Type of service How much you pay for covered How much the plan pays for covered services services Standard How much you pay (your coinsurance) • Preferred providers: The plan pays depends on the provider’s network 85% of the allowed amount. status: • Participating providers: The plan • Preferred providers: You pay 15% of pays 60% of the allowed amount. the allowed amount. The provider • Out-of-network providers: The plan cannot balance bill you. pays 60% of the allowed amount. • Participating providers: You pay 40% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 40% of the allowed amount. The provider may balance bill you. Preventive Covered preventive services are not • Preferred providers: The plan pays subject to your deductible. How much 100% of the allowed amount. you pay (your coinsurance) depends on • Participating providers: The plan the provider’s network status: pays 100% of the allowed amount. • Preferred providers: You pay $0. The • Out-of-network providers: The plan provider cannot balance bill you. pays 60% of the allowed amount. • Participating providers: You pay $0. The provider cannot balance bill you. • Out-of-network providers: You pay 40% of the allowed amount. The provider may balance bill you. Inpatient Most inpatient services require both The plan pays 100% of the allowed preauthorization (see page 103) and amount after you pay your deductible at notice (your provider must notify the plan preferred facilities. as soon as possible after you are The plan pays for professional services admitted to a facility, but not later than such as provider consultations or lab 24 hours after you are admitted; see page 104). tests, based on the provider’s network status: Services are considered inpatient only • Preferred providers: The plan pays when you are admitted to a facility. See 85% of the allowed amount. definition of “Inpatient stay” on page 178. • Participating providers: The plan When you are admitted to a facility, you pays 60% of the allowed amount. pay your deductible and: • Out-of-network providers: The plan • Preferred facilities: You pay 15% of pays 60% of the allowed amount. the allowed amount. The provider cannot balance bill you. • Participating facilities: You pay 40% of the allowed amount. The provider cannot balance bill you. 32 2024 UMP CDHP (PEBB) Certificate of Coverage