Summary of Benefits and Coverage

Effective July 1, 2018

The ISEP benefit program requires that you have two identification cards –the ASRM, LLC. - Sirius America Medical Insurance ID Card and the On Call International Medical Evacuation, Repatriation and Global Assistance ID Card.

The ISEP benefit program through ASRM, LLC. - Sirius America and On Call International provides the following benefits (note that those who are only enrolled in the On Call program only have benefits for items five through seven):

1-The basic medical expense benefit pays 100 percent of covered accident and sickness expenses up to US$25,000; subject to a US$50 deductible per policy year;

2-Once the basic medical expense benefit has been exhausted, the supplemental major medical benefit pays 80 percent of covered accident and sickness expenses until the covered person has paid US$5,000 out‐of‐pocket (20% co-insurance + per policy year deductible);

3-After the maximum out‐of-pocket amount under the supplemental major medical benefit has been met, the plan pays 100 percent of covered accident and sickness expenses under the catastrophic major medical benefit;

4-Accidental death, dismemberment and loss of sight;

5-Medical evacuation;

6-Repatriation of remains (in the event of death);

7-On Call International Assistance for 24‐hour worldwide medical and travel assistance.

Other Benefit Information

On Call International Assistance is only valid for emergencies that occur outside the United States. If you need assistance within the U.S., please contact ASRM, LLC.

A unique component of a covered person’s ISEP plan is the On Call International Assistance worldwide medical and travel assistance. This assistance includes referrals to doctors or hospitals, coordination of payment with the provider, and assistance with lost prescriptions or travel documents. Multilingual services are available.

To access these services contact On Call International Assistance directly. When a covered person calls, they will need to provide their name, the specific number assigned to the group (ISEP’s group ID is G800303A), the covered person’s school name and a brief description of the covered person’s problem.

What’s Not Covered

 Expenses incurred within the Covered Person’s home country or country of regular domicile.

 Treatment or services provided by any member of the Covered Person’s immediate family; or for which no charge is normally made.

 Routine physical examinations and routine testing; preventive testing or Treatment; screening examinations or testing in the absence of Injury or Sickness except as otherwise provided for under the policy. ISEP 7-1-18

 Dental care or Treatment other than care of sound, natural teeth and gums required due to an Injury resulting from an Accident while the Covered Person is insured under the policy, and rendered within 12 months of the Accident. Except for pediatric dental care.

 Eye examinations; prescriptions or fitting of eyeglasses and contact lenses; eyeglasses, contact lenses or other Treatment for visual defects and problems, except as required as a result of a covered Injury. “Visual defects” means any physical defect of the eye that does or can impair normal vision. Except for pediatric vision care.

 Hearing examinations or hearing aids; or other Treatment for hearing defects and problems, except as required as a result of a covered Injury. “Hearing defects” means any physical defect of the ear that does or can impair normal hearing.

 Routine foot care, including the Treatment of corns, calluses and bunions.

 Treatment of congenital anomalies and conditions arising or resulting directly there from.

 The diagnosis and Treatment of acne.

 Cosmetic surgery, except cosmetic surgery which the Covered Person needs as the result of an Accident which happens while the Covered Person is insured under the policy or reconstructive surgery needed as a result of a congenital disease or abnormality of a covered newborn dependent child which has resulted in a functional defect.

 The diagnosis and Treatment of infertility.

 War or any act of war, declared or undeclared; or while serving in the armed forces of any country (a pro-rata premium will be refunded for such period of service).

 Participation in a riot or civil disorder; fighting or brawling, except in self-defense; commission of or attempt to commit a felony.

 Suicide, attempted suicide or intentionally self-inflicted Injury while sane or insane. Applies to Accidental Death and Dismemberment Benefit only.

 Skydiving, parachuting, hang gliding, glider flying, parasailing, sail planing, bungee jumping, or flight in any type of aircraft, except while riding as a fare-paying passenger on a regularly-scheduled airline.

 Treatment that is not incurred by an Insured Person while insured here under.

 Charges used to meet any deductible, or in excess of the coinsurance level, or in excess of those considered Usual, Customary, and Reasonable Charges.

 Rest cures or custodial care (whether or not prescribed by a Physician), or transportation.

Benefits for Dependents

Benefits for dependents are the same as those described above, except for the accidental death, dismemberment and loss of sight benefits. Please see the brochure for benefit details.

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