Your Guide to GeoBlue Expat

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1 New York University Abu Dhabi Your Guide to GeoBlue Expat Welcome to GeoBlue, a program designed to keep you safe and healthy as you travel the world. Your GeoBlue Expat health insurance plan features a full range of personal solutions, including concierge-level services and convenient online and mobile self-service tools available on com. Register online to learn about the extra care you receive when you travel with GeoBlue. Please note, services provided in the United Arab Emirates are covered by Green Crescent. For more information about your coverage in the UAE please visit Register online to learn more about your benefits. Visit to register and access important plan information: Print a temporary ID card Review plan benefits Locate Blue Cross and Blue Shield providers and hospitals within the U.S. Locate trusted providers and hospitals outside of the U.S. and UAE You can also register through the GeoBlue app. Need help with registration? Visit how-to.geo-blue.com to watch the member tutorial video, or contact us: Inside the U.S.: Outside the U.S.: Get your GeoBlue ID card. It is important to have your GeoBlue ID card to access healthcare services; you will need to present your ID card whenever you receive medical care outside the UAE. This card can be accessed from multiple sources: GeoBlue ID card(s) will be mailed to you. A temporary ID card is available in the Member Hub. Customer Service can provide replacement ID cards. You can show, fax or your ID card through the GeoBlue app. When you receive your card, please check the information on your ID card for accuracy. Call Customer Service if you find an error on your card. Download the GeoBlue app. Download the GeoBlue app and login with the address and password you created when you registered on the website. If you have not previously registered, you can register directly through the app. The GeoBlue app provides you with the most convenient access to your ID card and GeoBlue s self-service tools. GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association. Made available in cooperation with Empire BlueCross BlueShield.

2 Medical Care Inside the U.S. Finding care inside the U.S.: GeoBlue members have access to the Blue Cross and Blue Shield network within the U.S., Puerto Rico, and U.S. Virgin Islands. To find a doctor or facility, visit the Find Doctors and Hospitals in the U.S. section in the Member Hub on or in the GeoBlue app. Contact us for assistance: Toll free within the U.S.: Outside the U.S.: Scheduling an appointment with a Blue Cross and Blue Shield provider: Call the provider to confirm they are in network and schedule your appointment. You will need to show the provider your GeoBlue ID card at the time of service. Using an out-of-network provider: If you receive care from an Out-of-Network provider, you may need to pay out of pocket and submit a claim for reimbursement. Submit claims electronically using the GeoBlue app or the Filing eclaims link on the Member Hub at In the event of a medical emergency: Members should go immediately to the nearest physician or hospital and then call GeoBlue at the phone number for 24/7 Medical Assistance located on the back of your ID card. Prescription benefits inside of the U.S.: Present your ID card at any participating pharmacy and you will be charged in accordance with your plan benefits.* Medical Care Outside the U.S. and UAE Locating a doctor or facility outside the U.S. and UAE: To find a contracted doctor or facility, visit the Find Doctors and Hospitals Outside the U.S. and UAE section in the Member Hub on or in the GeoBlue app. If you go to a contracted provider and contact GeoBlue to arrange for Direct Pay before your appointment, you will not need to pay out of pocket for treatment. Outside of the U.S. and UAE you are free to see any provider you choose without a reduction of benefits. Accessing care and arranging Direct Pay with participating providers outside the U.S. and UAE: To avoid paying up front for medical care and submitting a claim, schedule an appointment by: Calling GeoBlue at ing Using or the GeoBlue downloadable app to find a provider, view a profile and complete a request form If you prefer to make your own appointment, contact GeoBlue with as much notice as possible typically at least 24 hours prior to your appointment to request Direct Pay. Members are required to pay any applicable co-payments, coinsurance or deductibles at the time of service. Making your own appointment outside the U.S. and UAE? If you make your own appointment, contact GeoBlue (with as much notice as possible) to provide the doctor s office with the information required to arrange Direct Pay. This is necessary when scheduling follow-up appointments as well. In many countries providers require payment at the time of the visit unless Direct Pay has been arranged. Contact us to arrange for Direct Pay: Use the GeoBlue app, select the provider and submit a request for Direct Pay Only, Appointment Already Scheduled Call Collect: Toll Free Inside the U.S.: Prescription benefits outside of the U.S.: Utilize the international mail order process to fill your prescription, or pay for your prescription and complete and submit a claim form for reimbursement. *Certain limitations and exclusions apply to your coverage under this plan and may affect your coverage. Your Certificate of Insurance is on file with your Human Resources Department and in the Member Hub on GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association. Made available in cooperation with Empire BlueCross BlueShield.

3 GeoBlue provides you with an indispensable set of Personal Solutions. Call or us to enlist help with: Appointment Scheduling with Direct Pay outside the U.S. and UAE Request a convenient, cashless office visit with one of GeoBlue s trusted English-speaking doctors. Contact 24/7: Chronic Care and Maternity Support Let GeoBlue line up the best local resources outside the U.S. and UAE to manage cancer, heart disease, sports injuries, behavioral conditions and maternity. Contact 24/7: Informed Choice Consultation Understand your local, regional or international treatment options for serious unexpected medical problems that occur outside the U.S. and UAE. Then let GeoBlue help you put a plan into action. Contact 24/7: Global Employee Assistance Program* For confidential assistance with any school, work, life, personal or family issue, you can talk to professional counselors for in-the-moment support and information about local resources all around the world. Available any day, any time, contact: Inside the U.S.: Outside the U.S.: Global Wellness* Set your baseline by taking the Health Assessment and then work to improve your wellness via a one-on-one telephone relationship with a Wellness Coach or by using one of the online programs from the Mayo Clinic to address issues related to fitness, weight, smoking and stress. Check out the smart, timely advice on the best ways to manage diet and exercise around the world at Travel Well ( To contact a Wellness Coach: Inside the U.S.: Outside the U.S.: * Services are provided by WorkPlace Options, an independent company that is not affiliated with GeoBlue and does not provide Blue Cross or Blue Shield products or services. WorkPlace Options is solely responsible for referring participants for counseling, coaching and work-life services by providers who are appropriately licensed by local authorities. The evaluation and efficacy of any service delivered by a provider lies solely with the employee, spouse, dependent or other authorized party who inquires on behalf of the participant. GeoBlue shall have no responsibility or liability whatsoever for any aspect of the provider counseling or the counselor/participant relationship. Visit or download the GeoBlue app to access these self-service tools for navigating risks and finding the best care options: Check your symptoms* Translate symptoms into action with this authoritative triage tool. You can decide to seek treatment in an emergency room, schedule a doctor visit or employ home remedies. Find a doctor and schedule an appointment outside the U.S. and UAE Review detailed profiles of contracted doctors to find the best match and then locate the office. In order to avoid paying up-front for your medical care and having to submit a claim for reimbursement, schedule your appointment through GeoBlue. Translate medical terms Convert symptoms, diagnoses and treatment plans into the twelve most common languages. Understand health and security risks Receive daily alerts detailing the latest security and health issues in your destination. Dig into country or city-level profiles on crime, terrorism and natural disasters. Translate medications Find country-specific equivalents for prescriptions and over-the-counter medications. *Available on geo-blue.com only. GeoBlue is the trade name of Worldwide Insurance Services, LLC, an independent licensee of the Blue Cross and Blue Shield Association. Made available in cooperation with Empire BlueCross BlueShield.

4 Submitting a Claim If you are seeking reimbursement for covered services, you can quickly and conveniently submit claims electronically, using the GeoBlue app or the Filing eclaims link on the Member Hub at Scanned paper documents are delivered directly to our Claims Department, and your eclaims are saved in your Member Profile. Please visit to submit claims incurred in the UAE. If you prefer to submit a claim via , fax or postal mail, a printable claim form is available in the Member Hub on Fax: Postal Mail: GeoBlue, Attn: Claims, One Radnor Corporate Center, Suite 100, Radnor, PA If a physician, ambulance company or other provider sends their bill directly to you, or you pay the medical provider at the time of service, you will need to complete and submit a Claim Form. The Claim Form was developed for you to notify us of any covered health services for which we have not already been billed. Please read the following instructions about how to report health care services. Following these instructions will expedite the payment of your claim. 1. Complete the claim form. Answer all questions, even if the answer is none or N/A. Be certain that the name on the bill you are submitting is the same as that which is indicated on your ID card. If not, please enclose a short note of explanation. A signature is required on all claim forms. 2. Attach the provider bill/documentation to the claim form and follow the instructions on the back of the form for submission to GeoBlue. Bills must be itemized: Canceled checks, cash register receipts and non-itemized balance due statements cannot be processed. Each itemized bill must include: name and address of provider (doctor, hospital, laboratory, ambulance service, etc.), name of patient, date(s) of service, amount charged for each service, total charge, diagnosis or reason for treatment. Outpatient Prescription Drugs: duplicate pharmacy generated receipts (not register tape) must include Rx number; date filled, medication name, form, strength and quantity. (NOTE: All prescription drug charges will be reimbursed to the insured person only.) 3. Additional Information If submitting expenses for more than one family member, please use a SEPARATE claim form for each person. All claims should be filed with our office within the six (6) month period from the date of the incurred expense. If you have questions regarding the completion of this claim form, please contact Customer Service. To check your claim status, visit Claims in the Member Hub on Contact Information For questions about your medical plan: Toll free within the U.S.: Outside the U.S.: For medical assistance (including Direct Pay outside the U.S. and UAE): Toll free within the U.S.: Collect Calls Accepted: One Radnor Corporate Center Suite 100, Radnor PA GeoBlue

5 OVERVIEW MATRIX MEDICAL EXPENSES Lifetime Maximum Benefit Deductible Payment Level One Accidental Death and Dismemberment Limits Outside the U.S. Unlimited $0 per Insured Person per Policy Year the Usual and Customary Fee Limits U.S., In Network the Usual and Customary Fee Maximum Benefit: Principal Sum up to $25,000 Repatriation of Remains Maximum Benefit up to $100,000 Medical Evacuation Maximum Lifetime Benefit for all Evacuations up to $250,000 Limits U.S., Out-of-Network The Insurer will pay 100% of the Usual and Up to a maximum benefit of $5,000 for the cost of one economy round-trip air fare ticket Bedside Visit to, and the hotel accommodations in, the place of the Hospital Confinement for one (1) person *GeoBlue reserves the right to change underwriters (licensed by BCBSA) and to modify benefits to comply with state and federal regulations.

6 SCHEDULE OF BENEFITS (Subject to Maximums, Coinsurance, and Deductibles in Overview Matrix) Benefits Outside the U.S. U.S., In Network U.S., Out-of-Network Preventive Care Services Provided by a Physician or Provider Copayments and Deductible apply if applicable, unless specifically noted Physician Office Visits Surgical Care Medical Care Emergency Care Other Physician services Services and Supplies Provided by a Hospital Copayments and Deductible apply if applicable Inpatient Hospital Care Outpatient Hospital Care Emergency Care 1 Other Services and Special Conditions Copayments and Deductible apply if applicable, unless specifically noted Ambulance Transportation Ambulatory Surgical Facility Dental Care for an Accidental Injury Maternity Mental Illnesses Inpatient Treatment Serious Mental Illness Outpatient Treatment Mental Illness Outpatient Treatment Substance Abuse rehabilitation Inpatient Treatment 100% of Covered Expenses up to $500 per Policy Year and limited to $100 per tooth

7 Benefits Outside the U.S. U.S., In Network U.S., Out-of-Network Substance Abuse rehabilitation Outpatient Treatment Chiropractic Care Limited to 15 visits per Policy Year Physical/Occupational/Speech Therapy/Medicine Limited to 15 visits per Policy Year Infusion Therapy/Radiation Therapy/Chemotherapy Human Organ Transplants Home Health Care Limited to 40 visits per Policy Year Pharmacy Benefits 1. Generic Drugs 100% of actual charge 2. Brand name Drugs 100% of actual charge 3. Injectables 100% of actual charge Hearing Services No Deductible. 100% of Covered Expenses per Policy Year up to a maximum of $500 for Hearing Services that are not the result of an Injury or Illness. In addition, for a Covered Person who is a Dependent Child under age 24, 100% of Covered Expenses up to a maximum of $1,000 per Hearing Aid every three years International Employee Assistance Program Up to 5 telephonic sessions per case with a professional counselor and work/life support International EAP benefits.

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