Deductibles Dollar amounts What else you need to know For more and limits information, see page(s) Prescription $100 per member (maximum of • You pay the costs for Tier 2 94–95 drug $300 for a family of three or prescription drugs until you deductible more) meet your prescription drug deductible, except covered insulins. • You do not need to meet your prescription drug deductible for Preventive Tier, Value Tier, Tier 1 drugs, and covered insulins. Medical out- $2,000 per member (maximum Your medical deductible and all 27–28 of-pocket of $4,000 for a family of two or coinsurance and copays for limit more) covered services paid to For Medicare-primary members: preferred providers count $2,500/$5,000 toward this limit. Once you meet your medical out-of-pocket limit, covered services paid to preferred providers are paid at 100% of the allowed amount. Prescription $2,000 per member (maximum Your prescription drug 97 drug out-of- of $4,000 for a family of two or deductible and coinsurance pocket limit more) count toward this limit. Annual plan None No limit to how much the plan Not applicable payment limit pays per calendar year. Lifetime plan None No limit to how much the plan Not applicable payment limit pays over a lifetime. Types of services The table in this section describes how much you and the plan will pay for covered services. Unless otherwise noted, all payments are based on the allowed amount, and services are subject to your medical deductible. See the “What you pay for medical services” section for more information about your deductible. Type of How much you pay for covered services How much the plan pays for service covered services Standard How much you pay (your coinsurance) • Preferred providers: The plan depends on the provider’s network status: pays 85% of the allowed • Preferred providers: You pay 15% of the amount. allowed amount. The provider cannot • Participating providers: The balance bill you. plan pays 60% of the allowed • Participating providers: You pay 40% of amount. the allowed amount. The provider cannot balance bill you. 2024 UMP Classic (PEBB) Certificate of Coverage 29