UMP Plus - Understanding medical and Rx coverage - SEBB

UMP Plus medical and prescription drug coverage

 UMP 2022 premiums

For UMP 2022 premiums, visit the Health Care Authority (HCA) website (school employees or SEBB Continuation Coverage).

 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 $125 per member, with a maximum of $375 per family. When you first get services, you pay the first $125 in charges. After you pay that first $125, the plan begins to pay for covered services. This applies to each covered member, up to the $375 maximum for a family of three or more on one account.

If your family has four or more dependents enrolled, each member has a medical deductible of $125, and the maximum the family pays toward medical deductibles is $375. Once a member pays their $125 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 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 by $125. The subscriber is the only family member eligible to earn this incentive. You do not pay a deductible for prescription drugs.

 What does not count toward your medical deductible

The following out-of-pocket expenses do not count toward your $125 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 for PSHVN or UW Medicine ACN).
  • 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 your plan (see PSHVN or UW Medicine ACN).
  • 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 network 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 primary care providers in the core network: You pay nothing for office visits. You pay 15% of the allowed amount for other services not considered preventive you receive (like labs or x-rays) during a primary care office visit after you meet your deductible.
  • For specialty providers in the core or support networks: You pay 15% of the allowed amount after you meet your medical deductible.
  • For out-of-network providers: You pay 50% of the allowed amount after you meet your medical deductible and the provider may balance bill you, which means you pay any amount an out-of-network provider bills that is above 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.

For information on how much you will pay for services, read the "Summary of services and payments" section in your plan's certificate of coverage (PSHVN or UW Medicine ACN).

To learn about prescription drug coinsurance, see the Prescription drug coinsurance table.

 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 network 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 (PSHVN or UW Medicine ACN).

 Medical out-of-pocket limit

The medical out-of-pocket limit is the most you pay during a calendar year for covered services from network providers. After you meet your medical out-of-pocket limit for the year, the plan pays for covered services from network 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, inpatient and emergency room copays, coinsurance to covered providers in the core and support networks (and other providers for certain approved services), chiropractic, acupuncture, and massage therapy visit copays all count toward your medical out-of-pocket limit.

Your medical out-of-pocket limit is $2,000 per member, and $4,000 per family. “Family” is defined as all eligible family members (subscriber and dependents) who are enrolled on a single account.

 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 coinsurance
  • Your monthly premiums
  • Your coinsurance paid to 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.
 Network consent for out-of-network services

An approved network consent allows the plan to pay for services provided by an out-of-network provider at the network rate. If the network approves a network consent, the plan pays at the network rate (85% of the allowed amount) for services received from an out-of-network provider. An out-of-network consent must be submitted and approved prior to the service being performed.

To learn more, read the "Network consent for out-of-network services" section in your plan's certificate of coverage (PSHVN or UW Medicine ACN) section in your plan's certificate of coverage.

 Not all providers at a network hospital are network providers

Some providers who work in a network hospital or other network facility may not be network 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 an out-of-network provider bills separately from the hospital, you will pay 50% 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

If you see a provider with Regence who is not in the core or support network, they are considered out-of-network. If you see an out-of-network provider, you will pay 50% of the allowed amount, plus any amount the provider charges above the allowed amount (called balance billing).

Even after you meet your medical out-of-pocket limit, you still pay 50% coinsurance for out-of-network provider services. Out-of-network providers may balance bill you.

Note: The 50% 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.

 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 (PSHVN or UW Medicine ACN).

 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 coinsurance, up to the prescription cost-limit (when it applies), counts 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
  • Prescription drugs and products not covered by the plan
  • Costs for medical services, including prescription drugs covered under the medical benefit

See the Prescription drug coinsurance table.

 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 (PSHVN or UW Medicine ACN).

Your prescribing provider can also use CoverMyMeds to request an exception. CoverMyMeds is a free online platform that reviews exception requests from electronic health record systems or directly through the CoverMyMeds portal. To get started, have your provider visit the CoverMyMeds website at covermymeds.com.

 Prescription Drug Price Check Tool

Use the Prescription Drug Price Check tool to estimate the cost of your drug. UMP Plus does not have a prescription drug deductible so the prices shown are an estimate of what you will pay.

 Pharmacy Locator

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

Prescription drug 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**.

0% coinsurance

0% coinsurance

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

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

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

Tier 1
Primarily low-cost generic prescription drugs.

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

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

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

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

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 out-of-pocket limit.

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