Type of How much you pay for covered services How much the plan pays for service covered services • Fees for professional services, such as, but not limited to, provider consultations or lab tests. How much you pay for professional services depends on the provider’s network status: • Specialty providers in the core or support network: You pay 15% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 50% of the allowed amount. The provider may balance bill you. If you go to an out-of-network facility for non-emergency inpatient care, you pay 50% of the allowed amount, and the facility may balance bill you. See page 23 for more information on out-of-network facility charges. If you go to a network facility and see an out- of-network provider, you will pay 50% of the allowed amount. Outpatient If you receive services at a facility that offers • Specialty providers in the core inpatient services (like a hospital) but you are or support network: The plan not admitted, the services are covered as pays 85% of the allowed amount. outpatient. See the specific benefit (e.g., • Out-of-network providers: The emergency room or diagnostic tests) for how plan pays 50% of the allowed much you pay. You may be billed separately for amount. facility fees in addition to provider fees. • Specialty providers in the core or support network: You pay 15% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 50% of the allowed amount. The provider may balance bill you. 36 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage