• Outside the Regence BlueShield service area, but is not contracted with another Blue Cross or Blue Shield organization in the BlueCard® Program (designated as a provider in the PPO network) to provide services and supplies to plan members. See page 16 for a description of how services by these providers are covered. Out-of-network provider(s), vision Out-of-network provider(s), vision do not have a contract with VSP. Out-of-network rate Out-of-network providers are paid at the out-of-network rate. When you receive medical services from out-of-network providers, you pay 40 percent of the allowed amount after you meet your medical deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The plan pays 60 percent of the allowed amount. Out-of-pocket limit, medical The medical out-of-pocket limit is the most you pay during a calendar year for covered medical services before the plan pays 100 percent of the allowed amount for preferred providers. This limit does not include your premium, balance-billed charges, or services the plan does not cover. For more information on how this works, see the “Medical out-of-pocket limit” section. For this plan, 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. Out-of-pocket limit, prescription drug The prescription drug out-of-pocket limit is the most you pay during a calendar year for covered prescription drugs and products before the plan pays 100 percent of the allowed amount. The out-of- pocket limit is $2,000 per enrolled member up to a maximum of $4,000 for a family. See page 28 for a list of services that do not apply to this limit and that you pay even after you have met the limit. Outpatient rate The plan’s outpatient rate depends on the provider’s status: • Preferred providers: You pay 15 percent of the allowed amount after you meet your medical deductible. The plan pays 85 percent of the allowed amount. • Participating providers: You pay 40 percent of the allowed amount after you meet your medical deductible. The plan pays 60 percent of the allowed amount. • Out-of-network providers: You pay 40 percent of the allowed amount after you meet your medical deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The plan pays 60 percent of the allowed amount. Outpatient surgery center See the “Ambulatory surgery center (ASC)” definition. 196 2024 UMP Classic (PEBB) Certificate of Coverage