Network facilities Clinics and other outpatient facilities You pay 15 percent of the allowed amount for covered services at clinics and other outpatient facilities in the core network after you meet your deductible. Urgent care clinics: You pay 15 percent of the allowed amount when you see a provider at an urgent care clinic in the core or support network after you meet your deductible. Hospitals Inpatient services: You pay an inpatient copay of $200 per day, up to an annual maximum of $600 at hospitals in the core network. You pay 15 percent of the allowed amount for professional services after you meet your deductible. Outpatient services: You pay 15 percent of the allowed amount at hospitals in the core network after you meet your deductible. You may be balance billed at out-of-network hospitals. For emergency room visits, see the “Emergency room” benefit. Make sure the provider and the facility are in your network. When you see a network provider at a facility such as a clinic, confirm that the facility is also a network provider. Some providers are network providers at one location but not another. Contact UMP Customer Service if you have any questions about the network status of a provider at a specific location. Other services the plan pays at the network rate To search for a core network provider or a covered provider within the support network for the services listed in the table below, sign in to your Regence account and select Find a doctor. If you do not locate a provider, contact UMP Customer Service. If you do not sign in when using Find a doctor, you must select UMP Plus–UW Medicine ACN in the “Your Network” drop down box. This will ensure your search only yields providers that are paid at the network rate. The plan pays the services listed in the table below at the network rate. Covered service See page Applied Behavior Analysis (ABA) Therapy 43 Bariatric surgery (Contact UMP Customer Service to locate a network provider) 44 Emergency room 54 If your emergency room visit is determined to be a medical emergency, it will be paid at the network rate for both network and out-of-network facilities. Family planning services, voluntary pregnancy terminations 55 Gender affirming care 56 Inpatient services at children’s hospitals 61 Transplants 75 Urgent care 75 Out-of-network providers If you see a provider with Regence who is not in the core or support network, they are considered out-of- network. If you sign in to your Regence account and use the UMP Plus–UW Medicine ACN provider search tool, the results will only show you providers who are in your network unless you update the network filter to include out-of-network providers. Contact UMP Customer Service if you have questions about the network status of a provider. See Directory for link and contact information. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 21