Benefit calculation Amount Since the UMP Classic benefit available (dollar amount) is greater than the balance, UMP $266.40 pays the balance remaining after Medicare pays: The difference between the normal UMP Classic benefit and the amount UMP paid is: $31.10 This amount is considered “COB savings” (see page 131). Note: This is an example only and may not apply to your specific situation. Example of COB when Medicare pays first and UMP Classic pays second Below is an example to show how the COB process works after you have met your UMP Classic medical deductible and Medicare deductible. This example assumes you received care from a provider who accepts Medicare (has not “opted out” of Medicare) anywhere in the U.S. Benefit calculation Amount Provider’s billed charge $300 Medicare allowed amount $100 Medicare pays $80 (80% of $100) Remaining amount $20 UMP Classic allowed $100 amount UMP Classic normal $85 (85% of $100) benefit UMP Classic pays $20 You pay $0 COB savings accrued $65 ($85 - $20 =$65) The $65 of the normal UMP Classic benefit not paid on this claim is tracked as part of your COB savings. That excess benefit may be used to reimburse you directly for your UMP Classic medical deductible met earlier in the same year or used to pay more on a service covered by UMP Classic, but not covered by Medicare. See the “Why you might get a COB savings check from UMP Classic” section. In this example, you owe $0 because the provider accepts Medicare. You may still have to pay coinsurance and deductible amounts when you have not fully met your Medicare deductibles, or when Medicare does not cover a service. If UMP Classic covers a service or supply not covered by Medicare, then the benefit will be the normal UMP Classic benefit plus any COB savings you may have accrued in the same calendar year, up to allowed amount for the claim. If a provider does not bill Medicare for services covered by Medicare, UMP Classic may not cover services. Medicare accepts claims from members only under certain circumstances, and UMP Classic processes claims for services covered by Medicare only after Medicare has processed them. See the “What UMP Classic covers that Medicare does not” section below for exceptions. Ask your provider if they bill Medicare. Diabetes care supplies when Medicare pays first Medicare pays claims for some diabetes care supplies under the Part B medical benefit. As a result, UMP Classic pays the claim under the DME benefit, not the prescription drug benefit. This means you will have to meet your medical deductible before UMP Classic begins to pay on diabetes care supplies claims, then 2024 UMP Classic (PEBB) Certificate of Coverage 129