• Routine vision care: exams, glasses, and contacts. • Second opinions required by the plan. • Tobacco cessation services. Note: See page 92 for prescription drug deductible exemptions. How your medical deductible works with dependents If your family has three or fewer members enrolled, your medical deductible amount is $750 per member, with a maximum of $2,250. Once a member pays their $750 deductible, the plan begins paying for covered services for that member. Because the plan is now paying for this member’s covered services, they are no longer contributing toward your family deductible. Once your family deductible has been met, the plan begins paying for all covered services. If your family has four or more members enrolled, each member has a medical deductible of $750 and the maximum the family pays toward medical deductibles is $2,250. Once a member pays their $750 deductible, the plan begins paying for covered services for that member. Because the plan is now paying for this member’s covered services, they are no longer contributing toward your family deductible. Once your family deductible has been met, the plan begins paying for all covered services for all enrolled family members, even if some have not met their own deductible. If the subscriber earned the SmartHealth wellness incentive for the 2024 plan year, the subscriber’s medical deductible is reduced. See the “If you earned the SmartHealth wellness incentive” section above to learn more. Note: Only services that are covered and are subject to your medical deductible count toward the deductible. See page 24 for a list of services that do not count toward your medical deductible. Coinsurance TIP: Allowed amount is the most the plan pays for a specific covered service or supply. Out-of- network providers may charge more than this amount, and you are responsible for paying the difference between the billed amount and the allowed amount. This is called balance billing. Coinsurance is the percentage of the allowed amount you pay for most medical services and for prescription drugs when the plan pays less than 100 percent. After you meet your medical deductible, you pay the percentages described below for most covered medical services. See the following sections for more information on how much you pay for prescription drugs: “What you pay for prescription drugs,” “How the prescription drug cost-limit works,” “Your prescription drug out-of-pocket limit.” • For preferred providers: You pay 20 percent of the allowed amount. The plan pays 80 percent of the allowed amount. • For participating providers: You pay 40 percent of the allowed amount. The plan pays most covered services at 60 percent of the allowed amount. • For out-of-network providers: You pay 40 percent of the allowed amount, and the provider may balance bill you. The plan pays most covered services at 60 percent of the allowed amount. Professional charges, such as for physician services while you are in the hospital or lab work, may be billed separately. Note: 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, 2024 UMP Select (PEBB) Certificate of Coverage 25