Type of How much you pay for covered services How much the plan pays for service covered services Facility You may be charged facility fees in addition to • Preferred facility: The plan provider fees when accessing clinics, pays 85% of the allowed ambulatory surgery centers, and other amount. facilities. A facility may be referred to as a • Participating facility: The plan “provider” on the Explanations of Benefits or pays 60% of the allowed other documents. How much you pay amount. depends on the provider’s network status: • Out-of-network facility: The • Preferred facility: You pay 15% of the plan pays 60% of the allowed allowed amount; the provider cannot amount. balance bill you. • Participating facility: You pay 40% of the allowed amount; the provider cannot balance bill you. • Out-of-network facility: You pay 40% of the allowed amount; the provider may balance bill you. Special These services have unique payment rules, which are described in the “How much you will pay” column in the Summary of benefits table located in the “Summary of benefits” section. What else you need to know • Some services are not covered (see the “What the plan does not cover” section). • There is no waiting period for preexisting conditions. • You will save money by seeing preferred providers (see the “Finding a health care provider” section). • You must be enrolled in this plan for the plan to pay for medically necessary covered services. Benefits: what the plan covers Guidelines for coverage ALERT! A service or supply prescribed, ordered, recommended, approved, or given by a provider does not make it a medically necessary covered service or supply. This plan will cover a service or supply if it meets all of the following conditions. The service or supply must: • Be listed as covered; and • Be medically necessary; and 32 2024 UMP Classic (PEBB) Certificate of Coverage