Deductible and limits Deductible Dollar amounts What else you need to know For more and limits information, see page(s) Medical $125 per member You must meet your medical deductible 29–30 deductible (maximum of $375 before the plan pays for covered medical for a family of three services. Not all services count toward or more) this deductible. See page 29 if you earned the SmartHealth wellness incentive in 2023 for plan year 2024. Prescription None This plan does not have a prescription Not applicable drug drug deductible. deductible Medical out- $2,000 per member Your medical deductible and all 32–33 of-pocket limit (maximum of $4,000 coinsurance and copays for covered for a family of two or services paid to network providers count more) toward this limit. Once you meet your medical out-of-pocket limit, covered services paid to network providers are paid at 100% of the allowed amount. Prescription $2,000 per member Your prescription drug coinsurance 93 drug out-of- (maximum of $4,000 counts toward this limit. pocket limit for a family of two or more) Annual plan None No limit to how much the plan pays per Not applicable payment limit calendar year. Lifetime plan None No limit to how much the plan pays over Not applicable payment limit a lifetime. Types of services The table in this section describes how much you and the plan will pay for covered services. Unless otherwise noted, all payments are based on the allowed amount, and services are subject to your medical deductible. See the “What you pay for medical services” section for more information about your deductible. Type of How much you pay for covered services How much the plan pays for service covered services Primary • Primary care providers (PCPs) in the core • Primary care providers (PCPs) in care network: You pay $0; the plan pays in full the core network: The plan pays services when you see your PCP. See page 19 for the 100% for office visits. Other list of provider types that are considered services you receive during a PCPs. Other services you receive during a primary care office visit may be primary care office visit may be covered covered under the standard under the standard benefit described below. benefit described below. 34 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage