Appeal rights Any enrollee may appeal a decision made by the PEBB Program regarding PEBB eligibility, enrollment, premium payments, or premium surcharges to the PEBB Appeals Unit. Learn more at hca.wa.gov/pebb-appeals. Fax: 360-763-4709 Mail: Health Care Authority Attn: PEBB Appeals Unit PO Box 45504 Olympia, WA 98504-5504 Hand deliver: Health Care Authority 626 8th Avenue SE Olympia, WA 98501 Any enrollee may appeal a decision regarding the administration of a PEBB medical plan by following the appeal provisions of the plan, except when regarding eligibility, enrollment, and premium payment decisions. Relationship to law and regulations Any provision of this certificate of coverage that is in conflict with any governing law or regulation of Washington State is hereby amended to comply with the minimum requirements of such law or regulation. PEBB customer service For questions about PEBB retiree eligibility and enrollment, call the PEBB Program at 1-800-200-1004 (TRS:711) or visit hca.wa.gov/pebb-retirees. For questions about Medicare, call the Centers for Medicare and Medicaid Services (CMS) at 1-800-MEDICARE or visit medicare.gov. Definitions Allowed amount, medical services Allowed amount for medical services is the most the plan pays for a specific covered service or supply. The allowed amount is determined as follows: • For preferred providers that are within the Regence BlueShield service area, the Preferred Provider Organization (PPO) contract with Regence BlueShield is the relevant contract that determines the allowed amount. For preferred providers that are outside the Regence BlueShield service area, the contract with another Blue Cross or Blue Shield organization in the BlueCard® Program for its PPO network is the relevant contract that determines the allowed amount. • For participating providers that are within the Regence BlueShield service area, the participating provider contract with Regence BlueShield is the relevant contract that determines the allowed amount. For participating providers that are outside the Regence BlueShield service area, the contract with another Blue Cross or Blue Shield organization in the BlueCard® Program is the relevant contract that determines the allowed amount. 2024 UMP CDHP (PEBB) Certificate of Coverage 169