Page 1 of 8
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2022 – 12/31/2022
Washington State – Uniform Medical Plan (UMP) Classic (Medicare) (PEBB) Coverage for: Individual/Family | Plan Type: PPO
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
$250/per member, $750/family
Generally, you must pay all of the costs from providers up to the deductible amount before this
plan begins to pay. If you have other family members on the plan, each family member must
meet their own individual deductible until the total amount of deductible expenses paid by all
family members meets the overall family deductible.
Are there services
covered before you meet
your deductible?
Yes: Covered preventive care,
hearing aids, sterilization, tobacco
cessation and vision hardware are
covered before you meet your
medical deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount.
But a copayment or coinsurance may apply. For example, this plan covers certain preventive
services without cost sharing and before you meet your deductible. See a list of covered
preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other
deductibles for specific
services?
Yes, for prescription drugs:
$100/per member, $300/family for
Tier 2 drugs. There are no other
specific deductibles.
You must pay all of the costs for these services up to the specific deductible amount before this
plan begins to pay for these services.
What is the out-of-pocket
limit for this plan?
Medical: $2,500/per member,
$5,000/family
Prescription drugs:
$2,000/per member, $4,000/family
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other
family members in this plan, they have to meet their own out-of-pocket limits until the overall
family out-of-pocket limit has been met.
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan
would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided
separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit
ump.regence.com/pebb
or call 1-888-849-3681 (TRS: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance,
copayment,
deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary/ or call 1-888-849-3681
(TRS: 711) to request a copy.
Page 2 of 8
Important Questions
Answers
Why This Matters:
What is not included in the
out-of-pocket limit?
Medical: Premiums, balance
billing charges, prescription drug
costs, member coinsurance paid
to out-of-network providers and
non-network pharmacies,
amounts paid for services this
plan doesn’t cover, amounts paid
by the plan, amounts paid for
services over a benefit limit, and
amounts that are more than the
maximum dollar amount paid by
the plan.
Prescription drugs: Costs for
medical services and drugs
covered under the medical benefit,
prescription drugs and products
not covered by the plan, amounts
paid by the plan, and amounts
exceeding the allowed amount for
prescription drugs paid to non-
network pharmacies.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Will you pay less if you
use a network provider?
Yes. Find a doctor at
ump.regence.com/go/pebb/ump-
classic or call 1- 888-849-3681
(TRS: 711) for a list of network
providers (preferred providers). For
a list of network pharmacies, visit
the pharmacy-locator webpage at
ump.regence.com/go/2022/pebb/p
harmacy-locator or call 1-888-361-
1611 (TRS: 711).
This plan uses a provider network. You will pay less if you use a provider or pharmacy in the
plan's network. You will pay the most if you use an out-of-network provider or out-of-network
pharmacy, and you might receive a bill from a provider or pharmacy for the difference between
the provider's or pharmacy’s charge and what your plan pays (balance billing). Be aware, your
network provider (preferred provider) might use an out-of-network provider for some services
(such as lab work). Check with your provider before you get services.
Do you need a referral to
see a specialist?
No.
You can see the specialist you choose without a referral.
* For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc.
Page 3 of 8
Common Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
If you visit a health care
provider’s office or clinic
Primary care visit to treat an
injury or illness
15% coinsurance
40% coinsurance
Not applicable
Specialist visit
15% coinsurance
40% coinsurance
Not applicable
Preventive care/screening/
immunization
No charge
40% coinsurance
You may have to pay for services that aren’t
preventive. Ask your provider if the services
needed are preventive. Then check what your
plan will pay for.
If you have a test
Diagnostic test (x-ray, blood
work)
15% coinsurance
40% coinsurance
Not applicable
Imaging (CT/PET scans,
MRIs)
15% coinsurance
40% coinsurance
Certain tests aren’t covered and other tests
require preauthorization. Please refer to your
plan document. *See section Radiology.
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available at
ump.regence.com/pebb/b
enefits/prescriptions
Value Tier (high value
prescription drugs for chronic
condition)
Tier 1 drugs (low cost generic
prescription drugs)
5% coinsurance or $10
copayment, whichever is
less / prescription
10% coinsurance or
$25 copayment,
whichever is less /
prescription
5% coinsurance
10% coinsurance
Not subject to prescription drug deductible. Cost
based on a 30-day supply. You can receive up
to a 90-day supply for some prescriptions. Cost
share depends on whether you get up to 30
days, 60 days, or 90 days at a time. Tier 1 does
not include high-cost generic drugs. You can
receive up to a 90-day supply for some
prescriptions. Preauthorization may be required.
*See section Your prescription drug benefit.
Postal Prescription Services (PPS) is the plan’s
only network mail-order pharmacy.
Tier 2 Drugs (preferred brand
drugs and high cost generic
drugs)
30% coinsurance or
$75 copayment,
whichever is less /
prescription
30% coinsurance
Subject to prescription drug deductible except
covered insulins. Cost based on a 30-day supply.
You can receive up to a 90- day supply for some
prescriptions. Cost share depends on whether you
get up to 30 days, 60 days, or 90 days at a time.
Tier 2 includes some high-cost generic drugs.
Preauthorization may be required. *See section
Your prescription drug benefit. Note: PPS is the
plan’s only network mail-order pharmacy.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
* For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc.
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Common Medical Event
Services You May Need
Network Provider (You
will pay the least)
Out-of-Network Provider
(You will pay the most)
Specialty drugs
Value Tier: 0-30 day
supply: 5% coinsurance or
$10 copayment, whichever
is less / prescription
Tier 1: 0-30 day supply:
10% coinsurance or
$25 copayment, whichever
is less / prescription
Tier 2: 0-30 day supply:
30% coinsurance or
$75 copayment, whichever is
less / prescription
Not covered
No prescription drug deductible for Value Tier
and Tier 1. Prescription drug deductible applies
to Tier 2. Costs based on a 0-30-day supply.
Covers up to a 30-day supply for most specialty
prescription drugs.Preauthorization may be
required. *See section Your prescription drug
benefit. Most prescriptions must be filled from the
specialty pharmacy Ardon Health, except when a
drug can only be dispensed by a certain
pharmacy.
If you have outpatient
surgery
Facility fee (e.g., ambulatory
surgery center)
15% coinsurance
40% coinsurance
Not applicable
Physician/surgeon fees
15% coinsurance
40% coinsurance
Preauthorization may be required. *See section
Surgery.
If you need immediate
medical attention
Emergency room care
$75 copayment per visit;
15% coinsurance
$75 copayment per visit;
15% coinsurance
Emergency room copayment is waived if admitted
directly to a hospital or facility as inpatient from the
emergency room (but you will pay an inpatient
copayment).
Emergency medical
transportation
20% coinsurance
20% coinsurance
Coverage is not provided for air or water
ambulance if ground ambulance would serve the
same purpose. Ambulance services for personal
or convenience purposes are not covered.
Urgent care
15% coinsurance
40% coinsurance
Not applicable
If you have a hospital stay
Facility fee (e.g., hospital
room)
$200 copayment per day up
to $600 per member per
admission
40% coinsurance
Provider must notify plan on admission.
Physician/surgeon fees
15% coinsurance
40% coinsurance
Preauthorization may be required. *See section
Surgery.
Page 4 of 8
* For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc.
Common Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Network Provider (You
will pay the least)
Out-of-Network Provider
(You will pay the most)
If you need mental health,
behavioral health, or
substance abuse services
Outpatient services
15% coinsurance
40% coinsurance
Preauthorization may be required. No coverage
for marriage or family counseling. *See section
Behavioral health.
Inpatient services
$200 copayment per day up
to $600 per member per
admission. Professional
services: No charge
40% coinsurance
Preauthorization required for inpatient admissions.
Provider must notify the plan for detoxification,
intensive outpatient program, and partial
hospitalization. *See section Behavioral health.
If you are pregnant
Office visits
15% coinsurance
40% coinsurance
Cost sharing does not apply for preventive
services. Depending on the type of services,
copayment, coinsurance, or deductible may apply.
Maternity care may include tests and services
described elsewhere in the SBC (i.e., ultrasound).
Childbirth/delivery
professional
services
15% coinsurance
40% coinsurance
Elective deliveries before 39 weeks gestation
covered only if medically necessary.
Childbirth/delivery
facility services
$200 copayment per day
up to $600 per member
per admission
40% coinsurance
Elective deliveries before 39 weeks gestation
covered only if medically necessary.
If you need help
recovering or have other
special health needs
Home health care
15% coinsurance
40% coinsurance
Custodial care, maintenance care, and private
duty or continuous care in the member’s home
are not covered.
Rehabilitation services
Inpatient: $200 copayment
per day up to $600 per
member per admission
Professional services:
15% coinsurance
40% coinsurance
The total limit for therapies for inpatient
habilitative and inpatient rehabilitative services is
a combined limit of 60 days annually. The total
limit for therapies for outpatient habilitative and
outpatient rehabilitative services is a combined
limit of 60 visits annually. Inpatient admissions
for rehabilitation services must be
preauthorized. *See section Therapy:
Habilitative and rehabilitative.
Habilitation services
Inpatient: $200 copayment
per day up to $600 per
member per admission
Professional services: 15%
coinsurance
40% coinsurance
Coverage includes neurodevelopmental
therapy. The total limit for therapies for inpatient
habilitative and inpatient rehabilitative services
is a combined limit of 60 days annually.
Inpatient admissions for habilitation services
must be preauthorized. *See section Therapy:
Habilitative and rehabilitative.
Page 5 of 8
* For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc.
Common Medical Event
Services You May Need
What You Will Pay
Limitations, Exceptions, & Other Important
Information
Network Provider
(You will pay the least)
Out-of-Network Provider
(You will pay the most)
Skilled nursing care
Inpatient: $200
copayment per day up
to $600 per member
per admission
Professional services:
15% coinsurance
40% coinsurance
Coverage is limited to 150 days per calendar year.
Services must be preauthorized. *See section
Skilled nursing facility.
Durable medical equipment
15% coinsurance
40% coinsurance
Foot orthotics are covered only for prevention of
diabetic complications.
Hospice services
No charge
40% coinsurance
Hospice coverage is limited to 6 months.
Coverage for respite care is limited to 14
visits per the patient’s lifetime.
If your child needs dental
or eye care
Children’s routine eye exam
No charge
Not subject to the
deductible
Not covered
Coverage for children under the age of 19. You
pay $0 of the allowed amount when you see a
VSP Choice network provider for one covered
preventive eye exam with refraction or visual
analysis per calendar year.
Children’s glasses or contact
lenses
No charge
Not subject to the
deductible
Not covered
There is no contact lens fitting fee. Coverage for
children under the age of 19. Vision coverage is
provided by UMP, in collaboration with Regence
Choice Vision Plan administered by Vision
Service Plan (VSP).
Children’s dental check-up
Not covered
Not covered
Not applicable
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Computed Tomographic Colonography for
routine colorectal cancer screening
• Coronary or cardiac artery calcium scoring
• Cosmetic services or supplies
• Custodial care
• Dental care (Adult)
• Immunizations for travel or employment
• Infertility or fertility testing or treatment after
initial diagnosis
• Long-term care
• Maintenance care
• Marriage or family counseling
• Massage therapy services when the
massage therapist is not a preferred provider
• Medical foods or food supplements
• Medications for sexual dysfunction
• MRI, upright
• Private-duty or continuous care in the
member’s home
• Replacement of lost, stolen, or
damaged durable medical equipment
• Vitamins
• Weight loss programs and drugs
Page 6 of 8
Page 7 of 8
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture (24-visit limitation)
• Bariatric surgery
• Chiropractic care (24-visit limitation)
• Hearing aids
• Non-emergency care when traveling outside
the U.S.
• Routine eye care (Adult)
• Routine foot care
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1 (877) 267-2323 ext. 61565 or
cciio.cms.gov or your state insurance department. You may also contact the plan at 1-888-849-3681 (TRS: 711). Other coverage options may be available to you too,
including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call 1-
800-318-2596.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is
called a grievance or appeal. For more information about your rights, look at the explanation of benefits you receive for that medical claim. Your plan document
also provides complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or
assistance, contact: UMP Customer Service at 1-888-849-3681 (medical benefits) (TRS: 711); Washington State Rx Services at 1-888-361-1611 (prescription
benefits) (TRS: 711). The Consumer Protection Division of the Office of the Insurance Commissioner (OIC) is currently designated by the U.S. Department of
Health and Human Services as the official ombudsman in the State of Washington for consumers who have questions or complaints about health care appeals.
Consumers may contact the OIC Consumer Hotline number at 1-800-562-6900.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare,
Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the
premium tax credit.
Does this plan meet the Minimum Value Standards? Yes.
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
[Spanish (Español): Para obtener asistencia en Español, llame al 1-888-849-3681 (TRS: 711).]
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-849-3681 (TRS: 711).]
[Chinese (中文): 如果需要中文的帮助, 请拨打这个号码 1-888-849-3681 (TRS: 711).]
[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-849-3681 (TRS: 711).]
PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-
05, Baltimore, Maryland 21244-1850.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 8 of 8
About these Coverage Examples:
◼ The plan’s overall deductible $250
◼ Specialist coinsurance 15%
◼ Hospital (facility) copayment $200
◼ Other coinsurance 15%
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/Delivery Professional Services
Childbirth/Delivery Facility Services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
◼ The plan’s overall deductible $250
◼ Specialist coinsurance 15%
◼ Hospital (facility) copayment $200
◼ Other coinsurance 15%
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (insulin pumps and
insulin pump supplies)
◼ The plan’s overall deductible $250
◼ Specialist coinsurance 15%
◼ Hospital (facility) copayment $200
◼ Other coinsurance 15%
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy)
The plan would be responsible for the other costs of these EXAMPLE covered services.
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans. Please note these coverage examples are based on self-only coverage.
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
$250
Copayments
$200
Coinsurance
$700
What isn’t covered
Limits or exclusions
$60
The total Peg would pay is
$1,210
Total Example Cost
$5,600
In this example, Joe would pay:
Cost Sharing
Deductibles
$250
Copayments
$0
Coinsurance
$1,200
What isn’t covered
Limits or exclusions
$200
The total Joe would pay is
$1,650
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Deductibles
$250
Copayments
$80
Coinsurance
$400
What isn’t covered
Limits or exclusions
$0
The total Mia would pay is
$730
Peg is Having a Baby
(9 months of in-network pre-natal care and a
hospital delivery)
Managing Joe’s Type 2 Diabetes
(a year of routine in-network care of a well-
controlled condition)
Mia’s Simple Fracture
(in-network emergency room visit and follow up
care)
