How Much Will I Pay?

• Annual Deductibles
• Coinsurance
• Copayments

Preferred vs. Out-of-Network Costs

• Using Preferred Providers
• Using Out-of-Network Providers
• Access for Medicare Retirees
• Hospital-Based Providers

How Much Will I Pay?

Medical Deductible

The medical deductible for UMP Classic is $250 per person every calendar year. For most covered medical services, you pay toward this deductible before the plan begins to pay. To read more, including how the deductible works for families and what doesn't count toward the deductible, see "UMP Classic: How does the medical deductible work?quot;

Services Not Subject to the Medical Deductible

You don't have to pay toward the medical deductible for these services before the plan pays:

• Services covered under the preventive care benefit (includes well-baby care and screening mammograms)
• Certain contraceptive supplies for women.
• Routine vision care (eye exams, eyeglasses, and contact lenses)
• Routine hearing care (hearing exams and hearing aids)
• Select breast pumps during breastfeeding.
• The Quit For Life tobacco cessation program
• Required second opinions (for more information, see page 32 of the UMP Classic 2013 Certificate of Coverage)

Prescription Drug Deductible

You don't pay any deductible for Value Tier or Tier 1 drugs. You must pay a prescription drug deductible to the pharmacy for Tier 2 and Tier 3 prescription drugs before UMP Classic pays benefits. This deductible is $100 per person, or a maximum of $300 for a family (three or more people covered under the same account). You must pay toward this deductible no matter where you get your prescriptions.

Coinsurance

Your plan covers most medical services based on a percentage of the allowed amount providers agree to accept as payment in full. Coinsurance is the percentage of the allowed amount you must pay when the plan pays less than 100% of the allowed amount.

For preferred providers:	15% of the allowed amount.
For out-of-network providers:	40% of the allowed amount, plus any amount billed by the out-of-network provider that is above the allowed amount.*
* See table under "Avoid Using Out-of-Network Providers" for an example of how this works.

Coinsurance also applies to prescription drugs. How much you pay depends on whether the prescription drug is generic, preferred, or nonpreferred.

Copayment

A copayment (also called "copay") is a set dollar amount you pay when you receive specific services, treatments, or supplies, such as inpatient hospitalization or emergency room care. See the Summary of Benefits for specific dollar amounts.