• Visit the Blue Cross Blue Shield Global® Core website on the Blue Cross Blue Shield Global® Core website at bcbsglobalcore.com. After you create an account, you may find Blue Cross Blue Shield Global® Core information, get an international claim form, and submit claims electronically. Finding a preferred provider outside the U.S. Under Blue Cross Blue Shield Global® Core, you have access to network providers outside the U.S., including hospital care (inpatient and outpatient) and professional provider services at network rates. To find a contracted provider outside the U.S., register and sign in on the Blue Cross Blue Shield Global® Core website at bcbsglobalcore.com or call the Blue Cross Blue Shield Global® Core Service Center: 1-800-810-BLUE (2583) or collect at 1-804-673-1177. What you pay for services Deductible A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying for covered services. The deductible is combined for medical services and prescription drugs. Your deductible amount depends on the number of people enrolled in your plan: • For subscriber only (one member) it is $1,600; • For subscriber plus one or more dependents (two or more members), it is $3,200. Your deductible applies to all services, including prescription drugs paid by the member directly or paid on behalf of the member by another person including payments made through a manufacturer drug coupon or other manufacturer discount, unless otherwise stated in this COC. See below for services that are not subject to your deductible. Services apply to your UMP deductible in the order claims are received, not necessarily in the order the member receives the services. ALERT! If you receive services with a benefit limit (such as nutritional counseling) before meeting your deductible, those visits still apply to the benefit limit. For example, if you pay out of pocket for a nutritional counseling visit because you have not met your deductible, that visit will apply to the maximum of 12 visits per lifetime. See definition of “Limited benefit” for more information. What does not count toward your deductible The following out-of-pocket expenses do not count toward your deductible: • Charges for services that exceed the benefit limit. • Charges that exceed the maximum dollar limit. • Out-of-network provider charges above the allowed amount (see the “Sample payments to different provider network status” section). • Out-of-pocket costs for services that are not subject to your deductible, except when you pay for covered insulins. For example, covered preventive care received from an out-of-network provider. • Services you pay for that are not covered by the plan (see the “What the plan does not cover” section). 2024 UMP CDHP (PEBB) Certificate of Coverage 25