PEBB - Uniform Medical Plan (UMP) CDHP

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Uniform Medical Plan (UMP) CDHP

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Contact Information

Uniform Medical Plan (administered by Regence BlueShield)

Toll-Free: 1-888-849-3681
TTY: 711
Find a Provider | Visit the Plan's Website

Benefits Booklet (Certificate of Coverage)

If you have questions about the certificate of coverage, or to receive a copy, contact the plan.

Benefits Summary

Annual Costs	2013 Coverage
	Member Pays
Deductible What is the difference between deductibles and out-of-pocket maximums?	$1,400/individual $2,800/Subscriber with 1 or more dependents (must meet family deductible before plan pays benefits)
Out-of-pocket maximum What is the difference between deductibles and out-of-pocket maximums?	$4,200 individual/$8,400 family (must meet family out-of-pocket maximum before plan pays 100%)
Prescription drug deductible	Included in deductible

Medical Benefits	2013 Coverage
	Member Pays
Ambulance
Per trip, air	20%
Per trip, ground	20%
Diagnostic tests, laboratory, and x-rays	15%
Durable medical equipment, supplies, and prostheses	15%
Emergency room (Copay waived if admitted) When should I go to the emergency room?	15%
Hearing
Hardware	Any amount over $800 every 36 months after deductible has been met for hearing aid and rental/repair combined.
Routine annual exam	15%
Hospital services
Inpatient	15%
Outpatient	15%
Office visit
Chemotherapy	15%
Mental health	15%
Primary care	15%
Radiation	15%
Specialist	15%
Urgent care	15%
Physical, occupational, and speech therapy (Per-visit cost for 60 visits/year combined)	15%
Prescription drugs How can I find out more about drugs and supplements?
Mail order (up to a 90-day supply) Value tier	15%
Mail order (up to a 90-day supply) Tier 1	15%
Mail order (up to a 90-day supply) Tier 2	15%
Mail order (up to a 90-day supply) Tier 3	15%*
Retail pharmacy (up to a 30-day supply) Value tier	15%
Retail pharmacy (up to a 30-day supply) Tier 1	15%
Retail pharmacy (up to a 30-day supply) Tier 2	15%
Retail pharmacy (up to a 30-day supply) Tier 3	15%*
Preventive care Which immunizations are needed and when?	$0; See certificate of coverage or check with plan for full list of services.
Spinal manipulations	15%
Vision care
Exam (annual)	$0
Glasses and contact lenses	Any amount over $150 every 24 months (or two calendar years for UMP) for frames, lenses, contacts, and fitting fees combined.

UMP members who see an out-of-network provider will pay 40% of the allowed amount plus the amount the provider charged that was more than the allowed amount.

* May also be subject to an ancillary charge if drug has an available generic equivalent.