Your certificate of coverage is available online. For general topics, check the table of contents. For an overview of the most common benefits, see the “Summary of benefits” section. The summary also shows:
- How much you will pay.
- The page numbers where you may learn more about a benefit.
To look up unfamiliar terms, see the “Definitions” section.
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 $1,600. 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 $3,200. You will pay the entire cost of your medical services and prescription drugs until you meet your deductible unless it is covered preventive care. You will pay the entire cost of your prescription drugs until you meet your deductible unless it is a covered preventive drug, a covered insulin, or as specified in the UMP Preferred Drug List as a prescription drug that the deductible is waived.
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 during the prior plan year. 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 SEBB Program is not allowed to reduce the UMP High Deductible Health Plan 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.
UMP will transfer certain medical and prescription drug accumulators, such as deductibles and out-of-pocket limits, for the existing plan year when subscribers and their enrolled dependents change between the PEBB Program and the SEBB Program during a special open enrollment and stay with UMP. This applies only to subscribers who remain the subscriber, and to enrolled dependents who change plans with the subscriber.
The following out-of-pocket expenses do not count toward your deductible:
- Charges for services that exceed the benefit limit.
- Charges that exceed the maximum dollar limit.
- Out-of-network provider charges above the allowed amount.
- Out-of-pocket costs for services that are not subject to your deductible, 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.
The plan pays the allowed amount for the services listed below, subject to cost-share, 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
- Certain medications covered through the prescription drug benefit as outlined on the UMP Preferred Drug List
- Continuous glucose monitors
- Covered contraceptive supplies and services for women. See the "Family planning services" benefit in your certificate of coverage
- Covered preventive care, including covered immunizations
- Diabetes Management 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 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: When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of-network provider may be allowed to ask you to waive some of your balance billing protections.
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.
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 when you fill your prescription at a network pharmacy.
To learn how much you pay for prescription drugs, see Prescription drug deductible.
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, 2024, or your first day of enrollment (whichever is later) through December 31, 2024, 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.
- Coinsurance for covered prescription drugs paid by the member directly or paid on behalf of the member by another person including payments made through a manufacturer drug coupon or other manufacturer discount.
- Your coinsurance paid to preferred or participating providers
- Your coinsurance paid to out-of-network providers for emergency room services, air ambulance, and nonemergency services furnished during a visit or stay at a preferred and participating hospital, hospital outpatient department, critical access hospital, or ambulatory surgical center
- Your deductible paid to preferred or participating providers
- Your copay for chiropractic, acupuncture, and massage therapy visits after you meet your deductible
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.
- Amounts paid by the plan, including services covered in full
- Your monthly premium
- Your coinsurance paid to out-of-network providers and non-network pharmacies (except those listed above in "What count towards your out-of-pocket limit")
- 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.
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.
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.
When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of-network provider may be allowed to ask you to waive some of your balance billing protections.
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 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.
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. See a list of covered provider types on the Covered provider types webpage.
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.
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.
Use the Pharmacy Locator Tool to find a network pharmacy near you.
WSRxS and SmartHealth do not provide BlueCross BlueShield services and are separate companies solely responsible for their products/services.