Understanding coverage - PEBB

Understanding your coverage

Your UMP health plan is a valuable benefit that includes medical and prescription drug coverage to help you stay healthy and pay for the cost of an illness or injury. Many preventive care services—including routine annual physical exams and certain immunizations—are covered at no cost when you see a preferred or network provider. For everything else, your cost for care is determined in these ways:

 Know your costs

Learn more about the medical and prescription drug costs specific to your UMP health plan.

UMP Classic


UMP Plus

 Plan basics

Deductible: The amount you must pay each calendar year for medical and/or prescription drug expenses before the plan starts paying for covered services.

Coinsurance:The percentage of the allowed amount you must pay the provider on claims for which the plan pays less than 100 percent of the allowed amount. This includes most medical services and prescription drugs.

Out-of-pocket limit: The most you pay for covered medical services and prescription drugs during a calendar year before the plan pays 100% of the allowed amount

Copay: The set dollar amount you pay when receiving specific services, treatments, or supplies, such as inpatient hospitalization or emergency room visits.

 Understanding benefit limits and exclusions

To avoid unplanned costs, it’s a good idea to become familiar with the benefit limits and exclusions of your UMP health plan. A limited benefit is a benefit that is limited to a certain number of visits or a maximum dollar amount. The limit applies to these benefits even if the provider prescribes additional visits and even if the visits are medically necessary. UMP does not make exceptions to benefit limits. Read your plan’s certificate of coverage to learn which services have a benefit limit.

Other benefits have additional limits related to medical necessity or pre-authorization of services. Read your plan’s certificate of coverage to learn more.

Exclusions are non-covered services and refers to any service that is not covered by the plan. Some services may be medically necessary, yet still are not covered. See “What the plan does not cover" and “Guidelines for drugs not covered" in your plan’s certificate of coverage.

 When to submit a medical claim

There are some circumstances in which you need to submit a claim to your UMP health plan. Learn more in the Claims & appeals section of this website.