Benefit/service How much you will pay For information, see page(s): Behavioral health Mental health: 39, 113, 115 • 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 42, 60 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 preferred provider. manipulations” benefit on page 68 Diagnostic tests, Standard rate 46, 60, 109–119 laboratory, and x-rays Dialysis Inpatient: Standard rate 49 Outpatient: Initial treatment period: Standard rate Supplemental treatment period: Special rate: • Preferred and participating 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 46, 111, 114, 176 equipment (DME), supplies, and prostheses Emergency room (ER) Special rate: 49, 177 ER services are paid at the network rate at preferred, participating and out-of- network hospitals. You pay 20% 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: 52 • No medical deductible • You pay $0 of the $3,000 benefit limit per ear every 3 years. Home health care Standard rate 53, 112, 180, 182 2024 UMP Select (PEBB) Certificate of Coverage 35