Benefit/service How much you will pay For information, see page(s): Vision hardware, Special rate: 79 adults (age 19 or • No medical deductible older) • Lenses and frames: You pay $0 of the allowed (Lenses, frames, or amount for one pair of covered standard lenses contact lenses) and frames once every two calendar years; or • Contact lenses: Plan pays up to $150 every two calendar years in lieu of lenses and frames. You pay a $30 fitting fee for contact lenses Vision hardware, Special rate: 83 children (under age • No medical deductible. 19) • Lenses and frames: You pay $0 of the allowed (Lenses, frames, or amount for one pair of covered standard frames contact lenses) and lenses once per year; or • Contact lenses: You pay $0 of the allowed amount for a one-year supply in lieu of lenses and frames. There is no fitting fee. Note: For services requiring preauthorization or plan notification, see the list of services on the UMP Policies that affect your care webpage or contact UMP Customer Service (see Directory for link and contact information). Many services require both preauthorization and plan notification. See the “Limits on plan coverage” section for how this works. List of benefits Acupuncture The plan covers up to 24 visits for acupuncture treatment per calendar year (see definition of “Limited benefit”). You pay the special rate (a $15 copay) for acupuncture when you see a network provider. The copay will not apply toward your medical deductible, but the copay will apply to the out-of-pocket limit. All visits will apply to the 24-visit limit You may receive an office visit at the time of the acupuncture service (see the “Office visits” benefit for details). Not all acupuncture services are covered. See the “What the plan does not cover” section for more information. Note: For out-of-network providers, services are paid at the standard rate up to 24 visits per calendar year. Ambulance Ambulance services for personal or convenience purposes are not covered. Ground ambulance You pay 20 percent of the allowed amount for medically necessary ambulance services. Professional ground ambulance services are covered in a medical emergency: • From the site of the medical emergency to the nearest facility equipped to treat the medical emergency. • From one facility to the nearest other facility equipped to provide treatment for your condition. 42 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage