Type of How much you pay for covered services How much the plan pays for service covered services • Out-of-network facilities: You pay 40% of the allowed amount. The facility may balance bill you. • Fees for professional services, such as, but not limited to, provider consultations or lab tests. How much you pay for professional services depends on the provider’s network status: • Preferred providers: You pay 15% of the allowed amount. The provider cannot balance bill you. • Participating providers: You pay 40% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 40% of the allowed amount. The provider may balance bill you. Outpatient If you receive services at a facility that offers • Preferred providers: The plan inpatient services (like a hospital), but you are pays 85% of the allowed not admitted, the services are covered as amount. outpatient. See the specific benefit (e.g., • Participating providers: The emergency room or diagnostic tests) for how plan pays 60% of the allowed much you pay. You may be billed separately amount. for facility fees in addition to provider fees. • Out-of-network providers: The • Preferred providers: You pay 15% of the plan pays 60% of the allowed allowed amount. The provider cannot amount. balance bill you. • Participating providers: You pay 40% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 40% of the allowed amount. The provider may balance bill you. 2024 UMP Classic (PEBB) Certificate of Coverage 31