Benefit/service How much you will pay For information, see page(s): Behavioral health Mental health: 41, 110, 112 • Inpatient rate • Outpatient/professional services: Standard rate Substance use disorder: • Inpatient rate • Outpatient/professional services: Standard rate Breast health See the “Mammogram and Digital Breast 44, 61 screening tests Tomosynthesis (DBT)” benefit Chiropractic See the “Spinal and extremity manipulations” benefit See the “Spinal and physician services extremity manipulations” benefit on page 70 Diagnostic tests, Standard rate 48, 61, 106-116 laboratory, and x- rays Durable medical Standard rate 48, 108, 111, 173 equipment (DME), supplies, and prostheses Emergency room (ER) Special rate: 51, 174 ER services are paid at the network rate at preferred, participating and out-of- network hospitals. You pay 15% of the allowed amount. You are usually billed separately for: • Facility charges • Professional (physician) services • Lab tests, x-rays, and other imaging tests Hearing aids Special rate: 54 • Subject to the deductible • You pay $0 of the $3,000 benefit limit per ear every 3 years. Home health care Standard rate 54, 109, 177, 179 Hospice care Special rate: 54, 177 • You pay $0 for medical services after meeting your deductible • You pay $0 for prescription drugs after meeting your deductible • You pay $0 for end-of-life counseling while in hospice after meeting your deductible 2024 UMP CDHP (PEBB) Certificate of Coverage 37