When services received outside the U.S. are covered The plan covers the same benefits as described in this COC if the services received outside the U.S.: • Are appropriate for the condition being treated; • Are covered by the plan; • Are medically necessary; • Are not considered to be experimental or investigational by U.S. standards; and • Have met all medical policy criteria. Important tips for receiving care outside the U.S. • Always carry your UMP member ID card. • If you need emergency medical care, go to the nearest hospital. • If you need urgent medical care, contact the Blue Cross Blue Shield Global® Core Service Center for help finding a network provider. • If you are admitted to the hospital, contact the Blue Cross Blue Shield Global® Core Service Center to notify the plan of your admission. Blue Cross Blue Shield Global® Core contact and online information Contact Blue Cross Blue Shield Global® Core to learn about services received outside the U.S., find a provider outside the U.S., or submit a claim for medical care provided outside the U.S. • Call the Blue Cross Blue Shield Global® Core Service Center at 1-800-810-BLUE (2583), or call collect 1-804-673-1177 (available 24 hours a day, 7 days a week). • To use the online provider search tool, register and sign in on the Blue Cross Blue Shield Global® Core website at bcbsglobalcore.com. • 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 network 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 medical services Deductible A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying for covered services. Your medical deductible amount is $125 per member, with a maximum of $375 per family. When you first get services, you pay the first $125 in charges. After you pay that first $125, the plan begins to pay for covered services. This applies to each covered member, up to the $375 maximum. 28 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage