Discover the Power of A Journey Thru Education, Inc.

  Medical Benefits

Brochure 2023

GROUP NUMBER:

EPSWN00538987

BENEFITS POLICY LIMITSAccident & Sickness Medical Maximums Lifetime $5,000,000Per injury/per illness $100,000Deductible per injury/illness $250Emergency Room $350 Deductible if not admitted. ER for injury no deductible.Urgent Care $50 Co-payment Not subject to deductible.Walk In Clinic (Walgreens/CVS) $20 Co-payment Not subject to deductibleCoinsurance Plan pays 90%. Insured pays 10%$1,000 out of pocket maximumCoinsurance – Out of Network Plan pays 80%. Insured pays 20%Up to the policy maximumPrescription DrugsUse GOOD RX to find the most cost effective prescriptions in your areaCovered/URC — keep receipts and copies of payment along with copy of prescription. Needs to be submitted for reimbursement.Ambulance No deductible if illness resulting in a hospitalization admission or injuryDental Emergency/Accident For relief of sudden and unexpected pain: $350 maximum. For injury due to accident $500 maximumTeladoc/Telemedicinewww.Teladoc.comNot Subject to Deductible and Coinsurance.Does not include mental health.Always enter zip code 46208 when creating username and password.Coverage for a Teladoc Consultation is not a determination that any specific condition discussed, raised, or identified during such consultation is covered under this insurance. The Company reserves the right to decline future claims relating to or arising from any condition discussed, raised or identified during a Teladoc Consultation where the Illness or Injury is directly or indirectly related to any Pre-existing Condition or is otherwise excluded under this Certificate of InsuranceEmergency Medical Evacuation Up to $50,000Repatriation of Remains $25,000 maximum. Cremation/Burial: $5,000 maximumEmergency Reunion $15,000 needs to be coordinated by IMGMental Health Outpatient $50 per day $500 Lifetime maximum Inpatient Up to $10,000AD & D (see detailed schedule) $25,000Physical Therapy 1 visit per dayPersonal Liability Injury to 3rd party: $2,000 maximum after $100 deductible. Damage to 3rd party’s property $500 maximum after $100 deductibleLost Personal Property $250 maximumSports Benefit Includes high school, interscholastic, intramural or club sportsPlease note: the benefit table and description details are a consolidated summary of the plan benefits. Please refer to the Master Policy Certificate for a full description of the plan benefits and details.

Always try to utilize the Teladoc, Urgent Care or Walk In Clinics before going to Emergency Room/Hospital. You are subject to a lower co-payment and not the ER deductible. You will also wait longer at the Emergency Room.

Carry your Medical Insurance ID Card with you at all times.

Benefits Details

PROVIDER SEARCH

• Search the type of provider (Urgent Care, Walk in Clinic,

ER, Primary Care, Lab/Radiology and Specialists)

• Prescription Medications – Any medications that have

been prescribed, will need to be paid for at the time

of purchase and submitted along with copy of the

receipt of payment and copy of the prescription with

a claim form.

PRE-CERTIFICATION

The following treatments and/or supplies must always be pre-certified for medical necessity by IMG. Please contact IMG Customer Service for Pre-certification:

• Chemotherapy

• Home Nursing Care

• Inpatient hospitalization

• Any Surgery or Surgical procedure

• Extended Care Facility

• Computerized Axial Tomography (CAT Scan)

• Magnetic Resonance Imaging (MRI)

IMG CUSTOMER SERVICE INFORMATION: UNITED STATES & CANADA

Phone: +1.800.628.4664

Email: customercare@imglobal.com

MyIMG: Create an account, manage your claims,

initiate pre-certification, locate a provider, request ID cards, obtain plan documents and more at:

Additional Information

Group Number: EPSWN00538987

myimg.imglobal.com

www.imglobal.com

SUBMIT YOUR CLAIM TO:

International Medical Group, Inc., (IMG) Claims Department, PO Box 9162 Farmington Hills, MI 48333-9162

Email: insurance@imglobal.com Fax: (317) 655-4505

You have 90 days to submit a claim/claim form.

Our globally recognized partner, Sirius International Insurance Corporation (publ), offers the financial security and reputation demanded by international consumers. As our underwriter, Sirius is rated A (Excellent) by A.M. Best and A- by Standard and Poor’s, offering the stability of a well-established insurance company.

ECONOMIC SANCTIONS: Notwithstanding any other Terms under this insurance, the Company shall not provide coverage or make any payments or provide any service or benefit to any Insured Person, beneficiary, or third party who may have any rights under this insurance to the extent that such coverage, payment, service, or benefit would violate any sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws, or regulations of the European Union, United Kingdom or the United States of America. WAR; MILITARY ACTION: The Company shall not be liable for and will not provide coverage or benefits for any claim or Charges incurred with respect to any Illness, Injury, death and dismemberment, or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising or incurred in connection with or as a result of any of the following acts or occurrences: war, invasion, act of foreign enemy hostilities, warlike operations (whether war be declared or not), or civil war mutiny, riot, strike, military or popular uprising, insurrection, insurgency, rebellion, revolution, military or usurped power any act of any person acting on behalf of or in connection with any organization with activities directed towards the overthrow by force of the Government de jure or de facto or to the influencing of it by violence of any type martial law or state of siege or any events or causes which determine the proclamation or maintenance of martial law or state of siege any use of radiological, chemical, nuclear or biological weapons or any other radiological, chemical, nuclear or biological events of any type (including in connection with an act of Terrorism). Any claim, Charges, Illness, Injury or other consequence happening or arising during the existence of abnormal conditions (whether physical or otherwise), whether or not directly or indirectly, proximately or remotely occasioned by, or contributed to by, traceable to, or arising in connection with, any of the said occurrences shall be deemed and considered to be consequences for which the Company shall not be liable under the Master Policy or this Certificate, except to the extent that the Insured Person shall prove that such claim, Charges, Illness, Injury or other consequence happened independently of the existence of such abnormal conditions and/or occurrences.

(3) TERRORISM: The Company shall not be liable for and will not provide coverage or benefits in excess of the amount shown in the BENEFIT SUMMARY for any claim or Charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with any act of Terrorism. Further, the Company shall not be liable for and will not provide any coverage or benefits for any claim, Charges, Illness, Injury or other consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to or arising in connection with the following: (a) the Insured Person’s active and voluntary planning or coordination of or participation in any act of Terrorism (b) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning or Emergency Travel Advisory was issued or in effect on or within six (6) months prior to the Insured Person’s date of arrival in said location, post, area, territory or country (c) any act of Terrorism that takes place in a location, post, area, territory or country for which a Travel Warning or Emergency Travel Advisory becomes effective or is in effect on or after the Insured Person’s date of arrival in said location, post, area, territory or country, and the Insured Person unreasonably fails or refuses to heed such warning and thereafter remains in said location, post, area, territory or country. (4) PRE-EXISTING CONDITIONS: Charges resulting directly or indirectly from or relating to any Pre-existing Condition, (whether physical or mental, regardless of the cause of the condition) are excluded from coverage under this insurance until the Insured Person has maintained coverage under this insurance plan continuously for at least twelve (12) months (5) MATERNITY AND NEWBORN CARE: All Charges for pre-natal care, delivery, post-natal care, and care of Newborns, including complications of Pregnancy, miscarriage, complications of delivery and/or of Newborns are excluded from this insurance.

(6) PREVENTATIVE CARE: Charges for Routine Physical Examinations and immunizations are excluded from coverage under this insurance (7) Charges for any Treatment or supplies that are: (a) not incurred, obtained or received by an Insured Person during the Period of Coverage (b) not presented to the Company for payment by way of a completed Proof of Claim within one hundred eighty (180) days from the date such Charges are incurred (c) not administered or ordered by a Physician (d) not Medically Necessary for the diagnosis, care or Treatment of the physical or mental condition involved. This also applies when and if they are prescribed, recommended or approved by the attending Physician (e) provided at no cost to the Insured Person or for which the Insured Person is not otherwise liable (f) in excess of Usual, Reasonable, and Customary (g) related to Hospice care (h) incurred by an Insured Person who was HIV + on or before the Initial Effective Date of this insurance, whether or not the Insured Person had knowledge of their HIV status prior to the Effective Date, and whether or not the Charges are incurred in relation to or as a result of said status. This exclusion includes Charges for any Treatment or supplies relating to or arising or resulting directly or indirectly from HIV, AIDS virus, AIDS related Illness, ARC Syndrome, AIDS and/or any other Illness arising or resulting from any complications or consequences of any of the foregoing conditions (i) provided by or at the direction or recommendation of a chiropractor, unless ordered in advance by a Physician (j) performed or provided by a Relative of the Insured Person (k) not expressly included in the ELIGIBLE MEDICAL EXPENSES provision (l) provided by a person who resides or has resided with the Insured Person or in the Insured Person’s home (m) required or

recommended as a result of complications or consequences arising from or related to any Treatment, Illness, Injury, or supply received prior to coverage under this insurance or that is excluded from coverage or which is otherwise not covered under this insurance (n) for Congenital Disorders and conditions arising out of or resulting therefrom (8) Charges incurred for failure to keep a scheduled appointment (9) Telehealth or Telemedicine services not considered Medically Necessary as determined by the Company under the plan (10) Charges incurred for Surgeries, Treatment or supplies which are Investigational, Experimental, and for research purposes (11) Charges incurred related to genetic medicine, genetic testing, surveillance testing and/or wellness screening procedures for genetically predisposed conditions indicated by genetic medicine or genetic testing, including, but not limited to amniocentesis, drugs, recombinant adeno-associated virus vector-based gene therapy, and other medication Treatments associated with diagnoses related to genetic testing and discovery, genetic screening, risk assessment, preventive and prophylactic surgeries recommended by genetic testing, and/or any procedures used to determine genetic pre-disposition, provide genetic counseling, or administration of gene therapy (12) Charges incurred for testing that attempts to measure aspects of an Insured Person’s mental ability, intelligence, aptitude, personality and stress management. Such testing may include but is not limited to psychometric, behavioral and educational testing (13) Charges incurred for Custodial Care (14) Charges incurred for Educational or Rehabilitative Care that specifically relates to training or retraining an Insured Person to function in a normal or near-normal manner. Such care may include but is not limited to job or vocational training, counseling, occupational therapy and speech therapy (15) Charges for weight modification or any Inpatient, Outpatient, Surgical or other Treatment of obesity (including without limitation morbid obesity), including without limitation wiring of the teeth and all forms or procedures of bariatric Surgery by whatever name called, or reversal thereof, including without limitation intestinal bypass, gastric bypass, gastric banding, vertical banded gastroplasty, biliopancreatic diversion, duodenal switch, or stomach reduction or stapling (16) Charges for modification of the physical body in order to change or improve or attempt to change or improve the physical appearance or psychological, mental or emotional well-being of the Insured Person (such as but not limited to sex-change Surgery or Surgery relating to sexual performance or enhancement thereof) (17) Charges or Treatment for cosmetic or aesthetic reasons, except for reconstructive Surgery when such Surgery is Medically Necessary and is directly related to and follows a Surgery which was covered under this insurance (18) Elective Surgery or Treatment of any kind (19) Charges incurred for any Treatment or supply that either promotes or prevents or attempts to promote or prevent conception, insemination (natural or otherwise) or birth, including but not limited to: artificial insemination; oral contraceptives; Treatment for infertility or impotency; vasectomy; reversal of vasectomy; sterilization; reversal of sterilization; surrogacy or abortion (20) Charges incurred for any Treatment or supply that either promotes, enhances or corrects or attempts to promote, enhance or correct impotency or sexual dysfunction (21) any Illness or Injury sustained while taking part in, practicing or training for: Amateur Athletics; Professional Athletics; or athletic activities that are sponsored by any Governing Body or Authority including but not limited to the National Collegiate Athletic Association, any other collegiate sanctioning or Governing Body or the International Olympic Committee (22) any Illness or Injury sustained while taking part in activities designated as Adventure Sports, which are limited to the following: abseiling; BMX; bobsledding; bungee jumping; canyoning; caving; hot air ballooning; jungle zip lining; parachuting; paragliding; parascending; rappelling; skydiving; spelunking; wildlife safaris; and windsurfing (23) any Illness or Injury sustained while taking part in activities designated as Extreme Sports, which include but are in no way limited to the following (and include any combination or derivative of the following): BASE jumping; cave diving; cliff diving; downhill mountain biking and racing; extreme skiing; freediving; free flying; free running; free skiing; freestyle scootering; gliding; heli-skiing; ice canoeing; ice climbing; kitesurfing; mixed martial arts; motocross; motorcycle racing; motor rally; mountaineering above elevation of 4500 meters from Ground Level; parkour; piloting a commercial or non-commercial aircraft; powerbocking; scuba diving or sub aqua pursuits below a depth of 40 meters; snowmobile racing; truck racing; whitewater kayaking or whitewater rafting Class VI and higher difficulty; and wingsuit flying (24) any Illness or Injury sustained while taking part in snow skiing, snowboarding or snowmobiling where the Insured Person is in violation of applicable laws, rules or regulations of a ski resort, out of bounds or in unmarked or unpatrolled areas (25) any Illness or Injury sustained while taking part in backcountry skiing (26) any Illness or Injury sustained while taking part in skiing off-piste (27) any Illness or Injury sustained while taking part in athletic or recreational activities where the Insured Person is not physically or medically fit or does not hold the necessary qualifications to engage in said activities (28) any Illness or Injury sustained while taking part in Collision Sports (29) any Illness or Injury sustained while participating in any sporting, recreational or adventure activity where such activity is undertaken against the advice or direction of any local authority or any qualified instructor or contrary to the rules, recommendations and procedures of a recognized Governing Body for the sport or activity (30) any Illness or Injury sustained while

participating in any activity where such activity is undertaken in disregard of or against the recommendations, Treatment programs, or medical advice of a Physician or other healthcare

Exclusions

provider (31) any Injury or Illness sustained as a result of being under the influence of or due wholly or partly to the effects of alcohol, liquor, intoxicating substance, narcotics or drugs other than drugs taken in accordance with Treatment prescribed and directed by a Physician but not for the Treatment of Substance Abuse (32) any Injury or Illness sustained while operating a moving vehicle after consumption of intoxicating liquor or drugs in excess of the applicable blood/alcohol legal limit, other than drugs taken in accordance with Treatment prescribed and directed by a Physician. For purposes of this exclusion, “vehicle” shall include motorized devices regardless of whether or not a driver or operator license is required (including watercraft and aircraft) and non-motorized bicycles and scooters for which no permit or license is required (33) any willfully Self-inflicted Injury or Illness (34) any sexually transmitted or venereal disease (35) any testing for the following when not Medically Necessary: HIV, seropositivity to the AIDS virus, AIDS related Illnesses, ARC Syndrome, AIDS (36) any Illness or Injury resulting from or occurring during the commission of a violation of law by the Insured Person, including, without limitation, the engaging in an illegal occupation or act, but excluding minor traffic violations (37) biofeedback, acupuncture, music, occupational, recreational, sleep, speech, or vocational therapy (38) orthoptics, visual therapy or visual eye training (39) any non-surgical Illness or Treatment of the feet, including without limitation: orthopedic shoes; orthopedic prescription devices to be attached to or placed in shoes; Treatment of weak, strained, flat, unstable or unbalanced feet; metatarsalgia, bone spurs, hammer toes or bunions; and any Treatment or supplies for corns, calluses or toenails; except as otherwise expressly set forth (40) hair loss, including without limitation wigs, hair transplants or any drug that promises to promote hair growth, whether or not prescribed by a Physician (41) any sleep disorder, including without limitation sleep apnea (42) any exercise and/or fitness program or equipment, whether or not prescribed or recommended by a Physician (43) any exposure to any non-medical nuclear or atomic radiation, and/or radioactive material(s) (44) any organ or tissue or other transplant or related services, Treatment or supplies (45) any artificial or mechanical devices designed to replace human organs temporarily or permanently after termination of Inpatient status (46) any efforts to keep a donor alive for a transplant procedure (47) any Illness or Injury incurred in the Destination Country, Affected Area or Country of Residence as a result of a Public Health Emergency of International Concern, Epidemic, Pandemic, other disease outbreak, or Natural Disaster, that may affect an Insured Person’s health, unless coverage is expressly provided under the PUBLIC HEALTH EMERGENCY provision of this insurance This exclusion DOES NOT apply to Charges resulting from COVID-19/ SARS-CoV-2. (48) Charges incurred for eyeglasses, contact lenses, hearing aids or hearing implants and Charges for any Treatment, supply, examination or fitting related to these devices, or for eye refraction for any reason (49) Charges incurred for eye Surgery, such as but not limited to radial keratotomy, when the primary purpose is to correct or attempt to correct nearsightedness, farsightedness, or astigmatism (50) Charges incurred for Treatment or supplies for temporomandibular joint (TMJ) including but not limited to TMJ syndrome, craniomandibular syndrome, chronic TMJ pain, orthognathic Surgery, Le-Fort Surgery or splints (51) Charges incurred in the Insured Person’s Country of Residence, except as otherwise expressly provided for in this insurance (52) Charges incurred for any travel, meals, transportation and/or accommodations, except as otherwise expressly provided for in this insurance (53) Charges or expenses incurred for nonprescription drugs, medicines, vitamins, food extracts, or nutritional supplements; IV vitamin or herbal therapy; drugs or medicines not approved by the United States Food and Drug Administration (FDA) or which are considered “off-label” drug use; and for drugs or medicines not prescribed by a Physician (54) any Treatment for an Illness or Injury requiring an unapproved U.S. Food and Drug Administration (FDA) medical product, services, Surgery, Surgical Procedure, prescription medication, drug, biological product, Durable Medical Equipment (DME) or device when an Emergency Use Authorization (EUA) is in place issued by the U.S. Food and Drug Administration (FDA) (55) Charges and all costs related to or arising from or in connection with all trips to the Destination Country undertaken for the purpose of securing medical Treatment or supplies (56) Charges incurred for Dental Treatment, except as specifically provided for hereunder (57) Wear and tear of teeth due to cavities and chewing or biting down on hard objects, such as but not limited to pencils, ice cubes, nuts, popcorn, and hard candies (58) Dental Injury without associated face, skull, neck and/or jaws Injury or that can be evaluated and Treated in a dental office (59) Dental Treatment for services which provide oral care maintenance including tooth repair by fillings, root canals, tooth removal and x-rays (60) Charges for Treatment of an Illness or Injury for which payment is made or available through a workers’ compensation law or a similar law (61) Charges incurred for massage therapy (62) Charges incurred at a Hospital or Facility when the Insured Person checks themselves out Against Medical Advice of their Physician or leaves before reaching a Medically Necessary specified endpoint of Treatment (63) Charges incurred for the Worsening of an Illness or Injury after the Insured Person

left a Hospital or Facility Against Medical Advice or was a Discharge Against Medical Advice (64) Accidental Death or Dismemberment when the Insured Person’s death or dismemberment is caused directly or indirectly by, results from, or where there is a contribution from, any of the following: (a)

bodily or mental infirmity, Illness or disease (b) infection, other than infection occurring simultaneously with, and as a direct result of, the accidental Injury.