Services not subject to your medical deductible The plan pays the allowed amount for the services listed below, subject to cost-share, even if you have not met your medical deductible. When you see a network provider, you do not have to meet your medical deductible before the plan pays for these services: • Covered contraceptive supplies and services (see the “Family planning services” benefit). • Covered preventive care, including covered immunizations. • Diabetes Control Program. • Diabetes Prevention Program. • Prescription drugs covered under the prescription drug benefit. • Routine hearing exams. • Hearing aids. • Routine vision care: exams, glasses, and contacts. • Second opinions required by the plan. • Tobacco cessation services. How your medical deductible works with dependents If your family has three or fewer members enrolled, your medical deductible amount is $125 per member, with a maximum of $375. Once a member pays their $125 deductible, the plan begins paying for covered services for that member. Because the plan is now paying for this member’s covered services, they are no longer contributing toward your family deductible. Once your family deductible has been met, the plan begins paying for all covered services. If your family has four or more members enrolled, each member has a medical deductible of $125 and the maximum the family pays toward medical deductibles is $375. Once a member pays their $125 deductible, the plan begins paying for covered services for that member. Because the plan is now paying for this member’s covered services, they are no longer contributing toward your family deductible. Once your family deductible has been met, the plan begins paying for all covered services for all enrolled family members, even if some have not met their own deductible. If the subscriber earned the SmartHealth wellness incentive for the 2024 plan year, the subscriber’s medical deductible is reduced. See the “If you earned the SmartHealth wellness incentive” section above to learn more. Note: Only services that are covered and are subject to your medical deductible count toward the deductible. See page 29 for a list of services that do not count toward your medical deductible. Coinsurance TIP: Allowed amount is the most the plan pays for a specific covered service or supply. Out-of- network providers may charge more than this amount, and you are responsible for paying the difference between the billed amount and the allowed amount. This is called balance billing. Coinsurance is the percentage of the allowed amount you pay for most medical services and for prescription drugs when the plan pays less than 100 percent. After you meet your medical deductible, you pay the percentages described below for most covered medical services. See the following sections for 30 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage