F. Amounts paid for services the plan does not cover (see the “What the plan does not cover” section) G. Amounts that are more than the maximum dollar amount paid by the plan. Any amount you pay over the allowed amount does not count toward the medical out-of-pocket limit. H. Amounts paid for services over a benefit limit. For example, the benefit limit for acupuncture is 24 visits. If you have more than 24 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit. What you pay after reaching this limit After you meet your out-of-pocket limit for the year, you pay: • $0 of the allowed amount for covered medical services for core and support network providers and for covered drugs at network pharmacies. • C through H (above) in the “What does not count toward this limit” section. • 50% of the allowed amount for covered medical services for participating providers. • 50% of the allowed amount for covered medical services for out-of-network providers. You may be balance billed. Additional exception for approved network consent services In addition to the services listed in the “What does not count toward this limit” section above, your coinsurance for out-of-network provider services related to an approved network consent (see page 23) will apply to your medical out-of-pocket limit, and the plan will pay 100 percent of the allowed amount for these services after you meet your medical out-of-pocket limit. Summary of services and payments ALERT! Even if a provider orders a test or prescribes a treatment, the plan may not cover it. Review this COC or contact UMP Customer Service if you have questions about benefits or limitations. On the next several pages, you will find a summary of types of services and what you will pay for them. For a complete understanding of how a benefit works, read the pages listed in the “For more information” column. All services must be medically necessary to be covered. If you see an unfamiliar term, see the alphabetical list of definitions in the “Definitions” section. This COC applies only to dates of service between the day your coverage begins (no earlier than January 1, 2024) and the day your coverage ends (no later than December 31, 2024). ALERT! If you have coverage under another health plan, see the “If you have other medical coverage” section. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 33