PEBB - Uniform Medical Plan (UMP Classic)

Notice

The HCA will close its Lacey office at 3 p.m. Friday, February 17, to relocate staff to its office at Cherry Street Plaza, 626 8th Avenue SE, in Olympia. Details.

Coverage

My Account

PEBB Program

How Do I

Joining PEBB

PEBB Administration

Wellness

HCA Tools & Software

Uniform Medical Plan (UMP Classic)

Print Email

Bookmark & Share

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)

2011 Uniform Medical Plan Certificate of Coverage

The 2012 benefits booklet will be posted as soon as they are available. 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?	$2,000/person $4,000/family
Prescription drug deductible	$100/person $300/family (Tier 2 and 3 drugs)

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	15%
Hospital services
Inpatient	$200/day; $600 maximum/year per person + 15% professional fees
Outpatient	15%
Mental health care
Outpatient	Information unavailable, contact your plan
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.

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.