• Your coinsurance paid to preferred and participating providers • Your coinsurance paid to out-of-network providers for emergency room services, air ambulance, and nonemergency services furnished during a visit or stay at a preferred and participating hospital, hospital outpatient department, critical access hospital, or ambulatory surgical center. • Your deductible paid to preferred and participating providers • Your copay for chiropractic, acupuncture, and massage therapy visits after you meet your deductible What does not count toward this limit A. Amounts paid by the plan, including services covered in full B. Your monthly premiums C. Your coinsurance paid to out-of-network providers (except those listed above in “What counts toward this limit”) D. Balance billed amounts E. Amounts paid for services the plan does not cover (see the “What the plan does not cover” section) F. Amounts that are more than the maximum dollar amount paid by the plan. Any amount you pay over the allowed amount does not count toward the out-of-pocket limit. G. Amounts paid for services over a benefit limit. For example, the benefit limit for acupuncture is 24 visits. If you have more than 24 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit. What you pay after reaching this limit After you meet your out-of-pocket limit for the year, you pay: • $0 of the allowed amount for covered medical services from preferred providers and for covered drugs at network pharmacies. • B through G (above) in the “What does not count toward this limit” section. • 40% of the allowed amount for covered medical services for participating providers. • 40% of the allowed amount for covered medical services for out-of-network providers. You may be balance billed. Summary of services and payments ALERT! Even if a provider orders a test or prescribes a treatment, the plan may not cover it. Review this COC or contact UMP Customer Service if you have questions about benefits or limitations. On the next several pages, you will find a summary of types of services and what you will pay for them. For a complete understanding of how a benefit works, read the pages listed in the “For more information” column. All services must be medically necessary to be covered. If you see an unfamiliar term, see the alphabetical list of definitions in the “Definitions” section. 2024 UMP CDHP (PEBB) Certificate of Coverage 29