The intent of this type of COB is to maintain the level of benefits available through UMP. The nonduplication of benefits type of coordination is not designed to pay your covered expenses in full. When UMP pays second, it coordinates with these types of plans: • Governmental programs including, but not limited to, Medicare and Medicaid. • Group, blanket, or franchise health or disability insurance policies; health care service contractor and health maintenance organization group agreements issued by insurers; health care service contractors; and health maintenance organizations. • Labor management trusteed plans, labor organization plans, employer plans, or employee benefit organization plans. ALERT! If you have other primary coverage that pays for services, those services will apply to the UMP benefit limit. How much you may pay when UMP pays second When you see network providers under UMP, you will owe only the balance of the UMP allowed amount after your primary plan and UMP pay benefits for covered services. Your cost will usually be higher if you see out-of-network providers. See the “Sample payments to different provider network status” section on page on page 22 for examples. The examples in the table below assume that you have met your medical deductible. Situation Example Network UMP UMP Other UMP You pay provider allowed normal plan pays your charge amount benefit pays provider UMP is EXAMPLE 1: $200 $100 $85 N/A $85 $15 primary, When UMP (85% of other plan pays first (or $100) is is the only secondary plan) UMP is EXAMPLE 2: $200 $100 $85 $80 $5 $15 secondary, The other other plan plan pays is primary less than the normal UMP benefit UMP is EXAMPLE 3: $200 $100 $85 $85 $0 $15 secondary, The other other plan plan pays as is primary much as (or more than) the normal UMP benefit Contact UMP Customer Service for help with any questions if you are covered by more than one plan. 120 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage