more information on how much you pay for prescription drugs: “What you pay for prescription drugs,” “How the prescription drug cost-limit works,” “Your prescription drug out-of-pocket limit.” • For primary care providers in the core network: You pay nothing for office visits. You may pay 15 percent of the allowed amount for other services not considered preventive (see the “Preventive care” benefit) that you may receive (like labs and x-rays) during a primary care office visit after you meet your medical deductible. • For specialty providers in the core or support network: You pay 15 percent of the allowed amount after you meet your medical deductible. • For out-of-network providers: You pay 50 percent of the allowed amount after you meet your medical deductible and the provider may balance bill you, which means you will pay any amount an out-of-network provider bills that is above the allowed amount. Professional charges, such as for physician services while you are in the hospital or lab work, may be billed separately. Note: 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. At an out-of-network facility, when you receive emergency services you pay the network cost-sharing amount regardless of the network status of the provider or facility and cannot be balance billed. See descriptions of these provider types beginning on page 19. Visit the UMP Provider search to search a complete list of UMP Plus–PSHVN providers, including out-of-network providers. You can also confirm a provider’s network status by contacting UMP Customer Service. See the Directory for link and contact information. Copay A copay is a set dollar amount you pay when you receive treatments, supplies, or services including, but not limited to: • Emergency room copay: $75 per visit. See the “Emergency room” benefit for details. • Facility charges for services received while an inpatient at a hospital, or mental health, skilled nursing, or substance use disorder facility: $200 per day (see “Inpatient copay” below). • Covered chiropractic, acupuncture, and massage services when you see a network provider will have a $15 copay per visit. The copay for these services will apply toward the annual out-of-pocket maximums. See the “Spinal and extremity manipulations” benefit, “Acupuncture” benefit, and “Massage therapy” benefit for more details. Inpatient copay The inpatient copay of $200 per day is what you pay for inpatient services at a network facility, such as a hospital, or mental health, skilled nursing, or substance use disorder facility. You and your enrolled dependents pay up to $600 maximum per enrolled member per calendar year. The inpatient copay does not apply to your medical deductible but does apply to your medical out-of- pocket limit. Note: Professional charges, such as lab work or provider services, while you are in the hospital may be billed separately and are not included in this copay. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 31