UMP Classic - Understanding medical and Rx coverage - PEBB

UMP Classic 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.

 Medical deductible

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

The medical deductible amount is $250 per member, with a maximum of $750 per family. When you first get services, you pay the first $250 in charges. After you pay that first $250, the plan begins to pay for covered services. This applies to each covered member, up to the $750 maximum.

If your family has four or more members enrolled, each member has a medical deductible of $250, and the maximum the family pays toward medical deductibles is $750. Once a member pays their $250 deductible, the plan begins paying for covered services for that member. Because the plan is now paying for this member’s covered services, they are no longer contributing toward the family deductible. Once the family deductible has been met, the plan begins paying for all covered services for all enrolled family members, even if some have not met their own deductible.

If the subscriber earned the SmartHealth wellness incentive for the 2022 plan year, the subscriber's medical deductible is reduced. The subscriber is the only family member eligible to earn this incentive.

 What does not count toward your medical deductible

The following out-of-pocket expenses do not count toward your $250 medical 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 toward your medical deductible.
  • Charges for services over benefit maximums. Charges over this amount do not apply to your medical deductible.
  • Out-of-network provider charges above the allowed amount (see example)
  • Prescription drug costs
  • Services that are exempt from the medical deductible, even if you had out-of-pocket costs. For example, covered preventive care received from an out-of-network provider.
  • Services you pay for that are not covered by the plan.
  • Your emergency room copay
  • Your inpatient hospital copay
  • Your chiropractor copay
  • Your acupuncture copay
  • Your massage therapy copay
 Services exempt from the medical deductible

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

 Medical coinsurance

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

After you meet your medical deductible, you pay the percentages described below for most covered 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 for 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.

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

 Copay

A copay is a set dollar amount you pay when you receive services, treatments, or supplies, including, but not limited to:

  • Emergency room copay: $75 per visit
  • Facility charges for services received while an inpatient at a hospital, or mental health, skilled nursing, or substance use disorder facility: $200 per day
  • Covered chiropractic, acupuncture, and massage services when you see a preferred provider will have a $15 copay per visit. The copay for these services will apply toward the annual out-of-pocket maximums.

Read the copay section of your certificate of coverage for more information.

 Medical out-of-pocket limit

The medical out-of-pocket limit is the most you pay during a calendar year for covered services from preferred providers. After you meet your medical 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 medical deductible, coinsurance to preferred providers, and inpatient and emergency room copays all count toward your medical out-of-pocket limit.

Your medical out-of-pocket limit depends on your enrollee type:

  • Employees and retirees not enrolled in Medicare, including dependents: $2,000 per person and $4,000 per family*
  • Retirees enrolled in Medicare Part A and Part B, including dependents: $2,500 per person and $5,000 per family*

*"Family" is defined as all eligible family members (subscriber and dependents) who are enrolled on a single account.

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 medical out-of-pocket limit
  • Amounts paid by the plan, including services covered in full
  • Costs you pay under the prescription drug benefit including the prescription drug deductible and coinsurance
  • Your monthly premiums
  • 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 medical 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 the patient's 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.

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

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.

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.

 Prescription drug deductible
  • You pay a prescription drug deductible when you purchase Tier 2 drugs, except for covered insulins. You do not pay any deductible for Preventive, Value Tier, Tier 1 drugs, or covered insulins.
  • The prescription drug deductible is $100 per member, with a maximum of $300 for a family of three or more members covered under the same account. You pay this deductible to the pharmacy when you purchase a prescription drug to which it applies. For complete information, read the Prescription drug deductible section in your plan's certificate of coverage.
  • Once you meet the deductible, you only pay your coinsurance (a percentage of the covered drug's price) at network pharmacies for all tiers except Preventive.
  • The amount you pay depends on the tier of your prescription drug. Find your drug's tier by searching the UMP Preferred Drug List.
  • Where you purchase your prescriptions also affects how much you will pay. Visit the Prescription drugs page for more information. You may get up to a 90-day supply for most drugs—except for specialty drugs, which are usually limited to a maximum 30-day supply.
  • See the Prescription drug deductible and coinsurance table.
 Prescription drug out-of-pocket limit

The prescription drug out-of-pocket limit is the most you pay during a calendar year for covered prescription drugs and products. After you meet this limit, the plan pays for covered prescription drugs and products at 100% of the allowed amount. Your prescription drug deductible and your prescription drug coinsurance, up to the prescription cost-limit (when it applies), all count toward your prescription drug out-of-pocket limit.

For each member enrolled in the plan, your prescription out-of-pocket limit is $2,000 per member and $4,000 per family. "Family" means all members combined under one subscriber's account. Each member must meet their own prescription drug out-of-pocket limit separately until the family limit is reached.

After you reach your prescription out-of-pocket limit, you are still responsible for paying for the items listed below in “What does not count toward your prescription drug out-of-pocket limit?”

 What does not count toward your prescription drug out-of-pocket limit
  • Amounts paid by the plan, including services covered in full
  • Amounts exceeding the allowed amount for prescription drugs paid to non-network pharmacies (this is called balance billing)
  • Prescription drugs and products not covered by the plan
  • Costs for medical services, including prescription drugs covered under the medical benefit
 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 based on the Tier 2 cost-share (30% of the allowed amount, $75 maximum payment per 30-day supply). 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 for the Tier 2 drugs listed assume you’ve met your prescription drug deductible. For these Tier 2 drugs, you will pay the entire cost of prescription drugs until you meet your prescription drug deductible. Once you have met this deductible for the year, you only pay your coinsurance.

 Pharmacy Locator

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

Prescription drug deductible and coinsurance

Tier and description

Non-specialty drugs
All network pharmacies (retail and mail-order)

Specialty drugs
Must be purchased from Ardon Health, except when a drug can only be dispensed by certain pharmacies

Preventive
Preventive drugs required under PPACA* or recommended by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices of the CDC.**

No deductible

0% coinsurance

No deductible

0% coinsurance

Value tier
Specific high-value prescription drugs used to treat certain chronic conditions.

No deductible

0–30 day supply:
5% coinsurance or $10, whichever is less

31–60 day supply:
5% coinsurance or $20, whichever is less

61–90 day supply:
5% coinsurance or $30, whichever is less

No deductible

0–30 day supply:
5% coinsurance or $10, whichever is less

Tier 1
Primarily low-cost generic prescription drugs.

No deductible

0–30 day supply:
10% coinsurance or $25, whichever is less

31–60 day supply:
10% coinsurance or $50, whichever is less

61–90 day supply:
10% coinsurance or $75, whichever is less

No deductible

0–30 day supply:
10% coinsurance or $25, whichever is less

Tier 2
Preferred brand-name drugs and high-cost generic drugs.

Deductible applies

0–30 day supply:
30% coinsurance or $75, whichever is less

31–60 day supply:
30% coinsurance or $150, whichever is less

61–90 day supply:
30% coinsurance or $225, whichever is less

Deductible applies

0–30 day supply:
30% coinsurance or $75, whichever is less

*Patient Protection and Affordable Care Act
**Centers for Disease Control

Return to Prescription drug deductible.

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