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SCHEDULE OF BENEFITSThis Policy is intended to be read in its entirety. To understand all the conditions, exclusions, and limitations applicable toits benefits, please read all the policy provisions carefully. Only those benefits elected by each Participating School andshown on its Schedule of Benefits will apply to its enrolled Eligible Covered Students.The Company has appointed the Program Manager to administer the Policy on its behalf. References to the ProgramManager throughout this Policy include the Company where appropriate. Any notice delivered to the Program Manager shallbe considered received by the Company.The Schedule of Benefits provides a brief outline of the coverage and benefits provided by this Policy. The benefitssummarized in this Schedule of Benefits may be subject to definitions, exclusions and provisions. Please read each benefitdescription section for full details.Eligible Covered StudentsNon-United States Citizens traveling outside their Home Country, who has his or her true, fixed and permanent homeand principal establishment outside of the United States, and holds a current and valid passport, while actively engagedin educational or research activities. You are “actively engaged” in educational or research activities if you are one ofthe following:1. a legal resident of a country other than the United States, its territories, or possessions;2. is enrolled and actively engaged in Full-Time Studies;3. has not been granted permanent residency status in the United States, its territories, or possessions; and4. holds and continually maintains an F-1, J-1, M-1, Q-1 or other approved category of student visa orimmigration status.A Covered Student ceases to be attending classes on a full-time basis, and, therefore, upon graduation, the Covered Studentand his or her Covered Dependents, if any, become ineligible for coverage under the Plan. However, the Covered Studentmay be entitled to continued coverage after graduation if one of the following exceptions apply:1. The Covered Student is approved for OPT and, on that basis, qualifies for continued coverage under the terms ofthis Policy document; or2. The Covered Student qualifies for Extended Coverage because they have graduated, are returning to their HomeCountry, and applied for Extended Coverage as required by this Policy document.Optional Practical TrainingAn eligible Optional Practical Training student with the applicable F-1 visa may be considered eligible for coverage for nolonger than twelve months from the date the student is approved for OPT while he or she is participating in OptionalPractical Training work which is directly related to the major area of study. STEM OPT extension students are eligible for amaximum of twenty-four months coverage from the date the student is approved for OPT.Optional Practical Training students who fail to maintain Optional Practical Training eligibility or who have transitioned toH-1B status will no longer be eligible for coverage.LMK-SIR BROC-081521Page 9 of 34

SCHEDULE OF BENEFITS (CONTINUED.)The Policy provides different levels of benefits and copayments depending on where the Covered Person chooses to receivecare or whether or not he or she uses the services of a Participating Provider. A Covered Person is free, however, to use theprovider of his or her choice. The following benefits are available, per Covered Person, up to the amounts shown.POLICY BENEFITS – PER COVERED STUDENTPolicy Year Maximum Benefit 400,000Lifetime Maximum Benefit per Covered Injury or Covered Sickness 400,000Annual Deductible- Applies to all Covered Benefits except to Prescription Drugs,Wellness Benefit(s) and Medical Treatment received at Student Health Centers 150Policy Out-of-Pocket Expense Maximum 6,000Pre-Existing Condition Benefit – First six months of continuous coverage 5,000COPAYMENTSIn-NetworkOut-of-NetworkStudent Health Center 0N/AOffice Visit 20 20Hospital 100 100Hospital Emergency Room 100 100COINSURANCE (applies to all Covered Benefits)In-Network ProviderOut-of-Network Providers100% of Allowed Charge80% of Reasonable and Customary ExpensesCOVID-19 COVERAGETreatment for COVID-19 (coronavirus) is covered.Medically necessary, diagnostic testing for the coronavirus is covered. Not subject to Copay or Deductible.COVID-19 VACCINEThe COVID-19 (coronavirus) vaccine is covered up to 100 per policy year. Not subject to Copay or Deductible.After the Covered Person satisfies the Out-of-Pocket Maximum, the Policy pays 100% of Eligible Expenses for the remainderof the Policy Term.Satisfaction of the Policy Out-of-Pocket amount will not apply to outpatient prescription drugs expenses. Copayment andCoinsurance will continue to apply to the Prescription Drugs Benefits received on an outpatient basis.LMK-SIR BROC-081521Page 10 of 34

SCHEDULE OF BENEFITS (CONTINUED.)PRESCRIPTION DRUG BENEFITSDispensed by a Student Health Center100% of each 30-day supplyDispensed by a Participating Network Pharmacy60% of each 30-day supplyDispensed while Inpatient at a HospitalPrescription Drug Benefit Maximum100%NoneWith respect to outpatient prescriptions, the Policy will pay the stated percentage for each 30-day supply.CONTRACEPTIVE BENEFITSPrescription Contraceptives - OralPrescription Contraceptives - Select non-oralAt Student Health Centers andIn-Network ProvidersOut-of-Network100% of each 30-day supplyNot covered50%Not coveredThere is no coverage for intrauterine devices (IUDs) or birth control implants and the proceduresrelated to the placement and/or removal of such.Payments toward the Prescription Drug Out-of-Pocket Expense Maximum will not count toward satisfying the PolicyOut-of-Pocket Expense Maximum.Don’t forget to bring your ID card when youvisit the doctor or the pharmacy!LMK-SIR BROC-081521Page 11 of 34

SCHEDULE OF BENEFITS (CONTINUED.)COVERED nt Care100%80%Outpatient Medical Care and Supplies100%80%Pregnancy Benefits100%80%Laboratory, X-Ray, and Diagnostic ExaminationsProfessional Ground or Air Ambulancefor Emergency Services100%80%100%100%Hospital Room and Board at Semi-PrivateRoom RateIntensive Care Unit (Average Charge)Infusion Therapy BenefitRenal Dialysis/Hemodialysis BenefitMedical Treatment of a Mental ConditionMedical Treatment of Alcoholismor Drug DependencyWellness Benefit (Not subject to Copay or Deductible)Cystic Acne TreatmentSTD Testing (with symptoms present)Physiotherapy Expense Benefit – InpatientPhysiotherapy Expense Benefit – Outpatient(Only when prescribed in writing by a Physician)Home Country Coverage BenefitClub/Intramural/Recreational Sports BenefitIntercollegiate Sports Benefit Per Policy YearSelf-Inflicted Injury Benefit100%, up to a maximum of80%, up to a maximum of 10,000 per policy year 10,000 per policy year100%, up to a maximum of80%, up to a maximum of 10,000 per policy year 10,000 per policy yearInpatient – Aggregate maximum of 30 days per policy yearOutpatient – Aggregate maximum of 45 visits per policy yearInpatient – Aggregate maximum of 30 days per policy yearOutpatient – Aggregate maximum of 30 visits per policy year100% up to a Maximum Benefit of 500 per policy year100%Included in the Wellness Benefit80%80%100%80%100% of the Preferred80% of URC for up to aAllowance for up to amaximum of 20 visits formaximum of 20 visits foreach of:each of: physical therapy physical therapy acupuncture acupuncture chiropractics chiropractics 1,500 per policy year100%80%Not coveredNot coveredElective AbortionUp to 1,000 per policy yearDental Injury BenefitUp to 2,500 per policy yearPalliative Treatment of Dental Pain BenefitContinuation BenefitUp to 500 per policy yearAvailable up to a maximum of 13 weeks or up to aMaximum Benefit of 10,000, whichever is reached firstMedical Evacuation BenefitUp to 50,000 of Reasonable ExpensesRepatriation BenefitUp to 25,000 of Reasonable ExpensesLMK-SIR BROC-081521Page 12 of 34

ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) BENEFITSApplies only to covered students; terminates at age 65. Does not apply to spouses or dependents.Principal Sum: 10,000Loss must occur within 90 days of the covered accidentINSURED STUDENT’S COVERED LOSSAD&D BENEFITAccidental Death100% of the Principal SumBrain Death100% of the Principal SumLoss of Both Hands100% of the Principal SumLoss of Both Feet100% of the Principal SumLoss of Entire Sight of Both Eyes100% of the Principal SumLoss of One Hand and One Foot100% of the Principal SumLoss of One Hand and Entire Sight of One Eye100% of the Principal SumLoss of One Foot and Entire Sight of One Eye100% of the Principal SumLoss of Speech and Hearing (both ears)100% of the Principal SumQuadriplegia (total Paralysis of both upper and lower limbs)100% of the Principal SumParaplegia (total Paralysis of both lower or upper limbs)50% of the Principal SumLoss of One Hand50% of the Principal SumLoss of One Foot50% of the Principal SumLoss of Entire Sight of One Eye50% of the Principal SumLoss of Speech50% of the Principal SumLoss of Hearing (both ears)50% of the Principal SumHemiplegia (total Paralysis of upper and lower limbs on one side of body)50% of the Principal SumUniplegia (total Paralysis of one lower or upper limb)25% of the Principal SumLoss of Thumb and Index Finger of the Same Hand25% of the Principal SumIf, within 90 days from the date of an Accident or Injury covered by the Policy, the Covered Student suffers from a CoveredLoss, We will pay the percentage of the Principal Sum set opposite the loss in the table above. If the Covered Student sustains more than one such Loss as the result of one Accident, We will pay only one amount, the largest to which he is entitled.This amount will not exceed the Principal Sum which applies for the Covered Student. The Principal Sum is the MaximumBenefit Amount shown in Schedule of Benefit.Benefits are payable if such Injury occurs while the Covered Student is covered under the Policy.LMK-SIR BROC-081521Page 13 of 34

We will pay Accident and Sickness Medical Expense Benefits for Eligible Expenses. These benefits are subject to theCopayment, Coinsurance, Policy Period, Benefit Maximums and other terms or limits shown below and in the Scheduleof Benefits.Accident and Sickness Medical Expense Benefits are only payable:1. for the Preferred Allowance or Usual, Reasonable and Customary Charges incurred after the Copay has beenmet;2. for those Medically Necessary Eligible Expenses incurred by or on behalf of the Covered Student;3. for Eligible Expenses incurred within 365 days after the date of the Eligible Expense.No benefits will be paid for any expenses incurred that are in excess of the Preferred Allowance or Usual, Reasonableand Customary Charges.Eligible Medical Expenses include the following expenses as further indicated in the Schedule of Benefits or elsewherein this policy:1. Medical Treatment2. Hospital Admission Expenses: Charges for each hospital admission.3. Outpatient Pre-Surgical Testing benefit: Charges for Medically Necessary Pre-surgical testing.4. Nursing Services: Outpatient Charges for nursing services by a Registered Nurse or Licensed Professional.5. Skilled Nursing Facility (SNF): A SNF confinement must take place within 14 days from a hospital discharge andmust represent care for the same condition which required hospitalization that lasted a minimum of three days.Care may not be custodial in nature (e.g., care which could be performed at home). The facility may not beprimarily a place which provides general care for the aged.6. Hospice Care Benefit: Charges for a maximum of 14 days of:a. nursing care by a Registered Nurse or any of the following who are under the direct supervision of aRegistered Nurse: a Licensed Practical Nurse, a Licensed Vocational Nurse, or Public Health Nurse;b. physical therapy and speech therapy when rendered by a licensed therapist;c. medical supplies, including drugs and the use of medical appliances;d. physician’s services; ande. services, supplies, and treatments deemed Medically Necessary and ordered by a licensed Physician.7. Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Physicianor Surgeon.8. Charges made for artificial limbs, eyes, larynx, and orthotic appliances, but not for replacement of such items.9. Diabetes Coverage that includes medical supplies, equipment and education for diabetes care for all diabetics.10. Hospital Room & Board Benefit: We will pay charges for the Average Semiprivate Charge for each day ofthe Hospital Stay. In computing the number of days payable under this benefit, the date of admission willbe counted. Hospital Room and Board expenses will include floor nursing while confined in a ward or semiprivate room of a Hospital and other Hospital services inclusive of charges for professional service and with theexception of personal services of a non-medical nature; provided, however, that expenses do not exceed theHospital’s average charge for semiprivate room and board accommodation.11. Intensive Care Unit Benefit: We will pay charges for each day of Intensive Care Unit confinement. This paymentis in lieu of payment for the Hospital Room and Board charges for those days and includes nursing services.LMK-SIR BROC-081521Page 14 of 34

12. Hospital Miscellaneous Expense Benefit: We will pay for services, supplies and charges during a Hospital Stay.Miscellaneous services include 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; andsupplies; and blood and blood transfusions. Miscellaneous services do not include charges for telephone, radio ortelevision, extra beds or cots, meals for guests, take home items, or other convenience items.13. Surgeon (In or Outpatient) Benefits: We will pay charges for:1. A Physician, for primary performance of a surgical procedure, up to the Maximum Benefit Amount shown inthe Schedule of Benefits per procedure.2. A Physician, for assistant surgeon duties up to the Maximum Benefit shown in the Schedule of Benefits.14. Pre-Admission Testing Benefit: We will pay benefits for charges for Medically Necessary Pre-admission testing.15. Anesthesia Benefit: We will pay benefits for Anesthesia for pre-operative screening and administration ofanesthesia during a surgical procedure whether on an inpatient or outpatient basis.16. Day Surgery Miscellaneous Benefit: We will pay Day Surgery Miscellaneous benefits for services and supplies suchas: the cost of the operating room; laboratory tests; X-ray examinations; anesthesia; drugs or medicine;therapeutic services; and supplies, on an outpatient basis.17. Diagnostic X-Ray and Laboratory Benefit: We will pay the benefit if the Covered Student requires diagnostic x-rayand/or laboratory examinations and services due to a Covered Loss, up to the Maximum Benefit Amount percovered Injury or Sickness indicated in the Schedule of Benefits. Outpatient x-ray services and laboratory testsare limited to the amount shown in the Schedule of Benefits.18. Ambulance Benefit: When, by reason of Injury or Sickness, a Covered Student requires the use of a communityor Hospital Ambulance in a Medical Emergency, We will pay a Benefit Amount up to a Maximum shown in theschedule (if any), within the metropolitan area in which the Covered Student is located at that time the service isused. Ambulance Service is transportation by a vehicle designed, equipped and used only to transport the sick andinjured from home, the scene of the Accident or Medical Emergency to a Hospital or between Hospitals. Surfacetrips must be to the closest local facility that can provide the covered service appropriate to the condition.Air transportation is covered when Medically Necessary because of a Medical Emergency or if the Covered Student is in a rural area, then air ambulance transportation to the nearest metropolitan area will be considered aEligible Expense. Air Ambulance is air transportation by a vehicle designed, equipped and used only to transportthe sick and injured to and from a Hospital for inpatient care.19. Physician Visit Benefit (Inpatient): We will pay charges by a Physician for other than pre- or post-operative carefor in-Hospital visits, up to the Maximum Benefit Amount shown in the Schedule of Benefits for Physician’s VisitIn-Hospital.20. Physician Visit Benefit (Outpatient): We will pay charges by a Physician for office visits, up to the MaximumBenefit Amount shown in the Schedule of Benefits for Physician’s Office Visits.21. Consultant Physician Benefit: If, by reason of Injury or Sickness, a Covered Student requires the services of aConsultant or Specialist when they are deemed necessary and ordered by an attending Physician for the purposeof confirming or determining a diagnosis, We will pay the Covered Percentage of the Eligible Expenses incurred.22. Radiation/ Chemotherapy Therapy Expense Benefit: We will pay the Covered Percentage for the EligibleExpenses incurred by a Covered Student for drugs used in antineoplastic therapy and the cost of its administration. Coverage is provided for any drug approved by the Federal Food and Drug Administration (FDA), regardlessof whether the specific neoplasm for which the drug is being used as treatment is the specific neoplasm for whichthe drug was approved by the FDA, so long as:1. the drug is ordered by a Physician for the treatment of a specific type of neoplasm;2. the drug is approved by the FDA for use in antineoplastic therapy;LMK-SIR BROC-081521Page 15 of 34

3. the drug is used as part of an antineoplastic drug regimen;4. current medical literature substantiates its efficacy, and recognized oncology organizations generallyaccept the treatment; and5. the Physician has obtained informed consent from the patient for the treatment regimen that includesFDA approved drugs for off-label indications.23. Infusion Therapy: We will pay the Eligible Expenses, up to the policy year maximum shown in the schedule ofbenefits, if any, for infusion therapy prescribed and administered by a licensed Physician.24. Renal Dialysis/Hemodialysis: We will pay the Eligible Expenses, up to the policy year maximum shown in theschedule of benefits, if any, for Renal Dialysis/Hemodialysis prescribed and administered by a Physician.25. Post-Mastectomy Coverage: We will pay the Covered Percentage for a Medically Necessary mastectomy whichmay also include coverage of the following:a.b.c.d.physical complications during any stage of the mastectomy, including lymphedemas;reconstruction of the breast;surgery on the non-diseased breast to attain the appearance of symmetry between the two breasts; andtwo external breast prostheses.Eligible Expenses for the above are payable on the same basis as Eligible Expenses for any other surgery. Thiscoverage will be provided in consultation with the attending Physician and the patient.26. Emergency Room Benefit: We will pay this benefit if the Covered Student requires Emergency Room treatmentdue to a Covered Loss resulting directly and independently of all other causes from a covered Injury or Sickness.Emergency Room means a trauma center or special area in a Hospital that is equipped and staffed to give peopleemergency treatment on an outpatient basis. An Emergency Room is not a clinic or Physician’s office. Servicesincluding physician charges and related x-ray/laboratory interpretations will be paid under this benefit.27. Coronavirus Disease 2019 (COVID-19) Benefit: We will pay the Covered Percentage for Medically Necessarydiagnostic testing, Medical Treatment, vaccinations, and booster vaccinations related to the COVID-19coronavirus or any variants of interest, c

request for appointment-based support . My Student Support Advisors can help anytime, anywhere with: My SSP offers: Contact My SSP 24/7 Adapting to new cultures eing successful at school Relationships with friends and family Stress, sadness, loneliness and more onfidential short-term professional counseling support at no .