Out-of-Country Claim Forms

This form is for group plan members with out-of-country healthcare coverage. The type of out-of-country claim form you need to use depends on your policy plan number, which is available in your benefits plan booklet or from your plan administrator.

Does your group plan number fall between one of these number ranges?

• 56000 to 56300
• 56461 to 56599
• 250000 to 256499
• 330000 to 339999
• 340000 to 344999

Yes - My plan number falls between the policy ranges listed above.

No - My plan number is not included in the policy ranges listed above.

If you are unsure of which forms you should use, call our Out-of-Country Claims department at 1-800-957-9777.