UMP CDHP - PEBB

UMP CDHP medical and prescription drug coverage

 UMP 2022 premiums

For UMP 2022 premiums, visit the Health Care Authority (HCA) website (public employees, retirees, or PEBB Continuation Coverage).

Note: Non-represented ESD employees and employees who work for an educational service district, city, tribal government, county, port, water district, hospital, etc., must contact their payroll or benefits office to get their monthly premium costs.

 Deductible

A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying for covered services.

The deductible amount for a single person (subscriber only) enrolled in the plan is $1,400. For most covered services and covered prescription drugs, you pay your providers and pharmacies until you meet your deductible for the year, then the plan begins to pay benefits for your care.

For more than one person enrolled in the plan, the deductible is $2,800. You will pay the entire cost of your medical services and prescription drugs until you meet your deductible unless it is covered preventive care, a covered preventive drug, or a covered insulin.

As a plan subscriber, you can earn a one-time deposit of $125 into your health savings account (HSA) when you earn the SmartHealth wellness incentive. The subscriber is the only family member eligible to earn this incentive. A federal requirement mandates a minimum deductible for high-deductible health plans (HDHPs). Therefore, the PEBB Program is not allowed to reduce the UMP CDHP deductible.

The deposit counts toward your HSA’s maximum annual contribution. You may need to adjust your payroll contributions to make sure you don’t exceed your maximum allowed contribution for the year.

 What does not count toward your deductible

The following out-of-pocket expenses do not count toward your deductible:

  • Charges for service visits over benefit limits. For example, the annual benefit limit for physical therapy is 60 visits. Costs for more than 60 visits are not covered by the plan, and do not count to your deductible.
  • Charges for services over benefit maximums. Charges over this amount do not apply toward your medical deductible.
  • Out-of-network provider charges above the allowed amount (see example).
  • Services that are exempt from the deductible, even if you had out-of-pocket costs, except when you pay for covered insulins. For example, covered preventive care received from an out-of-network provider.
  • Services you pay for that are not covered by the plan.
 Services exempt from the deductible

The plan pays the allowed amount for services (subject to cost-share) listed below even if you have not met your deductible. When you see a preferred or participating provider, you do not have to meet your deductible before the plan pays for these services:

  • Blood pressure monitor if you have a diagnosis of high blood pressure
  • Covered contraceptive supplies and services for women
  • Covered preventive care, including covered immunizations
  • Diabetes Control Program
  • Diabetes Prevention Program
  • Hemoglobin A1c testing, and retinopathy screening if you have a diagnosis of diabetes
  • International Normalized Ratio (INR) testing if you have a diagnosis of liver disease and/or bleeding disorders
  • Low-Density Lipoprotein (LDL) testing if you have a diagnosis of heart disease
  • Peak flow meter if you have a diagnosis of asthma
  • Second opinions required by the plan
  • Tobacco cessation services
 Coinsurance

Coinsurance is the percentage of the allowed amount that you pay for most medical services and for prescription drugs when the plan pays less than 100%.

After you meet your deductible, you pay the following percentages:

Most medical services:

  • For preferred providers: You pay 15% of the allowed amount. The plan pays 85% of the allowed amount.
  • For participating providers: You pay 40% of the allowed amount. The plan pays most covered services at 60% of the allowed amount.
  • For out-of-network providers: You pay 40% of the allowed amount and the provider may balance bill you. The plan pays most covered services at 60% of the allowed amount.

Professional charges, such as for physician services while you are in the hospital or lab work, may be billed separately.

Note: At a network facility, when you receive surgery, anesthesia, pathology, radiology, laboratory, or hospitalist services from an out-of-network provider at a network hospital or network ambulatory surgical facility in Washington, you cannot be balance billed.

At an out-of-network facility, when you receive emergency services you pay the network cost-sharing amount regardless of the network status of the provider or facility and cannot be balance billed.

Some providers are preferred at one practice location but not another. Please call UMP Customer Service if you have any questions about the network status of a provider at a specific location.

For more information about how much you will pay for services, read the Summary of services and payments section in your plan’s certificate of coverage.

Prescription drugs:

Once you have met your deductible, you pay 15% of the allowed amount for covered prescription drugs when purchased through a network pharmacy up to your out-of-pocket limit. You may get up to a 90-day supply for most prescription drugs (except for specialty drugs). You pay $0 for covered preventive drugs when you use a network pharmacy.

For covered insulins, see the What you pay for prescription drugs section in your plan’s certificate of coverage for how much you will pay for covered insulins when you fill your prescription at a network pharmacy.

To learn how much you pay for prescription drugs, see Prescription drug deductible.

 Out-of-pocket limit

The out-of-pocket limit is the most you pay during a calendar year for covered services from preferred providers. After you meet your out-of-pocket limit for the year, the plan pays for covered services by preferred providers at 100% of the allowed amount. The plan will not pay more than the allowed amount. Expenses are counted from January 1, 2022, or your first day of enrollment (whichever is later) through December 31, 2022, or your last day of enrollment (whichever is earlier).

Your out-of-pocket limit depends on the number of persons enrolled in the plan:

  • One member enrolled: $4,200.
  • Two or more members enrolled: $8,400. Once a member meets $7,000 in covered out-of-pocket expenses annually, the plan will pay for covered services at 100% for that member.

After reaching your out-of-pocket limit, you are still responsible for certain medical costs, like your monthly premiums, services not covered by the plan, and coinsurance paid to out-of-network providers. Also, some fees do not count toward your out-of-pocket limit. Read below to learn what does not count toward your out-of-pocket limit.

 What does not count toward your out-of-pocket limit
  • Amounts paid by the plan, including services covered in full
  • Your monthly premium
  • Your coinsurance paid to participating and out-of-network providers, and non-network pharmacies
  • Balance billed amounts
  • Amounts paid for services the plan does not cover
  • Amounts that are more than the maximum dollar amount paid by the plan. Any amount you pay over the allowed amount does not count toward the out-of-pocket limit.
  • Amounts paid for services over a benefit limit. For example, the benefit limit for acupuncture is 24 visits. If you have more than 24 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit.
 When you do not have access to a preferred provider: network waiver

An approved network waiver allows the plan to pay for services provided by an out-of-network provider at the network rate. You may request a network waiver only when you do not have access to a preferred provider able to provide medically necessary services within 30 miles of your residence. A service or supply prescribed, ordered, recommended, approved, or given by a provider does not make it a medically necessary covered service or supply.

See your plan’s certificate of coverage for details about network waivers.

 Not all providers at a network hospital are network providers

Some providers who work in a network hospital or other network facility, including, but not limited to, anesthesiologists and emergency room doctors, may not be preferred providers.

At network facilities, when you receive surgery, anesthesia, pathology, radiology, laboratory, emergency department, or hospitalist services from an out-of-network provider at a network hospital or network ambulatory surgical facility in Washington, you will pay the network cost-sharing amount and cannot be balance billed.

If a participating or out-of-network provider bills separately from the hospital, you pay 40% of the allowed amount.

To find out the network status of anesthesiologists and emergency room doctors in Washington state hospitals, call UMP Customer Service.

 Out-of-network provider services

Out-of-network providers are not contracted with Regence BlueShield or another BlueCard® network.

You pay 40% of the allowed amount after you meet your medical deductible. The plan pays most covered services at 60% of the allowed amount. Even after you meet your medical out-of-pocket limit, you still pay 40% coinsurance for participating and out-of-network provider services. Out-of-network providers may balance bill you.

Note: The 40% coinsurance you pay to an out-of-network provider, and any balance billed amounts, do not count toward your medical out-of-pocket limit. Balance-billed amounts never apply toward your medical deductible or out-of-pocket limit.

Here are some other things to keep in mind when seeing out-of-network providers:

  • You may have to pay all charges at the time of service and then send a claim form to the plan for reimbursement.
  • The provider may not request pre-authorization for services that require it. As a result, payment may be delayed or denied.
  • Non-network pharmacies will not know if a prescription drug must be authorized, has a quantity limit, or has other coverage limits. If you purchase a drug from a non-network pharmacy and limits apply, the plan may not cover or reimburse it.
 Costs for providers by type

The plan pays the allowed amount for covered services only when performed by covered provider types within the scope of their license(s). When a facility charges facility fees, the plan pays the allowed amount if the services are covered services and are within the scope of the facility's license. For additional information on how much you pay for services for the plan's many provider types, consult your plan's certificate of coverage.

 Requesting an exception for noncovered drugs

If you are prescribed a noncovered drug, and you have tried all the alternative drugs and none are found to be effective, or if the alternatives are found to be not medically appropriate, you or your prescriber may request an exception by calling Washington State Rx Services (WSRxS). WSRxS will work with your prescribing provider to submit the required clinical information. When an exception is approved by the plan, you will pay 15% of the drug’s cost per 30-day supply after you pay your deductible. For more information, read the Requesting an exception for noncovered prescription drugs section in your plan’s certificate of coverage.

 Prescription Drug Price Check Tool

Use the Prescription Drug Price Check tool to estimate the cost of your drug. The prices listed assume you have met your combined (medical and prescription drug) deductible. You will pay the entire cost of prescription drugs until you meet your combined deductible. Once you have met your deductible for the year, you only pay your coinsurance.

 Pharmacy Locator

Use the Pharmacy Locator Tool to find a network pharmacy near you.

Washington State Prescription Services, Ardon Health, and SmartHealth do not provide BlueCross BlueShield services and are separate companies solely responsible for their products/services.