Type of How much you pay for covered services How much the plan pays for service covered services If you receive services from the following • Specialty providers in the core providers, services are subject to your medical or support network: The plan deductible and the following coinsurance: pays 85% of the allowed amount. • Specialty providers in the core or support • Out-of-network providers: The network: You pay 15% of the allowed plan pays 50% of the allowed amount. The provider cannot balance bill you. amount. • Out-of-network providers: You pay 50% of the allowed amount, and the provider may balance bill you. Standard How much you pay (your coinsurance) depends • Specialty providers in the core on the provider’s network status: or support network: The plan • Specialty providers in the core or support pays 85% of the allowed amount. network: You pay 15% of the allowed • Out-of-network providers: The amount. The provider cannot balance bill you. plan pays 50% of the allowed • Out-of-network providers: You pay 50% of amount. the allowed amount. The provider may balance bill you. Preventive Covered preventive services are not subject to • Primary care and specialty your medical deductible. How much you pay providers in the core or support (your coinsurance) depends on the provider’s network: The plan pays 100%. network status: • Out-of-network providers: The • Primary care and specialty providers in the plan pays 50% of the allowed core or support network: You pay $0. amount. • Out-of-network providers: You pay 50% 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 104) and notice (your amount after you pay your provider must notify the plan as soon as deductible and copay at network possible after you are admitted to a facility, but facilities. not later than 24 hours after you are admitted; The plan pays for professional see page 105). services such as provider You pay the $200-per-day copay at network consultations or lab tests, based on facilities, up to $600 maximum per calendar the provider’s network status: year. • Network providers: The plan Note: The inpatient copay counts toward your pays 85% of the allowed amount. medical out-of-pocket limit. Note: For behavioral health Services are considered inpatient only when you professional services, the plan are admitted to a facility. See definition of pays 100% of the allowed “Inpatient stay.” amount. When you are admitted to a facility, you pay: • Out-of-network providers: The • Your deductible; and plan pays 50% of the allowed • The inpatient copay; and amount. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 35