Summary of services and payments ALERT! Even if a provider orders a test or prescribes a treatment, the plan may not cover it. Review this COC or contact UMP Customer Service if you have questions about benefits or limitations. On the next several pages, you will find a summary of types of services and what you will pay for them. For a complete understanding of how a benefit works, read the pages listed in the “For more information” column. All services must be medically necessary to be covered. If you see an unfamiliar term, see the alphabetical list of definitions in the “Definitions” section. This COC applies only to dates of service between the day your coverage begins (no earlier than January 1, 2024) and the day your coverage ends (no later than December 31, 2024). ALERT! If you have coverage under another health plan, see the “If you have other medical coverage” section. Deductibles and limits Deductibles Dollar amounts What else you need to know For more and limits information, see page(s) Medical $750 per member (maximum of You must meet your medical 23–25 deductible $2,250 for a family of three or deductible before the plan pays more) for covered medical services. See page 24 if you earned the Not all services count toward SmartHealth wellness incentive your deductible. in 2023 for plan year 2024. Prescription $250 per member (maximum of • You pay the costs for Tier 2 92–93 drug $750 for a family of three or prescription drugs until you deductible more) meet your prescription drug deductible, except covered insulins. • You do not need to meet your prescription drug deductible for Preventive Tier, Value Tier, Tier 1 drugs, and covered insulins. 28 2024 UMP Select (PEBB) Certificate of Coverage