Benefit/service How much you will pay For information, see page(s): Behavioral health Mental health: 44, 111, 112 • Inpatient rate • Outpatient/professional services: Standard rate Substance use disorder: • Inpatient rate • Outpatient/professional services: Standard rate Breast health See the “Mammogram and Digital Breast 47, 62 screening tests Tomosynthesis (DBT)” benefit Chiropractic physician Special rate: See the “Spinal and services You pay a $15 copay per visit when you see a extremity network provider. manipulations” benefit on page 71 Diagnostic tests, Standard rate 51, 62, 106–117 laboratory, and x-rays Dialysis Inpatient: Standard rate 52 Outpatient: Initial treatment period: Standard rate Supplemental treatment period: Special rate: • Network providers: You pay 0% of the allowed amount. • Out-of-network providers: You pay 0% of the allowed amount. Any charges exceeding the allowed amount may be balance billed. Durable medical Standard rate 52, 109, 112, 172 equipment (DME), supplies, and prostheses Emergency room (ER) Special rate: 54, 173 ER services are paid at the network rate at network and out-of-network hospitals. You pay 15% of the allowed amount plus an ER copay of $75. You are usually billed separately for: • Facility charges • Professional (physician) services • Lab tests, x-rays, and other imaging tests Hearing aids Special rate: 57 • No medical deductible • You pay $0 of the $3,000 benefit limit per ear every 3 years Home health care Standard rate 58, 110, 176, 178 40 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage