Get access to health care around the world. Blue Shield and UC help expats, their families, and travelers access health care abroad

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1 Get access to health care around the world Blue Shield and UC help expats, their families, and travelers access health care abroad Effective January 1, 2015

2 A plan for your personal state of health Get access to health care when traveling or living outside the United States under the BlueCard Program.

3 What s inside Understanding the BlueCard Program, how to 02 find providers, and checklist before you travel Benefits for Non-Medicare plans 04 Benefits for Medicare plans 06 Fill your prescriptions before you travel 08 Tips for reimbursement 09 International coverage

4 Understanding the BlueCard program Access to covered services for nearly 50,000 contracted healthcare providers in over 200 countries and territories. Visit for more information. While you are not required to use a BlueCard provider when you travel, the BlueCard Program provides access to covered services for nearly 50,000 contracted healthcare providers in over 200 countries and territories. And it s convenient. You can call the BlueCard Worldwide Service Center toll-free at (800) 810-BLUE (2583) or collect at (804) , 24 hours a day, seven days a week. 02 Blue Shield of California

5 Find a provider before you travel BlueCard also has a website that offers valuable resources for members. The advanced search option lets you find the information you need in advance of travel. Here is how: Enter the alpha prefix (first three letters) of the ID# shown on your Blue Shield member ID card at If you do not have your ID card handy, use the table below to determine your plan s alpha prefix. Select what you are looking for (provider, pharmacist, and more). Enter your travel destination or the city closest to your destination. View your results. Click on a result to view details of specialties, languages spoken, and more. Blue Shield medical plan Core Plan Health Savings Plan (HSP) UC Care Plan High Option Supplement Plan Medicare PPO plan (with Rx) Medicare PPO plan (without Rx) (BUC) Not finding the provider you need? Other providers may be available to you. Call the BlueCard Worldwide Service Center tollfree at (800) 810-BLUE (2583) or collect at (804) if you are unable to find a suitable provider. While you are not required to use a BlueCard provider when you travel, it s in your best interest to do so to keep your costs down. You can locate a BlueCard provider anytime by calling toll-free (800) 810-BLUE (2583) from within the United States. If you re already outside the country, you can call collect at (804) or visit BlueCard alpha prefix BUC BUC UCY BUC BUC BUC Check list before you travel Know the location of the nearest doctor or hospital by visiting Know what services are covered. Consult your Benefit Booklet. Fill your prescription. See page 8 for details. Bring your Blue Shield member ID card. The BlueCard Worldwide Service Center phone number is on your ID card. While overseas, be prepared to make payment at the time of service and make sure you get an itemized record. Keep your BlueCard Worldwide Service Center phone number with you. visit blueshieldca.com/uc 03

6 Non-Medicare plan benefits that travel with you Live or travel outside the United States and still be covered for the same medical services Did you know? You must live inside the United States to enroll in the Health Savings Plan (HSP), and when you travel outside of the country, you are covered only for emergency and urgent care. However, you may use the available funds in your HSA to pay for eligible health care expenses not covered by the plan. As a member enrolled in the UC Care or Core plan, you can live or travel outside the United States and still be covered for the same medical services as members living in the United States. Call BlueCard Worldwide Service Center from anywhere in the world. From within the United States, call toll-free (800) 810-BLUE (2583), 24/7. If you re outside the country, call collect at (804) Blue Shield of California

7 This chart can help you understand the medical coverage you have abroad. Non-Medicare plans Benefit UC Care Core Plan Health Savings Plan Patient responsibility is 20% of the costs 1 of covered services after deductible. Patient responsibility is 20% of the costs 1 of covered services after deductible. Some of the services covered: Some of the services covered: Medical services outside the United States Physician office visits Specialist office visits Preventive health benefits Pregnancy and maternity care benefits Outpatient X-ray, pathology, and laboratory Hospital care (outpatient surgery in hospital) Emergency room services Acupuncture benefits 1 Chiropractic benefits 1 Rehabilitation (physical and occupational therapy) Physician office visits Specialist office visits Preventive health benefits Pregnancy and maternity care benefits Outpatient X-ray, pathology, and laboratory Hospital care (outpatient surgery in hospital) Emergency room services Acupuncture benefits 1 Chiropractic benefits 1 Rehabilitation (physical and occupational therapy) Patient responsibility is 20% of the costs 2 of covered urgent and emergency services after deductible. You may use available funds from your health savings account to pay for your deductible and any other eligible out-of-pocket healthcare expenses. 4 Plan deductible $250 per individual or $750 per family coverage $3,000 per individual $1,300 for individual coverage $2,600 for family coverage 3 Prescription drug coverage Prescriptions from a foreign pharmacy will be reimbursed at the full cost 2 of the medication, less any applicable plan copayment. Prescriptions from a foreign pharmacy will be reimbursed at the full cost 2 of the medication, less any applicable plan copayment. Patient responsibility is 20% of the costs 2 of covered urgent and emergency medications after deductible. You may use available funds from your health savings account to pay for for your deductible and any other eligible out-of-pocket healthcare expenses. 4 1 Please consult your plan contract for a detailed description of coverage benefits and limitations. 2 The cost is the total amount paid by the patient for the covered service or prescription drug. 3 For family coverage, the full family deductible must be met before the enrollee or covered dependents can receive benefits for covered services. Family coverage includes Employee + Spouse/Domestic Partner/Adult Dependent Relative, Employee + Child(ren) and Employee + Family 4 Non-emergency and non-urgent services will not be covered under the plan, but you may use the available funds in your HSA to pay for these and other eligible healthcare expenses. visit blueshieldca.com/uc 05

8 Medicare benefits travel with you Medicare retirees: Living or traveling abroad for up to six months or longer? visit Medicare retirees have access to health services when traveling or living outside the United States for up to six months. Medicare retirees who travel or live outside the United States for more than six months will need to call the UC Retirement Administration Service Center (RASC) toll-free at (800) (in the United States) or (510) (from outside the United States) from 8:30 a.m. to 4:30 p.m. PT, Monday through Friday, or visit 06 Blue Shield of California

9 Did you know? As a member enrolled in the High Option Supplement to Medicare or the Medicare PPO plan (with and without Rx) when traveling outside the United States for up to six months, you have access to coverage for the same covered services as you do in the United States. Here is a partial list of some of the services covered: Physician office visits Specialist office visits Preventive health benefits Outpatient X-ray, pathology, and laboratory Hospital care (outpatient surgery in hospital) Emergency room services Acupuncture benefits* Chiropractic benefits* Rehabilitation (physical and occupational therapy) * Please consult your plan contract for a detailed description of coverage benefits and limitations. This chart can help you understand the medical coverage you have abroad. Medicare plans Benefit High Option Supplement to Medicare plan Medicare PPO plan (with Rx) Medicare PPO plan (without Rx) Medical services outside the United States Patient responsibility is 20% of the costs 1 of covered services after deductible. Patient responsibility is 20% of the costs 1 of covered services after deductible. Patient responsibility is 20% of the costs 1 of covered services after deductible. Plan deductible $50 per individual $100 per individual $100 per individual Prescription drug coverage Prescriptions from a foreign pharmacy will be reimbursed at the full cost 1 of the medication, less any applicable plan copayment. Prescriptions from a foreign pharmacy will be reimbursed at the full cost 1 of the medication, less any applicable plan copayment. Not covered 1 The cost is the total amount paid by the patient for the covered service. This is only a brief overview of benefits and is not a contract. For a detailed description of plan benefits and exclusions, please reference your Benefit Booklet or Evidence of Coverage. To request copies of these documents, contact Shield Concierge from 7 a.m. to 7 p.m. PT, Monday through Friday: Non-Medicare and Medicare PPO plan members call toll-free at (855) ; UC Care plan members call toll-free at (855) Or, visit visit blueshieldca.com/uc 07

10 Fill your prescriptions before you travel M If you take prescription medicine, make sure you have enough to last the duration of your journey. If you need to fill a prescription early, contact Blue Shield at least five (5) business days prior to your travel and request a vacation override. Members who take certain medications may be able to receive up to a 90-day vacation supply with prior authorization. The request must be made close to your vacation departure date. If a supply greater than 90 days is needed, contact your Shield Concierge team. Visit blueshieldca.com/uc or contact your dedicated Shield Concierge team from 7 a.m. to 7 p.m. PT, Monday through Friday: Non-Medicare and Medicare PPO plan members call toll-free at (855) ; UC Care plan members call toll-free at (855) Blue Shield of California

11 Tips for reimbursement Be prepared to make payment at the time of service and to submit a claim for reimbursement. How to obtain eligible claims reimbursement from Blue Shield Download the UC International Claim Form by following the steps below: For the UC Care plan: Go to uc-care.org/tools-resources/forms. For the Core plan, High Option Supplement to Medicare, and Medicare PPO plans (with and without Rx): Go to blueshieldca.com/uc and select Forms. For the Health Savings Plan: Go to blueshieldca.com/uc and select Forms. To use funds from your Health Savings Account for reimbursement, visit healthequity.com/ed/uc. On the form, be sure to include: Diagnosis Description of service(s), provider name and address, country where services were rendered Itemized bill (date, description, and charge for each service billed) Billed amounts in foreign currency or U.S. dollars Proof of payment such as a credit card receipt Medical reports in English, including ambulance trip report, emergency room report, admitting history, surgical procedure, etc.v TIP: Ask your provider for copies of your/your family member s medical records before you leave. Request documentation in English, if possible, or get the forms translated to English before submitting your claim. There are several online translation services such as and that you can use. Universities, consulates, and embassies also offer translation assistance. For inpatient stay, attach an itemized list of ALL charges. Submit the completed UC International Claim Form with all supporting documentation to: Blue Shield of California Attn: International Claims P.O. Box Chico, CA If you need assistance, you can call BlueCard Worldwide Service Center from anywhere in the world. From within the United States, call toll-free (800) 810-BLUE (2583) 24 hours a day, seven days a week. If you re already outside the country, call collect at (804) visit blueshieldca.com/uc 09

12 Visit blueshieldca.com/uc or contact your dedicated Shield Concierge team from 7 a.m. to 7 p.m. PT, Monday through Friday: Non-Medicare and Medicare PPO plan members call toll-free at (855) ; UC Care plan members call toll-free at (855) To learn more about the HSA, contact HealthEquity toll-free at (866) , 24 hours a day, 7 days a week or visit healthequity.com/ed/uc. Member confidentiality Blue Shield protects the confidentiality and privacy of your personal and health information, including medical information and individually identifiable information such as your name, address, telephone number, and Social Security number. To ensure this, Blue Shield requires a signed authorization form for you to access health information for your spouse or dependents over the age of 18. To request an authorization form, go to blueshieldca.com/uc and select Forms. Then, scroll down to Other Forms and click on Authorization of Release of Personal Health Information. If you don t have access to the Internet, or have questions about how Blue Shield protects your privacy and confidentiality, please call our Privacy Office directly toll-free at (888) Blue Shield of California is an independent member of the Blue Shield Association A46607-UC-INTERNATIONAL (10/14)

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