Note: A provider may ask you to pay your deductible and copay, when applicable, at the time of service. When this happens, check your EOB to make sure the amount you paid is accurately reflected in the Member Responsibility section. Contact UMP Customer Service with questions. Medical out-of-pocket limit ALERT! Prescription drug costs do not apply to your medical out-of-pocket limit (see below). The medical out-of-pocket limit is the most you pay during a calendar year for covered services from preferred providers. After you meet your medical out-of-pocket limit for the year, the plan pays for covered services by preferred providers at 100 percent of the allowed amount. The plan will not pay more than the allowed amount. Expenses are counted from January 1, 2024, or your first day of enrollment (whichever is later) through December 31, 2024, or your last day of enrollment (whichever is earlier). Your medical out-of-pocket limit depends on your enrollee type. • Employees, continuation coverage subscribers, retired employees of a former employer group, and retirees or survivors not enrolled in Medicare, including dependents: $2,000 per person and $4,000 per family. • Retirees enrolled in Medicare Part A and Part B, including dependents: $2,500 per person and $5,000 per family. What counts toward this limit • Inpatient and emergency room copays • Your coinsurance paid to preferred and participating providers • Your coinsurance paid to out-of-network providers for emergency room services, air ambulance, and nonemergency services furnished during a visit or stay at a preferred and participating hospital, hospital outpatient department, critical access hospital, or ambulatory surgical center. • Your medical deductible paid to preferred and participating providers • Chiropractic, acupuncture, and massage therapy visit copays to preferred providers What does not count toward this limit A. Amounts paid by the plan, including services covered in full B. Costs you pay under the prescription drug benefit including your prescription drug deductible and coinsurance (see the "What you pay for prescription drugs" section) C. Your monthly premiums D. Your coinsurance paid to out-of-network providers and your coinsurance and copayments paid to non-network pharmacies (except those listed above in “What counts toward this limit”) E. Balance billed amounts F. Amounts paid for services the plan does not cover (see the “What the plan does not cover” section) G. Amounts that are more than the maximum dollar amount paid by the plan. Any amount you pay over the allowed amount does not count toward the medical out-of-pocket limit. 2024 UMP Classic (PEBB) Certificate of Coverage 27