Patriot Exchange Program^℠

Hello. Hola. Hallo. Hej. 您好.

You can greet someone in a foreign country in many ways. When you travel, stay safe and secure by saying hello to Patriot Exchange Program^SM, a one-of-a-kind international medical insurance plan that brings you Global Peace of Mind^® when you're traveling abroad.

Traveling abroad can be an exciting experience, especially when you're involved in an educational or cultural exchange program. But what would happen if you became ill or injured while away from home? Your experience can quickly turn frightening if you're not prepared for a medical emergency.

Whether your trip takes you abroad for a few weeks or a year, your cultural exchange experience should be an enjoyable one. You have enough to worry about when you're traveling. Don't let your medical coverage be an uncertainty. Patriot Exchange Program^SM provides you, your group, and your dependents traveling with you Coverage Without Boundaries^®. The plan offers a complete package of international benefits available 24-hours a day. Simply select the plan option that best fits your needs.

The Patriot Exchange Program is designed to meet the U.S. visa insurance requirements for individuals and groups of five or more students studying abroad or participating in a cultural exchange program, including J1 and J2 visa holders. Coverage may be purchased for spouses and unmarried, dependent children traveling with the student/participant. Individuals and groups can select from different plan options - $50,000, $100,000, $250,000, and $500,000 maximum limit per illness/ Injury. The $50,000 maximum limit per Illness/Injury option does not comply with J1 and J2 visa requirements. This program also offers two different areas of coverage, and an optional add-on rider for high school sports, personal liability and legal assistance. In addition, groups may purchase annually renewable long term plans that have the flexibility to be tailored to meet specific needs of each program.

Non-US Citizens: As non-resident aliens, international students, scholars, and people involved in cultural exchange programs on F, J, M and 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 for two years (out of the past six). Since international students are not subject to the mandate, they are not required to purchase a plan that meets ACA requirements and can purchase the Patriot Exchange Program.

US Citizens: Under 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 have a main place of work or employment, your main residence) in a foreign country, and is 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 and travel, au pair, high school, etc. - are not subject to the individual mandate for 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 to purchase or renew this product, or its terms and conditions, may be modified or amended based upon changes to applicable law, including ACA. Please note that it is solely your responsibility to determine if ACA is applicable to you and the Company and the administrator 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 contact us. You should contact your attorney to obtain advice with respect to any particular issue or problem.

We know that the reasons for traveling abroad are many and varied - that's why our products are too. Our full-service approach to providing international medical insurance products includes servicing vacationers, those working or living abroad for short or extended periods, people traveling frequently between countries, and those who maintain multiple countries of residence.

But providing insurance coverage is not enough. It's the service and support that matters the most. We've served millions of people around the globe with customer service that's second to none. We provide on-site medical staff who are available 24 hours a day for emergencies, multilingual customer service professionals and dedicated claims administrators who process tens of thousands of claims each year from all over the world. We're with you, providing you Global Peace of Mind^®.

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

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.

Client Center

An online service located in our Client Center that allows you to manage your accounts, 24 hours a day, seven days a week, from anywhere in the world. Some features include:

• Submission and management of claims
• Access to Explanation of Benefits (EOBs)
• Initiate precertification
• Access customer care via email or telephone
• Locate and recommend a provider/ facility
• Obtain ID cards and other insurance documents

Extensive Network Access

For students, scholars, and cultural exchange participants when inside the U.S., the UnitedHealthcare Options network is a longstanding reputable tier 1 network that gives you more access to more doctors and services, including:

• Over 895,000 physicians
• 5,600 hospitals in the U.S.
• Retail urgent care facilities
• A streamlined claims process

Students, scholars, and cultural exchange participants when outside the U.S. can also enjoy access to quality healthcare worldwide with our proprietary IPA network that includes:

• Over 18,550 physicians and facilities
• Direct billing arrangements that minimize time and upfront expense

Universal Rx Pharmacy Discount Savings

This discount savings program allows you to purchase prescriptions at one of over 35,000 participating pharmacies in the U.S. and receive the lower of 1) universal Rx contract price or 2) the pharmacy regular retail price. This program is not insurance coverage; it is purely a discount program.

Akeso Care Management^® (AkesoCare^SM)

The ability to access quality health care is of paramount importance when a medical emergency arises abroad. To coordinate care and provide U.S. and internationally based medical management services, the administrator formed AkesoCare, a URAC accredited, onsite specialized division devoted entirely to medical management. AkesoCare's clinical members are experts at assessing the need for services and ensuring those services are delivered in a timely, cost-effective manner.

From routine medical care to complex case management, from check-ups to emergency medical evacuations, AkesoCare is there for you. They are committed to patient protection and empowerment, quality operations and provider compliance. This translates into better care for you - around the world, around the clock.

Adventure Sports Rider:

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 can be covered up to the maximums listed below. Certain activities are never covered, regardless of whether or not you purchase the Adventure Sports Rider. For a list of all the activities which can be considered to be adventure sports, please look at Adventure Sports Rider.

Chaperone / Faculty Leader Trip Interruption Rider

Groups may request the Chaperone/Faculty Leader Trip Interruption Rider rider which offers up to $3,000 in benefits. In the event of the original chaperone/leader's hospitalization, a relative's unexpected death, or travel plans must be cancelled as a result of a break-in or destruction due to forces of nature at his/ her residence, the subsequent chaperone/faculty leader can be reimbursed for the certain transportation costs to join the group.

^*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.

Individual Monthly Rates

Individual Daily Rates

Individual Monthly Rates

Individual Daily Rates

Individual Monthly Rates

Individual Daily Rates

Individual Monthly Rates

Individual Daily Rates

New premium rates per insured person effective June 5, 2019 for eligible individuals whose applications are approved by the administrator. The administrator reserves the right to modify or replace these rates at any time.

Pricing is based on number of whole months plus remaining days
So July 1 to August 4 = 1 month 3 days
For your application, you would include one monthly rate and multiply the remaining daily rate times three (days).

Groups may also purchase a customizable long-term plan, for rates please contact us. U.S. J Visa participants must select $100,000 maximum limit or higher to satisfy the J Visa insurance requirements.

Eligibility:

To be eligible to apply to the Patriot Exchange Program plan, you must

• Be a participant: a student, scholar, intern, teacher or trainee enrolled in an educational or cultural exchange program for the purposes of teaching, study, research or receiving on the job training for a temporary period of time
• Be the spouse of a participant or children of a participant and residing outside his/her primary country of residence for a temporary period of time. Primary applicant must hold a J, M or F 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
• Not be hospitalized, disabled, pregnant or HIV+ on the initial effective date

Enrollment Process

Before you begin your travel, simply apply online or fill out the application and calculate the estimated premium for the time period you, your group, and/or your dependents will be traveling. Once you have completed the application, return it to us.

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 the administrator 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

Fulfillment Kits

The administrator processes applications in a quick, timely manner. Once processing is complete, they will mail and/or email the fulfillment kit(s) to the address/email listed in the application. The fulfillment kit(s) will include an identification card(s), and the insurance certificate providing a complete description of the rights and benefits under the contract. For your convenience, we will you this information and may also access it from the Client Center.

If you do not choose online fulfillment, we will mail your fulfillment materials. This may cause delays. We recommend online fulfillment for immediate access to your coverage information.

Conditions of Coverage

1) Coverage and benefits are subject to the deductible, limits and coinsurance, 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 is secondary 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.

Renewal of Coverage

Eligible insureds can request coverage under the plan be renewed monthly for up to 12 month periods, for a maximum of 48 continuous months, as long as the premium is paid when due and the insured continues to meet the eligibility requirements of the plan.

Precertification:

Certain treatment and supplies including hospital admission, inpatient or outpatient surgery, and other procedures as noted in the certificate wording must be precertified for medical necessity, which means the insured person or their attending physician must communicate with a representative at the number listed on the ID card prior to admission to a hospital before receiving certain treatments and supplies, or performance of a surgery. In case of an emergency admission, the precertification must be made within 48 hours of the admission, or as soon as reasonably possible. If a hospital admission or a surgery is not precertified, eligible claims and expenses will be reduced by 50%. It is important to note that precertification is only a determination of medical necessity, not an assurance of coverage, verification of benefits or a 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.

For Precertification, emergency evacuation and repatriation, please call: In the U.S.: 1.800.628.4664 (toll free) or 1.317.655.4500. Outside the U.S.: 001.317.655.4500 (collect if necessary). This information will also be provided on your ID card.

Note:You may begin the precertification process through Client Center. Simply look for the precertification option. You will be asked to provide the required information, which can then be submitted electronically. Once we have received all required information and medical records, our utilization management and review team will review the information provided and normally responds to the insured person or the provider within 2 business days. Please note that this online service will only initiate the process for treatment and supplies outlined in the contract, and it should not be used to request precertification for emergency admissions, procedures, or evacuations.

Claims Payment:

All benefits payable under Patriot Exchange Program are subject to the terms and conditions in the Certificate of Insurance. To make claim processing efficient, claims for eligible medical expenses may be paid in two ways:

1. Eligible expenses that have been paid by or on behalf of the insured person may reimbursed by check directly to the insured person.
2. Eligible expenses that have not yet been paid by the insured person may, at the option of the administrator, be paid either to the insured person or directly to the provider.

Claims must be presented to the administrator for payment within 180 days from the date the claim was incurred.

Claim forms can be accessed here and mailed to the address shown on the claim form. All contact numbers, claim forms and Certificate of Insurance are included in the fulfillment kit.

^*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.

FOR ADDITIONAL INFORMATION

Toll Free: +1 (866) INSUBUY
Phone: +1 (972) 985-4400
Fax: +1 (972) 767-4470
Website: www.insubuy.com

Version: CM00500679A190503
06/05/2019