Inter-Plan Programs: Federal or state taxes, surcharges, or fees Federal law or state law may require a surcharge, tax or other fee that applies to self-insured accounts. If applicable, any such surcharge, tax or other fee will be included as part of the claim fee passed on to the claimant. Out-of-network providers outside Regence’s service area Member liability When covered services are provided outside of Regence’s service area by out-of-network providers, the amount you pay for such services will generally be based on either the Host Blue’s out-of-network provider local payment or the pricing arrangements required by applicable state law. In these situations, you may be liable for the difference between the amount that the out-of-network provider bills and the payment Regence will make for the covered services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for nonparticipating emergency services. Exceptions In certain situations, Regence may use other payment bases such as billed covered charges, the payment Regence would make if the health care services had been obtained within Regence’s service area, or a special negotiated payment, as permitted under Inter-Plan Programs Policies, to determine the amount Regence will pay for services rendered by out-of-network providers. In these situations, you may be liable for the difference between the amount that the out-of-network provider bills and the payment Regence will make for the covered services as set forth in this paragraph. Services received outside the United States ALERT! The plan does not cover prescription drugs ordered through mail-order pharmacies located outside the U.S. See “Prescription drugs purchased outside the U.S.” on page 96 to learn more. Blue Cross Blue Shield Global® Core ALERT! Claims for services received outside the U.S. may take longer to process. UMP Customer Service is available to assist members with the Global® Core claim process. If you are outside the U.S., you may be able to take advantage of Blue Cross Blue Shield Global® Core when accessing covered health services. Blue Cross Blue Shield Global® Core is unlike the BlueCard® Program available in the U.S. in certain ways. For instance, although the Blue Cross Blue Shield Global® Core assists you with accessing a network of inpatient, outpatient, and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the U.S., you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical services (including locating a doctor or hospital) outside the U.S., you should call the service center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, 7 days a week. An assistance coordinator, working with a medical professional, will arrange a physician appointment or hospitalization, if necessary. 2024 UMP CDHP (PEBB) Certificate of Coverage 23