Out-of-pocket limit The out-of-pocket limit is the most you pay during a calendar year for covered medical services and prescription drugs before the plan pays 100 percent of the allowed amount to preferred providers and network pharmacies. This limit does not include your premium, balance-billed charges, or services the plan does not cover. For this plan, the limit is $4,200 for one member enrolled in the plan, or $8,400 if there are two or more members enrolled in the plan. However, no one member may exceed $7,000 in covered out-of-pocket expenses annually. Once the out-of-pocket limit has been reached, the plan pays 100 percent of the allowed amount for covered medical services from preferred providers and 100 percent of the allowed amount for covered prescription drugs and products for the rest of the calendar year. See page 28 for what does and does not apply to this limit. Your deductible does apply to this limit. Outpatient rate The plan’s outpatient rate depends on the provider’s status: • Preferred providers: You pay 15 percent of the allowed amount after you meet your deductible. The plan pays 85 percent of the allowed amount. • Participating providers: You pay 40 percent of the allowed amount after you meet your deductible. The plan pays 60 percent of the allowed amount. • Out-of-network providers: You pay 40 percent of the allowed amount after you meet your deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The plan pays 60 percent of the allowed amount. Outpatient surgery center See the “Ambulatory surgery center (ASC)” definition. Outward Bound An international network of outdoor education organizations whose aim is to foster the personal growth and social skills of participants by using challenging expeditions in the outdoors. Over-the-counter alternative An over-the-counter alternative is a drug that you may buy without a prescription that has similar safety, efficacy, and ingredients as a prescription drug. Over-the-counter drugs Over-the-counter drugs are medications you may get without a prescription. Over-the-counter equivalent An over-the-counter equivalent is a drug you may buy without a prescription that has identical active ingredients and strengths as a prescription drug or product in a comparable dosage form. P&T Committee See the “Pharmacy & Therapeutics (P&T) Committee” definition. 184 2024 UMP CDHP (PEBB) Certificate of Coverage