PEBB - Uniform Medical Plan Classic (Medicare)

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Uniform Medical Plan Classic (Medicare)

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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	2012 Coverage
	Member Pays
Deductible What is the difference between deductibles and out-of-pocket maximums?	$250/person $750/family
Out-of-pocket maximum What is the difference between deductibles and out-of-pocket maximums?	$2,500/person $5,000family
Prescription drug deductible	$100/person $300/family

Medical Benefits	2012 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?	$75 copay + 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	$0
Home health	See the plan’s Certificate of Coverage for details.
Hospital services
Inpatient	$200/day $600/admission + 15% professional fees
Outpatient	15%
Obstetric care
Inpatient	Information unavailable, contact your plan
Outpatient	Information unavailable, contact your plan
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	5% (up to $30/90-day supply)
Mail order (up to a 90-day supply) Tier 1	10% (up to $75/90-day supply)
Mail order (up to a 90-day supply) Tier 2	30% up to $225/90-day supply)
Mail order (up to a 90-day supply) Tier 3	50%* (specialty drugs up to $150; no limit for non-specialty)
Retail pharmacy (up to a 30-day supply) Value tier	5% (up to $10/30-day supply)
Retail pharmacy (up to a 30-day supply) Tier 1	10% (up to $25/30-day supply)
Retail pharmacy (up to a 30-day supply) Tier 2	30% (up to $75/30-day supply)
Retail pharmacy (up to a 30-day supply) Tier 3	50%*
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.