Table of Contents Directory .................................................................................................................................................................................................. 1 Directory: medical services ......................................................................................................................................................... 1 Directory: vision services ............................................................................................................................................................. 4 Directory: prescription drug services ..................................................................................................................................... 6 Online services ................................................................................................................................................................................... 13 How to use this certificate of coverage ................................................................................................................................. 14 About UMP Plus ................................................................................................................................................................................ 14 UMP Plus: High-quality care at a lower cost ................................................................................................................... 14 Accumulators ..................................................................................................................................................................................... 15 Finding a health care provider ................................................................................................................................................... 15 UMP Plus–PSHVN ........................................................................................................................................................................ 15 Covered and noncovered provider types ......................................................................................................................... 19 Core network primary care providers ................................................................................................................................. 19 Core network specialty providers ......................................................................................................................................... 20 Support network providers ..................................................................................................................................................... 20 Network facilities ......................................................................................................................................................................... 21 Out-of-network providers ....................................................................................................................................................... 21 How much you will pay ............................................................................................................................................................. 22 Network consent for out-of-network services ............................................................................................................... 23 Services received outside the service area ....................................................................................................................... 24 Out-of-area services ................................................................................................................................................................... 25 Services received outside the United States ................................................................................................................... 27 What you pay for medical services .......................................................................................................................................... 29 Deductible ....................................................................................................................................................................................... 29 Coinsurance .................................................................................................................................................................................... 30 Copay ................................................................................................................................................................................................ 31 When you pay ............................................................................................................................................................................... 32 Medical out-of-pocket limit .................................................................................................................................................... 32 Summary of services and payments ........................................................................................................................................ 33 Deductible and limits ................................................................................................................................................................. 34 Types of services .......................................................................................................................................................................... 34 What else you need to know .................................................................................................................................................. 37 Benefits: what the plan covers ................................................................................................................................................... 37 Guidelines for coverage ............................................................................................................................................................ 37 Health Technology Clinical Committee (HTCC) ............................................................................................................. 38 8 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage