PEBB - Uniform Medical Plan

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Contact Information
Benefit Summary

Contact Information

Retirees

Local Phone: 425-686-1350
Toll-Free Phone: 1-800-352-3968
TTY/TDD Phone: 1-888-923-5622 or 360-923-2701
Find a Provider
Visit the Plan's Website

Employees

Local Phone: 425-670-3000
Toll-Free Phone: 1-800-762-6004
TTY/TDD Phone: 1-888-923-5622 or 360-923-2701
Find a Provider
Visit the Plan's Website

Benefit Summary

Medical Benefit	2009 Coverage
Lifetime maximum	None
Annual deductible	Medical Services: Enrollee pays $200 per person/$600 per family (three or more people) Annual deductible does not apply to some benefits, including preventive care. Brand-name prescription drug deductible: Applies to Tier 2 and Tier 3 drugs only; enrollee pays $100 per person/$300 per family (three or more people)
Annual out-of-pocket maximum	Enrollee pays $1,500 per person/$3,000 per family
Office and clinic visits	Enrollee pays 10% coinsurance
Ambulance services (air)	Enrollee pays 20% coinsurance
Ambulance services (ground)	Enrollee pays 20% coinsurance
Chemical dependency services (inpatient)	Maximum payment for all plans is $14,500 per 24 consecutive calendar month period for any combination of inpatient/outpatient treatment Facility Enrollee Pays inpatient hospital copay Professional Services Enrollee pays 10% coinsurance
Chemical dependency services (outpatient)	Enrollee pays 10% coinsurance
Diabetic education Additional education programs available; costs vary	Enrollee pays 10% coinsurance; up to 10 hours per calendar year (see Certificate of Coverage for details)
Diagnostic tests, laboratory, and X-rays	Enrollee pays 10% coinsurance
Durable medical equipment, supplies, and prostheses	Enrollee pays 10% coinsurance
Emergency room (copay waived if admitted directly to hospital)	$75 copay per visit, then enrollee pays 10% coinsurance for physician and other professional provider fees
Hearing (examination)	Covered in full under preventive care benefit; one exam per calendar year
Hearing (hardware)	$800 maxiumum plan payment every three calendar years for hearing aid, and rental/repair combined
Home health care	Enrollee pays 10% coinsurance
Hospice care (including respite care)	Covered in full; $5,000 lifetime maximum plan payment for respite care
Hospital services (inpatient)	$200 copay per day (maximum $600 per person per calendar year), plus 10% coinsurance for professional services
Hospital services (outpatient)	Enrollee pays 10% coinsurance
Massage therapy	Enrollee pays 10% coinsurance, up to 16 visits per calendar year
Mental health care (inpatient)	Facility Enrollee pays inpatient hospital copay Professional Services Enrollee pays 10% coinsurance
Mental health care (outpatient)	Enrollee pays 10% coinsurance per visit, up to 50 visits per year
Physical, occupational, speech, and massage therapies (inpatient)	Does not include massage therapy (see massage therapy benefit) Includes neurodevelopmental therapy Enrollee pays inpatient hospital copay
Physical, occupational, speech, and massage therapies (outpatient)	Does not include massage therapy (see massage therapy benefit) Includes neurodevelopmental therapy Enrollee pays 10% coinsurance per visit, up to 60 visits per calendar year
Prescription drugs, insulin, and disposable diabetic supplies	Up to a 90-day supply for both retail and mail order (annual prescription-drug deductible applies only to Tier 2 and Tier 3 drugs) Retail Tier 1, (generic): 10% coinsurance Tier 2, (preferred brand): 30% coinsurance Tier 3, (nonpreferred brand): 50% coinsurance Note:* Tier 1 and 2 drugs purchased through a network retail pharmacy have a prescription cost-limit of $75 per 30-day supply. Mail order Tier 1, $10 copay Tier 2, $50 copay Tier 3, $100 copay Enrollees pay more for Tier 3 drugs that have a generic equivalent. The plan pays as if the enrollee purchased the generic; the enrollee pays the rest.
Preventive care	Covered in full (not subject to annual medical deductible)
Radiation and chemotherapy services	Enrollee pays 10% coinsurance
Skilled nursing facility care (150 days per benefit period)	Enrollee pays inpatient hospital copay
Spinal manipulations	Enrollee pays 10% coinsurance, up to 10 visits per year
Vision (examinations)	Enrollee pays 10% coinsurance; one annual eye exam (not subject to annual medical deductible)
Vision (hardware)	$150 maximum plan payment every two calendar years for frames, lenses, contacts, and fitting fees combined (not subject to annual medical deductible)