the maximum amounts are the same as any Sickness. $500 maximum Radiation Therapy and/or Chemotherapy Physiotherapy (Inpatient or Outpatient) Durable Medical Equipment Must be medical equipment prescribed by a Doctor that 1) is primarily and customarily used to serve a medical purpose; 2) can withstand repeated use; and 3) generally is not useful to a person in the absence of Injury. No benefits will be paid for rental charges in excess of the purchase price. Prescription Drugs (Outpatient) $1,000 maximum $35 per visit, 1 visit/day, 12 visits maximum $1,000 maximum $100 maximum 24JUL2015_GSFreedom

5 GLOBAL STUDENT FREEDOM BONUS BENEFITS ATM Safe: Provides lost cash replacement for losses occurring during a robbery at an ATM. $500 Travel benefits: Lost baggage. Expense reimbursement due to flight delays. $500 maximum benefit ($100 Deductible) EXCLUSIONS The Plan Document does not cover any loss resulting from any of the following unless otherwise covered under the Plan Document by Additional Benefits: 1. Suicide, attempted suicide (including drug overdose) self-destruction, attempted self-destruction or intentional self-inflicted Injury while sane or insane; 2. War or any act of war, declared or undeclared; 3. Voluntary, active participation in a riot or insurrection; 4. Medical expenses resulting from a motor vehicle accident in excess of that which is payable under any other valid and collectible insurance; 5. Organ transplants; 6. Treatment for an Injury or Sickness resulting from the Plan Participant's intoxication or use of illegal drugs or any drugs or medication that is intentionally not taken in the dosage recommended by the manufacturer or for the purpose prescribed by the Plan Participant's Physician; 7. Eligible Expenses for which the Plan Participant would not be responsible in the absence of the Plan Document; 8. Treatment of acne; 9. Charges which are in excess of Usual, Reasonable and Customary charges; 10. Charges that are not Medically Necessary; 11. Charges provided at no cost to the Plan Participant; 12. Expenses incurred for treatment while in Your Home Country in excess of $500; 13. Regular health checkups; routine physical, immunizations or other examination where there are no objective indications or impairment in normal health; 14. Services or treatment rendered by a Physician, Registered Nurse or any other person who is employed or retained by the Participating Organization; or an Immediate Family member of the Plan Participant; 15. Injuries paid under Workers Compensation, Employer s liability laws or similar occupational benefits or while engaging in an occupation for monetary gain from sources other than the Participating Organization; 16. Benefits for enrolling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician; 17. Pre-existing conditions; however a Pre-Existing condition will be covered after the Plan Participant has been continuously insured for 6 months under the same insurance plan; 18. Pregnancy or childbirth, except when conception occurs while covered under the Plan Document; elective abortion; elective cesarean section; or any complications of any of these conditions; pregnancy or childbirth or a dependent when dependent child of an Plan Participant (except for complications arising there from); 19. Drug, treatment or procedure that either promotes or prevents conception, or prevents childbirth, including but not limited to: artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof; 20. Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident while the Plan Participant is covered under the Plan Document, and rendered within 6 months of the Accident; 21. Eyeglasses, contact lenses, hearing aids braces, appliances, or examinations or prescriptions therefore; 22. Weak, strained or flat feet, corns, calluses, or toenails; 23. Expenses incurred during a Hospital emergency room visit which is not of an emergency nature; 24. Treatment paid for or furnished under any other individual or group Plan Document, or other service or medical pre payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for the treatment without cost to any individual; 25. Injury sustained while taking part in: mountaineering; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; snowmobiling; motorcycle/motor scooter riding; scuba diving, involving underwater breathing apparatus, unless PADI or NAUI certified; snorkeling; water skiing; jet skiing; snow skiing; spelunking; parasailing; white water rafting; surfing, unless part of a school credit course; and snowboarding. 26. Practice or play in any amateur, club, intramural, interscholastic, intercollegiate, professional or semi professional sports contest or competition; 27. Elective or Cosmetic surgery and Elective Treatment or treatment for congenital anomalies (except as specifically provided), except for reconstructive surgery on a diseased or injured part of the body (Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness); 28. Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from; or while riding as a passenger in any Aircraft not intended or licensed for the transportation of passengers. 24JUL2015_GSFreedom

6 GLOBAL STUDENT FREEDOM KEY PROVISIONS This is only a brief summary of key Plan provisions. Please refer to the Policy for complete details. Benefits are per person per policy coverage period and are based upon medical necessity and emergency. Benefits are payable after deductible at Usual, Customary and Reasonable (UCR) rates, or at Aetna negotiated rates. Minimum entry age is 12; Maximum entry age is 65. This policy will cover any emergency conditions except one which has not been stable in the 90 day prior to policy effective date. Where pre-authorization is required, the insured must obtain it in writing from the Provider and forward to the Insurance Company. When in doubt as to coverage specifics or whether pre-authorization is required, consult with GBG Assist. Pre-authorization is not required for annual physical or eye exam. Accidental Death and Dismemberment/Common Carrier Time Period for Loss 90 days Loss of: Benefit: Percentage of Principal Sum Accidental Death 100% Loss of Both Feet or Feet 100% Loss of Entire Sight of Both Eyes 100% Loss of One Hand and One Foot 100% Loss of One Hand and Entire Sight of One Eye 100% Loss of One Foot and Entire Sight of One Eye 100% Loss of One Hand or Foot 50% Loss of Sight of One Eye 50% 24JUL2015_GSFreedom

7 TieCare provides world-class services. The essence of outstanding health insurance comes in the form of customer service, and a cornerstone of GBG is the worldwide expertise of GBG Assist. GBG Assist offers 24/7 assistance to answer any customer need around the world including emergency evacuation, if necessary no matter the day or time. GBG Assist is a member s one-stop shop for any questions concerning benefits, deductibles & co-insurance, network providers, pre-authorization and coordination of benefits. In the case of hospitalization, Case Managers and the GBG Assist Medical Director work as a team to manage all aspects of a case from the initial referral until the patient returns home. GBG Assist provides empathetic patient advocacy while monitoring costs; whenever in doubt, make your first call to GBG Assist. International Claims Services (ICS) supports group and individual clients around the world by providing claims processing and reimbursement to both providers and individuals. All ICS services are available to members online at gbg.com. Of special importance, ICS has developed proprietary claims software to handle the complexities of international reimbursements whenever a member files a pay-and-claim form. ICS is staffed with experienced claims processing professionals who are fully conversant with the needs of international clients. In the United States, GBG utilizes the Coventry Health Care Network as its Preferred Provider Network. Coventry is positioned as a leading PPO Network that includes more than 4,800 hospitals and 555,000 professional providers in the United States. The network has coverage in all 50 states plus the District of Columbia and Puerto Rico. Networks are important to health insurance members because the overwhelming majority of these facilities will invoice the insurance company directly for services rendered, avoiding the need for a member to pay and claim. Coventry s ever-expanding network speaks to its client satisfaction and pride in its track record of success and aggressive growth supported by exceptional service. Outside of North America, GBG has built a proprietary Preferred Provider Organization called World Medical Network (WMN). Facilities that participate in World Medical Network will not only provide the finest care available in the local environment, but they have been chosen for their expertise in dealing with expatriates. They maintain an English speaking staff, have many Western trained staff members, and provide high quality and professional medical care. In addition, for Global Student Freedom members, WMN providers will bill GBG directly. For pharmacy coverage in the United States, GBG utilizes CVS Caremark, giving members access to one of the leading pharmaceutical service companies. CVS Caremark fills or manages more than 1 billion prescriptions per year, more than any other pharmacy services provider in the United States. Outside of the United States, pharmacy expenses are reimbursed on a pay-and-claim basis. 24JUL2015GSFreedom

8 The information contained herein is for illustrative purposes only. Please contact us for policy details and/or to request a customized proposal. Underwritten by GBG Insurance LTD. TIECARE INTERNATIONAL Portola Parkway, Suite 110 Foothill Ranch, CA USA Phone: Fax: info@gbg.com the educational division of