FOR MEDICARE RETIREES: The inpatient copay is $200 per day, with a maximum of $600 per inpatient admission, up to the medical out-of-pocket limit. Outpatient Services are considered “outpatient” when you are not admitted to the hospital. Your cost depends on the services provided, such as lab tests, and the network status of the provider(s) involved in your care. You do not pay the inpatient copay for outpatient services. Some services require preauthorization. Visit the UMP Policies that affect your care webpage for the list of these services, or contact UMP Customer Service. See Directory for link and contact information. Not all providers at a network hospital are network providers Some providers who work in a network hospital or other network facility, including, but not limited to, anesthesiologists and emergency room doctors, may not be network providers. 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. Infusion drug site of care program The plan covers provider-administered infusion drugs when administered at an approved site of care. Approved sites of care include standalone infusion sites, doctor's offices, home infusion and some outpatient hospital facilities. Infusion drugs in the site of care program require preauthorization by the plan before services are performed, or services will not be covered. Your provider must submit a preauthorization request for an unapproved site of care. See the “Limits on plan coverage” section for preauthorization instructions. Contact UMP Customer Service for the drugs covered under the site of care program, more information, or help finding an approved site of care near you. Joint replacement surgery, knees and hips in the Centers of Excellence (COE) Program FOR MEDICARE RETIREES: The COE Program is not available to UMP Classic members enrolled in Medicare as their primary coverage (see the “For retirees enrolled in Medicare and UMP Classic” section). Medicare members still have access to covered services related to joint replacement separate from the COE Program. Those services are paid at the standard rate. The Centers of Excellence (COE) Program covers 100 percent of the allowed amount for covered services related to single knee or single hip total joint replacement surgery. The program includes, but is not limited to: • Presurgical consultations. • Travel costs (see the “Travel benefits” section below). 2024 UMP Classic (PEBB) Certificate of Coverage 57