Provider Must provider accept Balance Itemized payments You owe type allowed amount? billing provider allowed? Preferred Yes. You pay 20% of the No Billed charge: $1,000 $180 provider allowed amount Allowed amount: $900 (coinsurance). Plan pays 80%: -$720 You pay 20%: $180 Participating Yes. You pay 40% of the No Billed charge: $1,000 $360 provider allowed amount Allowed amount: $900 (coinsurance). Plan pays 60%: -$540 You pay 40%: $360 Out-of- No. You pay 40% of the Yes Billed charge: $1,000 $460* network allowed amount Allowed amount: $900 provider* (coinsurance), plus all Plan pays 60%: -$540 charges above the You pay 40% plus allowed amount. $100** over allowed amount: $460* * This amount does not apply to your medical out-of-pocket limit. ** 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. How to find a preferred provider As a UMP member, you have access to Regence BlueShield preferred providers and Blue Cross and Blue Shield plan providers worldwide through the Blue Cross Blue Shield Global® Core program (see the “Services received outside the United States” section). This means your health coverage is with you wherever you are. Your access to care includes many acute care hospitals, urgent care and ambulatory surgery centers, physicians, and other health care professionals. To find a preferred provider, choose one of the following: • Use the UMP provider search. • Contact UMP Customer Service. • Sign in to your Regence account, where you have access to more information about providers, as well as other tools. • Use the Regence mobile application to find providers in your network. • Call Blue Cross Blue Shield Global® Core Service Center at 1-800-810-2583 or call collect at 1-804-673- 1177 to find providers outside the U.S. You can also use the online provider search tool on the Blue Cross Blue Shield Global Core website at bcbsglobalcore.com. • Visit the Prescription drug coverage webpage to locate network pharmacies. See the Directory pages at the beginning of this booklet for links and contact information. 2024 UMP Select (PEBB) Certificate of Coverage 17