Table of Contents Directory .................................................................................................................................................................................................. 1 Directory: medical services ......................................................................................................................................................... 1 Directory: vision services ............................................................................................................................................................. 4 Directory: prescription drug services ..................................................................................................................................... 5 Online services ................................................................................................................................................................................... 13 How to use this certificate of coverage ................................................................................................................................. 14 About UMP CDHP ............................................................................................................................................................................ 14 Features of UMP CDHP ............................................................................................................................................................. 14 Accumulators ..................................................................................................................................................................................... 15 Finding a health care provider ................................................................................................................................................... 15 Sample payments to different provider network status ............................................................................................ 17 How to find a preferred provider ......................................................................................................................................... 18 Covered and noncovered provider types ......................................................................................................................... 19 Primary care providers .............................................................................................................................................................. 19 When you do not have access to a preferred provider: network waiver ........................................................... 19 When and how to request a network waiver .................................................................................................................. 20 How an HSA works...................................................................................................................................................................... 21 Out-of-area services ................................................................................................................................................................... 21 Services received outside the United States ................................................................................................................... 23 What you pay for services ............................................................................................................................................................ 25 Deductible ....................................................................................................................................................................................... 25 Coinsurance .................................................................................................................................................................................... 27 When you pay ............................................................................................................................................................................... 27 Health savings account (HSA) ................................................................................................................................................ 27 Out-of-pocket limit ..................................................................................................................................................................... 28 Summary of services and payments ........................................................................................................................................ 29 Deductible and limits ................................................................................................................................................................. 31 Types of services .......................................................................................................................................................................... 31 What else you need to know .................................................................................................................................................. 34 Benefits: what the plan covers ................................................................................................................................................... 34 Guidelines for coverage ............................................................................................................................................................ 34 Health Technology Clinical Committee (HTCC) ............................................................................................................. 35 Summary of benefits .................................................................................................................................................................. 36 List of benefits ............................................................................................................................................................................... 39 Acupuncture .............................................................................................................................................................................. 39 8 2024 UMP CDHP (PEBB) Certificate of Coverage