Sample payments to different provider network status The table below shows how much you pay for professional services from preferred, participating, and out- of-network providers when UMP is your primary medical insurance. For these examples, assume you have met your medical deductible and have not reached your medical out-of-pocket limit. See descriptions of these provider types beginning on page 14. These are examples only and may not reflect your specific situation. Provider Must provider accept Balance Itemized payments You owe type allowed amount? billing provider allowed? Preferred Yes. You pay 15% of the No Billed charge: $1,000 $135 provider allowed amount Allowed amount: $900 (coinsurance). Plan pays 85%: -$765 You pay 15%: $135 Participating Yes. You pay 40% of the No Billed charge: $1,000 $360 provider allowed amount Allowed amount: $900 (coinsurance). Plan pays 60%: -$540 You pay 40%: $360 Out-of- No. You pay 40% of the Yes Billed charge: $1,000 $460* network allowed amount Allowed amount: $900 provider* (coinsurance), plus all Plan pays 60%: -$540 charges above the You pay 40% plus allowed amount. $100** over allowed amount: $460* * This amount does not apply to your medical out-of-pocket limit. ** When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of-network provider may be allowed to ask you to waive some of your balance billing protections. How to find a preferred provider As a UMP member, you have access to Regence BlueShield preferred providers and Blue Cross and Blue Shield plan providers worldwide through the Blue Cross Blue Shield Global® Core program (see the “Services received outside the United States” section). This means your health coverage is with you wherever you are. Your access to care includes many acute care hospitals, urgent care and ambulatory surgery centers, physicians, and other health care professionals. To find a preferred provider, choose one of the following: • Use the UMP provider search. • Contact UMP Customer Service. • Sign in to your Regence account, where you have access to more information about providers, as well as other tools. 2024 UMP Classic (PEBB) Certificate of Coverage 17