Benefit/service How much you will pay For information, see page(s): Hospital services Inpatient rate 56, 63, 109 Outpatient/professional services: Standard rate Mammograms Diagnostic: Standard rate 61 Screening: Preventive rate Mental health See the “Behavioral health” benefit 41, 110, 112 Naturopathic Standard rate 19, 62, 102, 107 physician services Obstetric and Inpatient rate 63, 112 newborn care Outpatient/professional services: Standard rate Office visits Standard rate 64, 111 Prescription drugs See the “What you pay for prescription drugs” section 90 Preventive care and Preventive care: Preventive rate 61, 64, 65, 91, 186 immunizations Covered preventive immunizations: Preventive rate Skilled nursing Inpatient rate 69, 109, 113, 190 facility Some services may be billed separately, such as physical therapy Spinal and extremity See the “Spinal and extremity manipulations” benefit 70 manipulations Substance use See the “Behavioral health” benefit 41 disorder Surgery Standard rate 56, 58, 62,65, 70, 70, 73, 77, 109, 114, 170,183 , 188 Therapy: Habilitative Inpatient rate 74 and Rehabilitative Outpatient/professional services: Standard rate Tobacco cessation Preventive rate 75 Vision care exam Preventive rate 81, 84 (routine) Vision hardware, Special rate: 81 adults (age 19 or • No medical deductible older) • Lenses and frames: You pay $0 of the allowed (Lenses, frames, or amount for one pair of covered standard lenses and contact lenses) frames once every two calendar years; or • Contact lenses: Plan pays up to $150 every two calendar years in lieu of lenses and frames. You pay a $30 fitting fee for contact lenses. 38 2024 UMP CDHP (PEBB) Certificate of Coverage