STUDENTHEALTHADVANTAGEWorldwide medical insurance for international
students and scholars

SMHello. Hola. Hallo. Hej. 您好.
You can greet someone in a foreign country in many ways. When you travel, stay safe and secureby saying hello to Student Health Advantage, a one-of-a-kind international medical insurance
plan that brings you Global Peace of Mind® when you’re traveling abroad.

2

Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing policy
documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

The
Advantage

Our focus on Service, Strength, and Safety Solutions provides
you with the ultimate advantage: Global Peace of Mind.

S E R V I C E Help when and where you need it.

S T R E N G T H A market leader you can trust.

Nobody wants to experience an emergency while traveling the world, but
if you do, you’ll want a team you can trust to have your back. IMG’s expert
staff is here for you 24/7. We’re accustomed to working in multiple timezones, languages, and currencies, so rest assured we have the training
to assist you—even in remote and hazardous locations. Our internationaland U.S. provider networks include more than one million physicians andfacilities across the globe, giving you access to quality care while awayfrom your primary care team. Our innovative technology allows you tomanage your claims, your account, and search for providers through ouronline portal and mobile app around the clock.

You can feel confident with IMG knowing our industry expertise has
led us to serve millions of customers worldwide since 1990. Owned by
SiriusPoint, a multi-billion-dollar insurance industry leader and rated “A-”by A.M. Best, an independent analyst of the insurance industry, IMG has astrong financial backing and vision to become the preeminent providerof travel and health safety solutions. With loyal customers ranging from
Fortune 500 companies, universities, to individuals and other insurancecompanies, our personalized offerings allow us to meet the needs ofnearly anyone traveling internationally.

S A F E T Y S O L U T I O N S Products and services designed with your safety in mind.
Pursuing an education away from your home country is already stressful. We know your safety and wellbeing while studying abroad is important toyou, so IMG’s Student Health Advantage has solutions designed to protect you and give you Global Peace of Mind.

PHYSICAL HEALTH
You can’t plan when you get sick, and unfortunately, it
can happen anytime and anywhere. Medical bills canbe expensive, and IMG plans provide the cross-border
medical coverage you need for unexpected medical careand routine visits.

CRISIS SUPPORTNavigating an emergency in a foreign country is never easy.
That’s why IMG offers a multilingual staff of nurses, doctors,
and case managers provide 24/7 assistance services tofacilitate a response to urgent and emergency situations,such as evacuations or search and rescue missions.

MENTAL WELLNESS
Being away from your support system can be challenging.
IMG provides access to mental health services, like virtual
counseling, to help with the transition as you adapt tocultural differences, adjust to a change in education, andnavigate new relationships while you’re away from loved
ones.

FINANCIAL PROTECTION
Costs can add up while seeking medical treatment.
However, access to IMG’s international physician andprovider networks and pharmacy discount programs canhelp you save on out-of-pocket medical expenses andprescription medications.

PERSONAL PROPERTY
There are some belongings you know you can’t live
without. IMG has you covered and can reimburse costs ifyour mobile device is lost, stolen, or damaged during yourtravels abroad.

3

Why Student Health Advantage?
As an international student or scholar, the thrill of studying abroad is
extraordinary. Your new surroundings are amazing and you’re involvedin new and exciting experiences. You’re seeing and visiting places for the
first time, while receiving the benefits of a long-term education.
Caught up in all the excitement, you may not think about falling ill or
getting injured during your studies. Without warning, your experienceabroad can quickly become frightening and risky if you’re not prepared
for a medical emergency. As an international student, peace of mind is apriority when you study abroad.

Your educational adventure or cultural exchange program should beenjoyable and gratifying. Maintaining the ability to be flexible andresponsive, International Medical Group ® (IMG®) has developed Student
Health Advantage(SM), an international medical plan designed to
specifically meet the needs of international students, scholars, and people
involved in long-term educational and cultural exchange programs. The
plan offers a robust package of benefits while outside your home country
available 24 hours a day, providing you with Global Peace of Mind®. Afterall, you are global. Your medical insurance should be too.

Plan Highlights
»
»
»
»
»
»

4

Meets U.S. student, scholar, and cultural exchange program visa requirements
Coverage for individuals or groups of five or more primaries and their dependents
Mental and nervous disorders and substance abuse coverage
Intercollegiate/interscholastic/intramural or club sports coverage
Maternity coverage (Platinum only)International emergency care

Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance andgoverning policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

STUDENT HEALTH ADVANTAGE

Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit

SUMMARY OF BENEFITS

Coverage Limit / Maximum Amount for Eligible Medical Expenses
Maximum Limit

Student: $500,000 Dependent: $100,000

Per Illness or Injury limit

Student: $300,000 Dependent: $100,000

Deductible$250

 Per Illness or Injury

Coinsurance for Eligible Medical Expenses

PLAN DETAILS

Benefits

In-Network

Coinsurance

Plan pays 90%
Insured pays 10%

 In addition to Deductible

Out of Pocket Maximum$1,000Out-of-Network
Plan pays 80%
Insured pays 20%

International
Plan pays 100%
Insured pays 0%

Up to the Maximum Limit$0

Precertification
Interfacility Ambulance Transfer, Emergency Medical Evacuation
All other Treatments & supplies

No coverage if Pre-certification requirements are not met
50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met

Pre-existing Conditions
Charges resulting directly or indirectly from or relating to any Pre-existing Condition that existed within 36 months prior to the Effective Date are excluded until the Insured Person has
maintained 12 months of continuous coverage under this insurance.

Student Health Center
Copayment per visit$5 Not subject to the per Illness or Injury Deductible

Plan pays 100%
Insured pays 0%

Coinsurance

Inpatient/Outpatient Benefits
Benefits
Eligible Medical Expenses

In-Network

Out-of-Network

International

90%

80%

100%

90%

80%

100%

90%

80%

100%

Physician Visits/Services
 Maximum Visits per day: 1
 Surgery is not subject to the Maximum visit limit

Hospital Emergency Room

PHYSICAL HEALTH Injury: Not subject to Emergency Room Deductible
 Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does

not result in a direct Hospital admission.

 Not subject to Deductible and Coinsurance Mental or Nervous Disorders are not covered Coverage for a Teleconsultation is not a determination that any specific condition

Teleconsultation (Groups only)

Hospitalization / Room & Board

discussed, raised or identified during such consultation is covered under thisinsurance. The Company reserves the right to decline future claims relating to or
arising from any condition discussed, raised or identified during a Teleconsultation
where the Illness or Injury is directly or indirectly related to any Pre-existing
Condition or is otherwise excluded under this Certificate of Insurance Average semi-private room rate Includes nursing, miscellaneous and Ancillary Services

90%

80%

100%

Intensive Care

90%

80%

100%

Outpatient Surgical / Hospital Facility

90%

80%

100%

Laboratory

90%

80%

100%

Radiology / X-ray

90%

80%

100%

Chemotherapy / Radiation Therapy

90%

80%

100%

Pre-admission Testing

90%

80%

100%

Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are
subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

5

STUDENT HEALTH ADVANTAGE

SUMMARY OF BENEFITS ( C O N T I N U E D )Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit

Inpatient/Outpatient Benefits (Continued)
Benefits

In-Network

Out-of-Network

International

90%

80%

100%

90%

80%

100%

90%

80%

100%

Anesthesia

90%

80%

100%

Durable Medical Equipment

90%

80%

100%

90%

80%

100%

90%

80%

100%

90%

80%

100%

90%

80%

100%

Surgery
Reconstructive Surgery

 Surgery is incidental to and follows Surgery that was covered under the plan

Assistant Surgeon

 20% of the primary surgeon’s eligible fee

Chiropractic CarePHYSICAL HEALTH

 Medical order or Treatment plan required

Physical Therapy

 Maximum Visits per day: 1
 Medical order or Treatment plan required

Extended Care Facility

 Upon direct transfer from an acute care Hospital

Home Nursing Care

 Provided Py a Home Health Care Agency
 Upon direct transfer from an acute care Hospital

Prescription Drugs and Medication
The following Prescription Drugs and Medication Period of Coverage limit accumulates toward the Maximum Limit
Period of Coverage limit Student: $250,000 per person
 Dependents: Up to the Maximum Limit ($100,000)

 Subject to the Coinsurance amounts listed below

Inpatient and Outpatient Surgery Prescription Drugs and Medication

90%

80%

100%

Emergency Room and Outpatient Office Visits
Prescription Drugs and Medication

90%

80%

100%

N/A

50%

50%

90%

80%

100%

90%

80%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

Retail Pharmacy Prescripton Drugs and Medication

 Dispensing maximum for Retail Pharmacy: 90 days per prescription

WELLNESS

Mental or Nervous / Substance Abuse
Inpatient Mental or Nervous / Substance AbuseMENTAL Maximum Limit: $10,000
 Not covered if incurred at the Student Health Center

Outpatient Mental or Nervous / Substance Abuse Maximum Limit per day: $50
 Maximum Limit: $500
 Not covered if incurred at the Student Health Center

Emergency Services
Emergency Local Ambulance Period of Coverage Limit per Injury $350
 Period of Coverage Limit per Illness $350 (resulting in an Inpatient Hospitalization)

CRISIS SUPPORTEmergency Medical Evacuation

 Maximum Limit: $500,000
 Must be approved in advance and coordinated by the Company

Emergency Reunion






Maximum Limit: $50,000
Maximum Days: 15
Meal Maximum per day: $25
Reasonable and necessary travel costs and accommodations
Must be approved in advance by the Company

Interfacility Ambulance Transfer

 Up to the per Injury or Illness limit
 Services rendered in the United States
 Transfer must be a result of an Inpatient Hospitalization

6

Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are
subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

STUDENT HEALTH ADVANTAGE

Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit

SUMMARY OF BENEFITS ( C O N T I N U E D )Emergency Services (Continued)
Benefits

In-Network

Out-of-Network

International

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

N/A

90%

100%

90%

80%

100%

90%

80%

100%

Political Evacuation and Repatriation

CRISIS SUPPORT Maximum Limit: $10,000
 Must be approved in advance by the Company

Repatriation for Medical Treatment

 Maximum Benefit: $100,000. This is in addition to the plan maximum limit/per injury orillness maximum limit

 Approved in advance and coordinated by the Company
 Refer to the REPATRIATION FOR MEDICAL TREATMENT provision for further details

Return of Mortal Remains






Maximum Limit: $50,000
Local Burial / Cremation at place of death
Maximum Limit: $5,000
Return of Insured Person’s Mortal Remains to Country of Residence
Must be approved in advance by the Company

Other Services
Terrorism Not subject to Deductible and Coinsurance
 Maximum Limit: $50,000

PHYSICAL HEALTH

Dental Treatment
 Period of Coverage Limit: $350

(Treatment due to Unexpected pain to sound, natural teeth) Period of Coverage Limit per Injury: $500

(Non-emergency Treatment by a Dental Provider due to an Accident)

Traumatic Dental Injury

 Treatment at a Hospital Facility due to an Accident
 Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%

Intercollegiate, Interscholastic, Intramural, or Club Sports
 Period of Coverage Limit per illness or injury: $5,000

Accidental Death: 100% of Principal Sum:
Student: $25,000
Spouse: $10,000
Child: $5,000

FINANCIAL PROTECTION

Accidental Dismemberment:
Accidental Death & Dismemberment

 Not subject to Deductible and Coinsurance Death must occur within 90 days of the Accident

Sight of 1 eye
1 hand or 1 foot1 hand and loss of sight of 1 eye
1 foot and loss of sight of 1 eye
1 hand and 1 footBoth hands or both feet
Sight of both eyes

50%
50%
100%
100%
100%
100%
100%

Incidental Trip

 Maximum days: 14
 Country of Residence is outside the United States Refer to the INCIDENTAL TRIP provision for further details

90%

80%

100%

Combined Maximum Limit: $10,000

Personal Liability

Injury to Third Person:
Per Injury Deductible: $100

 Secondary to any other insurance No coverage for Injury to a related Third Party or damage to related Third Person’s property
 Refer to the PERSONAL LIABILITY provision for further details and requirements

PERSONAL
PROPERTY

Percent of Principal Sum

Loss

Damage to Third Person’s property:
Per damage Deductible: $100

Mobile Device Protection Rider
Mobile Device Protection Rider

Coverage for repair or replacement of your cell phone if it is lost,
stolen or accidently damaged on your trip.

Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are
subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

7

STUDENT HEALTH ADVANTAGE PLATINUM

Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit

SUMMARY OF BENEFITS

Coverage Limit/Maximum Amount for Eligible Medical Expenses
Maximum Limit

Student: $1,000,000 Dependent: $100,000

Per Illness or Injury limit

Student: $500,000 Dependent: $100,000

Benefits

In-Network

Out-of-Network

International

$100

$150

$25

Deductible Options
 Per Illness or Injury

Coinsurance for Eligible Medical Expenses
Coinsurance

Plan pays 90%
Insured pays 10%

PLAN DETAILS In addition to Deductible

Out of Pocket Maximum$1,000Plan pays 80%
Insured pays 20%

Plan pays 100%
Insured pays 0%

Up to the Maximum Limit$0

Precertification
Interfacility Ambulance Transfer, Emergency Medical Evacuation

No coverage if Pre-certification requirements are not met

Maternity

50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met

All other Treatments & supplies

50% reduction of Eligible Medical Expenses if Pre-certification requirements are not met

Pre-existing Conditions
Charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded until the Insured Person has maintained 6 months of continuous coverage under thisinsurance.

Student Health Center
Copayment per visit$5 Not subject to the per Illness or Injury Deductible

Plan pays 100%
Insured pays 0%

Coinsurance

Inpatient/Outpatient Benefits
Benefits
Eligible Medical Expenses

In-Network

Out-of-Network

International

90%

80%

100%

90%

80%

100%

Physician Visits/Services
 Maximum Visits per day: 1
 Surgery is not subject to the Maximum visit limit

PHYSICAL HEALTH Not subject to Deductible and Coinsurance Mental or Nervous Disorders are not covered Coverage for a Teleconsultation is not a determination that any specific condition

discussed, raised or identified during such consultation is covered under thisinsurance. The Company reserves the right to decline future claims relating to or
arising from any condition discussed, raised or identified during a Teleconsultation
where the Illness or Injury is directly or indirectly related to any Pre-existing
Condition or is otherwise excluded under this Certificate of Insurance

Teleconsultation (Groups Only)

Hospital Emergency Room

 Injury: Not subject to Emergency Room Deductible
 Illness: Subject to a $250 Deductible for each Emergency Room visit for Treatment that does

90%

80%

100%

 Average semi-private room rate Includes nursing, miscellaneous and Ancillary Services

90%

80%

100%

Intensive Care

90%

80%

100%

Outpatient Surgical / Hospital Facility

90%

80%

100%

Laboratory

90%

80%

100%

not result in a direct Hospital admission.

Hospitalization / Room & Board

8Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are
subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

STUDENT HEALTH ADVANTAGE PLATINUM
SUMMARY OF BENEFITS ( C O N T I N U E D )Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit

Inpatient/Outpatient Benefits (Continued)
Benefits

In-Network

Out-of-Network

International

Radiology / X-ray

90%

80%

100%

Chemotherapy / Radiation Therapy

90%

80%

100%

Pre-admission Testing

90%

80%

100%

Surgery

90%

80%

100%

90%

80%

100%

90%

80%

100%

90%

80%

100%

 Maximum Limit: $5,000
 Pre-natal care, delivery of a Newborn, and post-natal care of an Insured Person, including

80%

60%

100%

Durable Medical Equipment

90%

80%

100%

90%

80%

100%

90%

80%

100%

90%

80%

100%

90%

80%

100%

Reconstructive Surgery

 Surgery is incidental to and follows Surgery that was covered under the plan

PHYSICAL HEALTH

Assistant Surgeon

 20% of the primary surgeon’s eligible fee

Anesthesia
Maternity and Newborn Carecomplications
 Newborn routine care during the first 31 days of life

Chiropractic Care Medical order or Treatment plan required

Physical Therapy

 Maximum Visits per day: 1
 Medical order or Treatment plan required

Extended Care Facility

 Upon direct transfer from an acute care Hospital

Home Nursing Care

 Provided Py a Home Health Care Agency
 Upon direct transfer from an acute care Hospital

Prescription Drugs and Medication
The following Prescription Drugs and Medication Period of Coverage limit accumulates toward the Maximum Limit
Period of Coverage limit

 Primary Insured Person: $250,000 per person
 Spouse and Child: Up to the Maximum Limit ($100,000)

 Subject to the Coinsurance amounts listed below

Inpatient and Outpatient Surgery Prescription Drugs and Medication

90%

80%

100%

Emergency Room and Outpatient Office Visits
Prescription Drugs and Medication

90%

80%

100%

N/A

50%

50%

90%

80%

100%

90%

80%

100%

Retail Pharmacy Prescripton Drugs and Medication

MENTALWELLNESS Dispensing maximum for Retail Pharmacy: 90 days per prescription

Mental or Nervous/Substance Abuse
Inpatient Mental or Nervous / Substance Abuse Maximum Limit: $10,000
 Not covered if incurred at the Student Health Center

Outpatient Mental or Nervous / Substance Abuse Maximum Limit per day: $50
 Maximum Limit: $500
 Not covered if incurred at the Student Health Center

Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are
subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

9

STUDENT HEALTH ADVANTAGE PLATINUM

Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit

SUMMARY OF BENEFITS ( C O N T I N U E D )Emergency Services
Benefits

In-Network

Out-of-Network

International

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

N/A

100%

100%

100%

100%

100%

100%

100%

100%

100%

In-Network

Out-of-Network

International

Emergency Local Ambulance Period of Coverage Limit per Injury $750
 Period of Coverage Limit per Illness $750 (resulting in an Inpatient Hospitalization)

Emergency Medical Evacuation

 Maximum Limit: $500,000
 Must be approved in advance and coordinated by the Company

Emergency Reunion
CRISIS SUPPORT







Maximum Limit: $50,000
Maximum Days: 15
Meal Maximum per day: $25
Reasonable and necessary travel costs and accommodations
Must be approved in advance by the Company

Interfacility Ambulance Transfer

 Up to the per Injury or Illness limit
 Services rendered in the United States
 Transfer must be a result of an Inpatient Hospitalization

Political Evacuation and Repatriation

 Maximum Limit: $10,000
 Must be approved in advance by the Company

Repatriation for Medical Treatment

 Maximum Benefit: $100,000
 Approved in advance and coordinated by the Company
 Refer to the REPATRIATION FOR MEDICAL TREATMENT provision for further details

Return of Mortal Remains

 Maximum Limit: $50,000
 Local Burial / Cremation at place of death Maximum Limit: $5,000
 Return of Insured Person’s Mortal Remains to Country of Residence Must be approved in advance by the Company

Other Services
Benefits
FINANCIAL PROTECTION

Accidental Death: 100% of Principal Sum:
Student: $25,000
Spouse: $10,000
Child: $5,000
Accidental Dismemberment:

Accidental Death & Dismemberment

Percent of Principal Sum
50%
50%
100%
100%
100%
100%
100%

Loss
Sight of 1 eye
1 hand or 1 foot1 hand and loss of sight of 1 eye
1 foot and loss of sight of 1 eye
1 hand and 1 footBoth hands or both feet
Sight of both eyes Not subject to Deductible and Coinsurance Death must occur within 90 days of the Accident

Incidental Trip

 Maximum days: 14
 Country of Residence is outside the United States Refer to the INCIDENTAL TRIP provision for further details

10

90%

80%

100%

Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are
subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

STUDENT HEALTH ADVANTAGE PLATINUM
SUMMARY OF BENEFITS ( C O N T I N U E D )Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Limits per Period of Coverage unless stated as Maximum Limit

Other Services (Continued)
Benefits

In-Network

Out-of-Network

International

N/A

90%

100%

90%

80%

100%

90%

80%

100%

PHYSICALHEALTH

Dental Treatment
 Period of Coverage Limit: $350

(Treatment due to Unexpected pain to sound, natural teeth) Period of Coverage Limit per Injury: $500

(Non-emergency Treatment by a Dental Provider due to an Accident)
Traumatic Dental Injury

 Treatment at a Hospital Facility due to an Accident
 Additional Treatment for the same Injury rendered by a Dental Provider will be paid at 100%

Intercollegiate, Intercholastic, Intramural, or Club Sports

PERSONAL
PROPERTY

CRISISSUPPORT

FINANCIALPROTECTION

 Period of Coverage Limit per Illness or Injury: $5,000

Combined Maximum Limit: $10,000

Personal Liability

Injury to Third Person:
Per Injury Deductible: $100

 Secondary to any other insurance No coverage for Injury to a related Third Party or damage to related Third Person’s property
 Refer to the PERSONAL LIABILITY provision for further details and requirements

Terrorism Not subject to Deductible and Coinsurance
 Maximum Limit: $50,000

Damage to Third Person’s property:
Per damage Deductible: $100

100%

100%

100%

Mobile Device Protection Rider

Mobile Device Protection Rider

Coverage for repair or replacement of your cell phone if it is lost,
stolen or accidently damaged on your trip.

Groups may also purchase a customizable long-term plan. Any coverages, benefits and premium rates offered are in U.S. Dollars. Benefits are
subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

11

SHA OPTIONAL RIDER
Adventure Sports Rider

Universal Rx is a discount savings program that allows you
to purchase prescriptions from one of 35,000 participating
pharmacies in the U.S. and receive the lower of 1)
Universal Rx contract price or 2) the pharmacy regularretail price. This program is not insurance coverage, it ispurely a discount program.

The Adventure Sports Rider is available on the Patriot Exchange
Program for individuals and groups, and their dependents, up to
the age of 65. Certain activities designated as adventure sports canbe covered up to the maximums listed below. Certain activities
are never covered, regardless of whether or not you purchase theAdventure Sports Rider. For a list of all the activities which can beconsidered to be adventure sports, a sample rider can be provided
upon request.

PHYSICAL HEALTH

Teleconsultation (For groups only)

12

Teleconsultation provides access to a national network ofboard-certified doctors and pediatricians in the U.S. who areavailable 24 hours a day, seven days a week, 365 days ayear to help diagnose, treat and prescribe medication (whennecessary and available) for many non-emergent medical
issues via phone or online video consultations.
Teleconsultation does not replace existing primary care
physician relationships, but supplements them as aconvenient, affordable alternative for non-emergency medicalcare. The use of Teleconsultation will be considered astreatment inside the U.S. - PPO Network.

PHYSICAL HEALTH

Pharmacy Discount Savings

PERSONAL PROPERTYFINANCIAL PROTECTIONSHA INCLUDED SERVICES

AGE

MAXIMUM LIMIT

Through age 49$50,000

50 - 59$30,000

60 - 64$15,000

Mobile Device Protection Rider (For individuals only)
Cell phones are essential when travelling internationally to keep
you safe, connect with friends and family back home, and to takephotos of your travels. Device protection is for individuals andprovides coverage for repair or replacement of your cell phonewhen it becomes lost, stolen, or accidentally damaged. With
Mobile Device Protection, you can continue your travels and staydigitally connected wherever you are in the world.

Benefits are subject to exclusions and limitations. This is only a summary and does not supersede in any way the Certificate of Insurance
and governing policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

SHA PLAN INFORMATION
Eligibility

Renewal of Coverage

To be eligible to apply to the Student Health Advantage, you must:» Be a participant: a student, scholar, intern, teacher, or trainee enrolled
in an educational or cultural exchange program for the purposesof teaching, study, research, or receiving on the job training for a
temporary period of time

Eligible insureds can request coverage under the plan be renewed aminimum of five (5) days, up to a maximum of 60 continuous months, aslong as the premium is paid when due and the insured continues to meetthe eligibility requirements of the plan.

» Be the spouse of a participant or children of a participant and residing
outside his/her primary country of residence for a temporary periodof time. Primary applicant must hold a J, M, F, or A visa
» Be at least 31 days old but not yet 65 years old» Be physically and legally residing in the destination country with
the intent to reside there for at least 30 days on the effective date
and at renewal
Enrollment Process
Before you begin your travel, simply apply online or fill out the applicationand calculate the estimated premium for the time period you, your group,
and/or your dependents will be traveling. Once you have completed theapplication, return it to your insurance agent and/or IMG.
Eligible individuals listed on the application and for whom premiums
have been paid will be covered from the latest of the following dates:
1. The date IMG approves your completed application and receives
the appropriate premium
2. The date you depart from your country of residence
3. The date requested on your application*Eligible individuals may pay their rates on a monthly basis but will incur a 4
percent administration fee
Fulfillment Kits
IMG processes applications in a quick, timely manner. Once processing
is complete, IMG will email the fulfillment kit(s) to the email listed in theapplication. The fulfillment kit(s) will include an IMG identification card(s),and the insurance certificate providing a complete description of therights and benefits under the contract. For your convenience, we will
send you this information and may also access it from the IMG website.
Conditions of Coverage
1) Coverage and benefits are subject to the deductible, limits, andcoinsurance, and all terms of the certificate of insurance and master
policy and all governing documents, as summarized in the certificate
of insurance. 2) Coverage under a Patriot Exchange Program plan issecondary to any other coverage. 3) Coverage and benefits are for eligible
medical expenses which are medically necessary and usual, reasonable,
and customary. 4) Charges must be administered or ordered by a licensed
physician. 5) Charges must be incurred during the period of coverage.

How Does the United States Affordable Care Act(ACA) Affect My Coverage?
Non-U.S. Citizens: As non-resident aliens, international students, scholars,
and people involved in cultural exchange programs on F, J, M, or Q visas(and certain family members) are not subject to the individual mandate
for their first five years in the U.S. All other J categories (teacher, trainee,
work and travel, au pair, high school, etc.) are not subject to the individual
mandate if in the U.S. for two of the past six years. Since international
students are not subject to the mandate, they are not required topurchase a plan that meets ACA requirements and can purchase theStudent Health Advantage.
U.S. Citizens: Under the ACA, all U.S. citizens, nationals, and resident aliens
are required to purchase minimum essential coverage (ACA-compliant
coverage), unless they are exempt. Exempt U.S. citizens include U.S.
citizens who reside outside of the U.S. for 330 of any 365-day period, or
have a tax home (main place of work or employment, or if you don’t havea main place of work or employment, your main residence) in a foreigncountry, and are a bona fide resident of a foreign country.
Please note that this insurance is not subject to, and does not provide benefits
required by, ACA. Since January 1, 2014, ACA requires U.S. citizens, U.S. nationals
and resident-aliens to obtain ACA compliant insurance coverage unless they
are exempt from ACA (international students on F, J, M and Q visas (and certain
family members of students) are not subject to the individual mandate for
their first 5 years in the U.S. All other J categories - teacher, trainee, work andtravel, au pair, high school, etc. - are not subject to the individual mandatefor 2 years out of the past six). Penalties may be imposed on persons who are
required to maintain ACA compliant coverage but do not do so. Eligibility topurchase or renew this product, or its terms and conditions, may be modified
or amended based upon changes to applicable law, including ACA. Please notethat it is solely your responsibility to determine if ACA is applicable to you andthe Company and IMG shall have no liability whatsoever, including for any
penalties that you may incur, for your failure to obtain required ACA compliant
coverage. For information on whether ACA applies to you or whether you are
eligible to purchase the Patriot Exchange Program, please see IMG’s Frequently
Asked Questions at imglobal.com/en/client-resources/PPACA-FAQ.aspx. The
materials available on this website are for informational purposes only and not
for the purpose of providing legal advice. You should contact your attorney toobtain advice with respect to any particular issue or problem. This brochure isintended to convey general information only and not to provide legal advice
or opinions.

13

SHA CLAIMS PROCEDURE
Precertification

How to File a Claim

Certain treatment and supplies including hospital admission, inpatientor outpatient surgery, and other procedures as noted in the certificate
wording must be precertified for medical necessity, which means theinsured person or their attending physician must communicate withan IMG representative at the number listed on the IMG ID card prior toadmission to a hospital before receiving certain treatments and supplies,
or performance of a surgery. In case of an emergency admission, theprecertification must be made within 48 hours of the admission, or assoon as reasonably possible. If a hospital admission or a surgery is notprecertified, eligible claims and expenses will be reduced by 50 percent.
It is important to note that precertification is only a determination of
medical necessity, not an assurance of coverage, verification of benefits, ora guaranty of payment. All medical expenses eligible for reimbursement
must be medically necessary and will be paid or reimbursed at usual,reasonable and customary rates. Please refer to the certificate wording
for full details of the precertification requirements.

If a provider doesn’t submit a claim on your behalf, the fastest and mostconvenient way to submit a claim is through our online customer portal,
MyIMG. If it is your first time using MyIMG, follow these steps to register:» Go to http://www.imglobal.com/member and click “Create an
Account”» On the next screen, enter your Certificate, Policy Number, or Insured/
Member ID, and click “Continue”» Once the system verifies this information, follow the remaining steps
to complete your registration» Once you’ve created a MyIMG account, follow these steps to submit
a claim:» Log in to the MyIMG portal, click “Claims”» In the drop-down menu, click “My Claims”» On the next screen, select the policy or certificate. Click “Submit New
Claim” and follow the prompts to complete your submission

Contact IMG at +1.317.655.4500 or precertification@imglobal.com.
Please be sure to send any private information in a secure manner.
Note: You may begin the precertification process through MyIMG
or the Client Resources section of imglobal.com. Simply look for theprecertification option. You will be asked to provide the required
information, which can then be submitted electronically. Once we havereceived all required information and medical records, our utilization
management and review team will review the information provided andnormally responds to the insured person or the provider within 2 businessdays. Please note that this online service will only initiate the process fortreatment and supplies outlined in the contract, and it should not be
used to request precertification for emergency admissions, procedures,or evacuations.

Self-Service Member Portal
Along with filing claims online, MyIMGSM provides service at your fingertips,
giving you the information and tools to manage your IMG plans anytime,
anywhere, through award-winning, easy-to-use technology. You’ll have
immediate access to these important resources online, including our
24/7/365 service centers, plan document access, claims management
tools, Explanations of Benefits, and much more.
U.S. Network Access
UnitedHealthcare provides travelers in the U.S. with direct access to oneof the largest networks of providers in the U.S. that includes:» Over 1.4M physicians» 6,797 hospitals» Over 45,000 clinics» 67,000 pharmacies» 1,800 convenience clinics
International Provider Access SM
Travelers outside of the U.S. can also enjoy access to quality healthcare
worldwide with our proprietary IPA network that includes:» Over 45,000 physicians and facilities» Direct billing arrangements that minimize time and upfront
expense14

STUDENTHEALTHA D V A N T A G E SM

Producer Contact Information

Coverage is underwritten and issued by SiriusPoint Specialty
Insurance Corporation, rated “A-” (excellent) by A.M. Best andA- by Standard & Poor’s (at the time of printing).

This invitation to inquire allows eligible applicants an opportunity to seek information about
the insurance offered and is limited to a brief description of any loss for which benefits may
be payable.
Benefits are offered as described in the Insurance Contract. Benefits are subject to all
deductibles, coinsurance, provisions, terms, conditions, limitations and exclusions in the
Insurance Contract. Certain contracts do contain a pre-existing condition exclusion and do
not cover losses or expenses related to a pre-existing condition.

CM0050A2330240328

HIRANO - HOLCOMB INSURANCE AGENCY, LLC
P.O. BOX 12580
MILL CREEK, WA 98082
Phone: 206-755-5585
Fax: 888-391-5155
masako@mhhinsurance.com
http://www.mhhinsurance.com

This brochure contains many of the valuable trademarks, names, titles, logos, images, designs,
copyrights and other proprietary materials owned and registered and used by International
Medical Group, Inc. and its representatives throughout the world. © 2007-2024 International
Medical Group, Inc. All rights reserved.
The UnitedHealthcare name and logo are registered trademarks of UnitedHealth Group in the
U.S. and other jurisdictions.

0324