SUMMARY PLAN DESCRIPTION STUDENT HEALTH PLAN Designed Especially for Students of

Transcription

1 SUMMARY PLAN DESCRIPTION STUDENT HEALTH PLAN Designed Especially for Students of

2 Table of Contents Privacy Policy 3 Eligibility 3 Qualifying Event 3 Effective and Termination Dates 3 General Provisions 4-5 Schedule of Medical Expense Benefits 6-12 List of Key Covered Preventive Care Services 13 Prescription Drugs Additional Exclusions 14 Prescription Pre-Certification 15 Specialty Medications 16 Preferred Provider Information 17 Accidental Death and Dismemberment Benefits 18 Coordination of Benefits 18 Continuation Privilege 19 Payable Benefits 19 Benefits for Maternity Benefits for Outpatient Services 20 Benefits for Rehabilitation and Habilitation Services and Devices Benefits for Preventive Care Services Benefits for Pediatric Dental Services Benefits for Pediatric Vision Services Benefits for Breast Cancer Treatment Benefits for Mental Health And Substance Abuse Disorder Benefits for Contraceptive Drugs or Devices 28 Benefits for Sterilization for Men 28 Benefits for Infertility 28 Benefits for Elective Termination of Pregnancy 28 Benefits for Reconstructive Surgery 28 Benefits for Second Opinion (Surgical) 28 Benefits for Autism Spectrum Disorder 28 Benefits for Bariatric Surgery 28 Benefits for Exercise Facility Reimbursement 28 Benefits for Oral Surgery 29 Definitions Exclusions and Limitations Emergency Medical Evacuation Exclusions and Limitations for Emergency Medical Evacuation 42 2

3 PRIVACY POLICY POLICY WORDING Federal law requires that we protect your personal health information in accordance with the Health Insurance Portability and Accountability Act/ The Health Information Technology for Economic and Clinical Act and related privacy rules. These laws require the Company to keep your health information private. We are not allowed to use or disclose it unless we receive your permission or unless permitted by law. ELIGIBILITY All St. George s University students taking a minimum of 5 credit hours, or students who are enrolled as a participant in the Individual Remediation Program, are eligible and must be enrolled in the SGU Student Health Plan. Students may waive this coverage if proof of comparable coverage is furnished. Students must actively attend classes for at least the first 31 days after the effective date of the policy. Home study, correspondence, and television (TV) courses do not fulfill the Eligibility requirements that the student actively attend classes. The Company maintains its right to investigate student status and attendance records to verify that the policy Eligibility requirements have been met. Students on an approved leave of absence are eligible to enroll and may continue coverage under this plan until the end of the policy term for which they were originally eligible. Members of faculty who are also students are not eligible to enroll in the student insurance plan. If the Company discovers the Eligibility requirements have not been met, its only obligation is to refund premium. Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the spouse and children up to the age of 26. Dependent Eligibility expires concurrently with that of the insured student. *Note: For the purpose of eligibility and Open Enrollment: Fall Term is defined as August, 1 through December, 31; Spring Term as January 1 through July 31 of any calendar year). QUALIFYING EVENTS A qualifying event is any of the following which results in loss of coverage for a qualified student or dependent. A qualified student must notify the Company within thirty one (31) days of: (a) Any loss of coverage from your prior carrier (b) Legal marital status including marriage, death of spouse, divorce, legal separation and annulment. (c) A change in the number of dependents; including birth, death adoption or a change which may impact You or Your Dependent s eligibility for coverage under this Policy. EFFECTIVE AND TERMINATION DATES The Master Policy on file at the school becomes effective on August 01, The individual coverage becomes effective on the first day of the period for which premium is paid. The Master Policy terminates on July 31, Coverage terminates on that date or at the end of the period through which premium is paid, whichever is earlier. Dependent coverage will not be effective prior to that of the Insured student or extend beyond that of the Insured student. Refunds of premiums are allowed only upon entry into the Armed Forces. The Policy is a nonrenewable One Year Term Policy. 3

4 GENERAL PROVISIONS STATEMENTS; ENTIRE CONTRACT; CHANGES: No statement made by an Insured Person shall avoid the insurance or reduce benefits there under unless contained in a written instrument signed by the Insured Person. All statements contained in any such written instrument shall be deemed representations and not warranties. This policy, including the endorsements and attached papers, if any, and the application of the Policyholder shall constitute the entire contract between the parties. No agent has authority to change this policy or to waive any of its provisions. No change in the policy shall be valid until approved by an executive officer of the Company and unless such approval be endorsed hereon or attached hereto. Such an endorsement or attachment shall be effective without the consent of the Insured Person but shall be without prejudice to any claim arising prior to its Effective Date. PAYMENT OF PREMIUM: All premiums are payable in advance for each policy term in accordance with the Company's premium rates. The full premium must be paid even if the premium is received after the policy Effective Date. There is no pro-rata or reduced premium payment for late enrollees. There will be no refunds to students who cancel coverage under the policy; unless the Insured enters the armed forces or a valid waiver has been submitted to SGU within 30 days of the effective date and no claims have been incurred. SGU has 90 days from the effective date to notify the Company of any student that no longer meets eligibility within the first 31 days. The only obligation of the Company is a full refund of premium provided that no benefits have been paid. Premium adjustments involving return of unearned premiums to the Policyholder will be limited to a period of 12 months immediately preceding the date of receipt by the Company of evidence that an adjustments should be made. Premiums are payable to the Company. NOTICE OF CLAIM: Written notice of claim must be given to the Company within 90 days from the date of service. CLAIM FORMS: Claim forms are not required from providers directly. Claim forms are required from students that are submitting claims for reimbursement. ISSUANCE OF CERTIFICATES: The Company will issue, either to the Policyholder or directly to the Named Insured, a certificate set forth in summary form a statement of the essential features and substance of the provisions of the insurance coverage. PROOF OF LOSS: Written proof of loss must be furnished to the Company at its office within 90 days after the date of such loss. Claims received after the 90 days will result in the claim being denied. After termination of this Policy, claims for expenses incurred while the Policy was in force shall be considered if they reach the lnsurer within 90 days of such termination. After expiration of this term, the Policyholder, the lnsured Persons, the recipient of benefit and the lnsurer have neither rights nor obligations. 4

5 TIME OF PAYMENT OF CLAIM: Indemnities payable under this policy for any loss will be paid within 30 days of receipt of a claim or bill for services rendered that is transmitted via the internet or electronic mail, or 45 days of receipt of a claim or bill for services rendered that is submitted by other means, such as paper or facsimile. PAYMENT OF CLAIMS: All benefits are payable to the Insured. If the Insured is a minor, such benefits may be made payable to his or her parent or legal guardian. A loss of life benefit, if any, will be paid in accordance with the beneficiary designation in effect at the time of payment. If none is then in effect, that benefit shall be paid to the estate of the Insured Person. Any other benefits unpaid at the death of the Insured Person may, at the Company s option, be paid to the beneficiary (other than the Policyholder or an officer of the Policyholder as such) or the Insured Person s estate. Subject to any written direction of the Insured, all or a portion of any indemnities provided by this policy may be paid directly to the Hospital, Physician or person rendering such service or treatment. Any payment so made shall discharge the Company s obligation to the extent of the amount of benefits so paid. PHYSICAL EXAMINATION: As a part of Proof of Loss, the Company at its own expense shall have the right and opportunity: 1) to examine the person of any Insured Person when and as often as it may reasonably require during the pendency of a claim; and, 2) to have an autopsy made in case of death where it is not forbidden by law. The Company has the right to secure a second opinion regarding treatment or hospitalization. Failure of an Insured to present himself or herself for examination by a Physician when requested shall authorize the Company to: (1) withhold any payment of Covered Medical Expenses until such examination is performed and Physician's report received; and (2) deduct from any amounts otherwise payable hereunder any amount for which the Company has become obligated to pay to a Physician retained by the Company to make an examination for which the Insured failed to appear. Said deduction shall be made with the same force and effect as a deductible herein defined. LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this policy. No such action shall be brought after the expiration of 2 years after the time written proofs of loss are required to be furnished. SUBROGATION: When benefits are paid to or for an Insured under the terms of this policy, the Company shall be subrogated, unless otherwise prohibited by law, to the rights of recovery of such Insured for Hospital, medical, or surgical services and benefits. The right of subrogation will only be exercised by the Company when the amounts (or portion) received by the Insured through a thirdparty settlement or satisfied judgment is specifically identified as amounts paid for Hospital, medical or surgical services and benefits. Such subrogation rights shall extend only to the recovery by the Company of the benefits it has paid for such hospitalization and treatment. The Insured shall execute and deliver such instruments and papers as may be required and do whatever else is necessary to secure such rights to the Company. RIGHT OF RECOVERY: Payments made by the Company which exceed the Covered Medical Expenses (after allowance for deductible and coinsurance clauses, if any) payable hereunder shall be recoverable by the Company from or among any persons, firms, or corporations to or for whom such payments were made or from any insurance organizations who are obligated in respect of any covered Injury or Sickness as their liability may appear. 5

6 St. George s University Student Health Plan Schedule of Benefits Unlimited Lifetime Maximum Benefit Paid as Specified Below $250 Deductible (per Student or member per year) 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 is used. The Preferred Provider in the United States for this plan is the Aetna Passport to Health Primary PPO Network: Note: For Preferred Provider Benefits outside of the US, after the Deductible has been satisfied, benefits will be paid for Usual and Customary charges for Covered Medical Expenses incurred. Maximum Lifetime Benefit is Unlimited. For Preferred Provider Benefits inside of the US, after the Deductible has been satisfied, benefits will be paid for 80% of the network contracted rate for Covered Medical Expenses incurred. Maximum Lifetime Benefit is Unlimited. For USA Out of Network Provider Benefits, after the Deductible has been satisfied, benefits will be paid for 70% of Usual and Customary charges for Covered Medical Expenses incurred. Maximum Lifetime Benefit is Unlimited. Coverage for charges at the Student Health Center (SHC) are paid in accordance to an agreed upon fee schedule and include physician s visits. *Charges covered at the SHC are not subject to the policy deductible or benefit copays or coinsurance. Needle Stick / Face Splash as a result of course work will be paid as any other Injury or Sickness. 6

7 SCHEDULE OF BENEFITS PRE-AUTHORIZATION OF SERVICES All services rendered must be provided by our Preferred Provider Network. The following medical services must be pre-authorized in writing: In-patient Hospitalization Outpatient Surgical Procedures Organ Transplant Evacuation Repatriation of Mortal Remains Bariatric Surgery Enteral Formulas TMJ Home Health Care Diagnostic Services Emergency Air Ambulance Emergency Transportation of a Family Member Oncology Treatment Physical Therapy Infertility Treatment Durable Medical Equipment Pre-authorization within the United States, the physician/hospital should contact +1 (866) or +1 (305) as indicated on the ID card. Pre-authorization outside of the United States, member, provider or hospital must contact +1 (305) or toll free within U.S.A./Canada/Caribbean +1 (800) Failure to comply with preauthorization requirements, within a minimum of 5 business days, prior to planned treatment will result in a 50% penalty. For Emergency services, you must pre-certify within 48 hours. Service U.S. In-Network U.S. Out-of- Network Out of U.S. Deductibles: Individual/Family $250 / $500 $500 / $1,000 *$250 / $500 Co-Insurance Out-of-Pocket Limit $6,000 / $8,000 $8,000 / $10,000 N/A Lifetime Maximum per insured: UNLIMITED All benefits are subject to Usual Customary and Reasonable Charges (UCC) for Out of Network U.S. and Out of U.S. All amounts are in USD - * Deductible waived at the Student Health Clinic Note: In-Network deductibles and Out-of-Network deductibles count separately and are not combined. Inpatient Service U.S. In-Network U.S. Out-of- Network Out of U.S. Room & Board, daily semi-private room rate; general nursing care provided by the Hospital. Hospital Miscellaneous, such as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take home drugs) or medicines, therapeutic services and supplies. In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge. Routine Newborn Care, while Hospital confined and newborn care provided immediately after birth. Assistant Surgeon charges limited to the primary surgeons allowable charge. Surgical Procedure Anesthesiologist Fees, professional services in connection with inpatient surgery. 70% 20% 20% 20% Inpatient Physician s Visits Pre-Admission Testing 7

8 Outpatient Benefits In-Network U.S. Out-of-Network U.S. Outside the U.S. Surgical Procedure Day Surgery Miscellaneous, related to scheduled surgery performed in a Hospital, including the cost of the operating room; laboratory tests and X-ray examinations, including professional fees; anesthesia; drugs or medicines; and supplies. Anesthesiologist Fees, professional services in connection with outpatient surgery. Primary Care Physician Visits/Chiropractic Assistant Surgeon charges limited to the primary surgeons allowable charge 20% 20% 20% Specialist Care visits Urgent Care Facility Preventive Care/ Screening/ Immunizations, Mammography (limits based on age), cervical cytology, gynecological exams, bone density, prostate cancer screening (1 per policy year for men ages 40 and over if family history or risk factors; any age if prior history.) 70% Emergency Room X-rays and Laboratory Oncology Treatment Diagnostic Testing and Procedures, diagnostic services and medical procedures performed by a Physician, other than Physician s Visits, Physiotherapy, X-rays and lab procedures. Injections, when administered in the Physician s office and charged on the Physician s statement. This benefit includes allergy treatment. Pre-exposure Rabies Vaccination, Preexposure Rabies Vaccination will be covered as any other injection. This benefit is only available to the Veterinarian Department for students who purchased the Rabies Vaccine Rider. This benefit is not extended to dependents. Prescription Drugs have a separate $6,000 Individual / $8,000 Family Out of Pocket Maximum. Copay for prescription drugs are based on a maximum of a 31 day supply per prescription. *Contraceptive Drugs or Devices Under Tier 1, Not subject to copay or deductible or coinsurance. If used for Family Planning. *Off Label Cancer Drugs Maximum of a 31 day supply per prescription. Tier 1: $10.00 copay Tier 2: $30.00 copay & 80% after Tier 3: $50.00 copay & 80% after Tier 1: $10.00 copay Tier 2: $30.00 copay & 80% after Tier 3: $50.00 copay & 80% after Tier 1: $10.00 copay Tier 2: $10.00 copay Tier 3: $10.00 copay 8

9 Additional Benefits In-Network U.S. Out-of-Network Out of U.S. Ambulance Services Durable Medical Equipment, prescription required when filing claim, limited to $1,500 per policy year. Prenatal & Postnatal Maternity and Delivery Services Complications of Pregnancy including High Risk Prenatal Child Wellness Acupuncture/Massage Therapy, available only at the Student Health Center (SHC), 3 Visits Maximum per year with referral. Home Health Care, 40 visits per policy year. Hearing Aids, limited to a single purchase every 3 years including repair and or/replace. Prosthesis, 1 external prosthetic device per limb per lifetime. Hospice services & Home Hospice, 210 days per policy year, inpatient and outpatient combined. Transplant, solely for surgeries determined to be non-experimental and non-investigative. Second Opinion, Surgical- on a surgical procedure not considered an emergency. Second Opinion, Cancer Specialist- by appropriate specialist, including one affiliated with a specialty care center for cancer. Exercise Facility Reimbursement, membership and paid receipt required. Infertility Treatment Basic and Comprehensive must be between the ages of 21 and 44. Covered services include: initial evaluation, evaluation of ovulatory function, postocoital test, hysterosalpingogram, treatment of ovulatory dysfunction, ovulation induction and monitoring with ultrasound, artificial insemination, hysteroscopy, laparoscopy and laparotomy. Correctable Medical Condition Leading to infertility. Advanced infertility is NOT covered. Prostate Cancer Screening, 1 per policy year for men ages 40 and over if family history or risk factors; any age is prior history. 70% 70% No Benefit No Benefit $400 / $200 Per year member/spouse $400 / $200 Per year member/spouse $400 / $200 Per year member/spouse 70% 9

10 Allergy Testing Diabetic Equipment & Supplies Diabetic Education and Self Management Male Sterilization, Vasectomy Bariatric Surgery Breast Reconstruction, following mastectomy, lumpectomy or lymph node dissection. *Pre-authorization required Reconstructive and corrective surgery, limited to correct a congenital birth defect of dependent child or incidental to surgery or follow surgery necessitated by trauma, infection or disease. Comprehensive Care Facility for Eating Disorders Bereavement Counseling, limited to 5 sessions for members family either before or after death of the member. Elective Termination of Pregnancy, 1 treatment per policy year. Oral Surgery, due to injury is limited to sound and natural teeth only; due to congenital anomaly; removal of tumors and cysts requiring pathological examination of jaws/cheeks/lips. Autism Spectrum Disorder, $45,000 per year for ABA with adjustments. Family Planning, including but not limited to Tubal Ligation, patches, diaphragms, and IUD s. Rehabilitation Services, inpatient and outpatient 60 visits per condition per lifetime. TMJ Habilitation Services, Short Term outpatient physical, speech and occupational therapy limited to 60 visits per condition per lifetime. Skilled Nursing Care, 200 days per policy year. Enteral Formula 70% 70% 10

11 Pediatric Dental and Vision In-Network U.S. Out-of-Network U.S. Outside the U.S. Dental Check-up for Children under age 19, One visit per 6 months. Major Dental Care for Children under age 19, refer to complete description under policy wording Orthodontic Benefits for Children under age 19, refer to complete description under policy wording Emergency Dental for Children under age 19, includes treatment required to alleviate pain and suffering caused by dental disease or trauma. Eye Examination for Children under age 19, One exam per policy year. Eye Glasses/ Contact Lenses for Children under age 19, $150 per policy year for one pair of standard frames or contacts when medically necessary and must provide a dioptre. 80% up to $500 80% up to $500 70% 70% up to $500 70% up to $500 up to $500 up to $500 70% 70% Mental Health and Substance Abuse Disorder Services In-Network U.S. Out-of-Network U.S. Outside the U.S. Mental/Behavioral Health Outpatient Services, 30 visits per year. Benefit limits include office visit and Outpatient visits combined. Biologically based services will count towards this limit. 70% Mental/Behavioral Health Inpatient Services, 30 visits per year. Members may choose to exchange 1 inpatient day for 2 visits of partial hospitalization. Visits for biologically based services will count towards this limit. 70% Substance Use Disorder Outpatient Services, 60 visits per year. Benefit limits include Office Visits and Outpatient Visits combined. Up to 20 of the visits may be used by the member s family. 70% Substance Use Disorder Inpatient Services, 30 visits per year. 70% Inpatient Alcohol & Substance Abuse Detoxification, 7 days Inpatient Detoxification. 70% 11

12 Life and AD&D Benefits In-Network U.S. Out-of-Network U.S. Outside the U.S. Accidental Death & Dismemberment Student Spouse Each Child Life Insurance Benefit Student Spouse Each Child $7,500 to $15,000 $1,250 to $5,000 $250 to $1,000 $7,500 to $15,000 $1,250 to $5,000 $250 to $1,000 Emergency Medical Evacuation $15,000 $5,000 $1,000 $7,500 to $15,000 $1,250 to $5,000 $250 to $1,000 Medical Evacuation Benefits up to $100,000 per policy period Emergency Reunion $15,000 for a maximum of 15 days which is exhausted first Return of Mortal Remains $20,000 Maximum payable benefits for all Medical Evacuation, Emergency Reunion or Return of Mortal Remains will not exceed $100,000 per policy period. **This Summary of Benefits is provided as a brief outline of the benefits afforded under the Student Health Plan. Please refer to your Policy Wording for further clarification, definitions, limitations, and exclusions. 12

13 LIST OF KEY COVERED PREVENTIVE CARE SERVICES Actual coverage may vary. Please See your plan documents for details. Children and Adolescents Additional Screening for Adolescents Screenings for Men Newborns Screening all newborns for - Hearing loss - Hypothyroidism - Sickle cell disease - Phenylketonuria (PKU) Gonorrhea preventive medication for eyes of all newborns Childhood/Adolescent Immunizations Diphtheria, tetanus, pertussis Haemophilus influenza type B Hepatitis A and B Human papillomavirus (HPV) Influenza (flu) Measles, mumps, rubella Meningococcal Pneumococcal (pneumonia) Inactivated poliovirus Rotavirus Varicella (chickenpox) Childhood Screenings Medical history for all children throughout development Height, weight, and body mass index (BMI) measurements Developmental screening for children throughout childhood Autism screening for children at 18 and 24 months Behavioral assessment for children of all ages Vision screening Oral health risk assessment for young children Hematocrit or Hemoglobin screening Obesity screening and weight management counseling for children age six or older Iron supplements for children six to 12 months who are at higher risk for anemia** Fluoride supplements for children without fluoride in their water** Lead screening for children at risk of exposure Dyslipidemia screening for children at higher risk of lipid disorder Tuberculin testing for children at higher risk of tuberculosis Depression screening Alcohol and drug use assessment Counselling to prevent sexually transmitted infections (STIs) for sexually active adolescents Cervical dysplasia screening for sexually active young women HIV screening for adolescents at higher risk Health Screening for Adults Blood pressure screening for adults Cholesterol screening for men age 35 and older, women age 45 and older and younger adults at higher risk Diabetes screening for type 2 diabetes for adults with high blood pressure HIV and sexually transmitted infection (STI) screening for adults at higher risk Cancer Screening Breast cancer mammography every one to two years for women over age 40 Breast cancer chemoprevention counseling for women at high risk for breast cancer Cervical cancer pap test for women Colorectal cancer screening including fecal occult blood testing, sigmoidoscopy or colonoscopy from age 50 to 75 Prostate cancer (PSA) screening for men Health Counseling Doctors are encouraged to counsel patients about these health issues and refer them to appropriate resources as needed: - Healthy Diet - Weight loss - Tobacco use - Alcohol misuse - Depression - Prevention of sexually transmitted infections (STIs) - Use of aspirin to prevent cardiovascular disease** Adult Immunization Hepatitis A and B Herpes Zoster Human papillomavirus (HPV) Influenza (flu) Measles, mumps, rubella Meningococcal Pneumococcal (pneumonia) Inactivated poliovirus Rotavirus Varicella (chickenpox) Abdominal aortic aneurysm one-time screening for men age 65 to 75 who have smoked Screenings for Women Osteoporosis screening for women age 60 and older, depending on risk factors Chlamydia infection screening for sexually active women age24 and younger and other women at higher risk Gonorrhea and syphilis screening for sexually active women at higher risk BRCA counseling about genetic testing for women at higher risk Annual well-woman visits Screening for gestational diabetes HPV DNA testing for women 30 years and older Sexually-transmitted infection counseling HIV screening and counseling FDA-approved contraceptive methods and contraceptive counseling Breast-feeding support, supplies and counseling Screening and counseling for interpersonal and domestic violence Specifically For Pregnant Women Folic acid supplements for women who may become pregnant** Anemia screening for iron deficiency Tobacco cessation counseling for all pregnant women who smoke Syphilis screening for all pregnant women Hepatitis B screening during the first prenatal visit Rh incompatibility blood type testing at first prenatal visit and at 24 to 28 weeks Bacteriuria urinary tract infection screening at 12 to 16 weeks Breast-feeding education to promote breastfeeding **Over-the-Counter with prescription 13

14 PRESCRIPTION DRUG BENEFITS Benefits are available for outpatient Prescription Drugs on our Prescription Drug List (PDL) when dispensed by a participating EHIM Network pharmacy. Benefits are subject to supply limits and copayments and/or co-insurance that varies depending on which tier of the PDL the medication is listed. There are certain Prescriptions that require Pre-Certification and must meet the specific clinical criteria in order to be eligible for coverage. You are responsible for paying all applicable copayments and/or coinsurance at the point of s ale. Your copayment/coinsurance is determined by the tier to which the Prescription Drug product is assigned on the PDL. Tier status may change periodically and with or without prior notice to you. You may contact EHIM in the United States at +1 (800) for any questions regarding your prescription drug coverage. EHIM s Pharmacy Help Desk is available 24 hours a day, 7 days per week, 365 days per year. Please present your ID card to the network pharmacy when the prescription is filled. If you do not use a network pharmacy, you will be responsible for paying the full cost for the prescription. If you do not present the card, you may need to pay for the prescription then submit a reimbursement form for the prescription along with the paid receipt and prescription receipt in order to be considered for reimbursement. You may submit the claim via your Member Portfolio. To obtain information regarding participating pharmacies, please contact EHIM at +1 (800) or you may visit EHIM s website at When prescriptions are filled at pharmacies outside of the USA, the Insured must pay for the prescription out-of-pocket and submit the receipts for reimbursement to: Lyncpay 135 San Lorenzo Ave, PH- 860 Coral Gables, FL You may also submit the claim via your Member Portfolio. ADDITIONAL EXCLUSIONS In addition to the policy Exclusions and Limitations, the following Exclusions apply to Network Pharmacy Benefits: Any prescription filled in excess of the quantity limit or day supply limit covered by the plan. Any prescription refilled in excess of the number specified by the physician, or any refill dispensed after one year from the physician s original order Experimental or Investigational medications. A drug is considered investigational or experimental if its use has not been approved by the U.S. Food and Drug Administration or if it is an approved drug but is not being used in a therapy for which it is generally prescribed. The Plan Administrator s decision, whether a drug or its use are investigational or experimental shall be binding. Compounded Drugs that do not contain at least one ingredient that has been approved by the US Food and Drug Administration and requires a Prescription Order of Refill. Compounded drugs that are available as a similar commercially available Prescription Drug Product. Drugs available over the counter that do not require a prescription order or refill by federal or state law before being dispensed, unless the Company has designated the over the counter medications eligible for coverage and it is obtained with a prescription order or refill from a physician. 14

15 Medication which is to be taken by or administered to an individual, in whole or in part, while he/she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals Prescriptions refilled before 85% of the previous filling has been used Prescriptions that are forged or otherwise wrongfully obtained Impotency Agents Cosmetic Drugs Growth Hormone Fertility Medication Medical Devices and Appliances PRESCRIPTION PRE-CERTIFICATON Specialty Medications require medical documentation submitted by the treating physician and are subject to clinical review in order to be covered by the Plan. The Preferred Pharmacy Provider in the United States for this plan is EHIM. EHIM s Pre-Certification process is as follows: The member, pharmacist or physician contacts EHIM s pharmacy help desk at +1 (800) to initiate the pre-certification process. Once EHIM is contacted, the assigned clinical case manager will send the necessary paperwork to the prescribing physician for their completion. The physician may be asked to provide medical documentation to EHIM outlining the member s diagnosis, previous failed treatments, duration of therapy, and specific course of treatment the physician is requesting. Upon receiving the completed documentation from the prescribing physician, the clinical case manager will review the information, and a determination will be made to approve or deny the request. Once the determination has been made, the patient will be notified. This entire process is dependent upon the prescribing physician s response time to EHIM s request for information. Determinations are made fairly quickly, typically within hours of our receipt of all required documentation. Please keep in mind that any medical or prescription information submitted to EHIM is highly confidential and used only to help determine whether the Pre-Certification request may be approved. 15

16 SPECIALTY MEDICATIONS Specialty medications are generally used to treat and manage complex conditions such as Multiple Sclerosis, Cancer, and Transplants. In addition to their high cost, these specialty medications may require special handling. Coverage of these medications is subject to the terms and conditions of your specific plan description as administered by EHIM. Examples of specialty medications are listed below, but are not all-inclusive. This list is subject to change without notice, for a full list; please refer to the pharmacy booklet. Anticoagulants & Blood Modifiers Chemotherapy Agents Aranesp Neulasta Afinitor Hycamtin Thalomid Arixtra Neumega Arimidex Iressa Tykerb Enoxacin Neupogen Aromasin Nexavar Votrient Fragmin Procrit Casodex Revlimid Xeloda Heparin Eligard Sprycel Tarceva Zoladex Innohep Femara Tasigna Zolinza Leukine Gleevec Temodar Lovenox Cystic Fibrosis Miscellaneous HIV Pulmozyne Forteo Atripla Tobi Lupron Fuzeon Rheumatoid Arthritis Lupron Depot Isentress Cimzia Enbrel Lysteda Kaletra Humira Kineret Sensipar Sustiva Simponi Vfed Truvada Psoriasis Pulmonary Hypertension Zerit Enbrel Humatropin Adcirca Valcyte Humira Norditropin Letairis Hepatitis Revatio Baraclude Multiple Sclerosis Tracleer Copegus Ampyra Tyvaso Intron A Avonex Ventavis Pegasys Copaxone Rebetrol Gilenya Immunosuppresants Ribavirin Rebif Cellcept Cyclosporine oral Tyzeka Gengraf Mycophenolate Myfortic Neoral Prograf Rapamune Sandimmune Tacrolimus 16

17 PREFERRED PROVIDER INFORMATION "Preferred Providers" are the Physicians, Hospitals and other health care providers who have contracted to provide specific medical care at negotiated prices. The Preferred Provider in the United States is Aetna Passport to Health Primary PPO Network. The availability of specific providers is subject to change without notice. Insured's should always confirm that a Preferred Provider is participating at the time services are required by calling the Company at +1 (800) or +1 (305) and/or by asking the provider when making an appointment for services. "Preferred Allowance" means the amount a Preferred Provider will accept as payment in full for Covered Medical Expenses. "Out of Network" providers have not agreed to any prearranged fee schedules. Insured's may incur significant out-of-pocket expenses with these providers. Charges in excess of the insurance payment are the Insured's responsibility. Regardless of the provider, each Insured is responsible for the payment of their Deductible. The Deductible must be satisfied before benefits are paid. The Company will pay according to the benefit limits in the Schedule of Benefits. INPATIENT HOSPITAL EXPENSES PREFERRED HOSPITALS- Eligible inpatient Hospital expenses at a Preferred Hospital will be paid at the coinsurance percentages specified in the Schedule of Benefits, up to any limits specified in the Schedule of Benefits. Call +1 (800) or +1 (305) for information about Preferred Hospitals. OUT-OF-NETWORK HOSPITALS - If care is provided at a Hospital that is not a Preferred Provider, eligible inpatient Hospital expenses will be paid according to the benefit limits in the Schedule of Benefits. OUTPATIENT HOSPITAL EXPENSES Preferred Providers may discount bills for outpatient hospital expenses. Benefits are paid according to the Schedule of Benefits. Insureds are responsible for any amounts that exceed the benefits shown in the Schedule, up to the Preferred Allowance. PROFESSIONAL & OTHER Benefits for Covered Medical Expenses provided by, Participating and Non-participating providers, will be paid at the coinsurance percentages in the Schedule of Benefits or up to any limits specified in the Schedule of Benefits. All other providers will be paid according to the benefit limits in the Schedule of Benefits. 17

18 ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Loss of Life, Limb or Sight If such Injury shall, independently of all other causes and within 180 days from the date of Injury, solely result in any one of the following specific losses, the Insured Person or beneficiary may request the Company to pay the applicable amount below. Payment under this benefit will not exceed the Policy Maximum Benefit. For Loss of: STUDENT Life $15, Two or More Members $15, One Member $ 7, SPOUSE Life $ 5, Two or More Members $ 5, One Member $ 1, CHILD Life $ 1, Two or More Members $ 1, One Member $ 1, Member means hand, arm, foot, leg, or eye. Loss shall mean with regard to hands or arms and feet or legs, dismemberment by severance at or above the wrist or ankle joint; with regard to eyes, entire and irrecoverable loss of sight. Only one specific loss (the greater) resulting from any one Injury will be paid. Coordination of Benefits Even if you have other insurance, this Plan may cover unpaid balances, deductibles and pay those eligible medical expenses not covered by other insurance. This Policy has been designed to help meet the cost of treating an injury or Illness. Since it is not intended that anyone should receive a greater benefit than the actual medical expenses incurred, the amount of the Benefits payable under this Policy will take into account any other individual or group health coverage. Policies issued in the Country of Residence, Workmen s Compensation or Medicare will be considered primary plans and will pay first and Benefits under this Policy, subject to all terms and conditions will start afterwards. In all other cases, Benefits under this Policy will be coordinated with the Benefits of any other medical insurance policies the Covered Person may have. The coordination of benefits will be determined as follows: 1. If an insured has local coverage in the country of residence, the local coverage would be primary for the services incurred locally over this plan. This plan would be secondary and our liability would only be the amount not covered by the primary carrier and such would be subject to the satisfaction of deductible under this policy. 2. If the Insured has a policy in the United States, the policy which has been in effect the longest would be primary over this policy. 3. If the Insured has two International policies, the policy which has been in effect the longest would be the primary over this policy. 4. If no other International policy is available and member travels outside country of residence, this policy would be primary. 18

19 CONTINUATION PRIVILEGE All Insured Persons who have been continuously insured under the school's regular student policy for at least 6 consecutive months and who no longer meet the Eligibility requirements under the Policy, are eligible to continue their coverage for a period of not more than 6 months. Continuation of coverage is applicable under the school's policy in effect at the time of such continuation. If an Insured Person is still eligible for continuation at the beginning of the next Policy Year, the Insured must purchase coverage under the new policy as chosen by the school. Coverage under the new policy is subject to the rates and benefits selected by the school for that Policy Year. An application must be completed and premium must be paid directly to Worldwide Expatriate Association (WEA) and be received within 14 days after the expiration date of your student coverage. For further information on the Continuation privilege, please contact Lyncpay at +1 (800) within the U.S.A. or +1 (305) PAYABLE BENEFITS Maternity Care Benefits for pregnancy are also covered as any other medical condition, as stipulated in the medical plan. Benefits will include coverage for an Insured mother and newborn confined to a Hospital as a resident inpatient for childbirth, but, in no event, will benefits be less than: hours after a non-cesarean delivery; or hours after a cesarean section. Benefits for maternity care shall include the services of a certified nurse-midwife under qualified medical direction. The Company will not pay for duplicative routine services actually provided by both a certified nurse-midwife and a Physician. Benefits cover: 1. parent education; 2. assistance and training in breast or bottle feeding; and 3. the performance of any necessary maternal and new born clinical assessments. In the event the mother chooses an earlier discharge, at least one home visit will be available to the mother, and not subject to any deductibles, coinsurance, or copayments. The first home visit, (which may be requested at any time within 48 hours of the time of delivery, or within 96 hours in the case of a cesarean section) shall be conducted within 24 hours following: 1. discharge from the Hospital; or 2. the mother s request; whichever is later. Subject Pre-authorization 19

20 Maternity Testing The following maternity routine tests and screening exams will be considered, if all other policy provisions have been met. This includes a pregnancy test, CBC, Hepatitis B Surface Antigen, Rubella Screen, Syphilis Screen, Chlamydia, HIV, Gonorrhea, Toxoplasmosis, Blood Typing ABO, RH Blood Antibody Screen, Urinalysis, Urine Bacterial Culture, Microbial Nucleic Acid Probe, AFP Blood Screening, Pap Smear, and Glucose Challenge Test). Ultrasound will be considered in every pregnancy, without additional diagnosis. Fetal Stress/Non-Stress tests are payable. For additional information of covered maternity items please refer to the Key Covered Preventive Care under Pregnant Women. For additional information regarding Maternity Testing, please call the Company at +1 (800) or +1 (305) Outpatient Benefits Benefits will be covered in accordance with the terms and conditions of your policy for covered illness or injury for services provided by: 1. Primary care physician visits for an injury or illness 2. Specialist visits 3. Other practitioner office visit or (nurse, physician s assistant, certified Nurse Midwife or duly licensed health professional). 4. Outpatient facility fee (outpatient hospital and Ambulatory surgical center). 5. Outpatient Surgery physician/ Surgical services Chiropractic Services Benefits will be covered with a primary care physician s referral and treatment plan for a covered medical condition or illness. Subject to Medical Necessity and Medical Review. Emergency Services Benefits will be covered in accordance with the terms and conditions of your policy for covered illness or injury for the services provided by and for: 1. Emergency room services 2. Urgent Care centers or facilities 3. Emergency transportation/ambulance limited to a one way trip Hospitalization Benefits will be covered in accordance with the terms and conditions of your policy for covered illness or injury for services provided by a hospital. (Mental Health and Substance abuse addressed under separate category): 1. Inpatient Hospital Services 2. Inpatient physician and surgical services 3. Skilled nursing limited to 200 days per year 4. Delivery and all inpatient services for maternity care (refer to Maternity Care for full details) Subject to Pre-authorization Transplant Benefits will be covered solely for surgeries determined to be non-experimental and noninvestigational. Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization 20

21 Chemotherapy Benefits will be covered for inpatient and outpatient chemotherapy. Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization Laboratory and Imaging Services Benefits will be covered in accordance with the terms and conditions of your policy for covered illness or injury for the services provided by and for: 1. Diagnostic Test (x-ray and lab work including pre-admission testing) 2. Imaging(CT/PET Scans, MRI) Allergy Testing Benefits will be covered for allergy testing subject to all the terms and conditions of the policy. Reconstructive and corrective Surgery Limited to correct a congenital birth defect of dependent child, incidental to surgery or follows surgery necessitated by trauma, infection or disease. Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization Temperomandibular Joint Dysfunction (TMJ) Based on Medical Necessity, Medical Review, and subject to Pre-authorization. REHABILITATION AND HABILITATION SERVICES AND DEVICES Inpatient Rehabilitation Benefit will be covered for one (1) consecutive 60 day period per condition per lifetime in a rehabilitation facility. Inpatient Short Term Rehabilitation Services (physical, speech and occupational therapy). Based on Medical Necessity, Medical Review, and subject to Pre-authorization Outpatient Rehabilitation Services Short term rehabilitative therapy services (physical, speech and occupational therapy) outpatient limited to 60 visits per condition per lifetime. Based on Medical Necessity, Medical Review, and subject to Pre- authorization. Habilitation Short term rehabilitative therapy services (physical, speech and occupational therapy) outpatient limited to 60 visits per condition per lifetime. Based on Medical Necessity, Medical Review, and subject to Pre-authorization. Durable Medical Equipment Benefit will be considered up to $1500 per year for non-essential DME & medical supplies. Braces must be standard equipment only. DME defined as Equipment which is: 1. Designed and intended for repeated use 2. Primarily and customarily used to serve a medical purpose 3. Generally not useful to person in the absence of a disease or injury 4. Is appropriate for use in the home Excluded from coverage are: orthotics, supports, corrective shoes, false teeth, maintenance and repairs due to member s misuse. Subject to Pre-authorization 21

22 Hearing Aids Benefits will be considered covered and limited to single purchase (including repair/replacement every three years coverage is limited to $1500 USD). Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization Bone Anchored Hearing Aids Benefit covered if a criteria below is satisfied, limited to one per lifetime. Bone Anchored hearing aids are excluded except when either of the following applies. Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization 1. For covered persons with craniofacial anomalies whose abnormal or absent canals preclude the use of a wearable hearing aid. 2. For covered persons with hearing loss of sufficient severity that it would not be adequate remedied by a wearable hearing aid. 3. Repairs and/or replacement for bone anchored hearing aid for covered persons who meet the above coverage criteria other than for malfunctions Prosthetic Devices Benefits will be covered in accordance with the terms and conditions as per the below: 1. One (1) external prosthetic device per limb per lifetime 2. Additional coverage for external device replacement for children for device that has been grown out 3. Coverage includes wigs for members suffering from severe hair loss due to injury or disease or treatment of a disease (e.g. Chemotherapy) This excludes coverage for external repairs or replacement in adults, Coverage for wigs made from human hair unless member is allergic to synthetic wig materials. Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization Internal Prosthetic Devices Benefits will be covered if it improves or restores function of internal body part; includes implanted breast prosthesis; includes repair or replacement. Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization PREVENTIVE CARE SERVICES Please refer to complete List of Key Covered Preventive Care Services 1. Children and adolescents 2. Health Screenings for Adults Benefits for Prostate Screening Benefits will be covered for men over age 50 and over (age 40 and over if family history or risk factor; any age if prior history). This includes exam and antigen test per mandate. Benefits for Cervical Cytological Screening Benefits will be covered for cervical cytology. This benefit includes an annual pelvic examination, collection and preparation of a Pap smear, and laboratory and diagnostic services provided in connection with examining and evaluating the Pap smear. 22

23 Benefits will be paid for mammograms as follows 1. Upon a Physician's recommendation, Insured s at any age who are at risk for breast cancer or who have a first degree relative with a prior history of breast cancer, and; 2. A single base line mammogram for Insured s age 35 but less than 40, and; 3. A mammogram every 2 years for Insured s age 40 and older. Routine Foot Care Not Covered Routine Vision and Dental For adults over the age of 19- Not covered Benefits for Bone Mineral Density Measurements or Tests Benefits will be covered for osteoporosis screening for woman age 60 and older depending on risk factors. Individuals qualifying for benefits shall at a minimum be age 60 depending on risk factors, include individuals: previously diagnosed as having osteoporosis or having a family history of osteoporosis; or with symptoms or conditions indicative of the presence, or the significant risk, of osteoporosis; or on a prescribed drug regimen posing a significant risk of osteoporosis; or with lifestyle factors to such a degree as posing a significant risk of osteoporosis; or with such age, gender and/or other physiological characteristics which pose a significant risk for osteoporosis. Benefits shall be subject to all deductible, copayment, coinsurance, limitations, or any other provisions of the policy. Pediatric Dental and Vision Coverage Pediatric is defined as under the age of 19. Coverage is provided under Preventive care as follows: Emergency Dental Care This benefit includes, emergency treatment required to alleviate pain and suffering caused by dental disease or trauma. It also includes procedures which help prevent oral disease from occurring, including but not limited to: Preventive Dental Care/ Basic Dental Care 1. Prophylaxis: Scaling and polishing teeth at 6 month intervals 2. Topical Fluoride application at 6 month intervals where local water supply is not fluorinated 3. Sealants on restored permanent molar teeth 4. Space maintainers: unilateral or bilateral space maintainers will be covered for placement on a restored deciduous and/or mixed detention to maintain space for normally developing permanent teeth. 5. Dental examinations, visits and consultations covered once within 6 months consecutive period (when primary teeth erupt) 6. X-ray, full mouth x-ray at 36 month intervals, if necessary, bitewings x-rays at 6-12 month intervals, or panoramic x-rays at 36 month intervals if necessary; and other x-rays as required (once primary teeth erupt) 7. All necessary procedures for simple extractions and other routine dental surgery requiring hospitalization including pre-operative care. 8. In office conscious sedation 9. Amalgam, composite materials appropriate for children 23

24 Major Dental Care (Endodontics and Prosthodontics) 1. All necessary procedures for treatment of disease pulp chamber and pulp canals, where hospitalization is not required. 2. Removable: Complete partial dentures including 6 month follow up care. Additional services include insertion of identification slips, repairs, relines and rebases and treatment of cleft palate. 3. Fixed Bridge are not covered unless: a. Required for replacement of a single upper anterior (central/lateral incisor or cuspid) in a patient with otherwise full complement of natural, functional and/or restored teeth b. Required for cleft-palate treatment or stabilization; c. Required, as demonstrated by medical documentation, due to the presence any neurologic or physiologic condition that would preclude the placement of a removable prosthesis Major Dental Benefits are limited to $500 per policy year Orthodontia (Orthodontics) Includes procedures which help to restore oral structures to health and function and to treat serious medical conditions such as cleft palate and cleft lip; maxillary/mandibular micrognathia (under developed upper or lower jaw); extreme mandibular prognathism; severe asymmetry (craniofacial anomalies); ankylosis of temporomandibular joint; and other significant skeletal dysplasias. Orthodontia coverage is not covered if the child does not meet the criteria described above. Procedures include but are not limited to: 1. Rapid Palatal Expansion (RPE) 2. Placement of components parts(e.g. brackets, bands) 3. Interceptive orthodontic treatment 4. Comprehensive orthodontic treatment (during which orthodontic appliances have been placed for active treatment and periodically adjusted). 5. Removable appliance therapy 6. Orthodontic retention(removal of appliances, construction and placement of retainers) Orthodontia Dental Benefits are limited to $500 per policy year Pediatric Vision Vision examination performed at a vision care center by an optometrist for the purpose of determining the need for corrective lenses, and if needed to provide a prescription. Vision Examination may include, but not limited to: 1. Case history 2. Internal and external examination of the eye 3. Opthalmoscopic exam 4. Determination of refractive status 5. Binocular balance 6. Tonometry test for glaucoma 7. Gross visual fields and color vision testing 8. Summary findings and recommendations for corrective lenses 24

25 Prescription Lenses Benefits will be covered for a quality standard prescription lenses provided by a physician, optometrist or optician are to be covered once in any twelve (12) month period, unless required more frequently with appropriate documentation. The lenses may be glass or plastic lenses. Frames / Contact Lenses Standard frames adequate to hold lenses will be covered once in any twelve (12) month period, unless required more frequently with appropriate documentation. Contact lenses are covered when medically necessary and with proof of dioptre. Vision Cover is limited to $150 per policy year. Vision Care Supplies are not covered. Benefits for Breast Cancer Treatment Benefits will be covered for medically appropriate care as determined by the attending Physician in consultation with the Insured for a lymph node dissection, a lumpectomy or mastectomy for the treatment of breast cancer. Breast reconstructive surgery Covered following a mastectomy, as any other illness, for medically appropriate care as determined by the attending Physician. Benefits will cover: 1. All stages of reconstruction of the breast on which the mastectomy has been performed; 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and any physical complications of all stages of mastectomy, including lymphedemas Experimental or investigational drugs will not be covered. This includes, any drug which, the Food and Drug Administration, has determined to be contraindicated for the treatment of the specific type of cancer for which the drug has been prescribed. Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization Benefits for Prescription Drugs for the Treatment of Cancer If Prescription Drugs are covered by the Policy, benefits will be paid provided that, the drug has been recognized for treatment of the specific type of cancer. Such drugs must be recognized by the following established reference compendia: 1. The American Medical Association Drug evaluations; 2. The American Hospital Formulary Service Drug Information; or 3. The United States Pharmacopeia Drug Information; or recommended by review article or editorial comment in a major peer reviewed professional journal. Experimental or investigational drugs will not be covered. This includes, any drug, which the Food and Drug Administration, has determined to be contraindicated for the treatment of the specific type of cancer for which the drug has been prescribed. Benefits for Second Medical Opinion for Diagnosis of Cancer Benefits will be covered for a second medical opinion by an appropriate specialist physician, including but not limited to a Physician affiliated with a specialty care center for the treatment of cancer, in the event of a positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation of a course of treatment for cancer. Hospice Services & Home Health Hospice Benefits will be covered for Medically Necessary Expenses up to a maximum of 210 days per year. This benefit limit is combined to hospice services and home hospice. For acute care services at Hospitals specializing in the treatment of terminally ill patient as certified by the Insured s attending Physician. Based on Medical Necessity, Medical Review, and subject to Pre-authorization 25

26 Bereavement Counseling Benefits will be covered up to 5 sessions for member s family either before or after death of the member. Home Health Care Services Benefits will be covered for Medically Necessary Home Health Care, limited to 40 visits per year. Based on Medical Necessity, Medical Review, and subject to Pre-authorization Benefits for Enteral Formulas Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization. Benefits for Diabetes Expense Benefits will be covered for the following equipment and supplies for the treatment of diabetes. Such equipment and supplies must be recommended or prescribed by a Physician. Covered Medical Expenses includes but are not limited to the following equipment and supplies: 1. lancets and automatic lancing devices; 2. glucose test strips; 3. blood glucose monitors; 4. blood glucose monitors for the visually impaired; 5. control solutions used in blood glucose monitors; 6. diabetes data management systems for management of blood glucose; 7. (g) urine testing products for glucose and ketones; oral anti-diabetic agents used to reduce blood sugar levels; 8. alcohol swabs; 9. (j) syringes; 10. injection aids including insulin drawing up devices for the visually impaired; 11. cartridges for the visually impaired; 12. disposable insulin cartridges and pen cartridges; 13. (n) all insulin preparations; 14. (o) insulin pumps and equipment for the use of the pump including batteries; 15. (p) insulin infusion devices; oral agents for treating hypoglycemia such as glucose tablets and gels; 16. glucagon for injection to increase blood glucose concentration. Benefits will also be covered for diabetes self-management education and education relating to diet. Such education may be provided by a Physician or the Physician's staff as a part of an office visit. Such education when provided by a certified diabetes nurse educator, certified nutritionist, certified dietitian or registered dietitian upon referral by a Physician may be provided in a group setting. When medically necessary, self- management education and diet education shall also include home visits. MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER SERVICES Mental and Behavioral Disorder Treatment Inpatient Benefits will be covered for the diagnosis and treatment of mental, nervous or emotional disorders. Outpatient Mental Health Services and Partial Hospitalization (includes Biologically Based services) benefit limit includes office visits and outpatient visits combined. Biologically based service visits will count towards this limit. Coverage is limited to 30 visits per year. Based on Medical Necessity, Medical Review, and subject to Pre-authorization 26

27 Mental and Behavioral Disorder Treatment Outpatient Benefits will be covered for the diagnosis and treatment of mental, nervous or emotional disorders. Outpatient Mental Health Services and Partial Hospitalization (includes Biologically Based services) benefit limit includes office visits and outpatient visits combined. Biologically based service visits will count towards this limit. Coverage is limited to 30 visits per year. Based on Medical Necessity, Medical Review, and subject to Pre-authorization. Benefits for Children with Serious Emotional Disturbances Benefits will be covered the same as any other condition for Children with Serious Emotional Disturbances. Children with Serious Emotional Disturbances means persons under the age of eighteen years who have diagnoses of attention deficit disorders, disruptive behavior disorders, or pervasive development disorders and where there are one or more of the following: 1. serious suicidal symptoms or other life-threatening self-destructive behaviors; 2. significant psychotic symptoms (hallucinations, delusion, bizarre behaviors; 3. behavior caused by emotional disturbances that placed the child at risk of causing personal injury or significant property damage; or 4. behavior caused by emotional disturbances that placed the child at substantial risk of removal from the household. SUBSTANCE ABUSE Substance abuse disorder inpatient Services Inpatient alcohol and substance abuse detoxification is limited to 7 days per year. Based on Medical Necessity, Medical Review, and subject to Pre-authorization Substance Abuse Inpatient treatment Inpatient alcohol and substance abuse rehabilitation limited to 30 days per year. Chemical abuse means alcohol and substance abuse. Chemical dependence means alcoholism and substance dependence. Based on Medical Necessity, Medical Review, and subject to Pre-authorization Substance Abuse Outpatient Treatment Outpatient alcohol and substance abuse rehabilitation limited to 60 visits per year. Benefit limit include office visits and outpatient visits combined. Up to 20 of the visits may be used by the member s family. "Family Member" means those family members covered under the insurance policy covering the person receiving or in need of treatment for alcoholism or substance abuse. Based on Medical Necessity, Medical Review, and subject to Pre-authorization Comprehensive Care Eating Disorders Benefits are covered as any other illness subject to the terms and conditions of the policy without a visit limit. Based on Medical Necessity, Medical Review, and subject to Pre-authorization 27

28 Benefits for Contraceptive Drugs or Devices Contraceptive Drugs or Devices that are used for the purpose of Family Planning are covered and are not subject to the deductible or co-insurance maximums. Food and Drug Administration (FDA) or generic equivalents approved as substitutes by the FDA. (e.g. birth control under Tier 1, patch, birth control pills, birth control rings, birth control shot, cervical cap, contraceptive implant, diaphragm, IUD and permanent contraception method for women such as tubal ligation limited to one per lifetime). Sterilization Procedures for Men Vasectomies for man will be covered subject to deductible and co-insurance maximums. Limited to one per lifetime and subject to Pre-authorization Infertility Treatment Members must be between the age of 21 and 44. Covered services include infertility treatment for basic and comprehensive: Initial evaluation, evaluation of ovulatory function, postcoital test, hysterosalpingogram, treatment ovulatory dysfunction, ovulation induction and monitoring with ultrasound, artificial insemination, hysteroscopy, laparoscopy and laparotomy. Correctable Medical Conditions leading to infertility. Based on Medical Criteria, Medical Review, FDA Approval and subject to Pre-authorization. Advanced infertility treatment is not covered. Elective Termination of Pregnancy Coverage will be provided for one treatment per year for an elective termination of pregnancy. Therapeutic Termination of Pregnancy Therapeutic, also known as medically indicated termination, or medically indicated abortion is only covered in cases where the mother is at risk of death by continuing the pregnancy, or if the fetus has a medical condition which is certain to result in death either before or shortly after birth. Preauthorization is required. Reconstructive Surgery Benefits will be covered for surgery to correct a congenital birth defect of dependent child, or incidental to surgery or follows surgery necessitated by trauma, infection or disease in accordance with the terms and conditions of the policy. Based on Medical Necessity, Medical Review, FDA Approval and subject to Pre-authorization. Second Opinion (Surgical) Benefit will be covered for a second opinion based on the need for surgery in accordance with the terms and conditions of the policy. Autism Spectrum Disorder Screening/ Diagnosis and Treatment Benefit is limited to $45,000 per year for Applied Behavioral Analysis (ABA) with adjustments. Based on Medical Necessity, Medical Review and subject to Pre-authorization. Bariatric Surgery This benefit must meet Medical Criteria and is subject to Medical Review. All devices and medication must be FDA approved. Pre-authorization is required. 28

29 Exercise Facility Reimbursement Benefits will be paid at $200 every six months for primary insured and $100 for spouse every six months. Member and spouse must show written proof of 50 visits per person from the exercise facility over a six month period, minimum of 100 visits per year. Payments will be made every six months with proper documentation including paid gym membership per person and attendance sheet from gym. Deadline to submit for reimbursement is within 30 days after termination of the current policy year. Oral Surgery Benefits will be covered for oral surgery due to injury. It is limited to sound and natural teeth only. Oral surgery due to congenital anomaly, removal of tumors and cyst requiring pathological examination of jaws, cheeks, lips. Based on Medical Necessity, Medical Review, and subject to Pre-authorization. **This benefit is not available for cysts related to teeth, oral surgery results of injury for teeth that are not sound/natural teeth. 29

30 Definitions APPLIED BEHAVIOR ANALYSES (ABA) is the use of multiple techniques and principles that bring about meaningful and positive change in behavior; widely recognized as a safe and effective treatment for autism. ACCIDENT means an unforeseen, unexpected, unintentional and fortuitous event due exclusively to an external cause of a violent nature beyond the control of the insured person, resulting directly and independently of all other causes, in bodily trauma to the insured person. CHILD HEALTH SUPERVISION SERVICES are those preventive and primary care services which include a physical examination, measurements, sensory screening, neuropsychiatric evaluation and development screening delivered or supervised by a Physician. Benefits shall include unlimited child health supervision. As recommended by a Physician, benefits will also be provided for hereditary and metabolic screening at birth, appropriate immunizations, urinalysis, tuberculin tests, hematocrit, hemoglobin and other appropriate blood tests, such as, tests to screen for sickle hemoglobinopathy. For a complete list of covered items please refer to the Key Covered Preventive Care List. COINSURANCE is your share of the costs covered services, calculated as a percent of the allowed amount for the service. COMPANY The Company, as referred to in the Master Policy and this Summary of Benefits, is Premier Assurance Group SPC Ltd under the Global Assurance Segregated Portfolio (incorporated and registered in Cayman Islands). This insurance and its risks are underwritten by the Company as the insurer and carrier, and the Company is solely obligated and liable for the coverage and benefits provided by this insurance. COMPLICATION OF PREGNANCY means: 1) conditions requiring Hospital stays (when the pregnancy is not terminated whose diagnoses are distinct from pregnancy but are adversely affected by pregnancy or are caused by pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion and similar medical and surgical conditions of comparable severity, and will not include false labor, occasional spotting, Physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, preeclampsia and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy; and 2) nonelective caesarean section, ectopic pregnancy which is terminated and spontaneous termination of pregnancy which occurs during a period of gestation in which a viable birth is not possible. COPAYMENT is a fixed dollar amounts you pay for covered health care when you receive the service (e.g. Physician visit or Specialist visit) COVERED MEDICAL EXPENSES means reasonable charges which are: 1) not in excess of Usual and Customary Charges; 2) not in excess of the maximum benefit amount payable per service as specified in the Schedule of Benefits; 3) made for services and supplies not excluded under the policy; 4) made for services and supplies which are Medically Necessary; 5) made for services included in the Schedule of Benefits; and 6) in excess of the amount stated as a deductible, if any. Covered Medical Expenses will be deemed "incurred" only: 1) when the covered services are provided; and when a charge is made to the Insured Person for such services. CUSTODIAL CARE means help in transferring, eating, dressing, bathing, toileting, and other such 30

31 related services. DAY SURGERY MISCELLANEOUS (OUTPATIENT): in connection with outpatient day surgery; excluding non-scheduled 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. DEDUCTIBLE means if an amount is stated in the Schedule of Benefits or any endorsement to this policy as a deductible, it shall mean an amount to be subtracted from the amount or amounts otherwise payable as Covered Medical Expenses, before, payment of any benefit is made. The deductible as specified in the Schedule of Benefits. DEPENDENT means the spouse (husband or wife) of the Named Insured and their dependent, unmarried children including legally adopted children, a child placed with the Insured pending adoption procedures, unless the child is removed from placement with the Insured prior to final adoption, and step- children. Children shall cease to be dependent on the first to occur: 1. The date of marriage or, 2. The day of their 26 th birthday The attainment of the limiting age will not operate to terminate the coverage of such child while the child is and continues to be both: 1. Incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation or physical handicap; and, 2. Chiefly dependent upon the Insured Person for support and maintenance. Proof of such incapacity and dependency shall be furnished to the Company: 1) by the Named Insured; and, within 31 days of the child's attainment of the limiting age. Subsequently, such proof must be given to the Company annually following the child's attainment of the limiting age. If a claim is denied under the policy because the child has attained the limiting age for dependent children, the burden is on the Insured Person to establish that the child is and continues to be handicapped as defined by subsections (1) and (2). DISMISSAL is an official notice of discharge from school attendance. DURABLE MEDICAL EQUIPMENT: 1) when prescribed by a Physician; and 2) a written prescription accompanies the claim when submitted. Replacements are never covered. Durable medical equipment includes equipment 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 or Sickness. No benefits will be paid for rental charges in excess of purchase price. ELECTIVE SURGERY OR ELECTIVE TREATMENT includes any surgery and/or treatment which is deemed not to be a Medical Necessity for the treatment of an Injury or Sickness. EMERGENCY means the sudden and unexpected onset of a medical condition accompanied by acute signs or symptoms, which could reasonably result in placing the Insured Person s life or physical integrity in immediate danger if medical attention is not provided immediately. FAMILY PLANNING means a program to regulate the number and spacing of children in a family through the practice of contraception or other methods of birth control. 31

32 FOOD AND DRUG ADMINISTRATIN (FDA) is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments. The FDA is responsible for protecting and promoting public health through the regulation and supervision of food safety, tobacco products, dietary supplements, prescription and over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), cosmetics and veterinary products. HIPAA is the federal Health Insurance Portability and Accountability Act of The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs. HIPAA provides for the protection of individually identifiable health information that is transmitted or maintained in any form or medium. The privacy rules affect the day-to-day business operations of all organizations that provide medical care and maintain personal health information. HITECH The Health Information Technology for Economic and Clinical Health Act, enacted as part of the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. This law that has been enacted is to also protect your personal health information that may be electronically transferable and submitted. HOME HEALTH CARE means Health services given in the home to an individual who is confined to the home. Such services are provided to individuals who do not need institutional care, but who need nursing services or therapy, medical supplies and special outpatient services. HOSPITAL means a short-term, acute, general hospital, which: 1) is open at all times; 2) is operated primarily and continuously for the treatment of and surgery for sick and injured persons as inpatients; 3) is under the supervision of a staff of one or more legally qualified Physicians available at all times; 4) continuously provides on the premises 24 hour nursing service by Registered Nurses; 5) provides organized facilities for diagnosis and major surgery on the premises; 6) if located in New York state, has in effect a hospitalization review plan applicable to all patients which meets at least the standards set forth in Section 1861(k) of United States Public Law 89-97, (42 USCA 1395xk0; and 7) is not, other than incidentally, a place of rest, a place primarily for the treatment of tuberculosis, a place for the aged, a place for drug addicts, alcoholics, or a place for convalescent, custodial, education, or rehabilitory care. HOSPITAL CONFINED/HOSPITAL CONFINEMENT means confined in a Hospital for at least 18 hours by reason of an Injury or Sickness for which benefits are payable. HOSPITAL MISCELLANEOUS EXPENSES: 1) while Hospital Confined; or 2) as a precondition for being Hospital Confined. Benefits will be paid for services and supplies such as: the cost of the operating room; laboratory tests; X-ray examinations; anesthesia; drugs (excluding take home drugs) or medicines; therapeutic services; and supplies. In computing the number of days payable under this benefit, the date of admission will be counted, but not the date of discharge. HOSPICE SERVICES AND HOME HOSPICE: services for acute care services at hospitals or home hospice specializing in the treatment of terminally ill patient for insured s diagnosed with advanced cancer (with no hope of reversal or primary disease and fewer than 210 days to live as certified by the insured s attending physician. 32

33 INJURY means bodily injury which is: 1) directly and independently caused by specific accidental contact with another body or object; 2) unrelated to any pathological, functional, or structural disorder; 3) a source of loss; 4) treated by a Physician within 30 days after the date of accident; and 5) sustained while the Insured Person is covered under this policy. All injuries sustained in one accident, including all related conditions and recurrent symptoms of these injuries will be considered one injury. Injury does not include loss which results wholly or in part, directly or indirectly, from disease or other bodily infirmity. Covered Medical Expenses incurred as a result of an injury that occurred prior to this policy s Effective Date will be considered a Sickness under this policy. INSURED PERSON means: 1) the Named Insured; and, 2) Dependents of the Named Insured, if: 1) the Dependent is properly enrolled in the program, and 2) the appropriate Dependent premium has been paid. The term "Insured" also means Insured Person. INTENSIVE CARE means: 1) a specifically designated facility of the Hospital that provides the highest level of medical care; and 2) which is restricted to those patients who are critically ill or injured. Such facility must be separate and apart from the surgical recovery room and from rooms, beds and wards customarily used for patient confinement. They must be: 1) permanently equipped with special life-saving equipment for the care of the critically ill or injured; and 2) under constant and continuous observation by nursing staff assigned on a full-time basis, exclusively to the intensive care unit. Intensive care does not mean any of these step-down units: 1. Progressive care; 2. Sub-acute intensive care; 3. Intermediate care units; 4. Private monitored rooms; 5. Observation units; or 6. Other facilities which do not meet the standards for intensive care. LATE ENROLLEE refers to a student that is admitted to SGU after the Open Enrollment Period but within the first 31 days of the plan effective date. LEAVE OF ABSENCE refers to a student that is still considered to be in active status by the University; however, is not currently attending classes. MEDICAL EMERGENCY means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: 1. Placing the health of the Insured's or others in serious jeopardy; 2. Serious impairment of bodily functions; 3. Serious dysfunction of any body organ or part; or 4. Serious disfigurement of the Insured. Expenses incurred for "Medical Emergency" will be paid only for Sickness or Injury which fulfills the above conditions. These expenses will not be paid for minor Injuries or minor Sicknesses. 33

34 MEDICAL NECESSITY or MEDICALLY NECESSARY mean health care services that a Healthcare Provider, exercising prudent clinical judgment, following evidence of medically based guidelines, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: 1. In accordance with the generally accepted standards of medical practice; (that are based on credible scientific evidence) 2. Clinically, appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient s illness, injury or disease; 3. Not primarily for the convenience of the Insured, the HealthCare provider, a Physician or any other HealthCare Provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.; 4. The most appropriate supply or level of service which can safely be provided to the Insured. The Medical Necessity of being Hospital Confined means that: 1) the Insured requires acute care as a bed patient; and, 2) the Insured cannot receive safe and adequate care as an outpatient. This policy only provides payment for services, procedures and supplies which are a Medical Necessity. No benefits will be paid for expenses which are determined not to be a Medical Necessity, including any or all days of Hospital Confinement. MENTAL AND NERVOUS DISORDER TREATMENT means medically necessary mental health care administered under the direct control of a Psychiatric Physician, in the opinion of the Company, is directed predominantly at treatable behavioral manifestations of a condition that the Company determines (a) is a clinically significant behavioral or psychological syndrome, pattern, illness or disorder; and (b) substantially or materially impairs a person s ability to function in one or more major life activities; and had been classified as a mental disorder in the current American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. NAMED INSURED means an eligible, registered student of the Policyholder, if: 1) the student is properly enrolled in the program; and 2) the appropriate premium for coverage has been paid. NEWBORN INFANT means: 1) any newly born child of an Insured provided that the person is insured under this policy; 2) a newborn adopted child of an Insured provided the person is insured under this policy on the date the adoption is effective; and 3) a newborn child placed with the Insured pending adoption procedures provided the person adopting the child is insured under the policy on the date the child is placed with the Insured. Newborn infants will be covered under the policy for the first 31 days after birth. Coverage will be for Injury or Sickness, including medically diagnosed congenital defects, birth abnormalities, prematurity and nursery care; benefits will be the same as for the primary Insured Person. The Insured will have the right to continue such coverage for the child beyond the first 31 days. To continue the coverage the Insured must, notify the company within the 31 days after the child's birth: 1) apply to us; and 2) pay the required additional premium, if any, for the continued coverage. If the Insured does not use this right as stated here, all coverage as to that child will terminate at the end of the first 31 days after the child's birth. 34

35 OPEN ENROLLMENT: Fall Term is defined as August, 1 through December, 31; Spring Term as January 1 through July 31 of any calendar year). PHYSICIAN means a legally qualified licensed practitioner of the healing arts, including a chiropractor, who provides care within the scope of his/her license, other than a member of the person s immediate family. The term member of the immediate family means any person related to an Insured Person within the third degree by the laws of consanguinity or affinity. PHYSIOTHERAPY means any form of the following: physical or mechanical therapy; diathermy; ultrasonic therapy; heat treatment in any form; manipulation administered by a Physician, including a chiropractor. PRE-ADMISSION TESTING: limited to routine tests such as: complete blood count; urinalysis; and chest X-rays. This benefit is payable within 3 working days prior to admission. PRESCRIPTION DRUGS means: 1) prescription legend drugs; 2) compound medications of which at least one ingredient is a prescription legend drug; 3) any other drugs which under the applicable state or federal law may be dispensed only upon written prescription of a Physician; and 4) injectable insulin. PRESCRIPTION DRUG OR PRESCRIPTION DRUG PRODUCT means a medication, product or device that has been approved by the U.S. Food and Drug Administration and that can, under federal or state law, be dispensed only pursuant to a Prescription Order or Refill. A Prescription Drug Product includes a medication that, due to its characteristics, is appropriate for self- administration or administration by a non-skilled caregiver. For the purpose of the benefits under the policy, this definition includes Insulin. PRESCRIPTION DRUG LIST means a list that categorizes into tiers medications, products or devices that have been approved by the U.S. Food and Drug Administration. This list is subject to the Company s periodic review and modification (generally quarterly, but no more than six times per calendar year). The Insured may determine to which tier a particular Prescription Drug Product has been assigned by contacting EHIM at +1 (800) PSYCHOTHERAPY means the treatment of a Mental and Nervous Disorder. REGISTERED NURSE means a professional nurse (R.N.) who is not a member of the Insured Person's immediate family. REPATRIATION: if the Insured dies while insured under the policy; benefits will be paid for: 1) preparing; and 2) transporting the remains of the deceased's body to his home country. This benefit is limited to the maximum benefit specified in the Schedule of Benefits. No additional benefits will be paid under Basic or Supplemental Medical coverage ROOM AND BOARD means a hospital semi-private room equipped to accommodate two persons. SICKNESS means sickness or disease of the Insured Person which causes loss, and originates while the Insured Person is covered under this policy. All related conditions and recurrent symptoms of the same or a similar condition will be considered one sickness. Covered Medical Expenses incurred as a result of an Injury that occurred prior to this policy s Effective Date will be considered a sickness under this policy. 35

36 SOUND, NATURAL TEETH means natural teeth, major portion of the individual tooth, is present, regardless of the fillings or caps; and is not carious, abscessed or defective. USUAL AND CUSTOMARY CHARGES means a reasonable charge which is: 1) usual and customary when compared with the charges made for similar services and supplies; and 2) made to persons having similar medical conditions in the locality where service is rendered. No payment will be made under this policy for any expenses incurred which in the judgment of the Company are in excess of Usual and Customary Charges. WITHDRAWAL means discontinuation of attendance 36

37 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. Advanced infertility 2. Weight Loss Programs, except as specifically stipulated by this policy. 3. Chemical Dependence (Alcoholism/Drug Abuse), except as specifically provided in Benefits for Chemical Dependence (Alcoholism/Drug Abuse); 4. Custodial care 5. Care or treatment provided by a family member who practices of medicine. The term member of the immediate family means any person related to an Insured Person within the third degree by the laws of consanguinity affinity. 6. Cosmetic procedures, except that cosmetic procedures does not include reconstructive surgery when such surgery is incidental to or follows surgery resulting from trauma, infection or other disease of the involved part and reconstructive surgery because of a congenital disease or anomaly of a covered Dependent child which has resulted in a functional defect. It also does not include breast reconstructive surgery after a mastectomy; 7. Dental treatment, except for accidental Injury to Sound, Natural Teeth or due to congenital disease or anomaly; 8. Routine dental and vision benefits for adults over the age of Elective Surgery or Elective Treatment; 10. Eye examinations, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses except as provided under the pediatric Vision and dental coverage. Vision correction, or other treatment for visual defects and problems; except when due to a disease process or a Medical Necessity; 11. Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet; 12. Acupuncture and massage therapy except as specifically provided under the Student Health Center and limited to 3 visits per year. 13. Private Duty Nursing 14. Vision Services for anyone over the age of Injury or Sickness for which benefits are paid or payable under any Workers' Compensation or Occupational Disease Law or Act, or similar legislation; 16. Participation in a felony, riot or insurrection. 17. Human Growth Hormone Treatment 18. Charges or fees to obtain medical records in order to validate a claim. 19. Charges for taxes, assessments, charges, fees or surcharges imposed by any governmental agency. 20. For or related to sex change surgery or any treatment for gender identity disorder. 21. Medical services received from a relative or family member who is in the medical field. 22. Care, treatment, services or supplies that are not prescribed, recommended or approved by the attending physician. 23. Services or supplies that promote or prevent conception included but not limited to: Impotence, Reversal of sterilization, Surrogacy, assisted conception other then Artificial Insemination. 37

38 24. Weight Loss Surgeries including but not limited to: Gastric Bypass combined with Gastric Band, Biliopancreatic Diversion without a duodenal switch, Fobi-Pouch, Loop Gastric Bypass, Intra- Gastric Balloons, Stomaphyx. 25. Any treatment, services or supplies not defined as covered under this Plan are excluded. 38

39 ST. GEORGE'S UNIVERSITY STUDENT Emergency Medical Evacuation Coverage ELIGIBILITY AND TERMINATION PROVISIONS Eligibility: Any St. George s University Student who belongs to one of the "Classes of Persons to Be Insured" as set forth in the application is eligible to be insured under this plan. The (student) Named Insured must be enrolled in a minimum of 5 credit hours and actively attend classes for at least the first 31 days after the date for which coverage is purchased. Home study, correspondence, and television (TV) courses do not fulfill the Eligibility requirements that the student actively attend classes. The Company maintains its right to investigate student status and attendance records to verify that the policy Eligibility requirements have been met. Students on an approved leave of absence are eligible to enroll as long as the premium is paid on or before the policy effective date (first day of the term). Members of faculty who are also students are not eligible to enroll in the student insurance plan. If the Company discovers the Eligibility requirements have not been met, its only obligation is to refund premium. Eligible students who do enroll may also insure their Dependents. Eligible Dependents are the spouse and children up to the age of 26. Dependent Eligibility expires concurrently with that of the Named Insured. *Note: any Named Insured on an approved Leave of Absence commencing after the first 31 days for which they were originally eligible for coverage, may continue coverage under this plan until the end of the Term for which they were originally eligible. (For the purpose of eligibility and Open Enrollment: Fall Term is defined as August, 1 through December, 31; Spring Term as January 1 through July 31 of any calendar year). The eligibility date for Dependents of the Named Insured (as defined) shall be determined in accordance with one of the following qualifying events: 1. If a Named Insured has Dependents on the date he or she is eligible for insurance; or 2. If a Named Insured acquires a Dependent after the Effective Date, such Dependent becomes eligible: a. On the date the Named Insured marries the Dependent; or b. On the date the Named Insured acquires a dependent child who is within the limits of a dependent, unmarried child set forth in the "Definitions" section of this policy. Eligible persons may be insured under this policy subject to the following: 1. Payment of premium as set forth on the policy application; and, 2. Application to the Company for such coverage within 31 days of the qualifying event outlined above in 2) (a) and (b). Effective Date: The date on which health insurance coverage comes into effect. Dependent coverage will not be effective prior to that of the Named Insured. 39

40 Termination Date: The coverage provided with respect to the Named Insured shall terminate on the earliest of the following dates: 1. The last day of the period through which the premium is paid; or 2. The date the policy terminates; or 3. The date the Named Insured is withdrawn from the University. The coverage provided with respect to any Dependent shall terminate on the earliest of the following dates: 1. The last day of the period through which the premium is paid; 2. The date the policy terminates; or 3. The date the Named Insured's coverage terminates. Conditions of Coverage: 1. Coverage under this plan is secondary to any other coverage. 2. All services provided under this plan must be coordinated and approved in advance by Lyncpay. 3. Coverage is limited to life threatening conditions, to the closest country with a medical facility capable of providing the adequate level of treatment. (This policy does not cover for extended evacuation - which is to evacuate the member to the hospital of his/her choice or family choice). Coverage is to the nearest hospital and not necessarily to the state or country of residence of the member or member s family. Lyncpay in connection with our medical team reserve the right to the most appropriate means of transportation. 4. Evacuation must be recommended by a treating physician or specialist physician. 5. Evacuation must be incurred during the period of coverage or the benefit period. 6. Claims must be presented to Lyncpay for payment within 90 days from the date of the evacuation. 40

41 SCHEDULE OF BENEFITS Maximum Aggregate Benefit: $100,000 per policy period Emergency Medical Evacuation: The plan includes coverage for emergency medical evacuation to the nearest qualified medical facility; expenses for reasonable travel and accommodations resulting from the evacuation; and the cost of returning to either the home country or the country where the evacuation occurred up to the Policy Maximum. Emergency Medical Evacuation is subject to pre-certification by Lyncpay prior to travel and certified instructions from the attending physician or specialist physician, including confirmation that the required treatment is unavailable at the place of incident. Our Medical Advisors will decide the most appropriate method of transportation for the evacuation and the most appropriate Medical Facility to which the Named Insured will be evacuated. Emergency Reunion: The plan provides emergency reunion coverage up to $15,000 for a maximum of 15 days, for the reasonable travel and lodging expenses of a relative or friend during an emergency medical evacuation: either the cost of accompanying the insured during the evacuation or traveling from the home country to be reunited with the insured. Return of Mortal Remains: If a covered illness/injury results in death, expenses for repatriation of bodily remains or ashes to the home country will be covered up to a maximum of $20,

42 Exclusions and Limitations: Charges for the following services, treatments and/or conditions are excluded from coverage under the Emergency Medical Evacuation Policy: 1. War, military action, terrorism, political insurrection, protest, or any act thereof. The Company will not pay for Political Evacuations. 2. Charges, injuries and/or illness resulting or arising from or occurring during the commission or continuing perpetration of a violation of law by the insured, including without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations. 3. Bodily injury or Illness sustained directly or indirectly as a result of the enrolled person committing a criminal offence. 4. Treatment required as a result of or arising from complications from a treatment or condition not covered under your current healthcare policy. 5. Any services or supplies performed or provided by a relative of the Insured or provided at no cost to Insured. 6. Charges incurred for any travel, meals, transportation and/or accommodations, unless previously approved in writing by Lyncpay as per the schedule of benefits. 7. Any taxes, involuntary or forced contributions, assessments, charges, fees or surcharges imposed by any governmental agency or authority. 8. Cosmetic procedures, except that cosmetic procedures does not include reconstructive surgery when such surgery is incidental to or follows surgery resulting from trauma, infection or other disease of the involved part and reconstructive surgery because of a congenital disease or anomaly of a covered Dependent child which has resulted in a functional defect. It also does not include breast reconstructive surgery after a mastectomy; 9. Pregnancy terminations and subsequent complications. 10. No coverage will be provided when services are obtained solely for outpatient treatment(s) or purposes. 11. Treatment directly or indirectly arising from or required as a result of chemical contamination or contamination by radioactivity from any nuclear material whatsoever or from the combustion of nuclear fuel, asbestosis or any related condition. 12. Treatment related to malpractice. 13. Any Cost or expenses where an Insured person has traveled against medical advice. 14. Any Cost or expenses not coordinated and approved in advance by Lyncpay or the Company. 42