Type of In Washington State In the U.S. (except Outside the U.S. service Washington State) Emergency You pay 15% of the You pay 15% of the You pay 15% of the room (ER) allowed amount* allowed amount* allowed amount See “Emergency room” benefit for details. Urgent care You pay 15% of the You pay 15% of the You pay 15% of the See “Urgent allowed amount for allowed amount for allowed amount for care” benefit network providers and 50% network providers and 50% network providers and 50% for details. of the allowed amount for of the allowed amount for of the allowed amount for out-of-network providers.* out-of-network providers.* out-of-network providers. Most other You pay 15% of the You pay 50% of the You pay 50% of the services allowed amount for allowed amount.* allowed amount. network providers and 50% of the allowed amount for out-of-network providers.* * When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of-network provider may be allowed to ask you to waive some of your balance billing protections. Out-of-area services Regence BlueShield has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements”. These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association. Whenever you access health care services outside of the geographic area Regence BlueShield services, the claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described below. When You receive care outside of Regence BlueShield’s service Area, you may receive it from Providers as described below. Providers contracted with the local Blue Cross and/or Blue Shield Licensee in that geographic area ("Host Blue") as a preferred provider are paid at the preferred provider level and will not bill you for balances beyond any deductible, copayment and/or coinsurance for covered services. Providers that contract with the Host Blue as a participating provider are paid at the out-of-network provider level and will bill you for balances beyond any deductible, copayment and/or coinsurance for covered services. Some providers (out of network providers) don't contract with the Host Blue. The section below explains how the Plan pays these different kinds of providers. BlueCard® Program Under the BlueCard® Program, when you access covered services within the geographic area served by a Host Blue, Regence will remain responsible for doing what was agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its preferred or participating providers. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 25