Member Quick Guide

Your institution provides access to an international health plan from GeoBlue®. You can self-enroll online using a credit card.
Visit the Resource Center on www.geobluestudents.com and enter your self-enrollment code listed below to review plan
details and pricing.

Program Name: Western Michigan University

Policy Year: Aug. 28, 2024-Aug 27, 2025
Self-Enrollment Code: VLN-59113
Link: http://ogse.geobluestudents.com/?ac=VLN-59113

Accessing Care

What do I do in the event of a medical emergency?

If you have an emergency, dial 911 or go to the closest emergency room immediately. If you’re not sure whether your
situation is an emergency, dial 911 and let the call-taker determine if you need emergency help.

Need to speak to a doctor?

We’ve teamed up with Teladoc Health to bring you Global TeleMDTM, a telemedicine smartphone app at no additional cost, that provides
unlimited, 24/7/365 access to doctor consultations by telephone or video. Doctors are available worldwide. You can access Global TeleMD
via the GeoBlue mobile app.

How can I find a provider if I do not want to use telemedicine?

Search for participating healthcare professionals or facilities via the provider directory on the Member Hub at www.geobluestudents.com
or through the GeoBlue mobile app. You can view physician profiles to see if they are in the Blue Cross Blue Shield® network and contact
them directly to schedule an appointment. At the time of service, you will need to show the provider your GeoBlue ID card to confirm you
are covered by Blue Cross and Blue Shield. Depending on your coverage you may be responsible for a copayment, coinsurance, and/or
deductible before a service is completed.

Want to speak to a counselor?

Try Global Wellness Assist. Global Wellness Assist is an assistance program for those traveling globally on behalf of a college or university,
providing access to free, confidential assistance any time, any day. You can access Global Wellness Assist via the GeoBlue mobile app.

Using an out-of-network provider

This typically results in a higher coinsurance and may result in additional costs to you. If you receive care from an out-of-network provider, you may
need to pay out-of-pocket and submit a claim for reimbursement.

Prescription Benefits
Present your ID card at any participating pharmacy and you will be charged in accordance with your plan benefits.*
 Using Your Plan
1 Register for the GeoBlue Member Hub or mobile app
We encourage you to register for the Member Hub or mobile app for convenient access to a wide range of tools and services. Once
you are enrolled with GeoBlue, you will receive a welcome email that contains all the information needed for your registration. The
app is available from the Apple App Store or Google Play.
• Access your Certificate of Insurance for details on your benefits
• Access your GeoBlue ID card
• Print a verification of health insurance letter for your visa appointment
• Locate Blue Cross and Blue Shield providers and hospitals inside of the U.S.
• Access global health and safety tools including translations, medicine equivalents guide, news and safety information
• Submit and track claims
You can register online at www.geobluestudents.com or through the mobile app.

2 Locate your digital 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. This card can be accessed from multiple sources:
• Your ID card is available in the Member Hub on www.geobluestudents.com or on the mobile app
• You can display or email your ID card through the app

3 Submit claims
Submit claims electronically through the app or through the Member Hub on www.geobluestudents.com. If you prefer to submit a
claim via postal mail, click “How to File Claims” in the Member Hub to download the appropriate claim form.

Questions? W
 e’re here for you 24/7/365 at 1-844-268-2686 (inside the U.S.) +1-610-263-2847 (outside the U.S.)

*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 school
and in the Member Hub on www.geobluestudents.com.

Apple and iTunes are trademarks of Apple Inc., registered in the U.S. and other countries. Google Play and the Google Play logo are trademarks of Google Inc.

 elemedicine services are provided by Teladoc Health, directly to members. GeoBlue assumes no liability and accepts no responsibility for information provided by
T
Teladoc Health andthe performance the services by Teladoc Health. Support and information provided through this service does not confirm that any related treatment
or additional support is covered under a member’s health plan. This service is not intended to be used for emergency or urgent treatment medical questions.

 lobal Wellness Assist services are provided by WorkPlace Options, an independent company that is not affiliated with GeoBlue and does not provide Blue Cross
G
or Blue Shield products or services. WorkPlace Options is solely responsible for referring participants for counseling, coaching and work-life services and health
assessments 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 those or other participants. GeoBlue shall have no responsibility or liability
whatsoever for any aspect of the provider counseling, coaching, work-life services and health assessments or other similar services, or the counselor/participant
relationship.

GeoBlue is the trade name of Worldwide Insurance Services, LLC (Worldwide Services Insurance Agency, LLC
in California and New York), an independent licensee of the Blue Cross and Blue Shield Association. GeoBlue
is the administrator of coverage provided under insurance policies issued in the District of Columbia by 4 Ever
Life International Limited, Bermuda, an independent licensee of the Blue Cross Blue Shield Association. This
coverage is offered to the members of the Global Citizens Association, Washington, D.C.

SCHL2309-MEM-3/22
 SCHEDULE OF BENEFITS
TABLE 1
Limits Limits Limits
Individual Insured Spouse Dependent Child(ren)
MEDICAL EXPENSES
Coverage Year Limit Unlimited Unlimited Unlimited
Coverage Year Deductible $0 per Coverage Year $0 per Coverage Year $0 per Coverage Year
After the Covered Person reaches a After the Covered Person reaches a After the Covered Person reaches a
$6,500 Out-of-pocket Limit per $6,500 Out-of-pocket Limit per $6,500 Out-of-pocket Limit per
Coverage Year Out-of-Pocket Limit Coverage Year, the Insurer pays the Coverage Year, the Insurer pays the Coverage Year, the Insurer pays the
The most You pay during a Plan Year Allowed Amount at 100% and up to Allowed Amount at 100% and up to Allowed Amount at 100% and up to
in Cost-Sharing before We begin to the applicable maximums in the the applicable maximums in the the applicable maximums in the
pay 100% of the Allowed Amount for Tables 2 and 3. Deductibles, Tables 2 and 3. Deductibles, Tables 2 and 3. Deductibles,
Covered Services, subject to the limits Copayments, Prescription Drug Copayments, Prescription Drug Copayments, Prescription Drug
and provisions of this Certificate Copayments and amounts above the Copayments and amounts above the Copayments and amounts above the
maximums do not apply toward the maximums do not apply toward the maximums do not apply toward the
Out-of-pocket Limit. Out-of-pocket Limit. Out-of-pocket Limit.
EMERGENCY TRANSPORTATION SERVICES
Maximum Benefit up to $250,000 per Maximum Benefit up to $250,000 per Maximum Benefit up to $250,000 per
Emergency Medical Evacuation
Coverage Year Coverage Year Coverage Year
Emergency Family Travel Maximum Benefit up to $1,500 per Maximum Benefit up to $1,500 per Maximum Benefit up to $1,500 per
Arrangements Coverage Year Coverage Year Coverage Year
Maximum Benefit up to $100,000 per Maximum Benefit up to $100,000 per Maximum Benefit up to $100,000 per
Repatriation of Mortal Remains
Coverage Year Coverage Year Coverage Year
OTHER COVERAGES
Accidental Death & Maximum Benefit: Principal Sum up Maximum Benefit: Principal Sum up Maximum Benefit: Principal Sum up
Dismemberment to $10,000 to $5,000 to $1,000

SCHEDULE OF BENEFITS
TABLE 2
MEDICAL EXPENSE BENEFITS
MEDICAL EXPENSES Participating Provider+ Non-Participating Provider
Physician Office Visits* 100% of the Allowed Amount 70% of the Allowed Amount
Treatment at an Urgent Care Facility 100% of the Allowed Amount 70% of the Allowed Amount
Hospital and Physician Outpatient Services 100% of the Allowed Amount 70% of the Allowed Amount
Inpatient Hospital Services 100% of the Allowed Amount 70% of the Allowed Amount
Emergency Hospital Services 100% of the Allowed Amount 70% of the Allowed Amount
+Payment of Covered Medical Expenses for Participating Providers is based on the Allowed Amount. Participating Providers have agreed to accept the Allowed Amount as
payment in full.
*All Physician Visit Copayments and Deductibles for an Injury or Sickness are waived for treatment received at Recognized Student Health Center.

If a Covered Person requires emergency treatment of an Injury or Sickness and incurs covered expenses at a non-Preferred Provider, Covered Medical Expenses for
the Emergency Medical Care rendered during the course of the emergency will be treated as if they had been incurred at a Preferred Provider.

If a Covered Person incurs Covered Medical Expenses for services or supplies that are not of the type provided by any Preferred Provider, these Covered Medical
Expenses will be treated as if they had been incurred at a Preferred Provider.

SCHEDULE OF BENEFITS
TABLE 3
MEDICAL EXPENSE BENEFITS

The benefits listed below are subject to coverage maximums, Deductible, Coinsurance, and Copayments listed in Tables 1 & 2 above.

MEDICAL EXPENSES Covered Person

Maternity Care for a Covered Pregnancy Allowed Amount
Complications of Pregnancy Allowed Amount
Inpatient treatment of mental and nervous disorders including substance Reasonable Expenses up to $10,000 Maximum per Coverage Year for a
abuse maximum period of 30 days per Coverage Year.
Outpatient treatment of mental and nervous disorders including Reasonable Expenses up to $5,000 Maximum per Coverage Year for a
substance abuse maximum period of 30 visits per Coverage Year.
Treatment of specified therapies, including acupuncture and
Allowed Amount up to 20 visits per Coverage Year on an Outpatient basis.
Physiotherapy
Routine Preventive Care Services Allowed Amount up to a Coverage Year Maximum of $1,000
Annual cervical cytology screening for women 18 and older Allowed Amount
Low dose mammography screening, one baseline mammogram and one
Allowed Amount
mammogram per year
Colorectal cancer screenings Allowed Amount
Diabetic Supplies/Education Allowed Amount
Prostate screening tests Allowed Amount
Child Preventive and Primary Care Services Allowed Amount
Breast Reconstruction due to Mastectomy Allowed Amount
Repairs to sound, natural teeth required due to an Injury Allowed Amount up to $500 per Coverage Year maximum
Outpatient prescription drugs including oral contraceptives and devices 100% of the Allowed Amount. Limited to a 31-day supply for initial fill or refill.

SECTION 7
PRE-EXISTING CONDITION LIMITATION
There is no limitation for Pre-Existing Conditions as defined under this Certificate.
 SECTION 8
GENERAL CERTIFICATE EXCLUSIONS
Unless specifically provided for elsewhere under the Certificate, the Certificate does not cover loss caused by or resulting from, nor is any premium charged for, any of
the following:

1. Expenses incurred in excess of Reasonable Expenses.

2. Services or supplies that the Insurer considers to be Experimental or Investigative.
3. Expenses incurred prior to the beginning of the current Period of Coverage or after the end of the current Period of Coverage except as described
in Covered General Medical Expenses and Limitations and Extension of Benefits.
4. Preventative medicines, routine physical examinations, or any other examination where there are no objective indications of impairment in normal
health, unless otherwise noted.
5. Services and supplies not Medically Necessary for the diagnosis or treatment of a Sickness or Injury, unless otherwise noted.
6. Surgery for the correction of refractive error and services and prescriptions for eye examinations, eyeglasses or contact lenses or hearing aids,
except when Medically Necessary for the Treatment of an Injury.
7. Cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat
psychological symptomatology or psychosocial complaints related to one’s appearance.
8. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, except as specifically provided for in the Certificate.
9. Expenses incurred for elective treatment or elective surgery except as specifically provided elsewhere in the Certificate and performed while the
Certificate is in effect.
10. For diagnostic investigation or medical treatment for reproductive services, infertility, fertility, or for male or female voluntary sterilization
procedures, or the reversal male or female voluntary sterilization procedures.
11. Expenses incurred for, or related to, sex change surgery.
12. Organ or tissue transplant.
13. Participating in an illegal occupation or committing or attempting to commit a felony.
14. While traveling against the advice of a Physician, while on a waiting list for a specific treatment, or when traveling for the purpose of obtaining
medical treatment.
15. The diagnosis or treatment of Congenital Conditions, except for a newborn child insured under the Certificate.
16. Expenses incurred within the Covered Person’s Home Country.
17. Treatment to the teeth, gums, jaw or structures directly supporting the teeth, including surgical extraction’s of teeth, TMJ dysfunction or skeletal
irregularities of one or both jaws including orthognathia and mandibular retrognathia, unless otherwise noted.
18. Expenses incurred in connection with weak, strained or flat feet, corns or calluses.
19. Diagnosis and treatment of acne.
20. Diagnosis and treatment of sleep disorders.
21. Expenses incurred for, or related to, services, treatment, education testing, or training related to learning disabilities or developmental delays.
22. Expenses incurred for the repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices.
23. Deviated nasal septum, including submucous resection and/or surgical correction, unless treatment is due to or arises from an Injury.
24. Expenses incurred for any services rendered by a family member or a Covered Person’s immediate family or a person who lives in the Covered
Person’s home.
25. Unless specifically provided for elsewhere under the Certificate, the cost of treatment or services that are provided normally without charge by
the Member’s Student Health Center, covered or provided by the student health fee, rendered by a person employed by the Member, including
team Doctor and trainers or any other service performed at no cost.
26. Loss due to an act of war; service in the armed forces of any country or international authority and Participation in a Riot or Civil Commotion.
27. Riding in any aircraft, except as a passenger on a regularly scheduled airline or charter flight.
28. Loss arising from:
a. participating in any intercollegiate/interscholastic or professional sports, contest or competition;
b. participating in any club sport competition, contest or competition;
c. Racing or speed contests;
d. SCUBA diving, sky diving, mountaineering (where ropes or other climbing gear is customarily used), ultra-light aircraft, parasailing,
sailplaning/gliders, hang gliding, parachuting, or bungee jumping.
29. Medical Treatment Benefits provision for loss due to or arising from a motor vehicle Accident if the Covered Person operated the vehicle without
a proper license in the jurisdiction where the Accident occurred.
30. Under the Accidental Death and Dismemberment provision, for loss of life or dismemberment for or arising from an Accident in the Covered
Person’s Home Country.
31. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an
outpatient basis.
32. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
33. Routine hearing tests except as provided under Preventive and Primary Care.
34. Expense covered under any Other Plan.
35. To the extent that such payments would be prohibited by law.