What you pay for medical services Deductible A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying for covered services. Your medical deductible amount is $125 per member, with a maximum of $375 per family. When you first get services, you pay the first $125 in charges. After you pay that first $125, the plan begins to pay for covered services. This applies to each covered member, up to the $375 maximum. Your medical deductible applies to all services unless otherwise stated in this COC. See below for services that are not subject to your medical deductible. Services apply to your UMP medical deductible in the order claims are received, not necessarily in the order the member receives the services. ALERT! If you receive services with a benefit limit (such as nutritional counseling) before meeting your medical deductible, those visits still apply to the benefit limit. For example, if you pay out of pocket for a nutritional counseling visit because you have not met your medical deductible, that visit will apply to the maximum of 12 visits per lifetime. See definition of “Limited benefit” for more information. If you earned the SmartHealth wellness incentive Eligible subscribers can qualify for a $125 reduction in their 2024 PEBB medical plan deductible. If you qualified in 2023 and you are still eligible to participate in the wellness incentive program, your medical deductible will be reduced by $125 in January 2024. More details on eligibility and program requirements are on HCA's SmartHealth webpage at hca.wa.gov/pebb-smarthealth. What does not count toward your medical deductible The following out-of-pocket expenses do not count toward your $125 medical deductible: • Charges for services that exceed the benefit limit. • Charges that exceed the maximum dollar limit. • Out-of-network provider charges above the allowed amount (see table on page 22). • Prescription drug costs. • Services that are not subject to your medical deductible, even if you had out-of-pocket costs. For example, covered preventive care received from an out-of-network provider. • Services you pay for that are not covered by the plan (see the “What the plan does not cover” section). • Your emergency room copay. • Your inpatient hospital copay. • Your chiropractor copay. • Your acupuncture copay. • Your massage therapy copay. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 29