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Visiting Scholar Benefit PlanPlan Year 2021 – 2022Benefit Plan OverviewGallagher Benefit Services, Inc.Disclaimer: This benefit plan information shown in this benefits plan overview is illustrative only. To the extent the benefit plan information summarizedherein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance ; theunderlying insurance documents will govern in all cases.Version 4.0 / Revised 08.21.19

Visiting Scholar Benefit PlanAll International Visiting Scholars Holding a J1 Visa Must Meet All the Insurance Policy Requirements Below:ooooooo 100,000 USD per accident & illness in medical coverageA deductible not to exceed 500 USD per accident or illnessCoinsurance that does not exceed 25%Medical evacuation coverage must be at least 50,000 USDRepatriation coverage must be at least 25,000 USDPre-existing conditions must be covered by the insurance policy with a waiting period no longer than 12 months.Carrier must be at least A- rated or backed by the full faith and credit of the Exchange Visitor's governmentGallagher Benefit Services (GBS) Offers Three Insurance Plan Options that Will Meet the Insurance Policy Requirements:Plan OptionsInsurance PlanEligibilityPayment FrequencyBasicIMG Basic PlanInternational Affiliates OnlyMonthly, Quarterly, Full Term**(up to 12 months)StandardIMG Standard PlanInternational Affiliates OnlyMonthly, Quarterly, Full Term**(up to 12 months)PlatinumIMG Platinum PlanInternational Affiliates onlyMonthly, Quarterly, Full Term**(up to 12 months)International Visiting ScholarsoYou may elect to waive out of purchasing either the Basic, Standard, or Platinum plans.o If you are buying your own health insurance:o You must complete the waiver process on the GBS websiteVisiting Scholars who are U.S. Citizens or U.S. Permanent Residents (“Green Card Holders”)oYou are subject to the insurance requirements of the Affordable Care Act (ACA)o You must purchase your own insurance and waive out of the Campus Visiting Scholar Benefit Plan by completing the waiver process on the GPA website2

Visiting Scholar Monthly Premium RatesPlan Year 2021 - 2022Plan OptionsInsurance PlanVisiting ScholarAdditional Premium for Spouseor Domestic PartnerAdditional Premium forOne ChildIMG Basic PlanAge Rated:Basic 31 days - 24 years old 25-49 years old 50-64 years old 55 68 125 55 68 125 55N/AN/AIMG Standard PlanAge Rated:Standard 19-23 years old24-30 years old31-40 years old41-50 years old51-64 years old 74 82 131 202 262 257 281 373 385 373 70IMG Platinum PlanAge Rated:Platinum 19-23 years old24-30 years old31-40 years old41-50 years old51-64 years old 178 203 350 571 762 674 755 1,004 1,038 1,004 158Additional Premium for Two or moreChildrenFor every child dependent (ages 31 days– 24 years old, the premium is an extra 55*Dependents Must be non-U.S. Citizens ornon-U.S. Permanent Residents.For every child dependent, the premiumis an extra 70*Dependents Must be non-U.S. Citizens ornon-U.S. Permanent Residents.For every child dependent, the premiumis an extra 158*Dependents Must be non-U.S. Citizens ornon-U.S. Permanent Residents.3

Visiting Scholar – Summary of BenefitsBasicStandardPlatinumIMGBasic PlanIMGStandard PlanIMGPlatinum PlanPPOPPOPPOLifetime MaximumPer Period ofCoverage 1,000,000Visiting Scholar - 500,000Dependent - 100,000Visiting Scholar - 1,000,000Dependent - 100,000For maternity, policy will only cover up to 10,000 per period (defined as 12 months)Plan Maximum PerIllness or Injury 100,000Visiting Scholar - 100,000Dependent - 100,000Visiting Scholar - 500,000Dependent - 100,000 250 per illness/Injury 500 per Illness/InjuryPPO Provider: 25 per Illness/ InjuryNon-PPO Provider: 50 per Illness/ Injury 1,000 per period of coverageIn-Network: N/AInternational: N/AOut-of-Network: 1,000In-Network: N/AInternational: N/AOut-of-Network: 1,000Visiting Scholar pays 20% of eligibleexpenses up to 5,000, then the planpays 100% thereafterPPO Provider: Visiting Scholar pays 0% of eligibleexpensesNon-PPO Provider: Visiting Scholar pays 20% ofeligible expenses up to 1,000, then the plan pays100% thereafterPPO Provider: Visiting Scholar pays 0% ofeligible expensesNon-PPO Provider: Visiting Scholar pays 20% ofeligible expenses up to 1,000, then the planpays 100% thereafterBenefitsPlan TypePlan r: This benefit plan information shown in this benefits plan overview is illustrative only. To the extent the benefit plan information summarizedherein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance ; theunderlying insurance documents will govern in all cases.4

Visiting Scholar – Summary of BenefitsPlan Year 2021 - 2022BenefitsPrescription DrugsBasicStandardPlatinumIMGBasic PlanIMGStandard PlanIMGPlatinum PlanUsual, Customary and ReasonableCostsVisiting Scholar Pays 50% of actual chargesUp to annual maximum of 1,500 20 Copay for Generic 40 Copay for Brand 80 Copay for Non-BrandUp to the annual maximum of 3,000Subject to deductible and coinsuranceMaternityNo CoverageNo CoverageConception must occur during period ofcoveragePolicy will only cover up to 10,000 per period(defined as 12 months).Routine NewbornCareNo CoverageNo Coverage 750 maximum per period of coverage 50,000 lifetime maximum 50,000 lifetime maximum 500,000 lifetime maximum 25,000 maximum 25,000 maximum 50,000 maximumEmergency MedicalEvacuationRepatriation ofRemainsDisclaimer: This benefit plan information shown in this benefits plan overview is illustrative only. To the extent the benefit plan information summarizedherein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance ; theunderlying insurance documents will govern in all cases.5

Visiting Scholar – Summary of BenefitsPlan Year 2021 - 2022BasicStandardPlatinumIMGBasic PlanIMGStandard PlanIMGPlatinum PlanPre-ExistingConditionsPre-existing conditions are coveredafter 6 months of continuouscoveragePlan will only cover up to 500 perperiodPre-existing conditions are covered after 12months of continuous coveragePre-existing conditions are covered after 6months of continuous coverageEmergency RoomSubject to deductible and coinsurance 250 DeductibleInjury: Not subject to Emergency RoomDeductibleIllness: Subject to a 250 Deductible for each visitfor Treatment which does not result in directHospital admissionBenefitsWITH inpatient admission: Usual,Customary and Reasonable CostsWITHOUT inpatient admission:Additional 250 deductibleHospitalizationUsual, Customary and ReasonableCosts 250 DeductibleInjury: Not subject to Emergency RoomDeductibleIllness: Subject to a 250 Deductible for eachvisit for Treatment which does not result indirect Hospital admissionOutpatient: 500 per Illness/InjuryUsual and Customary ChargesPPO Provider: 25 per Illness/ InjuryUsual and Customary ChargesNo BenefitsWell Exams covered at 100%(annual max of 500)Immunizations covered at 100%(annual max of 250)Subject to deductible and coinsurancePreventive CareServices includingImmunizationsNo BenefitsDisclaimer: This benefit plan information shown in this benefits plan overview is illustrative only. To the extent the benefit plan information summarizedherein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance ; theunderlying insurance documents will govern in all cases.6

Visiting Scholar – Summary of BenefitsPlan Year 2021 - 2022BenefitsMental & NervousDisordersEligibilityMeets J asic PlanIMGStandard PlanIMGPlatinum PlanNo BenefitsOutpatient: 50 Copay with 500 lifetimemaximumNot covered if incurred at the Student Health CenterInpatient: Lifetime maximum of 10,000Not covered if incurred at the Student HealthCenterOutpatient: 50 Copay with 500 lifetimemaximumNot covered if incurred at the Student HealthCenterInpatient: Lifetime maximum of 10,000Not covered if incurred at the Student HealthCenterNon-U.S. Citizens onlyNon-U.S. Citizens onlyNon-U.S. Citizens onlyYesYesYesDisclaimer: This benefit plan information shown in this benefits plan overview is illustrative only. To the extent the benefit plan information summarizedherein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance ; theunderlying insurance documents will govern in all cases.7

Frequently Asked QuestionsAbout the Three Insurance Plan OptionsBasicStandardPlatinumQuestionsIMGBasic PlanIMGStandard PlanIMGPlatinum PlanWhat if I am a U.S. Citizen or U.S.Permanent Resident, can I purchaseone of these plans?No, only available to Non-U.S. CitizensNo, only available to Non-U.S. CitizensNo, only available to Non-U.S. CitizensWhat if I am pregnant or if myspouse is pregnant, will theinsurance plan provide maternitycoverage?I was already diagnosed with a PreExisting condition (example: heartcondition, chronic asthma, cancer,back pain, etc.), will I be able toreceive treatment under this plan?What if I wanted to get an annualphysical exam or receiveimmunization shots, will the planprovide coverage for these type ofpreventive services?You will only receive coverage if conception occurred whileyou had the insurance policy. If you or your spouse are alreadypregnant prior to purchasing this plan, you will not receive anyinsurance coverage for any maternity claimsPolicy will only cover up to 10,000 per period (defined as 12months)NoNoYes, however you will need to wait 6 months onceyou purchase the plan to receive treatment; as longas the pre-existing condition is not an excludedcondition under the policy.The policy will only cover up to 500 of medicalexpenses per period (defined as 12 months).Please note: if you change policies, the pre-existingwaiting period starts over.Yes, however you will need to wait 12 months onceyou purchase the plan to receive treatment; aslong as the pre-existing condition is not an excludedcondition under the policyPlease note: if you change policies, the preexisting waiting period starts over.Yes, however you will need to wait 6 months once youpurchase the plan to receive treatment; as long as the preexisting condition is not an excluded condition under the policyPlease note: if you change policies, the pre-existing waitingperiod starts over.NoNoYesDisclaimer: This benefit plan information shown in this benefits plan overview is illustrative only. To the extent the benefit plan information summarizedherein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance ; theunderlying insurance documents will govern in all cases.8