• For out-of-network providers who are within the Regence BlueShield service area and not contracted with Regence BlueShield, the amount Regence has determined to be reasonable charges for covered services and supplies is the allowed amount. The allowed amount may be based upon the billed charges for some services, as determined by Regence or as otherwise required by law. If a provider is not in the network, as described above, but has a contract with Regence, the allowed amount is based on the negotiated rate. • For out-of-network providers accessed through the BlueCard® Program, the allowed amount is the lower of the provider’s billed charges and the amount that the other Blue plan identifies as the amount on which it would base a payment to that provider. Under the BlueCard® Program, when you access covered services within the geographic area served by a Host Blue, Regence BlueShield will remain responsible for fulfilling contractual obligations. However, the Host Blue is responsible for contracting with and generally handling all interactions with its network providers. Whenever you access covered services outside Regence BlueShield’s service area and the claim is processed through the BlueCard® Program, the amount you pay for covered services is calculated based on the lower of: • The covered billed charges for your covered services; or • The negotiated price that the Host Blue makes available to Regence. Often, this negotiated price will be a simple discount that reflects an actual price that the Host Blue pays to your health care provider. Sometimes, it is an estimated price that considers special arrangements with your health care provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of health care providers after considering the same types of transactions as with an estimated price. Estimated pricing and average pricing, going forward, also consider adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above. However, such adjustments will not affect the price Regence uses for your claim because they will not be applied retroactively to claims already paid. Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, Regence BlueShield would then calculate your liability for any covered services according to applicable law. Charges more than the allowed amount are not reimbursable. For questions regarding the basis for determination of the allowed amount, contact UMP Customer Service. Allowed amount, prescription drugs The allowed amount for prescription drugs is based on WSRxS’ contractually agreed reimbursement, unless other contractual arrangements or terms apply. All covered prescription drug claims are paid based on this allowed amount. Ambulatory surgery center (ASC) An ambulatory surgery center (ASC) is a health care facility that specializes in providing surgery, pain management, and certain diagnostic services in an outpatient setting. ASC-qualified procedures are typically more complex than those done in a doctor’s office but not so complex as to require an overnight stay. Procedures commonly performed in these centers include colonoscopies, endoscopies, cataract 170 2024 UMP CDHP (PEBB) Certificate of Coverage