• When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of-network provider may be allowed to ask you to waive some of your balance billing protections. ALERT! Not all providers contracted with Regence are included in the core or support network. If you see a contracted provider with Regence who is not in the UMP Plus core or support network, those providers are considered out-of-network. Regence contracted providers cannot balance bill you. The UMP provider search includes the network status of all providers, including out-of-network providers. Be sure to confirm that your provider is in the core or support network to have the highest level of coverage. Out-of-network providers—are any providers who are not in the core or support network. Out-of- network providers may include providers who have a contract with Regence, but are not included in the core or support network. If you see one of these providers, they are considered out-of-network. The UMP Plus–Plus–UW Medicine ACN provider search directory includes core, support, and out-of-network providers. The status of the provider is displayed in the provider search directory. • You pay 50 percent of the allowed amount after you meet your medical deductible. The plan pays most covered services at 50 percent of the allowed amount. Note: The provider may bill you for charges above the allowed amount, which is known as balance billing. You pay all charges billed to you above the allowed amount. Any balance billed amounts do not apply to your out-of-pocket limit. At an out-of-network facility, when you receive emergency services you pay the network cost-sharing amount regardless of the network status of the provider or facility, and cannot be balance billed. • You pay 50 percent of the allowed amount for covered preventive care services, including covered preventive immunizations. You will pay all charges above the allowed amount (balance billing). The plan pays 50 percent of the allowed amount. • You pay $0 for flu shots and COVID-19 vaccines. • The plan pays 100 percent of the allowed amount for covered preventive childhood immunizations. • The 50 percent coinsurance you pay to out-of-network providers, and any balance billed amounts, do not apply to your medical deductible or out-of-pocket limit. • You may have to pay for services upfront and send the claim to the plan yourself. • The provider may not be familiar with UMP prescription drug guidelines and prescribe drugs subject to higher cost, or that the plan does not cover. Note: The plan may send payment for out-of-network services to you or the provider. ALERT! Some services and supplies are not covered by the plan or have benefit limits. If you receive services that are not covered by the plan or you exceed your benefit limit, you will pay for those services or supplies, even if you see a network provider. Contact UMP Customer Service to find out if a service or supply is covered. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 17