Type of How much you pay for covered services How much the plan pays for service covered services • Out-of-network providers: You pay 40% • Out-of-network providers: The of the allowed amount. The provider may plan pays 60% of the allowed balance bill you. amount. Preventive Covered preventive services are not subject to • Preferred providers: The plan your medical deductible. How much you pay pays 100% of the allowed (your coinsurance) depends on the provider’s amount. network status: • Participating providers: The • Preferred providers: You pay $0. The plan pays 100% of the allowed provider cannot balance bill you. amount. • Participating providers: You pay $0. The • Out-of-network providers: The provider cannot balance bill you. plan pays 60% of the allowed • Out-of-network providers: You pay 40% amount. of the allowed amount. The provider may balance bill you. Inpatient Most inpatient services require both The plan pays 100% of the allowed preauthorization (see page 108) and notice amount after you pay your (your provider must notify the plan as soon as deductible and copay at preferred possible after you are admitted to a facility, facilities. but not later than 24 hours after you are The plan pays for professional admitted; see page 110). services such as provider You pay the $200-per-day copay at preferred consultations or lab tests, based on facilities up to: the provider’s network status: • $600 maximum copay per calendar year if • Preferred providers: The plan you are a member not enrolled in pays 85% of the allowed Medicare. amount. • $600 maximum per admission up to the Note: For behavioral health annual medical out-of-pocket limit if you professional services, the plan are a retiree or their dependent enrolled pays 100% of the allowed in Medicare. amount. Note: The inpatient copay counts toward your • Participating providers: The medical out-of-pocket limit. plan pays 60% of the allowed Services are considered inpatient only when amount. you are admitted to a facility. See definition of • Out-of-network providers: The “Inpatient stay.” plan pays 60% of the allowed When you are admitted to a facility, you pay amount. your deductible and: • Preferred facilities: You pay the inpatient copay. • Participating facilities: You pay 40% of the allowed amount. The facility cannot balance bill you. 30 2024 UMP Classic (PEBB) Certificate of Coverage