Welcome to GeoBlue®

Simplifying the international healthcare experience to keep you safe and healthy throughout your journey

2025-2026

Minnesota State Colleges and Universities

WELCOME

Embarking on a study abroad program is an exciting venture that gives students, faculty and staff a broader, more global view of the world. Your GeoBlue health insurance plan provides you access to global medical expertise with responsive, multi-channel service. Register on the GeoBlue mobile app or online through the Member Hub to learn about the extra care you receive when you travel with GeoBlue.

This pamphlet contains a brief summary of the features and benefits for insured participants covered under your school health insurance. This is not a contract of insurance. Coverage is provided under an insurance policy under which your school is a participating school. Coverage is provided under insurance policies issued by 4 Ever Life International Limited, Bermuda. Complete information on the insurance is contained in the Certificate of Insurance which is on file with the school and is made available to all insured participants. If there is a difference between this program description and the certificate wording, the certificate controls.

TO YOUR INSTITUTION’S

HEALTH PLAN

INTRODUCTION TO YOUR

HEALTH PLAN

Important plan information and health tools

ACCESSING CARE

How to receive care throughout your journey

SELF-SERVICE TOOLS

Convenient tools available on the GeoBlue mobile app and Member Hub

SUBMITTING A CLAIM

File a claim for reimbursement

REVIEWING PLAN BENEFITS

What is covered by your plan?

Need help? Email Use the contact form on the GeoBlue mobile app and Member Hub

PHONE

+1-610-263-2847We’re available to assist 24/7/365

Get your GeoBlue ID card

It is important to have your ID card available when receiving healthcare services. Your card can be accessed from multiple sources:

• A hardcopy ID card will be mailed to you

• You can obtain an electronic version of your ID card on the GeoBlue mobile app and Member Hub

• You can request a replacement ID card through the mobile app and Member Hub. You can also contact customer service for assistance in requesting a replacement ID card

When you receive your ID card, please check the information for accuracy. Contact customer service if you find any errors.Register on the GeoBlue mobile app or Member Hub to access important plan information

• Submit and track your claims

• Obtain electronic ID card

• Locate carefully selected, trusted providers and hospitals outside of the U.S

• Arrange Direct Pay to your provider

• Access global health and safety tools including medical translations, drug equivalents and news and safety information

To register, download the GeoBlue mobile app from the

Apple or Google Play app stores or visit the Member Hub on www.geobluestudents.com. After you register you can use your log in information for both the website and app.

INTRODUCTION TO

YOUR HEALTH PLAN

IMPORTANT PLAN INFORMATION AND HEALTH TOOLS

Your ID card

ID card images for illustration purposes only

ACCESSING CARE

FIND HEALTHCARE OUTSIDE THE U.S.

Find a Provider You have access to leading care through the

GeoBlue provider network. To find a contracted doctor or facility, select “Provider Finder” in the GeoBlue mobile app or visit the “Doctor and Facilities Finder” section in the Member

Hub on www.geobluestudents.com.

Scheduling an Appointment To schedule an appointment, choose a participating provider or hospital through the GeoBlue mobile app or Member Hub. Contact them directly using the information in their profile. After you make your appointment, contact us to provide the doctor’s office with the information required to arrange

Direct Pay. For optimal service, request Direct Pay at least 48 hours prior to your appointment. 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. If you need assistance with scheduling an appointment, submit a “Service Request” from the Tools & Services section on the Member Hub on www.geobluestudents.com.

Contact us for Direct Pay:

• Use the GeoBlue mobile app to search for a provider, view their profile and complete a request form

• Visit the Member Hub on www.geobluestudents.com

• Call GeoBlue at +1-610-254-8771

Global TeleMD™

We know it’s important to get the healthcare you need, when you need it. We’ve teamed up with Teladoc Health to bring you Global TeleMD, a telemedicine service that provides unlimited, 24/7/365 access to free doctor consultations by telephone or video. Doctors are available worldwide.

Prescriptions may also be provided, as appropriate

(subject to local regulations). To access Global

TeleMD, download the Global TeleMD app or select “Telehealth” then “Talk to a Doctor” in the GeoBlue mobile app.

Out-of-Network Providers If you receive care from an out-of-network provider, you may need to pay out of pocket and submit a claim for reimbursement. Click “How to File a Claim” in the Member Hub on www.geobluestudents.com to download the appropriate claim form. You can submit claims electronically using the GeoBlue mobile app or the Member Hub.

Prescription Benefits Present your ID card at any participating pharmacy, and you will be charged in accordance with your plan benefits.*

* Certain limitations and exclusions apply to your coverage under this plan and may affect your coverage. Your Certificate of

Coverage is on file with your institution and in the Member

Hub on www.geobluestudents.com.

Political and Natural Disaster Services Your plan includes political and natural disaster services. If you experience a political or natural disaster, please contact us immediately at +1-610-254-8771.

DEDICATED WELLNESS SUPPORT

GLOBAL WELLNESS ASSIST AVAILABLE 24/7/365

We offer a variety of emotional, practical and physical support services for you helping to make transitions more comfortable and assignments more successful.

Emotional Support

24/7/365 clinical intake, message and referral service

Harmony between academic and personal life

Managing anxiety, depression, stress and overall life changes

Surviving the loss of a loved one

Practical Support

Unlimited telephonic financial assistance from financial professionals

Telephonic or in-person legal assistance and consultation with attorneys

Managing academic or workplace pressure

Physical Support

Wellness coaching and support for wellness initiatives, including weight loss, fitness, nutrition, stress management and overall lifestyle improvement

Health risk assessment to obtain and assess individual and aggregate health data

Support in finding assistance with substance use

Global Wellness Assist Global Wellness Assist is an international employee assistance program (EAP) for students, faculty and staff traveling globally on behalf of an institution, providing access to six free confidential solution-focused counseling sessions. Professionals are ready to assist with any issue, anytime, any day.

SELECT

SELECT

To access Global Wellness Assist's services, download the GeoBlue mobile app or visit the "Wellness" section in the Member Hub on www.geobluestudents.com.

SELF-SERVICE

TOOLS

Our digital tools put access to global healthcare right in your hands! There is a wide range of information available to you on the GeoBlue mobile app or Member Hub, including:

Claims Submit and track the status of your claims.

Benefit Usage View your benefit history and past payments made toward your deductible and out-of-pocket/ coinsurance limits.

ID Card Obtain an electronic copy of your ID card and request replacements.

Telehealth Talk to a doctor through Global TeleMD and/or talk to a counselor through Global Wellness Assist—both services are free, and you do not need to leave your home.

Request Direct Pay Arrange direct payment for future appointments to secure cashless access to care outside of the U.S.

Provider Finder Review profiles of preferred doctors and hospitals to find the best match, view their contact details and locate the office.

Medical Translations Use the translation tool for common healthcare terms and phrases.

Medicine Equivalents Find country-specific equivalents for prescription and over-the-counter medications.

News and Safety Receive push notifications and alerts detailing the latest security and health issues based on your location. You can also view country or city profiles on crime, terrorism and natural disasters.

Download the app today!

Register on the GeoBlue mobile app or online through the Member Hub. Once registered, the login information will be the same whether using the app or online.

CLAIM

SUBMISSION

IF YOU NEED TO SUBMIT A CLAIM

FOR REIMBURSEMENT, YOU HAVE

THE FOLLOWING OPTIONS:

eClaims The quickest most convenient way to submit your claims is through the GeoBlue mobile app or Member Hub. Under

“Claims” you can chose to submit a claim through “File an eClaim” or “View My Claims” to see saved claims.

Email and Fax If you prefer to submit a claim via email or fax, a printable claim form and detailed instructions are available in the

Member Hub on www.geobluestudents.com.

Visit the “How to File a Claim” section of the Member

Hub and click “How do you file a claim with GeoBlue?”

to download the appropriate claim form.

Email: claims@geo-blue.com

Fax: 1-610-482-9623

Postal Mail If you prefer to submit a claim via postal mail, a printable claim form and detailed instructions are available in the Member

Hub on www.geobluestudents.com.

Visit the “How to File a Claim” section of the Member

Hub and click “How do you file a claim with GeoBlue?”

to download the appropriate claim form.

Mail to: GeoBlue Attn: Claims Dept PO Box 1748 Southeastern, PA 19399-1748 USA

Missing information on the claim form or supporting documentation may delay your claim reimbursement.

Follow these tips to speed up the claims reimbursement process:

If you mail or fax your claim(s) make sure your claim form is filled out completely, and don’t forget to sign it.

Fill out a separate form for each doctor or office visit.

Be sure to add a diagnosis or reason for treatment.

Provide a detailed description and amount charged for each service.

Clearly state how you’d like to be reimbursed.

Make and keep handy copies of your bills, receipts and claim forms.

Need to check the status of your claim?

No problem! Simply choose “Claims” in the GeoBlue app or visit the “Claims” section of the Member Hub.

If you are using the mobile app, you can elect to receive a push notification when your claim is processed.

For more help, visit the “Claims” section of the Member Hub.

Balance Billing: When a provider bills you for the difference between the provider’s charge and the amount your health insurance plan pays. Your normal deductible and coinsurance are not counted as balance billing.

Coinsurance: The percentage of your healthcare costs that is not paid by the health insurance plan. Therefore, it’s the percentage of the cost you are responsible for.

Coinsurance Maximum: The maximum amount of coinsurance a member pays during the policy year for covered expenses. Limitations may apply.

Copay or Copayment: The specific dollar amount you will pay at the time of service.

Claim: Documentation submitted for payment from a provider or you for medical services rendered.

Certificate of Coverage: It describes the benefit plan with specific conditions in which you and all eligible dependents have been enrolled (explains medical, dental, and vision coverage).

Coverage Period: The length of time that you are covered under a specific policy.

Deductible: An amount you are responsible to pay for eligible expenses before the health insurance plan begins to pay.

Direct Pay: The provider submits an invoice for payment directly to GeoBlue, instead of asking for payment from you up front. You may still be responsible for any deductible, coinsurance, or copays as defined on their health insurance contract.

Explanation of Benefits (EOB): An EOB is not a bill, but a summary of how your claims were processed and what you may owe. Your healthcare professional may bill you directly for the remainder of what you owe.

Guarantee of Payment (GOP): A legal document guaranteeing payment to a provider from GeoBlue based on specifically listed policy benefits on the document. This guarantee is based on your eligibility at the time of service. Also known as a

Direct Pay Letter.

Prescription (RX): An instruction written by a medical practitioner that authorizes you to be provided a medicine or treatment.

Performing Provider: The individual or group licensed to perform medical care that provided medical services to you.

Primary Care Physician (PCP): A physician who provides both the first contact for you with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis.

Premium: The specific amount of money you have to pay to the health insurance company each month in exchange for the health insurance company paying a portion of your healthcare costs.

Outpatient: When you receive care at a medical facility but are not admitted to the facility overnight or are at the facility for 24 hours or less.

Out-of-Network Provider: A medical provider who is not contracted with Blue Cross Blue Shield companies. This typically results in a higher coinsurance and may result in additional costs to you.

Out-of-Pocket Maximum: The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount.

Network: The facilities, providers, and suppliers your health insurance company contracts with to provide services at discounted rates. The network you would utilize is Blue Cross Blue Shield companies.

Medical Evacuation: The insurer will pay the medically necessary expenses incurred for you if you become ill or injured while traveling outside your home country for transportation to the closest location of adequate care. May also be referred to as “Medical Repatriation.”

Inpatient: When you receive care at a medical facility and are admitted overnight, or are at the facility for more than 24 hours.

GLOSSARY

of Important Terms and Phrases

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SCHEDULE OF BENEFITS

TABLE 1

Limits Individual Insured

Limits Spouse

Limits Dependent Child(ren)

MEDICAL EXPENSES

Coverage Year Limit $100,000 $100,000 $100,000 Coverage Year Deductible $0 per Coverage Year $0 per Coverage Year $0 per Coverage Year

EMERGENCY MEDICAL

EVACUATION

Maximum Benefit up to $250,000 per Coverage Year

Maximum Benefit up to $250,000 per Coverage Year

Maximum Benefit up to $250,000 per Coverage Year

EMERGENCY FAMILY

TRAVEL ARRANGEMENTS

Maximum Benefit up to $1,500 per Coverage Year

Maximum Benefit up to $1,500 per Coverage Year

Maximum Benefit up to $1,500 per Coverage Year

REPATRIATION OF MORTAL

REMAINS

Maximum Benefit up to $50,000 per Coverage Year

Maximum Benefit up to $50,000 per Coverage Year

Maximum Benefit up to $50,000 per Coverage Year

ACCIDENTAL DEATH &

DISMEMBERMENT

Maximum Benefit:

Principal Sum up to $10,000

Maximum Benefit:

Principal Sum up to $5,000

Maximum Benefit:

Principal Sum up to $1,000

POST DEPARTURE TRIP

INTERRUPTION

Transportation Benefit Deductible does not Apply. Maximum Benefit up to $1,500 per Coverage Year

Lodging & Incidentals Benefit Deductible does not Apply. Maximum Benefit up to $2,000 per Coverage Year and limited to $200 per day per for a Maximum of 10 calendar days.

TABLE 2

MEDICAL EXPENSE BENEFITS

COVERAGE A – MEDICAL EXPENSES Certificate Limits Physician Office Visits 100% of Reasonable Expenses Inpatient Hospital Services 100% of Reasonable Expenses Hospital and Physician Outpatient Services 100% of Reasonable Expenses Emergency Hospital Services 100% of Reasonable Expenses

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 Reasonable Expenses Inpatient treatment of mental and nervous disorders including substance abuse

Reasonable Expenses up to $2,500 Maximum per Coverage Year for a maximum period of 30 days per Coverage Year

Outpatient treatment of mental and nervous disorders including substance abuse Reasonable Expenses up to $500 Maximum per Coverage Year

Treatment of specified therapies, including acupuncture and Physiotherapy

Reasonable Expenses up to 20 visits per Coverage Year on an Outpatient basis

Annual cervical cytology screening for women 18 and older 100% of Reasonable Expenses Low dose mammography screening, one baseline mammogram and one mammogram per year 100% of Reasonable Expenses

Colorectal cancer screenings 100% of Reasonable Expenses Diabetic Supplies/Education 100% of Reasonable Expenses Prostate screening tests 100% of Reasonable Expenses Child Preventive and Primary Care Services 100% of Reasonable Expenses Breast Reconstruction due to Mastectomy 100% of Reasonable Expenses

Repairs to sound, natural teeth required due to an Injury 100% of Reasonable Expenses up to $500 per Coverage Year maximum

Outpatient prescription drugs including oral contraceptives and devices

100% of actual charge up to a maximum of $10,000 per Coverage Year, limited to a 31 day supply for initial fill or refill

PRE-EXISTING CONDITION LIMITATION

There is no limitation for Pre-Existing Conditions as defined under this Certificate

SECTION 9

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 amount 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, including routine care of a newborn infant, 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, eye glasses 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. Elective termination of pregnancy.

11. 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.

12. Expenses incurred for, or related to gender reassignment surgery.

13. Organ or tissue transplant.

14. Participating in an illegal occupation or committing or attempting to commit a felony.

15. 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.

16. Expenses incurred within the Covered Person’s Home Country.

17. The diagnosis or treatment of Congenital Conditions, except for a newborn child insured under the Certificate.

18. 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.

19. Expenses incurred in connection with weak, strained or flat feet, corns or calluses.

20. Diagnosis and treatment of acne.

21. Diagnosis and treatment of sleep disorders.

22. Expenses incurred for, or related to, services, treatment, education testing, or training related to learning disabilities or developmental delays.

23. Expenses incurred for the repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices.

24. Deviated nasal septum, including submucous resection and/or surgical correction, unless treatment is due to or arises from an Injury.

25. 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.

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 professional sport, contest or competition;

b. while participating in any practice or condition program for such sport, contest or competition;

c. SCUBA diving, sky diving, mountaineering (where ropes and climbing equipment are 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. Telephone, e-mail, and Internet consultations unless specifically approved by the Administrator due to limited resources while located in a country outside of the United States. This exclusion does not apply to services provided via GeoBlue’s Telemedicine Services and the Global TeleMDTM smartphone app.

33. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.

34. To the extent that such payments would be prohibited by law.

IMPORTANT CONTACT

INFORMATION

Contact us anytime, anywhere!

REACH US WORLDWIDE 24/7/365:

Collect calls outside the U.S.

+1-610-263-2847

Contact us through the GeoBlue mobile app or Member Hub

Telemedicine services are provided by Teladoc Health, directly to members. GeoBlue assumes no liability and accepts no responsibility for information provided by Teladoc Health and the performance of 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.

SCHL89944-MEM-8/23

This pamphlet contains a brief summary of the features and benefits for insured participants covered under your school health insurance. This is not a contract of insurance. Coverage is provided under an insurance policy under which your school is a participating school. Coverage is provided under insurance policies issued by 4

Ever Life International Limited, Bermuda. Complete information on the insurance is contained in the Certificate of Insurance which is on file with the school and is made available to all insured participants. If there is a difference between this program description and the certificate wording, the certificate controls.

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.

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.

Political Emergency and Natural Disaster Evacuation (PEND) services are provided under a contract with Crisis24. Full terms, conditions and exclusions are contained in the Crisis24 agreement. GeoBlue assumes no liability and accepts no responsibility for information provided by Crisis24 and the performance of the services by

Crisis24. Support and information provided through this service does not confirm that any related support is covered under a health plan.

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 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.