Type of How much you pay for covered services How much the plan pays for service covered services Facility You may be charged facility fees in addition to • Primary care office visits: The provider fees when accessing clinics, ambulatory plan pays 100%. surgery centers, and other facilities. A facility • Network facility: The plan pays may be referred to as a “provider” on the 85% of the allowed amount. Explanations of Benefits or other documents. • Out-of-network facility: The How much you pay depends on the provider’s plan pays 50% of the allowed network status: amount. • Network facility: You pay 15% of the allowed amount. The provider cannot balance bill you. • Out-of-network facility: You pay 50% of the allowed amount, and the provider may balance bill you. Note: You pay $0 for facility fees associated with primary care office visits with network primary providers (and naturopathic providers contracted with the Regence network). Special These services have unique payment rules, which are described in the “How much you will pay” column in the Summary of benefits table located in the “Summary of benefits” section. What else you need to know • Some services are not covered (see the “What the plan does not cover” section). • There is no waiting period for preexisting conditions. • You will save money by seeing network providers (see the “Finding a health care provider” section). • You must be enrolled in this plan for the plan to pay for medically necessary covered services. Benefits: what the plan covers Guidelines for coverage ALERT! A service or supply prescribed, ordered, recommended, approved, or given by a provider does not make it a medically necessary covered service or supply. This plan will cover a service or supply if it meets all of the following conditions. The service or supply must: • Be listed as covered; and • Be medically necessary; and • Be received by a member on a day between the date coverage begins (but no sooner than January 1, 2024) and the date coverage ends (but no later than December 31, 2024); and 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 37