Table of Contents Directory .................................................................................................................................................................................................. 1 Directory: medical services ......................................................................................................................................................... 1 Directory: vision services ............................................................................................................................................................. 4 Directory: prescription drug services ..................................................................................................................................... 6 Online services ................................................................................................................................................................................... 13 How to use this certificate of coverage ................................................................................................................................. 14 About UMP Select ............................................................................................................................................................................ 14 Accumulators ..................................................................................................................................................................................... 14 Finding a health care provider ................................................................................................................................................... 15 Sample payments to different provider network status ............................................................................................ 16 How to find a preferred provider ......................................................................................................................................... 17 Covered and noncovered provider types ......................................................................................................................... 18 Primary care providers .............................................................................................................................................................. 18 When you do not have access to a preferred provider: network waiver ........................................................... 18 When and how to request a network waiver .................................................................................................................. 19 Out-of-area services ................................................................................................................................................................... 20 Services received outside the United States ................................................................................................................... 21 What you pay for medical services .......................................................................................................................................... 23 Deductibles ..................................................................................................................................................................................... 23 Coinsurance .................................................................................................................................................................................... 25 Copay ................................................................................................................................................................................................ 26 When you pay ............................................................................................................................................................................... 26 Medical out-of-pocket limit .................................................................................................................................................... 26 Summary of services and payments ........................................................................................................................................ 28 Deductibles and limits ............................................................................................................................................................... 28 Types of services .......................................................................................................................................................................... 29 What else you need to know .................................................................................................................................................. 32 Benefits: what the plan covers ................................................................................................................................................... 32 Guidelines for coverage ............................................................................................................................................................ 32 Health Technology Clinical Committee (HTCC) ............................................................................................................. 33 Summary of benefits .................................................................................................................................................................. 34 List of benefits ............................................................................................................................................................................... 37 Acupuncture .............................................................................................................................................................................. 37 Ambulance ................................................................................................................................................................................. 37 Applied Behavior Analysis (ABA) Therapy ................................................................................................................... 38 8 2024 UMP Select (PEBB) Certificate of Coverage