H. Amounts paid for services over a benefit limit. For example, the benefit limit for acupuncture is 24 visits. If you have more than 24 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit. What you pay after reaching this limit After you meet your out-of-pocket limit for the year, you pay: • $0 of the allowed amount for covered medical services from preferred providers and for covered drugs at network pharmacies. • C through H (above) in the “What does not count toward this limit” section. • 40% of the allowed amount for covered medical services for participating providers. • 40% of the allowed amount for covered medical services for out-of-network providers. You may be balance billed. 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. If your other coverage is Medicare, see the “For retirees enrolled in Medicare and UMP Classic" section. Deductibles and limits Deductibles Dollar amounts What else you need to know For more and limits information, see page(s) Medical $250 per member (maximum of You must meet your medical 23–25 deductible $750 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. 28 2024 UMP Classic (PEBB) Certificate of Coverage