Deductible and limits Deductible Dollar amounts What else you need to know For more and limits information, see page(s) Deductible $1,600 per member (maximum of You must meet your deductible 25–27 $3,200 for a family of two or before the plan pays for covered more) Combined deductible for medical services and covered medical services and prescription prescription drugs. Not all drugs. services count toward this See page 28 if you earned the deductible. There is no SmartHealth wellness incentive in deductible for covered insulins. 2023 for plan year 2024. Out-of-pocket $4,200 per member (maximum of Your deductible and all 28–29 limit $8,400 for a family of two or coinsurance for all covered more) Combined out-of-pocket medical services and covered limit for medical services and prescription drugs paid to prescription drugs. preferred providers count toward Once a member meets $7,000 in this limit. Once you meet your covered out-of-pocket expenses out-of-pocket limit, covered annually, the plan will pay for services paid to preferred covered services at 100 percent providers are paid at 100% of the for that member. allowed amount. Health savings To confirm the maximum annual You may pay for any qualified 27 account (HSA) contribution, visit the medical expenses from your HSA, IRS website at including: irs.gov/government- • Services that apply to your entities/federal-state-local- deductible. governments/where-can-i-learn- • Services that are not covered more-about-health-savings- by the plan but are still accounts-hsa-and-health- qualified medical expenses. reimbursement-arrangements- hra Annual plan None No limit to how much the plan Not applicable payment limit pays per calendar year. Lifetime plan None No limit to how much the plan Not applicable payment limit pays over a lifetime. Types of services The table in this section describes how much you and the plan will pay for covered services. Unless otherwise noted, all payments are based on the allowed amount, and services are subject to the deductible. Unless stated otherwise, services received are subject to your deductible. See the “Deductible” section for more information about deductibles. 2024 UMP CDHP (PEBB) Certificate of Coverage 31