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. Services not subject to your medical deductible The plan pays the allowed amount for the services listed below, subject to cost-share, even if you have not met your medical deductible. When you see a network provider, you do not have to meet your medical deductible before the plan pays for these services: • Covered contraceptive supplies and services (see the “Family planning services” benefit). • Covered preventive care, including covered immunizations. • Diabetes Control Program. • Diabetes Prevention Program. • Prescription drugs covered under the prescription drug benefit. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 29