UMP Classic (PEBB) Certificate of Coverage (COC) 2023

HCA 54-0015 (10/22)

Printed under the direction of the Washington State Health Care Authority Public Employees Benets Board (PEBB)

Self-insured by the State of Washington · Eective January 1, 2023

2023 UMP Classic (PEBB)

Certicate of Coverage

2023 UMP Classic (PEBB) Certificate of Coverage 1

other documents. How much you pay

depends on the provider’s network status:

• Preferred facility: You pay 15% of the

allowed amount; the provider cannot

balance bill you.

• Participating facility: You pay 40% of the

allowed amount; the provider cannot

balance bill you.

• Out-of-network facility: You pay 40% of

the allowed amount; the provider may

balance bill you.

• Preferred facility: The plan

pays 85% of the allowed

amount.

• Participating facility: The plan

pays 60% of the allowed

amount.

• Out-of-network facility: The

plan pays 60% of the allowed

amount.

Special

These services have unique payment rules,

which are described in the “How much you

will pay” column in the Summary of benefits

table located in the “Summary of benefits”

section.

What else you need to know

• Some services are not covered (see the “What the plan does not cover” section).

• There is no waiting period for preexisting conditions.

• You will save money by seeing preferred providers (see the “Finding a health care provider” section).

2023 UMP Classic (PEBB) Certificate of Coverage 33

• You must be enrolled in this plan for the plan to pay for medically necessary covered services.

Benefits: what the plan covers

Guidelines for coverage

ALERT! A service or supply prescribed, ordered, recommended, approved, or given by a

provider does not make it a medically necessary covered service or supply.

This plan will cover a service or supply if it meets all of the following conditions. The service or supply

must:

• Be listed as covered; and

• Be medically necessary; and

• Be received by a member on a day between the date coverage begins (but no sooner than January 1,

2023) and the date coverage ends (but no later than December 31, 2023); and

• Have been determined to be a covered benefit by the Health Technology Clinical Committee (HTCC), if

reviewed by the HTCC, and, if determined to be covered with conditions, meet the conditions of

coverage established by the HTCC; and

• Meet the plan’s coverage policies and preauthorization requirements.

Limits and exclusions may apply to plan benefits. See both the benefit description and the “What the plan

does not cover” section.

Some services require preauthorization and/or notice before you receive treatment. Visit the UMP Policies

that affect your care webpage for a list of these services, or call UMP Customer Service to ask if a certain

service is covered, requires preauthorization, or requires notice. See Directory for link and contact

information.

The following sections describe the benefits provided by this plan. Be sure to read them carefully for

important information that may help you get the most from your health coverage. If you do not

understand the benefits, it is your responsibility to ask for help before receiving services by calling UMP

Customer Service.

FOR MEDICARE RETIREES: See the “For retirees enrolled in Medicare and UMP Classic”

section.

UMP Classic is a self-insured PPO health plan. UMP is offered through the Washington State Health Care

Authority’s Public Employees Benefits Board (PEBB) Program. UMP is administered by Regence BlueShield,

and Washington State Rx Services (WSRxS). All prescription drugs, services, or other benefit changes may

require approval by the PEB Board. Approval takes place when benefits are procured for the next calendar

year. For example, prescription drugs newly approved by the U.S. Food and Drug Administration (FDA)

may require approval by the PEB Board before the plan will cover them.

34 2023 UMP Classic (PEBB) Certificate of Coverage

Health Technology Clinical Committee (HTCC)

ALERT! HTCC determinations may be implemented by the plan at any time during the calendar

year, but are often implemented the January following the HTCC’s decision. HTCC decisions are

posted on the HCA website at hca.wa.gov/hta. Contact UMP Customer Service if you have

questions about specific services that the HTCC has reviewed.

Created by chapter 70.14 of the Revised Code of Washington (RCW), the HTCC is a committee of 11

independent health care professionals that reviews selected health technologies (services) to determine

appropriate coverage, if any, for the services. These may include medical or surgical devices and

procedures, medical equipment, and diagnostic tests.

In public meetings, the HTCC considers public comments and scientific evidence regarding the safety,

medical effectiveness, and cost-effectiveness of the services when making its determination.

How HTCC decisions affect UMP benefits

Under state law, the plan must comply with HTCC decisions, RCW 70.14.120 (1)(a), unless such

determination conflicts with federal or state law. Services reviewed by the HTCC are either covered,

covered with conditions, or not covered. The HTCC determines the conditions, if any, under which the

service will be included as a covered benefit and, if covered, the criteria the plan must use to decide

whether the service is medically necessary. Criteria established by the HTCC take precedence over

Regence’s medical policies. When the HTCC determines that a service is not covered, then the service is

not covered by the plan. Some HTCC decisions include a requirement to follow FDA or Centers for

Medicare and Medicaid Services (CMS) guidelines. You may review these guidelines on the FDA website at

fda.gov or CMS website at cms.gov.

Where to find HTCC decisions

You may view the list of services that the HTCC has reviewed or currently has under review on the HCA

website at hca.wa.gov/hta. The website includes:

• Evidence reports

• Instructions on providing public comments on pending reviews or re-reviews

• Public comments

• The decisions and criteria for coverage

• The public meeting schedule

You may also call UMP Customer Service with questions about coverage of conditions for HTCC

technologies.

Summary of benefits

ALERT! Not all covered services and limitations are listed in the table below. See the

alphabetical list of all covered services in the “List of benefits” section and see the “Your routine

vision benefits” section.

2023 UMP Classic (PEBB) Certificate of Coverage 35

Read the pages listed in the “For information” column for detailed information about each benefit. Not all

details are included in the table. Also read:

• Services for which your provider must notify the plan (see page 109)

• Services that are not covered (exclusions) (see the “What the plan does not cover” section)

• Services that require preauthorization (see the “Limits on plan coverage” section)

If you have questions about your benefits, benefit limitations, services that require preauthorization or

notice, or services not covered by the plan, call UMP Customer Service.

For a description of the types of services listed in the “How much you will pay” column in the table below,

see the “Types of services” section. For definitions of the rates, see the definitions of “Inpatient rate,”

“Preventive rate,” “Special rate,” and “Standard rate.”

Benefit/service

How much you will pay

For information,

see page(s):

Ambulance

Special rate:

• 20% of the allowed amount for any provider

• Applies to your out-of-pocket limit

38, 112, 119

Applied Behavior

Analysis (ABA)

Therapy

Standard rate

Behavioral health

Mental health:

• Inpatient rate

• Outpatient/professional services: Standard rate

Substance use disorder:

• Inpatient rate

• Outpatient/professional services: Standard rate

40, 116, 117

Breast health

screening tests

See the “Mammogram and Digital Breast

Tomosynthesis (DBT)” benefit

42, 61

Chiropractic physician

services

Special rate:

You pay a $15 copay per visit when you see a

preferred provider.

See the “Spinal and

extremity

manipulations”

benefit on page 70

Diagnostic tests,

laboratory, and x-rays

Standard rate

47, 61, 111–121

Durable medical

equipment (DME),

supplies, and

prostheses

Standard rate

48, 113, 116, 184

36 2023 UMP Classic (PEBB) Certificate of Coverage

Benefit/service

How much you will pay

For information,

see page(s):

Emergency room (ER)

Special rate:

ER services are paid at the network rate at preferred,

participating and out-of- network hospitals.

You pay 15% of the allowed amount plus an ER

copay of $75. You are usually billed separately for:

• Facility charges

• Professional (physician) services

• Lab tests, x-rays, and other imaging tests

50, 184

Hearing aids

Special rate:

• No medical deductible

• You pay $0 for the purchase of a hearing aid for

each ear once every five calendar years

53, 129

Home health care

Standard rate

54, 115, 187, 190

Hospice care

Special rate:

• You pay $0 for medical services after meeting the

medical deductible

• You pay $0 for prescription drugs after meeting

the prescription drug deductible

• You pay $0 for end-of-life counseling while in

hospice after meeting the medical deductible

54, 188

Hospital services

Inpatient rate

Outpatient/professional services: Standard rate

55, 62, 115

Mammograms

Diagnostic: Standard rate

Screening: Preventive rate

Mental health

See the “Behavioral health” benefit

40, 116, 117

Naturopathic

physician services

Standard rate

18, 62, 107, 113

Obstetric and

newborn care

Inpatient rate

Outpatient/professional services: Standard rate

62, 117

Office visits

Standard rate

64, 116

Prescription drugs

See the “What you pay for prescription drugs”

section

Preventive care and

immunizations

Preventive care: Preventive rate

Covered preventive immunizations: Preventive rate

61, 64, 65, 90, 197

Skilled nursing facility

Inpatient rate

Some services may be billed separately, such as

physical therapy

68, 115, 118, 200

2023 UMP Classic (PEBB) Certificate of Coverage 37

Benefit/service

How much you will pay

For information,

see page(s):

Spinal and extremity

manipulations

Special rate:

You pay a $15 copay per visit when you see a

preferred provider.

Substance use

disorder

See the “Behavioral health” benefit

Surgery

Standard rate

55, 57, 62, 65, 70, 70,

73, 77, 114, 119, 181,

193, 199

Therapy: Habilitative

and Rehabilitative

Inpatient rate

Outpatient/professional services: Standard rate

Tobacco cessation

Preventive rate

Vision care exam

(routine)

Preventive rate

81, 85

Vision hardware,

adults (ages 19 and

over)

(Lenses, frames, or

contact lenses)

Special rate:

• No medical deductible

• Lenses and frames: You pay $0 up to the allowed

amount for one pair of covered standard lenses

and frames once every two calendar years; or

• Contact lenses: Plan pays up to $150 every two

calendar years in lieu of lenses and frames. You

pay a $30 fitting fee for contact lenses

Vision hardware,

children (under the

age of 19)

(Lenses, frames, or

contact lenses)

Special rate:

• No medical deductible.

• Lenses and frames: You pay $0 up to the allowed

amount for one pair of covered standard frames

and lenses once per year; or

• Contact lenses: You pay $0 up to the allowed

amount for a one-year supply in lieu of lenses and

frames. There is no fitting fee.

Note: For services requiring preauthorization or plan notification, see the list of services on the UMP

Policies that affect your care webpage or call UMP Customer Service (see Directory for link and contact

information). Many services require both preauthorization and plan notification. See the “Limits on plan

coverage” section for how this works.

List of benefits

Acupuncture

The plan covers up to 24 visits for acupuncture treatment per calendar year (see definition of “Limited

benefit”). You pay the special rate (a $15 copay) for acupuncture when you see a preferred provider. The

copay will not apply toward the medical deductible, but the copay will apply to the out-of-pocket limit.

38 2023 UMP Classic (PEBB) Certificate of Coverage

You may receive an office visit at the time of the acupuncture service (see the “Office visits” benefit for

details). Not all acupuncture services are covered. See the “What the plan does not cover” section for

more information.

Note: For participating providers and out-of-network providers, services are paid at the standard rate up

to 24 visits per calendar year.

Ambulance

Ambulance services for personal or convenience purposes are not covered.

Ground ambulance

You pay 20 percent of the allowed amount for medically necessary ambulance services. Professional

ground ambulance services are covered in a medical emergency:

• From the site of the medical emergency to the nearest facility equipped to treat the medical

emergency.

• From one facility to the nearest other facility equipped to provide treatment for your condition.

When other means of transportation are considered unsafe due to your medical condition, the plan

covers professional ambulance services:

• From one facility to another facility, for inpatient or outpatient treatment;

• From home to a facility; or

• From a facility to home.

Air ambulance

You pay 20 percent of the allowed amount for medically necessary ambulance services regardless of

network status. You may not be balanced billed. Air professional ambulance services are covered only

when all the following conditions are met:

• Ground ambulance is not appropriate

• The situation is a medical emergency

• Air ambulance is medically necessary

• Transport is to the nearest facility able to provide the care you need

ALERT! The plan will not pay for air ambulance or other forms of air transport to move you to

a facility closer to your home. If you travel outside the U.S., consider getting separate insurance

that covers such air ambulance services.

Water ambulance

You pay 20 percent of the allowed amount for medically necessary ambulance services. Water

professional ambulance services are covered only when all the following conditions are met:

• Ground ambulance is not appropriate

• The situation is a medical emergency

• Water ambulance is medically necessary

• Transport is to the nearest facility able to provide the care you need

2023 UMP Classic (PEBB) Certificate of Coverage 39

Applied Behavior Analysis (ABA) Therapy

The plan covers Applied Behavior Analysis (ABA) Therapy only for a diagnosis of autism spectrum

disorder. Providers of ABA Therapy services must be appropriately credentialed and qualified to prescribe

or perform ABA Therapy services.

The plan must preauthorize ABA Therapy services for members ages 18 years old and older before

services are performed. No preauthorization is required for members under the age of 18 years old. Like

other preauthorized services, approved ABA preauthorization is specific to the provider who made the

ABA preauthorization request. ABA Therapy hours preauthorized for one provider are not automatically

transferable to another provider. A change in the provider requires a new ABA preauthorization. The initial

assessment and ABA therapy treatment order or prescription do not require preauthorization for

members of any age.

As for other covered services, you receive the highest-level benefit by using preferred providers. See the

“Types of services” section for differences in your cost for preferred, participating, and out-of-network

providers. To find a preferred provider, visit the UMP Provider search or call UMP Customer Service.

You can also find more information on ABA Therapy by viewing the ABA policy on the UMP Policies that

affect your care webpage. See the Directory pages at the beginning of this booklet for links and contact

information.

Autism treatment

To determine how a service, supply, or intervention is covered, see that specific benefit. For example,

Applied Behavior Analysis (ABA) Therapy is addressed on page 39; speech or occupational therapy is

addressed on page 74 under the “Therapy: Habilitative and Rehabilitative” benefit; and mental health

coverage is found under “Behavioral health” on page 40. If a specific benefit is subject to limits, such as

number of visits, these limits do not apply when the services, supplies, or interventions are for an autism

diagnosis.

Bariatric surgery

TIP: Call UMP Customer Service to locate a provider.

For the plan to cover bariatric surgery, you must get preauthorization from the plan and follow all your

chosen facility’s bariatric surgery requirements. This includes working with a multidisciplinary bariatric

surgery team and ensuring your surgery and postsurgical treatment meet all plan medical policies.

The plan covers only certain types of bariatric surgery procedures. If you meet the plan’s clinical criteria,

non-Medicare adults ages 18 and over will be eligible for covered bariatric procedures.

FOR MEDICARE RETIREES: If you are Medicare-eligible or close to becoming eligible for

Medicare and are considering bariatric surgery, call UMP Customer Service.

Related care following bariatric surgery

Panniculectomy (removal of loose skin) is covered following bariatric surgery only when specific medical

criteria are met. Most panniculectomies are considered cosmetic and are not covered.

40 2023 UMP Classic (PEBB) Certificate of Coverage

UMP will cover medically necessary surgical follow-up care related to a covered bariatric procedure, such

as care for complications and needed revisions. The follow-up surgery must be appropriate and essential

to the long-term success of the initial bariatric surgery and must be preauthorized.

Members who had a bariatric procedure before coverage under a UMP plan and have complications or

need medically necessary revision are not required to verify prior coverage or that they met the plan’s

medical policy criteria for the initial bariatric procedure. However, you must follow plan requirements for

follow-up care, including requesting preauthorization.

Behavioral health

The plan covers behavioral health services including care for mental health and substance use disorder.

You pay the inpatient rate when admitted to an inpatient facility, and the standard rate for all other care

and services.

When you receive nonemergency services from an out-of-network provider at a network hospital, network

hospital outpatient department, network critical access hospital, or network ambulatory surgical center,

you pay the network rate and cannot be balance billed for services performed in Washington State or

without your informed consent in states that allow you to waive the federal balance billing protections.

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.

Mental health

The plan covers mental health services for members with neuropsychiatric and mental health conditions.

Marriage or family counseling is not covered. The amount the plan pays depends on the provider’s

network status (see the “Finding a health care provider” section and page 30). See below for details about

coverage for substance use disorder treatment.

Inpatient

ALERT! Your provider must notify the plan as soon as possible after you are admitted to a

facility, but not later than 24 hours after you are admitted when you receive inpatient services.

If the plan is not notified of inpatient treatment, the plan may not cover the treatment.

Inpatient treatment is subject to clinical review.

Services are considered inpatient when you are admitted to a facility. This may include either psychiatric

inpatient hospitalization or care at a residential treatment facility. The plan must preauthorize non-

emergency inpatient services. See the “Limits on plan coverage” section for details.

Your provider must notify the plan as soon as possible after you are admitted to a facility, but no later

than 24 hours after you are admitted to a:

• Hospital

• Residential treatment facility

Contact UMP Customer Service about preauthorization requirements. Visit UMP Policies that affect your

care webpage for a list of services that require plan notice. See Directory for link and contact information.

You pay an inpatient copay for facility charges at a preferred facility (see the “Copay” section). Professional

services (for example, doctors) may be billed separately from the facility charges. The plan pays the

inpatient rate unless it is for emergency services. All covered professional services are paid based on the

allowed amount.

2023 UMP Classic (PEBB) Certificate of Coverage 41

FOR MEDICARE RETIREES: The inpatient copay is $200 per day, with a maximum of $600 per

inpatient admission, up to the medical out-of-pocket limit.

Outpatient

ALERT! See page 39 for preauthorization requirements related to Applied Behavior Analysis

(ABA) Therapy services.

You pay the standard rate for outpatient mental health services. You pay based on the allowed amount

and the network status of the provider. Most outpatient mental health services do not require

preauthorization. Visit the UMP Policies that affect your care webpage for a list of services that require

plan notice.

Your provider must notify the plan as soon as possible, but not later than 24 hours after the following

services are initiated:

• Intensive Outpatient Therapy

• Partial Hospitalization Program (PHP)

Substance use disorder

Substance use disorder is defined as an illness characterized by a physiological or psychological

dependency on a controlled substance or alcohol. Substance use disorder does not include dependence

on tobacco, caffeine, or food.

To be covered, treatment programs must be licensed to provide treatment to persons requiring substance

use disorder treatment. The amount the plan pays depends on the provider’s network status (see the

“Finding a health care provider” section and page 30). See above for details about coverage for mental

health services. Contact UMP Customer Service about preauthorization requirements.

Inpatient

ALERT! Your provider must notify the plan as soon as possible after you are admitted to a

facility, but not later than 24 hours after you are admitted when you receive inpatient services

for substance use disorder treatment. If the plan is not notified of inpatient treatment, the plan

may not cover the treatment. Inpatient treatment is subject to clinical review.

You pay an inpatient copay for facility charges at a preferred facility (see the “Copay” section). Professional

services (for example, doctors or lab tests) may be billed separately from the facility charges. The plan

pays for these services according to the network status of the provider, unless it is for emergency services.

Your provider must notify the plan when:

• You receive detoxification services

• You are admitted to a hospital

• You are admitted to a residential treatment facility

42 2023 UMP Classic (PEBB) Certificate of Coverage

FOR MEDICARE RETIREES: The inpatient copay is $200 per day, with a maximum of $600 per

inpatient admission, up to the medical out-of-pocket limit.

Outpatient

You pay the standard rate for outpatient substance use disorder treatment. You pay based on the allowed

amount and the network status of the provider.

Your provider must notify the plan when you receive the following services:

• Detoxification

• Intensive Outpatient Program (IOP)

• Partial Hospitalization Program (PHP)

Preauthorization for outpatient substance use disorder treatment is not required in most cases. The plan

may require that your provider submit a treatment plan to determine medical necessity.

Behavioral health support resources

UMP provides behavioral health support resources to meet your needs.

myStrength

myStrength is a self-guided health and resiliency online tool clinically proven to improve emotional

health. This secure resource is available 24 hours a day, 7 days a week to members ages 13 and over at no

cost to you. myStrength’s interactive and activity-based tools are personalized to you and address

conditions such as depression, anxiety, stress, substance use disorders, and chronic pain. Visit the

myStrength website at hca.wa.gov/ump-pebb-mystrength to sign up and learn more.

Quartet

Quartet can help match you to in-person and telemedicine behavioral health providers who are in the

plan’s network and offer an array of behavioral health services, including, but not limited to, mental health

counseling, substance use disorder, and psychiatry services. You pay the standard rate for behavioral

health services. Get started by visiting Quartet’s website at qrt.care/pebb-network-providers or by calling

Quartet’s Care Navigation Team at (253) 248-6588 (TRS: 711).

Note: Quartet is only available to UMP members ages 18 and older who reside and are seeking care in

Washington State.

Breast health screening tests

See also the “Mammogram and Digital Breast Tomosynthesis (DBT)” benefit for more information about

breast health screening tests. The tests listed below may be covered for diagnostic purposes as indicated

under plan medical policy.

Services covered

• Members ages 40 and older: Breast health screening tests, as well as digital mammograms, are

covered as preventive.

• Members under age 40: See the “Mammogram and Digital Breast Tomosynthesis (DBT)” benefit for

how preventive breast health screening tests are covered for high-risk members.

Services not covered

The procedures listed below are not covered by the plan when they are performed supplementary to

digital mammography for screening purposes for members with or without dense breasts.

2023 UMP Classic (PEBB) Certificate of Coverage 43

Non-high-risk members:

• Automated Breast Ultrasound (ABUS)

• Handheld Ultrasound (HHUS)

• Magnetic Resonance Imaging (MRI)

High-risk members:

• Automated Breast Ultrasound (ABUS)

• Handheld Ultrasound (HHUS)

Care Gap Closure Program

The Care Gap Closure Program encourages members to receive recommended preventive and chronic

care services and screenings, also known as “gaps in care.” These include screenings for cancer, diabetes,

and more at no cost to you. This support includes helping members find a PCP, making appointments,

ensuring members understand their benefits, and providing members ongoing support through case

management, as needed. Call UMP Customer Service for more information.

Care management

Regence care management supports the unique needs of members with chronic, serious, or sudden

illness or injury and prioritizes those needs by providing personalized services that enhance well-being.

Care management teams can help with:

• Advocating for members and their support systems and improving care through close collaboration

with providers.

• Assisting members as they navigate the health care system, including helping members find preferred

providers and facilities, and supporting members transitioning to different levels of care.

• Educating members about their care options, benefits, and coverage, as well as helping members make

educated decisions regarding their health care.

• Supporting members with coordination of care needs.

We offer a single-nurse model dedicated to delivering personalized and holistic medical and behavioral

health support to each member and their family. Once a member is engaged in the care management

program, they may be assigned a case manager who is a licensed social worker or registered nurse.

Regence case managers work closely with a member and their providers to help meet treatment plan

goals and improve a member’s overall health.

How to get started

Providers may refer members, and Regence also proactively reaches out to members most likely to

benefit from care management support. Members can also self-refer by calling Regence at 1-866-543-

5765 (TRS: 711) for information about care management services.

What’s next

Once a member is identified for care management, the designated case manager calls the member. The

Regence case manager will attempt at least three calls and will send a letter to the member. The member

can respond to the letter if they wish to engage with a case manager. Providers are sent a letter or

contacted by phone when their patient is enrolled in care management.

Care management newsletters

Newsletters are sent once per year with an option to opt into care management to all members with a

new diagnosis of depression, anxiety, a painful condition, or adult/pediatric cancer.

44 2023 UMP Classic (PEBB) Certificate of Coverage

Condition-specific newsletters are sent twice per year with an option to opt into care management to all

members diagnosed with coronary artery disease (CAD), congestive heart failure (CHF), chronic

obstructive pulmonary disease (COPD), asthma, or diabetes.

Case management as a condition of coverage

An HCA or plan medical director may review medical records and determine that your use of certain

services is potentially harmful, excessive, or medically inappropriate. Based on this determination, the plan

may require you to participate in and comply with a case management plan as a condition of continued

benefit payment.

Chiropractic physician services

See the “Spinal and extremity manipulations” benefit.

Dental services

ALERT! Dentists and other dental providers are not included in the UMP provider network,

even if they are listed in the Regence provider directory.

The plan does not cover most dental services. For example, dental implants, orthodontic services, and

treatment for damage to teeth or gums caused by biting, chewing, grinding, or any combination of these

are not covered. However, your PEBB dental plan may cover these services. Refer to your dental plan’s

COC, found on the HCA website at hca.wa.gov/erb, for more information.

What is covered by the plan

The plan covers oral surgery and other dental services under the medical benefit when they are

considered medical. Oral surgery and dental services are considered medical if the condition being

diagnosed and treated is either one which is not connected to the teeth and/or gums or is related to a

disease or illness that affects the whole body. These medical services may be performed by a dentist or

medical professional provider. You can find examples of these medical services in the Regence Medical

Policy Administrative Guidelines to Determine Dental vs Medical Services by visiting the UMP Policies that

affect your care webpage (see Directory for link). You pay 20 percent of the allowed amount for covered

dental services unless otherwise stated, and the provider may balance bill you.

Note: UMP is not affiliated with the Uniform Dental Plan (UDP). If you are enrolled in UDP, contact UDP

for information about services covered under your dental plan. Visit the HCA website at hca.wa.gov/erb

and select “Contact” to find UDP contact information.

Fluoride treatment

Under certain circumstances, the plan may cover fluoride supplements (see the “Preventive care” benefit)

at the preventive rate. The application of fluoride varnish may be covered for infants and children starting

at the age when primary teeth come in (primary teeth eruption) in primary care practices for prevention of

tooth decay (dental caries or cavities). Coverage of fluoride treatment depends on the network status of

the medical provider as described in the “Finding a health care provider” section. Health care providers,

such as your child’s medical PCP, may apply fluoride varnish.

General anesthesia during a dental procedure

General anesthesia performed during a dental procedure is covered only when:

• It is provided by an anesthesiologist; and

• The charges are covered by the plan (see below).

2023 UMP Classic (PEBB) Certificate of Coverage 45

Dental procedures

General anesthesia may be performed in a dental office for covered procedures and is paid at the

standard rate. Dental procedures that are performed in a hospital or ambulatory surgery center are

covered only when the member:

• Is under age 8 with a dental condition that cannot be safely and effectively treated in a dental office; or

• Has a dental condition that cannot be safely and effectively treated in a dental office because of a

physical or developmental disability; or

• Has a medical condition that would put the member at undue risk if the procedure were performed in a

dental office.

Accidental injuries

To receive coverage for repair of an accidental injury to natural teeth, the injury must be evaluated, and a

treatment plan developed and finalized within 30 days of the injury.

The actual treatment may extend beyond 30 days if your provider determines upon the initial assessment

that treatment should start later or continue longer. Treatment must be completed by the end of the

calendar year following the accident. The plan does not cover treatment after UMP coverage ends.

Example: You have an accident on March 12, 2023, resulting in injuries that are covered by the plan. Your

treatment plan must be finalized no later than April 11, 2023. All related treatment must be completed by

December 31, 2024 (the calendar year following the accident).

The plan does not cover treatment that:

• Was not included in the treatment plan developed within the first 30 days following the accident;

• Extends past the end of the calendar year following the accident; or

• Extends past the end of your enrollment in the plan.

Diabetes care supplies

TIP: If a health plan other than UMP is your primary payer, claims for diabetes care supplies

may be paid differently (see page 125).

Medical

FOR MEDICARE RETIREES: When Medicare is primary, UMP covers continuous glucose

monitors, lancets, and test strips under your medical benefit.

Insulin pumps and pump supplies are covered as durable medical equipment (DME). See page 49 for

coverage of insulin pumps and related supplies.

Prescription drug

FOR MEDICARE RETIREES: If Medicare is your primary health coverage, see “Diabetes care

supplies when Medicare pays first” on page 129 for information on how claims for diabetes

46 2023 UMP Classic (PEBB) Certificate of Coverage

care supplies are processed. UMP covers lancets, test strips and continuous glucose monitors

under your medical benefit.

Diabetes care supplies listed below are only covered under your plan’s prescription drug benefit

according to the tier shown on the UMP Preferred Drug List (see “The UMP Preferred Drug List” section

for more information):

• Insulin syringes

• Lancets

• Test strips

• Continuous glucose monitors

To be covered, you must get a written prescription for these supplies and purchase them from a

pharmacy. Limits, such as quantity limits or preauthorization, may apply. To find out the tier of a diabetes

care supply, check the UMP Preferred Drug List online by visiting the UMP Prescription drug coverage

webpage or call WSRxS Customer Service (see Directory for link and contact information).

You save money and avoid having to submit your own claims when you purchase these diabetes care

supplies from a WSRxS network pharmacy. Locate a network pharmacy by visiting the UMP Prescription

drug coverage webpage or call WSRxS Customer Service.

For more information, see “Exceptions covered" on page 90.

Diabetes Control Program

TIP: The Diabetes Control Program is exempt from the medical deductible and is offered at no

additional cost for UMP (non-Medicare) members ages 18 and older.

For non-Medicare members ages 18 and older with a diagnosis of diabetes, the plan offers the Diabetes

Control Program administered by the Care Management Program at Regence. Case managers are trained

to help you reduce the risk of complications of diabetes by tracking and controlling blood sugar,

cholesterol levels, blood pressure, and weight in a series of quarterly consultations. The plan offers the

Diabetes Control Program at no additional cost to members.

You may find out if you have diabetes by visiting your primary care provider for a blood sugar laboratory

test. If you qualify for the Diabetes Control Program, you may self-refer by calling Regence at 1-866-543-

5765 (TRS: 711).

Diabetes education

The plan covers diabetes self-management training and education, including nutritional therapy by

registered dieticians. When diabetes education includes nutritional therapy, the nutritional therapy

services are not subject to the 12-visit lifetime limit stated under “Nutrition counseling and therapy” on

page 62.

Diabetes Prevention Program (DPP)

You may be eligible for DPP if:

• You are not a Medicare member;

• You are age 18 and older;

2023 UMP Classic (PEBB) Certificate of Coverage 47

• Your provider ordered a blood sugar test in the last 12 months; and

• Laboratory results showed you are in the prediabetes range

DPP provides access to a virtual (online) program through Omada Health.

You may take an online screening questionnaire to see if you meet the program’s criteria by visiting the

DPP website at go.omadahealth.com/wapebb , creating an account, and signing in. If you meet the

criteria, you may participate in the program at no cost to you. The virtual program includes a professional

health coach, a wireless scale, and weekly online classes with a small group of participants who provide

real-time support. You may also call UMP Customer Service for more information.

Diagnostic tests, laboratory, and x-rays

You pay the standard rate for covered diagnostic tests, laboratory tests, and x-rays when medically

necessary. If there are alternative diagnostic approaches with different fees, the plan will cover the least

expensive, evidence-based diagnostic method. Visit the UMP Policies that affect your care webpage or call

UMP Customer Service for a list of services requiring preauthorization (see Directory for link and contact

information).

Covered services include:

• All prostate cancer screening (prostate-specific antigen [PSA testing]), which is subject to the medical

deductible and coinsurance, even if billed as preventive.

• Colonoscopy performed to diagnose disease or illness. See the list on page 65 for coverage of

preventive or screening colonoscopy.

• Diagnostic laboratory tests, x-rays (including diagnostic mammograms), and other imaging studies.

• Electrocardiograms (EKG, ECG).

• Skin allergy testing.

TIP: See page 61 to learn how the plan covers mammograms.

The plan does not pay for the following tests (this list does not include all tests not covered by the plan):

• Carotid Intima Media Thickness testing.

• Computed Tomographic Colonography (CTC) (also called a virtual colonoscopy) for routine screening.

• Upright Magnetic Resonance Imaging (uMRI), also known as “positional,” “weight-bearing” (partial or

full), or “axial loading.”

Dialysis

You pay the standard rate for covered dialysis services. The plan pays based on the allowed amount and

the network status of the provider. Other professional providers may bill separately from the facility.

48 2023 UMP Classic (PEBB) Certificate of Coverage

Durable medical equipment (DME), supplies, and prostheses

TIP: The plan pays for covered DME at the standard rate. To receive the highest benefit, you

must get the equipment or supply from a preferred DME supplier or other preferred medical

provider. To find preferred DME providers, see the “Finding a preferred DME supplier” section

below.

You pay the standard rate for covered DME services and supplies if they are prescribed by a provider

practicing within their scope of practice, medically necessary, and used to treat a covered condition,

including, but not limited to:

• Artificial limbs or eyes (including implant lenses prescribed by a physician and required due to cataract

surgery or to replace a missing portion of the eye).

• Automatic Positive Airway Pressure (APAP) devices and related supplies.

• Bi-level Positive Airway Pressure (BiPAP) devices and related supplies.

• Bone growth (osteogenic) stimulators.

• Breast prostheses and bras as required by mastectomy. See the “Mastectomy and breast

reconstruction” benefit.

• Breast pumps for pregnant and nursing members (see “Services covered as preventive” on page 64).

• Casts, splints, crutches, trusses, and braces.

• Compression stockings.

• Continuous Positive Airway Pressure (CPAP) devices and related supplies.

• Diabetic shoes, only as prescribed for a diagnosis of diabetes. See the “Foot orthotics” section below.

• Elemental formulas for Eosinophilic Gastrointestinal Disorders (EGIDs).

• Insulin pumps and related pump supplies (see the “Insulin pumps and related pump supplies” section

below).

• Ostomy supplies.

• Oxygen and its equipment, such as all types of concentrators and tanks for administration, are covered

on a rental basis only.

• Penile prosthesis when other accepted treatment has been unsuccessful and impotence is:

▪ Caused by a covered medical condition; or

▪ A complication directly resulting from a covered surgery; or

▪ A result of an injury to the genitalia or spinal cord.

• Rental or purchase (at the plan's discretion) of DME such as wheelchairs, hospital beds, and respiratory

equipment. (The combined rental fees cannot exceed full purchase price.)

• Wig or hairpiece to replace hair loss due to radiation therapy or chemotherapy for a covered condition,

up to a lifetime maximum of $100. Wigs and hairpieces for any other reason are not covered.

Some items require preauthorization. Find the list of supplies that require a preauthorization by visiting

forms and publications at hca.wa.gov/ump-forms-pubs and search “durable medical equipment” or call

UMP Customer Service.

2023 UMP Classic (PEBB) Certificate of Coverage 49

The plan limits coverage of DME to one item of a particular type of equipment and the accessories

needed to operate the item. If you receive a higher-cost DME item when a less expensive, medically

appropriate option is available, the plan will not pay for the more expensive item.

The plan also covers the repair or replacement of DME due to normal use or a change in the member’s

condition (including the growth of a child). You are responsible for the entire cost of any additional pieces

of the same or similar DME you purchase or rent for personal convenience or mobility.

Note: The plan does not cover replacement of lost, stolen, expired, or damaged DME.

Foot orthotics

Items such as shoe inserts, foot orthotics, and other shoe modifications are covered only when both of

these conditions are met:

• The member has been diagnosed with diabetes.

• Specialized (including customized) orthotics are prescribed to treat or reduce the risk of diabetes

complications.

If you have questions about what services are covered, call UMP Customer Service.

Insulin pumps and related pump supplies

Insulin pumps and related pump supplies are covered as DME. For the highest benefit level, use a

preferred DME supplier.

ALERT: Continuous glucose monitors are not covered under the DME benefit. They are

covered under the prescription drug benefit. See the “Diabetes care supplies” benefit for more

information.

Finding a preferred DME supplier

You may purchase DME through a medical supplier. To find a preferred DME supplier, visit the UMP

Provider search (see Directory for link). You do not have to sign in to the Regence member site to search

for a provider, but you will get more personalized results if you do. Click on the “All categories” link

(found beneath “Doctors by name” and “Doctors by specialty”). Type “durable medical” into the search

box; a drop-down list will appear. Select “Durable Medical Equipment & Supplies.” You should now have a

list of network DME suppliers. Preferred providers are paid at the highest rate and are noted as a Category

1 provider in the UMP provider search. Different DME suppliers carry different types of supplies. You may

need to call to confirm that a supplier has what you need.

Note: DME supplies are not available through the network mail-order pharmacies.

Commercial DME

You may purchase DME on Amazon by signing in to your Regence account and going to the Regence

medical supplies webpage at regence.com/member/medical-supplies/. Select “Get started” in the Shop

smart and save section. This will take you to the Amazon page where you will select and shop from one of

the four categories for DME supplies:

• Post-mastectomy

• Illness and injury

• New parents

• Manage a condition

50 2023 UMP Classic (PEBB) Certificate of Coverage

You pay 100 percent of the billed charge and submit a claim for reimbursement. To submit a claim, select

“Start your claim” in the “How to get repaid” section on the Regence medical supplies webpage at

regence.com/member/medical-supplies/. The plan will reimburse you 85 percent of the allowed amount

for covered DME supplies purchased through Amazon. To learn more contact UMP Customer Service.

Emergency room

TIP: If you need immediate care but your situation is not a medical emergency, see the “Urgent

care” benefit for how to get treatment at a lower cost than in an emergency room.

You pay a $75 copay and coinsurance for each emergency room visit, in addition to any amount owed

toward your medical deductible. The plan covers facility charges for emergency room treatment when the

treatment is for covered diagnoses and treatment of an injury.

Charges for professional services may be billed separately from facility (hospital or emergency room)

charges. When you receive emergency services, you cannot be balanced billed.

If your emergency room visit is determined to be a medical emergency, it will be paid at the network rate

for preferred, participating, and out-of-network facilities. Separate professional services charges will also

be paid at the network rate if your emergency room visit is determined to be a medical emergency.

If you are admitted to the hospital directly from the emergency room, the $75 emergency room copay will

be waived. However, you must pay the inpatient copay.

End-of-life counseling

End-of-life counseling involves discussing and planning for your end-of-life care, including treatment

options and advanced directives. The plan covers end-of-life counseling for all members up to 30 visits

per year. There is no requirement to be terminally ill, on hospice, or in the final stages of life to receive

end-of-life counseling services. End-of-life counseling associated with hospice services is paid at 100

percent after you meet your medical deductible. Outside of hospice, these services are paid as a medical

benefit, subject to the medical deductible and coinsurance. For more information on hospice care, see

page 54.

Family planning services

The plan covers contraceptive drugs and devices as preventive, including condoms and spermicides.

Covered contraceptive drugs and devices are paid at the preventive rate — you do not pay a deductible

(medical or prescription) or coinsurance.

Services related to voluntary and involuntary termination of pregnancy (abortion or miscarriage) are

covered under the medical benefit.

Education and counseling related to contraception are paid at the preventive rate.

If you receive care from an out-of-network provider, services are paid at the standard rate and the

provider may balance bill you. If you go to a non-network pharmacy, you may have to pay at the time of

purchase and submit a claim for reimbursement (see the "Submitting a claim for prescription drugs"

section). You must get over-the-counter contraceptive supplies from a network pharmacy for these items

to be covered (see “Over-the-counter contraceptives” in the section below). Prescriptions purchased from

an excluded pharmacy will not be covered. See the definition of “Excluded pharmacy.”

2023 UMP Classic (PEBB) Certificate of Coverage 51

Contraceptives

ALERT! Visits for placement and removal of covered contraceptive devices that require

professional insertion and removal are covered at the preventive rate.

Contraceptives are covered under the prescription drug benefit. Contraceptives include, but are not

limited to, birth control pills, emergency contraception (the “morning after” pill), vaginal rings, patches,

implants, injectables, condoms, and spermicides. Final determination of medical necessity for FDA

approved contraceptives is determined by the prescribing provider. Quantity limits still apply.

You may purchase up to a 12-month supply of contraceptives. Call Washington State Rx Services (WSRxS)

Customer Service for information on how to obtain a 12-month supply. The replacement of lost, expired,

or stolen contraceptives is not covered.

You may obtain emergency contraception over the counter without a prescription. When possible, it is

best to obtain a prescription, since not all pharmacies have prescribing authority. If you go to a pharmacy

without a prescription and the pharmacy does not have prescribing authority, you will need to submit a

claim to WSRxS. Members will need to contact the pharmacy directly for information on prescribing

authority.

Barrier devices

All barrier devices requiring a prescription, fitting, insertion (includes IUD placement immediately after

delivery), or removal are paid at the preventive rate when you see a preferred or participating provider or

use a network pharmacy. Barrier devices requiring a prescription or fitting include intrauterine devices

(IUDs), diaphragms, and cervical caps.

Over-the-counter contraceptives

Over-the-counter contraceptives are covered under the Preventive Tier (P) on the UMP Preferred Drug List

(see “The UMP Preferred Drug List” section for more information), only if they are approved by and

registered with the FDA.

For the plan to cover FDA-registered over-the-counter contraceptives, you must present your UMP

member ID card and make your purchase at the pharmacy counter. When possible, it is best to obtain a

prescription, since not all pharmacies have prescribing authority. If you go to a pharmacy without a

prescription and the pharmacy does not have prescribing authority, you will need to submit a claim to

WSRxS.

Sterilization

When you see a preferred or participating provider, sterilization procedures, such as tubal ligation or

vasectomy, are paid at the preventive rate and are not subject to the medical deductible.

Services and products not covered under the family planning benefit

The plan does not cover the following services and products as a family planning benefit:

• Over-the-counter products not approved by and registered with the FDA

• Reversal of voluntary sterilization

• Treatment of fertility or infertility, including direct complications resulting from such treatment

52 2023 UMP Classic (PEBB) Certificate of Coverage

Foot care, maintenance

Maintenance foot care includes services such as toenail trimming and corn or callous removal or

trimming. These services are covered only for a diagnosis of diabetes and when provided by an approved

provider type. The plan does not cover maintenance foot care provided outside the diagnosis of diabetes.

Gender affirming care

With a diagnosis of gender dysphoria, the following services are covered at the standard rate for

outpatient services and at the inpatient rate for inpatient services:

• Covered surgical services

• Non-surgical services, including, but not limited to, hormone therapy, office visits, mental health

counseling, and tests

This is not a complete list of medical and surgical treatments of gender dysphoria in transgender

individuals. For more information on gender affirming care, visit the UMP Policies that affect your care

webpage to find the clinical criteria for gender affirming care (see Directory for link). Some services and

prescription drugs associated with gender dysphoria may require preauthorization.

Genetic services

Covered genetic tests require preauthorization. With preauthorization, the plan covers medically

necessary, evidence-based genetic testing services. Some genetics tests are not covered. For information

about genetic services related to the fetus during pregnancy, see “Services for obstetric and newborn

care” on page 63. Call UMP Customer Service with any questions.

Headaches, chronic migraine or chronic tension type

The plan only covers the treatment of chronic migraine with OnabotulinumtoxinA (Botox) when both the

following criteria are met:

• The condition has not responded to at least three prior pharmacological prophylaxis therapies from

two different classes of prescription drugs; and

• The condition is appropriately managed for medication overuse.

Botox injections must be discontinued when:

• The condition has shown inadequate response to treatment (defined as less than 50 percent reduction

in headache days per month after two treatment cycles); or

• The member has received a maximum of five treatment cycles.

The following treatments are not covered:

• Treatment of chronic tension-type headaches with Botox or acupuncture; and

• Treatment of chronic migraine or chronic tension-type headaches with massage, trigger point

injections, transcranial magnetic stimulation, or manipulation/manual therapy (such as chiropractic

services).

Hearing care (diseases and disorders of the ear)

The plan pays under the medical benefit for covered services for treatment of diseases and disorders of

the ear or auditory canal not related to routine hearing loss. These services are not part of the “Hearing

exam and hearing aids” benefit.

Hearing exam and hearing aids

This benefit is exempt from the medical deductible and includes the services and supplies outlined below.

2023 UMP Classic (PEBB) Certificate of Coverage 53

Hearing exam (routine)

ALERT! The plan pays for a hearing exam performed as part of a newborn screening at the

preventive rate.

You pay $0 for one routine hearing exam per calendar year when you see a preferred or participating

provider. However, if you see an out-of-network provider, you pay 40 percent of the allowed amount and

the provider may balance bill you.

Hearing aids

You pay $0 and the plan pays 100 percent once every five calendar years for:

• Purchase of a hearing aid, either an instrument set (binaural) or single instrument for each ear

(monaural), prescribed as a result of an exam that shows the hearing aid is necessary for the treatment

of hearing loss, including:

▪ Ear mold(s)

▪ Hearing aid instrument

▪ Initial battery, cords, and other ancillary equipment

▪ Warranty (only as included with the initial purchase)

▪ Follow-up consultation within 30 days after delivery of hearing aid

▪ Rental charges up to 30 days if you return the rented hearing aid before actual purchase

▪ Repair of hearing aid equipment

The following hearing-related items are not covered:

• Charges incurred after your plan coverage ends, unless you ordered the hearing aid before that date

and it is delivered within 45 days after your coverage ended

• Extended warranties, or warranties not related to the initial purchase of the hearing aid(s)

• Purchase of replacement batteries or other ancillary equipment, except those covered under terms of

the initial hearing aid purchase

The following ancillary equipment is not covered:

• Alerting devices

• Assistive listening devices for FM/DM systems, receivers and transmitters

• Assistive listening devices for microphone transmitters

• Assistive listening devices for TDD machines

• Assistive listening devices for telephones

• Assistive listening devices for televisions (including amplifiers and caption decoders)

• Assistive listening devices for use with cochlear implants

• Assistive listening devices, supplies, and accessories not otherwise specified

• Hearing aid batteries

54 2023 UMP Classic (PEBB) Certificate of Coverage

Home health care

ALERT! See the “What the plan does not cover” section for services the plan does not cover.

In certain circumstances, the plan covers short-term, provider-directed, medically necessary home health

services on an intermittent or part-time basis by a licensed home health, hospice, or home care agency, to

help a member recover from an acute covered illness, injury, or hospital stay. Home Health care is

provided through visits from specialized clinicians, performing specific tasks (rather than time-based

shifts), on a short-term basis, until specified individual goals are met. These services must be part of a

treatment plan written by your provider (such as your physician or advanced registered practitioner

[ARNP]). The provider must certify that you are homebound. These short-term visits may include:

• Skilled nursing care, physical, occupational, or speech therapy

• Home health aides and clinical social services, provided in conjunction with the skilled services of a

registered nurse (RN), licensed practical nurse (LPN) or physical, occupational, or speech therapist

• Disposable medical supplies as well as prescription drugs provided by the home health agency

• Home infusion therapy

• Home care of wounds resulting from injury or surgery

• End-of-life counseling (see page 50)

For services that may be covered under another benefit, such as nutritional counseling or follow-up care

for bariatric surgery, see that benefit in this COC for coverage rules and limitations. These limitations

apply even if the services are provided in the home or by a home health provider. For information on

substitution of private duty nursing as an alternative benefit in lieu of hospitalization or in lieu of

admission to a skilled nursing facility, see page 56 (hospital services) or page 68 (skilled nursing facility).

Call UMP Customer Service if you have questions.

Hospice care

Hospice (inpatient, outpatient, and respite care) is services provided by a state-licensed hospice program

in the home or in a hospice facility to terminally ill patients. Services include pain relief care and support

services that address the needs of terminally ill members and their families without intent to cure.

Medical

Hospice services received from preferred and participating providers are covered at 100 percent of the

allowed amount after you meet your medical deductible. The plan covers hospice care for terminally ill

members for no more than six months. See page 50 for coverage of end-of-life counseling.

If you need hospice care, your provider will refer you to the program. For additional assistance, you may

call UMP Customer Service.

Prescription drugs

For covered prescription drugs, UMP members in hospice care receive special coverage when using

network pharmacies, including the network specialty drug pharmacy and the network mail-order

pharmacies.

Until the prescription drug deductible is met:

2023 UMP Classic (PEBB) Certificate of Coverage 55

• The member pays the normal coinsurance for Value Tier (five percent) and Tier 1 (10 percent) covered

prescription drugs, subject to the prescription cost-limit (see the "How the prescription drug cost-limit

works" section).

• The member pays the full cost (allowed amount at a network pharmacy) for covered Tier 2 prescription

drugs.

For covered insulins, the member pays the normal coinsurance for Value Tier (five percent), Tier 1 (10

percent) and Tier 2 (30 percent) up to the prescription cost-limit (see the "How the prescription drug cost-

limit works" section). Covered insulins are not subject to the prescription drug deductible.

After you meet your prescription drug deductible, you pay $0 for all covered prescription drugs purchased

through a network pharmacy for members in hospice care. This applies only to the member in hospice

care.

All quantity limits, preauthorization requirements, and coverage limits apply.

ALERT! The member pays the full cost for noncovered prescription drugs. If the member

purchases covered prescription drugs from a non-network pharmacy, the plan pays under the

normal prescription drug benefit as described in the following sections: “What you pay for

prescription drugs,” “How the prescription drug cost-limit works,” and “Your prescription drug

out-of-pocket limit.” Prescriptions purchased from an excluded pharmacy will not be covered.

See the definition of “Excluded pharmacy.”

Respite care

Respite care is continuous care of more than four hours a day to give caretakers temporary relief from

caring for a member who is homebound or in hospice. The plan covers these services at 100 percent of

the allowed amount after you meet your medical deductible, up to 14 visits per the member’s lifetime.

Death with Dignity

The Washington Death with Dignity Act allows terminally ill adults seeking to end their life to request

lethal doses of prescription drugs. These terminally ill patients must be Washington residents who have

less than six months to live. For more information about this Act, see chapter 70.245 RCW.

Care described under this Act includes services covered by UMP, subject to standard plan requirements.

If you have questions about medical services UMP covers, contact UMP Customer Service. If needed, UMP

may assign a case manager to support you.

If you have questions about prescription drugs UMP covers, contact WSRxS Customer Service.

If your current provider is unable to meet your needs, or if you need assistance in finding a provider for

these services, visit End of Life Washington’s website at endoflifewa.org. End of Life Washington is a

community resource available to support the public in finding available providers.

For more information about the Death with Dignity Act, visit:

• The Department of Health’s website at

doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct.

• The Washington State Hospital Association’s website at wsha.org/for-patients/end-of-life/.

56 2023 UMP Classic (PEBB) Certificate of Coverage

Hospital services

ALERT! Many services provided in a hospital setting require preauthorization, notice, or both.

Failure to request or receive preauthorization, or to notify the plan, may result in complete

denial of claims. See the “Limits on plan coverage” section for how preauthorization and notice

work.

This benefit covers hospital accommodations and inpatient, outpatient, and ambulatory care services,

supplies, equipment, and prescribed drugs to treat covered conditions. Room and board is limited to the

hospital’s average semiprivate room rate, except where a private room is determined to be medically

necessary. Some services require preauthorization. Visit the UMP Policies that affect your care webpage

for the list of these services, or call UMP Customer Service. See Directory for link and contact information.

If you receive a higher-cost service or device at a hospital when a less expensive, medically appropriate

option is available, you may have to pay the difference in cost. A preferred hospital cannot charge you for

the difference in cost between the standard and higher-cost item (unless you agreed in writing to pay

before receiving the services).

If benefits change under the plan while you are in the hospital (or any other facility as an inpatient),

coverage is based on the benefit in effect when the stay began.

Inpatient

Services are considered “inpatient” when you are admitted as inpatient to a hospital. Your provider must

notify the plan as soon as possible after you are admitted, but not later than 24 hours after you are

admitted. You pay an inpatient copay at a preferred facility. See the “Copay” section for details.

Professional services — such as lab tests, surgery, or other services — may be billed separate from the

hospital. The plan pays these services according to the network status of the provider, unless your

condition is a medical emergency (see the “Emergency room" benefit for more information). The plan

pays for all covered professional services at the standard rate.

Private duty nursing furnished by a licensed home health agency may be substituted as an alternative to

hospitalization only if:

• Inpatient hospitalization is medically necessary and would be covered by the plan;

• Private duty nursing is the most cost-effective setting (private duty nursing must be an equal or lesser

cost compared to hospitalization); and

• The member's provider agrees that private duty nursing is medically appropriate and will adequately

meet the member's needs.

Private duty nursing is shift-based, hourly nursing care at home for adults and children, typically with a

chronic illness, injury, or disability.

Substitution of private duty nursing in lieu of inpatient hospitalization has the same requirements as the

hospital benefit. For example, all deductibles and coinsurances apply.

FOR MEDICARE RETIREES: The inpatient copay is $200 per day, with a maximum of $600 per

inpatient admission, up to the medical out-of-pocket limit.

2023 UMP Classic (PEBB) Certificate of Coverage 57

Outpatient

Services are considered “outpatient” when you are not admitted to the hospital. Your cost depends on the

services provided, such as lab tests, and the network status of the provider(s) involved in your care. You

do not pay the inpatient copay for outpatient services. Some services require preauthorization. Visit the

UMP Policies that affect your care webpage for the list of these services, or call UMP Customer Service.

See Directory for link and contact information.

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.

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.

Infusion drug site of care program

The plan covers provider-administered infusion drugs when administered at an approved site of care.

Approved sites of care include standalone infusion sites, doctor's offices, home infusion and some

outpatient hospital facilities. Infusion drugs in the site of care program require preauthorization by the

plan before services are performed, or services will not be covered. Your provider must submit a

preauthorization request for an unapproved site of care. See the “Limits on plan coverage” section for

preauthorization instructions.

Call UMP Customer Service for the drugs covered under the site of care program, more information, or

help finding an approved site of care near you.

Joint replacement surgery, knees and hips in the Centers of

Excellence (COE) Program

FOR MEDICARE RETIREES: The COE Program is not available to UMP Classic members

enrolled in Medicare as their primary coverage (see the “For retirees enrolled in Medicare and

UMP Classic” section). Medicare members still have access to covered services related to joint

replacement separate from the COE Program. Those services are paid at the standard rate.

The Centers of Excellence (COE) Program covers 100 percent of the allowed amount for covered services

related to single knee or single hip total joint replacement surgery. The program includes, but is not

limited to:

• Presurgical consultations.

• Travel costs (see the “Travel benefits” section below).

• Hospitalization and surgery, if surgery is determined to be appropriate.

• Postsurgical check-ups.

In the COE program, members work with Premera Blue Cross (the administrator of the program) and

Virginia Mason Medical Center (the Center of Excellence) to make sure that their treatment is consistent

with established standards of medical care.

58 2023 UMP Classic (PEBB) Certificate of Coverage

Premera will help you understand how the COE Program works, what is covered under the Program,

connect you with Virginia Mason Medical Center providers if you are eligible, and work to resolve any

questions or issues you may have.

If you receive services related to joint replacement that are not covered under the COE Program, but are

covered under the plan, you will pay your normal UMP cost-share, depending on the services received

and the network status of the provider(s). This may be a deductible, coinsurance, copay, or amounts not

covered by the plan. Services billed to the plan outside of the COE Program are subject to the plan’s

preauthorization requirements.

COE for knee and hip joint replacement: Virginia Mason Medical Center

Virginia Mason Medical Center is the only provider approved to perform single knee and single hip

replacement under the COE Program. Virginia Mason Medical Center has proven that it provides high-

quality joint replacements using the most up-to-date medical guidelines and services.

Who is eligible to participate in the COE Program?

You are eligible to participate in the COE Program if you are:

• A member enrolled in UMP Classic.

• Not enrolled in Medicare as your primary coverage.

• Age 18 or older.

How to apply to participate in the COE Program

If you are interested in participating in the COE Program:

• You may self-refer by calling Premera at 1-855-784-4563 (TRS: 711).

• Your regular provider may refer you.

You may receive information in the mail about the COE Program, which will explain how the program

works and whom to contact for more information. Premera will screen applicants to initially determine

whether they are eligible to participate in the COE Program.

What happens after you are approved to participate

After you are approved to participate in the program, Premera will:

• Provide a booklet to participants describing their journey through the program.

• Assign participants a dedicated case manager who will walk participants through each step of the

journey.

• Gather relevant medical records to supply to the participant’s COE care team as part of the referral

process. This information helps the care team assess next steps.

After Premera’s referral, Virginia Mason Medical Center will:

• Review the participant’s medical records and schedule an evaluation appointment to determine

whether the surgery is medically appropriate for the participant under the COE Program.

• Provide a list from which participants may select their surgeon if the participant is approved for

surgery.

Virginia Mason Medical Center must determine if surgery for joint replacement is appropriate based on

established medical guidelines. You may find these guidelines on the Policies that affect your care

webpage (see Directory for link).

2023 UMP Classic (PEBB) Certificate of Coverage 59

What is included in the COE Program

In general, all eligible expenses associated with single knee or single hip replacement surgery (if

determined surgically appropriate) under the COE Program are covered. If surgery is recommended, this

includes expenses from the day you arrive for your pre-operative visit through discharge, including your:

• Assessment(s).

• Surgery.

• Hospital stay.

• Hospital discharge (excluding take-home prescription drugs, which are covered under your UMP

prescription drug benefit).

Travel benefits

Members participating in the COE Program may qualify for assistance with travel and lodging expenses.

These expenses may include partial coverage by Premera for mileage, flights, parking, and lodging.

To be covered by the program, all travel must be arranged through Premera. This travel may be

arranged by calling Premera at 1-855-784-4563 (TRS: 711).

You must have an approved adult care companion, whose travel expenses will be covered as described

below. You may be partially reimbursed for expenses related to:

• Mileage for driving within Washington. To qualify for reimbursement for mileage, members must live at

least 60 driving miles from Virginia Mason Medical Center, located at 1100 9th Ave., Seattle, WA 98101.

• Flights departing from and arriving at airports within Washington or Portland International Airport. You

must depart from the airport closest to your residence.

• Ground transportation from Seattle-Tacoma International Airport to Virginia Mason Medical Center.

• Lodging expenses (excluding meals) at a COE-designated hotel. Premera must arrange all lodging.

• Parking at Virginia Mason Medical Center and parking at your departing airport.

TIP: Reimbursement for travel expenses is based on cost or current IRS rates for medical

expenses, whichever is less, and may not cover all of your costs. For the IRS rates, visit the

IRS website at irs.gov/tax-professionals/standard-mileage-rates.

What is not included in the COE Program

If you receive services outside of the COE Program, or choose to receive services at Virginia Mason

Medical Center that are not related to your single knee or single hip replacement surgery, covered

services will be processed at the standard rate.

The following services are not included in the COE Program (but may be covered by other plan benefits):

• Care received as part of the plan Virginia Mason Medical Center gives you as a condition of surgery,

regardless of where you receive care. Examples include tobacco cessation and weight loss programs.

• Physical therapy that is not provided during your hospitalization.

• Follow-up care other than the initial postsurgical checkup at Virginia Mason Medical Center. An

example of follow-up care is a visit with your regular doctor.

• Prescription drugs received from a pharmacy after discharge from the hospital.

• Convenience items, such as a personal phone.

60 2023 UMP Classic (PEBB) Certificate of Coverage

Call UMP Customer Service if you have questions about services not included in the COE Program.

What happens if you are not an appropriate candidate for joint replacement

surgery under the COE Program

If Virginia Mason Medical Center determines you are not an appropriate candidate for joint replacement

surgery, you may still receive joint replacement through other providers under this plan. Services received

outside the COE Program are processed according to the plan’s medical policies, benefit structure, and

the network status of your provider.

Appeals related to the COE Program

UMP members may appeal denials made by Premera. Appeals must be submitted to Premera. A decision

by your Virginia Mason Medical Center provider regarding whether the provider is willing to perform joint

replacement surgery on you is a decision of the provider, not the plan, and cannot be appealed to the

plan or Premera.

TIP: Appeal deadlines and other rules remain the same. See the “Complaint and appeal

procedures” section for details of how non-COE appeals work.

An appeal for services related to the COE Program must be submitted within 180 days after you receive

notice of the denial to Premera, not to Regence or Virginia Mason Medical Center. Appeals can be

submitted to:

Premera Blue Cross

Attn: Member Appeals

PO Box 91102

Seattle, WA 98111-9202

Secure inbound fax: 1-425-918-5592

Knee arthroplasty, total

Covered services are paid at the standard rate. Computer navigated and unicompartmental knee

arthroplasty for treatment of end-stage osteoarthritis and rheumatoid arthritis of the knee are covered

only as follows:

• Total knee arthroplasty performed with computer navigation is covered.

• For individuals with unicompartmental disease, unicompartmental partial knee arthroplasty is covered.

• Multi-compartmental partial knee arthroplasty (including bicompartmental and bi-unicompartmental)

is not covered.

TIP: You may be eligible to have your joint replacement surgery covered in full. See the “Joint

replacement surgery, knees and hips in the Centers of Excellence (COE) Program” benefit.

2023 UMP Classic (PEBB) Certificate of Coverage 61

Mammogram and Digital Breast Tomosynthesis (DBT)

ALERT! Not all mammograms are paid at 100 percent (preventive rate). Only screening

mammograms are considered preventive. Diagnostic mammograms are subject to the medical

deductible and coinsurance. Claims are paid based on how your provider bills the service.

Screening (preventive)

• For members ages 40 and older, with or without a clinical breast exam, the plan covers screening

mammograms and Digital Breast Tomosynthesis (DBT) every year, and they are not subject to the

medical deductible.

• For members under age 40, the plan covers screening mammograms and DBT for members who are

at an increased risk for breast cancer. A covered health care provider must order the service, and the

claim must be billed with an “at risk” diagnosis to be covered under the preventive care benefit.

Note: Digital Breast Tomosynthesis (DBT) is only covered when you receive it along with a screening

mammogram.

How much you will pay

For all members, services are covered at the preventive rate.

Diagnostic (medical)

You pay the standard rate for medically necessary mammograms to diagnose a medical condition under

the “Diagnostic tests, laboratory, and x-rays” benefit. There are no age requirements for diagnostic

mammograms and DBT. A covered health care provider must order the service, and the claim must be

billed as a diagnostic mammogram.

ALERT! See the “Breast health screening tests” benefit for coverage of diagnostic testing other

than mammograms.

Massage therapy

You pay the special rate (a $15 copay) for up to 24 massage therapy visits per calendar year for covered

diagnoses when you see a preferred provider. The copay will not apply toward the medical deductible, but

the copay will apply to the out-of-pocket limit. All visits will apply to the 24-visit limit. See the definition

of “Limited benefit.” You must have a prescription for massage therapy treatment from a covered provider

type, such as a physician. The plan does not cover massage therapy when you see a participating or out-

of-network provider.

ALERT! The plan only covers preferred massage therapists. To find a preferred massage

therapist, use the UMP Provider search or call UMP Customer Service (see Directory for link and

contact information).

62 2023 UMP Classic (PEBB) Certificate of Coverage

Mastectomy and breast reconstruction

ALERT! See page 52 for coverage of breast reconstruction or mastectomy services related to

gender affirming care.

You pay the standard rate for a mastectomy as treatment for disease, illness, or injury, as well as:

• Physical complications of all stages of a mastectomy.

• Prostheses.

• Reconstruction of the breast on which the mastectomy was performed.

• Surgery and reconstruction of the other breast to produce a symmetrical appearance.

Mental health

See the “Behavioral health” benefit.

Naturopathic physician services

While naturopaths are a covered provider type, naturopaths may recommend services that the plan does

not cover. You will pay all costs for excluded and non-medically necessary services, even if your

naturopathic physician recommends or prescribes them (see the “Medically necessary or medical

necessity” definition for more information).

The plan does not cover herbal, homeopathic, or other dietary supplements (including vitamins and

minerals, except as described on page 90), even if a covered provider type prescribes them.

Nurse line

UMP’s nurse line is provided by Advice24. Registered nurses are available by phone or chat 24 hours a

day, 7 days a week at no cost to you. Registered nurses provide immediate symptom assessment, health

information, and advice. They can help you decide if you need to go to the emergency room, make a

doctor appointment, or care for your symptoms at home. UMP members can call the nurse line at 1-800-

267-6729 (TRS: 711).

Nutrition counseling and therapy

TIP: See the “Diabetes education” benefit for how these services are covered for members with

diabetes.

The plan covers up to 12 visits per lifetime for nutrition counseling and therapy services. Similar services

may be covered under other benefits that are not subject to the 12-visit limit, including, but not limited to,

the “Diabetes Control Program,” “Diabetes education,” and the “Diabetes Prevention Program.”

Obstetric and newborn care

Pregnancy program

As an expectant parent, the program helps you manage your health throughout pregnancy and offers

access to a nurse line, pregnancy support, and education 24 hours a day, 7 days a week. It also includes a

smartphone application to help you track milestones, identify symptoms, and get one-click access to the

2023 UMP Classic (PEBB) Certificate of Coverage 63

nurse line. To enroll in the program, call 1-888-569-2229 (TRS: 711) or sign in to your Regence account

(see Directory for link). This program is covered at no cost to you.

Services for obstetric and newborn care

See the “Covered and noncovered provider types” section for providers whose services are covered by the

plan. Covered professional services include:

• Amniocentesis and related genetic counseling and testing during pregnancy.

• Care of complications associated with pregnancy, including pregnancies resulting from fertility or

infertility treatment.

• Prenatal and postnatal care.

• Prenatal testing (as stated in Washington Administrative Code [WAC] 246-680-020).

• Vaginal or cesarean delivery.

• Placement of IUD including immediately after delivery.

Note: Early elective deliveries may not be covered. See “Deliveries before 39 weeks gestation” below.

For inpatient hospital charges related to a childbirth, you:

• Meet the medical deductible.

• Pay the inpatient copay.

• Pay the coinsurance for professional services while hospitalized.

• Meet the medical deductible for the newborn. However, if only covered preventive care services (see

page 65) are billed for the newborn, you will not meet the newborn’s medical deductible, pay the

inpatient copay, or pay the coinsurance when you see a preferred provider.

For hospitalization of the newborn, you will also pay a separate inpatient copay for the newborn.

Circumcision of the penis is covered as a medical benefit (subject to the medical deductible and

coinsurance). Because this is not a preventive service, your out-of-pocket cost may include the newborn’s

medical deductible, coinsurance for professional provider services, and an inpatient copay for inpatient

services.

Note: The Newborns’ and Mother’s Health Protection Act (NMHPA) requires a hospital length of stay in

connection with childbirth for a mother or her newborn and may not restrict benefits for the stay to less

than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section.

A newborn dependent of a covered gestational parent is covered by the plan from birth to at least 21

days following birth. Even if the newborn is later enrolled in different coverage, the newborn will still be

covered under the gestational parent’s plan coverage for the first 21 days. Visit the HCA website at

hca.wa.gov/erb for what you need to do for continued coverage.

If your obstetric care began while covered under another health plan, and your providers are not part of

the UMP network, call UMP Customer Service to discuss your options.

Deliveries before 39 weeks gestation

Vaginal or cesarean deliveries before 39 weeks of gestation are covered when the services are medically

necessary. Examples include:

• A medical emergency affecting the member or baby.

• A medical condition of the member or baby for which a delivery is medically necessary.

64 2023 UMP Classic (PEBB) Certificate of Coverage

• Labor begins naturally (without medical intervention) before the member reaches 39 weeks of

gestation.

Vaginal or cesarean deliveries before 39 weeks of gestation are not covered when the services are:

• Scheduled for convenience and not for medical necessity or medical emergency affecting the member

or baby.

• Neither the member nor baby have a medical condition for which immediate delivery is medically

necessary.

Talk to your provider about whether early delivery is for a medically necessary reason. For questions about

this policy, call UMP Customer Service.

Services covered as preventive

The following services are covered as preventive (not subject to the medical deductible or coinsurance

when you see a preferred provider):

• HIV counseling and testing.

• Purchase of manual and electric breast pumps for pregnant and nursing members, plus supplies

included with the initial purchase. Hospital-grade pumps are not covered.

• Screening for diabetes during pregnancy.

See “The UMP Preferred Drug List” section for prescription drugs that are preventive. They are listed as

"Preventive" in the Tier column.

Lactation (breastfeeding) counseling

Lactation counseling is covered at the preventive rate during pregnancy and after birth to support

breastfeeding when members receive services by a covered provider type.

Note: Donor human milk from an approved milk bank for inpatient use may be covered when medically

necessary.

Ultrasounds during pregnancy

The following limits do not apply to high-risk pregnancies. For example, a multiple pregnancy is

considered high risk. Call UMP Customer Service to learn what is covered for high-risk pregnancies.

Routine ultrasounds during pregnancy are covered as follows:

• One in week 13 or earlier

• One during weeks 13-28

Adding a new dependent to your coverage

For information about how to enroll new dependents in your health plan, refer to the Employee

Enrollment Guide or the Retiree Enrollment Guide on the HCA website at hca.wa.gov/

employee-retiree-benefits/forms-and-publications. You can also refer to “Making changes” in the

“Eligibility and Enrollment” and in the “Eligibility and enrollment for a retiree or survivor” sections of this

certificate of coverage for more information.

Office visits

The plan pays for office visits for covered conditions under the medical benefit. Preventive care visits with

preferred providers as described under the definition of “Preventive care” are covered in full and are not

subject to the medical deductible.

2023 UMP Classic (PEBB) Certificate of Coverage 65

Orthognathic and Telegnathic surgery

Orthognathic and telegnathic surgery must be preauthorized by the plan. Call UMP Customer Service if

you have questions. See page 74 for treatment of temporomandibular joint (TMJ) disorder.

Pain and joint management, interventional

Interventional pain management is a medical subspecialty that treats pain with invasive interventions like

injections, spinal cord stimulations, and implantable drug delivery systems. The purpose of interventional

pain management is to help members have less pain, so they can return to normal activities, when

possible.

Preauthorization is required for interventional pain and joint management, such as:

• Epidural injections

• Facet blocks

• Pain pumps

• Radiofrequency ablations

• Sacroiliac joint injections

Preauthorization is not required for post-procedural pain management in an inpatient setting, including,

but not limited to, treating acute pain due to trauma, acute post-thoracotomy pain, and acute

postoperative pain.

Prescription drugs

See the “Your prescription drug benefit” section.

Preventive care

ALERT! This benefit covers only services that meet the requirements below. If you receive

services during a preventive care visit that do not meet these requirements, or your provider

bills your visit as medical treatment instead of a preventive service, the services are not covered

as preventive. Instead, when medically necessary, they are covered under the standard rate.

Covered preventive care services are paid at the preventive rate. You do not have to meet your medical

deductible before the plan pays the allowed amount for services covered under the preventive care

benefit. When you see a preferred or participating provider for these services, you pay $0. If you see an

out-of-network provider, you pay 40 percent of the allowed amount, and the provider may balance bill

you. If you do not have access to a preferred or participating provider for preventive care services, see the

“When you do not have access to a preferred provider: network waiver” section for how to request a

network waiver.

For a list of services covered as preventive, visit the HealthCare.gov website at healthcare.gov/

preventive-care-benefits. This site also features links to specific preventive services covered for members

based on age and other risk factors. The plan may not cover recommendations added during the calendar

year as preventive until later years. For a list of immunizations covered as preventive, see the “Covered

immunizations” section below.

Examples of services covered under the preventive care benefit include:

• Certain radiology and lab tests, such as screening mammograms (see page 42).

• Certain screening tests performed during pregnancy (see page 64 for more on prenatal care).

66 2023 UMP Classic (PEBB) Certificate of Coverage

• Fluoride for prevention of dental decay when prescribed by a primary care provider to children ages 17

and under, and when the water source is fluoride deficient (see page 44 for coverage of fluoride

varnish).

• Hearing tests as part of a newborn screening.

• Immunizations as specified under “Covered immunizations” on page 66.

• Intensive behavioral counseling for adults who are overweight or obese and have additional

cardiovascular disease risk factors.

• Certain statin prescription drugs to adults ages 40 and over (statin prescription drugs that are listed as

“Preventive” in the Tier column on the UMP Preferred Drug List [see “The UMP Preferred Drug List”

section]).

• One-time screening by ultrasound for abdominal aortic aneurysm for men ages 65-75 who have ever

smoked.

• Preventive vision acuity screening from birth through 18 years of age.

• Preventive visits such as well-baby care and annual physical exams.

• Routine screenings for adults.

• Screening for hepatitis B for adolescents and adults at high risk and those who are pregnant.

• Screening procedures, such as colonoscopy (see page 47 for coverage of colonoscopy performed to

diagnose or treat disease or illness). If you have a screening and the provider diagnoses and treats a

condition during the colonoscopy, services will be paid at the standard rate.

Note: Prostate cancer screening (prostate-specific antigen [PSA testing]) is not covered under the

preventive care benefit but is covered as a medical benefit (subject to the medical deductible and

coinsurance). For more information, see page 47.

ALERT! Follow-up visits or tests as a result of your preventive care visit are not covered under

the preventive care benefit. If the plan normally covers the test or visit and it is medically

necessary, it is covered under the medical benefit.

Call UMP Customer Service to ask if a medical service is covered as preventive. Call WSRxS Customer

Service for questions about preventive prescription drugs.

The following specific services are covered as preventive:

• Chlamydia and gonorrhea testing in sexually active women ages 24 and younger, and for women ages

25 and older who are at increased risk for infection.

• Counseling and screening for HIV, counseling and screening for interpersonal and domestic violence,

and counseling for sexually transmitted infections.

• Education and counseling regarding contraception.

• Human Papillomavirus (HPV) testing for women ages 30 and over, once every three years.

For additional services covered as preventive, see the following benefits: “Family planning services,”

“Mammogram and Digital Breast Tomosynthesis (DBT),” and “Obstetric and newborn care.”

Covered immunizations

You pay the standard rate for covered immunizations that are not considered preventive.

2023 UMP Classic (PEBB) Certificate of Coverage 67

The plan covers immunizations listed on the Centers for Disease Control and Prevention (CDC) applicable

immunization schedule (children, adolescents, adults) for U.S. residents. For a list of immunizations

covered as preventive, visit the CDC website at cdc.gov/vaccines/schedules/index.html or call UMP

Customer Service.

Some covered immunizations are classified as “may be recommended” by the CDC depending on medical

condition or lifestyle. For those immunizations to be covered as preventive, you must meet the criteria

specified on the CDC schedule.

Immunizations covered under the preventive rate are not subject to either the medical or the prescription

drug deductibles. Covered immunizations given by the providers listed under the “Where to get

immunizations” section below are paid under the preventive care benefit. If you see an out-of-network

provider for covered preventive immunizations, you pay 40 percent of the allowed amount and the

provider may balance bill you. Flu shots are paid at 100 percent of the allowed amount regardless of the

provider’s network status.

TIP: The plan covers flu shots and COVID-19 vaccines listed on the applicable CDC

immunization schedule. For a list of immunizations covered as preventive, find a link to the

CDC immunization schedules at the CDC website at cdc.gov/vaccines/schedules/index.html or

call UMP Customer Service.

Where to get immunizations

You pay $0 for immunizations covered under the preventive care benefit when received from a:

• Preferred or participating provider

• Network vaccination pharmacy (Many network pharmacies have vaccination pharmacists who may give

covered preventive immunizations to members. Call a network pharmacy ahead of time to make sure

the pharmacy has the vaccine you need. Present your UMP member ID card at the pharmacy counter

for billing before receiving a vaccine.)

• Public health department

The plan does not cover immunizations for travel or employment, even when recommended by the CDC

or required by travel regulations. Exception: COVID-19 vaccines are covered when required for

employment.

TIP: If you get a vaccine from an out-of-network provider, submit your claim to Regence

BlueShield as a medical claim (see the “Billing and payment: submitting a claim” section). If you

get a vaccine from an out-of-network pharmacy, submit your prescription drug claim to WSRxS

(see the "Submitting a claim for prescription drugs" section). If you use an out-of-network

provider or an out-of-network pharmacy, services will be paid at the out-of-network rate and

you may be balanced billed. Vaccines from an excluded pharmacy will not be covered. See the

definition of “Excluded pharmacy.”

Radiology

Preauthorization is required for all non-emergency diagnostic imaging. Providers should obtain

preauthorization before scheduling or performing any elective outpatient imaging service. Examples of

imaging tests that require a preauthorization are:

68 2023 UMP Classic (PEBB) Certificate of Coverage

• Computed tomography (CT)

• Computed tomography angiography (CTA)

• Magnetic resonance angiography (MRA)

• Magnetic resonance imaging (MRI)

• Myocardial perfusion imaging (MPI)

• Nuclear cardiology:

▪ Blood pool imaging

▪ First pass ventriculography

▪ Infarct imaging

▪ Multiple-gated acquisition (MUGA) scan

• Positron emission tomography (PET and PET-CT)

Second opinions

This benefit covers:

• Second opinions you choose to get. The plan covers these under the medical benefit, once you meet

your medical deductible and pay the coinsurance.

• Second opinions required by the plan. The plan covers these at 100 percent (you do not need to

meet your medical deductible or pay the coinsurance). If you do not get a second opinion when

required by the plan, coverage for services may be denied.

• Expert Second Opinion program. This program, provided by 2nd.MD, offers members the

opportunity to consult virtually with specialists. It also provides for expert lead consultation and post-

consultation follow-up support. To learn more visit the 2nd.MD website at 2nd.md/ump or call 1-866-

982-1434 (TRS: 711).

Skilled nursing facility

Skilled nursing facility services are paid at the inpatient rate. The plan must preauthorize services before

you are admitted to a skilled nursing facility (see the “Limits on plan coverage” section). In addition, the

facility must notify the plan within 24 hours of your admission (see page 110).

This benefit covers skilled nursing facility charges for services, supplies, and room and board, including

charges for services such as general nursing care made in connection with room occupancy. The plan

covers up to 150 days per calendar year. Room and board is limited to the skilled nursing facility’s average

semiprivate room rate, except where a private room is determined to be medically necessary.

The plan does not cover stays at a skilled nursing facility that are primarily convalescent or custodial in

nature.

Private duty nursing furnished by a licensed home health agency may be substituted as an alternative to

placement at a skilled nursing facility only if:

• Skilled nursing facility care is medically necessary, not primarily convalescent or custodial in nature, and

would be covered by the plan;

• Private duty nursing is the most cost-effective setting (private duty nursing must be an equal or lesser

cost compared to a nursing facility); and

• The member's provider agrees that private duty nursing is medically appropriate and will adequately

meet the member's needs.

2023 UMP Classic (PEBB) Certificate of Coverage 69

Private duty nursing is shift-based, hourly nursing care at home for adults and children, typically with a

chronic illness, injury, or disability.

Substitution of private duty nursing in lieu of placement in a skilled nursing facility has the same

requirements and limitations as the facility benefit. For example, all deductibles and coinsurances apply

and the benefit is limited to the equivalent of a maximum of 150 skilled nursing facility days per calendar

year.

Skilled nursing care limits for Medicare retirees

FOR MEDICARE RETIREES: This section provides information for Medicare retirees only.

Medicare covers the first 100 days during a benefit period. A Medicare benefit period begins the day of

hospital or skilled nursing facility admission and ends based on the time between hospital or skilled

nursing facility admissions. There may be multiple benefit periods in a year. The benefit period ends when

you have not received any inpatient hospital care or skilled care in a nursing facility for 60 days in a row. If

you go into a hospital or skilled nursing facility after one benefit period has ended, a new benefit period

begins. There is no limit to the number of benefit periods in a year.

If Medicare is your primary coverage, this plan covers your first 100 days in a skilled nursing facility as

your secondary insurer. Those 100 days count against the 150-day calendar year maximum allowed by the

plan.

After you have reached your Medicare maximum of 100 days, the plan covers an additional 50 days

during the same calendar year if services are medically necessary and meet the plan’s criteria for skilled

nursing facility coverage.

Sleep therapy

Preauthorization is required for any facility-based diagnostic or titration study (free-standing or hospital),

and for sleep treatment equipment and related supplies, such as:

• Initial treatment order and supplies (APAP, CPAP, BiPAP).

• In-lab sleep study (PSG, MSLT, MWT).

• Ongoing Treatment Order (APAP, CPAP, BiPAP).

• Titration study.

Exception

The following supplies do not require a preauthorization:

• Ongoing APAP supplies

• Ongoing BiPAP supplies

• Ongoing CPAP supplies

Locations where sleep therapy services are not covered

Sleep therapy services are not covered:

• In the emergency room

• At urgent-care facilities

• During inpatient hospitalization

70 2023 UMP Classic (PEBB) Certificate of Coverage

Spinal and extremity manipulations

The plan covers up to 24 visits per calendar year for manipulations (adjustments) of the spine and

extremities (arms and legs). When you have reached your 24-visit limit for the year, the plan will not pay

for any more manipulations of the spine and extremities. See the definition of “Limited benefit.”

You pay the special rate (a $15 copay) for spinal and extremity manipulations when you see a preferred

provider. The copay will not apply toward the medical deductible, but the copay will apply to the out-of-

pocket limit. All visits apply to the 24-visit limit.

You may receive an office visit (see the “Office visits” benefit for more details) and/or x-ray (see the

“Diagnostic tests, laboratory, and x-rays” benefit for more details) at the time of your spinal and extremity

manipulation service.

Note: For participating providers and out-of-network providers, services are paid at the standard rate up

to 24 visits per calendar year.

Spinal injections

The plan must preauthorize some spinal injections (see the “Limits on plan coverage” section for how this

works). The following therapeutic injections are covered for treatment of chronic pain:

• Cervical-thoracic epidural injections

• Lumbar epidural injections

• Sacroiliac joint injections

Note: See page 119 for a list of spinal injections that are not covered by the plan.

Spinal injections not specified in this section may be covered subject to the plan’s medical policy. Call

UMP Customer Service for more information.

Spinal surgery

The plan must preauthorize inpatient and outpatient spinal surgery performed outside of the Centers of

Excellence (COE) Program.

Spine care in the Centers of Excellence (COE) Program

FOR MEDICARE RETIREES: The COE Program is not available to UMP Classic members

enrolled in Medicare as their primary coverage (see the “For retirees enrolled in Medicare and

UMP Classic” section). Medicare members still have access to covered services related to spine

care separate from the COE Program. Those services are paid at the standard rate.

The Centers of Excellence (COE) Program covers 100 percent of the allowed amount for covered services

related to lumbar fusion. The program includes, but is not limited to:

• An evaluation to determine if surgery is appropriate.

• Presurgical consultations.

• Travel costs (see the “Travel benefits” section below).

• Hospitalization and surgery, if surgery is determined to be appropriate.

• Postsurgical check-ups.

2023 UMP Classic (PEBB) Certificate of Coverage 71

In the COE program, members work with Premera Blue Cross (the administrator of the program) and

Virginia Mason Medical Center or MultiCare Capital Medical Center (the Centers of Excellence) to make

sure that their treatment is consistent with established standards of medical care.

Premera will help you understand how the COE Program works, what is covered under the Program,

connect you with Virginia Mason Medical Center or MultiCare Capital Medical Center providers if you are

eligible, and work to resolve any questions or issues you may have.

If you receive services related to spine care that are not covered under the COE Program, but are covered

under the plan, you will pay your normal UMP cost-share, depending on the services received and the

network status of the provider(s). This may be a deductible, coinsurance, copay, or amounts not covered

by the plan. Services billed to the plan outside of the COE Program are subject to the plan’s

preauthorization requirements.

Centers of Excellence for spine care: Virginia Mason Medical Center and

MultiCare Capital Medical Center

Virginia Mason Medical Center and MultiCare Capital Medical Center are the two providers approved to

perform spine care evaluations and surgeries under the COE Program. These facilities have proven that

they provide high-quality spine care using the most up-to-date medical guidelines and services.

Who is eligible to participate in the COE Program?

You are eligible to participate in the COE Program if you are:

• A member enrolled in UMP Classic.

• Not enrolled in Medicare as your primary coverage.

• Age 18 or older.

How to apply to participate in the COE Program

If you are interested in participating in the COE Program:

• You may self-refer by calling Premera at 1-855-784-4563 (TRS: 711).

• Your regular provider may refer you.

You may receive information in the mail about the COE Program, which will explain how the program

works and whom to contact for more information. Premera will screen applicants to initially determine

whether they are eligible to participate in the COE Program.

What happens after you are approved to participate

After you are approved to participate in the program, Premera will:

• Provide a booklet to participants describing their journey through the program.

• Assign participants a dedicated case manager who will walk participants through each step of the

journey.

• Gather relevant medical records to supply to the participant’s COE care team as part of the referral

process. This information helps the care team assess next steps

After Premera’s referral, Virginia Mason Medical Center or MultiCare Capital Medical Center will review

participant’s medical records and schedule an evaluation appointment to determine whether the surgery

is medically appropriate for the participant under the COE Program.

Virginia Mason Medical Center or MultiCare Capital Medical Center must determine if surgery for spine

care is appropriate based on established medical guidelines. You may find these guidelines on the Policies

that affect your care webpage (see Directory for link).

72 2023 UMP Classic (PEBB) Certificate of Coverage

What is included in the COE Program

In general, all eligible expenses associated with a spine care evaluation and a spine care surgery (if

determined surgically appropriate) under the COE Program are covered. If surgery is recommended, this

includes expenses from the day you arrive for your pre-operative visit through discharge, including your:

• Assessment(s).

• Surgery.

• Hospital stay.

• Hospital discharge (excluding take-home prescription drugs, which are covered under your UMP

prescription drug benefit).

Travel benefits

Members participating in the COE Program may qualify for assistance with travel and lodging expenses.

These expenses may include partial coverage by Premera for mileage, flights, parking, and lodging.

To be covered by the program, all travel must be arranged through Premera. This travel may be

arranged by calling Premera at 1-855-784-4563 (TRS: 711).

You must have an approved adult care companion, whose travel expenses will be covered as described

below.

You may be partially reimbursed for expenses related to:

• Mileage for driving within Washington. To qualify for reimbursement for mileage, members must live at

least 60 driving miles from Virginia Mason Medical Center, located at 1100 9th Ave., Seattle, WA 98101,

or MultiCare Capital Medical Center, located at 3900 Capital Mall Drive SW, Olympia, WA 98502.

• Flights departing from and arriving at airports within Washington or Portland International Airport. You

must depart from the airport closest to your residence.

• Ground transportation from Seattle-Tacoma International Airport to Virginia Mason Medical Center or

MultiCare Capital Medical Center.

• Lodging expenses (excluding meals) at a COE-designated hotel. Premera must arrange all lodging.

• Parking at Virginia Mason Medical Center or MultiCare Capital Medical Center and parking at your

departing airport.

TIP: Reimbursement for travel expenses is based on cost or current IRS rates for medical

expenses, whichever is less, and may not cover all of your costs. For the IRS rates, visit the IRS

website at irs.gov/tax-professionals/standard-mileage-rates.

What is not included in the COE Program

If you receive spine care services outside of the COE Program, or choose to receive services at Virginia

Mason Medical Center or MultiCare Capital Medical Center that are not related to your spine care

evaluation or surgery, covered services will be processed at the standard rate.

The following services are not included in the COE Program (but may be covered by other plan benefits):

• Care received as part of the plan Virginia Mason Medical Center or MultiCare Capital Medical Center

gives you as a condition of surgery, regardless of where you receive care. Examples include tobacco

cessation and weight loss programs.

2023 UMP Classic (PEBB) Certificate of Coverage 73

• Physical therapy that is not provided during your hospitalization.

• Follow-up care other than the initial postsurgical checkup at Virginia Mason Medical Center or

MultiCare Capital Medical Center. An example of follow-up care is a visit with your regular doctor.

• Prescription drugs received from a pharmacy after discharge from the hospital.

• Convenience items, such as a personal phone.

Call UMP Customer Service if you have questions about services not included in the COE Program.

What happens if you are not an appropriate candidate for spine care surgery

under the COE Program

If Virginia Mason Medical Center or MultiCare Capital Medical Center determine you are not an

appropriate candidate for spine care surgery, you may still receive spine care surgery through other

providers under this plan. Services received outside the COE Program are processed according to the

plan’s medical policies, benefit structure, and the network status of your provider.

Appeals related to the COE Program

UMP members may appeal denials made by Premera. Appeals must be submitted to Premera. A decision

by your Virginia Mason Medical Center or MultiCare Capital Medical Center provider regarding whether

the provider is willing to perform spine care surgery on you is a decision of the provider, not the plan, and

cannot be appealed to the plan or Premera.

TIP: Appeal deadlines and other rules remain the same. See the “Complaint and appeal

procedures” section for details of how non-COE appeals work.

An appeal for services related to the COE Program must be submitted within 180 days after you receive

notice of the denial to Premera, not to Regence, Virginia Mason Medical Center, or MultiCare Capital

Medical Center. Appeals can be submitted to:

Premera Blue Cross

Attn: Member Appeals

PO Box 91102

Seattle, WA 98111-9202

Secure inbound fax: 1-425-918-5592

Substance use disorder

See the “Behavioral health” benefit.

Surgery

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.

74 2023 UMP Classic (PEBB) Certificate of Coverage

You pay the standard rate for covered surgical services. The plan pays for covered surgical services

according to the network status of the provider. The surgeon and other professional providers may bill

separately from the facility.

Your provider must notify the plan when you are admitted for inpatient treatment and when you receive

certain services. Some outpatient procedures require preauthorization. Find the list of services that require

preauthorization on the UMP Policies that affect your care webpage. Call UMP Customer Service if you

have questions. See Directory for link and contact information.

If services are inpatient (see definition of “Inpatient stay”), you will also pay an inpatient copay for facility

charges at a preferred facility.

The plan covers the following services as outpatient:

• Outpatient surgery at a hospital

• Short-stay obstetric (childbirth) services (released within 24 hours of admission)

• Surgery and procedures performed at an ambulatory surgery center

ALERT! All surgeries must follow the plan’s coverage rules. We recommend that you call UMP

Customer Service before any procedure to ask if it is covered or requires preauthorization.

Temporomandibular joint (TMJ) disorder treatment

The plan covers diagnosis and medically necessary treatment of temporomandibular joint (TMJ) disorders,

including surgery and non-surgical services. Treatment must follow the plan’s medical policy and requires

preauthorization. Treatment that is experimental or investigational, or primarily for cosmetic purposes, is

not covered.

Therapy: Habilitative and Rehabilitative

Note: 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.

Habilitative (Neurodevelopmental) Services

The plan covers inpatient and outpatient habilitative (neurodevelopmental) services to assist a person to

keep, learn, or improve skills and functioning for daily living. This could be related to issues such as:

• A congenital anomaly (such as cleft lip or palate).

• Conditions of developmental delay, including autism.

For the purposes of this benefit, developmental delay means a significant lag in achieving skills such as:

• Cognitive (thinking).

• Language (speech, reading, writing).

• Motor (crawling, walking, feeding oneself).

• Social (getting along with others).

You must have a prescription for occupational, physical, and speech therapy services from a covered

provider type (see the “Covered and noncovered provider types” section), such as a physician.

2023 UMP Classic (PEBB) Certificate of Coverage 75

Inpatient habilitative services

Preauthorization is required for inpatient habilitative admissions. The plan covers therapy services when

they are provided during inpatient habilitative admission, up to 60 days combined per calendar year,

counting all types of therapies listed here (see definition of “Limited benefit”). You must pay the inpatient

copay and your coinsurance for inpatient services.

Outpatient habilitative services

The plan covers medically necessary outpatient occupational, physical, and speech therapy services up to

60 visits combined per calendar year, counting all types of therapies listed here (see definition of “Limited

benefit”).

Rehabilitative Services

The plan covers inpatient and outpatient services to improve or restore function lost due to issues such as:

• An illness.

• An acute injury.

• Worsening or aggravation of a chronic injury.

You must have a prescription for occupational, physical, and speech therapy services from a covered

provider type (see the “Covered and noncovered provider types” section, such as a physician.

Inpatient rehabilitation services

Preauthorization is required for inpatient rehabilitation admissions. The plan covers therapy services when

they are provided during inpatient rehabilitation admission, up to 60 days combined per calendar year,

counting all types of therapies listed here (see definition of “Limited benefit”). You must pay the inpatient

copay and your coinsurance for inpatient services.

Outpatient rehabilitation services

The plan covers medically necessary outpatient neurodevelopmental, occupational, physical, and speech

therapy services up to 60 visits combined per calendar year, counting all types of therapies listed here (see

definition of “Limited benefit”).

Tobacco cessation services

ALERT! If you get nicotine replacement therapy or prescription drugs for tobacco cessation at

a non-network pharmacy, or purchase at a cash register other than the pharmacy counter, and

submit a claim, you may not receive full reimbursement from the plan. See the “Where to buy

your prescription drugs” section for how to locate a network pharmacy. Prescriptions

purchased from an excluded pharmacy will not be covered. See the definition of “Excluded

pharmacy.”

The services described in this section are covered only for tobacco cessation. Nicotine replacement

therapy and prescription drugs for tobacco cessation that are listed as “Preventive” in the Tier column on

the UMP Preferred Drug List are not subject to the prescription drug deductible or coinsurance.

If you purchase an over-the-counter tobacco cessation product without a valid prescription, the plan will

not cover it and you will pay the full cost.

76 2023 UMP Classic (PEBB) Certificate of Coverage

TIP: You do not have to enroll in the Quit for Life program to get coverage of nicotine

replacement therapy or prescription drugs for tobacco cessation. See below for limits and rules

on accessing these services.

Nicotine replacement therapy

The plan covers only certain nicotine replacement therapy products (such as gum, patches, sprays,

inhalers, tablets, or lozenges) at the preventive rate. Those that are preventive are listed as “Preventive” in

the Tier column on the UMP Preferred Drug List. The plan does not normally cover over-the-counter

drugs, but the plan covers nicotine replacement products when they are purchased at a network

pharmacy using your UMP member ID card.

You may get nicotine replacement therapy directly from the Quit for Life program (see the “Quit for Life

program” section below), or by following these steps:

1. Get a prescription from your provider.

2. Take the prescription to a network pharmacy.

3. Make your purchase at the pharmacy counter of a network pharmacy. Give your prescription and

your UMP member ID card to the pharmacist. The purchase must be submitted through the

prescription drug system to be covered. If you do not provide a valid prescription at the pharmacy

counter, the plan will not cover it.

If you get a nicotine replacement therapy product not designated as preventive, the plan will not cover it,

and you will pay the full cost. To request full coverage of non-preventive nicotine replacement therapy for

a medical reason, see “How to request an exception” below.

The plan does not cover e-cigarettes or vaporizers (“vapes”).

Counseling

The plan covers in-person counseling related to tobacco cessation at the preventive rate when you see a

preferred or participating provider.

Phone or online counseling is covered only through the Quit for Life program described below. UMP

members ages 17 and under may use the Smokefree Teen program as explained below.

How to request an exception

To request coverage of a prescription drug or nicotine replacement therapy not usually covered under this

benefit, see “Requesting an exception for noncovered prescription drugs” on page 97 for how to request

an exception. If your exception is approved, you will receive the approved product or prescription drug at

no cost.

Quit for Life program

UMP members ages 18 and older may participate in the Quit for Life tobacco cessation program. The Quit

for Life program offers a variety of resources, including phone counseling, medications, personalized

coaching, web tools, educational materials, nicotine replacement therapy, and other resources to help you

stop tobacco use. It also offers a free personalized quit plan and has been proven to help individuals quit

more successfully than trying to quit without support. To learn more, visit the Quit Now website at

quitnow.net/ump or call 1-866-784-8454 (TRS: 711).

If you get nicotine replacement therapy or prescription drugs for tobacco cessation that are not listed as

“Preventive” in the Tier column on the UMP Preferred Drug List, you will pay as described in the “Nicotine

replacement therapy” section on page 76.

2023 UMP Classic (PEBB) Certificate of Coverage 77

For nicotine replacement therapy, you may get supplies sent to you from Quit for Life or get a

prescription from your provider and purchase as described under “Nicotine replacement therapy” on page

76.

ALERT! You may attest for an exemption to the PEBB tobacco use premium surcharge if you or

a dependent are tobacco-free for two months, enroll in Quit for Life (for members ages 18 and

over), or access the information and resources aimed at teens in Smokefree Teen (for members

ages 13 through 17). Visit the HCA website at hca.wa.gov/erb for details about the surcharge.

Smokefree Teen

UMP members ages 17 and under may access tobacco cessation support services through the Smokefree

Teen program online at teen.smokefree.gov or by calling 1-800-QUIT-NOW (784-8669) (TRS: 711).

Transplants

You must receive preauthorization from the plan for all transplants (except kidney and cornea). This

benefit covers services related to transplants, including professional and facility fees for inpatient

accommodation, diagnostic tests and exams, surgery, and follow-up care.

Donor coverage

If a UMP member receives an organ, eye, or tissue donation from a live donor, the plan pays the standard

rate for the donor’s covered expenses as primary, regardless of any other coverage the donor may have.

Covered donor expenses include costs to remove the donor’s organ and treat complications directly

resulting from the donor’s surgery.

Urgent care

See the “Emergency room” benefit for care during a medical emergency.

If you need immediate care or need care when your usual provider is closed, and your situation is not a

medical emergency, you may use urgent care facilities to receive care at a lower cost than an emergency

room. You do not pay the emergency room copay for urgent care services. These services are paid at the

standard rate, according to the provider’s network status. Visit the UMP Provider search to find preferred

urgent care facilities (see Directory for link).

Virtual care

Telemedicine services

Telemedicine is the delivery of health care services through audio and visual technology, allowing real-

time communication between the member at the originating site and a provider for the purpose of

diagnosis, consultation, or treatment. Telemedicine includes audio-only telemedicine. Telemedicine does

not include the use of fax or email.

“Store and forward technology” is a term used for the transfer of a member’s medical information from

one health care provider to another at a distant site, which results in medical diagnosis and management

of the covered person. The purpose of telemedicine and store and forward technology is diagnosis,

consultation, or treatment of the member. It does not include the use of fax or email.

If you see a network provider, telemedicine services are paid at the network rate. If you see an out-of-

network provider, telemedicine services are paid at the out-of-network rate.

The plan covers store and forward technology and telemedicine from authorized originating sites under

the medical benefit if:

78 2023 UMP Classic (PEBB) Certificate of Coverage

• The plan provides coverage for the service when provided in person by the provider;

• The service is medically necessary;

• The service is determined to be safely and effectively provided through telemedicine or store and

forward technology according to generally accepted health care practices and standards;

• The technology used to provide the service meets the standards required by state and federal laws

governing the privacy and security of protected health information; and

• The service is recognized as an essential health benefit under section 1302(b) of the federal Patient

Protection and Affordable Care Act (PPACA) in effect on January 1, 2015.

If services are provided through store and forward technology, there must be an associated office visit

between the covered person and the referring health care provider. The associated office visit may be in

person or via telemedicine. For audio-only telemedicine, the member must have an established

relationship with the provider.

The originating site (the member’s physical location) for telemedicine services must be one of the

following sites:

• Community mental health center

• Federally qualified health center

• Home or any location determined by the individual receiving the service

• Hospital

• Physician's or other health care provider's office

• Renal dialysis center (except independent renal dialysis center)

• Rural health clinic

• Skilled nursing facility

Any originating site, except home, may charge a facility fee for infrastructure and preparation of the

member.

Telemedicine and store and forward technology are subject to all terms and conditions of the plan,

including utilization review, preauthorization requirements, deductibles, and copay requirements. Services

obtained from out-of-network providers will be reimbursed at the out-of-network rate.

The following are not covered by the plan:

• Email or fax transmissions between provider and member

• Home health monitoring

• Installation or maintenance of any telecommunication devices or systems

• Originating sites’ professional fees

• Services that are not medically necessary

• Services that would not be covered if delivered in person

• Store and forward technology without an associated office visit between the covered member and the

referring health care provider

• Telemedicine or store and forward services for services that are not recognized as essential health

benefits under section 1302(b) of the PPACA in effect on January 1, 2015

2023 UMP Classic (PEBB) Certificate of Coverage 79

• Telemedicine or store and forward services that cannot be safely and effectively provided through

telemedicine or store and forward technology

• Telemedicine or store and forward services that use technology that does not meet state and federal

requirements for privacy and security of protected health information

• Telemedicine visits originating from a location other than the specified originating sites

Doctor On Demand

Doctor On Demand is a virtual care service that gives you access to providers 24 hours a day, 7 days a

week. It is a good option to consider when you need medical attention, but not emergency room or

urgent care. Doctor On Demand providers are board-certified, U.S.-based providers who are specifically

trained in video medicine. Members can connect in minutes with doctors face-to-face through a

smartphone, tablet, or computer via the website or Doctor On Demand smartphone application. To learn

more, visit the Telemedicine (virtual care) webpage at ump.regence.com/pebb/benefits/telemedicine.

Providers review a member's history and symptoms, perform an exam, and recommend treatment, which

may include prescription drugs and lab work. Doctor On Demand providers can treat most common

health conditions, including, but not limited to:

• Asthma.

• Colds and allergies.

• Diabetes.

• Eczema and acne.

• Heartburn and indigestion.

• High blood pressure and high cholesterol.

• Migraines.

• Pink eye.

• Urinary Tract Infections (UTIs).

A Doctor On Demand virtual care appointment is paid at the standard rate. Doctor On Demand providers

are considered preferred providers.

Doctor On Demand does not include the use of audio-only telephone, fax, or email. For additional

questions, call UMP Customer Service.

Vision care (diseases and disorders of the eye)

You pay the standard rate under the medical benefit for treatment of diseases and disorders of the eye

that are not part of a routine vision exam. Orthoptic therapy is not covered except for the diagnosis of

strabismus, a muscle disorder of the eye. LASIK surgery is not covered.

Following cataract surgery, vision hardware (contact lenses or eyeglasses, including frames and

prescription lenses) is covered as DME (see page 48). These services are paid at the standard rate.

Your routine vision benefits

Vision coverage is provided by UMP, in collaboration with Regence Choice Vision Plan administered by

Vision Service Plan (VSP). Regence BlueShield administers benefits for the treatment of diseases and

disorders of the eyes. VSP administers benefits for routine eye exams and hardware (prescription lenses,

frames or prescription contact lenses) and provides claims administration for this plan.

When you have questions about treatment of diseases and disorders of the eyes call UMP Customer

Service. When you have questions about routine eye exams and hardware, call VSP Member Services at

1-844-299-3041 or Deaf, DeafBlind, Late Deafened and Hard of Hearing members call 1-800-428-4833.

See the Directory at the beginning of the COC for vision services contact information.

80 2023 UMP Classic (PEBB) Certificate of Coverage

Finding a routine vision provider

Get the most out of your UMP vision benefits and save money with a VSP Choice network provider. As a

UMP member, you may search for a VSP Choice network provider for preventive (routine) vision services

through the VSP website by logging in to your VSP account or by selecting “Find a doctor,“ and using the

advanced search option to select “Choice” for “Doctor network.“ You can also search by signing in to your

Regence account, selecting “Find care,” and selecting “Vision.” See the Directory pages at the beginning of

this booklet for links and contact information. Members under the age of 19 do not have out-of-network

provider benefits.

• VSP Choice network provider: When you choose to see a VSP Choice network provider for covered

preventive vision care, you pay $0 of the allowed amount and the plan pays 100 percent of the allowed

amount. Select a VSP Choice network provider who participates in the Premier Program to receive the

best value for lenses and frames or contact lenses. VSP providers who participate in the Premier

Program provide access to special offers and savings.

• Out-of-network provider: For members ages 19 and over, out-of-network providers will cost you

more. See the table below for more information. Members under the age of 19 do not have out-of-

network benefits.

ALERT! This benefit covers only services that meet the requirements below. If you receive

services during a comprehensive routine eye exam and your provider bills your visit as a

medical treatment instead of as a routine service, the services are not covered as routine.

Instead, when medically necessary, they may be covered under your medical benefits. See the

“Vision care (diseases and disorders of the eye)” benefit for more information.

Adults (ages 19 and over)

This section explains how the plan pays for covered services for members ages 19 and over. The

explanation includes information about maximum benefits, covered services, and payment. The below VSP

coverage table applies to adults and dependents ages 19 and over.

Benefit

Frequency

Your cost with a VSP Choice

network provider

Your cost with an out-of-

network provider

Professional

comprehensive

routine eye

exams

One per calendar

year.

You pay $0 of the allowed

amount and the plan pays

100% of the allowed amount.

You pay 100% of billed

charges.

VSP will reimburse you up to

$45 when you submit a

claim for a covered exam.

Frames

One every two

calendar years.

You pay $0 up to a $150 frame

allowance; or

You pay $0 up to an $80 frame

allowance for Walmart®,

Sam’s Club®, or Costco®

providers.

You pay 100% of billed

charges.

VSP will reimburse you up to

$70 when you submit a

claim for covered frames.

2023 UMP Classic (PEBB) Certificate of Coverage 81

Benefit

Frequency

Your cost with a VSP Choice

network provider

Your cost with an out-of-

network provider

Lenses and

enhancements

One set every two

calendar years.

You pay $0 for the following

covered lenses and the plan

pays 100% of the allowed

amount:

• Single vision lenses

• Lined bifocal lenses

• Standard progressive lenses

• Lined trifocal lenses

• Lenticular lenses

Note: Lens enhancement is not

covered except for impact-

resistant coating for dependent

children ages 19 and over.

You pay 100% of billed

charges.

VSP will reimburse you up to

the following amounts when

you submit a claim for

covered lenses:

• $30 single vision lenses

• $50 lined bifocal lenses

• $50 standard progressive

lenses

• $65 lined trifocal lenses

• $100 lenticular lenses

Contacts

One set of contact

lenses or

disposable contact

lenses up to the

maximum

allowance instead

of frames and

lenses every two

calendar years.

You pay $30 copay for a

contact lens evaluation and

fitting exam.

You pay $0 up to a $150

contact allowance for elective

contact lenses.

You pay $0 for necessary

contact lenses. Note: You are

still responsible for paying a

$30 copay for the contact lens

evaluation and fitting exam.

You pay 100% of billed

charges.

VSP will reimburse you up to

the following amounts when

you submit a claim for

contact lenses:

• $105 for elective contact

lenses

• $210 for necessary

contact lenses

Note: See below for reimbursement rates for vision services received outside the U.S.

Vision exam

You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount when you see a

VSP Choice network provider for one professional comprehensive routine eye examination with refraction

or visual analysis per calendar year, including:

• Prescribing and ordering proper lenses;

• Verifying the accuracy of the finished lenses; and

• Progress or follow-up work as necessary.

When you see an out-of-network provider you pay 100 percent of the billed charges. VSP will reimburse

you up to $45 when you submit a claim for covered services.

When you receive services outside the country, you pay 100 percent of the billed charges. VSP will

reimburse you up to $80 when you submit a claim for covered services.

Vision hardware

Lenses for glasses

You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount once every two

calendar years for one set of covered glass or plastic lenses:

82 2023 UMP Classic (PEBB) Certificate of Coverage

• Single vision lenses

• Lined bifocal lenses

• Lined trifocal lenses

• Lenticular lenses

• Standard progressive lenses

• Lens enhancement covered for dependent children ages 19 and over only:

▪ Impact-resistant coating

When you see an out-of-network provider you pay 100 percent of the billed charges. When you submit a

claim for covered lenses, VSP will reimburse you up to the following amounts:

• $30 single vision lenses

• $50 lined bifocal/standard progressive lenses

• $65 lined trifocal lenses

• $100 lenticular lenses

When you receive services outside the country, you pay 100 percent of the billed charges. When you

submit a claim for covered lenses, VSP will reimburse you up to the following amounts:

• $70 single vision lenses

• $80 lined bifocal/standard progressive lenses

• $90 lined trifocal lenses

• $125 lenticular lenses

Frames

The plan covers one frame every two calendar years:

• When you see a VSP Choice network provider, the plan pays up to $150. You pay any amount over

$150.

• When you see an out-of-network provider you pay 100 percent of the billed charges. VSP will

reimburse you up to $70 when you submit a claim.

• When you see a VSP approved wholesale/retail vendor the plan pays up to the VSP approved

wholesale/retail limit of $80. You pay any amount over $80. VSP approved wholesale/retail vendors

include both community-based providers, as well as national retail chains. For a list of wholesale/retail

vendors, contact VSP Member Services at 1-844-299-3041 or Deaf, DeafBlind, Late Deafened and Hard

of Hearing members call 1-800-428-4833.

• When you receive services outside the country, you pay 100 percent of the billed charges. When you

submit a claim, VSP will reimburse you up to $150.

Contact lenses

The plan covers elective contact lenses or necessary contact lenses in lieu of frames and lenses once every

two calendar years.

• Elective contact lenses are contact lenses that are covered under the frame limit in lieu of coverage

for eyeglasses.

2023 UMP Classic (PEBB) Certificate of Coverage 83

• Necessary contact lenses are contact lenses that are prescribed by your provider for other than

elective or cosmetic purposes. Necessary contact lenses are used to treat specific conditions for which

contact lenses provide better visual correction.

When you see a VSP Choice network provider:

• The plan pays up to $150 for elective contacts. You pay a $30 copay when you receive contact lens

evaluation and fitting exam at the time of service. You also pay any amount over $150.

• The plan pays 100 percent of the allowed amount for necessary contact lenses. You pay a $30 copay

when you receive contact lens evaluation and fitting exam at the time of service.

When you see an out-of-network provider you pay 100 percent of the billed charges. When you submit a

claim, VSP will reimburse you up to the following amounts:

• $105 for elective contacts including any fitting/evaluation services

• $210 for necessary contact lenses including any fitting/evaluation services

When you receive services from outside the country you pay 100 percent of the billed charges. When you

submit a claim, VSP will reimburse you up to the following amounts:

• $150 elective contacts including any fitting/evaluation services

• $150 necessary contact lenses including any fitting/evaluation services

Low vision benefit

The plan covers low vision benefits when vision loss is sufficient enough to prevent reading and

performing daily activities with standard corrective eyewear. If you fall within this category, you are

entitled to professional services, as well as ophthalmic materials. These services and equipment are

subject to the limitations stated below. Contact your VSP Choice network provider for more information.

You pay 25 percent of the allowed amount for covered supplemental aids. The plan pays 75 percent of the

allowed amount for medically necessary supplemental aids provided by VSP choice network providers and

out-of-network providers. When you see an out-of-network provider for covered supplemental aids, you

pay 100 percent of the billed charges. VSP will reimburse you up to 75 percent of the allowed amount

when you submit a claim for covered aids.

The maximum low vision benefit available is $1,000 (excluding your coinsurance) every two calendar years

for supplemental examinations (testing) and supplemental aids combined when provided by VSP Choice

network providers and out-of-network providers. There is a benefit maximum of two supplemental

examinations (testing) and all supplemental aids combined.

Supplemental examinations (testing)

You may receive up to two medically necessary supplemental tests (complete low vision analysis and

diagnosis), including a comprehensive examination of visual functions, and the prescription of corrective

eyewear or low vision aids when noted by the provider every two calendar years. When you see a VSP

Choice network provider, you pay $0 and the plan pays 100 percent of the allowed amount. When you

see an out-of-network provider you pay 100 percent of the billed charges. VSP will reimburse you up to

$125 when you submit a claim for covered services.

Supplemental aids

The plan pays for covered supplemental aids every two calendar years, which may include:

• Optical and non-optical aids; and

• Training on how to use the aids.

84 2023 UMP Classic (PEBB) Certificate of Coverage

Children (under the age of 19)

ALERT! Out-of-network providers are not covered for any routine vision services.

The below VSP coverage table applies to children under the age of 19.

Benefit

Frequency

Your cost with a VSP

Choice network provider

Your cost with an out-

of-network provider

Professional

comprehensive

routine eye

exams

One per calendar

year.

You pay $0 of the allowed

amount and the plan pays

100% of the allowed amount.

You pay 100% of billed

charges.

Frames

One per calendar

year.

You pay $0 of the allowed

amount and the plan pays

100% of the allowed amount.

You pay 100% of billed

charges.

Lenses and

enhancements

One set per calendar

year.

You pay $0 for the following

covered lenses and the plan

pays 100% of the allowed

amount:

• Single vision lenses

• Lined bifocal lenses

• Standard progressive

lenses

• Lined trifocal lenses

• Lenticular lenses

You pay $0 for the following

lens enhancements and the

plan pays 100% of the

allowed amount:

• Scratch-resistant coating

• Ultraviolet (UV) protected

lenses

• Impact-resistant coating

You pay 100% of billed

charges.

Contacts

One set of contact

lenses or disposable

contact lenses up to

the maximum

allowance instead of

frames and lenses

every calendar year.

You pay $0 of the allowed

amount for elective or

necessary contact lenses and

the plan pays 100% of the

allowed amount.

You pay $0 of the allowed

amount for contact lens

evaluation and fitting exam

and the plan pays 100% of

the allowed amount.

You pay 100% of billed

charges.

2023 UMP Classic (PEBB) Certificate of Coverage 85

Note: Walmart®, Sam’s Club ®, and Costco® providers are not VSP Choice network providers for

children under the age of 19 for frames, lenses, and contact lenses. Call VSP Member Services at 1-844-

299-3041 for out-of-network plan details. Deaf, DeafBlind, Late Deafened and Hard of Hearing members

call 1-800-428-4833.

Vision exam

You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount when you see a

VSP Choice network provider for one professional comprehensive routine eye examination with refraction

or visual analysis per calendar year, including:

• Prescribing and ordering proper lenses;

• Verifying the accuracy of the finished lenses; and

• Progress or follow-up work as necessary.

Vision hardware

Lenses for glasses

You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount when you see a

VSP Choice network provider once every calendar year for one set of covered glass or plastic lenses:

• Single vision lenses

• Lined bifocal lenses

• Lined trifocal lenses

• Lenticular lenses

• Standard progressive lenses

• Lens enhancements:

▪ Scratch-resistant coating

▪ Ultraviolet (UV) protected lenses

▪ Impact-resistant coating

Frames

You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount for one covered

frame every calendar year when you see a VSP Choice network provider.

Contact lenses

• You pay $0 of the allowed amount and the plan pays 100 percent of the allowed amount for elective

contact lenses or necessary contact lenses in lieu of frames and lenses once every calendar year when

you see a VSP Choice network provider.

• You pay $0 and the plan pays 100 percent of the allowed amount for contact lens evaluation and fitting

exam when you see a VSP Choice network provider.

Low vision benefit

ALERT! Out-of-network providers are not covered for any low vision services.

86 2023 UMP Classic (PEBB) Certificate of Coverage

The plan covers low vision benefits when vision loss is sufficient enough to prevent reading and

performing daily activities with standard corrective eyewear. If you fall within this category, you are

entitled to professional services, as well as ophthalmic materials at no cost to you when the services are

provided by a VSP Choice network provider. These services and equipment are subject to the limitations

stated below. Contact your VSP Choice network provider for more information.

Supplemental examinations (testing)

You may receive up to two medically necessary supplemental tests (complete low vision analysis and

diagnosis), including a comprehensive examination of visual functions, and the prescription of corrective

eyewear or low vision aids when noted by the provider every two calendar years when you see a VSP

Choice network provider.

Supplemental aids

The plan pays for covered supplemental aids every two calendar years, which may include:

• Optical and non-optical aids; and

• Training on how to use the aids.

Vision claims administration

This section explains how VSP administers claims.

How to submit a vision claim for reimbursement

When you visit a VSP Choice network provider, the doctor will submit the claim directly to VSP for

payment.

If you are a member and are age 19 or older and you see an out-of-network provider, you pay 100

percent of the billed charges. You can submit the claim online or by mail. See the Directory pages at the

beginning of this booklet for links and contact information.

When you submit a claim, attach an itemized receipt that includes the following information:

• Doctor’s name or office name;

• Name of patient;

• Date of service; and

• Each service received and the amount paid.

Timely submitting of claims

You have 12 months from the date of service to submit your claim. If you do not submit your claim within

12 months of the date of service, it will be denied.

If you disagree with how your claim was processed, you may file a complaint or an appeal.

Vision complaints and appeals

How to submit a vision complaint

Complaints can be submitted through a written or verbal request. See the Directory pages at the

beginning of this booklet for links and contact information.

How to submit a vision appeal

You have the right to appeal if:

• You do not agree with VSP's decision about your health care.

2023 UMP Classic (PEBB) Certificate of Coverage 87

• VSP will not approve or give you care you feel it should cover.

• VSP is stopping care you feel you still need.

VSP normally has 30 days to process your appeal. In some cases, you have a right to an expedited appeal.

You can get an expedited appeal if your health or ability to function could be seriously harmed by waiting

30 days for a standard appeal. If you ask for an expedited appeal, VSP will decide whether your request is

approved. If not approved, your appeal will be processed in 30 days. If any doctor asks VSP to give you an

expedited appeal, or supports your request for an expedited appeal, it must be given to you.

If you want to file an appeal which will be processed within 30 days, do the following:

File the request in writing with VSP. See the Directory pages at the beginning of this booklet for contact

information. Your appeal request will be processed within 30 days from the date your request is received.

If you want to file an expedited appeal, which will be processed within 24 hours, do the following:

• File an oral or written request for an expedited appeal. Specifically state that "I am requesting an

expedited appeal," or "I believe that my health could be seriously harmed by waiting 30 days for a

normal appeal."

• To file a request orally, call VSP Member Services. VSP will document the oral request in writing.

See the Directory pages at the beginning of this booklet for contact information.

Help with your appeal:

If you decide to appeal and want help with your appeal, you may have your doctor, a friend, lawyer, or

someone else help you. There are several groups that can help you. If you are covered by Medicare, you

may contact the Medicare Rights Center toll free at 1-888-466-9050 (TRS: 711). You may also contact the

National Institute on Aging at 1-800-222-2225 (TRS: 711) to request the phone number of your local Area

Agency on Aging or Health Insurance Counseling and Assistance Program (HICAP).

Your prescription drug benefit

FOR MEDICARE RETIREES: If Medicare is your primary coverage, see the “How UMP Classic

prescription drug coverage works with Medicare” section for important information.

See the Directory for prescription drug contact information.

Your plan’s prescription drug benefit is managed by a partnership of companies known as Washington

State Rx Services (WSRxS):

• Preauthorization, appeals, and customer service: Moda Health

• Network mail-order pharmacies:

▪ Costco Mail-Order Pharmacy

▪ Postal Prescription Services (PPS)

• Network specialty drug pharmacy: Ardon Health

When you have questions about your prescription drug coverage or need help finding a network

pharmacy, call WSRxS Customer Service. Contact the mail-order or specialty drug pharmacy directly for

help placing or tracking prescription orders.

Note: Regence BlueShield does not provide prescription drug benefits for UMP. Always contact WSRxS

with questions about your prescription drug coverage.

88 2023 UMP Classic (PEBB) Certificate of Coverage

TIP: The UMP Preferred Drug List is available on the UMP Prescription drug coverage webpage

(see Directory for link). On this webpage, you will also find a link to the Drug Price Check tool

(the prices for drugs listed in this tool assume you have met your prescription drug deductible).

The UMP Preferred Drug List

The UMP Preferred Drug List (sometimes called a “formulary”) lists all of the preferred drugs that UMP

covers. Drugs not listed on the Preferred Drug List are not covered unless an exception is requested and

approved by UMP. Excluded prescription drugs and products are not eligible for an exception. For the

exception process, refer to “Requesting an exception for noncovered prescription drugs” on page 97. The

UMP Preferred Drug List includes:

• How much your cost share will be based on the drug tier

• If the plan must preauthorize a prescription drug (see page 102)

• If you must purchase a prescription drug from the plan’s network specialty drug pharmacy (see page

104)

• If there are any limits on a prescription drug’s coverage (see the "Limits on your prescription drug

coverage" section)

• If there are less expensive alternatives

The UMP Preferred Drug List is updated online throughout the year, and how a prescription drug is

covered may change at any time. You may look up your prescription drugs online on the UMP

Prescription drug coverage webpage or by calling WSRxS. New brand-name prescription drugs may not

be covered during the first 180 days they are available. To check if a new prescription drug is covered, call

WSRxS Customer Service.

Preferred drugs

Preferred drugs, including preferred specialty drugs, have been reviewed by the Washington State

Pharmacy and Therapeutics (P&T) Committee or by WSRxS and found to be safe and clinically effective

when compared to other drugs in the same therapeutic class or category. HCA or WSRxS has found these

drugs to be among the most cost-effective drugs for their therapeutic class or category due to their

favorable pricing.

Noncovered prescription drugs

Noncovered prescription drugs are not covered unless a Preferred Drug List exception is requested and

approved. These prescription drugs have been reviewed by the Washington State Pharmacy and

Therapeutics (P&T) Committee or WSRxS. HCA or WSRxS has found these drugs are not as cost-effective

and do not have a clinically significant therapeutic advantage over the Preferred Drug List alternative(s). If

you need to request an exception for a noncovered drugs, see “Requesting an exception for noncovered

prescription drugs” on page 97.

ALERT! When a generic equivalent for a brand-name prescription drug becomes available, the

brand-name drug immediately becomes noncovered. Always ask your provider to allow

substitution on your prescriptions to save you money.

2023 UMP Classic (PEBB) Certificate of Coverage 89

How UMP decides which prescription drugs are preferred

Washington State P&T Committee and WSRxS P&T Committee provide recommendations to HCA. WSRxS

and HCA review the recommendations and determine which medications are included on the UMP

Preferred Drug List, as well as the tier level. The UMP Preferred Drug List includes the committees’

coverage recommendations.

Not all prescription drug classes are reviewed by the Washington State P&T Committee. For these

prescription drugs, the WSRxS P&T Committee makes coverage recommendations for HCA’s review and

final determination of a drug’s tier level.

For the plan to cover a prescription drug for you, it must be medically necessary for your health condition.

Your provider may prescribe a drug or drug dosage that does not meet the plan’s definition of medically

necessary and therefore will not be covered.

ALERT! A prescription drug may be noncovered even if no generic equivalent is available.

Guidelines for prescription drugs UMP covers

The plan is a self-insured PPO health plan. UMP is offered through the Washington State Health Care

Authority’s PEBB Program. UMP is administered by Regence BlueShield and WSRxS.

To be covered, a prescription drug must meet all of the following:

• Does not have a nonprescription alternative, including an over-the-counter alternative with similar

safety, effectiveness, and ingredients.

• Has been dispensed from a licensed pharmacy employing licensed, registered pharmacists.

• Has been prescribed by a provider with prescribing authority within their scope of license.

• Has been reviewed by either the Washington State P&T Committee or WSRxS (see the "How UMP

decides which prescription drugs are preferred" section).

• Is approved by the FDA.

• Is medically necessary.

• Is not classified as a vitamin, mineral, dietary supplement, homeopathic drug, or medical food.

• Is not a noncovered prescription drug or product, unless an exception is granted.

• Is not an excluded prescription drug or product.

• May be legally obtained in the U.S. only with a written prescription.

• Meets plan coverage criteria.

Note: The plan may require that you try standard treatment(s) before it will cover a prescription drug for

off-label use (prescribed for a use other than its FDA-approved label).

The plan will not cover any prescription drug when the FDA has determined its use to be unsafe.

ALERT! The plan does not cover prescription drugs purchased through mail-order pharmacies

located outside the U.S.

90 2023 UMP Classic (PEBB) Certificate of Coverage

Exceptions covered

ALERT! The plan does not cover prescriptions that contain DHA (docosahexaenoic acid). DHA

is a dietary supplement, and dietary supplements are not covered by the plan.

If you are prescribed a noncovered prescription drug not listed on the UMP Preferred Drug List, you may

request an exception. For the exception process, refer to “Requesting an exception for noncovered

prescription drugs” on page 97.

Your prescription drug benefit also includes the following nonprescription drugs and supplies:

• Certain nicotine replacement therapy products (see page 76).

• Covered contraceptive devices (see page 51).

• FDA-approved over-the-counter contraceptives. For the plan to cover FDA-approved over-the-counter

contraceptives, you must present your UMP member ID card and make your purchase at the pharmacy

counter. When possible, get a prescription, as not all pharmacies have prescribing authority. If you go

to a pharmacy without a prescription and the pharmacy does not have prescribing authority, you will

need to submit a claim to WSRxS.

• Diabetes care supplies, such as test strips, lancets, insulin syringes, and continuous glucose monitors

used in the treatment of diabetes. See the “Diabetes care supplies” benefit for more information.

• Other over-the-counter products that are specifically noted in the UMP Preferred Drug List as covered

by the plan.

The plan covers FDA-approved prescription drugs for off-label use (prescribed for a use other than its

FDA-approved label) only if it is not considered experimental or investigational by WSRxS and is

recognized as effective for treatment:

• In a standard reference compendium and supported by peer-reviewed clinical evidence; or

• In most relevant peer-reviewed medical literature, if not recognized in a standard reference

compendium; or

• By the federal Secretary of Health and Human Services.

Products covered under the preventive care benefit

ALERT! For products covered as preventive — even if normally available over the counter

without a prescription — you must have a prescription and buy it at the pharmacy counter in a

network pharmacy to receive 100 percent reimbursement. You may not receive full

reimbursement for claims from non-pharmacy register receipts and non-network pharmacies.

Prescriptions purchased from an excluded pharmacy will not be covered. See the definition of

“Excluded pharmacy.”

Some products are covered under the preventive care benefit if they:

• Are recommended by the U.S. Preventive Services Task Force and the Advisory Committee on

Immunization Practices of the Centers for Disease Control and Prevention (see the “Preventive care”

benefit); and

2023 UMP Classic (PEBB) Certificate of Coverage 91

• Conform to coverage guidelines (see the "How UMP decides which prescription drugs are preferred"

section).

The brands and types of products covered are limited. Call WSRxS Customer Service for more information

on which ones are covered. You pay $0 if your provider writes you a prescription and you purchase these

products from the pharmacy counter at a network pharmacy. If you purchase over the counter and send

in a paper claim, you may pay part of the cost.

Contraceptive drugs and supplies are covered as preventive (see the “Family planning services” benefit for

details). See the “Tobacco cessation services” benefit for products covered as preventive for tobacco

cessation.

Some injectable drugs are covered only under the

prescription drug benefit

Certain prescription drug categories are covered only under the prescription drug benefit and not the

medical benefit. Your pharmacy may submit a claim for these prescription drug classes to WSRxS.

Compounded prescription drugs

Compounded prescription drugs are the result of combining, mixing, or altering ingredients by a

pharmacist in response to a physician’s prescription to create a new drug tailored to the specialized

medical needs of an individual member. Traditional compounding typically occurs when an FDA-approved

prescription drug is unavailable, or a licensed health care provider decides that an FDA-approved drug is

not appropriate for a member’s medical needs. Compounded prescription drugs are covered under Tier 2

and require preauthorization. Claims for compounded drugs require additional information submitted on

the claim form. This information is available from the compounding pharmacy.

What you pay for prescription drugs

The amount you pay for your prescription drugs depends on the prescription drug’s tier, where you

purchase your prescriptions, whether you have met your annual out-of-pocket limit, and for some drugs,

whether you have met your deductible.

• Prescription drug deductible: $100 per member/$300 maximum for family of three of more

• Annual out-pocket-limits: $2,000 per member / $4,000 maximum for family of three of more

Tier and

description

Nonspecialty drugs

All network pharmacies (retail and

mail-order)

Specialty drugs*

Preventive

(Preventive)***

• No deductible

• 0% coinsurance

• No deductible

• 0% coinsurance

Value Tier

(Value)

• 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:

• No deductible

• 0–30-day supply:

▪ 5% coinsurance or $10, whichever

is less

92 2023 UMP Classic (PEBB) Certificate of Coverage

Tier and

description

Nonspecialty drugs

All network pharmacies (retail and

mail-order)

Specialty drugs*

▪ 5% coinsurance or $30, whichever

is less

Tier 1 (Tier

1/Tier 1

Specialty)

Select generic

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 (Tier

2/Tier 2

Specialty)

Preferred 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

*Specialty drugs must be purchased from the plan’s network specialty drug pharmacy, except when you

are authorized by WSRxS to receive certain drugs that can only be dispensed by certain pharmacies.

** Except for insulins covered at Tier 2. See the UMP Preferred Drug List for cost limits.

***Preventive drugs required under Patient Protection and Affordable Care Act (PPACA) or recommended

by the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices of the

CDC.

You may find a prescription drug’s tier by searching the UMP Preferred Drug List on the UMP Prescription

drug coverage webpage or by calling WSRxS Customer Service (see Directory for link and contact

information). You may purchase up to a 90-day supply for most prescription drugs. For the majority of

specialty drugs, you may purchase up to a 30-day supply.

To check your cost, use the Drug Price Check tool on the UMP Prescription drug coverage webpage (the

prices for drugs listed in this tool assume you have met your prescription drug deductible).

Using Value Tier and Tier 1 drugs reduces prescription costs for both you and the plan. Generic drugs,

follow-on biologics, and biosimilars have the same active ingredient as their brand-name counterparts

and are usually less expensive.

2023 UMP Classic (PEBB) Certificate of Coverage 93

Note: You must use UMP’s network mail-order pharmacies to fill mail-order prescriptions. If you use any

other mail-order service to fill your prescription drugs, or you purchase them outside of the U.S., the plan

will not cover these drugs if UMP is your primary plan.

ALERT! When you use network pharmacies, retail or mail-order, you pay based on the

prescription drug’s allowed amount, a discounted price negotiated by the plan. If you use a

non-network pharmacy, the pharmacy may charge more than the plan’s allowed amount. You

will have to pay this additional amount, which does not apply to your prescription drug

deductible or out-of-pocket limit. Prescriptions purchased from an excluded pharmacy will not

be covered. See the definition of “Excluded pharmacy.”

Prescription drug deductible

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 Tier 2 prescription drug (except for covered insulins).

TIP: Since you do not pay any deductible for Preventive, Value Tier, Tier 1 drugs or covered

insulins, if you only get drugs from these tiers during the year, you will not need to meet the

prescription drug deductible.

How the deductible works

Note: The medical deductible and prescription drug deductible are separate.

You pay the prescription drug deductible for Tier 2 drugs. Until you meet your prescription drug

deductible, you pay the deductible plus any applicable coinsurance, up to the cost of the drug. For

prescription drugs that cost less than your deductible, you pay the cost of the drug until you meet the

prescription drug deductible.

Note: If UMP pays second, you must still meet your prescription drug deductible before UMP covers Tier

2 drugs except for covered insulins (see “How COB works with prescription drugs” on page 126).

What applies to your deductible

The following 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:

• Amounts paid toward covered Tier 2 prescription drugs.

• Amounts paid toward supplies designated as Tier 2 and covered under the prescription drug benefit.

• Amounts paid toward covered insulins.

94 2023 UMP Classic (PEBB) Certificate of Coverage

What does not apply to your deductible

• Amounts exceeding the allowed amount paid to non-network pharmacies.

• Coinsurance amounts paid for Value Tier or Tier 1 prescription drugs except for covered insulins.

• Costs for medical services, including prescription drugs covered under the medical benefit.

• Costs for prescription drugs not covered by the plan (see the “Prescription drugs and products UMP

does not cover” section).

• Costs for prescription drugs purchased from excluded pharmacies. See the definition of “Excluded

pharmacy.”

What you will pay for after reaching your deductible

• Any prescription drugs or other products not covered by the plan. See the “Prescription drugs and

products UMP does not cover” section.

• Charges exceeding the allowed amount from a non-network pharmacy.

• Coinsurance amounts paid for all tiers except preventive.

• Costs for other enrolled members who have not met their prescription drug deductible (and the family

maximum has not been met).

Where you pay the deductible

You pay the prescription drug deductible at any pharmacy.

The prescription drug deductible must be met before the plan begins paying benefits for Tier 2 drugs

except for covered insulins. Network pharmacies will know if you’ve met your prescription drug

deductible, or if it does not apply to your prescription. This means that you pay only the amount

remaining after the plan pays.

If you use a non-network pharmacy (see page 100) you must pay the billed charges for the drug and

submit a paper claim for reimbursement of the covered amount. Prescriptions purchased from an

excluded pharmacy will not be covered. See the definition of “Excluded pharmacy.”

Your coinsurance for prescription drugs

ALERT! See page 54 for special prescription drug coverage while in hospice care.

You pay coinsurance for most covered prescription drugs, which is a percentage of the drug’s cost. You

may purchase up to a 90-day supply for most prescription drugs. For the majority of specialty drugs, you

may purchase up to a 30-day supply.

Non-network pharmacies may charge more than the allowed amount for prescription drugs. You are

responsible for paying this amount in addition to your coinsurance. Prescriptions purchased from an

excluded pharmacy will not be covered. See the definition of “Excluded pharmacy.”

2023 UMP Classic (PEBB) Certificate of Coverage 95

How the prescription drug cost-limit works

ALERT! For annual limits to your prescription drug costs, see the “Your prescription drug out-

of-pocket limit” section.

The prescription drug cost-limit is the maximum you pay for an individual prescription at a network

pharmacy. The prescription cost-limit applies at all network pharmacies.

Value tier cost-limit

• 0–30-day supply: $10

• 31–60-day supply: $20

• 61–90-day supply: $30

Tier 1 cost-limit

• 0–30-day supply: $25

• 31–60-day supply: $50

• 61–90-day supply: $75

Tier 2 cost-limit after you meet your prescription drug deductible, except for covered insulins. See

the UMP Preferred Drug List for cost limits

• 0–30-day supply: $75

• 31–60-day supply: $150

• 61–90-day supply: $225

If your normal coinsurance is less than the prescription cost-limit, you pay the normal coinsurance. If the

normal coinsurance is more than the prescription cost-limit, you pay the prescription cost-limit. See the

table below for examples (these examples assume you’ve met your prescription drug deductible when it

applies).

Tier of drug

Allowed amount

Normal

coinsurance

You pay

Prescription

cost-limit for a

30-day supply

Value Tier

(Value)

$100

(5% x $100=$5)

$10

Tier 1 (Tier 1/Tier

1 Specialty)

$300

10%

(10% x $300=$30)

$25

Tier 2 (Tier 2/Tier

2 Specialty)

Must meet

prescription drug

deductible first

$500

30%

(30% x

$500=$150)

$75

96 2023 UMP Classic (PEBB) Certificate of Coverage

ALERT! If you get your prescription filled at a non-network pharmacy, the prescription cost-

limit does not apply. See “Non-network pharmacies: Retail” on page 100. Prescriptions

purchased from an excluded pharmacy will not be covered. See the definition of “Excluded

pharmacy.”

Your prescription drug out-of-pocket limit

Expenses are counted from January 1, 2023, or your first day of enrollment, whichever is later, to

December 31, 2023, or your last day of enrollment, whichever is earlier.

For each member enrolled in the plan, the prescription drug out-of-pocket limit is $2,000 per member,

with a family limit of $4,000. Each member must meet their own prescription drug out-of-pocket limit

separately until the family limit is reached.

After you reach this limit, the plan pays 100 percent of the allowed amount for covered prescription drugs

and products. If you receive prescription drugs from a non-network pharmacy that charges more than the

allowed amount, you must still pay the difference. Prescriptions purchased from an excluded pharmacy

will not be covered. See the definition of “Excluded pharmacy.”

How the prescription drug out-of-pocket limit works

What applies to this limit

The following 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 prescription drug coinsurance, up to the allowed amount.

• Your prescription drug deductible.

What does not apply to this limit

A. Amounts paid by the plan, including payments for drugs covered in full.

B. Amounts exceeding the allowed amount for prescription drugs paid to non-network pharmacies.

C. Prescription drugs and products not covered by the plan. See the “Prescription drugs and products

UMP does not cover” section.

D. Costs for medical services and prescription drugs covered under the medical benefit. See the “Medical

out-of-pocket limit” section for how the medical out-of-pocket limit works.

What you will pay for after reaching your prescription drug out-of-pocket limit

You will still be responsible for paying letters B through D above after you meet your individual

prescription drug out-of-pocket limit.

Non-network pharmacies may charge more than the allowed amount for prescription drugs. You are

responsible for paying this amount in addition to your coinsurance. Prescriptions purchased from an

excluded pharmacy will not be covered. See the definition of “Excluded pharmacy.”

2023 UMP Classic (PEBB) Certificate of Coverage 97

Requesting an exception for noncovered prescription drugs

ALERT! The UMP Preferred Drug List may not show every alternative prescription drug you

must try before an exception may be granted. If your exception request is denied, the plan’s

response letter will include the reason for the denial and the steps you can take next. Excluded

prescription drugs and products are not eligible for an exception. However, non-covered

prescription drugs are eligible for an exception.

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 not be medically appropriate, you or your prescribing

provider can request an exception by calling WSRxS Customer Service.

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 (see Directory

for link).

Your prescribing provider must submit clinical information to request an exception. When the plan

approves an exception based on the criteria below, you will pay the Tier 2 cost-share. See ”What you pay

for prescription drugs.”

If your exception request is denied, the plan’s response letter will include the reason for the denial and the

steps you can take next.

Preferred drug list exceptions and coverage determinations are based on medical necessity. Because

requesting a noncovered drug exception requires medical information, only your prescribing provider

may submit clinical information for review. The prescribing provider will need to provide WSRxS with the

following information:

• The prescribing provider’s contact information;

• An explanation of why the plan should grant an exception;

• An explanation of how the requested medication therapy is evidence-based and generally accepted

medical practice;

• Documentation of medical necessity for the requested prescription drug over all other preferred

therapeutic alternatives (Value Tier, Tier 1, and Tier 2); and

• At least one of the following items must also be included with the exception request:

▪ Confirmation and documentation from your prescribing provider that all preferred therapeutic

alternatives (Value Tier, Tier 1, and Tier 2) were tried for a clinically appropriate duration of treatment

and failed to produce a therapeutic response. If the requested exception is for a brand-name

prescription drug that has an FDA-approved generic equivalent, your prescribing provider must

document your inadequate response to at least two manufacturers of the generic drug, or to all

manufacturers of the generic drug if there are fewer than two manufacturers, in addition to all other

preferred therapeutic alternatives, before an exception is granted; or

▪ Confirmation and documentation from your prescribing provider that all preferred therapeutic

alternatives (Value Tier, Tier 1, and Tier 2), including the required number of manufacturers of the

same generic prescription drug, caused an adverse drug reaction that prevents you from taking the

prescription drug as directed. If the requested exception is for a brand-name prescription drug that

has an FDA-approved generic equivalent, your prescribing provider must document your adverse

98 2023 UMP Classic (PEBB) Certificate of Coverage

drug reaction to at least two manufacturers of the generic drug, or to all manufacturers of the

generic drug if there are fewer than two manufacturers, in addition to all other preferred therapeutic

alternatives, before an exception is granted.

ALERT! The exception process for noncovered drugs cannot be used for drugs that UMP

excludes. For more information about drugs UMP excludes, see the “Prescription drugs and

products UMP does not cover” and the “What the plan does not cover” sections.

If you have other prescription drug coverage

If you have primary medical coverage through another plan that covers prescription drugs, some of the

limits and restrictions to prescription drug coverage listed on page 126 will apply when UMP pays

secondary to another plan. See the “Submitting a claim for prescription drugs” section for how to submit

your prescription drug claim.

Using network pharmacies when UMP is secondary

If you have primary coverage through another plan that covers prescription drugs, show both plan cards

to the pharmacy and make sure they know which plan is primary. It is important that the pharmacy bills

the plans in the correct order, or claims may be denied or paid incorrectly.

Using mail-order pharmacies when UMP is secondary

FOR MEDICARE RETIREES: When Medicare is your primary coverage, UMP’s network mail-

order pharmacies cannot bill Medicare for prescription drugs that are also covered by

Medicare Part B. You must submit a claim to Regence after Medicare has paid its share. See the

“Submitting a claim for medical services” section.

If your primary plan uses UMP’s network mail-order pharmacies, these pharmacies may process payments

for both plans and charge you only what is left. Make sure that UMP’s network mail-order pharmacies

have your information for both plans and know which plan is primary.

However, if your primary plan uses a different mail-order pharmacy, you will have to use your primary

plan’s mail-order pharmacy, then submit a paper claim for payment by UMP. See the “Submitting a claim

for prescription drugs” section for how to do this.

Where to buy your prescription drugs

ALERT! If you use a non-network retail pharmacy, you will pay the entire cost of the

prescription drug at the time of purchase and must submit a claim for reimbursement.

However, only the allowed amount for covered drugs will apply to your prescription drug

deductible or prescription drug out-of-pocket limit. Prescriptions purchased from an excluded

pharmacy will not be covered. See the definition of “Excluded pharmacy.”

Pharmacies are contracted through a different network than medical providers. The below sections explain

how to confirm a pharmacy is in the plan’s network.

2023 UMP Classic (PEBB) Certificate of Coverage 99

Retail pharmacies

FOR MEDICARE RETIREES: See the “How UMP Classic prescription drug coverage works with

Medicare” section for more information on how UMP prescription drug coverage works with

Medicare.

WSRxS has a large national network of retail pharmacies, which includes many independent and regional

pharmacies in Washington State, as well as national chains. Search for a network pharmacy on the UMP

Prescription drug coverage webpage or call WSRxS Customer Service (see Directory for link and contact

information).

When you get your prescriptions at a network pharmacy, the pharmacy sends the claim to the plan for

you, and you pay only your cost-share (coinsurance and prescription drug deductible) as described in the

“What you pay for prescription drugs” section. Covered insulin prescriptions filled at network pharmacies

are not subject to the prescription drug deductible.

Note: You will pay the entire cost for any prescription drug not covered by the plan, which does not apply

to your prescription drug deductible or your prescription drug out-of-pocket limit.

TIP: If you take a prescription drug regularly, you may be able to save money by filling up to a

90-day supply at a network retail pharmacy or through UMP’s network mail-order pharmacies.

Search for a network pharmacy and compare prices on the UMP Prescription drug coverage

webpage.

Network vaccination pharmacies

Many network retail pharmacies have vaccination pharmacists who may give covered preventive

immunizations at no cost to you. Call a network pharmacy ahead of time to make sure the pharmacy has

the vaccine you need. Present your UMP member ID card at the pharmacy counter before receiving a

vaccine.

Mail-order pharmacies: Costco Mail-Order Pharmacy and

Postal Prescription Services (PPS)

ALERT! UMP’s network mail-order pharmacies cannot ship outside of the U.S. See “Travel

overrides for prescription drugs” on page 106 if you will be traveling.

Costco Mail-Order Pharmacy and PPS are the plan’s only network mail-order pharmacies. Prescriptions

purchased through other mail-order pharmacies will not be covered if UMP is your primary plan. For

more information about mail-order, visit the UMP Prescription drug coverage webpage, call UMP’s

network mail-order pharmacies, or call WSRxS Customer Service. See the Directory pages at the beginning

of this booklet for links and contact information.

Note: You may mail in a prescription, however only a provider can call, fax, or electronically submit a

prescription to the pharmacy. You must follow these instructions to avoid a delay in filling your

prescription.

100 2023 UMP Classic (PEBB) Certificate of Coverage

ALERT! The plan does not cover other mail-order pharmacies outside of UMP’s network mail-

order pharmacies if UMP is your primary insurance. If UMP is your secondary insurance, you

may use another mail-order pharmacy.

Refills may be ordered through UMP’s network mail-order pharmacies. When using UMP’s network mail-

order pharmacies, the same prescription drug deductible, coinsurance, preauthorization requirements,

and limits on coverage apply as for prescription drugs purchased at retail network pharmacies.

ALERT! Drugs can be expensive. If you are not able to be home to receive the drug in the mail,

it may be a good idea to request that it be sent with a requirement for a signature, or find an

alternate point of delivery to ensure the package is not stolen. The plan is not responsible for

replacement of lost, stolen, expired, or damaged prescription drugs or products (see the “What

the plan does not cover” section).

Prescriptions mailed, or orders placed in December but not filled until January 1 or after, are subject to the

prescription drug deductible applicable on the date the prescription is processed. Because of increased

volume at the end of the year, prescriptions submitted to the network mail-order pharmacies in

December may not be processed during the current benefit year.

If there is a shortage of a specific prescription drug that UMP’s network mail-order pharmacies cannot

control, and it does not have the quantity you ordered, the network mail-order pharmacies will contact

you to discuss your options for obtaining your prescription(s).

ALERT! Some Durable Medical Equipment (DME) items are not available through UMP’s

network mail-order pharmacies. You will need to get them through a network retail pharmacy

or preferred DME provider.

How to get the plan discount

You pay for prescription drugs based on the allowed amount (WSRxS’ standard reimbursement). If you

use a non-network pharmacy or do not show your UMP member ID card at a network pharmacy, and the

amount charged is more than the UMP discounted allowed amount, you will pay the difference in

addition to your coinsurance.

If UMP is your primary insurance coverage, always show your UMP member ID card at the pharmacy to

make sure you pay the right amount for your prescription. If UMP is your secondary insurance coverage,

show both plan member ID cards at the pharmacy and make sure they know which plan pays first so the

pharmacy may bill the plans in the correct order.

Non-network pharmacies: Retail

You will save money when you buy your prescriptions at network retail pharmacies and network mail-

order pharmacies. You may buy your prescriptions (except specialty drugs) at a non-network retail

pharmacy, but you will pay more if you do. If you get your prescriptions filled at a non-network retail

pharmacy, the following applies:

• You need to submit your claim to WSRxS for reimbursement (see the “Submitting a claim for

prescription drugs” section).

2023 UMP Classic (PEBB) Certificate of Coverage 101

• You do not get the plan discount.

• You will pay the difference between the allowed amount and what the pharmacy charges, and it will

not apply to your prescription drug deductible or prescription drug out-of-pocket limit. Claims for

covered insulins must be submitted to WSRxS for reimbursement before they can apply to your

prescription drug deductible.

• The plan pays the allowed amount for prescription drugs covered by the plan, whether from a network

or non-network retail pharmacy, under the coinsurance percentages as shown in the “What you pay for

prescription drugs” section.

• The prescription cost-limit (see the “What you pay for prescription drugs” section) does not apply.

• Non-network pharmacies will not know if a prescription drug must be preauthorized, 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.

• Prescriptions purchased from an excluded pharmacy will not be covered. See the definition of

“Excluded pharmacy.”

• Specialty drugs must be purchased from the plan’s network specialty drug pharmacy. See the “Specialty

drug” section on page 104.

TIP: To submit claims for prescriptions purchased from non-network pharmacies (U.S. retail or

international retail pharmacies), see the “Submitting a claim for prescription drugs” section.

Prescription drugs purchased outside the U.S.

If you purchase prescription drugs outside the U.S. for any reason, the following rules apply:

• If the prescription drug is available only by prescription in the U.S. but does not require one outside the

U.S., the drug is covered only if prescribed by a provider practicing within their scope of practice.

• If you get a prescription drug that is approved for use in another country but not in the U.S., the plan

will not cover it.

• If you get a prescription drug that is available over the counter in the U.S., the plan will not cover the

drug, even if you have a prescription from a provider prescribing within their scope of practice. The

plan does not cover most over-the-counter drugs.

• If you get a prescription drug that is not covered by UMP, the plan will not pay any amount of the cost

of the drug. You will be responsible for the full cost of the drug.

To submit a claim for a prescription drug purchased at retail pharmacies outside the U.S., see the

“Submitting a claim for prescription drugs” section. All necessary information must be included on the

prescription drug claim form with drugs and dosage documented.

Limits on your prescription drug coverage

WSRxS may exclude, not cover, discontinue, or limit coverage for any prescription drug or manufacturer’s

version of a drug — or shift a drug to a different tier, or to noncovered or excluded status — for any of

the following reasons:

• A more cost-effective alternative is available to treat the same condition.

• A nonprescription alternative, including an over-the-counter alternative, becomes available.

102 2023 UMP Classic (PEBB) Certificate of Coverage

• A prescription drug receives FDA approval for a new use.

• A prescription drug is purchased from an excluded pharmacy.

• Generic, biosimilar, interchangeable biosimilar, or follow-on biologic prescription drugs become

available.

• New prescription drugs are developed.

• The FDA denies, withdraws, or limits the approval of a prescription drug.

• The FDA’s Drug Efficacy Study Implementation (DESI) classifications finds a prescription drug to be less

than effective.

• The Washington State P&T Committee or WSRxS recommends a change (see the "How UMP decides

which prescription drugs are preferred" section).

• There is a sound medical reason.

• There is lack of scientific evidence that a prescription drug is as safe and effective as existing drugs

used to treat the same or similar conditions.

• There is new scientific evidence demonstrating a prescription drug has been found to be less safe or

effective than existing drugs to treat the same or similar conditions.

Using free prescription drug samples does not guarantee coverage or waive requirements for

preauthorization, step therapy, quantity limits, day supply limits, or other limitations.

Prescription drugs will only be covered if they are not excluded by the plan, are a covered prescription

drug on the UMP Preferred Drug List, and are medically necessary for your health condition. Your provider

may prescribe a prescription drug or drug dose that is not medically necessary.

The plan excludes experimental or investigational prescription drugs. You may be liable for all charges if

you receive prescription drugs or products that are determined to be experimental or investigational (see

the “What the plan does not cover” section). If you disagree with the plan’s determination, you have the

right to an appeal (see the “Complaint and appeal procedures” section for that process).

The limits and restrictions described in the “Limits on your prescription drug coverage” section help

WSRxS monitor drug usage, safety, and costs. These limits and restrictions may be added or removed

from prescription drugs at any time. You may find out if your prescription drug falls under any of these

limits and restrictions by checking the UMP Preferred Drug List on the UMP Prescription drug coverage

webpage or calling WSRxS Customer Service (see Directory for link and contact information).

Risk Evaluation and Mitigation Strategies (REMS)

Risk Evaluation and Mitigation Strategy (REMS) is a drug safety program that the FDA can require for

certain prescription drugs with serious safety concerns to help make sure the benefits of the drug

outweigh its risks. REMS are designed to reinforce prescription drug use behaviors and actions that

support the safe use of that drug. While all drugs have labeling that describe possible risks, only a few

prescription drugs require a REMS. REMS are not designed to mitigate all the adverse events of a

prescription drug. These are communicated to health care providers in the drug’s prescribing information.

Rather, REMS focuses on preventing, monitoring, and/or managing a specific serious risk by informing,

educating, and/or reinforcing actions to reduce the frequency and/or severity of the event.

If the REMS program is not followed, the plan may not cover the restricted drug.

Preauthorizing prescription drugs

Preauthorization is a process that helps make sure that prescription drug benefits are administered as

designed and that plan members receive a drug therapy that is safe and effective for their conditions, and

2023 UMP Classic (PEBB) Certificate of Coverage 103

provides the greatest value. Some prescription drugs require preauthorization to determine whether they

are medically necessary and meet all applicable coverage criteria, or the plan will not cover them. You may

find out if your prescription drug requires preauthorization by calling WSRxS Customer Service or

checking the UMP Preferred Drug List on the UMP Prescription drug coverage webpage (see the Directory

pages at the beginning of this booklet for links and contact information). You and your prescribing

provider may also find the coverage criteria for your prescription drug by referring to the Washington

State Rx Services (Moda) preauthorization (UMP [PEBB] Plans) preauthorization requirements on forms and

publications at hca.wa.gov/ump-forms-pubs.

If your prescription drug requires preauthorization, your pharmacist or prescribing provider may initiate a

request through CoverMyMeds, a free online platform that accepts requests from electronic health

records, or directly through the CoverMyMeds Portal. To get started, your pharmacist or prescribing

provider can go to the CoverMyMeds website. They may also call WSRxS Customer Service to request it.

If you have an existing authorization from UMP for a brand-name drug, and a generic drug becomes

available, you may need to renew your authorization to continue filling the brand-name drug. However, if

you switch to the generic drug, a new preauthorization is not required until the existing authorization

expires.

Note: Prescription drugs covered under the medical benefit rather than the prescription drug benefit have

different rules for preauthorization. Call UMP Customer Service for details.

Emergency fill

Emergency fill lets you get a limited quantity of certain prescription drugs while the plan processes your

preauthorization request. This option is only available when a delay could result in emergency care,

hospital admission, or a serious threat to your health or others in contact with you. Call WSRxS Customer

Service for questions about which prescriptions drugs may qualify for emergency fills.

You must bring your prescription to a network pharmacy and state that you need an emergency fill while

the plan processes your preauthorization request. You pay your coinsurance under the prescription drug’s

tier.

The plan will cover an emergency fill of up to a seven-day prescription drug supply.

If your preauthorization request is denied, you will pay the full cost of the prescription drug for any

quantity you receive after the emergency fill.

Emergency fill limits

The following limits still apply to emergency fill prescription drugs:

• Quantity limits: You cannot get more than the stated quantity limit under an emergency fill. If you

have a current filled prescription for a prescription drug (or its therapeutic equivalent) and it was filled

to the quantity limit, you cannot get an emergency fill until you have used 84 percent or more of the

filled prescription.

• Refill too soon: If you have a filled prescription for a prescription drug (or its therapeutic equivalent),

you cannot get an emergency fill until you have used 84 percent or more of the filled prescription.

Quantity limits

Certain prescription drugs have a per prescription limit on how much you get for each fill. If you need

more than this limit allows, your pharmacist or prescribing provider may initiate a request through

CoverMyMeds on the CoverMyMeds website or call WSRxS Customer Service. See the Directory pages at

the beginning of this booklet for links and contact information.

If WSRxS denies your request or your provider or pharmacist does not get preauthorization, the plan will

cover the prescription drug only up to the quantity limit amount. You will pay for any extra amount.

104 2023 UMP Classic (PEBB) Certificate of Coverage

Specialty drugs

ALERT! Specialty drugs can be expensive. If you are not able to be home to receive the drug in

the mail, it may be a good idea to request that it be sent with a requirement for a signature, or

find an alternate point of delivery to ensure the package is not stolen.

Specialty drugs are high-cost injectable, infused, oral, or inhaled prescription drugs or products that

require special handling and storage and are subject to additional rules. You may find out if a drug is a

specialty drug by checking the UMP Preferred Drug List on the UMP Prescription drug coverage webpage,

or by calling WSRxS Customer Service (see Directory for link and contact information). Specialty drugs are

covered under the cost-share tier listed on the UMP Preferred Drug List.

Specialty drugs are covered only when purchased through the plan’s network specialty drug pharmacy. If

that pharmacy does not have access to a specialty drug, you will be notified to fill your prescription at

another specialty drug pharmacy. If the network specialty drug pharmacy gains access to the specialty

drug, you will receive notification to transfer your prescription to that pharmacy.

You may receive up to a 30-day supply for most specialty prescription drugs per prescription or refill.

However, some may be limited to a 15-day supply due to high discontinuation rate, short duration of use,

or to make sure that the prescription drug is not causing harmful side effects.

Specialty drugs require preauthorization. See “Preauthorizing prescription drugs” on page 102 for how to

request preauthorization. A patient care coordinator will work with you to schedule a delivery time for the

prescription drug. The specialty drug pharmacy will deliver your prescription drugs anywhere in the U.S.

that you choose, such as to your workplace or to a neighbor if you cannot be home for the delivery.

Specialty prescription drugs often require special handling and storage. The plan is not responsible for

replacement of lost, stolen, expired, or damaged prescription drugs or products (see the “What the plan

does not cover” section).

If your provider will be administering the prescription drug, you may have it shipped to the provider’s

office. However, once the provider’s office receives the prescription drug, the provider takes responsibility

for it.

The plan’s network specialty drug pharmacy cannot ship outside the U.S. See “Travel overrides for

prescription drugs” on page 106 if you will be traveling.

Prescription cost-limit for specialty drugs

ALERT! The prescription cost-limit is the most you will pay for an individual prescription.

However, you may pay less based on normal coinsurance (see the "What you pay for

prescription drugs" section).

See the “How the prescription drug cost-limit works” section for details about the prescription cost-limit.

This limit applies to individual prescriptions only. See the “Your prescription drug out-of-pocket limit”

section for the annual limit to your prescription drug costs.

Specialty drugs are usually limited to no more than a 30-day supply. The prescription cost-limit for a 30-

day (or under) supply corresponds to the “You pay” column in the table found in the "How the

prescription drug cost-limit works" section.

2023 UMP Classic (PEBB) Certificate of Coverage 105

However, some specialty prescription drugs are available only in packages with more than a 30-day

supply. In such cases, the prescription cost-limit shown in the table found in the "How the prescription

drug cost-limit works" section is calculated by multiplying the standard 30-day prescription cost-limit

amount as follows:

• A 31- to 60-day supply, multiply the standard prescription cost-limit by two.

• A 61-day and greater supply, multiply the standard prescription cost-limit by three.

Example: If your specialty drug is Tier 2 and you receive a 45-day supply, the most you will pay

(prescription cost-limit) is $150 (standard 30-day limit $75 x 2=$150).

Step therapy

ALERT! If a Step 1 or Step 2 drug is approved for coverage by WSRxS, you will pay the

applicable cost-share of that prescription drug according to its tier in the UMP Preferred Drug

List.

When a prescription drug is part of the step therapy program, you have to try certain drugs (Step 1)

before the plan will cover the prescribed (Step 2) drug. When a prescription for a step therapy drug is

submitted “out of order,” meaning you have not first tried the Step 1 drug before submitting a

prescription for a Step 2 drug, the plan will not cover your prescription. When this happens, your provider

will need to prescribe the Step 1 drug for you.

If you or your provider feels that you need the Step 2 prescription filled as originally written without first

trying the Step 1 drug, your pharmacist or prescribing provider may call WSRxS Customer Service and

request coverage. You will have to pay the entire cost of the prescription drug if you have not tried the

Step 1 drug and coverage has not been authorized before you get the Step 2 drug.

To find out if step therapy applies to your drug, check the UMP Preferred Drug List on the UMP

Prescription drug coverage webpage, or call WSRxS Customer Service (see Directory for link and contact

information).

Note: Only network pharmacies will check to see if step therapy applies to your prescription drug. If you

get a step therapy drug at a non-network pharmacy, the plan may not cover the drug.

Substitution under Washington State law

ALERT! New generic prescription drugs are released throughout the year. If you want to save

money by using generics, ask your provider to allow substitution on your prescriptions, even if

a generic drug is not available now. That way, when one becomes available, the pharmacist

may automatically refill with the generic.

When a brand-name or biologic prescription drug has a generic equivalent or interchangeable biosimilar,

pharmacists in Washington State must substitute the generic equivalent or interchangeable biosimilar

drug for the brand-name or biologic prescription drug. When a generic equivalent for a brand-name

prescription drug becomes available, the brand-name drug immediately becomes noncovered.

Your provider may write the prescription “dispense as written” if they want you to get only the prescribed

brand-name or biologic prescription drug. Or you may tell the pharmacist you want the brand-name or

106 2023 UMP Classic (PEBB) Certificate of Coverage

biologic drug. Regardless of whether you or your prescribing provider ask the pharmacist to “dispense as

written,” if you get the noncovered prescription drug, the plan may not cover it. Final determination of

medical necessity for FDA-approved contraceptives is determined by the attending prescribing provider.

To request an exception for a noncovered drug, see page 97.

Therapeutic Interchange Program

The Washington State Therapeutic Interchange Program allows a pharmacist to substitute a “therapeutic

alternative” drug for a noncovered drug in certain cases. Therapeutic alternatives are drugs that are

chemically different from your prescribed drug but provide the same therapeutic benefit.

You may find out if your prescription drug is affected by the Therapeutic Interchange Program by

checking the UMP Preferred Drug List on the UMP Prescription drug coverage webpage or by calling

WSRxS Customer Service (see Directory for link and contact information). The Therapeutic Interchange

program does not affect all noncovered prescription drugs.

The pharmacist will substitute the preferred drug when your prescribing provider has “endorsed” the

Washington Preferred Drug List, and:

• You are filling your prescription in Washington State or through UMP’s network mail-order pharmacies.

• Your prescribing provider allows substitution on your prescription.

If you do not want your prescription drug to be changed, the plan may not cover your drug if you ask the

pharmacist to fill the prescription as written.

Regardless of whether you or your prescribing provider ask the pharmacist to “dispense as written,” if you

get the noncovered prescription drug, the plan may not cover it.

The pharmacy will contact your provider to request authorization for the substitution. If approved by the

provider, you will receive the alternative preferred drug along with a letter of explanation. If the pharmacy

cannot get an authorization from your provider within 48 hours, the prescription will be filled as written,

and you will be charged the full price of the drug.

Travel overrides for prescription drugs

You may request a travel override to get an extra supply of prescription drugs for extended travel. All of

the conditions listed below apply.

• You may request a travel override up to two weeks before your departure.

• You may request no more than two travel overrides per calendar year, including all travel within or

outside the U.S.

• Within the U.S., you may request up to a 90-day supply per prescription, or as allowed under that

prescription.

• Outside the U.S., you may request up to a six-month supply per prescription, or as allowed under that

prescription.

• Travel overrides will be granted only while you are covered by the plan. If your eligibility is ending, the

plan does not cover prescription drugs past the time your enrollment in the plan ends.

• You will pay applicable charges (deductible and coinsurance) for each extra supply received.

To request a travel override, call WSRxS Customer Service.

Refill too soon

The plan will not cover a refill until 84 percent of the last prescription should be used up. Claims for

therapeutic equivalents of the previously prescribed drug will also be denied. This also applies if your

2023 UMP Classic (PEBB) Certificate of Coverage 107

prescription is damaged, destroyed, lost, or stolen. For example, if you get a 90-day supply and you try to

refill this prescription before 76 days have passed, coverage will be denied.

However, in the event of an emergency or other urgent circumstance, you may request an exception to

override the refill too soon policy. The plan may require documentation to support your request. Approval

of your request is at the sole discretion of the plan.

Early refill for a natural disaster

You may request an early refill for your prescription when you need to evacuate for a natural disaster. To

request an early refill or to locate pharmacies that remain open near you, call WSRxS Customer Service.

What to do if the plan denies coverage

TIP: If your prescription claims are denied by the pharmacy due to plan eligibility issues or

termination of coverage, contact:

Employees: Your employer’s payroll or benefits office.

Retirees and PEBB Continuation Coverage: PEBB Program at 1-800-200-1004 (TRS: 711).

If a network pharmacy (including the mail-order or specialty drug pharmacy) tells you that

preauthorization is required, coverage is denied, or quantities are limited, you, your pharmacist, or your

prescribing provider may call WSRxS Customer Service to request a coverage review or preauthorization.

If WSRxS denies the coverage request, you have the right to submit an appeal (see the “Complaint and

appeal procedures” section).

If your provider thinks you need the prescription drug immediately, they may request an expedited review

by submitting all clinically relevant information to the plan by phone or fax. An expedited appeal replaces

the first and second level appeals. WSRxS will decide on coverage of the prescription drug within 72 hours

of the request. In this case, you may choose to purchase a three-day supply at your own expense.

Prescription drugs and products UMP does not cover

Prescription drugs and products not covered under the prescription drug benefit include, but are not

limited to, noncovered prescription drugs and excluded drugs and products.

Noncovered prescription drugs

• Noncovered prescription drugs without a UMP Preferred Drug List exception authorization

For more information see the “Noncovered prescription drugs” section on page 88.

Excluded drugs and products

• Dental preparations, such as rinses and pastes

• Dietary/food supplements, vitamins, minerals, herbal supplements, and medical foods

• Experimental or investigational prescription drugs

• Homeopathic drugs, including FDA-approved prescription products

• Over-the-counter drugs, products containing an over-the-counter drug, or prescription drugs that have

a nonprescription alternative, except for the drugs specified under “Exceptions covered” on page 90, or

otherwise listed on the UMP Preferred Drug List.

108 2023 UMP Classic (PEBB) Certificate of Coverage

Note: Prescription drugs with a nonprescription alternative — including an over-the-counter

alternative having similar safety, efficacy, and ingredients — are excluded.

• Over-the-counter products not approved by and registered with the FDA

• Prescription drug costs covered by other insurance (see page 126 for coordination with other plans)

• Prescription drugs not approved by the FDA

• Prescription drugs provided to a member, in whole or in part, while the member is admitted to an

inpatient facility. Drugs provided in an inpatient setting are covered under the medical benefit.

• Prescription drugs that are not medically necessary

• Prescription drugs that are repackaged

• Prescription drugs that the FDA’s DESI classifications have found to be less than effective

• Prescription drugs under a REMS program required by the FDA when prescribed outside REMS

guidelines (see page 102 for details)

• Most products considered as a medical device by the FDA. Medical devices may be covered under your

medical benefit

The plan also excludes prescription drugs to treat conditions that are not covered under the medical

benefit. These include, but are not limited to, prescription drugs for:

• Cosmetic purposes.

• Fertility or infertility.

• Obesity (or weight loss).

• Promoting hair growth.

• Sexual dysfunction.

ALERT! Prescription drugs classified as proton pump inhibitors (PPIs) have over-the-counter

alternatives and are not covered for persons ages 18 and over. The plan does cover PPIs for

persons under age 18 when prescribed, because the available over-the-counter alternatives are

not approved for persons under age 18.

Limits on plan coverage

If you receive a service that is not medically necessary, is experimental or investigational, is listed as an

exclusion in the “What the plan does not cover” section, or is listed as a noncovered or excluded

prescription drug, you are responsible for paying all associated charges.

Preauthorizing medical services

ALERT! This section does not apply to prescription drugs. See page 102 for how to request

preauthorization of drugs covered under the prescription drug benefit.

2023 UMP Classic (PEBB) Certificate of Coverage 109

The plan must preauthorize some medical services and supplies to determine whether the service or

supply meets the plan’s medical necessity criteria to be covered. The fact that a service or supply is

prescribed or furnished by a provider does not, by itself, make it a medically necessary covered

service. Preauthorization is not a guarantee of coverage.

A change after the plan has approved a preauthorization request — including, but not limited to, a

change of provider or different/additional services — requires your provider to submit a new

preauthorization request and for the plan to approve it.

Your preauthorization role

ALERT! Excluded, experimental, and investigational services do not require a preauthorization

because they are not covered by the plan. To confirm whether a service is covered, call UMP

Customer Service.

To be covered, some services, including, but not limited to, Applied Behavior Analysis (ABA) Therapy for

members ages 18 and older (see page 39) and bariatric surgery (see page 39), must be preauthorized

before services are received. A preferred or participating provider may be required to request

preauthorization before providing services.

An out-of-network provider is not obligated to obtain prior authorization for services that require a

preauthorization because they do not have a contract with Regence. If an out-of-network provider does

not obtain a required preauthorization in advance of the service, you will be responsible for all charges

billed to you.

You are encouraged to request that an out-of-network provider preauthorize certain services on your

behalf to determine medical necessity before the services are provided. They have the clinical details and

technical billing information needed to submit a request. Call UMP Customer Service to ask if a service

requires preauthorization and how to submit a request.

You may be liable for all charges if you receive services that are determined to be not medically necessary,

experimental or investigational, or not covered under this plan (see the “What the plan does not cover”

section).

ALERT! See the “Complaint and appeal procedures” section for how to appeal denial of a

preauthorization request before receiving services.

List of services and supplies requiring preauthorization or

notice

For a list of services and supplies requiring preauthorization or notice:

• Visit the UMP Policies that affect your care webpage.

• Call UMP Customer Service to request a printed list or ask questions.

See the Directory pages at the beginning of this booklet for links and contact information.

110 2023 UMP Classic (PEBB) Certificate of Coverage

ALERT! The UMP preauthorization list is updated throughout the year. You may find a link to

the current list of services that require preauthorization on the UMP Policies that affect your

care webpage or call UMP Customer Service to determine if services require preauthorization

or notice. The fact that a service does not require preauthorization or notice does not

guarantee coverage.

Notice for facility admissions

Your provider must notify the plan upon your admission to a facility for services requiring plan notice. You

may find a list of services requiring plan notice by visiting the UMP Policies that affect your care webpage

or calling UMP Customer Service (see Directory for link and contact information). Facility admissions for

which the plan is not notified may not be covered. Notice is usually done by the facility at the time you

are admitted. Notice is not the same as preauthorization and many services require both.

What is the difference between preauthorization and notice?

ALERT! Many services, including, but not limited to, inpatient services, require both

preauthorization and notice. Call UMP Customer Service or talk to your provider if you have

questions about services needing preauthorization or notice.

“Preauthorization” is when your provider sends a request for coverage of a service on the UMP

preauthorization list. Preauthorization is usually requested by the provider performing the services. The

plan sends either an approval or denial of coverage.

If the plan does not approve services that require preauthorization before services are received, the plan

may deny coverage. The plan does not approve or deny preauthorization for services that are not on the

UMP preauthorization list.

“Notice” means that your provider must contact the plan to let us know when you receive services. Notice

is usually done by the facility when you are admitted.

ALERT! If the plan denies preauthorization and you receive those services anyway, you are

responsible for the provider’s entire billed charge.

How long the plan has to make a decision

You will be notified in writing within 15 calendar days of the plan receiving the preauthorization request

whether the request has been approved, denied, or if more information is needed to make a decision.

If additional information is requested:

• You are allowed up to 45 calendar days from the date on the letter to submit the information

requested.

• You will be notified in writing of the decision within 15 calendar days from either the plan receiving the

additional requested information or the end of the 45-day period if no additional information is

received.

2023 UMP Classic (PEBB) Certificate of Coverage 111

If you or your provider believes that waiting for a decision under the standard time frame could place

your life, health, or ability to regain maximum function in serious danger, your provider should notify the

plan by phone or fax as a shorter time limit may apply. This is also known as an expedited

preauthorization request. Regence BlueShield will decide on your expedited preauthorization request

within 72 hours of receipt.

General information from UMP Customer Service

For services not requiring preauthorization, you may call UMP Customer Service to ask if a particular

service is generally covered by the plan, and for an estimate of how much you will pay. The plan does not

approve or deny preauthorization for services that are not on the UMP preauthorization list.

Until a claim is submitted and reviewed, the plan cannot guarantee that your service will be covered or

give you an exact amount you will pay out of pocket. This is because when a provider bills for a service,

the plan pays for it based on procedure codes. Each code describes a service in some detail, and there are

many codes for similar-sounding services. Your provider, not the plan, determines which of these codes is

used on the submitted claim.

Alternative benefits

Alternative benefits mean benefits for services or supplies that are not otherwise covered as specified in

this COC, but for which the plan may approve coverage after case management evaluation. The plan may

cover alternative benefits through case management (see the “Care management” benefit) if the plan

determines that alternative benefits are medically necessary and will result in overall reduced covered

costs and improved quality of care.

Before alternative benefits will be covered, the plan, you (or your legal representative), and, if required by

the plan, your physician or other provider, must enter into a written agreement of the terms and

conditions for payment. Alternative benefits are approved on a case-specific basis only. Approval of an

alternative benefit applies to only the services and member listed in the written agreement. The rest of

this COC remains in effect.

What the plan does not cover

TIP: If you have any questions about services the plan does not cover, call UMP Customer

Service or WSRxS Customer Service.

This plan covers only the services and conditions specifically identified in this COC. Unless a service or

condition fits into one of the specific benefit definitions, it is not covered. You may pay all costs associated

with a noncovered service.

Here are some examples of common services and conditions that are not covered. Many others are also

not covered — these are examples only, not a complete list. These examples are called exclusions,

meaning these services are not covered, even if the services are medically necessary.

1. Activity therapy. The following activity therapy services include, but are not limited to:

◦ Aroma;

◦ Creative arts;

◦ Dance;

◦ Equine or other animal-assisted;

112 2023 UMP Classic (PEBB) Certificate of Coverage

◦ Music;

◦ Play;

◦ Recreational or similar therapy; and

◦ Sensory movement groups.

2. Air ambulance, if ground ambulance would serve the same purpose

3. Ambulance (all types), to move you to a facility closer to your home or for purposes that are not

medically necessary

4. Autologous blood and platelet-rich plasma injections

5. Bariatric surgery under the following circumstances:

◦ BMI 30 to less than 35 without Type II Diabetes Mellitus

◦ BMI less than 30

◦ Patients younger than 18 years of age

6. Bone growth stimulators for:

◦ Nonunion of skull, vertebrae, or tumor related

◦ Ultrasonic stimulator – delayed fractures and concurrent use with another noninvasive stimulator.

7. Bone morphogenetic protein-7 (rhBMP-7) for use in lumbar fusion

8. Bronchial thermoplasty for asthma

9. Carotid artery stenting of intracranial arteries

10. Carotid intima media thickness testing

11. Catheter ablation for non-reentrant supraventricular tachycardia

12. Cervical spinal fusion without evidence of radiculopathy or myelopathy

13. Complications arising directly from services that would not be covered by the plan during the

current plan year. The plan will cover complications arising directly from services that a PEBB plan

covered for you in the past.

14. Computed Tomographic Colonography (CTC), also called a virtual colonoscopy, for routine

colorectal cancer screening

15. Corneal Refractive Therapy (CRT), also called Orthokeratology

16. Coronary or cardiac artery calcium scoring

17. Cosmetic services or supplies, including drugs and pharmaceuticals, unless part of the following

care:

◦ Reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury

◦ Reconstructive surgery of a congenital anomaly, such as cleft lip or palate, to improve or restore

function

18. Court-ordered care, unless determined by the plan to be medically necessary and otherwise covered

19. Custodial care (see definition on page 183)

20. Deep brain stimulation and transcranial direct current stimulation when used as nonpharmacological

treatments for treatment-resistant depression

2023 UMP Classic (PEBB) Certificate of Coverage 113

21. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental

services (see pages 44–45)

22. Dietary/food supplements, including, but not limited to:

◦ Herbal supplements, dietary supplements, and homeopathic drugs

◦ Infant or adult dietary formulas

◦ Medical foods (except when prescribed for inborn errors of metabolism)

◦ Minerals

◦ Prescription or over-the-counter vitamins (see page 107)

23. Dietary programs

24. Discography for patients with chronic low back pain and lumbar degenerative disc disease. This does

not apply to patients with the following conditions:

◦ Degenerative disease associated with significant deformity

◦ Fracture, tumor, infection, and inflammatory disease

◦ Functional neurologic deficits (motor weakness or Electromyography [EMG] findings of

radiculopathy)

◦ Isthmic spondylolysis

◦ Primary neurogenic claudication associated with stenosis

◦ Radiculopathy

◦ Spondylolisthesis greater than Grade 1

25. Drugs or medicines not covered by the plan, as described in the “Your prescription drug benefit”

section, see pages 87-108

26. Drugs or medicines obtained through mail-order pharmacies located outside the U.S.

27. Educational programs, except as described under:

◦ “Diabetes Control Program” on page 46

◦ “Diabetes education” on page 46

◦ “Diabetes Prevention Program” on page 46

◦ “Tobacco cessation services” on page 75

28. Electrical Neural Stimulation (ENS), which includes Transcutaneous Electrical Nerve Stimulation

(TENS) units, outside of medically supervised facility settings (e.g., in-home use).

29. Email consultations or e-visits, except as described under the telemedicine benefit.

30. Equipment not primarily intended to improve a medical condition or injury, including, but not

limited to:

◦ Air conditioners or air purifying systems

◦ Arch supports

◦ Communication aids

◦ Elevators

◦ Exercise equipment

◦ Massage devices

◦ Overbed tables

◦ Residential accessibility modifications

◦ Sanitary supplies

◦ Telephone alert systems

114 2023 UMP Classic (PEBB) Certificate of Coverage

◦ Vision aids except when covered

through VSP

◦ Whirlpools, portable whirlpool pumps,

or sauna baths

31. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals

32. Experimental or investigational services, supplies, or drugs (see page 185)

33. Extracorporeal shock wave therapy for musculoskeletal conditions

34. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy,

photokeratectomy, or LASIK surgery

35. Facet neurotomy for headache

36. Facet neurotomy for thoracic spine

37. Fecal microbiota transplantation for treatment of inflammatory bowel disease

38. Foot care not related to diabetes: Toenail cutting; diagnosed corns and calluses treatment; or any

other maintenance-related foot care

39. Functional neuroimaging for primary degenerative dementia or mild cognitive impairment

40. Gene expression profile testing for multiple myeloma or colon cancer

41. Headaches:

◦ Treatment of chronic tension-type headache with Botox or acupuncture

◦ Treatment of chronic migraine or chronic tension-type headache with massage, trigger point

injections, transcranial magnetic stimulation, or manipulation/manual therapy (e.g., chiropractic

services)

Note: For chronic migraines and tension-type headaches, see page 52

42. Hearing aid items:

◦ Charges incurred after your plan coverage ends, unless you ordered the hearing aid before that

date and it is delivered within 45 days after your coverage ended

◦ Extended warranties, or warranties not related to the initial purchase of the hearing aid(s)

◦ Purchase of replacement batteries or other ancillary equipment, except those covered under

terms of the initial hearing aid purchase

The types of ancillary equipment not covered are:

◦ Alerting devices

◦ Assistive listening devices for FM/DM systems, receivers and transmitters

◦ Assistive listening devices for microphone transmitters

◦ Assistive listening devices for TDD machines

◦ Assistive listening devices for telephones

◦ Assistive listening devices for televisions (including amplifiers and caption decoders)

◦ Assistive listening devices for use with cochlear implants

◦ Assistive listening devices, supplies, and accessories not otherwise specified

43. Hip resurfacing

44. Hip surgery for treatment of Femoroacetabular Impingement (FAI) Syndrome

2023 UMP Classic (PEBB) Certificate of Coverage 115

45. Home health care, except as described on page 54. The plan does not cover the following services:

◦ Housekeeping or meal services

◦ Care in any nursing home or convalescent facility

◦ Care provided by a family member

46. Hospital inpatient charges for non-essential services or features, such as:

◦ Admissions solely for diagnostic procedures that could be performed on an outpatient basis

◦ Personal or convenience items

◦ Reserved beds

◦ Services and devices that are not medically necessary (see definition on page 190)

47. Hyperbaric oxygen therapy treatment for:

◦ Acute and chronic sensorineural hearing loss

◦ Brain injury including traumatic (TBI) and chronic brain injury

◦ Cerebral palsy

◦ Migraine or cluster headaches

◦ Multiple sclerosis

◦ Non-healing venous, arterial, and pressure ulcers

◦ Thermal burns

48. Imaging of the sinus for rhinosinusitis using x-ray or ultrasound

49. Immunizations for the purpose of travel or employment, even if recommended by the CDC

50. Implantable drug delivery systems (IDDS or infusion pumps) for chronic, non-cancer pain

51. Incarceration: Services and supplies provided while confined in a prison or jail

52. Infertility or fertility testing or treatment after initial diagnosis, including drugs, pharmaceuticals,

artificial insemination, and any other type of testing, treatment, complications resulting from such

treatment (e.g., selective fetal reduction), or visits for infertility

53. In Vitro Fertilization (IVF) and all related services and supplies, including all procedures involving

selection of embryo for implantation

54. Knee arthroplasty: Multi-compartmental arthroplasty and partial knee arthroplasty (including bi-

compartmental and bi-unicompartmental)

55. Knee arthroscopy for osteoarthritis of the knee

56. Late fees, finance charges, or collections charges

57. Learning disabilities treatment after diagnosis, except as covered under the following benefits:

◦ “Applied Behavior Analysis (ABA) Therapy” on page 39;

◦ “Therapy: Habilitative and Rehabilitative” on page 74;

◦ When part of treating a mental health disorder; or

◦ When part of treating a substance use disorder.

58. Liposuction for the treatment of lipedema is not covered.

116 2023 UMP Classic (PEBB) Certificate of Coverage

59. Lumbar artificial disc replacement

60. Lumbar fusion for degenerative disc disease

61. Lumbar radiculopathy/sciatica surgery: Minimally invasive procedures that do not include

laminectomy, laminotomy, or foraminotomy, including, but not limited to, energy ablation

techniques, Automated Percutaneous Lumbar Discectomy (APLD), percutaneous laser, nucleoplasty,

etc.

62. Magnetic resonance imaging, (upright) (uMRI), also known as “positional,” “weight-bearing” (partial

or full), or “axial loading”

63. Maintenance care (see definition on page 190)

64. Manipulations of the spine or extremities, except as described under “Spinal and extremity

manipulations” on page 70

65. Marriage, family, or other counseling or training services, except as provided to treat an individual

member’s neuropsychiatric, mental health, or substance use disorder

66. Massage therapy services when the massage therapist is not a preferred provider

67. Medicare-covered services or supplies delivered by a provider who does not offer services through

Medicare, when Medicare is the member’s primary coverage

68. Microprocessor-controlled lower limb prostheses (MCP) for the feet and ankle

69. Migraine and tension-type headaches:

◦ Treatment of chronic tension-type headache with Botox or acupuncture

◦ Treatment of chronic migraine or chronic tension-type headache with massage, trigger point

injections, transcranial magnetic stimulation, or manipulation/manual therapy (e.g., chiropractic

services)

Note: For chronic migraines and tension-type headaches, see page 52

70. Missed appointment charges

71. Negative pressure wound therapy in patients with contraindications referred to by the FDA Safety

Communication dated February 24, 2011

72. Noncovered provider types: Services delivered by providers not listed as a covered provider type

(see page 18)

73. Novocure (i.e., Optune) (tumor treating fields)

74. Orthoptic therapy except for the diagnosis of strabismus, a muscle disorder of the eye

75. Orthotics, foot or shoe: Items such as shoe inserts and other shoe modifications, except as specified

on page 49

76. Osteochondral allograft/autograft transplantation for joints other than the knee

77. Out-of-network provider charges that are above the allowed amount

78. Peripheral nerve ablation, using any technique, to treat limb pain for adults and children, including

for knee, hip, foot, or shoulder due to osteoarthritis or other conditions

79. Pharmacogenetic testing for patients being treated with oral anticoagulants

80. Pharmacogenomics testing for depression, mood disorders, psychosis, anxiety, attention deficit

hyperactivity disorder (ADHD), and substance use disorder

81. Positron Emission Tomography (PET) scans for routine surveillance of lymphoma

2023 UMP Classic (PEBB) Certificate of Coverage 117

82. Prescription drug charges over the allowed amount, regardless of where purchased

83. Prescription drugs that require preauthorization, unless the request is:

◦ Approved by the plan

◦ Supported by medical justification from a clinician other than the member or the member’s family

84. Printing costs for medical records

85. Private duty nursing or continuous care in the member's home, except as described on pages 56 and

86. Proton beam therapy for individuals ages 21 and older for conditions other than:

◦ Brain/spinal

◦ Esophageal

◦ Head/neck

◦ Hepatocellular carcinoma

◦ Ocular

◦ Skull-based

◦ Other primary cancers where all other

treatment options are contraindicated

after review by a multidisciplinary tumor

board

87. Provider administrative fees: Any charges for completing forms, copying records, or finance charges,

except for records requested by the plan to perform retrospective (i.e., post-payment) review

88. Repetitive transcranial magnetic stimulation for tinnitus

89. Replacement of lost, stolen, or damaged durable medical equipment (DME)

90. Replacement of prescription drugs that are any of the following:

◦ Confiscated or seized by Customs or

other authorities

◦ Contaminated

◦ Damaged

◦ Expired

◦ Lost or stolen

◦ Ruined

91. Residential treatment programs offered at facilities that do not meet the definition of Residential

Treatment Facility (see definition of “Residential treatment facility”)

92. Reversal of voluntary sterilization (vasectomy, tubal ligation, or similar procedures)

93. Riot, rebellion, and illegal acts: Services and supplies for treatment of an illness, injury, or condition

caused by a member’s voluntary participation in a riot, armed invasion or aggression, insurrection or

rebellion, or sustained by a member arising directly from an act deemed illegal by a court of law

94. Routine ultrasounds during pregnancy, except one in week 13 or earlier, one during weeks 13-28, or

high-risk pregnancies (see description on page 64)

95. Sacroiliac joint fusion: Minimally invasive and open sacroiliac joint fusion procedures in adults, ages

18 and older, with chronic sacroiliac joint pain related to degenerative sacroiliitis and/or sacroiliac

joint disruption

96. Screening and monitoring tests for osteopenia/osteoporosis:

◦ Once treatment for osteoporosis has begun, serial monitoring is not covered

◦ Development of a fragility fracture alone is not a covered indication

97. Separate charges for records or reports

98. Service animals: Any expenses related to a service animal

118 2023 UMP Classic (PEBB) Certificate of Coverage

99. Services covered by other insurance, including, but not limited to:

◦ Automobile no-fault

◦ Commercial premises

◦ General no-fault

◦ Homeowner’s

◦ Medical payments (Med-Pay)

◦ Motor vehicle

◦ Personal injury protection (PIP)

◦ Renter’s

◦ Underinsured or uninsured motorist

See page 144 for more about how this works.

100. Services delivered by providers or facilities delivering services outside the scope of their licenses

101. Services or supplies:

◦ For which no charge is made, or for which a charge would not have been made if you had no

health care coverage

◦ For which you are not obligated to pay

◦ Provided by a resident physician or intern acting in that capacity

◦ Provided by someone in the member’s family or household

◦ That are not medically necessary for the diagnosis and treatment of injury or illness or restoration

of physiological functions and are not covered as preventive care. This applies even if services are

prescribed, recommended, or approved by your provider.

◦ That are solely for comfort

102. Services performed during a noncovered service

103. Services performed primarily to ensure the success of a noncovered service, including, but not

limited to, a hiatal hernia repair done to ensure the success of a noncovered laparoscopic adjustable

gastric banding surgery

104. Services supplemental to digital mammography. When performed supplementary to digital

mammography for screening purposes for members with or without dense breasts, the following

procedures are not covered:

◦ Non-high-risk patients:

• Automated Breast Ultrasound (ABUS)

• Handheld Ultrasound (HHUS)

• Magnetic Resonance Imaging (MRI)

◦ High-risk patients:

• Automated breast ultrasound (ABUS)

• Handheld Ultrasound (HHUS)

• Magnetic Resonance Imaging (MRI) less than 11 months after a prior screening

105. Services, supplies, or drugs related to occupational injury or illness (see page 143)

106. Services, supplies, or items that require preauthorization unless the request is:

◦ Approved by the plan

◦ Supported by medical justification from a clinician other than the member or the family of a

member

107. Skilled nursing facility services or confinement:

◦ When primary use of the facility is as a place of residence

2023 UMP Classic (PEBB) Certificate of Coverage 119

◦ When treatment is primarily custodial

108. Sleep apnea diagnosis and treatment as indicated in referenced Medicare national and local

coverage determinations

109. Sleep therapy services performed at the following locations are not covered:

◦ Emergency room services

◦ Inpatient hospitalization

◦ Urgent-care facilities

110. Sound therapies for treatment of tinnitus, including, but not limited to:

◦ Masking devices (sound maskers)

◦ Altered auditory stimuli

◦ Auditory attention training

111. Spinal cord stimulation for chronic neuropathic pain

112. Spinal injections, therapeutic (except as described under “Spinal injections” on page 70) of the

following types:

◦ Facet injections

◦ Intradiscal injections

◦ Medial branch nerve block injections

113. Spinal surgical procedures known as vertebroplasty, kyphoplasty, and sacroplasty

114. Stem cell therapies for musculoskeletal conditions

115. Stereotactic radiation surgery and stereotactic body radiation therapy: Stereotactic radiation surgery

for conditions other than central nervous system primary and metastatic tumors and stereotactic

body radiation therapy for conditions other than cancers of spine/paraspinal structures or

inoperable non-small cell lung cancer, stage 1

116. Surrogacy

117. Telephone or virtual consultations or appointments, except as described under “Telemedicine

services” on page 77

118. Tinnitus specific therapies including, but not limited to:

◦ Tinnitus retraining therapy (TRT)

◦ Neuromonics tinnitus treatment (NTT)

◦ Tinnitus activities treatment (TAT)

◦ Tinnitus-masking counseling

119. Transcutaneous vagal nerve stimulation (does not include or apply to support of previous implanted

VNS)

120. Transcutaneous vagal nerve stimulation for epilepsy or depression

121. Travel, transportation, and lodging expenses, except as specified for ambulance services covered by

the plan (see page 38), or approved travel and lodging costs related to the COE Program for single

knee and single hip replacement (see page 58) and for spine care (see page 71)

120 2023 UMP Classic (PEBB) Certificate of Coverage

122. Treatment of varicose veins with Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA),

Sclerotherapy, and Phlebectomy in patients with pregnancy, active infection, peripheral arterial

disease, or deep vein thrombosis (DVT)

123. Upright magnetic resonance imaging (uMRI), also known as “positional,” “weight-bearing” (partial or

full), or “axial loading”

124. Vagal nerve stimulation (VNS) for treatment-resistant depression

125. Vagal nerve stimulation (VNS) for the treatment of depression (does not include or apply to support

of previously implanted VNS)

126. Vision hardware replacements:

◦ The plan does not cover the replacement of any lost, stolen or broken lenses and/or frames.

127. Vision, routine:

◦ Certain contact lens expenses:

• Artistically-painted or non-prescription contact lenses;

• Contact lens modification, polishing or cleaning;

• Refitting of contact lenses after the initial (90-day) fitting period;

• Additional office visits associated with contact lens pathology; and

• Contact lens insurance policies or service agreements.

◦ Corrective vision treatment of an experimental or investigational nature

• The VSP benefits do not cover investigational or experimental treatments or procedures (health

interventions), services, supplies, and accommodations provided in connection with health

interventions.

◦ Lens enhancements: The VSP benefits do not cover lens enhancements, including, but not limited

to:

• Anti-reflective coating;

• Color coating;

• Mirror coating;

• Scratch-resistant coating;*

• Blended lenses;

• Cosmetic lenses;

• Laminated lenses;

• Oversize lenses;

• Premium and custom progressive multifocal lenses;

• Photochromic lenses;

• Tinted lenses, except Pink #1 and Pink #2;

• UV (ultraviolet) protected lenses;* and

• Impact-resistant coating.*

*These lens enhancements are covered for children under the age of 19. Impact-resistant coating

is also covered for dependent children ages 19 and over.

◦ Medical or surgical treatment of the eyes

128. Vision services and supplies:

◦ The plan does not cover services or supplies that are not medically necessary:

• Plano lenses (less than a ± .50 diopter power).

• Two pair of glasses instead of bifocals.

• Services and/or materials not described as covered under this vision benefit.

129. Vitamin D screening and testing as part of routine screening

2023 UMP Classic (PEBB) Certificate of Coverage 121

130. Weight control, weight loss, and obesity treatment:

◦ Non-surgical: Any program, drugs, services, or supplies for weight control, weight loss, or obesity

treatment. Exercise or diet programs (formal or informal), exercise equipment, or travel expenses

relating to non-surgical or surgical services are not covered. Such treatment is not covered even if

prescribed by a provider, except as covered under "Bariatric surgery" (see page 39), “Diabetes

Control Program” (see page 46), “Diabetes Prevention Program” (see page 46), “Nutrition

counseling and therapy” (see page 62), or “Preventive care” (see page 65).

◦ Surgical: Any bariatric surgery procedure, any other surgery for obesity or morbid obesity, and

any related medical services, drugs, or supplies, except when approved by preauthorization

review.

131. Whole exome sequencing for:

◦ Uncomplicated autism spectrum disorder, developmental delay, mild to moderate global

developmental delay.

◦ Other circumstances (e.g. environmental exposures, injury, infection) that reasonably explain the

constellation of symptoms.

◦ Carrier testing for “at risk” relatives.

◦ Prenatal or pre-implantation testing.

132. Workers’ compensation: When a claim for workers’ compensation is accepted, all services related to

that injury or illness are not covered, even if some services are denied by workers’ compensation

If you have questions about whether a certain service or supply is covered, call UMP Customer Service.

If you have other medical coverage

FOR MEDICARE RETIREES: Different rules apply to members who have Medicare as their

primary payer. See the “How UMP Classic and Medicare work together” section for how UMP

Classic works with Medicare.

Coordination of benefits

Coordination of benefits (COB) happens when you have health coverage through two or more groups

(such as your employer and your spouse’s employer), and these two group health plans both pay a

portion of your health care claims.

The rules beginning under the “Who pays first” section determine which plan pays first (primary payer)

and which pays second (secondary payer). See page 124 for a description of how the plan coordinates

benefits when it pays second.

The plan processes claims differently depending on if it is the primary payer or the secondary payer. The

differences are described in the next several pages.

TIP: If you have other health coverage, it is important that you let your providers know,

including the pharmacies where you get your prescription drugs.

122 2023 UMP Classic (PEBB) Certificate of Coverage

Contact UMP and WSRxS

If you or your dependents have other insurance, you must let UMP and WSRxS know so claims are

processed correctly. To do this, you must complete and submit a separate form for medical services and

prescription drugs. Each person claiming payment for benefits under the plan is required to give Regence

and WSRxS any facts needed to apply these COB rules. If your coverage under other plans changes, you

must let UMP and WSRxS know so claims are processed correctly. See the Directory pages at the

beginning of this booklet for contact information and ways to get and submit COB forms.

Who pays first

Note: If you cannot determine which plan pays first, call UMP Customer Service.

Alert: Medicare will be the primary payer for covered benefits provided to Medicare-eligible

members who are enrolled in UMP as a dependent of a currently employed state-registered

domestic partner. Medicare will remain the secondary payer for benefits payable under UMP

for (1) individuals age 65 or over who have UMP as a result of their own current employee

status, or (2) individuals age 65 or over who have UMP as a result of the current employment

status of a spouse of any age.

When UMP coordinates benefits with other plans, the following rules determine which plan pays first.

These rules apply in order, so the first rule below that applies to your situation will determine which plan

is your primary coverage, and subsequent rules will not apply.

The following plan pays first:

• Any group plan that does not coordinate benefits.

• The plan that covers the member as a subscriber, not a dependent.

Exception: When the subscriber is a Medicare beneficiary, the plan covering the person as the retiree

is secondary to the plan covering the person as a dependent.

• The plan that covers the member (or their spouse or state-registered domestic partner) as an active

employee pays before a plan that covers the member as a retired employee.

• A plan covering the member as an employee, subscriber, retiree, or the dependent of such an

employee, subscriber, or retiree will pay before a COBRA or a state right of continuation plan.

• If the other plan is Medicare, UMP pays first if the member is age 65 or over who have UMP as a result

of their own active employee status or the active employee status of a spouse of any age. Note:

Medicare benefits are primary to UMP for members who are enrolled in UMP as a dependent of a

currently employed state-registered domestic partner.

• The plan that has covered the member (or their spouse or state-registered domestic partner) as a

subscriber the longest, if there are two plans and the first five bullets do not determine which plan pays

first.

• If none of the preceding rules determines the order of benefits, the allowable expenses must be shared

equally between the plans.

For dependent children

A group plan is usually primary over Medicaid programs that cover children. If a dependent child has

group coverage through their employer, the child’s coverage pays first.

2023 UMP Classic (PEBB) Certificate of Coverage 123

Dependent children of married parents

The group plan of the parent whose birthday is earlier in the year pays first. For example, the plan of a

parent born April 14 is primary over the plan of a parent born August 21. This is called the “birthday rule.”

This rule looks only at the month and day, not the year. If both parents have the same birthday, the plan

that has covered either parent the longest is primary.

Exception for newborn children

Under Washington State law, the plan must cover newborns under the mother’s coverage for the first 21

days of life. Therefore, the mother’s plan pays first for covered charges during the first 21 days of a

newborn’s life.

Dependent children of legally separated or divorced parents

When no court order specifies which parent is responsible for providing health insurance coverage, the

following standard COB rules determine which plan pays first:

1. The plan of the custodial parent.

2. The plan of the custodial parent’s spouse, if the custodial parent has remarried.

3. The plan of the non-custodial parent.

4. The plan of the non-custodial parent’s spouse, if the non-custodial parent has remarried.

The custodial parent is the parent awarded custody by a court decree or, in the absence of a court decree,

is the parent with whom the child resides more than one half of the calendar year, excluding any

temporary visitation.

The birthday rule is used to determine which parent’s plan pays first if:

• The court order states that both parents are responsible for the child’s/children’s health coverage and

expenses.

• The court order awards joint custody without specifying that one parent is responsible for the

child’s/children’s health coverage and expenses.

If the court order states one parent is to assume primary financial responsibility for the child but does not

specify that one parent is responsible for health coverage and health care expenses, the plan of the parent

assuming financial responsibility is the primary payer.

In some cases, a court order determines payment for health care expenses. In those cases, standard COB

rules may not apply. You must promptly provide the plan with copies of the court order for the plan to

determine which plan pays first.

If a dependent child is covered under more than one plan through persons who are not the child’s parent

or stepparent (e.g., a grandparent or other guardian), the plan will use the birthday rule to determine

which plan pays first.

If none of the preceding rules determine who pays first, then each plan covers half of the allowed

expenses.

Federal and military plans

UMP usually pays first over certain federal or military programs for veterans (retired military members).

When UMP pays first

When the plan is the primary payer (pays first), UMP pays its normal benefit as described in this COC. You

may need to send UMP’s Explanation of Benefits and a copy of your provider’s bill to your secondary

payer to receive payment. Check with that plan for more information.

124 2023 UMP Classic (PEBB) Certificate of Coverage

When UMP is supposed to pay first, but another plan did instead

If another plan pays first on claims where UMP should have paid first:

• UMP may pay the other plan the amount UMP should have paid.

• Amounts UMP pays to the other plan are considered benefits paid by UMP.

How UMP coordinates benefits when it pays second

FOR MEDICARE RETIREES: For more detail on how Medicare and UMP Classic interact when

Medicare pays first, and UMP Classic pays second, see page 127.

UMP uses a type of COB called nonduplication of benefits (see definition of “Nonduplication of benefits”).

When UMP pays second to another plan that covers the member, UMP will pay only an amount needed to

bring the total benefit up to the amount UMP would have paid if the member did not have another plan.

The intent of this type of COB is to maintain the level of benefits available through UMP. The

nonduplication of benefits type of coordination is not designed to pay your covered expenses in full.

When UMP pays second, it coordinates with these types of plans:

• Governmental programs including, but not limited to, Medicare and Medicaid.

• Group, blanket, or franchise health or disability insurance policies; health care service contractor and

health maintenance organization group agreements issued by insurers; health care service contractors;

and health maintenance organizations.

• Labor management trusteed plans, labor organization plans, employer plans, or employee benefit

organization plans.

ALERT! If you have other primary coverage that pays for services, those services will apply to

the UMP benefit limit.

How much you may pay when UMP pays second

When you see preferred providers under UMP, you will owe only the balance of the UMP allowed amount

after your primary plan and UMP pay benefits for covered services. Your cost will usually be higher if you

see out-of-network providers. See the “Sample payments to different provider types” section for

examples.

The examples in the table below assume that you have met your medical deductible.

Situation

Example

Preferred

provider

charge

UMP

allowed

amount

UMP

normal

benefit

Other

plan

pays

UMP

pays

You pay

your

provider

UMP is

primary,

other plan is

secondary

EXAMPLE 1:

When UMP

pays first (or is

the only plan)

$200

$100

$85

(85% of

$100)

N/A

$85

$15

UMP is

secondary,

EXAMPLE 2:

$200

$100

$85

$80

$15

2023 UMP Classic (PEBB) Certificate of Coverage 125

Situation

Example

Preferred

provider

charge

UMP

allowed

amount

UMP

normal

benefit

Other

plan

pays

UMP

pays

You pay

your

provider

other plan is

primary

The other plan

pays less than

the normal

UMP benefit

UMP is

secondary,

other plan is

primary

EXAMPLE 3:

The other plan

pays as much

as (or more

than) the

normal UMP

benefit

$200

$100

$85

$15

Contact UMP Customer Service for help with any questions if you are covered by more than one plan.

Submit secondary claims promptly

All health plans have a “timely submitting” deadline. The timely submitting deadline for UMP is 12 months

from the date of service. If a claim is not submitted within the plan’s timely submitting deadline, UMP will

deny it. If your primary plan delays payment on a claim, you must still submit to UMP within the

submitting deadline to prevent denial of the claim.

UMP may try to contact your primary plan for their benefit payment information or may estimate it to

provide timely processing of your secondary benefit. Adjustments may be made when the primary plan

pays their portion of your claim. Notifying your providers of any change to your coverage will help avoid

errors and delays in processing of claims (see the “Billing and payment: submitting a claim” section).

How diabetes care supplies are covered when UMP pays second

FOR MEDICARE RETIREES: If Medicare is your primary health coverage, see “Diabetes care

supplies when Medicare pays first” on page 129 for information on how claims for diabetes

care supplies are processed.

UMP covers diabetes care supplies under the prescription drug benefit. If you get your supplies from a

pharmacy, ask if the pharmacy can bill both your primary plan and UMP. If your pharmacy does, you do

not need to do anything further. If not, you will need to send a claim to WSRxS for secondary payment

(see the “Submitting a claim for prescription drugs” section for instructions).

If you get your supplies from a diabetes care supplier, the primary plan may process the claim as medical.

In this case, you need to send your Explanation of Benefits and a claim form to WSRxS for secondary

payment (see the “Submitting a claim for prescription drugs” and the “False claims or statements” sections

for instructions).

Note: Nonduplication of benefits applies to these claims, which means that UMP may pay nothing after

your primary plan pays.

See the “Diabetes care supplies” benefit for more information.

126 2023 UMP Classic (PEBB) Certificate of Coverage

ALERT! You must submit secondary claims for diabetes care supplies to WSRxS. Regence

BlueShield will deny these claims.

How COB works with prescription drugs

Some of the limits and restrictions to prescription drug coverage listed in the “Limits on your prescription

drug coverage” section will apply when UMP pays second to another plan. See the “Submitting a claim for

prescription drugs” section for how to submit your prescription drug claim.

Nonduplication of benefits applies when UMP pays second to another plan. This means that UMP may

pay nothing after your primary plan pays.

ALERT! If UMP pays second, you must still meet your prescription drug deductible before UMP

covers Tier 2 drugs.

Using network pharmacies when UMP is secondary

If you have primary coverage through another plan that covers prescription drugs, show both plan

member ID cards to the pharmacy and make sure they know which plan pays first and which plan pays

second. It is important that the pharmacy bills the plans in the correct order, or claims may be denied or

paid incorrectly.

Using mail-order pharmacies when UMP is secondary

If your primary plan also uses one of UMP’s network mail-order pharmacies as the plan’s network mail-

order pharmacy, UMP’s network mail-order pharmacies may process payments for both plans and charge

you only the remainder. Make sure that UMP’s network mail-order pharmacies have the information for

both plans and know which plan is primary.

However, if your primary plan uses a different mail-order pharmacy, you will have to use your primary

plan’s mail-order pharmacy, then submit a paper claim to UMP. See the “Submitting a claim for

prescription drugs” section for how to do this.

For retirees enrolled in Medicare and UMP

Classic

FOR MEDICARE RETIREES: When you see this format throughout this COC, it gives specific

tips for Medicare retirees.

Are you a Medicare retiree?

You are considered a Medicare retiree if all the following apply. You are:

• Enrolled in PEBB retiree insurance coverage;

• Age 65 or older (or younger and eligible for Medicare due to medical disability); and

• Enrolled in both Medicare Part A (hospital) and Part B (medical).

2023 UMP Classic (PEBB) Certificate of Coverage 127

Alert! If you are the subscriber and are an employee, see “When UMP Classic pays first and

Medicare pays second” below for coverage when UMP Classic pays before Medicare. This also

applies to dependents enrolled in UMP Classic under an employee’s account.

How UMP Classic and Medicare work together

Because Medicare pays first, a few rules are different for Medicare retirees. This section tells you about

these rules, including:

• How UMP Classic and Medicare work together.

• What UMP Classic covers that Medicare does not cover.

• What your choices for providers are.

• How billing works.

• How your prescription drug coverage works.

• Where to go for more information.

To enroll in PEBB retiree insurance coverage, retirees and their eligible dependents who are eligible for

Medicare are required to enroll in Medicare Part A and Part B. If a retiree or an enrolled dependent

becomes eligible for Medicare after enrollment in UMP, they must enroll in Medicare Part A and Part B.

Enrollment in Medicare Part A and Part B must be maintained to remain enrolled in a PEBB retiree health

plan. You may not enroll in a Medicare Part D drug plan and be covered by UMP. Your monthly premiums

will be lower because Medicare pays part of your medical costs. Be sure to tell Medicare you are enrolled

in UMP so that they send us your claims after Medicare processes them.

If you are retired but you or an eligible dependent are not yet eligible to enroll in Medicare Part A and

Part B, this section does not apply to you. If you think you might be eligible for Medicare and need

information on how to sign up, see the “Medicare eligibility and enrollment” section.

When UMP Classic pays first and Medicare pays second

If UMP Classic pays first and Medicare pays second, make sure that you tell Medicare about your UMP

Classic coverage and that your provider agrees to bill Medicare as secondary to get the maximum benefit

from both plans. Medicare generally accepts claims only from providers, so you may not be able to send a

claim to Medicare for secondary payment. The provider would need to bill Medicare after UMP Classic has

processed the claim.

Note: Medicare accepts claims directly from members only under certain circumstances.

FOR MEDICARE RETIREES: UMP Classic does not bill Medicare or in any way coordinate

benefits with Medicare when Medicare is the secondary payer.

When Medicare pays first and UMP Classic pays second

UMP Classic and Medicare are two separate health plans that work together to pay for covered services

and supplies. Here is how coordination of benefits works:

• Your providers bill Medicare. Medicare pays your claims first. After Medicare processes the claim,

Medicare sends the claim to UMP Classic.

128 2023 UMP Classic (PEBB) Certificate of Coverage

• UMP Classic pays your claims second. For most covered services, UMP Classic pays the rest of the

Medicare allowed amount and you owe $0.

Each calendar year, you must meet the UMP Classic medical deductible before UMP Classic starts paying

benefits. If you receive more covered services during the same calendar year, you may be reimbursed for

at least some of your UMP Classic deductible. That reimbursement will come from the COB savings. This

savings is the part of your UMP benefit saved because Medicare pays part of your claims. See the “Why

you might get a COB savings check from UMP Classic” section.

Note: Services apply to the UMP medical deductible in the order claims are received, not necessarily in

the order the member receives the services.

Paying the UMP Classic and Medicare deductibles

If you meet the UMP Classic deductible, you do not pay both the Medicare Part B and the UMP Classic

deductible. The Part B deductible is a part of the same total calendar year expenses processed by UMP

Classic. An example is below. This example assumes you received care from a provider who accepts

Medicare (has not “opted out” of Medicare) anywhere in the U.S.

Benefit calculation

Amount

Medicare allowed amount

$600

Medicare deductible

$183

Subtract Medicare deductible from allowed amount: $600 - $183 =

$417

Medicare pays 80% of this amount (0.80 x $417) =

$333.60

Balance remaining after Medicare pays: $600 - $333.60 =

$266.40

UMP Classic allowed amount

$600

UMP Classic deductible

$250

Subtract UMP Classic deductible from allowed amount: $600 - $250 =

$350

Normal UMP Classic benefit (85% of this amount) (0.85 x $350) =

$297.50

Since the UMP Classic benefit available (dollar amount) is greater than the balance, UMP

pays the balance remaining after Medicare pays:

$266.40

The difference between the normal UMP Classic benefit and the amount UMP paid is:

This amount is considered “COB savings” (see page 131).

$31.10

Note: This is an example only and may not apply to your specific situation.

Example of COB when Medicare pays first and UMP Classic pays second

Below is an example to show how the COB process works after you have met your UMP Classic medical

deductible and Medicare deductible. This example assumes you received care from a provider who

accepts Medicare (has not “opted out” of Medicare) anywhere in the U.S.

Benefit calculation

Amount

Provider’s billed charge

$300

Medicare allowed amount

$100

Medicare pays

$80 (80% of $100)

Remaining amount

$20

UMP Classic allowed

amount

$100

UMP Classic normal

benefit

$85 (85% of $100)

2023 UMP Classic (PEBB) Certificate of Coverage 129

Benefit calculation

Amount

UMP Classic pays

$20

You pay

COB savings accrued

$65 ($85 - $20 =$65)

The $65 of the normal UMP Classic benefit not paid on this claim is tracked as part of your COB savings.

That excess benefit may be used to reimburse you directly for your UMP Classic medical deductible met

earlier in the same year or used to pay more on a service covered by UMP Classic, but not covered by

Medicare. See the “Why you might get a COB savings check from UMP Classic” section.

In this example, you owe $0 because the provider accepts Medicare. You may still have to pay coinsurance

and deductible amounts when you have not fully met your Medicare deductibles, or when Medicare does

not cover a service.

If UMP Classic covers a service or supply not covered by Medicare, then the benefit will be the normal

UMP Classic benefit plus any COB savings you may have accrued in the same calendar year, up to allowed

amount for the claim.

If a provider does not bill Medicare for services covered by Medicare, UMP Classic may not cover services.

Medicare accepts claims from members only under certain circumstances, and UMP Classic processes

claims for services covered by Medicare only after Medicare has processed them. See the “What UMP

Classic covers that Medicare does not” section below for exceptions. Ask your provider if they bill

Medicare.

Diabetes care supplies when Medicare pays first

Medicare pays claims for some diabetes care supplies under the Part B medical benefit. As a result, UMP

Classic pays the claim under the DME benefit, not the prescription drug benefit. This means you will have

to meet your medical deductible before UMP Classic begins to pay on diabetes care supplies claims, then

UMP Classic pays its share based on medical benefit coinsurance (85 percent of the allowed amount for

providers that accept Medicare).

See also the “Diabetes care supplies” benefit for more information.

What UMP Classic covers that Medicare does not

FOR MEDICARE RETIREES: Services listed below are paid at the standard rate. You will pay

more if you use out-of-network providers for these services.

UMP Classic covers some services that Medicare does not cover. For these services, it does not matter if

the provider accepts Medicare, because Medicare does not cover the service. You will receive the highest

level of benefit if you choose a preferred provider.

Services listed below are not covered by Medicare, but they are covered by UMP Classic. Out-of-network

providers may balance bill you.

Services not covered by Medicare Part A or Part B include, but are not limited to:

• Hearing aids.

• Hearing exams for getting a hearing aid.

• Massage therapy (a massage therapist must be a preferred provider).

130 2023 UMP Classic (PEBB) Certificate of Coverage

• Naturopathic medicine.

• Prescription drugs (see “Use network pharmacies that bill Medicare Part B directly” on page 132 for

exceptions).

• Routine vision exams and hardware. (Medicare covers medical vision exams and vision hardware

following cataract surgery.)

• Services outside of the U.S. (see the “Services received outside the United States” section for details).

• Wigs for cancer patients (see page 48).

If you see a preferred provider, they will submit the claim for you. For out-of-network providers, check if

the provider will submit the claim. If not, you will need to send a claim to UMP Classic. See the “Billing and

payment: submitting a claim” section.

When to see a preferred provider

FOR MEDICARE RETIREES: Preferred providers do not necessarily accept Medicare. You

should always ask.

To find preferred providers outside the U.S., see page 23.

Type of service

Higher benefits with UMP

preferred provider?

Important information

Services covered by Medicare

You should see a provider who

accepts Medicare. See “When

providers do not accept

Medicare” on page 131 to learn

why this is important.

Services covered by UMP

Classic but not by Medicare

Yes

See “What UMP Classic covers

that Medicare does not” starting

on page 129 to see which

services apply. Use the provider

search on the UMP website at

ump.regence.com/go/pebb/

UMP-Classic, or call UMP

Customer Service, to find a

preferred provider.

Massage therapy

Yes

UMP Classic pays for massage

therapy services only when the

provider is preferred.

Prescription drugs

Yes

You must also choose pharmacies

that participate in and may bill

Medicare Part B directly. See “Use

network pharmacies that bill

Medicare Part B directly” on page

132 for more information.

2023 UMP Classic (PEBB) Certificate of Coverage 131

When providers do not accept Medicare

When services are covered by Medicare, you must see providers who accept Medicare for the services to

be covered by Medicare and UMP Classic. If your provider is not contracted with Medicare or has chosen

to “opt out” of participating in Medicare, UMP Classic will not cover services by that provider, even if the

provider is in the Regence or Blue Card network (preferred) for UMP Classic members (see the “Finding a

health care provider” section). Providers that opt out of Medicare are supposed to have you sign a private

contract before providing services, but you are responsible for all costs even if you did not sign a contract.

When you pay: How billing works

Most of the time, you pay only after both Medicare and UMP Classic have processed your claim. Here is

how it typically works:

1. Your provider bills Medicare.

2. Medicare processes the claim and sends you a Medicare Summary Notice (MSN). An MSN may also

be called an Explanation of Medicare Benefits (EOMB). The MSN tells you how much Medicare paid

on your claim.

3. Medicare then sends the claim to UMP Classic for processing. You do not need to submit a claim

form or other paperwork to UMP Classic.

4. UMP Classic processes the claim and sends you an Explanation of Benefits (EOB). The EOB tells you

how much UMP Classic and Medicare paid, plus how much you owe the provider.

5. You receive a bill from your provider for any remaining amount due. To confirm that the provider

has credited your account with both Medicare and UMP Classic payments:

◦ Note the allowed amount on the Medicare MSN.

◦ Subtract both Medicare’s and UMP Classic’s payments from that amount. This should match the

bill from your provider.

6. You pay your provider the amount due, if any. After you’ve met both your Medicare and UMP Classic

deductibles, you will not pay anything for most claims.

If you have not received any paperwork on a health care service within three months, call your provider’s

billing office and ask if they have sent the claim. Neither Medicare nor UMP Classic may process a claim

they have not received. While you are welcome to call UMP Classic and ask, if we have not received the

claim, we will not have any record of the service.

Why you might get a COB savings check from UMP Classic

At the beginning of the year, you must first satisfy your Medicare and UMP Classic deductibles to receive

coordination of benefits (COB) savings. Once you have satisfied these deductibles in full and receive more

health care services during the year, UMP Classic usually pays less than its normal benefit when it is a

secondary payer to Medicare. The difference between what UMP Classic pays as the secondary plan and

what UMP Classic would have paid had it been the primary payer, is your COB savings.

UMP Classic keeps track of how much you’ve paid out of pocket during the year. If your Medicare

coverage generates COB savings, we may send you a “COB savings check” to pay you back for the out-of-

pocket expenses you paid earlier in the year. UMP Classic does not reimburse you for more than you paid

out of pocket. See the “How UMP Classic and Medicare work together” section for examples.

132 2023 UMP Classic (PEBB) Certificate of Coverage

How UMP Classic prescription drug coverage works with

Medicare

FOR MORE INFORMATION: See the “Your prescription drug benefit” section for complete

information about your prescription drug coverage.

Use network pharmacies that bill Medicare Part B directly

ALERT! UMP’s network mail-order pharmacies cannot bill Medicare for diabetes care supplies

when Medicare is your primary coverage. To find a Medicare-approved mail-order pharmacy

for diabetes care supplies, contact Medicare at 1-800-MEDICARE (1-800-633-4227) (TTY: 1-

877-486-2048).

Most prescription drugs or supplies covered under Medicare Part B are paid as medical. When paying

secondary to Medicare Part B, UMP Classic also pays under the medical benefit. Therefore, these charges

are subject to the medical deductible.

For those drugs and medical supplies covered under your prescription drug benefit, we recommend that

you choose a network pharmacy that may bill Medicare Part B directly to get the most from your

prescription drug coverage. Medicare Part B does cover a few drugs and supplies for specific purposes.

Note: Medicare Part B quantity restrictions may apply.

Medicare accepts claims only from pharmacies, not from individuals. If Medicare covers a prescription

drug or supply and the pharmacy does not send the claim to Medicare first for payment, UMP Classic will

deny the claim. To find a network retail pharmacy, see the pharmacy locator on the UMP Prescription drug

coverage webpage or call WSRxS Customer Service (see Directory for link and contact information).

You may not have UMP Classic and Medicare Part D

You may not enroll in both UMP Classic and a Medicare Part D prescription drug plan. UMP Classic

provides your prescription drug coverage and you may not have both. Medicare will notify the PEBB

Program if you enroll in a Part D plan while enrolled in UMP Classic. You could lose your eligibility for

PEBB retiree health plan coverage if you do this. If you think you want a Part D prescription drug plan, you

must change your medical plan from UMP Classic to a PEBB Medicare Supplement Plan. See “Medicare

Part D” on page 170 or more information. Contact the PEBB Program at 1-800-200-1004 (TRS: 711) to ask

when and how you may change your PEBB medical plan.

Where to go for more information

See the Directory at the beginning of this booklet for links and contact information.

Types of questions

Contact

Medicare premiums

What Medicare covers

Whether your claim has been processed by Medicare

Medicare

2023 UMP Classic (PEBB) Certificate of Coverage 133

Types of questions

Contact

Your Medicare deductibles and coinsurance amounts

What UMP Classic covers

Your UMP Classic copays, coinsurance, and deductible

amounts

UMP Customer Service or visit the

UMP website

Your claim after it has been processed by Medicare

UMP Customer Service or sign in to

your Regence account

Prescription drugs

WSRxS Customer Service or visit the

UMP Prescription drug coverage

webpage

Adding or removing dependents from your account

Address changes

Changing your PEBB medical coverage

UMP Classic premiums

PEBB Program

If the member responsibility dollar amount on your UMP

Classic Explanation of Benefits does not match your

provider’s bill

Whether your claim has been submitted to Medicare

Your provider’s billing office

Billing and payment: submitting a claim

FOR MEDICARE RETIREES: Read the “For Retirees Enrolled in Medicare and UMP Classic”

section.

Submitting a claim for medical services

When UMP is your primary insurance and your provider is preferred, or participating, you do not need to

submit claims. The provider will do it for you. If you have a question about whether your provider’s office

has submitted a claim, sign in to your Regence account or call UMP Customer Service (see Directory for

links and contact information). See the “Submitting a Blue Cross Blue Shield Global® Core claim” section

on page 22 for instructions on submitting a claim for services received outside of the United States.

TIP: In the following section, Uniform Medical Plan (UMP) refers to the administrative functions

for submitting claims to UMP. Regence BlueShield handles medical claims, and WSRxS handles

prescription drugs claims.

When you need to submit a claim

You may need to submit a claim to UMP for payment if:

134 2023 UMP Classic (PEBB) Certificate of Coverage

• You receive services from an out-of-network provider.

• You have other insurance that pays first and UMP is secondary.

Out-of-network providers may submit a claim on your behalf. Ask your provider.

How to submit a claim

To submit a claim yourself, you may sign in to your Regence account and go to the Submit claim

webpage at regence.com/member/submit-claim/ or you may complete a medical claim form and mail

the following documents:

• UMP (Regence) Medical Claim Form — You may find the form by visiting forms and publications at

hca.wa.gov/ump-forms-pubs or you may request a form by calling UMP Customer Service.

• An itemized bill from your provider that describes the services you received and the charges.

The following information must appear on the provider’s itemized bill for the plan to consider the claim

for payment:

• Member’s name and member ID number, including the alpha prefix (three letters and the ‘W’ before

member ID number)

• Procedure and diagnosis code(s) or description of the injury or illness

• Date and type of service

• Provider’s name, address, phone number, and National Provider Identifier (NPI) or Tax ID number

• For ambulance claims, also include the ZIP code of where the member was picked up and where they

were taken

If UMP is secondary, you must include a copy of your primary plan’s Explanation of Benefits, which lists

the services covered and how much the other plan paid. You should wait until the primary plan has paid

to submit a secondary claim to UMP, unless the primary plan’s processing of the claim is delayed. Claims

not submitted to UMP within 12 months of the date of service will not be paid.

If we must request additional information, the processing of your claim may be delayed.

Note: Be sure to make copies of your documents for your records.

Mail both the claim form and the provider’s claim document (or bill) to:

Regence BlueShield

Attn: UMP Claims

PO Box 1106

Lewiston, ID 83501-1106

Or you can fax documents to Regence at 1-877-357-3418.

The plan may send reimbursement for services received from an out-of-network provider to the provider

or to you in the form of a check listing both you and the provider as payees. If you paid up front for

services, proof of payment may be required. Call UMP Customer Service if you have a question about the

processing of your claim or for information on what is acceptable as proof of payment.

2023 UMP Classic (PEBB) Certificate of Coverage 135

Important information about submitting claims

ALERT! You or your provider must submit claims within 12 months of the date you received

health care services. This is called the “timely submitting” deadline. The plan will not pay claims

submitted more than 12 months after the date of service. See “Submit secondary claims

promptly” on page 125 for how this works when you have other coverage that pays first.

For information about submitting claims for services outside of the U.S., call UMP Customer Service. You

may have to pay services upfront and submit a claim for reimbursement.

If you have other health care coverage, see the “If you have other medical coverage” section for

information on how the plan coordinates benefits with other plans.

Services apply to the UMP medical deductible in the order claims are received, not necessarily in the order

the member receives services.

Claims reimbursement

Most of the time, the plan will pay preferred or participating providers directly. For claims submitted by

you or an out-of-network provider, the plan will determine whether to pay you, the provider, or both. For

a child covered by a legal qualified medical child support order (see page 122) the plan may pay the

child’s custodial parent or legal guardian.

Claims determinations

The plan will notify you of action taken on a claim within 30 days of the plan receiving it. This 30-day

period may be extended by 15 days when action cannot be taken on the claim due to:

• Circumstances beyond the plan’s control. Notice will include an explanation why an extension is

needed and when the plan expects to act on the claim.

• Lack of information. The plan will notify you within the 30-day period that an extension is necessary,

with a description of the information needed and why it is needed.

Submitting a claim for prescription drugs

You may need to submit your own prescription drug claim to WSRxS for reimbursement if you:

• Buy prescription drugs at a non-network retail pharmacy.

• Fail to show your UMP member ID card at a network pharmacy.

• Have other prescription coverage that pays first, and UMP is secondary.

TIP: If you get a vaccine from an out-of-network provider, make sure that you submit your

claim to Regence BlueShield as a medical claim (see the “Submitting a claim for medical

services” section).

Prescription drug claim forms are available by visiting forms and publications at hca.wa.gov/ump-forms-

pubs or by calling WSRxS Customer Service. Send the completed claim form, along with your pharmacy

receipt(s), to:

136 2023 UMP Classic (PEBB) Certificate of Coverage

Pharmacy Manual Claims

PO Box 999

Appleton, WI 54912-0999

It is a good idea to keep copies of all your paperwork for your records.

When you submit a prescription drug claim to WSRxS, the plan pays the claim based on the following

rules, no matter where you purchased the drug:

• The plan pays based on the allowed amount. If the pharmacy charges you more than the allowed

amount, you will pay your usual coinsurance (and prescription drug deductible if applicable), plus the

difference between what the plan paid and the pharmacy’s charge.

• The plan pays all prescription drug claims, including non-network retail pharmacies, based on the

drug’s tier coinsurance (see the “What you pay for prescription drugs" section).

• If your claim exceeds the quantity limit or the maximum days’ supply allowed by the plan, the plan will

pay only for the amount of the prescription drug up to the quantity limit or maximum days’ supply.

• If you receive a refill before 84 percent of the last supply you received should have been taken, the plan

will not pay for it. This is called a “refill too soon” (see page 106).

You must submit prescription drug claims within 12 months of purchase. The plan will not pay claims for

prescription drugs submitted more than 12 months after purchase or prescription drugs purchased from

an excluded pharmacy. See the definition of “Excluded pharmacy.”

ALERT! If you do not show your UMP member ID card when purchasing a prescription at a

WSRxS’ network pharmacy, you will have to pay the full cash price and submit a Prescription

Drug Claim Form. You will not receive the plan discount.

False claims or statements

Neither you nor your provider (or any person acting for you or your provider) may submit a claim for

services or supplies that were not received, were resold to another party, or for which you are not

expected to pay.

In addition, neither you nor any person acting for you may make any false or incomplete statements or

any false claims on any document for your plan coverage.

The plan may recover any payments or overpayments made because of a false claim or false statement by

withholding future claim payments, by suing you, or by other means. False claims may also be crimes.

If you represent yourself as being enrolled in this plan when you are not, the plan will deny all claims.

If the plan asks you for more information, you will be allowed at least 45 days to provide it. If the plan

does not receive the information requested within the time allowed, the plan will deny the claim.

2023 UMP Classic (PEBB) Certificate of Coverage 137

Complaint and appeal procedures

ALERT! In the following section, UMP refers to the administrative functions for appeals for

UMP Classic. Regence BlueShield handles medical appeals; WSRxS handles appeals involving

prescription drugs; and Premera handles appeals for the COE Program. See the “Joint

replacement surgery, knees and hips in the Centers of Excellence (COE) Program” and “Spine

care in the Centers of Excellence (COE) Program” benefits for more information. VSP handles

appeals for routine vision benefits. See “Your routine vision benefits” for more information.

Appeals procedures may change during the year if required by federal or Washington State

law.

What is a complaint or grievance?

A complaint or grievance is an oral statement or written document submitted by or on behalf of a

member regarding:

• Dissatisfaction with medical care.

• Dissatisfaction with service provided by the health plan.

• Provider or staff attitude or demeanor.

• Waiting time for medical services.

Note: If your issue is regarding a denial, reduction, or termination of payment or nonprovision of medical

services, it is an appeal.

How to submit a complaint or grievance

For all medical complaints or grievances, it’s recommended that you first call UMP Customer Service. For

prescription drug complaints or grievances, we recommend calling WSRxS Customer Service. Many issues

may be resolved with a phone call. If an initial phone call does not resolve your complaint or grievance,

you may submit your complaint or grievance:

• Over the phone: If you want a written response, you must request one.

• By mail, fax, or email (see the “Where to send complaints or appeals” section below).

You will receive notice of the action on your complaint or grievance within 30 calendar days of our

receiving it. The plan will notify you if it needs more time to respond.

What is an appeal?

An appeal is an oral or written request submitted by you or your authorized representative to Regence

BlueShield or WSRxS to reconsider:

• A decision to deny, modify, reduce, or terminate payment, coverage, certification, or provision of health

care services or benefits, including the admission to, or continued stay in, a health care facility.

• A preauthorization.

• A retroactive decision to deny coverage based on eligibility (see the “Appeals related to eligibility”

section below).

138 2023 UMP Classic (PEBB) Certificate of Coverage

• Claims payment, processing, or reimbursement for health care services or supplies.

The appeals process

ALERT! If your appeal is for an urgent or life-threatening condition, see the "Expedited appeals

process" section below.

You or someone you authorize to represent you (see “How to designate an authorized representative” on

page 148) may submit an appeal. There are three levels to the appeals process:

1. First-level appeal

2. Second-level appeal

3. External review (independent review)

Each of those parts are described in further detail below.

Coverage during each review

If your request involves a decision to change, reduce, or terminate coverage for services, supplies, or

prescription drugs already being covered, the plan must continue to cover the disputed service until the

outcome of the review. If the plan upholds the decision to change, reduce, or terminate coverage, you will

be responsible for the cost of the services received during the review period. If you request payment for

denied claims or approval of services, supplies, or prescription drugs not yet covered by the plan, the plan

will not cover the services, supplies, or prescription drugs while the appeal is under consideration.

First-level and second-level appeal reviewers

Claim processing disputes will be reviewed by administrative staff. The plan will consult with a health care

professional employed by Regence BlueShield on medical appeals, or with a health care professional

employed by Washington State Rx Services on prescription drug appeals, when appeals involve issues

requiring medical judgment about covering, authorizing, or providing health care. That includes decisions

based on determinations that a treatment, prescription drug, or other item is experimental,

investigational, or not medically necessary. Your appeal will be reviewed by Regence BlueShield or

Washington State Rx Services employees who have not been involved in, or subordinate to anyone

involved in, reviewing the previous decisions.

How to submit an appeal

You or your authorized representative (including a relative, friend, advocate, attorney, or provider) may

submit an appeal by using the methods described below in the “Where to send complaints or appeals”

section. You may authorize a representative to submit an appeal on your behalf in writing or by calling

UMP Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals).

For each appeal request, you must appeal within 180 days of receiving the plan’s decision. You may

include written comments, documents, and any other information, such as medical records and letters

from your provider, to support your appeal request. The plan will consider all information submitted when

reviewing your appeal. You may also request copies of documents the plan has that are relevant to your

appeal, which the plan will provide at no cost to you.

The plan will mail you a written response within 14 days of receiving your appeal request. If more time is

needed to thoroughly research and review your appeal, the plan is allowed up to 30 days to respond. The

plan will ask your permission if it needs more time to respond. You can access the UMP (Regence) Medical

appeals and grievance form by visiting forms and publications at hca.wa.gov/ump-forms-pubs.

2023 UMP Classic (PEBB) Certificate of Coverage 139

Information to provide with an appeal

You can submit information, documents, written comments, records, evidence, and testimony, including

second opinions, with your appeal. When you provide all the necessary documentation, it allows the plan

to review your appeal faster. Include the following when requesting an appeal:

• The member’s full name (the name of the employee, retiree, or dependent covered by the plan)

• The member ID number (starting with a “W” on your UMP member ID card)

• The name(s) of any providers involved in the issue you are appealing

• Date(s) of service or incident

• Your mailing address

• Your daytime phone number(s)

• A statement describing the issue and your desired outcome

• A copy of the Explanation of Benefits, if applicable, or a list of the claim numbers you are appealing

• Medical records from your provider, if applicable. Your provider should supply clinically relevant

information, such as medical records for services denied based on medical necessity or for other clinical

reasons. The plan must receive all relevant information with the appeal to make sure the most accurate

decision is made.

First-level appeals

You or your authorized representative may submit a first-level appeal no more than 180 days after you

receive the plan’s decision. If you do not submit an appeal within this time, your appeal will not be

reviewed, and you will not be able to continue further appeals (second-level and external review). You

may authorize a representative to submit an appeal on your behalf in writing or by calling UMP Customer

Service (medical appeals) or WSRxS Customer Service (prescription drug appeals).

Regence BlueShield manages first-level appeals for medical services, and WSRxS manages first-level

appeals for prescription drugs. Employees from Regence BlueShield and WSRxS reviewing the appeals will

not have been involved in the initial decision you are appealing. Administrative staff review claim

processing disputes. A staff of health care professionals at Regence BlueShield or WSRxS evaluate appeals

that involve issues requiring medical judgment about covering, authorizing, or providing health care.

ALERT! Deadlines for submitting an appeal are based on the first date you are notified of how

a claim was processed, usually when you receive you an Explanation of Benefits (including

services that applied to the deductible or were denied). The plan does not waive deadlines

based on untimely billing by your provider.

Second-level appeals

If you disagree with the decision made on your first-level appeal, you or your authorized representative

may submit a second-level appeal. You must submit second-level appeals no more than 180 days after

you receive the letter responding to your first-level appeal. If you do not submit an appeal within this

time, your appeal will not be reviewed, and you will not be able to continue further appeals (external

review). You may authorize a representative to submit an appeal on your behalf in writing or by calling

UMP Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals).

Regence BlueShield manages second-level appeals for medical services, and WSRxS manages second-

level appeals for prescription drugs. Employees from Regence BlueShield and WSRxS reviewing the

140 2023 UMP Classic (PEBB) Certificate of Coverage

appeals will not have been involved in, or subordinate to anyone involved in, reviewing the first-level

appeal or initial decision. If new or additional evidence or rationale is considered in reviewing your appeal,

the plan will provide you with this information free of charge, and you may respond before the final

decision.

Expedited appeals process

Expedited appeals for medical services

You or your authorized representative may submit an expedited appeal within 180 days of receiving the

previous decision if:

• You are currently receiving or prescribed treatment or benefits that would end because of the denial; or

• Your provider determines that taking the usual time allowed could seriously affect your life, health, or

ability to regain maximum function, or would subject you to severe pain that cannot be adequately

managed without the disputed care or treatment; or

• The issue is related to admission, availability of care, continued stay, or emergency health care services

and you have not been discharged from the emergency room or transport service.

You may authorize a representative to submit an expedited appeal on your behalf in writing or by calling

UMP Customer Service.

An expedited appeal replaces both the first- and second-level appeals. Regence BlueShield will call you, or

your authorized representative, with a decision on your expedited appeal within 72 hours of the request.

Regence BlueShield will also mail a written response within 72 hours of the decision.

Your provider must submit all clinically relevant information to the plan by phone or fax at:

• Phone: 1-888-849-3682 (TRS: 711)

• Fax: 1-877-663-7526

If you disagree with the expedited appeal decision, your provider may request an expedited external

review (see the “External review (independent review)” section below).

Expedited appeals for prescription drugs

You or your authorized representative may submit an expedited appeal within 180 days of receiving the

previous decision if you or your provider thinks you need a prescription drug immediately. You may

authorize a representative to submit an appeal on your behalf in writing or by calling WSRxS Customer

Service.

An expedited appeal replaces both the first- and second-level appeals. WSRxS will call you, or your

authorized representative, with a decision on your expedited appeal within 72 hours of the request.

WSRxS will also mail a written response within 72 hours of the decision.

You or your provider must submit all clinically relevant information to the plan by phone or fax at:

• Phone: 1-888-361-1611 (TRS: 711)

• Fax: 1-866-923-0412

During an expedited appeal, you may choose to purchase a three-day supply at your own expense. If

WSRxS decides to cover the prescription drug, WSRxS will reimburse you up to the allowed amount minus

the member cost-share (coinsurance and prescription drug deductible, if applicable). If WSRxS decides not

to cover the prescription drug (denies the appeal), you are responsible for the full cost of the drug.

If you disagree with the expedited appeal decision, you or your provider may request an expedited

external review (see the “External review (independent review)” section below).

2023 UMP Classic (PEBB) Certificate of Coverage 141

Time limits for the plan to decide appeals

ALERT! The plan will comply with shorter time limits than those below when required by

federal or Washington State law.

The time limits for both first- and second-level appeals are calculated from when the plan receives the

appeal. The plan will decide your appeal within 14 days of receiving it but may take up to 30 days unless a

different time limit applies as explained below. The plan will request written permission from you or your

authorized representative if an extension to the 30-day time limit is needed to get medical records or a

second opinion.

For expedited appeals, the plan will decide as soon as possible but always within 72 hours. The plan will

notify you (or your authorized representative) of the decision verbally within 72 hours and will mail a

written notice within 72 hours of the decision.

External review (independent review)

You or your authorized representative may submit a request for an external review by an independent

review organization (IRO) if you have gone through both a first- and second-level appeal (or expedited

appeal) and your appeal was based on the plan’s decision to deny, modify, reduce, or terminate coverage

of or payment for a health care service.

You may also submit a request for an external review:

• If the plan has exceeded the timelines for response to your appeal without good cause and without

reaching a decision; or

• If the plan has failed to adhere to the requirements of the appeals process.

You may submit a request for an expedited external review if you meet the requirements for the

expedited process as described above. You may also request an expedited external review at the same

time that you request an expedited appeal, called concurrent expedited review. When you request

concurrent expedited review, you are not required to go through both a first- and second-level appeal.

An IRO will conduct the external review. An IRO is a group of medical and benefit experts certified by the

Washington State Office of the Insurance Commissioner and not related to the plan, Regence BlueShield,

WSRxS, or HCA. An external review provides unbiased, independent clinical and benefit expertise to

determine whether the plan’s decision is consistent with state law and the 2023 UMP Classic (PEBB)

Certificate of Coverage.

Requesting an external review

To request an external review, see the contact information listed in the “Where to send complaints or

appeals” section below.

You or your authorized representative must submit a request for an external review no more than 180

days after you receive the letter responding to your second-level appeal (or expedited appeal). Only the

member or an authorized representative may submit a request for an external review. You may authorize

a representative to submit a request for an external review on your behalf in writing or by calling UMP

Customer Service (medical appeals) or WSRxS Customer Service (prescription drug appeals).

The plan — Regence BlueShield for medical services, and WSRxS for prescription drugs — will send the

IRO all of the relevant information and correspondence they considered in making the decision. You may

send more information directly to the IRO. The IRO will notify you of their decision.

142 2023 UMP Classic (PEBB) Certificate of Coverage

Additional legal options

You are required to exhaust the plan’s appeals process before you may bring a cause of action in court

against the plan or HCA. If an IRO reviews your appeal, their decision is binding on both the plan and you

except to the extent that other remedies are available under state or federal law.

If the IRO overturns the plan’s decision the plan will provide benefits (including making payment on the

claim) according to the IRO’s decision without delay, regardless of whether the plan intends to seek

judicial review of the IRO’s decision and unless and until there is a judicial decision otherwise.

Complaints about quality of care

For complaints or concerns about the quality of care you received from preferred and participating

providers only, call UMP Customer Service or send a secure email through your Regence account (see

Directory for link and contact information).

For complaints or concerns about the quality of care you received from any provider:

• Call Washington State Department of Health at 360-236-4700 (TRS: 711) or 1-800-562-6900 (TRS: 711).

• Email the Department of Health at [email protected].

• Visit the Department of Health website at doh.wa.gov/about-us/file-complaint.

Appeals related to eligibility

Appeals related to eligibility and enrollment are handled by the PEBB Program and governed by chapter

182-16 WAC.

Information on how to file an appeal is available:

• On the HCA website at hca.wa.gov/pebb-appeals.

• By contacting the PEBB Appeals Unit at 1-800-351-6827 (TRS: 711).

Where to send complaints or appeals

ALERT! Premera handles appeals for the COE Program. See the “Joint replacement surgery,

knees and hips in the Centers of Excellence (COE) Program” and “Spine care in the Centers of

Excellence (COE) Program” benefits for more information. VSP handles appeals for routine

vision benefits. See “Your routine vision benefits” for more information.

It is recommended that you call first with a complaint or appeal, since many problems may be resolved

quickly over the phone. The Directory at the beginning of this booklet includes links and contact

information to contact UMP (medical services) or WSRxS (prescription drugs) with a complaint or appeal.

When another party is responsible for injury or

illness

You may receive a letter from the plan asking if your injury or illness was the result of an accident or

might be someone else’s responsibility. To make sure claims are paid in a timely manner, it is important

that you respond as directed in the letter, even if the answer is no. If you do not, the plan may deny

coverage. You may call UMP Customer Service if you have questions.

2023 UMP Classic (PEBB) Certificate of Coverage 143

Occupational injury or illness (workers’ compensation) claims

When a claim for occupational injury or illness (workers’ compensation) is accepted by your employer’s

workers' compensation carrier, UMP will not cover any services related to that injury or illness, even if the

compensation carrier denies some services. You must file a workers’ compensation claim with your

workers’ compensation carrier. If your claim for workers’ compensation is denied because it is determined

the injury or condition is not related to an occupational injury or illness, UMP will pay for covered services

under the terms of this COC.

Legal rights and responsibilities

Coverage under the plan is not provided for medical, dental, prescription, or vision expenses you incur for

treatment of an injury or illness if the costs associated with the injury or illness may be covered by another

first party insurance or may be recoverable from any of the following:

• A third party;

• Any other source, including no fault automobile medical payments (Med-Pay), no fault automobile

personal injury protection (PIP), homeowner’s no-fault coverage, commercial premises no-fault medical

coverage, and sports policies. This includes excess, underinsured, or uninsured motorist coverage, or

similar contract or insurance, when the contract or insurance is either issued to or makes benefits

available to you, whether or not you make a claim under such coverage; or

• Services or supplies for work-related injury or illness, even when the service or supply is not a covered

workers’ compensation benefit under the workers’ compensation plan.

ALERT! You must respond to any communication sent to you about other sources of benefits,

or the plan may deny claims.

However, after expiration or exhaustion of the above benefits, if you also have a potential right of

recovery for illnesses or injuries from a third party who may have legal responsibility or from any other

source, benefits may be provided or advanced by the plan pending the resolution of a claim to the right

of recovery subject to all of the following conditions:

• By accepting or claiming benefits, you agree that the plan is entitled to reimbursement of the full

amount of benefits paid out of any settlement or recovery from any source to the extent that the

settlement or recovery exceeds full compensation to you for the injury or illness that you sustained.

This includes any arbitration award, judgment, settlement, disputed claim settlement, underinsured or

uninsured motorist payment, or any other recovery related to the injury or illness for which benefits

under the plan have been provided or advanced.

• The plan may choose to recover expenses directly from the third party (or third party’s insurer)

responsible for your injury or illness. This is called subrogation. The plan is authorized, but not

obligated, to recover any expenses, to the extent that they were paid under the plan, directly from any

party liable to you, upon mailing of a written notice to the potential payer, to you, or to your

representative.

• The plan’s rights apply without regard to the source of payment for medical expenses, whether from

the proceeds of any settlement, arbitration award, or judgment, or other characterization of the

recovery by you or any third party or the recovery source. The plan is entitled to reimbursement from

the first dollar received from any recovery to the extent that the settlement or recovery exceeds full

compensation to you for the injury or illness that you sustained. This applies regardless of whether:

144 2023 UMP Classic (PEBB) Certificate of Coverage

▪ The third party or third party’s insurer admits liability;

▪ The health care expenses are itemized or expressly excluded in the recovery; or

▪ The recovery includes any amount (in whole or in part) for services, supplies, or accommodations

covered under the plan.

• You may be required to sign and deliver all legal papers and take any other actions requested to secure

the plan’s rights (including an assignment of rights to pursue your claim if you fail to pursue your claim

of recovery from the third party or other source). If you are asked to sign a trust/reimbursement

agreement or other document to reimburse the plan from the proceeds of any recovery, you will be

required to do so as a condition to advancement of any benefits. If you or your agent or attorney fail to

comply during the course of the case, we may request refunds from the providers or offset future

benefits.

• You will not do anything to prejudice the plan’s rights and that you will cooperate fully with the plan,

including signing any documents within the required time and providing prompt notice of any

settlement or other recovery. You must notify the plan of any facts that may impact the right to

reimbursement or subrogation, including, but not necessarily limited to, the following:

▪ The filing of a lawsuit;

▪ The making of a claim against any third party;

▪ Scheduling of settlement negotiations with a minimum of 21 days advance notice of the date, time,

location and participants to be involved in any settlement conferences or mediations); or

▪ Intent of a third party to make payment of any kind to your benefit or on your behalf and that in any

manner relates to the injury or illness that gives rise to the plan’s right of reimbursement or

subrogation (notice is required a minimum of five business days before the settlement).

• You and your agent or attorney must agree to keep segregated in its own account any recovery or

payment of any kind to your benefit that in any manner relates to the injury or illness giving rise to the

plan’s right of reimbursement or subrogation, until the plan’s right is satisfied or released.

• In the event you or your agent or attorney fails to comply with any of these conditions, any such

benefits provided or advanced for any illness or injury may be recovered through legal action to the

extent that the settlement or recovery exceeds full compensation to you for the injury or illness that

you sustained.

• Any benefits provided or advanced under the plan are provided or advanced solely to assist you. By

paying such benefits, the plan is not waiving any right to reimbursement or subrogation.

Fees and expenses

You may incur attorney’s fees and costs in connection with obtaining a recovery. We may pay a

proportional share of such attorney’s fees and costs you incur at the time of any settlement or recovery to

otherwise reduce the amount of reimbursement paid to the plan to less than the full amount of benefits

paid by the plan.

Services covered by other insurance

The plan does not cover services that are covered by other insurance, including, but not limited to, no

fault automobile medical payments (Med-Pay), no fault automobile personal injury protection (PIP),

homeowner’s no-fault coverage, commercial premises no fault medical coverage, or sports policies,

including excess, underinsured or uninsured motorist coverage or similar contract or insurance. You are

responsible for any cost-sharing required under the other coverage as allowed by state law. Once you

2023 UMP Classic (PEBB) Certificate of Coverage 145

have exhausted benefits (e.g., reached the maximum medical expenses amount of the other insurance

policy (-ies), or services are no longer injury-related), the plan will cover services according to this COC.

Motor vehicle coverage

If you are involved in a motor vehicle accident, whether as a driver, passenger, pedestrian, or other

capacity, you may have rights under multiple motor vehicle insurance no fault coverages and also against

a third party who may be responsible for the accident. In that case, this right of reimbursement and

subrogation provision still applies.

Future medical expenses

Benefits for otherwise covered services may be excluded as follows:

• When you have received a recovery from another source relating to an illness or injury for services for

which we normally would provide benefits. The amount of any exclusions under this provision,

however, will not exceed the amount of your recovery.

• Until the total amount excluded under this subrogation provision equals the third-party recovery.

General provisions

UMP is administered by Regence BlueShield and Washington State Rx Services under contract with the

Washington State Health Care Authority.

What you need to know: your rights and responsibilities

To make sure UMP offers access to the best possible medical care, we must work together with you and

your providers as partners. To achieve this goal, you must know your rights and responsibilities.

As a plan member, you have the right to:

• Ask your provider to submit secondary claims to Medicare, if applicable.

• Be informed by your providers about all appropriate or medically necessary treatment options for your

condition, regardless of cost or benefit coverage.

• Be treated with respect.

• Complain about or appeal plan services or decisions, or the care you receive.

• Get a second opinion about your provider’s care recommendations.

• Have a translator’s assistance, if required, when calling the plan.

• Keep your medical records and personal information confidential as described in the UMP Notice of

Privacy Practices, available online on the HCA website at

hca.wa.gov/ump-privacy.

• Make decisions with your providers about your health care.

• Make recommendations about member rights and responsibilities.

• On request, receive information from the plan about:

▪ How new technology is evaluated for inclusion as a covered service.

▪ How the plan reimburses providers.

▪ Preauthorization review requirements.

▪ Providers you select and their qualifications.

146 2023 UMP Classic (PEBB) Certificate of Coverage

▪ Services and treatments that have completed HTCC review and how that affects coverage by UMP.

▪ Technologies and treatments currently under review by the HTCC.

▪ The plan and preferred providers.

▪ Your covered expenses, exclusions, reductions, and maximums or limits.

• Receive:

▪ A written explanation from the plan about any request to refund an overpayment.

▪ All covered services and supplies determined to be medically necessary as described in this COC,

subject to the maximums, limits, exclusions, deductibles, coinsurance, and copays.

▪ Courteous, prompt answers from the plan.

▪ Timely, proper medical care without discrimination of any kind — regardless of health status or

condition, sex, ethnicity, race, marital status, color, national origin, age, disability, or religion.

As a plan member, you have the responsibility to:

• Comply with requests for information by the date given.

• Confirm provider and facility network status before every visit.

• Contact the plan as soon as possible if you do not understand what is covered, if you have any

questions, or if you need information.

• Enroll in Medicare Part A and Part B if you are retired and you or your enrolled dependents are eligible

for Medicare Part A and Part B. You must notify the PEBB Program when you enroll in Medicare Part A

and Part B. Call 1-800-200-1004 (TRS: 711) to speak with a customer service representative for the PEBB

Program.

• Follow your providers’ instructions about your health care.

• Give your providers complete information about your health to get the best possible care.

• Keep your mailing address current by reporting changes as follows:

▪ Employees: To your payroll or benefits office.

▪ Retirees and PEBB Continuation Coverage members: To the PEBB Program. Send your address

changes to:

Health Care Authority

PEBB Program

PO Box 42684

Olympia, WA 98504

• Know how to access emergency care.

• Not engage in fraud or abuse in dealing with the plan or your providers.

• Participate with your providers in making decisions about your health care.

• Pay your copays, coinsurance, and deductibles promptly.

• Refund promptly any overpayment made to you or for you.

• Report to the plan any outside sources of health care coverage or payment.

• Return your completed Multiple Coverage Inquiry form you receive from the plan in a timely manner to

prevent delay in claims payment.

2023 UMP Classic (PEBB) Certificate of Coverage 147

• Understand how to contact the plan for more information and help with any covered service or

information described in this COC.

• Understand how UMP coverage coordinates with other insurance coverage you may have, including

Medicare.

• Understand your plan benefits, including what is covered, preauthorization and notice requirements,

and other information described in this COC.

Information available to you

We support the goal of giving you and your family the detailed information you need to make the best

possible health care decisions. See the Directory pages at the beginning of this booklet for links and

contact information.

You may find the following information in this COC:

• Benefit exclusions, reductions, and maximums or limits (see the “What the plan does not cover” section)

• Clear explanation of complaint and appeal procedures (see the “Complaint and appeal procedures”

section)

• Definition of terms (see the “Definitions” section)

• List of covered expenses (see the “List of benefits” section)

• Policies regarding prescription drug coverage and how the plan adds and removes drugs from the

UMP Preferred Drug List (see “The UMP Preferred Drug List” and the “Guidelines for prescription drugs

UMP covers” sections)

• Preventive health care benefits that are covered (see the “Preventive care” benefit and page 90)

• Process for preauthorization, notice, or review (see the “Limits on plan coverage” section and page 102)

You may find the following on the UMP website or by calling UMP Customer Service:

• Accreditation information, including measures used to report the plan’s performance, such as

consumer satisfaction survey results or Healthcare Effectiveness Data and Information Set (HEDIS)

measures

• Clinical coverage criteria applicable to health care services and supplies that require preauthorization

• Description and justification for provider compensation programs, including any incentives or penalties

intended to encourage providers to withhold services

• General reimbursement or payment arrangements between the plan and preferred providers

• Information on the plan’s care management programs

• Notice of privacy practices (includes plan policy for protecting the confidentiality of health information;

see “Confidentiality of your health information” on page 148)

• Online directory of preferred providers, including both primary care providers and specialists

• Procedures to follow for consulting with providers

• The Summary of Benefits and Coverage (SBC)

• When the plan may retroactively deny coverage for preauthorized medical services

The following are available through your Regence account or by calling UMP Customer Service:

• Medical claims history and medical deductible status

• Online directory of preferred providers, including both primary care providers and specialists

148 2023 UMP Classic (PEBB) Certificate of Coverage

The following are available on the UMP Prescription drug coverage webpage or by calling WSRxS

Customer Service:

• The UMP Preferred Drug List

• Clinical coverage criteria applicable to prescription drugs that require preauthorization (through your

online prescription drug account)

• Prescription drug claims history and prescription drug deductible status (through your online

prescription drug account)

You may also call UMP Customer Service for an annual accounting of all payments made by the plan that

have been counted against medical payment limits, day limits, visit limits, or other limits on your coverage.

The plan will provide a written summary of payments within 30 calendar days of your request. Some of

this information is also available through your Regence account.

You may call WSRxS Customer Service with questions about coverage of and limitations on prescription

drugs.

The plan does not prevent or discourage providers from telling you about the care you require, including

various treatment options and whether the provider thinks that care is consistent with the plan’s coverage

criteria. You may, at any time, get health care outside of plan coverage for any reason. However, you must

pay for those services and supplies. In addition, the plan does not prevent or discourage you from talking

about other health plans with your provider.

Confidentiality of your health information

The plan follows the UMP Notice of Privacy Practices, available online on the HCA website at

hca.wa.gov/ump-privacy or by calling UMP Customer Service. The plan will release member health

information only as described in that notice or as required or permitted by law or court order.

How to designate an authorized representative

TIP: Because of privacy laws, the plan usually cannot share information on appeals or

complaints with family or other persons unless the member is a minor, or the plan has received

written authorization to release personal health information to the other person.

In most cases, the plan must have written authorization to communicate with anyone but the member.

However, a parent or legal guardian may act as a representative for a member under age 13 without

written authorization, except for issues involving contraceptive use. For members ages 13 to 17, a parent

or legal guardian may usually act as a representative, except for certain specially protected types of

information, for which the plan must receive written authorization as described below.

You may choose to authorize a representative to:

• Communicate with the plan on your behalf regarding an appeal in process.

• Share your protected health information.

• Talk to the plan about claims or services.

To authorize release of protected health information, you must complete an Authorization to Disclose

Protected Health Information form. The forms for medical and prescription drug appeals are different. To

get the forms, follow the instructions below:

• Medical benefits: Call UMP Customer Service or use your Regence account (see Directory for link and

contact information).

2023 UMP Classic (PEBB) Certificate of Coverage 149

• Prescription drug benefits: Call WSRxS Customer Service or download the UMP (WSRxS) Prescription

drug complaints and appeals form by visiting forms and publications at

hca.wa.gov/ump-forms-pubs.

Send the form to the address on the form. UMP cannot share information until we receive the completed

form. On the form, you must specify:

• What information may be disclosed;

• The purpose of the disclosure (e.g., receiving an outcome of an appeal); and

• Who is designated to receive or release the information.

Release of information

The plan or Washington State Health Care Authority may require you to give information when needed to

determine eligibility, administer benefits, or process claims. This could include medical and other records.

The plan could deny coverage if you do not provide the information when requested.

Relationship to Blue Cross and Blue Shield Association

HCA, on behalf of itself and its members, hereby expressly acknowledges that this contract constitutes an

agreement solely between HCA and Regence BlueShield, an independent corporation operating under a

license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and

Blue Shield plans (the “Association”), permitting the contractor Regence BlueShield to use the Washington

license for those counties designated in its service area.

Right to receive and release needed information

Regence BlueShield may need certain facts about your health care coverage or services provided to

process your claims correctly. Regence may get these facts from or give them to other organizations or

persons without your consent. You must give Regence any facts necessary for processing of claims to get

benefits under this plan. See page 148 for more information about the confidentiality of your health

information.

Right of recovery

The plan has the right to a refund of incorrect payments. The plan may recover excess payment from any:

• Person that received an excess payment.

• Person on whose behalf an excess payment was made.

• Other issuers of payment.

• Other plans involved.

Limitations on liability

In all cases, you have the exclusive right to choose a health care provider. Since neither UMP nor Regence

BlueShield provides any health care services, neither may be held liable for any claim or damages

connected with injuries you may suffer while receiving health services or supplies provided by

professionals who are neither employees nor agents of either UMP or Regence BlueShield. Neither

Regence BlueShield nor UMP is responsible for the quality of health care you receive, except as provided

by law.

In addition, UMP will not be liable to any person or entity for the inability or failure to procure or provide

the benefits of the plan by reason of epidemic, disaster, or other cause or condition beyond UMP’s

control.

150 2023 UMP Classic (PEBB) Certificate of Coverage

Governing law

The plan is governed by and construed in accordance with the laws of the United States of America and

by applicable laws of Washington State without regard to its conflict of law rules.

Anti-assignment

Members may not assign this COC, or any rights, interests or obligations contained in this COC, in whole

or in part, to a third party (including, but not limited to, providers of medical services), without the plan’s

written consent. Any attempt to assign any rights, interests or obligations contained in this COC, in whole

or in part, to a third party is void and/or invalid, and the plan will not recognize it.

No waiver

The failure or refusal of either party to demand strict performance of the plan or to enforce any provision

will not act as or be construed as a waiver of that party’s right to later demand its performance or to

enforce that provision. No provision of the plan will be considered waived unless such waiver is in writing

and signed by one of the Washington State Health Care Authority’s authorized officers.

2023 UMP Classic (PEBB) Certificate of Coverage 151

Acronyms

ABA – Applied Behavior Analysis [Therapy]

ACP – Accountable Care Program

ASC – Ambulatory surgery center

CDC – Centers for Disease Control and

Prevention

CDHP – Consumer-directed health plan

CHIP – Children’s Health Insurance Program

CMS – Centers for Medicare and Medicaid

Services

COB – Coordination of benefits

COBRA – Consolidated Omnibus Budget

Reconciliation Act

COC – Certificate of coverage

COE – Centers of Excellence Program

DME – Durable medical equipment

DPP – Diabetes Prevention Program

EOB – Explanation of benefits

EOMB – Explanation of Medicare benefits

ER – Emergency room

ERB – Employee and Retiree Benefits [Division]

FDA – Food and Drug Administration

FMLA – Family Medical Leave Act

FSA – Flexible spending arrangement

HCA – Health Care Authority

HDHP – High-deductible health plan

HIPAA – Health Insurance Portability and

Accountability Act

HRA – Health reimbursement arrangement

HRSA – Health Resources and Services

Administration

HSA – Health savings account

HTCC – Health Technology Clinical Committee

IRC – Internal Revenue Code

IRO – Independent review organization

IRS – Internal Revenue Service

MSN – Medicare Summary Notice

NMSN – National Medical Support Notice

P – Preventive

P&T – Pharmacy and Therapeutics Committee

PCP – Primary care provider

PEBB – Public Employees Benefits Board

PFML – Paid Family and Medical Leave

PPACA – Patient Protection and Affordable Care

Act

PPO – Preferred Provider Organization

PPS – Postal Prescription Services

RCW – Revised Code of Washington

REMS – Risk Evaluation and Mitigation Strategies

SBC – Summary of Benefits and Coverage

SEBB – School Employees Benefits Board

TMJ – Temporomandibular joint

TRS – Telecommunications Relay Service

UMP – Uniform Medical Plan

V – Value tier

WAC – Washington Administrative Code

WSRxS – Washington State Rx (prescription

drug) Services

152 2023 UMP Classic (PEBB) Certificate of Coverage

Eligibility and enrollment

In these sections, “health plan” is used to refer to a plan offering medical or dental, or both, developed by

the Public Employees Benefits Board (PEBB) and provided by a contracted vendor or self-insured plans

administered by the Health Care Authority (HCA).

Eligibility for subscribers and dependents

Employee eligibility

The employee’s state agency will inform the employee in writing whether or not they are eligible for PEBB

benefits upon employment and whenever their eligibility status changes. The written notice will include

information about the employee’s right to appeal eligibility and enrollment decisions.

An employee of an employer group (such as a county, city, port, water district, etc.) that contracts with

HCA for PEBB benefits should contact their payroll or benefits office for eligibility criteria.

Employees have the right to appeal eligibility and enrollment decisions. Information about appeals can be

found under “Appeal rights.”

Continuation coverage eligibility

The PEBB Program determines whether subscribers are eligible for continuation coverage (COBRA or

Unpaid Leave) upon receipt of a PEBB Continuation Coverage (COBRA) Election/Change or PEBB

Continuation Coverage (Unpaid Leave) Election/Change form. If the subscriber requests to enroll in and is

not eligible for continuation coverage, the PEBB Program will notify them of their right to appeal.

Information about appeals can be found under “Appeal rights.”

Dependent eligibility

The following are eligible dependents:

• Legal spouse

• State-registered domestic partner and substantially equivalent legal unions from jurisdictions as

defined in Washington State statute. Individuals in a state-registered domestic partnership are treated

the same as a legal spouse except when in conflict with federal law.

• Children, through the last day of the month in which their 26th birthday occurred regardless of marital

status, student status, or eligibility for coverage under another plan. It also includes children age 26 or

older with a disability as described below in “Children of any age with a developmental or physical

disability.” Children are defined as the subscriber’s:

▪ Children based on establishment of a parent-child relationship, as described in Washington

State statutes, except when parental rights have been terminated.

▪ Children of the subscriber’s spouse, based on the spouse’s establishment of a parent-child

relationship, except when parental rights have been terminated. The stepchild’s relationship to the

subscriber (and eligibility as a dependent) ends on the same date the marriage with the spouse ends

through divorce, annulment, dissolution, termination, or death.

▪ Children for whom the subscriber has assumed a legal obligation for total or partial support in

anticipation of adoption of the child.

▪ Children of the subscriber’s state-registered domestic partner, based on the state-registered

domestic partner’s establishment of a parent-child relationship, except when parental rights have

been terminated. The child’s relationship to the subscriber (and eligibility as a dependent) ends on

2023 UMP Classic (PEBB) Certificate of Coverage 153

the same date the subscriber’s legal relationship with the state-registered domestic partner ends

through divorce, annulment, dissolution, termination, or death.

▪ Children specified in a court order or divorce decree for whom the subscriber has a legal

obligation to provide support or health care coverage.

▪ Extended dependents in the legal custody or legal guardianship of the subscriber, the

subscriber’s spouse, or the subscriber’s state-registered domestic partner. The legal

responsibility is demonstrated by a valid court order and the child’s official residence with the

custodian or guardian. Extended dependent child does not include foster children unless the

subscriber, the subscriber’s spouse, or the subscriber’s state-registered domestic partner has

assumed a legal obligation for total or partial support in anticipation of adoption.

▪ Children of any age with a developmental or physical disability that renders them incapable of

self-sustaining employment and chiefly dependent upon the subscriber for support and

maintenance, provided such condition occurs before the age of 26. The following requirements

apply to a dependent child with a disability:

◦ The subscriber must provide proof of the disability and dependency within 60 days of the child’s

attainment of age 26.

◦ The subscriber must notify the PEBB Program in writing when the child is no longer eligible under

this subsection.

◦ A child with a developmental or physical disability who becomes self-supporting is not eligible as

of the last day of the month in which they become capable of self-support.

◦ A child with a developmental or physical disability age 26 and older who becomes capable of self-

support does not regain eligibility if they later become incapable of self-support.

◦ The PEBB Program, with input from the medical plan, will periodically verify the eligibility of a

dependent child with a disability beginning at age 26, but no more frequently than annually after

the two-year period following the child’s 26th birthday. Verification will require renewed proof of

disability and dependence from the subscriber.

Enrollment for subscribers and dependents

For all subscribers and dependents

• To enroll at any time other than during the initial enrollment period, see “Making changes.”

• Any dependents enrolled in medical coverage will be enrolled in the same medical plan as the

subscriber.

Employee enrollment

An employee must submit a PEBB Employee Enrollment/Change or PEBB Employee Enrollment/Change (for

Medical Only Groups) form and any supporting documents to their employing agency when they become

newly eligible or regain eligibility for PEBB benefits. The forms must be received by their employing

agency no later than 31 days after the date the employee becomes eligible or regains eligibility.

If the employee does not return the form by the deadline, the employee will be enrolled in Uniform

Medical Plan Classic and a tobacco use premium surcharge will be incurred. Consequently, dependents

cannot be enrolled until the PEBB Program’s next annual open enrollment or when a qualifying event

occurs that creates a special open enrollment for enrolling a dependent.

154 2023 UMP Classic (PEBB) Certificate of Coverage

Waiving medical enrollment

An eligible employee may waive enrollment in PEBB medical only if they are enrolled in other employer-

based group medical, a TRICARE plan, or Medicare. They may not waive enrollment in PEBB medical if

they are enrolled in PEBB retiree insurance coverage. When a retiree becomes eligible for the employer

contribution toward PEBB benefits, PEBB retiree insurance coverage will be automatically deferred.

If an employee waives enrollment in PEBB medical, the employee cannot enroll eligible dependents. For

information on when an eligible employee may waive medical plan enrollment after their initial

enrollment period, or to enroll after having waived, see “Making changes.”

Continuation coverage enrollment

A subscriber enrolling in PEBB Continuation Coverage (COBRA or Unpaid Leave) may enroll by submitting

the applicable PEBB Continuation Coverage Election/Change form and any supporting documents to the

PEBB Program. The PEBB Program must receive the election form no later than 60 days from the date the

enrollee’s PEBB health plan coverage ended or from the postmark date on the PEBB Continuation

Coverage Election Notice sent by the PEBB Program, whichever is later.

Premiums and applicable premium surcharges associated with continuing PEBB medical must be made

directly to HCA. The first premium payment and applicable premium surcharges are due to HCA no later

than 45 days after the election period ends as described above. For more information, see “Options for

continuing PEBB medical coverage” and the PEBB Continuation Coverage Election Notice.

Dependent enrollment

To enroll an eligible dependent, the subscriber must include the dependent’s information on the

applicable enrollment form and provide the required document(s) as proof of the dependent’s eligibility.

The dependent will not be enrolled in PEBB health plan coverage if the PEBB Program or the employing

agency is unable to verify their eligibility within the PEBB Program enrollment timelines.

National Medical Support Notice (NMSN)

When a National Medical Support Notice (NMSN) requires a subscriber to provide health plan coverage

for a dependent child, the following provisions apply:

The subscriber may enroll their dependent child and request changes to their health plan coverage as

described under “Changes to health plan coverage or enrollment are allowed as directed by the NMSN,”

below.

• An employee submits the required form(s) to their employing agency.

• A continuation coverage subscriber submits the required form(s) to the PEBB Program.

If the subscriber fails to request enrollment or health plan coverage changes as directed by the NMSN, the

employing agency or the PEBB Program may make enrollment or health plan coverage changes according

to “Changes to health plan coverage or enrollment are allowed as directed by the NMSN,” below, upon

request of:

• The child’s other parent.

• A child support enforcement program.

Changes to health plan coverage or enrollment are allowed as directed by the NMSN:

A. The dependent will be enrolled under the subscriber’s health plan coverage as directed by the NMSN.

B. An employee who has waived PEBB medical will be enrolled in medical as directed by the NMSN, in

order to enroll the dependent.

C. The subscriber’s selected health plans will be changed if directed by the NMSN.

2023 UMP Classic (PEBB) Certificate of Coverage 155

D. If the dependent is already enrolled under another PEBB subscriber, the dependent will be removed

from the other health plan coverage and enrolled as directed by the NMSN.

E. If the dependent is enrolled in both PEBB medical and School Employee Benefits Board (SEBB)

medical as a dependent and there is an NMSN in place, enrollment will be in accordance with the

NMSN.

F. If the subscriber is eligible for and elects Consolidated Omnibus Budget Reconciliation Act (COBRA)

coverage or other continuation coverage, the NMSN will be enforced and the dependent must be

covered in accordance with the NMSN.

Changes to health plan coverage or enrollment as described above in A through C will begin the first day

of the month following receipt of the NMSN. If the NMSN is received on the first day of the month, the

change to health plan coverage or enrollment begins on that day.

A dependent will be removed from the subscriber’s health plan coverage as described above in D the last

day of the month the NMSN is received. If that day is the first of the month, the change in enrollment will

be made the last day of the previous month.

When a NMSN requires a subscriber’s spouse, former spouse, or other individual to provide health plan

coverage for a dependent who is already enrolled in the subscriber’s PEBB coverage, and that health plan

coverage is in fact provided, the dependent may be removed from the subscriber’s PEBB health plan

coverage prospectively.

Dual enrollment

A subscriber and their dependents may each be enrolled in only one PEBB medical plan.

An employee or their dependent who is eligible to enroll in both the PEBB Program and the School

Employees Benefits Board (SEBB) Program is limited to a single enrollment in either the PEBB or SEBB

Program.

For example:

• A child who is an eligible dependent under two parents enrolled in PEBB Program benefits may be

enrolled as a dependent under both parents but is limited to a single enrollment in PEBB medical.

• A child who is an eligible dependent of an employee in the PEBB Program and a school employee in

the SEBB Program may only be enrolled as a dependent under one parent in either the PEBB or SEBB

Program.

Medicare eligibility and enrollment

Employee and dependent

If an employee or their dependent becomes eligible for Medicare, they should contact the Social Security

Administration to ask about the advantages of immediate or deferred Medicare enrollment.

An employee or their dependent are deemed eligible for Medicare when they have the option to receive

Medicare Part A benefits. If an employee or their dependent chooses to enroll in Medicare Part A,

Medicare regulations and guidelines will determine whether Medicare is the primary or secondary payer.

An employee or their dependent who is enrolled in Medicare may remain enrolled in PEBB medical

coverage. However, an employee may choose to waive their PEBB medical coverage or remove their

dependent from their PEBB medical coverage and choose Medicare as their primary insurer. If an

employee does so, neither the employee nor their dependent can enroll in PEBB medical except during

the annual open enrollment or a special open enrollment.

156 2023 UMP Classic (PEBB) Certificate of Coverage

In most situations, an employee and their dependent can defer Medicare Part B enrollment without a

penalty while enrolled in PEBB medical coverage. When the employee terminates employment, the

employee and the dependent can enroll in Medicare Part B during a Special Enrollment Period. If

Medicare eligibility is due to a disability, the employee or their dependent must contact the Social

Security Administration about deferring enrollment in Medicare Part B.

Upon retirement, Medicare will become the primary insurance payer, and the PEBB medical plan will

become secondary. See “PEBB retiree insurance coverage.”

Continuation coverage subscriber and dependent

If a continuation coverage subscriber or their dependent becomes eligible for Medicare, federal

regulations allow enrollment in Medicare three months before they turn age 65. If they do not enroll

within three months before the month they turn age 65, enrollment in Medicare may be delayed. If

enrollment in Medicare does not occur when the subscriber or their dependent is first eligible, a late

enrollment penalty may apply.

When medical coverage begins

Employees and dependents

For a newly eligible employee and their eligible dependents, medical coverage begins the first day of

the month following the date the employee becomes eligible. If the employee becomes eligible on the

first working day of the month, then coverage begins on that date.

If the eligible employee is a faculty member hired on a quarter-to-quarter or semester-to-semester basis,

medical coverage begins the first day of the month following the beginning of the second consecutive

quarter or semester. If the first day of the second consecutive quarter or semester is the first working day

of the month, medical coverage begins on that day.

For an employee regaining eligibility following a period of leave or after being between periods of

leave as described in PEBB Program rules, and their eligible dependents, medical coverage begins the first

day of the month the employee is in pay status eight or more hours. If the employee is a faculty member

regaining eligibility no later than the 12th

month after the month in which they lost eligibility for the

employer contribution toward PEBB benefits, medical coverage begins the first day of the month in which

the quarter or semester begins.

Note: When an employee who is called to active duty in the uniformed services under the Uniformed

Services Employment and Reemployment Rights Act (USERRA) loses eligibility for the employer

contribution toward PEBB benefits, they regain eligibility for the employer contribution toward PEBB

benefits the day they return from active duty. Medical coverage begins the first day of the month in which

the employee returns from active duty.

Continuation coverage subscriber and dependents

For a continuation coverage subscriber and their eligible dependents enrolling when newly eligible due

to a qualifying event, medical coverage begins the first day of the month following the day they lost

eligibility for PEBB medical plan coverage.

All subscribers and dependents

For a subscriber or their eligible dependents enrolling during the PEBB Program’s annual open

enrollment, medical coverage begins January 1 of the following year.

For a subscriber or their eligible dependents enrolling during a special open enrollment, medical

coverage begins the first day of the month following the later of the event date or the date the required

form is received. If that day is the first of the month, medical coverage begins on that day.

2023 UMP Classic (PEBB) Certificate of Coverage 157

If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has

assumed a legal obligation for total or partial support in anticipation of adoption of a child, medical

coverage will begin as follows:

• For an employee, medical coverage will begin the first day of the month in which the event occurs.

• For a newly born child, medical coverage will begin the date of birth.

• For a newly adopted child, medical coverage will begin on the date of placement or the date a legal

obligation is assumed in anticipation of adoption, whichever is earlier.

• For a spouse or state-registered domestic partner of a subscriber, medical coverage will begin the

first day of the month in which the event occurs.

If the special open enrollment is due to the enrollment of an extended dependent or a dependent child

with a disability, medical coverage will begin the first day of the month following the event date or

eligibility certification, whichever is later.

Making changes

Removing a dependent who is no longer eligible

A subscriber must provide notice to remove a dependent who is no longer eligible due to divorce,

annulment, dissolution, or a qualifying event of a dependent ceasing to be eligible as a dependent child

as described under “Dependent eligibility.” The notice must be received within 60 days of the last day of

the month the dependent no longer meets the eligibility criteria.

• An employee must notify their employing agency.

• A continuation coverage subscriber must notify the PEBB Program.

Consequences for not submitting notice within the required 60 days may include, but are not limited to:

• The dependent may lose eligibility to continue PEBB medical coverage under one of the continuation

coverage options described in “Options for continuing PEBB medical coverage.”

• The subscriber may be billed for claims paid by the medical plan for services that were rendered after

the dependent lost eligibility.

• The subscriber may not be able to recover subscriber-paid insurance premiums for the dependent that

lost eligibility.

• The subscriber may be responsible for premiums paid by the state for the dependent’s medical plan

coverage after the dependent lost eligibility.

Voluntary termination for continuation coverage subscribers

A continuation coverage subscriber may voluntarily terminate enrollment in a medical plan at any time by

submitting a request in writing to the PEBB Program. Enrollment in the medical plan will be terminated

the last day of the month in which the PEBB Program receives the request or on the last day of the month

specified in the termination request, whichever is later. If the request is received on the first day of the

month, medical plan enrollment will be terminated on the last day of the previous month.

Making changes during annual open enrollment and special

open enrollment

A subscriber may make certain changes to their enrollment during the annual open enrollment and if a

specific life event creates a special open enrollment period.

158 2023 UMP Classic (PEBB) Certificate of Coverage

Annual open enrollment changes

An employee may make the following changes to their enrollment during the PEBB Program’s annual

open enrollment period:

• Change their medical plan

• Waive their medical plan enrollment

• Enroll after waiving medical plan enrollment

• Enroll or remove eligible dependents

An employee must submit the election change online in PEBB My Account or submit the required PEBB

Employee Enrollment/Change form and any supporting documents to their employing agency. The change

must be completed in PEBB My Account or the forms received no later than the last day of the annual

open enrollment period and will be effective January 1 of the following year.

A continuation coverage subscriber may make the following changes to their enrollment during the

PEBB Program’s annual open enrollment period:

• Enroll in or terminate enrollment in a medical plan

• Change their medical plan

• Enroll or remove eligible dependents

A continuation coverage subscriber must submit the election change online in PEBB My Account or

return the required PEBB Continuation Coverage (COBRA) Election/Change, or PEBB Continuation Coverage

(Unpaid Leave) Election/Change form (as appropriate) and any supporting documents to the PEBB

Program. The change must be completed in PEBB My Account or the forms received no later than the last

day of the annual open enrollment period and will be effective January 1 of the following year.

Special open enrollment changes

A subscriber may change their enrollment outside of the annual open enrollment period if a qualifying

event creates a special open enrollment period. However, the change in enrollment must be allowable

under Internal Revenue Code (IRC) and Treasury Regulations and correspond to and be consistent with

the event that creates the special open enrollment for the subscriber, their dependent, or both.

A special open enrollment event must be other than an employee gaining initial eligibility or regaining

eligibility for PEBB benefits. The subscriber must provide evidence of the event that created the special

open enrollment.

A special open enrollment may allow a subscriber to make the following changes:

• Enroll in or change their medical plan

• Waive their medical plan enrollment

• Enroll after waiving medical plan enrollment

• Enroll or remove eligible dependents

To request a special open enrollment:

• An employee must submit the required PEBB Employee Enrollment/Change form and any supporting

documents to their employing agency.

• A continuation coverage subscriber must submit the required PEBB Continuation Coverage (COBRA)

Election/Change, or PEBB Continuation Coverage (Unpaid Leave) Election/Change form (as appropriate)

and any supporting documents to the PEBB Program.

2023 UMP Classic (PEBB) Certificate of Coverage 159

The forms must be received no later than 60 days after the event that creates the special open enrollment.

In addition, the PEBB Program or the employing agency will require the subscriber to provide proof of a

dependent’s eligibility, evidence of the event that created the special open enrollment, or both.

Exceptions:

• A continuation coverage subscriber has six months from the date of their or their dependent’s

enrollment in Medicare Part B to change their enrollment to a PEBB Medicare Supplement Plan. The

PEBB Program must receive the required form(s) no later than six months after the enrollment in

Medicare Part B for either the subscriber or their dependent.

• When a continuation coverage subscriber or their dependent is enrolled in a Medicare Advantage or

Medicare Advantage-Prescription Drug plan, they may disenroll during a special enrollment period as

allowed under federal regulations.

• A continuation coverage subscriber has seven months to enroll in a Medicare Advantage or Medicare

Advantage-Prescription Drug plan that begins three months before they or their dependent first

enrolled in both Medicare Part A and Part B and ends three months after the month of Medicare

eligibility. They may also enroll themselves or their dependent in a Medicare Advantage or Medicare

Advantage-Prescription Drug plan before their last day of the Medicare Part B initial enrollment period.

The forms must be received by the PEBB Program no later than the last day of the month prior to the

month the continuation coverage subscriber or their dependent enrolls in the Medicare Advantage or

Medicare Advantage-Prescription Drug plan.

• If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a

legal obligation for total or partial support in anticipation of adoption in PEBB health plan coverage,

the subscriber should notify their employing agency or the PEBB Program by submitting the required

forms as soon as possible to ensure timely payment of claims. If adding the child increases the

premium, the required forms must be received no later than 60 days after the date of the birth,

adoption, or the date the legal obligation is assumed for total or partial support in anticipation of

adoption.

Special open enrollment events that allow for a change in health plans

A subscriber may not change their health plan if their state-registered domestic partner or state-

registered domestic partner’s child is not a tax dependent.

Any of the following events may create a special open enrollment:

• Subscriber gains a new dependent due to:

▪ Marriage or registering a state-registered domestic partnership.

▪ Birth, adoption, or assuming a legal obligation for total or partial support in anticipation of adoption.

▪ A child becoming eligible as an extended dependent through legal custody or legal guardianship.

• Subscriber or their dependent loses other coverage under a group health plan or through health

insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA).

• Subscriber has a change in employment status that affects their eligibility for the employer contribution

toward their employer-based group health plan.

• Subscriber’s dependent has a change in their own employment status that affects their eligibility or

their dependent’s eligibility for the employer contribution under their employer-based group health

plan. “Employer contribution” means contributions made by the dependent’s current or former

employer toward health coverage as described in the Treasury Regulation.

• Subscriber or their dependent has a change in residence that affects health plan availability. If the

subscriber moves and their current health plan is not available in the new location, the subscriber must

160 2023 UMP Classic (PEBB) Certificate of Coverage

select a new health plan, otherwise there will be limited accessibility to network providers and covered

services.

• A court order requires the subscriber or any other individual to provide insurance coverage for an

eligible dependent of the subscriber (a former spouse or former state-registered domestic partner is

not an eligible dependent).

• Subscriber or their dependent enrolls in coverage under Medicaid or a state Children’s Health

Insurance Program (CHIP), or the subscriber or their dependent loses eligibility for coverage under

Medicaid or CHIP.

• Subscriber or their dependent becomes eligible for state premium assistance subsidy for PEBB health

plan coverage from Medicaid or CHIP.

• Subscriber or their dependent enrolls in coverage under Medicare, or the subscriber or their dependent

loses eligibility for coverage under Medicare or enrolls in or terminates enrollment in a Medicare

Advantage-Prescription Drug or a Part D plan. If the subscriber’s current medical plan becomes

unavailable due to the subscriber or their dependents enrollment in Medicare, the subscriber must

select a new medical plan.

• Subscriber or their dependent’s current medical plan becomes unavailable because the subscriber or

enrolled dependent is no longer eligible for a health savings account (HSA).

• Subscriber or their dependent experiences a disruption of care for active and ongoing treatment that

could function as a reduction in benefits for the subscriber or their dependent. The subscriber may not

change their health plan election because the subscriber or dependent’s physician stops participation

with the subscriber’s health plan unless the PEBB Program determines that a continuity of care issue

exists. The PEBB Program will consider but not limit its consideration to the following:

▪ Active cancer treatment, such as chemotherapy or radiation therapy

▪ Treatment following a recent organ transplant

▪ A scheduled surgery

▪ Recent major surgery still within the postoperative period

▪ Treatment for a high-risk pregnancy

Note: The plan cannot guarantee that any physician, hospital, or other provider will be available or remain

under contract with the plan. An enrollee may not change medical plans simply because their provider or

health care facility discontinues participation with this medical plan until the PEBB Program’s next annual

open enrollment or when another qualifying event creates a special open enrollment for changing health

plans, unless the PEBB Program determines that a continuity of care issue exists.

Special open enrollment events that allow adding or removing a dependent

Any of the following events may create a special open enrollment:

• Subscriber gains a new dependent due to:

▪ Marriage or registering a state-registered domestic partnership.

▪ Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in

anticipation of adoption.

▪ A child becoming eligible as an extended dependent through legal custody or legal guardianship.

• Subscriber or their dependent loses other coverage under a group health plan or through health

insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA).

2023 UMP Classic (PEBB) Certificate of Coverage 161

• Subscriber has a change in employment status that affects their eligibility for the employer contribution

toward their employer-based group health plan.

• Subscriber’s dependent has a change in their own employment status that affects their eligibility or

their dependent’s eligibility for the employer contribution under their employer-based group health

plan. “Employer contribution” means contributions made by the dependent’s current or former

employer toward health coverage as described in the Treasury Regulation.

• Subscriber or their dependent has a change in enrollment under an employer-based group health plan

during its annual open enrollment that does not align with the PEBB Program’s annual open

enrollment.

• Subscriber’s dependent has a change in residence from outside of the United States to within the

United States, or from within the United States to outside of the United States and that change in

residence resulted in the dependent losing their health insurance.

• A court order requires the subscriber or any other individual to provide insurance coverage for an

eligible dependent of the subscriber (a former spouse or former state-registered domestic partner is

not an eligible dependent).

• Subscriber or their dependent enrolls in coverage under Medicaid or a state Children’s Health

Insurance Program (CHIP), or the subscriber or their dependent loses eligibility for coverage under

Medicaid or CHIP.

• Subscriber or their dependent becomes eligible for a state premium assistance subsidy for PEBB health

plan coverage from Medicaid or CHIP.

• Subscriber’s dependent enrolls in Medicare or loses eligibility for Medicare.

Special open enrollment events that allow waiving medical enrollment and

enrolling after waiving

An employee may waive PEBB medical during a special open enrollment only if they are enrolled in other

employer-based group medical, a TRICARE plan, or Medicare. An employee may not waive enrollment in

PEBB medical if they are enrolled in PEBB retiree insurance coverage.

Any of the following events may create a special open enrollment:

• Employee gains a new dependent due to:

▪ Marriage or registering a state-registered domestic partnership.

▪ Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in

anticipation of adoption.

▪ A child becoming eligible as an extended dependent through legal custody or legal guardianship.

• Employee or their dependent loses other coverage under a group health plan or through health

insurance coverage, as defined by the HIPAA.

• Employee has a change in employment status that affects their eligibility for the employer contribution

toward their employer-based group medical.

• Employee’s dependent has a change in their own employment status that affects their eligibility or their

dependent’s eligibility for the employer contribution under their employer-based group medical.

“Employer contribution” means contributions made by the dependent’s current or former employer

toward health coverage as described in the Treasury Regulation.

162 2023 UMP Classic (PEBB) Certificate of Coverage

• Employee or their dependent has a change in enrollment under an employer-based group medical plan

during its annual open enrollment that does not align with the PEBB Program’s annual open

enrollment.

• Employee’s dependent has a change in residence from outside of the United States to within the

United States, or from within the United States to outside of the United States and the change in

residence resulted in the dependent losing their health insurance.

• A court order requires the employee or any other individual to provide a health plan for an eligible

dependent of the employee (a former spouse or former state-registered domestic partner is not an

eligible dependent).

• Employee or their dependent enrolls in coverage under Medicaid or a state Children’s Health Insurance

Program (CHIP), or the employee or their dependent loses eligibility for coverage under Medicaid or

CHIP. Note: An employee may only return from having waived PEBB medical for the events described

in this paragraph. An employee may not waive their PEBB medical for the events described in this

paragraph.

• Employee or their dependent becomes eligible for a state premium assistance subsidy for PEBB health

plan coverage from Medicaid or CHIP.

• Employee or their dependent becomes eligible and enrolls in a TRICARE plan, or loses eligibility for a

TRICARE plan.

• Employee becomes eligible and enrolls in Medicare or loses eligibility for Medicare.

When medical coverage ends

Termination dates

Medical coverage ends on the following dates:

• On the last day of the month when any enrollee ceases to be eligible.

• On the date a medical plan terminates due to a change in contracted service area or when the group

policy ends. If that should occur, the subscriber will have the opportunity to enroll in another PEBB

medical plan.

• For an employee and their dependents, on the last day of the month the employment relationship is

terminated. The employment relationship is considered terminated:

▪ On the date specified in an employee’s letter of resignation.

▪ On the date specified in any contract or hire letter.

▪ On the effective date of an employer-initiated termination notice.

Note: If the employing agency deducted the employee’s premium for PEBB insurance coverage after the

employee was no longer eligible for the employer contribution, medical coverage ends the last day of the

month for which employee premiums were deducted.

• For a continuation coverage subscriber who submits a written request to terminate medical coverage,

enrollment in medical coverage will be terminated the last day of the month in which the PEBB

Program receives the request or on the last day of the month specified in the termination request,

whichever is later. If the request is received on the first day of the month, medical coverage will be

terminated on the last day of the previous month.

A subscriber will be responsible for payment of any services received after the date medical coverage

ends as described above.

2023 UMP Classic (PEBB) Certificate of Coverage 163

Final premium payments

Premium payments and applicable premium surcharges are not prorated during any month, for any

reason, even if an enrollee dies or asks to terminate their medical plan before the end of the month.

If the monthly premium or applicable premium surcharges remain unpaid for 30 days the account will be

considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly

premiums or applicable premium surcharges become delinquent to pay the unpaid premium balance and

applicable premium surcharges. If the subscriber’s premium balance or applicable premium surcharges

remain unpaid for 60 days from the original due date, the subscriber’s medical coverage (including

enrolled dependents) will be terminated retroactive to the last day of the month for which the monthly

premiums and any applicable premium surcharges were paid.

For a subscriber enrolled in a Medicare Advantage or a Medicare Advantage-Prescription Drug plan, a

notice will be sent notifying them that they are delinquent on their monthly premium and that the

enrollment will be terminated prospectively to the end of the month after the notice is sent.

If an enrollee is hospitalized

An enrollee who is receiving covered services in a hospital on the date medical coverage ends will

continue to be eligible for covered services while an inpatient for the condition which the enrollee was

hospitalized, until one of the following events occur:

• According to this plan’s clinical criteria, it is no longer medically necessary for the enrollee to be an

inpatient at the facility.

• The remaining benefits available for the hospitalization are exhausted, regardless of whether a new

calendar year begins.

• The enrollee becomes covered under another agreement with a group health plan that provides

benefits for the hospitalization.

• The enrollee becomes enrolled under an agreement with another carrier that provides benefits for the

hospitalization.

This provision will not apply if the enrollee is covered under another agreement that provides benefits for

the hospitalization at the time medical coverage ends, except as set forth in this section, or if the enrollee

is eligible for PEBB Continuation Coverage as described in “Options for continuing PEBB medical

coverage.”

Options for continuing PEBB medical coverage

When medical coverage ends, the subscriber and their dependents covered by this medical plan may be

eligible to continue PEBB medical coverage during temporary or permanent loss of eligibility.

There are three options the subscriber and their dependents may qualify for when coverage ends.

• PEBB Continuation Coverage (COBRA)

• PEBB Continuation Coverage (Unpaid Leave)

• PEBB retiree insurance coverage

A subscriber also has the right to convert to individual medical insurance coverage with the plan when

continuation of group medical insurance coverage is no longer possible.

PEBB Continuation Coverage

The PEBB Program administers the following continuation coverage options to temporarily extend group

insurance coverage when the enrollee’s PEBB medical plan coverage ends due to a qualifying event:

164 2023 UMP Classic (PEBB) Certificate of Coverage

• PEBB Continuation Coverage (COBRA) includes eligibility and administrative requirements under

federal COBRA laws and regulations. Some enrollees who are not qualified beneficiaries under federal

COBRA, may also qualify for PEBB Continuation Coverage (COBRA).

• PEBB Continuation Coverage (Unpaid Leave) is an option created by the PEBB Program with wider

eligibility criteria and qualifying event types than COBRA.

An enrollee who qualifies for both types of PEBB Continuation Coverage (COBRA and Unpaid Leave) may

enroll in only one of these options. See “Continuation coverage enrollment” and the PEBB Continuation

Coverage Election Notice.

Premium payments for PEBB Continuation Coverage

If a subscriber enrolls in continuation coverage, the subscriber is responsible for timely payment of

premiums and applicable premium surcharges.

PEBB retiree insurance coverage

The following are eligible to continue enrollment or defer enrollment in PEBB retiree insurance coverage if

they meet procedural and substantive eligibility requirements:

• Retiring employee

• Retiring school employee

• Eligible elected or full-time appointed official of the legislative or executive branch of state government

leaving public office

• Dependent becoming eligible as a survivor

• Retiree or survivor enrolled in PEBB retiree insurance coverage

For details, see the PEBB Retiree Enrollment Guide.

Family and Medical Leave Act of 1993

An employee on approved leave under the federal Family and Medical Leave Act (FMLA) may continue to

receive the employer contribution toward PEBB benefits in accordance with the federal FMLA.

The employing agency determines if the employee is eligible for leave and the duration of the leave under

FMLA. The employee must continue to pay their monthly premium contribution and applicable premium

surcharges during this period to maintain eligibility.

If an employee exhausts the period of leave approved under FMLA, they may continue PEBB insurance

coverage by self-paying the monthly premium and applicable premium surcharges set by HCA, with no

contribution from the employing agency. See “Options for continuing PEBB medical coverage.”

Paid Family and Medical Leave Act

An employee on approved leave under the Washington State Paid Family and Medical Leave (PFML)

Program may continue to receive the employer contribution toward PEBB benefits. The Employment

Security Department determines if the employee is eligible for leave under PFML. The employee must

continue to pay their monthly premium contribution and applicable premium surcharges during this

period to maintain eligibility.

If an employee exhausts the period of leave approved under PFML, they may continue PEBB insurance

coverage by self-paying the monthly premium and applicable premium surcharges set by HCA, with no

contribution from the employing agency. See “Options for continuing PEBB medical coverage.”

2023 UMP Classic (PEBB) Certificate of Coverage 165

Conversion of coverage

An enrollee (including a spouse or dependent of a subscriber terminated for cause) has the right to switch

from PEBB group medical to an individual conversion plan offered by this plan when they are no longer

eligible to continue the PEBB group medical plan and are not eligible for Medicare or covered under

another group insurance coverage that provides benefits for hospital or medical care.

An enrollee must apply for conversion coverage and pay the first month’s premium no later than 31 days

after their group medical plan ends or within 31 days from the date the notice of termination of coverage

is received, whichever is later.

Evidence of insurability (proof of good health) is not required to obtain the conversion coverage. Rates,

coverage, and eligibility requirements of this conversion plan differ from those of the enrollee’s current

group medical plan. To receive detailed information on conversion options under this medical plan, call

UMP Customer Service.

General provisions for eligibility and enrollment

Payment of premiums during a labor dispute

Any employee or dependent whose monthly premiums are paid in full or in part by the employing agency

may pay premiums directly to HCA if the employee’s compensation is suspended or terminated directly or

indirectly because of a strike, lockout, or any other labor dispute, for a period not to exceed six months.

When the employee’s compensation is suspended or terminated, HCA will notify the employee

immediately, by mail at the last address of record, that the employee may pay premiums as they become

due.

If coverage is no longer available to the employee under this certificate of coverage, then the employee

may be eligible to purchase an individual medical plan from this plan consistent with premium rates filed

with the Washington State Office of the Insurance Commissioner.

Termination for just cause

The purpose of this provision is to allow for a fair and consistent method to process the plan-designated

provider’s request to terminate coverage from this plan for just cause.

An eligible dependent may have coverage terminated by HCA for the following reasons:

• Failure to comply with the PEBB Program’s procedural requirements, including failure to provide

information or documentation requested by the due date in written requests from the PEBB Program

• Knowingly providing false information

• Failure to pay the monthly premium and applicable premium surcharges when due

• Misconduct. Examples of such termination include, but are not limited to the following:

▪ Fraud, intentional misrepresentation or withholding of information the subscriber knew or should

have known was material or necessary to accurately determine eligibility or the correct premium

▪ Abusive or threatening conduct repeatedly directed to an HCA employee, a health plan, or other

HCA-contracted vendor providing PEBB insurance coverage on behalf of HCA, its employees, or

other persons

The PEBB Program will enroll an employee and their eligible dependents in another PEBB medical plan

upon termination from this plan.

166 2023 UMP Classic (PEBB) Certificate of Coverage

Appeal rights

Any current or former employee of a state agency or their dependent may appeal a decision made by

the state agency regarding PEBB eligibility, enrollment, or premium surcharges to the state agency.

Any current or former employee of an employer group, such as a county, city, port, water district, etc.,

that contracts with HCA for PEBB benefits, or their dependent may appeal a decision made by an

employer group regarding PEBB eligibility, enrollment, or premium surcharges to the employer group.

Any enrollee may appeal a decision made by the PEBB Program regarding PEBB eligibility, enrollment,

premium payments, or premium surcharges to the PEBB Appeals Unit.

Any enrollee may appeal a decision regarding the administration of a PEBB medical plan by following the

appeal provisions of the plan, except when regarding eligibility, enrollment, and premium payment

decisions.

Learn more at hca.wa.gov/pebb-appeals.

Relationship to law and regulations

Any provision of this certificate of coverage that is in conflict with any governing law or regulation of

Washington State is hereby amended to comply with the minimum requirements of such law or

regulation.

Eligibility and enrollment for a retiree or

survivor

In these sections, the term “retiree” or “retiring employee” includes an elected or full-time appointed

official of the legislative and executive branch of state government eligible to continue enrollment in

Public Employees Benefits Board (PEBB) retiree insurance coverage. The term “retiree” or “retiring school

employee” includes a retiring non-represented employee of an educational service district (ESD) or

retiring school employee from a School Employees Benefits Board (SEBB) organization. Additionally,

“health plan” is used to refer to a plan offering medical or dental, or both, developed by PEBB and

provided by a contracted vendor or self-insured plans administered by the Health Care Authority (HCA).

Eligibility for subscribers and dependents

Retiree eligibility

The PEBB Program determines if a retiring employee or retiring school employee is eligible to enroll in

PEBB retiree insurance coverage upon receipt of a PEBB Retiree Election Form (form A). If the retiring

employee or retiring school employee does not have substantive eligibility or does not meet the

procedural requirements for enrollment in PEBB retiree insurance coverage, the PEBB Program will notify

them of their right to appeal eligibility decisions. Information about appeals can be found under “Appeal

rights.”

Survivor eligibility

The PEBB Program determines whether a dependent is eligible to enroll or continue enrollment in PEBB

retiree insurance coverage as a survivor upon receipt of a PEBB Retiree Election Form (form A). If the

survivor does not meet the eligibility and procedural requirements for enrollment in PEBB retiree

insurance coverage, the PEBB Program will notify them of their right to appeal. Information about appeals

can be found under “Appeal rights.”

2023 UMP Classic (PEBB) Certificate of Coverage 167

Dependent eligibility

The following are eligible dependents:

• Legal spouse

• State-registered domestic partner and substantially equivalent legal unions from jurisdictions as

defined in Washington State statute. Individuals in a state-registered domestic partnership are treated

the same as a legal spouse except when in conflict with federal law.

• Children, through the last day of the month in which their 26th birthday occurred regardless of marital

status, student status, or eligibility for coverage under another plan. It also includes children age 26 or

older with a disability as described below in “Children of any age with a developmental or physical

disability.” Children are defined as the subscriber’s:

▪ Children based on establishment of a parent-child relationship, as described in Washington

State statutes, except when parental rights have been terminated.

▪ Children of the subscriber’s spouse, based on the spouse’s establishment of a parent-child

relationship, except when parental rights have been terminated. The stepchild’s relationship to the

subscriber (and eligibility as a dependent) ends on the same date the marriage with the spouse ends

through divorce, annulment, dissolution, termination, or death.

▪ Children for whom the subscriber has assumed a legal obligation for total or partial support in

anticipation of adoption of the child.

▪ Children of the subscriber’s state-registered domestic partner, based on the state-registered

domestic partner’s establishment of a parent-child relationship, except when parental rights have

been terminated. The child’s relationship to the subscriber (and eligibility as a dependent) ends on

the same date the subscriber’s legal relationship with the state-registered domestic partner ends

through divorce, annulment, dissolution, termination, or death.

▪ Children specified in a court order or divorce decree for whom the subscriber has a legal

obligation to provide support or health care coverage.

▪ Extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber’s

spouse, or the subscriber’s state-registered domestic partner. The legal responsibility is

demonstrated by a valid court order and the child’s official residence with the custodian or guardian.

Extended dependent child does not include foster children unless the subscriber, the subscriber’s

spouse, or the subscriber’s state-registered domestic partner has assumed a legal obligation for

total or partial support in anticipation of adoption.

▪ Children of any age with a developmental or physical disability that renders them incapable of

self-sustaining employment and chiefly dependent upon the subscriber for support and

maintenance, provided such condition occurs before the age of 26. The following requirements

apply to a dependent child with a disability:

◦ The subscriber must provide proof of the disability and dependency within 60 days of the child’s

attainment of age 26.

◦ The subscriber must notify the PEBB Program in writing when the child is no longer eligible under

this subsection.

◦ A child with a developmental or physical disability who becomes self-supporting is not eligible as

of the last day of the month in which they become capable of self-support.

◦ A child with a developmental or physical disability age 26 and older who becomes capable of self-

support does not regain eligibility if they later become incapable of self-support.

168 2023 UMP Classic (PEBB) Certificate of Coverage

◦ The PEBB Program, with input from the medical plan, will periodically verify the eligibility of a

dependent child with a disability beginning at age 26, but no more frequently than annually after

the two-year period following the child’s 26th birthday. Verification will require renewed proof of

disability and dependence from the subscriber.

A retiree, a survivor, or their enrolled dependents are required to enroll in Medicare Part A and

Part B if eligible. Any enrollee who is eligible for Medicare must enroll and stay enrolled in Medicare Part

A and Part B to enroll in or continue enrollment in a PEBB retiree health plan. A subscriber must provide a

copy of their or their dependent’s Medicare card or entitlement letter from the Social Security

Administration with Medicare Part A and Part B effective dates to the PEBB Program as proof of Medicare

enrollment. If a subscriber or their dependent is not enrolled in either Medicare Part A or Part B on their

65th birthday, the subscriber must provide the PEBB Program with a copy of the denial letter from the

Social Security Administration. The only exception to this rule is for an employee or school employee who

retired on or before July 1, 1991.

Enrollment for subscribers and dependents

Deferring enrollment

A retiring employee, a retiring school employee, or a dependent becoming eligible as a survivor may

defer (postpone) enrollment in PEBB retiree insurance coverage if they meet the substantive eligibility

requirements to enroll and also meet the procedural requirement by submitting a PEBB Retiree Election

Form (form A) to the PEBB Program within the enrollment timelines.

Deferring enrollment in PEBB retiree insurance coverage will also defer enrollment for all eligible

dependents, except as described below.

A retiring employee, a retiring school employee, or a dependent becoming eligible as a survivor who does

not enroll in PEBB retiree insurance coverage is only eligible to enroll later if they have deferred

enrollment for one or more of the qualifying coverages below:

• Beginning January 1, 2001, enrollment in PEBB retiree insurance coverage may be deferred when the

subscriber is enrolled in employer-based group medical insurance as an employee or the dependent of

an employee, or such medical insurance continued under Consolidated Omnibus Budget Reconciliation

Act (COBRA) coverage or continuation coverage.

• Beginning January 1, 2001, enrollment in PEBB retiree insurance coverage may be deferred when the

subscriber is enrolled as a retiree or the dependent of a retiree in a federal retiree medical plan.

• Beginning January 1, 2006, enrollment in PEBB retiree insurance coverage may be deferred when the

subscriber is enrolled in Medicare Parts A and B and a Medicaid program that provides creditable

coverage. Eligible dependents who are not enrolled in Medicaid coverage that provides creditable

coverage may be enrolled.

• Beginning January 1, 2014, subscribers who are not eligible for Medicare Part A and Part B may defer

enrollment in PEBB retiree insurance coverage when the subscriber is enrolled in qualified health plan

coverage through a health benefit exchange developed under the Affordable Care Act.

• Beginning July 17, 2018, enrollment in PEBB retiree insurance coverage may be deferred when the

subscriber is enrolled in the Civilian Health and Medical Program of the Department of Veterans Affairs

(CHAMPVA).

Exception: A retiree may defer enrollment in PEBB retiree insurance coverage during the period of time

they are enrolled as a dependent in a medical plan sponsored by PEBB, a Washington State educational

service district, or School Employees Benefits Board (SEBB), including such coverage under COBRA or

continuation coverage. They do not need to submit a PEBB Retiree Election Form.

2023 UMP Classic (PEBB) Certificate of Coverage 169

If a retiree or a survivor chooses to defer enrollment in PEBB medical, enrollment in PEBB dental will also

be deferred.

Enrollment in PEBB retiree insurance coverage is automatically deferred if a retiree or a survivor becomes

eligible for the employer contribution toward PEBB benefits. They do not need to submit a PEBB Retiree

Election Form.

If a retiree or a survivor becomes eligible for the employer contribution toward SEBB benefits and enrolls

in a SEBB health plan, they may request to defer enrollment in PEBB retiree insurance coverage.

A retiree or a survivor who deferred their enrollment in PEBB retiree insurance coverage may enroll as

described in the section titled “Enrollment following deferral.”

Retiree and survivor enrollment

An eligible retiree, a survivor, or their dependent can enroll in only one PEBB medical plan, even if

eligibility criteria is met under two or more subscribers.

An eligible retiring employee or a retiring school employee must submit a PEBB Retiree Election Form

(form A) along with any other required forms and supporting documents to the PEBB Program. They must

be received no later than 60 days after the employee’s or the school employee’s employer-paid coverage,

COBRA coverage, or continuation coverage ends. The first premium payment and applicable premium

surcharges are due to HCA no later than 45 days after the election period ends.

An eligible elected or full-time appointed official must submit a PEBB Retiree Election Form (form A)

along with any other required forms and supporting documents to the PEBB Program. They must be

received no later than 60 days after the official leaves public office. The first premium payment and

applicable premium surcharges are due to HCA no later than 45 days after the election period ends.

An eligible survivor of a retiree must submit a PEBB Retiree Election Form (form A) along with any other

required forms and supporting documents to the PEBB Program. They must be received no later than 60

days after the death of the retiree.

An eligible survivor of an employee or school employee must submit a PEBB Retiree Election Form

(form A) along with any other required forms and supporting documents to the PEBB Program. They must

be received no later than 60 days after the later of the date of the employee’s or the school employee’s

death, or the date the survivor’s PEBB insurance coverage, educational service district coverage, or SEBB

insurance coverage ends. The first premium payment and applicable premium surcharges are due to HCA

no later than 45 days after the election period ends.

An eligible employee or school employee determined to be retroactively eligible for disability

retirement must submit a PEBB Retiree Election Form (form A) along with any other required forms,

supporting documents, and their formal determination letter to the PEBB Program. They must be received

no later than 60 days after the date on the determination letter. The first premium payment and

applicable premium surcharges are due to HCA no later than 45 days after the election period ends.

An eligible survivor of an emergency service personnel killed in the line of duty must submit a PEBB

Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB

Program. They must be received no later than 180 days after the later of:

• The date on the letter from the Department of Retirement Systems or the Board for Volunteer

Firefighters and Reserve Officers that informs the survivor that they are determined to be an eligible

survivor;

• The date of the emergency service worker’s death; or

• The last day the survivor was covered under any health plan through the emergency service worker’s

employer or COBRA coverage from the emergency service worker’s employer.

170 2023 UMP Classic (PEBB) Certificate of Coverage

A retiree or a survivor who deferred enrollment and is enrolling in a PEBB retiree health plan, must

submit a PEBB Retiree Election Form (form A) along with any other required forms, supporting documents,

and evidence of continuous enrollment to the PEBB Program. They must be received no later than 60 days

after a loss of other qualifying coverage. The first premium payment and applicable premium surcharges

are due to HCA no later than 45 days after the election period ends. See “Enrollment following deferral”

for additional enrollment timelines.

Note: Enrollment in the PEBB Program’s Medicare Advantage-Prescription Drug plan may not be

retroactive. If a subscriber elects a Medicare Advantage-Prescription Drug plan and the required forms are

received by the PEBB Program after the date PEBB retiree insurance coverage is to begin, the subscriber

and their enrolled dependents will be enrolled in the Uniform Medical Plan Classic during the gap

month(s) prior to when the Medicare Advantage-Prescription Drug plan begins.

Dependent enrollment

To enroll an eligible dependent, the subscriber must include the dependent’s information on the

applicable enrollment form and provide the required document(s) as proof of the dependent’s eligibility.

The dependent will not be enrolled in PEBB health plan coverage if the PEBB Program is unable to verify

their eligibility within the PEBB Program enrollment timelines.

Dependents who are enrolled in medical coverage must be enrolled in the same PEBB medical plan as the

retiree or survivor.

Exception: If a retiree or a survivor selects a Medicare Supplement Plan or a Medicare Advantage-

Prescription Drug plan, non-Medicare enrollees will be enrolled in the Uniform Medical Plan Classic.

A retiree or a survivor may also enroll an eligible dependent during the PEBB Program’s annual open

enrollment or during a special open enrollment. See “Making changes.”

Medicare eligibility and enrollment

Medicare Part A and Part B

If a subscriber or their enrolled dependent becomes eligible for Medicare, they should contact the

Social Security Administration to ask about Medicare enrollment.

Any enrollee who is eligible for Medicare must enroll and stay enrolled in Medicare Part A and Part

B to continue enrollment in a PEBB retiree health plan.

In most cases, Medicare will become the primary insurance coverage and the PEBB retiree medical plan

will become the secondary insurance coverage.

A subscriber must provide a copy of their or their dependent’s Medicare card or entitlement letter from

the Social Security Administration with effective dates to the PEBB Program. If a subscriber or their

dependent is not enrolled in either Medicare Part A or Part B on their 65th birthday, the subscriber must

provide the PEBB Program with a copy of the denial letter from the Social Security Administration. If this

procedural requirement is not met, eligibility will end as described in the termination notice sent by the

PEBB Program. The only exception to this rule is for an employee or school employee who retired on or

before July 1, 1991.

Medicare Part D

The PEBB Program has determined that this medical plan has prescription drug coverage that is, on

average, as good as or better than the standard Medicare Part D prescription drug coverage (it is

“creditable coverage”). Therefore, a subscriber or their enrolled dependent cannot enroll in a Medicare

Part D plan and stay in this medical plan.

2023 UMP Classic (PEBB) Certificate of Coverage 171

If the subscriber terminates this medical plan, they may contact the PEBB Program to request a certificate

of creditable coverage. If creditable prescription drug coverage is not maintained, Medicare Part D

premiums may be higher in the future.

If a subscriber, or their enrolled dependent chooses to enroll in a Medicare Part D plan, PEBB retiree

insurance coverage may only be continued by enrolling in the PEBB-sponsored Medicare supplement

plan.

When medical coverage begins

For an eligible retiring employee or retiring school employee and their eligible dependents, medical

coverage begins the first day of the month after the employer-paid coverage, COBRA coverage, or

continuation coverage ends.

For an eligible employee or school employee determined to be retroactively eligible for disability

retirement and their eligible dependents, medical coverage begins on the date chosen by the employee

or school employee as allowed under PEBB Program rules.

For an eligible elected or full-time appointed official and their eligible dependents, medical coverage

begins the first day of the month following the date the official leaves public office.

For an eligible survivor of a retiree and their eligible dependents, medical coverage will be continued

without a gap, subject to payment of premiums and applicable premium surcharges. If the eligible

survivor is not enrolled at the time of the retiree’s death, medical coverage will begin the first day of the

month following the retiree’s death.

For an eligible survivor of an employee or school employee and their eligible dependents, medical

coverage begins the first day of the month following the later of the date of the employee’s or the school

employee’s death or the date the survivor’s PEBB insurance coverage, educational service district

coverage, or SEBB insurance coverage ends. This does not include emergency service personnel killed in

the line of duty.

For an eligible survivor of an emergency service personnel killed in the line of duty and their eligible

dependents, medical coverage begins on the date chosen, as allowed under PEBB Program rules.

For a retiree or a survivor who deferred enrollment and is enrolling in a PEBB retiree health plan

following loss of other qualifying coverage, medical coverage for the retiree or the survivor and their

eligible dependents begins the first day of the month after the loss of the other qualifying coverage.

For a retiree, a survivor, or their eligible dependents enrolling during the PEBB Program’s annual

open enrollment, medical coverage begins January 1 of the following year.

For a retiree, a survivor, or their eligible dependents enrolling during a special open enrollment,

medical coverage begins the first of the month following the later of the event date or the date the

required form is received. If that day is the first of the month, medical coverage begins on that day.

If the special open enrollment is due to the birth or adoption of a child, or when the subscriber has

assumed a legal obligation for total or partial support in anticipation of adoption of a child, medical

coverage will begin as follows:

• For a newly born child, medical coverage will begin the date of birth;

• For a newly adopted child, medical coverage will begin on the date of placement or the date a legal

obligation is assumed in anticipation of adoption, whichever is earlier; or

• For a spouse or state registered domestic partner of a subscriber, medical coverage will begin the

first day of the month in which the event occurs.

172 2023 UMP Classic (PEBB) Certificate of Coverage

If the special open enrollment is due to the enrollment of an extended dependent or a dependent child

with a disability, medical coverage will begin the first day of the month following the later of the event

date or eligibility certification, whichever is later.

Making changes

Removing a dependent who is no longer eligible

A subscriber must provide notice to the PEBB Program to remove a dependent who is no longer eligible

due to divorce, annulment, dissolution, or a qualifying event of a dependent ceasing to be eligible as a

dependent child, as described under “Dependent eligibility.” The notice must be received within 60 days

of the last day of the month the dependent no longer meets the eligibility criteria.

Consequences for not submitting notice within the required 60 days may include, but are not limited to:

• The dependent may lose eligibility to continue PEBB medical coverage under one of the continuation

coverage options described in “Options for continuing PEBB medical coverage.”

• The subscriber may be billed for claims paid by the medical plan for services that were rendered after

the dependent lost eligibility.

• The subscriber may not be able to recover subscriber-paid insurance premiums for the dependent that

lost eligibility.

• The subscriber may be responsible for premiums paid by the state for the dependent’s medical plan

coverage after the dependent lost eligibility.

Voluntary termination

An enrolled retiree or survivor may voluntarily terminate enrollment in a medical plan at any time by

submitting a request in writing to the PEBB Program. Enrollment in the medical plan will be terminated

the last day of the month in which the PEBB Program receives the request or on the last day of the month

specified in the termination request, whichever is later. If the request is received on the first day of the

month, medical plan enrollment will be terminated on the last day of the previous month. When a retiree,

a survivor, or their dependent is enrolled in a Medicare Advantage plan, medical plan enrollment will be

terminated on the last day of the month when the Medicare Advantage Plan Disenrollment Form (form D)

is received.

A retiree or a survivor who voluntarily terminates their enrollment in a medical plan also terminates all

other health plan enrollment and enrollment for all eligible dependents. Once coverage is terminated, a

retiree or a survivor may not enroll again in the future unless they reestablish eligibility for PEBB insurance

coverage by becoming newly eligible.

Deferring enrollment

An enrolled retiree or survivor may defer enrollment in PEBB retiree insurance coverage at any time by

submitting the PEBB Retiree Change Form (form E) along with any other required forms and supporting

documents to the PEBB Program. Enrollment in PEBB retiree insurance coverage will be deferred effective

the first of the month following the date the required forms are received. If the forms are received on the

first day of the month, enrollment will be deferred effective that day. When a retiree, a survivor, or their

dependent is enrolled in a Medicare Advantage plan, medical plan enrollment will be deferred the first of

the month following the date the Medicare Advantage Plan Disenrollment Form (form D) is received. A

retiree or a survivor who deferred their enrollment may enroll as described in “Enrollment following

deferral.”

Enrollment following deferral

A retiree or a survivor who defers enrollment in PEBB retiree insurance coverage:

2023 UMP Classic (PEBB) Certificate of Coverage 173

• While enrolled in employer-based group medical or such coverage under COBRA coverage or

continuation coverage may enroll in a PEBB medical plan during the PEBB Program’s annual open

enrollment period, or no later than 60 days after the date their enrollment in employer-based group

medical coverage or such coverage under COBRA coverage or continuation coverage ends.

• While enrolled in a federal retiree medical plan as a retiree or dependent will have a one-time

opportunity to enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment

period, or no later than 60 days after their enrollment in a federal retiree medical plan ends.

• While enrolled in Medicare Parts A and B and a Medicaid program that provides creditable

coverage may enroll in a PEBB medical plan during the PEBB Program’s annual open enrollment

period, or no later than 60 days after their Medicaid coverage ends, or no later than the end of the

calendar year when their Medicaid coverage ends if they were also enrolled in a subsidized Medicare

Part D plan.

• While enrolled in qualified health plan coverage through a health benefit exchange developed

under the Affordable Care Act will have a one-time opportunity to enroll or reenroll in a PEBB medical

plan during the PEBB Program’s annual open enrollment period, or no later than 60 days after

exchange coverage ends.

• While enrolled in CHAMPVA will have a one-time opportunity to enroll in a PEBB medical plan during

the PEBB Program’s annual open enrollment period, or no later than 60 days after their enrollment in a

CHAMPVA medical plan ends.

• While enrolled as a dependent in a medical plan sponsored by PEBB, a Washington State educational

service district, or SEBB, including coverage under COBRA or continuation coverage, may enroll in a

PEBB medical plan during the PEBB Program’s annual open enrollment period, or no later than 60 days

after the enrollment in a medical plan sponsored by PEBB, a Washington State educational service

district, or SEBB ends, or such coverage under COBRA or continuation coverage ends.

Note: Enrollment in the PEBB Program’s Medicare Advantage-Prescription Drug plan may not be

retroactive. If a subscriber elects a Medicare Advantage-Prescription Drug plan and the required forms are

received by the PEBB Program after the date PEBB retiree insurance coverage is to begin, the subscriber

and their enrolled dependents will be enrolled in the Uniform Medical Plan Classic during the gap

month(s) prior to when the Medicare Advantage-Prescription Drug plan begins.

For a retiree or a survivor to enroll in a PEBB medical plan, the PEBB Program must receive a PEBB Retiree

Election Form (form A), any other required forms, supporting documents, and evidence of continuous

enrollment in one or more qualifying coverages during the timelines described in this section. A gap in

coverage of 31 days or less is allowed between the date PEBB retiree insurance coverage is deferred and

the start date of a qualifying coverage, and between each period of enrollment in qualifying coverages

during the deferral period.

A retiree or a survivor who deferred their enrollment in PEBB retiree insurance coverage while enrolled in

qualifying coverage as described above may also enroll in a PEBB medical plan if they receive formal

notice that HCA has determined it is more cost-effective to enroll in a PEBB medical plan than a medical

assistance program.

A retiree or a survivor should contact the PEBB Program or visit hca.wa.gov/pebb-retirees to get the

required forms, information on premiums, and a list of available medical plans.

Making changes during annual open enrollment and special

open enrollment

A subscriber may make certain changes to their enrollment during the annual open enrollment and if a

specific life event creates a special open enrollment period.

174 2023 UMP Classic (PEBB) Certificate of Coverage

Annual open enrollment changes

A subscriber may make the following changes to their enrollment during the PEBB Program’s annual open

enrollment period:

• Enroll in a medical plan following a deferral

• Defer or terminate their enrollment in a medical plan

• Enroll or remove eligible dependents

• Change their medical plan

A subscriber must submit the election change online in PEBB My Account or return the required PEBB

Retiree Election Form (form A-OE) along with any other required forms, and any supporting documents to

the PEBB Program. The change must be completed in PEBB My Account or the forms must be received no

later than the last day of the annual open enrollment period and will be effective January 1 of the

following year.

Special open enrollment changes

A subscriber may change their enrollment outside of the annual open enrollment period if a qualifying

event creates a special open enrollment period. However, the change in enrollment must be allowable

under Internal Revenue Code (IRC) and Treasury Regulations and correspond to and be consistent with

the event that creates the special open enrollment for the subscriber, their dependent, or both.

The subscriber must provide evidence of the event that created the special open enrollment.

To disenroll from a Medicare Advantage plan or Medicare Advantage-Prescription Drug plan, the change

in enrollment must be allowable under federal regulations.

To make an enrollment change, the subscriber must submit the required PEBB Retiree Change Form (form

E) along with any other required forms to the PEBB Program. The PEBB Program must receive the forms

no later than 60 days after the event that creates the special open enrollment. In addition, the PEBB

Program will require the subscriber to provide proof of the dependent’s eligibility, evidence of the event

that created the special open enrollment, or both.

Exceptions:

• A subscriber enrolled in PEBB retiree insurance coverage has six months from the date of their or their

dependent’s enrollment in Medicare Part B to change their enrollment to a PEBB Medicare Supplement

Plan. The PEBB Program must receive the required form(s) no later than six months after the enrollment

in Medicare Part B for either the subscriber or their dependent.

• When a subscriber or their dependent is enrolled in a Medicare Advantage or Medicare Advantage-

Prescription Drug plan, they may disenroll during a special enrollment period as allowed under federal

regulations. The new medical plan coverage will begin the first day of the month following the date the

Medicare Advantage Plan Disenrollment Form (form D) is received.

• A subscriber enrolled in PEBB retiree insurance coverage has seven months to enroll in a Medicare

Advantage or Medicare Advantage-Prescription Drug plan that begins three months before they or

their dependent first enrolled in both Medicare Part A and Part B and ends three months after the

month of Medicare eligibility. A subscriber may also enroll themselves or their dependent in a Medicare

Advantage or Medicare Advantage-Prescription Drug plan before their last day of the Medicare Part B

initial enrollment period. The forms must be received by the PEBB Program no later than the last day of

the month prior to the month the subscriber or their dependent enrolls in the Medicare Advantage or

Medicare Advantage-Prescription Drug plan.

• If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a

legal obligation for total or partial support in anticipation of adoption, the subscriber should notify the

2023 UMP Classic (PEBB) Certificate of Coverage 175

PEBB Program by submitting the required form(s) as soon as possible to ensure timely payment of

claims. If adding the child increases the premium, the required form(s) must be received no later than

60 days after the date of the birth, adoption, or the date the legal obligation is assumed for total or

partial support in anticipation of adoption.

Special open enrollment events that allow for a change in health plans

A subscriber may not change their health plan if their state-registered domestic partner or state-

registered domestic partner’s child is not a tax dependent.

Any of the following events may create a special open enrollment:

• Subscriber gains a new dependent due to:

▪ Marriage or registering a state-registered domestic partnership.

▪ Birth, adoption, or assuming a legal obligation for total or partial support in anticipation of adoption.

▪ A child becoming eligible as an extended dependent through legal custody or legal guardianship.

• Subscriber or their dependent loses other coverage under a group health plan or through health

insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA).

• Subscriber has a change in employment status that affects their eligibility for the employer contribution

toward their employer-based group health plan.

• Subscriber’s dependent has a change in their own employment status that affects their eligibility or

their dependent’s eligibility for the employer contribution under their employer-based group health

plan. “Employer contribution” means contributions made by the dependent’s current or former

employer toward health coverage as described in the Treasury Regulation.

• Subscriber or their dependent has a change in residence that affects health plan availability. If the

subscriber moves and their current health plan is not available in the new location, the subscriber must

select a new health plan, otherwise there will be limited accessibility to network providers and covered

services.

• A court order requires the subscriber or any other individual to provide insurance coverage for an

eligible dependent of the subscriber (a former spouse or former state-registered domestic partner is

not an eligible dependent).

• Subscriber or their dependent enrolls in coverage under Medicaid or a state Children’s Health

Insurance Program (CHIP), or the subscriber or their dependent loses eligibility for coverage under

Medicaid or CHIP.

• Subscriber or their dependent becomes eligible for state premium assistance subsidy for PEBB health

plan coverage from Medicaid or CHIP.

• Subscriber or their dependent enrolls in coverage under Medicare, or the subscriber or their dependent

loses eligibility for coverage under Medicare or enrolls in or terminates enrollment in a Medicare

Advantage-Prescription Drug or a Part D plan. If the subscriber’s current medical plan becomes

unavailable due to the subscriber or their dependents enrollment in Medicare, the subscriber must

select a new medical plan.

• Subscriber or their dependent’s current medical plan becomes unavailable because the subscriber or

enrolled dependent is no longer eligible for a health savings account (HSA).

• Subscriber or their dependent experiences a disruption of care for active and ongoing treatment that

could function as a reduction in benefits for the subscriber or their dependent. The subscriber may not

change their health plan election because the subscriber or dependent’s physician stops participation

176 2023 UMP Classic (PEBB) Certificate of Coverage

with the subscriber’s health plan unless the PEBB Program determines that a continuity of care issue

exists. The PEBB Program will consider but not limit its consideration to the following:

▪ Active cancer treatment, such as chemotherapy or radiation therapy

▪ Treatment following a recent organ transplant

▪ A scheduled surgery

▪ Recent major surgery still within the postoperative period

▪ Treatment for a high-risk pregnancy

Note: The plan cannot guarantee that any physician, hospital, or other provider will be available or remain

under contract with the plan. An enrollee may not change medical plans simply because their provider or

health care facility discontinues participation with this medical plan until the PEBB Program’s next annual

open enrollment or when another qualifying event creates a special open enrollment for changing health

plans, unless the PEBB Program determines that a continuity of care issue exists.

Special open enrollment events that allow adding or removing a dependent

Any of the following events may create a special open enrollment:

• Subscriber gains a new dependent due to:

▪ Marriage or registering a state-registered domestic partnership.

▪ Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in

anticipation of adoption.

▪ A child becoming eligible as an extended dependent through legal custody or legal guardianship.

• Subscriber or their dependent loses other coverage under a group health plan or through health

insurance coverage, as defined by the Health Insurance Portability and Accountability Act (HIPAA).

• Subscriber has a change in employment status that affects their eligibility for the employer contribution

toward their employer-based group health plan.

• Subscriber’s dependent has a change in their own employment status that affects their eligibility or

their dependent’s eligibility for the employer contribution under their employer-based group health

plan. “Employer contribution” means contributions made by the dependent’s current or former

employer toward health coverage as described in the Treasury Regulation.\

• Subscriber or their dependent has a change in enrollment under an employer-based group health plan

during its annual open enrollment that does not align with the PEBB Program’s annual open

enrollment.

• Subscriber’s dependent has a change in residence from outside of the United States to within the

United States, or from within the United States to outside of the United States and that change in

residence resulted in the dependent losing their health insurance.

• A court order requires the subscriber or any other individual to provide insurance coverage for an

eligible dependent of the subscriber (a former spouse or former state-registered domestic partner is

not an eligible dependent).

• Subscriber or their dependent enrolls in coverage under Medicaid or a state Children’s Health

Insurance Program (CHIP) or the subscriber or their dependent loses eligibility for coverage under

Medicaid or CHIP.

• Subscriber or their dependent becomes eligible for a state premium assistance subsidy for PEBB health

plan coverage from Medicaid or CHIP.

2023 UMP Classic (PEBB) Certificate of Coverage 177

• Subscriber’s dependent enrolls in Medicare or loses eligibility for Medicare.

When medical coverage ends

Termination dates

Medical coverage ends on the following dates:

• On the last day of the month when any enrollee ceases to be eligible.

• On the date a medical plan terminates due to a change in contracted service area or when the group

policy ends. If that should occur, the subscriber will have the opportunity to enroll in another PEBB

medical plan.

• On the last day of the month in which the monthly premium and applicable premium surcharges were

paid.

The first of the month following the date the required forms are received when an enrolled retiree or

survivor requests to defer enrollment in PEBB retiree insurance coverage. If the forms are received on the

first day of the month, enrollment will be deferred effective that day. When a retiree, a survivor, or their

dependent is enrolled in a Medicare Advantage plan, medical plan enrollment will be deferred the first of

the month following the date the Medicare Advantage Plan Disenrollment Form (form D) is received.

The last day of the month in which the PEBB Program receives a written request and all required forms

requesting to voluntarily terminate enrollment in a medical plan. If a future date is specified, medical

coverage terminates the last day of the month specified. If the termination request is received on the first

day of the month, medical plan enrollment will be terminated on the last day of the previous month.

When a retiree, a survivor, or their dependent is enrolled in a Medicare Advantage plan, medical plan

enrollment will be terminated on the last day of the month when the Medicare Advantage Plan

Disenrollment Form (form D) is received.

A subscriber will be responsible for payment of any services received after the date medical coverage

ends, as described above.

Final premium payments

The subscriber is responsible for timely payment of premiums and applicable premium surcharges.

Premium payments and applicable premium surcharges are not prorated during any month, for any

reason, even if an enrollee dies or asks to terminate their medical plan before the end of the month.

If the monthly premium or applicable premium surcharges remain unpaid for 30 days, it will be

considered delinquent. A subscriber is allowed a grace period of 30 days from the date the monthly

premium or applicable premium surcharges become delinquent to pay the unpaid premium balance or

applicable premium surcharges. If the subscriber’s premium balance or applicable premium surcharges

remain unpaid for 60 days from the original due date, coverage will be terminated retroactive to the last

day of the month for which the monthly premium and any applicable premium surcharges were paid.

For a subscriber enrolled in a Medicare Advantage or Medicare Advantage-Prescription Drug plan, a

notice will be sent to them notifying them that they are delinquent on their monthly premiums and that

the enrollment will be terminated prospectively to the end of the month after the notice is sent.

If an enrollee is hospitalized

An enrollee who is receiving covered services in a hospital on the date medical coverage ends will

continue to be eligible for covered services while an inpatient for the condition which the enrollee was

hospitalized, until one of the following events occur:

178 2023 UMP Classic (PEBB) Certificate of Coverage

• According to this plan’s clinical criteria, it is no longer medically necessary for the enrollee to be an

inpatient at the facility.

• The remaining benefits available for the hospitalization are exhausted, regardless of whether a new

calendar year begins.

• The enrollee becomes covered under another agreement with a group health plan that provides

benefits for the hospitalization.

• The enrollee becomes enrolled under an agreement with another carrier that provides benefits for the

hospitalization.

This provision will not apply if the enrollee is covered under another agreement that provides benefits for

the hospitalization at the time medical coverage ends, except as set forth in this section, or if the enrollee

is eligible for PEBB Continuation Coverage as described in “Options for continuing PEBB medical

coverage.”

Options for continuing PEBB medical coverage

A subscriber and their dependents covered by this medical plan may be eligible to continue enrollment

under PEBB Continuation Coverage (COBRA) if they lose eligibility. PEBB Continuation Coverage (COBRA)

temporarily extends group insurance coverage if certain circumstances occur that would otherwise end

the subscriber or their dependent’s PEBB medical coverage. PEBB Continuation Coverage (COBRA)

includes eligibility and administrative requirements under federal COBRA laws and regulations and also

includes coverage for some enrollees who are not qualified beneficiaries under federal COBRA

continuation coverage.

The PEBB Program administers this coverage. Call the PEBB Program at 1‑800‑200‑1004 (TRS: 711) or refer

to the PEBB Continuation Coverage Election Notice for details.

Options for continuing coverage under PEBB Retiree

Insurance Coverage

A dependent becoming eligible as a survivor of a retiree is eligible to continue enrollment or defer

enrollment in PEBB retiree insurance coverage if they meet procedural and substantive eligibility

requirements. See the PEBB Retiree Enrollment Guide for details.

Conversion of coverage

An enrollee (including a spouse or dependent of a subscriber terminated for cause) has the right to switch

from PEBB group medical to an individual conversion plan offered by this plan when they are no longer

eligible to continue the PEBB group medical plan and are not eligible for Medicare or covered under

another group insurance coverage that provides benefits for hospital or medical care.

An enrollee must apply for conversion coverage and pay the first month’s premium no later than 31 days

after their group medical plan ends or within 31 days from the date the notice of termination of coverage

is received, whichever is later.

Evidence of insurability (proof of good health) is not required to obtain the conversion coverage. Rates,

coverage, and eligibility requirements of this conversion plan differ from those of the enrollee’s current

group medical plan. To receive detailed information on conversion options under this medical plan, call

UMP Customer Service.

2023 UMP Classic (PEBB) Certificate of Coverage 179

General provisions for eligibility and enrollment

Termination for just cause

The purpose of this provision is to allow for a fair and consistent method to process the plan-designated

provider’s request to terminate an enrollee’s coverage from this plan for just cause.

A retiree or eligible dependent may have coverage terminated by HCA for the following reasons:

• Failure to comply with the PEBB Program’s procedural requirements, including failure to provide

information or documentation requested by the due date in written requests from the PEBB Program

• Knowingly providing false information

• Failure to pay the monthly premium and applicable premium surcharges when due

• Misconduct. Examples of such termination include, but are not limited to the following:

▪ Fraud, intentional misrepresentation or withholding of information the subscriber knew or should

have known was material or necessary to accurately determine eligibility or the correct premium

▪ Abusive or threatening conduct repeatedly directed to an HCA employee, a health plan, or other

HCA-contracted vendor providing PEBB insurance coverage on behalf of HCA, its employees, or

other persons

If a retiree’s PEBB insurance coverage is terminated by HCA for the above reasons, PEBB insurance

coverage for all of the retiree’s eligible dependents is also terminated.

Appeal rights

Any enrollee may appeal a decision made by the PEBB Program regarding PEBB eligibility, enrollment,

premium payments, or premium surcharges to the PEBB Appeals Unit.

Learn more at hca.wa.gov/pebb-appeals.

Fax: 360-763-4709

Mail: Health Care Authority

Attn: PEBB Appeals Unit

PO Box 45504

Olympia, WA 98504-5504

Hand deliver: Health Care Authority

626 8th Avenue SE

Olympia, WA 98501

Any enrollee may appeal a decision regarding the administration of a PEBB medical plan by following the

appeal provisions of the plan, except when regarding eligibility, enrollment, and premium payment

decisions.

Relationship to law and regulations

Any provision of this certificate of coverage that is in conflict with any governing law or regulation of

Washington State is hereby amended to comply with the minimum requirements of such law or

regulation.

PEBB customer service

For questions about PEBB retiree eligibility and enrollment, please call the PEBB Program at

1-800-200-1004 (TRS:711) or visit hca.wa.gov/pebb-retirees.

180 2023 UMP Classic (PEBB) Certificate of Coverage

For questions about Medicare, please call the Centers for Medicare and Medicaid Services (CMS) at

1-800-MEDICARE or visit medicare.gov.

Definitions

Allowed amount, medical services

Allowed amount for medical services is the most the plan pays for a specific covered service or supply.

The allowed amount is determined as follows:

• For preferred providers that are within the Regence BlueShield service area, the Preferred Provider

Organization (PPO) contract with Regence BlueShield is the relevant contract that determines the

allowed amount. For preferred providers that are outside the Regence BlueShield service area, the

contract with another Blue Cross or Blue Shield organization in the BlueCard® Program for its PPO

network is the relevant contract that determines the allowed amount.

• For participating providers that are within the Regence BlueShield service area, the participating

provider contract with Regence BlueShield is the relevant contract that determines the allowed amount.

For participating providers that are outside the Regence BlueShield service area, the contract with

another Blue Cross or Blue Shield organization in the BlueCard® Program is the relevant contract that

determines the allowed amount.

• For out-of-network providers who are within the Regence BlueShield service area and not contracted

with Regence BlueShield, the amount Regence has determined to be reasonable charges for covered

services and supplies is the allowed amount.

The allowed amount may be based upon the billed charges for some services, as determined by

Regence or as otherwise required by law. If a provider is not in the network, as described above, but

has a contract with Regence, the allowed amount is based on the negotiated rate.

• For out-of-network providers accessed through the BlueCard® Program, the allowed amount is

the lower of the provider’s billed charges and the amount that the other Blue plan identifies as the

amount on which it would base a payment to that provider.

Under the BlueCard® Program, when you access covered services within the geographic area served

by a Host Blue, Regence BlueShield will remain responsible for fulfilling contractual obligations.

However, the Host Blue is responsible for contracting with and generally handling all interactions with

its network providers.

Whenever you access covered services outside Regence BlueShield’s service area and the claim is

processed through the BlueCard® Program, the amount you pay for covered services is calculated based

on the lower of:

• The covered billed charges for your covered services; or

• The negotiated price that the Host Blue makes available to Regence.

Often, this negotiated price will be a simple discount that reflects an actual price that the Host Blue pays

to your health care provider. Sometimes, it is an estimated price that considers special arrangements with

your health care provider or provider group that may include types of settlements, incentive payments,

and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results

in expected average savings for similar types of health care providers after considering the same types of

transactions as with an estimated price.

Estimated pricing and average pricing, going forward, also consider adjustments to correct for over- or

underestimation of modifications of past pricing for the types of transaction modifications noted above.

2023 UMP Classic (PEBB) Certificate of Coverage 181

However, such adjustments will not affect the price Regence uses for your claim because they will not be

applied retroactively to claims already paid.

Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any

state laws mandate other liability calculation methods, including a surcharge, Regence BlueShield would

then calculate your liability for any covered services according to applicable law.

Charges more than the allowed amount are not reimbursable. For questions regarding the basis for

determination of the allowed amount, call UMP Customer Service.

Allowed amount, prescription drugs

The allowed amount for prescription drugs is based on WSRxS’ contractually agreed reimbursement,

unless other contractual arrangements or terms apply. All covered prescription drug claims are paid based

on this allowed amount.

Ambulatory surgery center (ASC)

An ambulatory surgery center (ASC) is a health care facility that specializes in providing surgery, pain

management, and certain diagnostic services in an outpatient setting. ASC-qualified procedures are

typically more complex than those done in a doctor’s office but not so complex as to require an overnight

stay. Procedures commonly performed in these centers include colonoscopies, endoscopies, cataract

surgery, orthopedic, and ENT (ear, nose, and throat) procedures. An ASC may also be known as an

outpatient surgery center or same-day surgery center.

Annual open enrollment

Annual open enrollment is a period of time defined by HCA when a subscriber may change to another

health plan offered by the PEBB Program and make certain other account changes for an effective date

beginning January 1 of the following year.

Appeal

See the “Complaint and appeal procedures” section for an explanation of appeals and how the process

works. For appeals related to PEBB eligibility or enrollment see "Appeal rights" in the "Eligibility and

Enrollment" and in the “Eligibility and enrollment for a retiree or survivor” sections for more information.

Authorized representative

An authorized representative is someone you have designated in writing to communicate with the plan

on your behalf. See page 148 for how this works.

Balance billing

Balance billing is a provider billing you for the difference between the billed amount and the allowed

amount. Preferred and participating providers cannot balance bill you for covered services above the

allowed amount. See an example of how this works in the “Sample payments to different provider types”

section.

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.

182 2023 UMP Classic (PEBB) Certificate of Coverage

At an out-of-network facility, when you receive emergency services you cannot be balance billed.

Birthday rule

In some instances, the birthday rule is used to determine which group health plan will pay first for the

dependent children of married, living together and not married, legally separated, or divorced parents.

This rule looks at only the month and day, not the year, of the parents’ birthdays. For example, the plan of

a parent born April 14 is primary over the plan of a parent born August 21. If both parents have the same

birthday, the plan that has covered either parent the longest is primary.

Brand-name drug

A brand-name drug is a prescription drug sold under the proprietary name or trade name selected by

the manufacturer.

Business day

Business days are Mondays through Fridays, except for legal holidays observed by Washington State.

Calendar day

A calendar day is any day of the week regardless of whether it is observed as a legal holiday by

Washington State.

Calendar year

A calendar year is January 1 through December 31.

Chronic migraine

A chronic migraine is having a headache on 15 or more days per month of which eight or more days are

a migraine.

Clinical review

Clinical review is when the plan has a clinical professional review medical records related to treatment to

determine if treatment is medically necessary.

Coinsurance

Coinsurance is the percentage of the allowed amount you must pay the provider on claims for which the

plan pays less than 100 percent of the allowed amount. This includes most medical services and

prescription drugs.

Continuation Coverage

Continuation Coverage means the temporary continuation of PEBB benefits available to enrollees under

the Consolidated Omnibus Budget Reconciliation Act (COBRA), the Uniformed Services Employment and

Reemployment Rights Act (USERRA), or PEB Board policies.

Coordination of benefits (COB)

For members covered by more than one group health plan, coordination of benefits (COB) is the

method the plan uses to determine which plan pays first, which pays second, and the amount paid by

each plan. See description and examples in the “If you have other medical coverage” section.

2023 UMP Classic (PEBB) Certificate of Coverage 183

Copay

Copay is a set dollar amount you pay when receiving specific services, treatments, or supplies, such as

chiropractic, acupuncture, massage therapy, inpatient hospitalization, or emergency room visits.

Cost-share

Cost-share means the amount you pay for a service, supply, or prescription drug. This may be a

deductible, coinsurance, copay, or amounts not covered by the plan.

Custodial care

Custodial care is care primarily to assist in activities of daily living, including institutional care primarily to

support self-care and provide room and board. Custodial care includes, but is not limited to, help in

walking, getting into and out of bed, bathing, dressing, feeding and preparing special diets, and

supervising prescription drugs that are ordinarily self-administered.

Deductible, medical

The medical deductible is a fixed dollar amount you must meet each calendar year for health care

expenses before the plan starts paying for covered services. You pay the first $250 per member in medical

expenses to your providers ($750 maximum if you have a family of three or more on one account). Only

expenses covered by the plan apply to your deductible. For example, if you receive LASIK surgery (see

exclusion on 114), the plan does not apply this payment to your medical deductible. Some services are

exempt from this deductible (see the “Summary of benefits” section). See the “What you pay for medical

services” section for details on how the medical deductible works.

The medical and prescription drug deductibles are separate: Medical services do not apply to your

prescription drug deductible. Prescription drug purchases do not apply to your medical deductible. See

“Prescription drug deductible” starting on page 93.

Deductible, prescription drugs

The prescription drug deductible is a fixed dollar amount you must meet each calendar year for Tier 2

prescription drugs before the plan starts paying benefits for these drugs. Covered insulins are not subject

to the deductible. You pay the first $100 per member in prescription drug charges ($300 maximum for a

family of three or more on one account). Only expenses for Tier 2 drugs covered by the plan apply to your

deductible. For example, if you receive a prescription for a drug for cosmetic purposes (see exclusion on

page 112), the plan does not apply the cost of a noncovered drug to your deductible.

What you pay (coinsurance) for Value Tier and Tier 1 drugs does not apply to your prescription drug

deductible.

The prescription drug and medical deductibles are separate: Prescription drug purchases do not apply

to your medical deductible. Medical services do not apply to your prescription drug deductible. See

“Prescription drug deductible” on page 93.

Dependent

A dependent is an eligible spouse, state-registered domestic partner, child, or other eligible family

member as described in “Dependent eligibility” (see the “Eligibility for subscribers and dependents”

sections on page 152 and 166) that is either covered by or eligible to be covered by the plan under the

subscriber’s account.

184 2023 UMP Classic (PEBB) Certificate of Coverage

Detoxification

Detoxification is a medically supervised treatment program for individuals with alcohol or drug

intoxication, designed to rid the body of toxic substances and manage withdrawal symptoms.

Developmental delay

Developmental delay is a significant lag in reaching developmental milestones as expected during

infancy and early childhood. The cause may be present at birth or acquired after birth from a disease or

disorder of the body, an injury, a disorder of the mind or emotions, or harmful effects of the surrounding

environment. Only a physician or other provider may diagnose a developmental delay.

Durable medical equipment (DME)

Durable medical equipment (DME) is:

• Designed for prolonged use.

• For a specific therapeutic or clinical purpose, or to assist in the treatment of an injury or illness.

• Medically necessary (meeting all plan medical necessity criteria).

• Primarily and customarily used only for a medical purpose.

See page 113 for examples of equipment that is not covered.

Effectiveness

Effectiveness means the extent to which a specific intervention, procedure, service, level of service,

supply, prescription drug, or drug dose may reasonably be expected to produce the intended results and

to have expected benefits that outweigh potential harmful effects under real-world circumstances.

Efficacy

Efficacy is the extent to which a specific intervention, procedure, service, supply, or prescription drug

produces the desired effect under ideal conditions (in a controlled environment under lab circumstances).

Elective contact lenses

Elective contact lenses are covered lenses under the frame limit in lieu of coverage for eyeglasses.

Emergency

See the “Medical emergency” definition.

Emergency fill

Emergency fill is a process where the plan covers a limited amount of a prescription drug on an

emergency basis while the plan processes your drug preauthorization request.

Employing agency

Employing agency means a division, department, or separate agency of state government, including an

institution of higher education; a county, municipality, or other political subdivision; and a tribal

government covered by chapter 41.05 RCW.

2023 UMP Classic (PEBB) Certificate of Coverage 185

Enrollee

Enrollee means a person who meets all eligibility requirements and is enrolled in PEBB benefits, and for

whom applicable premium payments have been made.

Excluded pharmacy

Excluded pharmacies are pharmacies that have been excluded due to fraud, waste, or abuse. Locate a

network pharmacy by visiting the UMP Prescription drug coverage webpage (see Directory for link).

Experimental or investigational

Experimental or investigational means any treatment that is not recognized by the plan as conforming

to standard medical care for the condition, disease, illness, or injury being treated. ”Treatment” in this

setting may include any intervention, therapy, procedure, facility, equipment, drug usage, device, service,

supply, intervention, biologic product or drug (prescription or non-prescription). Experimental and

investigational treatments are not covered, even if the treatment is considered medically necessary. The

plan will review scientific evidence from well-designed clinical studies found in peer-reviewed medical

literature, if available, and information obtained from the treating provider regarding the treatment to

determine if it is experimental or investigational.

A treatment meeting any of the following criteria is considered experimental or investigational:

• Approval of the treatment or one of its components by one or more government agencies (e.g., FDA) is

required but has not been obtained at the time the treatment is requested or administered.

• The improvement has not been shown to be attainable outside the laboratory or clinical research

setting.

• The scientific evidence does not permit conclusions concerning the effect of the treatment on health

outcomes, which include the disease process, injury or illness, length of life, ability to function, and

quality of life.

• The scientific evidence does not show that the treatment is as beneficial as any established alternatives.

• The treatment has not been demonstrated to improve net health outcomes.

• The treatment has scientific evidence to support its use, but not for the specific indication for which it is

being requested.

• The treatment is a drug or device that is prescribed for other than its FDA-approved use(s) and is not

recognized as “effective” for the use for which it is being prescribed. To be considered “effective” for

other than its FDA-approved use, a prescription drug or device must be so recognized in one of the

standard reference compendia or, if not, then in a majority of relevant peer-reviewed medical literature;

or by the U.S. Secretary of Health and Human Services.

• The treatment is considered to be experimental or investigational by U.S. standards.

• The treatment is drug combination therapy, when the scientific literature only supports the drug’s use

as monotherapy and not when utilized in combination with other drugs.

• The treatment is drug monotherapy, when the scientific literature only supports the drug’s use when

utilized in combination with other drugs.

• The treatment is not provided by a provider that has demonstrated medical proficiency in the provision

of the treatment.

• The treatment is only available in the U.S. as part of a clinical trial or research program for the illness or

condition being treated.

186 2023 UMP Classic (PEBB) Certificate of Coverage

▪ Although the plan does not pay for items, drugs, devices, or services (including items, drugs, devices,

or services provided in a clinical trial) for investigational use, the plan does not deny qualified

individuals from participating in approved clinical trials. The terms “qualified individual” and

“approved clinical trial” are defined in 42 U.S.C. §300gg-8. If a qualified individual is participating in

an approved clinical trial, the plan will not deny, limit, or impose additional conditions on the

coverage for routine patient costs for items and services furnished in connection with participation

in the trial and will not discriminate against the individual on the basis of the individual’s

participation in such trial. The plan will apply its standard terms and conditions for routine patient

costs for items and services furnished in connection with participation in the trial.

• The treatment is the subject of an on-going phase I or phase II clinical trial or is the research,

experimental, study, or investigational arm of an on-going phase III clinical trial.

Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is a detailed account of each medical claim processed by the plan,

which the plan sends to you to notify you of claim payment or denial. You may also sign in to your

Regence account or call UMP Customer Service to request a copy of an EOB (see Directory for link and

contact information). You will need to provide identifying information over the phone.

Family

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

account.

Fee schedule

A fee schedule is a list of the plan’s maximum payment amounts for specific services or supplies.

Preferred providers have agreed to accept these fees as payment in full for services to members. See the

definition of “Allowed amount, medical services” for more details.

Formulary

A formulary is a list available online that specifies how prescription drugs are covered by the plan. By

using this list, you may find out if a prescription drug is covered, if the drug must be ordered through the

plan’s specialty drug pharmacy, and whether the drug has any limitations (such as needing

preauthorization or quantity limits; see the “Limits on your prescription drug coverage” section).

The UMP Preferred Drug List is sometimes called a formulary (see “The UMP Preferred Drug List” section

for more information).

Generic drug

A generic drug is a prescription drug with the same active ingredient(s), but not necessarily the same

inactive ingredients, as a brand-name drug that is no longer protected by a commercial patent. A generic

drug is therapeutically equivalent to the brand-name prescription drug, which means it works like the

brand-name drug in dosage, strength, performance, and use. All generic drugs sold in the U.S. must be

reviewed and approved by the FDA, and meet the same quality and safety standards as brand-name

drugs.

Generic equivalent

A generic equivalent is a generic prescription drug that has the same active ingredients as its brand-

name counterpart. For a generic drug to be considered “equivalent,” it has to be approved by the FDA as

being interchangeable with that brand-name drug. Under Washington State law, the pharmacist is

2023 UMP Classic (PEBB) Certificate of Coverage 187

required to dispense a generic equivalent in place of a brand-name drug, unless your provider objects.

See “Substitution under Washington State Law” on page 105 for how this works.

Gestational Parent

The individual who carries the pregnancy and gives birth.

Grievance

A grievance is also called a complaint. See the “Complaint and appeal procedures” section for details on

how these are handled.

Habilitative (neurodevelopmental) services

Habilitative (neurodevelopmental) services are health care services that help you keep, learn, or

improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or

talking at the expected age. These services may include physical and occupational therapy, speech-

language pathology, and other services for people with disabilities in a variety of inpatient and/or

outpatient settings.

Health Care Authority (HCA)

The Health Care Authority (HCA) is the Washington State agency that administers the Uniform Medical

Plan (UMP Classic, UMP Select, UMP CDHP, and the UMP Plus plans: UMP Plus–Puget Sound High Value

Network and UMP Plus–UW Medicine Accountable Care Network), in addition to the following health care

programs: Washington Prescription Drug Program, PEBB Program, SEBB Program, Behavioral Health and

Recovery, and Apple Health (also known as Medicaid).

Health intervention

Health intervention is a prescription drug, service, or supply provided to prevent, diagnose, detect, treat,

or palliate the following: disease, illness, injury, genetic or congenital anomaly, pregnancy, or biological or

psychological condition that lies outside the range of normal, age-appropriate human variation. A health

intervention may also maintain or restore functional ability. A health intervention is defined not only by

the intervention itself, but also by the medical condition and patient indications for which it is being

applied. A health intervention is new if it is not yet in widespread use for the medical condition and the

patient indications being considered.

Health outcomes

Health outcomes are results that affect health status as measured by the length or quality (primarily as

perceived by the member) of a person’s life.

High-cost generic drug

High-cost generic drug is a generic prescription drug (see the definition of “Generic drug”) that the plan

covers under Tier 2 (see the “What you pay for prescription drugs” section).

Home health agency

A home health agency is an agency or organization that:

• Provides a program of home health care;

• Practices within the scope of its license as a provider of home health services; and

188 2023 UMP Classic (PEBB) Certificate of Coverage

• Is Medicare-certified, accredited by the Joint Commission on Accreditation of Healthcare Organizations,

or a preferred provider.

Hospice

Hospice is services provided by a state-licensed hospice program in the member’s home or in a hospice

facility to terminally ill members. Hospice care includes services such as pain care relief for terminally ill

members without the intent to cure, and support services for their families.

Hospital

A hospital is an institution accredited under the Hospital Accreditation Program of the Joint Commission

and licensed by the state where it is located. A hospital has a defined course of therapeutic intervention

and special programming in a controlled environment. A hospital also offers a degree of security,

supervision, and structure. Hospital patients must be medically monitored with 24-hour medical

availability and 24-hour onsite services as defined in federal guidelines outlining Conditions of

Participation for Hospitals.

The term hospital does not include a convalescent nursing home or institution (or a part of one) that:

• Furnishes primarily domiciliary or custodial care.

• Is operated as a school.

• Is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged.

Inpatient copay

The inpatient copay is what you pay for inpatient services at a preferred facility, such as a hospital, or

skilled mental health, nursing, or substance use disorder facility. Non-Medicare members pay $200 per

day up to $600 maximum per member per calendar year. Medicare members pay $200 per day up to $600

per facility admission. The inpatient copay does not apply to your medical deductible but does apply to

the medical out-of-pocket limit.

Professional charges, such as for physicians or lab work, may be billed separately and are not included in

this copay.

Inpatient rate

The inpatient rate means that the plan pays 100 percent of the allowed amount after you pay your

deductible and copay at preferred facilities.

The plan pays for professional services, such as provider visits or lab tests, based on the provider’s

network status during an inpatient stay:

• Preferred providers: You pay 15 percent of the allowed amount after you meet your medical

deductible. The plan pays 85 percent of the allowed amount.

Note: For behavioral health professional services, the plan pays 100 percent of the allowed amount.

• Participating providers: You pay 40 percent of the allowed amount after you meet your medical

deductible. The plan pays 60 percent of the allowed amount.

• Out-of-network providers: You pay 40 percent of the allowed amount after you meet your medical

deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The

plan pays 60 percent of the allowed amount.

2023 UMP Classic (PEBB) Certificate of Coverage 189

Inpatient stay

An inpatient stay begins when you are admitted to a hospital or other medical facility, and ends when

you are discharged from that facility.

Independent review organization (IRO)

An independent review organization (IRO) conducts the independent (or external) review of an appeal.

An IRO is a group of medical and benefit experts certified by the Washington State Department of Health

and not related to the plan, Regence BlueShield, WSRxS, or the Health Care Authority. An IRO is intended

to provide unbiased, independent clinical and benefit expertise, as well as evidence-based decision

making while ensuring confidentiality. The IRO reviews your appeal to determine if the plan’s decision is

consistent with state law and the applicable COC. The plan pays the IRO’s charges. See “External review

(independent review)” on page 141.

Intensive Outpatient Program

Intensive Outpatient Program (IOP) is an outpatient program that is licensed as a facility or agency by

the appropriate state agency and is provided under the supervision of a psychiatrist or psychiatric

extender. IOP is intended to provide treatment on an outpatient basis, does not include boarding or

housing, and is intended to provide treatment interventions in a structured setting, with patients returning

to their home environments each day. IOP is a minimum of three hours per day, three days per week.

Limited benefit

TIP: This definition applies only to those benefits in which it is used in this COC. Other benefits

have additional limits related to medical necessity or preauthorization of services (see the

“Limits on plan coverage” section).

A limited benefit is a benefit that is limited to a certain number of visits or a maximum dollar amount.

The limit applies to these benefits even if the provider prescribes additional visits and even if the visits are

medically necessary.

For benefits limited to a certain number of visits, any visits that are applied to your medical deductible

also count against your annual visit or dollar limit. In addition, visits that are paid by another health plan

that is primary apply to the plan limit. For example, if your primary plan applies your first 12 chiropractor

sessions to your medical deductible, you may receive coverage for 12 more sessions in that calendar year,

for a total of 24 visits (the visit maximum for chiropractic services).

These limits apply per member.

Services are counted against a limited benefit according to the type of service, not the provider type.

When a provider practicing within the scope of their license provides services coded under a limited

benefit (e.g., spinal manipulation or physical therapy), those services will be counted against the benefit

regardless of the provider type. In addition, if more than one type of limited benefit service is provided

during a single visit, the services will count against all the limited benefits. For example, if both

manipulation and physical therapy codes are billed for a visit, that visit will count against both the spinal

and extremity manipulation and physical therapy benefit limits.

190 2023 UMP Classic (PEBB) Certificate of Coverage

Maintenance care

Maintenance care is a health intervention after the member has reached maximum rehabilitation

potential or functional level and has shown no significant improvement for one to two weeks, and

instruction in the maintenance program has been completed.

Maintenance care may apply to several different services, including, but not limited to, physical therapy,

speech therapy, neurodevelopmental therapy, home health care, and skilled nursing care.

Medical

Medical generally refers to all plan benefits and services other than those covered under preventive care

and prescription drug benefits (except as the term is used in the eligibility sections of this COC).

Medical benefit

Medical benefit refers to services subject to the medical deductible, and copay or coinsurance. See the

“What you pay for medical services” section for a description of how this works.

Medical emergency

A medical emergency means a medical condition that manifests itself by acute symptoms of sufficient

severity (including severe pain) so that a prudent layperson who has an average knowledge of medicine

and health would reasonably expect that not seeking immediate medical treatment at an emergency

room would result in any one of the following:

• Places the member’s health, or with respect to pregnancy, the health of an unborn child, in serious

jeopardy;

• Causes serious impairment to bodily functions; or

• Causes serious dysfunction of any bodily organ or part.

Medical food

Medical food is food administered under the supervision of a provider, intended for the specific dietary

management of a disease or condition for which there are distinctive nutritional requirements.

Medically necessary or medical necessity

ALERT! The provider or member must provide documentation demonstrating medical

necessity when requested by the plan, or the plan may deny services as not medically

necessary. The plan may not cover some medically necessary services. All benefits or services

that are medically necessary are subject to the plan’s coverage limitations, exclusions, and

provisions of the plan. It is important to review this COC or verify coverage with UMP Customer

Service before receiving services.

Medically necessary or medical necessity means health care services, supplies, prescription drugs, or

interventions that a licensed health care provider recommends and all the following conditions are met:

• The purpose of the service, supply, intervention, or prescription drug is to prevent, evaluate, treat, or

diagnose an illness, injury, disease, or its symptoms.

2023 UMP Classic (PEBB) Certificate of Coverage 191

• The level of service, supply, intervention, prescription drug, or prescription drug dose is appropriate

considering the potential benefits and harm to the member.

• The level of service, supply, intervention, prescription drug, or prescription drug dose is known to be

effective in improving health outcomes.

• The level of service, supply, intervention, prescription drug, or prescription drug dose recommended for

this condition is cost-effective compared to alternative interventions, including no intervention.

• The service, supply, or intervention is not being recommended for reasons of convenience to the

patient or health care provider.

• For services that the HTCC has reviewed, and that UMP has implemented, medical necessity is

established only when HTCC’s coverage conditions are met.

The fact that a physician or other provider prescribes, orders, recommends, or approves a service or

supply, prescription drug, or prescription drug dose does not make it medically necessary.

The plan may require proof that services, interventions, supplies, or prescription drugs (including court-

ordered care) are medically necessary. Depending on the circumstances, such proof may be

documentation about the member’s condition or scientific evidence about the effectiveness of the

treatment.

The plan will not provide benefits if the required proof is not received, or does not adequately justify the

medical necessity of the service, supply, prescription drug, or prescription drug dose. Claims processing

may be delayed if proof of medical necessity is required but not adequately provided by the health

service provider.

The plan uses scientific evidence from peer-reviewed medical literature to determine effectiveness for

services and interventions not yet in widespread use for the medical condition and member indications

being considered.

For services that the HTCC has reviewed, and that UMP has implemented, state law requires that UMP use

the HTCC’s coverage criteria in determining whether the service is medically necessary. When the HTCC

determines that a service is not covered, then the service is not covered by the plan. If the HTCC

determines that a service is covered, then the HTCC’s criteria (if any) determine medical necessity. The

HTCC’s decisions and related documentation are available on the HCA website at

hca.wa.gov/hta.

For services, interventions, supplies, prescription drugs, or prescription drug doses not related to an HTCC

review, the plan first uses scientific evidence, then professional standards, then expert opinion to

determine coverage.

Scientific evidence consists primarily of controlled clinical trials that either directly or indirectly

demonstrate the effect of the intervention on health outcomes. If controlled clinical trials are not available,

observational studies that demonstrate a causal relationship between the intervention and health

outcomes may be used. Partially controlled observational studies and uncontrolled clinical series may be

suggestive, but do not by themselves demonstrate a causal relationship unless the magnitude of the

effect observed exceeds anything that could be explained either by the natural history of the medical

condition or potential experimental biases.

Interventions for which clinical trials have not been conducted because of epidemiological reasons (that is,

rare or new diseases or orphan populations) shall be evaluated based on professional standards of care or

expert opinion.

A level of service, supply, prescription drug, prescription drug dose, or intervention is considered cost

effective if the benefits and harms relative to the costs represent an economically efficient use of

192 2023 UMP Classic (PEBB) Certificate of Coverage

resources for members with this condition. The plan applies this criterion based on the individual

member’s medical situation and characteristics. Cost-effective does not always mean the lowest price.

Preventive services not covered by the plan’s preventive care benefit will still be covered under the

medical benefit or prescription drug benefit if the outlined criteria are met for medical necessity.

Member

A member is an eligible employee, retiree, former employee or former dependent in Continuation

Coverage, survivor, or dependent enrolled in the plan (see also the “Enrollee” definition).

Necessary contact lenses

Necessary contact lenses are contact lenses that are prescribed by your provider for other than elective

or cosmetic purposes. Necessary contact lenses are used to treat specific conditions for which contact

lenses provide better visual correction.

Network

Network is the preferred and participating facilities, providers, and suppliers your health plan contracts

with to provide health care services.

Network pharmacy

A network pharmacy contracts with WSRxS to provide prescription drug coverage to UMP members at the

contracted rate (allowed amount). See the “Where to buy your prescription drugs” section for details

about the advantages of using network pharmacies.

Network provider

A network provider is a preferred or participating provider. See the “Participating provider” definition

and the “Preferred provider” definition for specific details.

Network rate

The network rate means payment at the in-network level.

Network status

Network status refers to whether a provider is preferred, participating, or out-of-network with the plan.

You may find out the network status of your provider by visiting the UMP Provider search or by calling

UMP Customer Service (see Directory for link and contact information).

Network vaccination pharmacy

A network vaccination pharmacy is a pharmacy that contracts with WSRxS to give covered

immunizations to plan members at the preventive rate. You may find out which pharmacies are contracted

on the UMP Prescription drug coverage webpage or by calling WSRxS Customer Service (see Directory for

link and contact information).

Noncovered prescription drugs

Noncovered prescription drugs refer to any drug that is only covered if the member receives an

exception from the plan. Some drugs may be medically necessary, yet still are not covered. See the

"Prescription drugs and products UMP does not cover" section.

2023 UMP Classic (PEBB) Certificate of Coverage 193

Noncovered services

Noncovered services refers to any medical service that is not covered by the plan. Some services may be

medically necessary, yet still are not covered. See the “What the plan does not cover” section. When the

HTCC determines that a service is not covered, then the service is not covered by the plan.

Nonduplication of benefits

Nonduplication of benefits is how UMP coordinates benefits when UMP is your secondary coverage.

When another plan is primary (pays first), that plan pays their normal benefit. UMP then pays up to the

amount we would have paid if UMP had been the primary plan. If the primary plan pays as much or more

than the normal UMP benefit, UMP pays nothing. UMP does not pay the rest of the allowed amount. See

examples on page 124.

Non-network pharmacy

A non-network pharmacy does not contract with WSRxS. See page 100 for what happens if you use a

non-network pharmacy to purchase covered prescription drugs. Non-network pharmacies do not include

excluded pharmacies (see the definition of “Excluded pharmacy”).

Nonprescription alternative

A nonprescription alternative includes an over-the-counter drug, dietary supplement, herbal

supplement, vitamin, mineral, medical food, or medical device that you may buy without a prescription

that has similar safety, efficacy, and ingredients as a prescription drug.

Nonprescription drug

A nonprescription drug includes an over-the-counter drug, dietary supplement, herbal supplement,

vitamin, mineral, medical food, or medical device that you may buy without a prescription.

Normal benefit

The plan’s normal benefit is the dollar amount the plan would normally pay if no other group health plan

had the primary responsibility to pay the claim for a benefit.

Occupational injury or illness

An occupational injury or illness is one resulting from work that is for pay or profit.

Orthognathic and Telegnathic surgery

Orthognathic surgery is surgery to correct conditions of the jaw and face related to structure, growth, or

TMJ disorders, or to correct orthodontic problems that cannot be easily treated with braces.

Telegnathic surgery means skeletal advancement to enlarge and stabilize the pharyngeal airway to treat

obstructive sleep apnea.

Out-of-network provider(s)

An out-of-network provider is a health care provider that is:

• In the Regence BlueShield service area, but is not contracted as part of Regence BlueShield’s PPO

network; or

194 2023 UMP Classic (PEBB) Certificate of Coverage

• Outside the Regence BlueShield service area, but is not contracted with another Blue Cross or Blue

Shield organization in the BlueCard® Program (designated as a provider in the PPO network) to

provide services and supplies to plan members.

See page 16 for a description of how services by these providers are covered.

Out-of-network provider(s), vision

Out-of-network provider(s), vision do not have a contract with VSP.

Out-of-network rate

Out-of-network providers are paid at the out-of-network rate. When you receive medical services from

out-of-network providers, you pay 40 percent of the allowed amount after you meet your medical

deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The

plan pays 60 percent of the allowed amount.

Out-of-pocket limit, medical

The medical out-of-pocket limit is the most you pay during a calendar year for covered medical services

before the plan pays 100 percent of the allowed amount for preferred providers. This limit does not

include your premium, balance-billed charges, or services the plan does not cover. For more information

on how this works, see the “Medical out-of-pocket limit” section.

For this plan, 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.

Out-of-pocket limit, prescription drug

The prescription drug out-of-pocket limit is the most you pay during a calendar year for covered

prescription drugs and products before the plan pays 100 percent of the allowed amount. The out-of-

pocket limit is $2,000 per enrolled member up to a maximum of $4,000 for a family. See page 28 for a list

of services that do not apply to this limit and that you pay even after you have met the limit.

Outpatient rate

The plan’s outpatient rate depends on the provider’s status:

• Preferred providers: You pay 15 percent of the allowed amount after you meet your medical

deductible. The plan pays 85 percent of the allowed amount.

• Participating providers: You pay 40 percent of the allowed amount after you meet your medical

deductible. The plan pays 60 percent of the allowed amount.

• Out-of-network providers: You pay 40 percent of the allowed amount after you meet your medical

deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The

plan pays 60 percent of the allowed amount.

Outpatient surgery center

See the “Ambulatory surgery center (ASC)” definition.

2023 UMP Classic (PEBB) Certificate of Coverage 195

Outward Bound

An international network of outdoor education organizations whose aim is to foster the personal growth

and social skills of participants by using challenging expeditions in the outdoors.

Over-the-counter alternative

An over-the-counter alternative is a drug that you may buy without a prescription that has similar

safety, efficacy, and ingredients as a prescription drug.

Over-the-counter drugs

Over-the-counter drugs are medications you may get without a prescription.

Over-the-counter equivalent

An over-the-counter equivalent is a drug you may buy without a prescription that has identical active

ingredients and strengths as a prescription drug or product in a comparable dosage form.

P&T Committee

See the “Pharmacy & Therapeutics (P&T) Committee” definition.

Partial Hospitalization Program

Partial Hospitalization Program (PHP) is an outpatient program that is provided under the supervision

of an attending psychiatrist or psychiatric extender. PHP is intended to provide treatment on an

outpatient basis, does not include boarding or housing, and is intended to provide treatment

interventions in a structured setting, with patients returning to their home environments each day. PHP is

a minimum of five hours per day, five days per week.

Participating provider

A participating provider is:

• Contracted with Regence BlueShield but is in

another network, and they cannot balance bill

you.

• Considered out of network for your plan.

• Considered network for only the following

services:

▪ Covered preventive services.

▪ Mental health or substance use disorder.

Peer-reviewed medical literature

Peer-reviewed medical literature is scientific studies printed in journals or other publications in which

original manuscripts are published only after being critically reviewed for scientific accuracy, validity, and

reliability by unbiased independent experts. Peer-reviewed medical literature, for example, does not

include information from health-related websites or in-house publications of pharmaceutical

manufacturers.

Pharmacy & Therapeutics (P&T) Committee

Pharmacy & Therapeutics (P&T) Committee is a group of providers and other health care professionals

who review prescription drugs and make recommendations on the status of prescription drugs on the

UMP Preferred Drug List (see “The UMP Preferred Drug List” section for more information).

196 2023 UMP Classic (PEBB) Certificate of Coverage

Physician services

Physician services are health care services provided or coordinated by a licensed medical physician, such

as a:

• Doctor of osteopathic medicine (D.O.)

• Medical doctor (M.D.)

• Naturopathic physician (N.D.)

Find the complete list of covered provider types on the UMP website at

ump.regence.com/pebb/benefits/providers/covered-providers.

Plan

Plan, as referred to in this document, means Uniform Medical Plan Classic (UMP Classic), a self-insured

PPO plan offered by the PEBB Program. In the eligibility sections (see “Eligibility for subscribers and

dependents” on page 152 or 166) “plan” may include other plans not sponsored by the PEBB Program. In

the “If you have other medical coverage” section, “plan” may mean any health insurance coverage.

Preauthorization

Preauthorization is plan approval for coverage of specific services, supplies, or prescription drugs before

they are provided to the member. Preauthorization is not a guarantee of coverage. If you or your provider

do not receive preauthorization for certain medical services or prescription drugs, the plan may deny the

claim. See the “Preauthorizing medical services” section for how this works. A list of medical services that

require preauthorization is available on the UMP Policies that affect your care webpage or by calling UMP

Customer Service (see Directory for link and contact information). See page 102 for information on

prescription drugs that must be preauthorized.

Preferred drug

A preferred drug is a prescription drug that is listed on the UMP Preferred Drug List and covered under

the Preventive, Value Tier, Tier 1, or Tier 2.

Preferred Drug List

The UMP Preferred Drug List is a list available online that specifies how prescription drugs are covered

by the plan. By using this list, you may find out if a prescription drug is covered, how much you will pay, if

the drug must be ordered through the plan’s specialty drug pharmacy, and whether the drug has any

limitations (such as needing preauthorization or quantity limits; see the ”Limits on your prescription drug

coverage” section).

Drugs are designated by “tiers”:

• Preventive Tier drugs (e.g. contraceptives) cost you $0

• Value Tier are cost-effective prescription drugs for treatment of certain chronic conditions

• Tier 1 are primarily generic prescription drugs

• Tier 2 are preferred brand-name prescription drugs and some high-cost generic drugs

The UMP Preferred Drug List is based on the Washington Preferred Drug List and recommendations by

one of the P&T Committees that partner with WSRxS (see the “How UMP decides which prescription

drugs are preferred” section for more information).

2023 UMP Classic (PEBB) Certificate of Coverage 197

Preferred provider(s)

A preferred provider is a provider:

• In the Regence service area and contracted as part of Regence BlueShield’s PPO network; or

• Outside the Regence service area and contracted with another Blue Cross or Blue Shield organization in

the BlueCard® Program (designated as a Provider in the “Preferred Provider Organization (“PPO”)

Network”) to provide services and supplies to plan members.

Preferred Provider Organization (PPO)

A Preferred Provider Organization (PPO) is a health plan that has a network of providers who have

agreed to provide services at discounted rates. Members may self-refer to most specialists. UMP Classic is

a PPO.

Prenatal

Prenatal means during pregnancy.

Prescription cost-limit

The prescription cost-limit is the most you pay for a Value Tier drug, Tier 1 drug, and Tier 2 drug at a

network pharmacy. See the “How the prescription drug cost-limit works” section for more information.

See the “Your prescription drug out-of-pocket limit” section for annual limits to covered prescription drug

costs.

Prescription drug

Prescription drug means a drug approved by the FDA that can be dispensed only with an order given by

a properly authorized person. The designation of a medication as a prescription drug is made by the FDA.

Prescription drug benefit

Prescription drug benefit refers to services subject to the prescription drug deductible and coinsurance.

See the “What you pay for prescription drugs” section for a description of how this works.

Prescription drug out-of-pocket limit

See the “Out-of-pocket limit, prescription drug” definition.

Preventive care

Preventive care means those services described by the Public Health Services Act, Section 2713:

• Covered immunizations recommended by the CDC.

• Evidence-informed preventive care and screenings for women as described in HRSA Guidelines in

accordance with 45 CFR §147.130 (a)(iv).

• Evidence-informed preventive care screenings for infants, children, and adolescents supported by the

Health Resources and Services Administration (HRSA).

• Services with an A or B rating by the U.S. Preventive Services Task Force.

198 2023 UMP Classic (PEBB) Certificate of Coverage

Preventive rate

Covered preventive services are not subject to the medical deductible. The plan’s preventive rate

depends on the provider’s status:

• Preferred providers: You pay $0. The plan pays 100 percent of the allowed amount.

• Participating providers: You pay $0. The plan pays 100 percent of the allowed amount.

• Out-of-network providers: You pay 40 percent of the allowed amount after you meet your medical

deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The

plan pays 60 percent of the allowed amount.

Primary care provider (PCP)

A primary care provider (PCP) is a physician (see the “Physician services” definition), nurse practitioner,

or physician assistant who provides, coordinates, or helps a member access a range of health care

services. See page 18 for a list of specialties that may be a primary care provider.

Primary payer

The primary payer is the insurance plan that processes the claim first when a member has more than one

group insurance plan covering the services and the plans must coordinate benefits.

Professional services

Professional services are non-facility medical services performed by professional providers, including,

but not limited to, medical doctors, doctors of osteopathy, naturopathic physicians, and advanced

registered nurse practitioners.

Provider

A provider is an individual medical professional (such as a doctor or nurse), hospital, skilled nursing

facility, pharmacy, program, equipment and supply vendor, or other facility, organization, or entity that

provides care or bills for health care services or products.

Provider network

A provider network is a group of providers who negotiate a contract with Regence BlueShield to provide

health care services to plan members. These providers have agreed to see members under certain rules,

including billing at contracted rates (see the “Allowed amount, medical services” definition). The Regence

BlueShield, including the BlueCard Program, provider network for UMP Classic members in 2023 consist of

preferred and participating providers.

Public Employees Benefits Board (PEBB)

The Public Employees Benefits Board (PEBB), is a group of representatives, appointed by the governor,

who approves insurance benefit plans for employees and their dependents, and establishes eligibility

criteria for participation in insurance benefit plans.

Public Employees Benefits Board (PEBB) plan

A Public Employees Benefits Board (PEBB) plan is one of several health benefit plans, including the

Uniform Medical Plan (UMP Classic, UMP Select, UMP Consumer-Directed Health Plan, and UMP Plus

plans: UMP Plus–Puget Sound High Value Network and UMP Plus–UW Medicine Accountable Care

Network), offered through the PEBB Program to eligible public employees, former employees and

2023 UMP Classic (PEBB) Certificate of Coverage 199

dependents in Continuation Coverage, retirees, survivors, and their eligible dependents. The PEB Board

designs benefits and eligibility and is administered by HCA as part of a comprehensive benefits package.

Public Employees Benefits Board (PEBB) Program

The Public Employees Benefits Board (PEBB) Program is the HCA program that administers PEBB

benefit eligibility and enrollment.

Quantity limit

A quantity limit is a limit on how much of a prescription drug you may get for a specific time period

(days’ supply).

Reconstructive surgery

Reconstructive surgery is surgery and follow-up treatment needed to correct or improve a part of the

body because of birth defects, accidents, injuries, or medical conditions.

Regence BlueShield service area

The Regence BlueShield service area means the Washington counties of Clallam, Columbia, Cowlitz,

Grays Harbor, Jefferson, King, Kitsap, Klickitat, Lewis, Mason, Pacific, Pierce, San Juan, Skagit, Skamania,

Snohomish, Thurston, Yakima, Wahkiakum, Walla Walla, Whatcom, and any other areas designated by

Regence. Check the Regence website at regence.com for up-to-date information.

Rehabilitative services

Rehabilitative services are health care services that help you keep, get back, or improve skills and

functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These

services may include physical and occupational therapy, speech-language pathology, and psychiatric

rehabilitation services in a variety of inpatient and/or outpatient settings.

Residential treatment facility

Residential treatment facility means a facility that offers a defined course of therapeutic intervention

and special programming in a controlled environment; offers a degree of security, supervision, and

structure; and is licensed by the appropriate state and local authority to provide such services. Patients

also must be medically monitored with 24-hour medical availability and 24-hour onsite clinician services.

Residential treatment facilities typically do not include halfway houses; supervised living; group homes;

wilderness courses or camps; Outward Bound; outdoor youth programs; boarding houses; or settings that

primarily either focus on building self-esteem or leadership skills or provide a supportive environment to

address long-term social needs. However, services by providers in such settings may be covered if they

are billed separately and otherwise would be covered.

Respite care

Respite care is continuous care for a homebound hospice member of more than four hours a day to

provide family members temporary relief from caring for the member.

Routine

Routine services are those provided as preventive, not because of an injury or illness. In the case of

covered immunizations, routine refers to covered immunizations included on the CDC schedules (see

page 66).

200 2023 UMP Classic (PEBB) Certificate of Coverage

Same-day surgery center

See the “Ambulatory surgery center (ASC)” definition.

School Employees Benefits Board (SEBB)

The School Employees Benefits Board (SEBB) is a group of representatives, appointed by the governor,

who designs and approves insurance benefit plans for school employees and their dependents, and

establishes eligibility criteria for participation in insurance benefit plans.

School Employees Benefits Board (SEBB) Program

The School Employees Benefits Board (SEBB) Program is the program within HCA that administers

insurance and other benefits for eligible school employees and eligible dependents.

Scientific evidence

Scientific evidence means scientific studies published in or accepted for publication by medical journals

that meet nationally recognized requirements for scientific manuscripts and that submit most of their

published articles for review by experts who are not part of the editorial staff. Scientific evidence also

refers to findings, studies, or research conducted by or under the auspices of federal government

agencies and nationally recognized federal research institutes. However, scientific evidence does not

include published peer-reviewed literature sponsored to a significant extent by a pharmaceutical

manufacturing company or medical device manufacturer or a single study without other supportable

studies.

Scope of practice

Scope of practice refers to the services a provider may perform and bill for, based on the provider’s

professional license as issued by local authorities. For example, some provider types may prescribe

prescription drugs, and some may not.

Screening

Screening refers to services performed to prevent or detect illness in the absence of disease or

symptoms.

Secondary coverage

When you are covered by more than one group health plan, you have secondary coverage that may pay

a part or the rest of a provider’s bill after your primary payer has paid. See the “If you have other medical

coverage” section for more information on how this plan coordinates benefits.

Skilled nursing care

Skilled nursing care is services from licensed nurses in your own home or in a nursing home. Skilled care

services are from technicians and therapists in your own home or in a nursing home.

Skilled nursing facility

A skilled nursing facility is an institution, or part of an institution, that provides skilled nursing care 24

hours a day and is classified as a skilled nursing facility by Medicare. Medicaid-eligible, long-term care

facilities are not necessarily skilled nursing facilities.

2023 UMP Classic (PEBB) Certificate of Coverage 201

SmartHealth

SmartHealth is a voluntary wellness program offered by the PEBB Program that allows eligible

subscribers to qualify for wellness incentives. Employees who waive medical enrollment and eligible

retirees who defer PEBB retiree insurance coverage are not eligible to qualify for the incentive.

Qualifying for the wellness incentive during the 2022 plan year reduces the subscriber’s 2023 plan year

medical deductible by $125 if the subscriber is still eligible to participate in the wellness incentive

program. Qualifying for the wellness incentive during the 2023 plan year reduces the subscriber’s 2024

plan year deductible by $125 if the subscriber is still eligible to participate in the wellness incentive

program and is enrolled in the 2024 plan year. More details on eligibility and program requirements are

on HCA's SmartHealth webpage at hca.wa.gov/pebb-smarthealth.

Special rate

The plan’s special rate is for services that have unique payment rules. These rules are described in the

table (see the “How much you pay for covered services” column) located in the “Types of services” section.

Specialty drugs

Specialty drugs are high-cost injectable, infused, oral, or inhaled prescription drugs or products that

require special storage or handling and are subject to additional rules. Specialty drugs are identified on

the UMP Preferred Drug List. See page 104 for information on how specialty drug prescriptions are

handled.

Standard rate

The plan’s standard rate depends on the provider’s status:

• Preferred providers: You pay 15 percent of the allowed amount after you meet your medical

deductible. The plan pays 85 percent of the allowed amount.

• Participating providers: You pay 40 percent of the allowed amount after you meet your medical

deductible. The plan pays 60 percent of the allowed amount.

• Out-of-network providers: You pay 40 percent of the allowed amount after you meet your medical

deductible. You pay all charges billed to you above the allowed amount (known as balance billing). The

plan pays 60 percent of the allowed amount.

Standard reference compendium

Standard reference compendium refers to any of these sources:

• The American Hospital Formulary Service Drug Information

• The American Medical Association Drug Evaluation

• The United States Pharmacopoeia Drug Information

• Other authoritative compendia as identified from time to time by the U.S. Secretary of Health and

Human Services

State Agency

State agency means an office, department, board, commission, institution, or other separate unit or

division, however designated, of the Washington state government. It includes the legislature, executive

branch, and agencies or courts within the judicial branch, as well as institutions of higher education and

any unit of state government established by law.

202 2023 UMP Classic (PEBB) Certificate of Coverage

State-registered domestic partner

State-registered domestic partner means an adult who meets the requirements for a valid state-

registered domestic partnership and has been issued a certificate of state-registered domestic partnership

by the Washington State Secretary of State, or an adult whose legal union (other than a marriage) was

validly formed in another jurisdiction and is substantially equivalent to a domestic partnership under

Washington law.

Subscriber

A subscriber is an eligible employee, retiree, former employee or former dependent in Continuation

Coverage, or survivor who is the primary certificate holder and plan member.

Substance use disorder

Substance use disorder is an illness characterized by a physiological or psychological dependency on a

controlled substance or alcohol.

Substance use disorder facility

A substance use disorder facility is an institution, or part of an institution, that specifically treats

dependency on a controlled substance or alcohol and meets all of these criteria:

• Is certified by the Washington State Division of Behavioral Health and Recovery (DBHR), or for facilities

outside of the Regence BlueShield service area, is contracted with the local BlueCard® network

• Is licensed by the state

• Keeps adequate patient records that contain course of treatment, progress, discharge summary, and

follow-up programs

• Performs services under full-time supervision of a physician or registered nurse

• Provides services, for a fee, to persons receiving substance use disorder treatment, including room and

board, as well as 24-hour nursing

Therapeutic alternative

A therapeutic alternative is a drug that is not chemically identical to a nonpreferred drug but has similar

effects when given in therapeutically equivalent doses.

Therapeutic equivalent

A therapeutic equivalent is a drug that is chemically identical to a nonpreferred drug and is expected to

have the same effectiveness and toxicity when given in the same doses.

Therapeutic interchange

Therapeutic interchange is when a pharmacist, with the endorsing provider’s permission (see page 106),

substitutes a nonpreferred prescription drug with a preferred drug that is a therapeutic alternative or

equivalent.

Tier

A prescription drug’s tier tells you how much you will have to pay for a covered prescription drug. The

UMP prescription drug benefit categorizes covered prescription drugs into four tiers. See the "What you

pay for prescription drugs" section for details on the prescription drug tiers.

2023 UMP Classic (PEBB) Certificate of Coverage 203

Tobacco cessation services

Tobacco cessation services are provided for quitting tobacco use through counseling and nicotine

replacement therapy products.

Unicompartmental

Unicompartmental refers to a diagnosis or procedure affecting only one part, or “component,” of a joint

(e.g. knee) as opposed to more than one part of a joint.

Uniform Medical Plan Classic (UMP Classic)

Uniform Medical Plan Classic (UMP Classic) is a self-insured PPO health plan offered through the PEBB

Program and managed by HCA.

Value Tier

Value Tier refers to cost-effective prescription drugs that are used to treat certain chronic conditions. See

the "What you pay for prescription drugs" section for details. Use the UMP Preferred Drug List by visiting

hca.wa.gov/ump-pdl to find Value Tier drugs.

VSP Choice network provider, vision

VSP Choice network provider, vision means an optometrist or ophthalmologist licensed and otherwise

qualified to practice vision care and/or provide vision care materials who has contracted with VSP to

provide vision care services and/or vision care materials to members. This plan’s provider network is VSP

Choice.

Disclosures

If you need this document in another format or if you need information about how to file a discrimination

complaint, read the Regence nondiscrimination and language assistance notice by visiting

hca.wa.gov/regence-nondiscrimination.

Advice24, Ardon Health, CoverMyMeds, Moda Health, Postal Prescription Services (PPS), Costco Mail-

Order Pharmacy, Washington State Rx Services (WSRxS), Premera Blue Cross, and SmartHealth do not

provide Blue Cross Blue Shield services and are separate companies solely responsible for their

products/services.

VSP is a separate company that provides vision services.

Doctor On Demand is a separate company that provides telehealth services.

Quartet is a separate company that provides assistance accessing behavioral health services.

Pregnancy program is a separate company that provides maternity support.

Omada Health is a separate company that provides diabetes prevention program.

2nd.MD is a separate company that provides treatment decision support through their Expert Second

Opinion program.

Quit for Life is a separate company that provides tobacco cessation support. Regence BlueShield serves

select counties in the state of Washington and is an Independent Licensee of the Blue Cross and Blue

Regence BlueShield 1800 Ninth Avenue | Seattle, WA 98101