UMP Classic COC (2024)
2024 UMP Classic (PEBB) Certi昀椀cate of Coverage Self-insured by the State of Washington · E昀昀ective January 1, 2024 Printed under the direction of the Washington State Health Care Authority Public Employees Bene昀椀ts Board (PEBB) HCA 54-0015 (8/23)
2024 UMP Classic (PEBB) Certificate of Coverage Directory Directory: medical services Contact type and description Contact information UMP Customer Service Call: 1-888-849-3681 (TRS: 711) Contact UMP Customer Service Monday–Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. for questions about your medical (Pacific) benefits, including information Chat now: Sign in to your Regence account at on behavioral health support ump.regence.com/ump/signin to chat now services, the expert second Monday–Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. opinion program, your care (Pacific) management benefit, and more. Email: Send secure email via your Regence account at ump.regence.com/ump/signin Visit: UMP website at ump.regence.com/pebb If you are outside the U.S. and you have questions about your benefits and coverage, you can use email, chat now, or Skype to contact UMP Customer Service. You may request to have a customer service representative contact you at a scheduled time during normal business hours. If you are outside the U.S. and need to find a local provider, make an appointment, or be hospitalized, call Blue Cross Blue Shield Global® Core at 1-800-810-2583 or call collect at 1-804-673-1177, 24 hours a day, 7 days a week. You can also use the online provider search tool on the Blue Cross Blue Shield Global Core website at bcbsglobalcore.com. Network provider directory Call: 1-888-849-3681 (TRS: 711) Monday–Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific) Chat now: Sign in to your Regence account at ump.regence.com/ump/signin to chat now Monday–Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific) Provider search: ump.regence.com/go/pebb/UMP-Classic 2024 UMP Classic (PEBB) Certificate of Coverage 1
Contact type and description Contact information Medical appeals and grievances Call: 1-888-849-3681 (TRS: 711) (aka complaints) Monday–Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific) Chat now: Sign in to your Regence account at ump.regence.com/ump/signin to chat now Monday–Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific) Fax: 1-877-663-7526 Online: Sign in to your secure Regence account at ump.regence.com/ump/signin. Go to Appeals to appeal online. Email: [email protected] Mail: UMP Appeals and Grievances Regence BlueShield PO Box 1106 Lewiston, ID 83501-1106 Preauthorization Call: 1-888-849-3682 (TRS: 711) For providers submitting medical Monday–Friday: 7 a.m. to 5 p.m. (Pacific) service preauthorization requests Fax: 1-844-679-7763 Visit: availity.com Access to medical claims Visit: Sign in to your Regence account at ump.regence.com/ump/signin Claims Fax: 1-877-357-3418 For members submitting medical Mail: service claims Regence BlueShield Attn: UMP Claims PO Box 1106 Lewiston, ID 83501-1106 Coordination of benefits Call: 1-888-849-3681 (TRS: 711) to request a form Contact UMP if you or your Visit: UMP commonly used forms available online webpage at dependents have other insurance ump.regence.com/pebb/forms/common-forms and under to make sure your claims are Medical forms choose the “Multiple Coverage Inquiry” form processed correctly. You may fax Fax: 1-877-357-3418 or mail the “Multiple Coverage Mail: Inquiry” form to UMP. Regence BlueShield Attn: UMP Claims PO Box 1106 Lewiston, ID 83501-1106 Medicare Call: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) 24 hours, 7 days a week Visit: medicare.gov or MyMedicare.gov 2 2024 UMP Classic (PEBB) Certificate of Coverage
Contact type and description Contact information Eligibility, enrollment, and Employees: Contact your payroll or benefits office address changes Continuation Coverage and retired employees of a former employer group: Call the PEBB Program: 1-800-200-1004 (TRS: 711) Retirees: Call the PEBB Program: 1-800-200-1004 (TRS: 711) Monday–Friday: 8 a.m. to 4:30 p.m. (Pacific) Visit: hca.wa.gov/erb Medical policies that affect Visit: Policies that affect your care webpage at coverage or care ump.regence.com/pebb/benefits/policies Including preauthorization, Health Technology Clinical Committee (HTCC) information, clinical policies, and drugs covered under medical benefits 2024 UMP Classic (PEBB) Certificate of Coverage 3
Directory: vision services Contact type and Contact information description UMP vision benefits Visit: UMP Vison benefits webpage at Get an overview of your vision ump.regence.com/pebb/benefits/vision benefit Vision Service Plan (VSP) Call: 1-844-299-3041 Member Services Monday–Friday: 6 a.m. to 8 p.m.; Saturday: 7 a.m. to 8 p.m.; Sunday 8 a.m. to 8 p.m. (Pacific). If you are outside of the U.S. dial the exit code of your country, which is typically 00, and then 1-916-635-7373. Deaf, DeafBlind, Late Deafened and Hard of Hearing members call (TTY): 1-800-428-4833 Monday–Saturday: 6 a.m. to 5 p.m.; Sunday 5 a.m. to 8 p.m. (Pacific). If you are outside of the U.S. dial the exit code of your country, which is typically 00, and then 1-916-851-1375. Visit: VSP website at vsp.com Mail: Vision Service Plan PO Box 997100 Sacramento, CA 95899-7100 VSP provider directory Provider search: Create an account on the VSP website at vsp.com and log in to find a VSP Choice network provider. If you don’t have an account, you can visit the VSP website at vsp.com/eye-doctor, use the Advanced search, and select “Choice” for the “Doctor network” to find a provider. Call: 1-844-299-3041 Monday–Friday: 6 a.m. to 8 p.m.; Saturday: 7 a.m. to 8 p.m.; Sunday 8 a.m. to 8 p.m. (Pacific) Deaf, DeafBlind, Late Deafened and Hard of Hearing members call (TTY): 1-800-428-4833 Monday–Saturday: 6 a.m. to 5 p.m.; Sunday 5 a.m. to 8 p.m. (Pacific) VSP appeals Call: 1-844-299-3041 to submit an expedited appeal (will be processed within 24 hours) Monday–Friday: 6 a.m. to 8 p.m.; Saturday: 7 a.m. to 8 p.m.; Sunday 8 a.m. to 8 p.m. (Pacific) Deaf, DeafBlind, Late Deafened and Hard of Hearing members call (TTY): 1-800-428-4833 Monday–Saturday: 6 a.m. to 5 p.m.; Sunday 5 a.m. to 8 p.m. (Pacific) Mail: To appeal in writing with VSP, including expedited appeals: Vision Service Plan Attn: Appeals Department PO Box 2350 Rancho Cordova, CA 95741 4 2024 UMP Classic (PEBB) Certificate of Coverage
VSP complaints Call: 1-844-299-3041 Monday–Friday: 6 a.m. to 8 p.m.; Saturday: 7 a.m. to 8 p.m.; Sunday 8 a.m. to 8 p.m. (Pacific) Deaf, DeafBlind, Late Deafened and Hard of Hearing members call (TTY): 1-800-428-4833 Monday–Saturday: 6 a.m. to 5 p.m.; Sunday 5 a.m. to 8 p.m. (Pacific) Visit: VSP website at vsp.com/contact-us/grievance and complete the online form. Mail: Vision Service Plan Attention: Complaint and Grievance Unit PO Box 997100 Sacramento, CA 95899-7100 VSP Claims Call: 1-844-299-3041 to request a VSP Member Reimbursement Form. Monday–Friday: 6 a.m. to 8 p.m.; Saturday: 7 a.m. to 8 p.m.; Sunday 8 a.m. to 8 p.m. (Pacific) Deaf, DeafBlind, Late Deafened and Hard of Hearing members call (TTY): 1-800-428-4833 to request a VSP Member Reimbursement Form. If you are outside of the U.S. and you need to submit a claim form for services received outside the U.S. dial the exit code of your country, which is typically 00, and then 1-916-851-1375. Monday–Saturday: 6 a.m. to 5 p.m.; Sunday 5 a.m. to 8 p.m. (Pacific) Visit: VSP website at vsp.com/claims/submit-oon-claim and select “Start new claim” to submit an out-of-network claim online Mail: Vision Service Plan Attention: Claims Services PO Box 495918 Cincinnati, OH 45249-5918 2024 UMP Classic (PEBB) Certificate of Coverage 5
Directory: prescription drug services Contact type and description Contact information Prescription drugs Washington State Rx Services (WSRxS) Contact customer service, locate Call: 1-888-361-1611 (TRS: 711) network pharmacies, ask Monday–Friday: 7:30 a.m. to 5:30 p.m. (Pacific) prescription drug questions, access Available outside these hours with limited services. your WSRxS account, and check Visit: Prescription drug coverage webpage at prescription drug prices ump.regence.com/pebb/benefits/prescriptions Network mail-order pharmacies Costco Mail-Order Pharmacy Order new prescriptions and refills, UMP members do not need to be Costco members to use check order status, manage their mail-order service. prescriptions, track your package Call: 1-800-607-6861 (TRS: 711) Monday–Friday: 5 a.m. to 7 p.m.; Saturday: 9:30 a.m. to 2 p.m. (Pacific) Providers fax: 1-800-633-0334 Mailing a prescription order: Costco Pharmacy (#581) 802 134th St SW STE 140 Everett, WA 98204-7314 Visit: Sign in to your Costco account at pharmacy.costco.com Postal Prescription Services (PPS) Call: 1-800-552-6694 (TRS: 711) Monday–Friday: 6 a.m. to 6 p.m.; Saturday: 9 a.m. to 2 p.m. (Pacific) Providers fax: 1-800-723-9023 Mailing a prescription order: Postal Prescription Services PO Box 2718 Portland, OR 97208-2718 Visit: Sign in to your PPS account at ppsrx.com Network specialty drug pharmacy Ardon Health Order new prescriptions and refills Call: 1-855-425-4085 (TRS: 711) for specialty drugs Monday–Friday: 8 a.m. to 7 p.m.; Saturday: 8 a.m. to 12 p.m. (Pacific) Closed Sundays and all major holidays For urgent health questions that require the assistance of a clinician after-hours, you can reach an Ardon Health pharmacist 24 hours a day, seven days a week, by calling 1-855-425-4085 and following the prompts. Providers fax: 1-855-425-4096 6 2024 UMP Classic (PEBB) Certificate of Coverage
Contact type and description Contact information Visit: ardonhealth.com Email: [email protected] (This email is not secure.) Prescription drug appeals and WSRxS complaints Call: 1-888-361-1611 (TRS: 711) Monday–Friday: 7:30 a.m. to 5:30 p.m. (Pacific) Fax appeals to: 1-866-923-0412 Mail: WSRxS Attn: Appeal Unit PO Box 40168 Portland, OR 97240-0168 Prescription drug WSRxS preauthorization Call: 1-888-361-1611 (TRS: 711) For providers and pharmacists Monday–Friday: 7:30 a.m. to 5:30 p.m. (Pacific) submitting prescription drug Fax: 1-800-207-8235 preauthorization requests, including Visit: covermymeds.com requests for an exception for noncovered prescription drugs or changing quantity limits Prescription drug claims WSRxS Call: 1-888-361-1611 (TRS: 711) Monday–Friday: 7:30 a.m. to 5:30 p.m. (Pacific) Fax: 1-855-668-8550 Mail: Pharmacy Manual Claims PO Box 999 Appleton, WI 54912-0999 Visit: Find claim forms by visiting forms and publications at hca.wa.gov/ump-forms-pubs Coordination of benefits WSRxS Contact WSRxS if you or your Call: 1-888-361-1611 (TRS: 711) to request a form. dependents have other insurance to Visit: UMP commonly used forms available online webpage at make sure your claims are processed ump.regence.com/pebb/forms/common-forms and under correctly. You may fax, email, or mail Prescription drug forms choose the “WSRxS Multiple the “WSRxS Multiple Prescription Prescription Drug Coverage Inquiry” form Drug Coverage Inquiry” form to Fax: 1-855-668-8550 WSRxS. Email: Send email through your WSRxS account at ump.regence.com/pebb/benefits/prescriptions (This email is not secure) Mail: Pharmacy Manual Claims PO Box 999 Appleton, WI 54912-0999 2024 UMP Classic (PEBB) Certificate of Coverage 7
Table of Contents Directory .................................................................................................................................................................................................. 1 Directory: medical services ......................................................................................................................................................... 1 Directory: vision services ............................................................................................................................................................. 4 Directory: prescription drug services ..................................................................................................................................... 6 Online services ................................................................................................................................................................................... 13 How to use this certificate of coverage ................................................................................................................................. 14 Section for Medicare retirees ................................................................................................................................................. 14 About UMP Classic .......................................................................................................................................................................... 14 Accumulators ..................................................................................................................................................................................... 14 Finding a health care provider ................................................................................................................................................... 15 Sample payments to different provider network status ............................................................................................ 17 How to find a preferred provider ......................................................................................................................................... 17 Covered and noncovered provider types ......................................................................................................................... 18 Primary care providers .............................................................................................................................................................. 18 When you do not have access to a preferred provider: network waiver ........................................................... 19 When and how to request a network waiver .................................................................................................................. 19 Out-of-area services ................................................................................................................................................................... 20 Services received outside the United States ................................................................................................................... 22 What you pay for medical services .......................................................................................................................................... 23 Deductibles ..................................................................................................................................................................................... 23 Coinsurance .................................................................................................................................................................................... 25 Copay ................................................................................................................................................................................................ 26 When you pay ............................................................................................................................................................................... 26 Medical out-of-pocket limit .................................................................................................................................................... 27 Summary of services and payments ........................................................................................................................................ 28 Deductibles and limits ............................................................................................................................................................... 28 Types of services .......................................................................................................................................................................... 29 What else you need to know .................................................................................................................................................. 32 Benefits: what the plan covers ................................................................................................................................................... 32 Guidelines for coverage ............................................................................................................................................................ 32 Health Technology Clinical Committee (HTCC) ............................................................................................................. 33 Summary of benefits .................................................................................................................................................................. 34 List of benefits ............................................................................................................................................................................... 37 Acupuncture .............................................................................................................................................................................. 37 Ambulance ................................................................................................................................................................................. 37 8 2024 UMP Classic (PEBB) Certificate of Coverage
Applied Behavior Analysis (ABA) Therapy ................................................................................................................... 38 Autism treatment .................................................................................................................................................................... 39 Bariatric surgery ....................................................................................................................................................................... 39 Behavioral health .................................................................................................................................................................... 39 Breast health screening tests ............................................................................................................................................. 42 Care Gap Closure Program ................................................................................................................................................. 42 Care management .................................................................................................................................................................. 43 Chiropractic physician services ......................................................................................................................................... 43 Dental services.......................................................................................................................................................................... 44 Diabetes care supplies .......................................................................................................................................................... 45 Diabetes Control Program .................................................................................................................................................. 46 Diabetes education ................................................................................................................................................................ 46 Diabetes Prevention Program (DPP) .............................................................................................................................. 46 Diagnostic tests, laboratory, and x-rays ....................................................................................................................... 47 Dialysis ......................................................................................................................................................................................... 47 Durable medical equipment (DME), supplies, and prostheses........................................................................... 48 Emergency room ..................................................................................................................................................................... 50 End-of-life counseling .......................................................................................................................................................... 50 Family planning services ...................................................................................................................................................... 50 Foot care, maintenance ........................................................................................................................................................ 52 Gender affirming care ........................................................................................................................................................... 52 Genetic services ....................................................................................................................................................................... 52 Headaches, chronic migraine or chronic tension type ........................................................................................... 52 Hearing care (diseases and disorders of the ear) ..................................................................................................... 52 Hearing exam and hearing aids (instruments) .......................................................................................................... 53 Home health care .................................................................................................................................................................... 54 Hospice care .............................................................................................................................................................................. 54 Hospital services ...................................................................................................................................................................... 56 Infusion drug site of care program ................................................................................................................................. 57 Joint replacement surgery, knees and hips in the Centers of Excellence (COE) Program ..................... 57 Knee arthroplasty, total ........................................................................................................................................................ 60 Mammogram and Digital Breast Tomosynthesis (DBT) ........................................................................................ 61 Massage therapy ..................................................................................................................................................................... 61 Mastectomy and breast reconstruction ........................................................................................................................ 62 Mental health ............................................................................................................................................................................ 62 Naturopathic physician services ....................................................................................................................................... 62 Nurse line .................................................................................................................................................................................... 62 2024 UMP Classic (PEBB) Certificate of Coverage 9
Nutrition counseling and therapy ................................................................................................................................... 62 Obstetric and newborn care ............................................................................................................................................... 62 Office visits ................................................................................................................................................................................. 64 Orthognathic and Telegnathic surgery ......................................................................................................................... 65 Pain and joint management, interventional ............................................................................................................... 65 Prescription drugs................................................................................................................................................................... 65 Preventive care ......................................................................................................................................................................... 65 Radiology .................................................................................................................................................................................... 67 Second opinions ...................................................................................................................................................................... 68 Skilled nursing facility ........................................................................................................................................................... 68 Sleep therapy ............................................................................................................................................................................ 69 Spinal and extremity manipulations............................................................................................................................... 70 Spinal injections ....................................................................................................................................................................... 70 Spinal surgery ........................................................................................................................................................................... 70 Spine care in the Centers of Excellence (COE) Program ........................................................................................ 70 Substance use disorder ........................................................................................................................................................ 73 Surgery ......................................................................................................................................................................................... 73 Temporomandibular joint (TMJ) disorder treatment ............................................................................................. 74 Therapy: Habilitative and Rehabilitative ...................................................................................................................... 74 Tobacco cessation services ................................................................................................................................................. 75 Transplants ................................................................................................................................................................................. 77 Urgent care ................................................................................................................................................................................ 77 Virtual care ................................................................................................................................................................................. 77 Vision care (diseases and disorders of the eye) ........................................................................................................ 79 Your routine vision benefits ........................................................................................................................................................ 79 Finding a routine vision provider ......................................................................................................................................... 79 Adults (age 19 or older) ............................................................................................................................................................ 80 Children (under age 19) ............................................................................................................................................................. 84 Vision claims administration .................................................................................................................................................. 86 Vision complaints and appeals .............................................................................................................................................. 86 Your prescription drug benefit .................................................................................................................................................. 87 The UMP Preferred Drug List ................................................................................................................................................. 88 How UMP decides which prescription drugs are preferred ..................................................................................... 90 Guidelines for prescription drugs UMP covers .............................................................................................................. 90 What you pay for prescription drugs ................................................................................................................................. 92 How the prescription drug cost-limit works ................................................................................................................... 96 Your prescription drug out-of-pocket limit..................................................................................................................... 97 10 2024 UMP Classic (PEBB) Certificate of Coverage
Where to buy your prescription drugs .............................................................................................................................. 98 Limits on your prescription drug coverage ................................................................................................................... 101 What to do if the plan denies coverage .......................................................................................................................... 107 Prescription drugs and products UMP does not cover ............................................................................................ 107 Limits on plan coverage .............................................................................................................................................................. 108 Preauthorizing medical services ......................................................................................................................................... 108 General information from UMP Customer Service ..................................................................................................... 111 What the plan does not cover .................................................................................................................................................. 111 If you have other medical coverage ...................................................................................................................................... 121 Coordination of benefits ........................................................................................................................................................ 122 Contact UMP and WSRxS ....................................................................................................................................................... 122 Who pays first ............................................................................................................................................................................. 122 For retirees enrolled in Medicare and UMP Classic ........................................................................................................ 127 Are you a Medicare retiree? .................................................................................................................................................. 127 How UMP Classic and Medicare work together .......................................................................................................... 127 When you pay: How billing works ..................................................................................................................................... 131 Why you might get a COB savings check from UMP Classic ................................................................................. 132 How UMP Classic prescription drug coverage works with Medicare ................................................................ 132 Where to go for more information ................................................................................................................................... 133 Billing and payment: submitting a claim ............................................................................................................................. 133 Submitting a claim for medical services.......................................................................................................................... 134 Submitting a claim for prescription drugs ..................................................................................................................... 135 False claims or statements ..................................................................................................................................................... 136 Complaint and appeal procedures ......................................................................................................................................... 137 What is a complaint (aka: grievance)? ............................................................................................................................. 137 How to submit a complaint (aka: grievance) ................................................................................................................ 137 What is an appeal? .................................................................................................................................................................... 137 The appeals process ................................................................................................................................................................. 138 Complaints about quality of care ....................................................................................................................................... 142 Appeals related to eligibility................................................................................................................................................. 142 Where to send complaints or appeals ............................................................................................................................. 142 When another party is responsible for injury or illness ................................................................................................ 143 Occupational injury or illness (workers’ compensation) claims ........................................................................... 143 Legal rights and responsibilities ......................................................................................................................................... 143 Fees and expenses ..................................................................................................................................................................... 144 Services covered by other insurance ................................................................................................................................ 145 Motor vehicle coverage .......................................................................................................................................................... 145 2024 UMP Classic (PEBB) Certificate of Coverage 11
Future medical expenses ........................................................................................................................................................ 145 General provisions ......................................................................................................................................................................... 145 What you need to know: your rights and responsibilities ...................................................................................... 145 Relationship to Blue Cross and Blue Shield Association .......................................................................................... 149 Right to receive and release needed information ...................................................................................................... 149 Right of recovery ....................................................................................................................................................................... 149 Limitations on liability ............................................................................................................................................................. 149 Governing law ............................................................................................................................................................................. 150 Anti-assignment ......................................................................................................................................................................... 150 No waiver ...................................................................................................................................................................................... 150 Acronyms ........................................................................................................................................................................................... 151 Eligibility and enrollment ........................................................................................................................................................... 152 Eligibility for subscribers and dependents ..................................................................................................................... 152 Enrollment for subscribers and dependents ................................................................................................................. 153 Medicare eligibility and enrollment .................................................................................................................................. 156 When medical coverage begins .......................................................................................................................................... 156 Making changes ......................................................................................................................................................................... 158 When medical coverage ends .............................................................................................................................................. 163 General provisions for eligibility and enrollment ....................................................................................................... 166 Eligibility and enrollment for a retiree or survivor .......................................................................................................... 167 Eligibility for subscribers and dependents ..................................................................................................................... 167 Enrollment for subscribers and dependents ................................................................................................................. 169 Medicare eligibility and enrollment .................................................................................................................................. 171 When medical coverage begins .......................................................................................................................................... 172 Making changes ......................................................................................................................................................................... 173 When medical coverage ends .............................................................................................................................................. 178 General provisions for eligibility and enrollment ....................................................................................................... 180 Definitions ......................................................................................................................................................................................... 181 Disclosures ......................................................................................................................................................................................... 205 12 2024 UMP Classic (PEBB) Certificate of Coverage
Online services See the Directory pages at the beginning of this booklet for links and contact information. Visit the UMP website to register for a Regence account and get personalized information such as: • Access the certificate of coverage (this booklet) and the summary of benefits and coverage (SBC) for your plan, as well as the Glossary of Health Coverage and Medical Terms. • Access your online pharmacy account to view prescription claims. • Chat now with customer service. • Download the Regence mobile application. • Find providers in your plan’s network. • View or order your UMP member ID card. • View your Explanations of Benefits (EOBs). • View letters UMP sent you. Visit the UMP website to: • Access information on BlueCard® or Blue Cross Blue Shield Global® Core. • Access resources and programs. • Access the certificates of coverage (this booklet) and the summaries of benefits and coverage (SBCs) for all plans. • Access UMP medical policies. • Access wellness tools. • Download or print documents and forms. • Find providers in any plan network. • Get cost estimates for treatment of common medical conditions. • Learn about submitting medical claims. • Review complaints and appeals procedures. Visit the Policies that affect your care webpage to: • View Regence medical policies. Visit the UMP vision benefits webpage to: • Find a link to the Vision Service Plan (VSP) website. • Find information on your vision benefit. Visit the UMP Prescription drug coverage webpage to: • Find a link to the UMP Preferred Drug List and the Drug Price Check tool. • Find a link to your online pharmacy account. • Find information on mail-order and specialty drugs. • Learn about submitting prescription drug claims. • Locate network pharmacies or network vaccination pharmacies. 2024 UMP Classic (PEBB) Certificate of Coverage 13
• Review prescription drug policies and programs. How to use this certificate of coverage For general topics, check the table of contents. For an overview of the most common benefits, see the “Summary of benefits” section. The summary also shows: • How much you will pay. • The page numbers where you may learn more about a benefit. To look up unfamiliar terms, see the “Definitions” section. Section for Medicare retirees See the “For retirees enrolled in Medicare and UMP Classic” section just for retirees enrolled in Medicare. Throughout the rest of this certificate of coverage (COC), look for the blue text boxes like the one below. They indicate information specific to Medicare retirees. FOR MEDICARE RETIREES: Information specifically for Medicare retirees. About UMP Classic Uniform Medical Plan (UMP) Classic is a self-insured Preferred Provider Organization (PPO) health plan. UMP is offered through the Washington State Health Care Authority’s (HCA’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. This plan is available only to people eligible for coverage through the PEBB Program. See the “Eligibility and enrollment” section for more information. This plan is designed to keep you and your enrolled dependents healthy and provide benefits in case of injury or illness. Review this certificate of coverage (COC) carefully so you may get the most from your health care benefits. Accumulators Insurance accumulators may transfer when a subscriber changes their enrollment from one UMP plan to another UMP plan mid-year during a special open enrollment (SOE). When a subscriber enrolled in a PEBB Program UMP plan changes their own enrollment to another PEBB Program UMP plan (meaning the subscriber continues to be the subscriber on the new PEBB Program UMP Plan) during an SOE, the amounts already accrued toward medical and pharmacy deductibles, out- of-pocket limits, and benefit limits (see definition of “Limited benefit”) will transfer to the new PEBB Program UMP plan. These accumulators will also transfer for any member on the subscriber’s account who changes UMP plans with the subscriber. When a subscriber enrolled in a SEBB Program UMP plan changes their enrollment to a PEBB Program UMP plan (meaning the subscriber continues to be the subscriber on the new PEBB Program UMP Plan) during an SOE, the amounts already accrued toward the medical and pharmacy deductibles and the out- 14 2024 UMP Classic (PEBB) Certificate of Coverage
of-pocket limits for themselves and their enrolled dependents will transfer to the new PEBB Program UMP plan. These accumulators will also transfer for any member on the subscriber’s account who changes UMP plans with the subscriber. If you have questions, contact UMP Customer Service. Finding a health care provider FOR MEDICARE RETIREES: See “When to see a preferred provider” on page 130 for more information on choosing providers. As a UMP member, you may see preferred, participating, or out-of-network providers. The amount you pay for services depends on the network status of the provider. Seeing preferred providers will save you money. Visit the UMP provider search to find UMP Classic providers. You can search for preferred or participating providers by signing in to your Regence account and selecting Find a Doctor. See the Directory pages at the beginning of this booklet for links and contact information. If you use Find a Doctor by searching as a guest, you will only see preferred providers. You can confirm a provider’s network status before your visit by using the provider search or contacting UMP Customer Service. Preferred providers are in the Preferred Provider Organization (PPO) network that applies to UMP Classic members. ALERT! Some providers are preferred at one practice location but not another (example: urgent care clinics). Contact UMP Customer Service if you have any questions about the network status of a provider at a specific location. • You pay 15 percent of the allowed amount after you meet your medical deductible. The plan pays 85 percent of the allowed amount. • You pay $0 for covered preventive care services, including covered immunizations. The plan pays 100 percent of the allowed amount. • The provider cannot bill you for charges above the allowed amount. • When you are signed in to your Regence account the online provider directory labels preferred providers with a bar icon and “category 1” like this: • If you see a preferred provider, you will not have to file a claim if the plan is your primary coverage. • 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. 2024 UMP Classic (PEBB) Certificate of Coverage 15
ALERT! Some services and supplies are not covered by the plan (see the “What the plan does not cover” section) or have benefit limits. If you receive services or supplies that are not covered by the plan or you exceed your benefit limit, you will pay for those services or supplies, even if you see preferred providers. Contact UMP Customer Service to find out if a service or supply is covered. Participating providers contract with Regence BlueShield or another BlueCard® network as a participating provider. • You pay 40 percent of the allowed amount after you meet your medical deductible. The plan pays most covered services at 60 percent of the allowed amount. • You pay $0 for covered preventive care services, including covered immunizations. The plan pays 100 percent of the allowed amount. • The provider cannot bill you for charges above the allowed amount. • When you are signed in to your Regence account the online provider directory labels participating providers with a bar icon and “category 2” like this: • If you see a participating provider, you will not have to file a claim if the plan is your primary coverage. Out-of-network providers are not contracted with Regence BlueShield or another BlueCard® network. • You pay 40 percent of the allowed amount after you meet your medical deductible. The plan pays most covered services at 60 percent of the allowed amount. Note: The provider may bill you for charges above the allowed amount, which is known as balance billing. You pay all charges billed to you above the allowed amount. Any balance billed amounts do not apply to your out-of-pocket limit. At an out-of-network facility, when you receive emergency services you pay the network cost-sharing amount regardless of the network status of the provider or facility, and cannot be balance billed. • You pay 40 percent of the allowed amount for covered preventive care services, including covered preventive immunizations. You will pay all charges above the allowed amount (balance billing). The plan pays 60 percent of the allowed amount. • You pay $0 for flu shots and COVID-19 vaccines. • The plan pays 100 percent of the allowed amount for covered preventive childhood immunizations. • The 40 percent coinsurance you pay to out-of-network providers will not apply to your medical deductible or medical out-of-pocket limit. • Any amount you pay above the allowed amount does not apply to your medical deductible or medical out-of-pocket limit. • You may have to pay all charges at the time of service and then fill-out and send a claim form to the plan for reimbursement. • The provider may choose not to request preauthorization for services that require it. As a result, the plan may delay or deny payment. Note: The plan may send payment for covered out-of-network services to you or the provider. 16 2024 UMP Classic (PEBB) Certificate of Coverage
Sample payments to different provider network status The table below shows how much you pay for professional services from preferred, participating, and out- of-network providers when UMP is your primary medical insurance. For these examples, assume you have met your medical deductible and have not reached your medical out-of-pocket limit. See descriptions of these provider types beginning on page 14. These are examples only and may not reflect your specific situation. Provider Must provider accept Balance Itemized payments You owe type allowed amount? billing provider allowed? Preferred Yes. You pay 15% of the No Billed charge: $1,000 $135 provider allowed amount Allowed amount: $900 (coinsurance). Plan pays 85%: -$765 You pay 15%: $135 Participating Yes. You pay 40% of the No Billed charge: $1,000 $360 provider allowed amount Allowed amount: $900 (coinsurance). Plan pays 60%: -$540 You pay 40%: $360 Out-of- No. You pay 40% of the Yes Billed charge: $1,000 $460* network allowed amount Allowed amount: $900 provider* (coinsurance), plus all Plan pays 60%: -$540 charges above the You pay 40% plus allowed amount. $100** over allowed amount: $460* * This amount does not apply to your medical out-of-pocket limit. ** 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. How to find a preferred provider As a UMP member, you have access to Regence BlueShield preferred providers and Blue Cross and Blue Shield plan providers worldwide through the Blue Cross Blue Shield Global® Core program (see the “Services received outside the United States” section). This means your health coverage is with you wherever you are. Your access to care includes many acute care hospitals, urgent care and ambulatory surgery centers, physicians, and other health care professionals. To find a preferred provider, choose one of the following: • Use the UMP provider search. • Contact UMP Customer Service. • Sign in to your Regence account, where you have access to more information about providers, as well as other tools. 2024 UMP Classic (PEBB) Certificate of Coverage 17
• Use the Regence mobile application to find providers in your network. • Call Blue Cross Blue Shield Global® Core Service Center at 1-800-810-2583 or call collect at 1-804-673- 1177 to find providers outside the U.S. You can also use the online provider search tool on the Blue Cross Blue Shield Global Core website at bcbsglobalcore.com. • Visit the Prescription drug coverage webpage to locate network pharmacies. See the Directory pages at the beginning of this booklet for links and contact information. Covered and noncovered provider types Covered provider types The plan pays the allowed amount for covered services only when performed by covered provider types within the scope of their license(s). When a facility charges facility fees, the plan pays the allowed amount if the services are covered services and are within the scope of the facility’s license. All preferred and participating providers are covered provider types. See the list of covered provider types at the UMP website at ump.regence.com/pebb/benefits/providers/covered-providers Noncovered provider types If you see a provider who is not a covered provider type, such as a Licensed Athletic Trainer, the plan will not pay for any of the services received, and you will pay for all charges. As with all noncovered services, any payments you make to a noncovered provider type will not apply to your medical deductible or medical out-of-pocket limit. If you have questions about noncovered providers contact UMP Customer Service. Primary care providers A primary care provider (PCP) is a physician, nurse practitioner, or physician assistant who provides, coordinates, and helps you access a range of health care services, such as covered immunizations. A PCP may also help coordinate care for you when you need to see specialists. You are not required to choose a PCP. However, a PCP may help prevent and treat health care conditions early, promoting your health and well-being. Patients who have a PCP have better health outcomes and a better care experience. To be designated as a PCP, a provider must be one of the provider types and practice under one of the specialties listed below. Provider type: • Doctor of Osteopathic Medicine (D.O.) • Nurse Practitioner (A.R.N.P.) • Medical Doctor (M.D.) • Physician Assistant (P.A.) • Naturopathic Physician (N.D.) Specialties: • Adult Medicine • Internal Medicine • Family Practice • Obstetrics and gynecology (OB/GYN) • General Practice • Pediatrics (for members under age 18) • Geriatrics • Preventive Medicine 18 2024 UMP Classic (PEBB) Certificate of Coverage
When you do not have access to a preferred provider: network waiver An approved network waiver allows the plan to pay for covered services provided by an out-of-network provider at the network rate. You may request a network waiver only when you do not have access to a preferred provider able to provide covered medically necessary services within 30 miles of your residence. A service or supply prescribed, ordered, recommended, approved, or given by a provider does not make it a medically necessary covered service or supply. When and how to request a network waiver Before your visit When services require preauthorization, you may request a network waiver before services are provided. Visit the UMP Policies that affect your care webpage for the list of services requiring preauthorization (see Directory for link). Your network waiver request should be included with the preauthorization request. See the “Information needed to submit a network waiver request” section below to learn what to include in your request. When the plan approves the network waiver before you receive medical services from an out-of-network provider: • You pay your cost-share for medical services the plan has approved through this waiver as though the provider is preferred. • You pay $0 for covered preventive services, including covered immunizations. The plan pays 100 percent of the allowed amount. After your visit When you receive any service, except those that require preauthorization, you may request a network waiver after the claims have been processed. Network waiver requests not approved in advance are considered an appeal and must be submitted within 180 days of receiving an Explanation of Benefits. See the “Complaint and appeal procedures” section for information about your appeal rights. Information needed to submit a network waiver request You should include all the following information in your request: • A letter of explanation from you or your provider stating the need to see the out-of-network provider. • Details of the research conducted by you or your provider to locate a preferred provider (e.g., dates network status was checked, names and phone numbers of preferred providers that were researched and may have been contacted before receiving services from the out-of-network provider). More information needed for preauthorization requests When submitting a request for preauthorization that includes a network waiver, all the following additional information should also be included: • Performing provider’s name, address, phone • Procedure codes number, and National Provider Identifier (NPI) • Length of treatment requested or required for or Tax ID number (TIN) services • Diagnosis codes • Estimated charges 2024 UMP Classic (PEBB) Certificate of Coverage 19
See the “Preauthorizing medical services” section for more information about requesting medical services preauthorization from the plan. Where to send your network waiver request UMP Member Appeals Regence BlueShield PO Box 1106 Lewiston, ID 83501-1106 If you have questions about the network waiver process, contact UMP Customer Service. ALERT! If a network waiver is approved, you must still pay your cost-share for most medical services. Services provided under an approved network waiver are subject to your medical deductible and out-of-pocket limit. Network waivers for ongoing services may require periodic review. Out-of-area services Regence BlueShield has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “Inter-Plan Arrangements.” These Inter-Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association. Whenever you access health care services outside of the geographic area Regence BlueShield services, the claim for those services may be processed through one of these Inter-Plan Arrangements. The Inter-Plan Arrangements are described below. When you receive care outside of Regence BlueShield’s service Area, you may receive it from Providers as described below. Providers contracted with the local Blue Cross and/or Blue Shield Licensee in that geographic area ("Host Blue") as a preferred provider are paid at the preferred provider level and will not bill you for balances beyond any deductible, copayment and/or coinsurance for covered services. Providers that contract with the Host Blue as a participating provider are paid at the participating provider level and will not bill you for balances beyond any deductible, copayment and/or coinsurance for covered services. Some providers (out of network providers) don't contract with the Host Blue. The section below explains how the Plan pays these different kinds of providers. BlueCard® Program Under the BlueCard® Program, when you access covered services within the geographic area served by a Host Blue, Regence will remain responsible for doing what was agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its preferred or participating providers. When covered services are received outside the Regence’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 billed covered 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, 20 2024 UMP Classic (PEBB) Certificate of Coverage
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 take into account adjustments to correct for over- or underestimation of modifications of past pricing of claims, as noted above. However, such adjustments will not affect the price Regence BlueShield uses for your claim because they will not be applied after a claim has already been 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 would then calculate your liability for any covered services according to applicable law. Value-Based Programs If covered services are received under a Value-Based Program inside a Host Blue's service area, you will not be responsible for paying any of the provider incentives, risk-sharing, and/or care coordinator fees that are a part of such an arrangement, except when a Host Blue passes these fees to the Regence through average pricing or fee schedule adjustments. For the purpose of this section, the following definitions apply. Value-Based Program: An outcomes-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is evaluated against cost and quality metrics/factors and is reflected in provider payment. Provider Incentive: An additional amount of compensation paid to a healthcare provider by a Blue Cross and/or Blue Shield Plan, based on the provider's compliance with agreed-upon procedural and/or outcome measures for a particular group of covered persons. A Care Coordination Fee is a fixed amount paid by a Blue Cross and/or Blue Shield Licensee to Providers periodically for Care Coordination under a Value-Based Program. Inter-Plan Programs: Federal or state taxes, surcharges, or fees Federal law or state law may require a surcharge, tax or other fee that applies to self-insured accounts. If applicable, any such surcharge, tax or other fee will be included as part of the claim fee passed on to the claimant. Out-of-network providers outside Regence’s service area Member liability When covered services are provided outside of Regence’s service area by out-of-network providers, the amount you pay for such services will generally be based on either the Host Blue’s out-of-network provider local payment or the pricing arrangements required by applicable state law. In these situations, you may be liable for the difference between the amount that the out-of-network provider bills and the payment Regence will make for the covered services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for nonparticipating emergency services. Exceptions In certain situations, Regence may use other payment bases such as billed covered charges, the payment Regence would make if the health care services had been obtained within Regence’s service area, or a special negotiated payment, to determine the amount Regence will pay for services rendered by out-of- network providers. In these situations, you may be liable for the difference between the amount that the out-of-network provider bills and the payment Regence will make for the covered services as set forth in this paragraph. 2024 UMP Classic (PEBB) Certificate of Coverage 21
Services received outside the United States ALERT! The plan does not cover prescription drugs ordered through mail-order pharmacies located outside the U.S. See “Prescription drugs purchased outside the U.S.” on page 101 to learn more. Blue Cross Blue Shield Global® Core ALERT! Claims for services received outside the U.S. may take longer to process. UMP Customer Service is available to assist members with the Global® Core claim process. If you are outside the U.S., you may be able to take advantage of Blue Cross Blue Shield Global® Core when accessing covered health services. Blue Cross Blue Shield Global® Core is unlike the BlueCard® Program available in the U.S. in certain ways. For instance, although the Blue Cross Blue Shield Global® Core assists you with accessing a network of inpatient, outpatient, and professional providers, the network is not served by a Host Blue. As such, when you receive care from providers outside the U.S., you will typically have to pay the providers and submit the claims yourself to obtain reimbursement for these services. If you need medical services (including locating a doctor or hospital) outside the U.S., you should call the service center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, 7 days a week. An assistance coordinator, working with a medical professional, will arrange a physician appointment or hospitalization, if necessary. Inpatient services In most cases, if you contact the service center for assistance, hospitals will not require you to pay upfront for covered inpatient services, except for your medical deductible, coinsurance, and copays. In such cases, the hospital will submit your claims to the service center to begin claims processing. However, if you paid in full at the time of services, you must submit a claim to receive reimbursement for covered health care services. Outpatient services Physicians, urgent care centers, and other outpatient providers located outside the U.S. will typically require you to pay in full at the time of services. You must submit a claim to obtain reimbursement for covered health care services. Submitting a Blue Cross Blue Shield Global® Core claim When you pay for covered health care services outside the BlueCard® service area, you must submit a claim to obtain reimbursement. For institutional and professional claims, complete a Blue Cross Blue Shield Global® Core claim form and send the claim form with the provider's itemized bill(s) to the service center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from the claims administrator, the service center, or online at the Blue Cross Blue Shield Global Core® website at bcbsglobalcore.com. If you need assistance with your claim submission, you should call the service center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, 7 days a week. 22 2024 UMP Classic (PEBB) Certificate of Coverage
When services received outside the U.S. are covered The plan covers the same benefits as described in this COC if the services received outside the U.S.: • Are appropriate for the condition being treated; • Are covered by the plan; • Are medically necessary; • Are not considered to be experimental or investigational by U.S. standards; and • Have met all medical policy criteria. Important tips for receiving care outside the U.S. • Always carry your UMP member ID card. • If you need emergency medical care, go to the nearest hospital. • If you need urgent medical care, contact the Blue Cross Blue Shield Global® Core Service Center for help finding a network provider. • If you are admitted to the hospital, call the Blue Cross Blue Shield Global® Core Service Center to notify the plan of your admission. Blue Cross Blue Shield Global® Core contact and online information Contact Blue Cross Blue Shield Global® Core to learn about services received outside the U.S., find a provider outside the U.S., or submit a claim for medical care provided outside the U.S. • Call the Blue Cross Blue Shield Global® Core Service Center at 1-800-810-BLUE (2583), or call collect 1-804-673-1177 (available 24 hours a day, 7 days a week). • To use the online provider search tool, register and sign in on the Blue Cross Blue Shield Global® Core website at bcbsglobalcore.com. • Visit the Blue Cross Blue Shield Global® Core website on the Blue Cross Blue Shield Global® Core website at bcbsglobalcore.com. After you create an account, you may find Blue Cross Blue Shield Global® Core information, get an international claim form, and submit claims electronically. Finding a preferred provider outside the U.S. Under Blue Cross Blue Shield Global® Core, you have access to network providers outside the U.S., including hospital care (inpatient and outpatient) and professional provider services at network rates. To find a contracted provider outside the U.S., register and sign in on the Blue Cross Blue Shield Global® Core website at bcbsglobalcore.com or call the Blue Cross Blue Shield Global® Core Service Center: 1-800-810-BLUE (2583) or collect at 1-804-673-1177. What you pay for medical services Deductibles A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying for covered services. Your medical deductible amount is $250 per member, with a maximum of $750 per family. When you first get services, you pay the first $250 in charges. After you pay that first $250, the plan begins to pay for covered services. This applies to each covered member, up to the $750 maximum. 2024 UMP Classic (PEBB) Certificate of Coverage 23
Your medical deductible applies to all services unless otherwise stated in this COC. See below for services that are not subject to your medical deductible. Services apply to your UMP medical deductible in the order claims are received, not necessarily in the order the member receives the services. Note: You also pay a separate deductible for prescription drugs. See the “What you pay for prescription drugs” section for more information. ALERT! If you receive services with a benefit limit (such as nutritional counseling) before meeting your medical deductible, those visits still apply to the benefit limit. For example, if you pay out of pocket for a nutritional counseling visit because you have not met your medical deductible, that visit will apply to the maximum of 12 visits per lifetime. See definition of “Limited benefit” for more information. If you earned the SmartHealth wellness incentive Eligible subscribers can qualify for a $125 reduction in their 2024 PEBB medical plan deductible. If you qualified in 2023 and you are still eligible to participate in the wellness incentive program, your medical plan deductible will be reduced in January 2024. More details on eligibility and program requirements are on HCA's SmartHealth webpage at hca.wa.gov/pebb-smarthealth. What does not count toward your medical deductible The following out-of-pocket expenses do not count toward your $250 medical deductible: • Charges for services that exceed the benefit limit. • Charges that exceed the maximum dollar limit. • Out-of-network provider charges above the allowed amount (see the “Sample payments to different provider network status” section). • Prescription drug costs (see the “What you pay for prescription drugs” section for more information). • Services that are not subject to your medical deductible, even if you had out-of-pocket costs. For example, covered preventive care services received from an out-of-network provider. • Services you pay for that are not covered by the plan (see the “What the plan does not cover” section). • Your emergency room copay. • Your inpatient hospital copay. • Your chiropractor copay. • Your acupuncture copay. • Your massage therapy copay. Services not subject to your medical deductible The plan pays the allowed amount for the services listed below, subject to cost-share, even if you have not met your medical deductible. When you see a preferred or participating provider, you do not have to meet your medical deductible before the plan pays for these services: • Covered contraceptive supplies and services (see the “Family planning services” benefit). • Covered preventive care services, including covered immunizations. • Diabetes Control Program. 24 2024 UMP Classic (PEBB) Certificate of Coverage
• Diabetes Prevention Program. • Prescription drugs covered under the prescription drug benefit. • Routine hearing exams. • Hearing aids • Routine vision care: exams, glasses, and contacts. • Second opinions required by the plan. • Tobacco cessation services. Note: See page 94 for prescription drug deductible exemptions. How your medical deductible works with dependents If your family has three or fewer members enrolled, your medical deductible amount is $250 per member, with a maximum of $750. Once a member pays their $250 deductible, the plan begins paying for covered services for that member. Because the plan is now paying for this member’s covered services, they are no longer contributing toward your family deductible. Once your family deductible has been met, the plan begins paying for all covered services. If your family has four or more members enrolled, each member has a medical deductible of $250 and the maximum the family pays toward medical deductibles is $750. Once a member pays their $250 deductible, the plan begins paying for covered services for that member. Because the plan is now paying for this member’s covered services, they are no longer contributing toward your family deductible. Once your family deductible has been met, the plan begins paying for all covered services for all enrolled family members, even if some have not met their own deductible. If the subscriber earned the SmartHealth wellness incentive for the 2024 plan year, the subscriber’s medical deductible is reduced. See the “If you earned the SmartHealth wellness incentive” section above to learn more. Note: Only services that are covered and are subject to your medical deductible count toward the deductible. See page 24 for a list of services that do not count toward your medical deductible. Coinsurance TIP: Allowed amount is the most the plan pays for a specific covered service or supply. Out-of- network providers may charge more than this amount, and you are responsible for paying the difference between the billed amount and the allowed amount. This is called balance billing. Coinsurance is the percentage of the allowed amount you pay for most medical services and for prescription drugs when the plan pays less than 100 percent. After you meet your medical deductible, you pay the percentages described below for most covered medical services. See the following sections for more information on how much you pay for prescription drugs: “What you pay for prescription drugs,” “How the prescription drug cost-limit works,” “Your prescription drug out-of-pocket limit.” • For preferred providers: You pay 15 percent of the allowed amount. The plan pays 85 percent of the allowed amount. • For participating providers: You pay 40 percent of the allowed amount. The plan pays most covered services at 60 percent of the allowed amount. 2024 UMP Classic (PEBB) Certificate of Coverage 25
• For out-of-network providers: You pay 40 percent of the allowed amount, and the provider may balance bill you. The plan pays most covered services at 60 percent of the allowed amount. Professional charges, such as for physician services while you are in the hospital or lab work, may be billed separately. Note: When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of-network provider may be allowed to ask you to waive some of your balance billing protections. At an out-of-network facility, when you receive emergency services you pay the network cost-sharing amount regardless of the network status of the provider or facility and cannot be balance billed. Copay A copay is a set dollar amount you pay when you receive treatments, supplies, or services including, but not limited to: • Emergency room copay: $75 per visit. See the “Emergency room” benefit for details. • Facility charges for services received while an inpatient at a hospital, or mental health, skilled nursing, or substance use disorder facility: $200 per day (see “Inpatient copay” below). • Covered chiropractic, acupuncture, and massage services when you see a preferred provider will have a $15 copay per visit. The copay for these services will apply toward the annual out-of-pocket maximums. See the “Spinal and extremity manipulations” benefit, “Acupuncture” benefit, and “Massage therapy” benefit for more details. Inpatient copay FOR MEDICARE RETIREES: The maximum inpatient copay is $600 per facility admission up to your medical out-of-pocket limit. The inpatient copay of $200 per day is what you pay for inpatient services at a preferred facility, such as a hospital, or mental health, skilled nursing, or substance use disorder facility. You and your enrolled dependents pay up to $600 maximum per enrolled member per calendar year. The inpatient copay does not apply to your medical deductible but does apply to your medical out-of- pocket limit. Note: Professional charges, such as lab work or provider services, while you are in the hospital may be billed separately and are not included in this copay. When you pay Most of the time, you pay after your claim is processed. • You will receive an Explanation of Benefits (EOB) from the plan that explains how much the plan paid the provider. The Member Responsibility section of your EOB tells you how much you owe the provider. • The provider sends you a bill. • You pay the provider. 26 2024 UMP Classic (PEBB) Certificate of Coverage
Note: A provider may ask you to pay your deductible and copay, when applicable, at the time of service. When this happens, check your EOB to make sure the amount you paid is accurately reflected in the Member Responsibility section. Contact UMP Customer Service with questions. Medical out-of-pocket limit ALERT! Prescription drug costs do not apply to your medical out-of-pocket limit (see below). The medical out-of-pocket limit is the most you pay during a calendar year for covered services from preferred providers. After you meet your medical out-of-pocket limit for the year, the plan pays for covered services by preferred providers at 100 percent of the allowed amount. The plan will not pay more than the allowed amount. Expenses are counted from January 1, 2024, or your first day of enrollment (whichever is later) through December 31, 2024, or your last day of enrollment (whichever is earlier). Your medical out-of-pocket limit depends on your enrollee type. • Employees, continuation coverage subscribers, retired employees of a former employer group, and retirees or survivors 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. What counts toward this limit • Inpatient and emergency room copays • Your coinsurance paid to preferred and participating providers • Your coinsurance paid to out-of-network providers for emergency room services, air ambulance, and nonemergency services furnished during a visit or stay at a preferred and participating hospital, hospital outpatient department, critical access hospital, or ambulatory surgical center. • Your medical deductible paid to preferred and participating providers • Chiropractic, acupuncture, and massage therapy visit copays to preferred providers What does not count toward this limit A. Amounts paid by the plan, including services covered in full B. Costs you pay under the prescription drug benefit including your prescription drug deductible and coinsurance (see the "What you pay for prescription drugs" section) C. Your monthly premiums D. Your coinsurance paid to out-of-network providers and your coinsurance and copayments paid to non-network pharmacies (except those listed above in “What counts toward this limit”) E. Balance billed amounts F. Amounts paid for services the plan does not cover (see the “What the plan does not cover” section) G. Amounts that are more than the maximum dollar amount paid by the plan. Any amount you pay over the allowed amount does not count toward the medical out-of-pocket limit. 2024 UMP Classic (PEBB) Certificate of Coverage 27
H. Amounts paid for services over a benefit limit. For example, the benefit limit for acupuncture is 24 visits. If you have more than 24 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit. What you pay after reaching this limit After you meet your out-of-pocket limit for the year, you pay: • $0 of the allowed amount for covered medical services from preferred providers and for covered drugs at network pharmacies. • C through H (above) in the “What does not count toward this limit” section. • 40% of the allowed amount for covered medical services for participating providers. • 40% of the allowed amount for covered medical services for out-of-network providers. You may be balance billed. Summary of services and payments ALERT! Even if a provider orders a test or prescribes a treatment, the plan may not cover it. Review this COC or contact UMP Customer Service if you have questions about benefits or limitations. On the next several pages, you will find a summary of types of services and what you will pay for them. For a complete understanding of how a benefit works, read the pages listed in the “For more information” column. All services must be medically necessary to be covered. If you see an unfamiliar term, see the alphabetical list of definitions in the “Definitions” section. This COC applies only to dates of service between the day your coverage begins (no earlier than January 1, 2024) and the day your coverage ends (no later than December 31, 2024). ALERT! If you have coverage under another health plan, see the “If you have other medical coverage” section. If your other coverage is Medicare, see the “For retirees enrolled in Medicare and UMP Classic" section. Deductibles and limits Deductibles Dollar amounts What else you need to know For more and limits information, see page(s) Medical $250 per member (maximum of You must meet your medical 23–25 deductible $750 for a family of three or deductible before the plan pays more) for covered medical services. See page 24 if you earned the Not all services count toward SmartHealth wellness incentive your deductible. in 2023 for plan year 2024. 28 2024 UMP Classic (PEBB) Certificate of Coverage
Deductibles Dollar amounts What else you need to know For more and limits information, see page(s) Prescription $100 per member (maximum of • You pay the costs for Tier 2 94–95 drug $300 for a family of three or prescription drugs until you deductible more) meet your prescription drug deductible, except covered insulins. • You do not need to meet your prescription drug deductible for Preventive Tier, Value Tier, Tier 1 drugs, and covered insulins. Medical out- $2,000 per member (maximum Your medical deductible and all 27–28 of-pocket of $4,000 for a family of two or coinsurance and copays for limit more) covered services paid to For Medicare-primary members: preferred providers count $2,500/$5,000 toward this limit. Once you meet your medical out-of-pocket limit, covered services paid to preferred providers are paid at 100% of the allowed amount. Prescription $2,000 per member (maximum Your prescription drug 97 drug out-of- of $4,000 for a family of two or deductible and coinsurance pocket limit more) count toward this limit. Annual plan None No limit to how much the plan Not applicable payment limit pays per calendar year. Lifetime plan None No limit to how much the plan Not applicable payment limit pays over a lifetime. Types of services The table in this section describes how much you and the plan will pay for covered services. Unless otherwise noted, all payments are based on the allowed amount, and services are subject to your medical deductible. See the “What you pay for medical services” section for more information about your deductible. Type of How much you pay for covered services How much the plan pays for service covered services Standard How much you pay (your coinsurance) • Preferred providers: The plan depends on the provider’s network status: pays 85% of the allowed • Preferred providers: You pay 15% of the amount. allowed amount. The provider cannot • Participating providers: The balance bill you. plan pays 60% of the allowed • Participating providers: You pay 40% of amount. the allowed amount. The provider cannot balance bill you. 2024 UMP Classic (PEBB) Certificate of Coverage 29
Type of How much you pay for covered services How much the plan pays for service covered services • Out-of-network providers: You pay 40% • Out-of-network providers: The of the allowed amount. The provider may plan pays 60% of the allowed balance bill you. amount. Preventive Covered preventive services are not subject to • Preferred providers: The plan your medical deductible. How much you pay pays 100% of the allowed (your coinsurance) depends on the provider’s amount. network status: • Participating providers: The • Preferred providers: You pay $0. The plan pays 100% of the allowed provider cannot balance bill you. amount. • Participating providers: You pay $0. The • Out-of-network providers: The provider cannot balance bill you. plan pays 60% of the allowed • Out-of-network providers: You pay 40% amount. of the allowed amount. The provider may balance bill you. Inpatient Most inpatient services require both The plan pays 100% of the allowed preauthorization (see page 108) and notice amount after you pay your (your provider must notify the plan as soon as deductible and copay at preferred possible after you are admitted to a facility, facilities. but not later than 24 hours after you are The plan pays for professional admitted; see page 110). services such as provider You pay the $200-per-day copay at preferred consultations or lab tests, based on facilities up to: the provider’s network status: • $600 maximum copay per calendar year if • Preferred providers: The plan you are a member not enrolled in pays 85% of the allowed Medicare. amount. • $600 maximum per admission up to the Note: For behavioral health annual medical out-of-pocket limit if you professional services, the plan are a retiree or their dependent enrolled pays 100% of the allowed in Medicare. amount. Note: The inpatient copay counts toward your • Participating providers: The medical out-of-pocket limit. plan pays 60% of the allowed Services are considered inpatient only when amount. you are admitted to a facility. See definition of • Out-of-network providers: The “Inpatient stay.” plan pays 60% of the allowed When you are admitted to a facility, you pay amount. your deductible and: • Preferred facilities: You pay the inpatient copay. • Participating facilities: You pay 40% of the allowed amount. The facility cannot balance bill you. 30 2024 UMP Classic (PEBB) Certificate of Coverage
Type of How much you pay for covered services How much the plan pays for service covered services • Out-of-network facilities: You pay 40% of the allowed amount. The facility may balance bill you. • Fees for professional services, such as, but not limited to, provider consultations or lab tests. How much you pay for professional services depends on the provider’s network status: • Preferred providers: You pay 15% of the allowed amount. The provider cannot balance bill you. • Participating providers: You pay 40% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 40% of the allowed amount. The provider may balance bill you. Outpatient If you receive services at a facility that offers • Preferred providers: The plan inpatient services (like a hospital), but you are pays 85% of the allowed not admitted, the services are covered as amount. outpatient. See the specific benefit (e.g., • Participating providers: The emergency room or diagnostic tests) for how plan pays 60% of the allowed much you pay. You may be billed separately amount. for facility fees in addition to provider fees. • Out-of-network providers: The • Preferred providers: You pay 15% of the plan pays 60% of the allowed allowed amount. The provider cannot amount. balance bill you. • Participating providers: You pay 40% of the allowed amount. The provider cannot balance bill you. • Out-of-network providers: You pay 40% of the allowed amount. The provider may balance bill you. 2024 UMP Classic (PEBB) Certificate of Coverage 31
Type of How much you pay for covered services How much the plan pays for service covered services Facility You may be charged facility fees in addition to • Preferred facility: The plan provider fees when accessing clinics, pays 85% of the allowed ambulatory surgery centers, and other amount. facilities. A facility may be referred to as a • Participating facility: The plan “provider” on the Explanations of Benefits or pays 60% of the allowed other documents. How much you pay amount. depends on the provider’s network status: • Out-of-network facility: The • Preferred facility: You pay 15% of the plan pays 60% of the allowed allowed amount; the provider cannot amount. 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. 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). • 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 32 2024 UMP Classic (PEBB) Certificate of Coverage
• Be received by a member on a day between the date coverage begins (but no sooner than January 1, 2024) and the date coverage ends (but no later than December 31, 2024); 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 contact 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 contacting 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 HCA’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. 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, 2024 UMP Classic (PEBB) Certificate of Coverage 33
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 contact 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. 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, contact 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: 37, 112, 120 • 20% of the allowed amount for any provider • Applies to your out-of-pocket limit 34 2024 UMP Classic (PEBB) Certificate of Coverage
Benefit/service How much you will pay For information, see page(s): Applied Behavior Standard rate 38 Analysis (ABA) Therapy Behavioral health Mental health: 39, 116, 117 • Inpatient rate • Outpatient/professional services: Standard rate Substance use disorder: • Inpatient rate • Outpatient/professional services: Standard rate Breast health See the “Mammogram and Digital Breast 42, 61 screening tests Tomosynthesis (DBT)” benefit Chiropractic physician Special rate: See the “Spinal and services You pay a $15 copay per visit when you see a extremity preferred provider. manipulations” benefit on page 70 Diagnostic tests, Standard rate 47, 61, 111–121 laboratory, and x-rays Dialysis Inpatient: Standard rate 49 Outpatient: Initial treatment period: Standard rate Supplemental treatment period: Special rate: • Preferred and participating providers: You pay 0% of the allowed amount. • Out-of-network providers: You pay 0% of the allowed amount. Any charges exceeding the allowed amount may be balance billed. Durable medical Standard rate 47, 113, 116, 185 equipment (DME), supplies, and prostheses Emergency room (ER) Special rate: 50, 186 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 2024 UMP Classic (PEBB) Certificate of Coverage 35
Benefit/service How much you will pay For information, see page(s): Hearing aids Special rate: 53, 130 • No medical deductible • You pay $0 of the $3,000 benefit limit per ear every 3 years Home health care Standard rate 54, 114, 189, 191 Hospice care Special rate: 54, 190 • You pay $0 for medical services after meeting your medical deductible • You pay $0 for prescription drugs after meeting your prescription drug deductible • You pay $0 for end-of-life counseling while in hospice after meeting your medical deductible Hospital services Inpatient rate 56, 62, 115 Outpatient/professional services: Standard rate Mammograms Diagnostic: Standard rate 61 Screening: Preventive rate Mental health See the “Behavioral health” benefit 39, 116, 117 Naturopathic Standard rate 18, 62, 107, 112 physician services Obstetric and Inpatient rate 62, 117 newborn care Outpatient/professional services: Standard rate Office visits Standard rate 64, 116 Prescription drugs See the “What you pay for prescription drugs” 90 section Preventive care and Preventive care services: Preventive rate 61, 64, 65, 91, 199 immunizations Covered preventive immunizations: Preventive rate Skilled nursing facility Inpatient rate 68, 114, 118, 203 Some services may be billed separately, such as physical therapy Spinal and extremity Special rate: 70 manipulations You pay a $15 copay per visit when you see a preferred provider. Substance use See the “Behavioral health” benefit 39 disorder Surgery Standard rate 56, 57, 62, 65, 70, 70, 73, 77, 114, 119, 182, 195, 201 Therapy: Habilitative Inpatient rate 74 and Rehabilitative Outpatient/professional services: Standard rate Tobacco cessation Preventive rate 75 36 2024 UMP Classic (PEBB) Certificate of Coverage
Benefit/service How much you will pay For information, see page(s): Vision care exam Preventive rate 81, 85 (routine) Vision hardware, Special rate: 81 adults (age 19 or • No medical deductible older) • Lenses and frames: You pay $0 of the allowed (Lenses, frames, or amount for one pair of covered standard lenses contact 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, Special rate: 85 children (under age • No medical deductible. 19) • Lenses and frames: You pay $0 of the allowed (Lenses, frames, or amount for one pair of covered standard frames contact lenses) and lenses once per year; or • Contact lenses: You pay $0 of 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 contact 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 your medical deductible, but the copay will apply to the out-of-pocket limit. All visits will apply to the 24-visit limit. 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: 2024 UMP Classic (PEBB) Certificate of Coverage 37
• 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 balance 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 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 age 18 or older before services are performed. No preauthorization is required for members under age 18. 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. 38 2024 UMP Classic (PEBB) Certificate of Coverage
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 contact 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 38; 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 39. 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: Contact 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 age 18 or older 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, contact UMP Customer Service. Related care following bariatric surgery Panniculectomy (removal of loose skin) is covered following bariatric surgery when specific medical criteria are met. Most panniculectomies are considered cosmetic and are not covered. 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. 2024 UMP Classic (PEBB) Certificate of Coverage 39
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. 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 38 for preauthorization requirements related to Applied Behavior Analysis (ABA) Therapy services. 40 2024 UMP Classic (PEBB) Certificate of Coverage
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 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) 2024 UMP Classic (PEBB) Certificate of Coverage 41
• 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 age 13 or older 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. 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 age 18 or 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 age 40 or 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. 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, 42 2024 UMP Classic (PEBB) Certificate of Coverage
ensuring members understand their benefits, and providing members ongoing support through case management, as needed. Contact 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. 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. 2024 UMP Classic (PEBB) Certificate of Coverage 43
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). 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. 44 2024 UMP Classic (PEBB) Certificate of Coverage
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, 2024, resulting in injuries that are covered by the plan. Your treatment plan must be finalized no later than April 11, 2024. All related treatment must be completed by December 31, 2025 (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 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 2024 UMP Classic (PEBB) Certificate of Coverage 45
• 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 contact 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 contact WSRxS Customer Service. For more information, see “Exceptions covered” on page 91. Diabetes Control Program TIP: The Diabetes Control Program is not subject to your medical deductible and is offered at no additional cost for UMP (non-Medicare) members age 18 or older. For non-Medicare members age 18 or 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; • 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 contact UMP Customer Service for more information. 46 2024 UMP Classic (PEBB) Certificate of Coverage
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 contact 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 your 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 Inpatient Dialysis You pay the standard rate for covered inpatient 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. Outpatient Dialysis and Supplemental Kidney Dialysis During your initial outpatient treatment period of three months (42 treatments of hemodialysis or 30 days of peritoneal dialysis), you pay the standard rate for covered outpatient dialysis services. Once the supplemental treatment period begins, you pay the special rate (0% of the allowed amount) for covered outpatient dialysis services. You will also be eligible for Medicare Part B coverage. Our care managers can help you apply for Medicare Part B. To reach a care manager, call UMP Customer Service. Once enrolled in Medicare Part B, you are eligible to get your Medicare Part B premiums reimbursed by the plan as long as you remain enrolled in Medicare Part B and are eligible under this plan. Proof of payment of your Medicare Part B premiums is required for reimbursement. If you are not enrolled in Medicare Part B and you receive outpatient dialysis from an out-of-network provider, you may be balance billed. 2024 UMP Classic (PEBB) Certificate of Coverage 47
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 contact UMP Customer Service. 48 2024 UMP Classic (PEBB) Certificate of Coverage
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, contact 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, with the exception of UMP Medicare Retiree members. 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 contact to confirm that a supplier has what you need. 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 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 2024 UMP Classic (PEBB) Certificate of Coverage 49
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 balance 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 your medical deductible and coinsurance. For more information on hospice care, see page 54. Family planning services If you receive care from a network provider, the plan will pay for the following covered services at the preventive rate: • Contraceptive drugs and devices including condoms and spermicides • Voluntary and involuntary termination of pregnancy (abortion or miscarriage) • Education and counseling related to contraception If you receive care from an out-of-network provider, covered 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.” 50 2024 UMP Classic (PEBB) Certificate of Coverage
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. Contact 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 your 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 2024 UMP Classic (PEBB) Certificate of Coverage 51
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. Contact 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. 52 2024 UMP Classic (PEBB) Certificate of Coverage
Hearing exam and hearing aids (instruments) This benefit is not subject to your medical deductible and includes the services and supplies outlined below. 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 of the $3,000 benefit limit per ear every 3 calendar years for prescribed hearing aids. You are responsible for hearing aid charges exceeding the $3,000 benefit limit. See the definition of “Limited Benefit”. You pay the standard rate for the following hearing-related services: ▪ Ear mold(s) ▪ 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 initial assessment, fitting, adjustment, auditory training, and other ear molds as necessary to maintain an optimal fit for those who have obtained or intend to obtain a hearing aid The following hearing-related items are not covered: • Over-the-counter hearing aids that are not prescribed, except for initial assessment, fitting, adjustment, auditory training, and other ear molds as necessary to maintain an optimal fit. • 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 2024 UMP Classic (PEBB) Certificate of Coverage 53
• 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 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). Contact 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 contact UMP Customer Service. 54 2024 UMP Classic (PEBB) Certificate of Coverage
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 your prescription drug deductible is met: • The member pays the normal coinsurance for Value Tier and Tier 1 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, Tier 1 and Tier 2 up to the prescription cost-limit (see the "How the prescription drug cost-limit works" section). Covered insulins are not subject to your 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. 2024 UMP Classic (PEBB) Certificate of Coverage 55
• The Washington State Hospital Association’s website at wsha.org/for-patients/end-of-life/. 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 contact 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. 56 2024 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 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 contact 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. Contact 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). 2024 UMP Classic (PEBB) Certificate of Coverage 57
• 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. 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. 58 2024 UMP Classic (PEBB) Certificate of Coverage
• 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). 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. 2024 UMP Classic (PEBB) Certificate of Coverage 59
• 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. Contact 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. 60 2024 UMP Classic (PEBB) Certificate of Coverage
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 your medical deductible and coinsurance. Claims are paid based on how your provider bills the service. Screening (preventive) • For members age 40 or 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 your 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 The plan covers up to 24 visits per calendar year for massage therapy (no more than 90 minutes per visit). See the definition of “Limited benefit.” 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 your medical deductible, but the copay will apply to the out-of-pocket limit. All visits will apply to the 24-visit limit. 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 contact UMP Customer Service (see Directory for link and contact information). 2024 UMP Classic (PEBB) Certificate of Coverage 61
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 91), even if a covered provider type prescribes them. Nurse line UMP members have access to Advice24 Nurse Triage. Registered nurses are available by phone 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, see a doctor either virtually or in-person, or care for your symptoms at home. UMP members can call the nurse line at 1-877-375-2599 (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, access education, and get one- 62 2024 UMP Classic (PEBB) Certificate of Coverage
click access to the 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 your medical deductible. • Pay the inpatient copay. • Pay the coinsurance for professional services while hospitalized. • Meet your 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 your medical deductible and coinsurance). Because this is not a preventive service, your out-of-pocket cost may include your 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, contact 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. 2024 UMP Classic (PEBB) Certificate of Coverage 63
• 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, contact UMP Customer Service. Services covered as preventive The following services are covered as preventive (not subject to your 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. Contact 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” section 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 your medical deductible. 64 2024 UMP Classic (PEBB) Certificate of Coverage
Orthognathic and Telegnathic surgery Orthognathic and telegnathic surgery must be preauthorized by the plan. Contact 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 • Radiofrequency ablations • Facet blocks • Sacroiliac joint injections • Pain pumps 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). 2024 UMP Classic (PEBB) Certificate of Coverage 65
• 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 age 40 or older (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 your 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. Contact UMP Customer Service to ask if a medical service is covered as preventive. Contact 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 age 25 or 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 age 30 or older, 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. 66 2024 UMP Classic (PEBB) Certificate of Coverage
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 contact 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 your medical or your 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 and COVID-19 vaccines are paid at 100 percent 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 contact 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. Contact 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 balance 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: 2024 UMP Classic (PEBB) Certificate of Coverage 67
• 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 have 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. 68 2024 UMP Classic (PEBB) Certificate of Coverage
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 2024 UMP Classic (PEBB) Certificate of Coverage 69
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). See the definition of “Limited benefit.” You pay the special rate (a $15 copay) for up to 24 visits for spinal and extremity manipulations when you see a preferred provider. The copay will not apply toward your 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. Contact 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. 70 2024 UMP Classic (PEBB) Certificate of Coverage
In the COE program, members work with Premera Blue Cross (the administrator of the program) and Virginia Mason Medical Center 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 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. Center of Excellence for spine care: Virginia Mason Medical Center Virginia Mason Medical Center is the provider approved to perform spine care evaluations and surgeries under the COE Program. This facility has 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 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 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). 2024 UMP Classic (PEBB) Certificate of Coverage 71
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. • 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 spine care services outside of the COE Program, or choose to receive services at Virginia Mason 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 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. 72 2024 UMP Classic (PEBB) Certificate of Coverage
• Convenience items, such as a personal phone. Contact 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 determines 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 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 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 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. 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 2024 UMP Classic (PEBB) Certificate of Coverage 73
preauthorization on the UMP Policies that affect your care webpage. Contact 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 contact 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. 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. 74 2024 UMP Classic (PEBB) Certificate of Coverage
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 your 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. TIP: You do not have to enroll in the tobacco cessation program to get coverage of nicotine replacement therapy or prescription drugs for tobacco cessation. See below for limits and rules on accessing these services. 2024 UMP Classic (PEBB) Certificate of Coverage 75
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 tobacco cessation program (see the “Tobacco cessation 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 Tobacco cessation 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 90 for how to request an exception. If your exception is approved, you will receive the approved product or prescription drug at no cost. Tobacco cessation program UMP members age 18 or older may participate in the tobacco cessation program. The 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 UMP Care programs webpage at ump.regence.com/pebb/benefits/programs. 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. For nicotine replacement therapy, you may get supplies sent to you from the program or get a prescription from your provider and purchase as described under “Nicotine replacement therapy” on page 76. 76 2024 UMP Classic (PEBB) Certificate of Coverage
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 the tobacco cessation program (for members age 18 or older), 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: • The plan provides coverage for the service when provided in person by the provider; • The service is medically necessary; 2024 UMP Classic (PEBB) Certificate of Coverage 77
• 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 • 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 78 2024 UMP Classic (PEBB) Certificate of Coverage
• 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. • High blood pressure and high cholesterol. • Colds and allergies. • Migraines. • Diabetes. • Pink eye. • Eczema and acne. • Urinary Tract Infections (UTIs). • Heartburn and indigestion. 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, contact 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 47). 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 contact UMP Customer Service. When you have questions about routine eye exams and hardware, call VSP Member Services at 1-844-299-3041 or TTY 1-800-428-4833. See the Directory at the beginning of the COC for vision services contact information. 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 2024 UMP Classic (PEBB) Certificate of Coverage 79
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 age 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 age 19 or older, out-of-network providers will cost you more. See the table below for more information. Members under age 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 (age 19 or older) This section explains how the plan pays for covered services for members age 19 or older. The explanation includes information about maximum benefits, covered services, and payment. The below VSP coverage table applies to adults and dependents age 19 or older. Benefit Frequency Your cost with a VSP Choice Your cost with an out-of- network provider network provider Professional One per calendar You pay $0 of the allowed You pay 100% of billed comprehensive year. amount and the plan pays charges. routine eye 100% of the allowed amount. VSP will reimburse you up to exams $45 when you submit a claim for a covered exam. Frames One every two You pay $0 up to a $150 frame You pay 100% of billed calendar years. allowance; or charges. You pay $0 up to an $80 frame VSP will reimburse you up to allowance for Walmart®, $70 when you submit a claim for covered frames. Sam’s Club®, or Costco® providers. 80 2024 UMP Classic (PEBB) Certificate of Coverage
Benefit Frequency Your cost with a VSP Choice Your cost with an out-of- network provider network provider Lenses and One set every two You pay $0 for the following You pay 100% of billed enhancements calendar years. covered lenses and the plan charges. pays 100% of the allowed VSP will reimburse you up to amount: the following amounts when • Single vision lenses you submit a claim for • Lined bifocal lenses covered lenses: • Standard progressive lenses • $30 single vision lenses • Lined trifocal lenses • $50 lined bifocal lenses • Lenticular lenses • $50 standard progressive lenses Note: Lens enhancement is not • $65 lined trifocal lenses covered except for impact- • $100 lenticular lenses resistant coating for dependent children age 19 or older. Contacts One set of contact You pay $30 copay for a You pay 100% of billed lenses or contact lens evaluation and charges. disposable contact fitting exam. VSP will reimburse you up to lenses up to the You pay $0 up to a $150 the following amounts when maximum contact allowance for elective you submit a claim for allowance instead contact lenses. contact lenses: of frames and You pay $0 for necessary • $105 for elective contact lenses every two contact lenses. Note: You are lenses calendar years. still responsible for paying a • $210 for necessary $30 copay for the contact lens contact lenses evaluation and fitting exam. 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: 2024 UMP Classic (PEBB) Certificate of Coverage 81
• Single vision lenses • Lined bifocal lenses • Lined trifocal lenses • Lenticular lenses • Standard progressive lenses • Lens enhancement covered for dependent children age 19 or older 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 (TTY) 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. • 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. 82 2024 UMP Classic (PEBB) Certificate of Coverage
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. 2024 UMP Classic (PEBB) Certificate of Coverage 83
Children (under age 19) ALERT! Out-of-network providers are not covered for any routine vision services. The below VSP coverage table applies to children under age 19. Benefit Frequency Your cost with a VSP Your cost with an out- Choice network provider of-network provider Professional One per calendar You pay $0 of the allowed You pay 100% of billed comprehensive year. amount and the plan pays charges. routine eye 100% of the allowed amount. exams Frames One per calendar You pay $0 of the allowed You pay 100% of billed year. amount and the plan pays charges. 100% of the allowed amount. Lenses and One set per calendar You pay $0 for the following You pay 100% of billed enhancements year. covered lenses and the plan charges. 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 Contacts One set of contact You pay $0 of the allowed You pay 100% of billed lenses or disposable amount for elective or charges. contact lenses up to necessary contact lenses and the maximum the plan pays 100% of the allowance instead of allowed amount. frames and lenses You pay $0 of the allowed every calendar year. amount for contact lens evaluation and fitting exam 84 2024 UMP Classic (PEBB) Certificate of Coverage
Benefit Frequency Your cost with a VSP Your cost with an out- Choice network provider of-network provider and the plan pays 100% of the allowed amount. Note: Walmart®, Sam’s Club ®, and Costco® providers are not VSP Choice network providers for children under age 19 for frames, lenses, and contact lenses. Call VSP Member Services at 1-844-299-3041 for out-of-network plan details or TTY 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. 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. 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 2024 UMP Classic (PEBB) Certificate of Coverage 85
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. • 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. 86 2024 UMP Classic (PEBB) Certificate of Coverage
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, contact 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) ▪ Note: The plan does not cover prescription drugs purchased through mail-order pharmacies located outside the U.S. • Network specialty drug pharmacy: Ardon Health Visit the UMP Prescription drug coverage webpage to: • Find a link to the UMP Preferred Drug List and the Drug Price Check tool. • Find a link to your online pharmacy account. • Find information on mail-order and specialty drugs. • Learn about submitting prescription drug claims. • Locate network pharmacies or network vaccination pharmacies. • Review prescription drug policies and programs. 2024 UMP Classic (PEBB) Certificate of Coverage 87
Contact the mail-order or specialty drug pharmacy directly for help placing or tracking prescription orders. If additional help is needed, contact WSRxS Customer Service. Note: Regence BlueShield does not provide prescription drug benefits for UMP. Always contact WSRxS with questions about your prescription drug 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 90. 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 103) • 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 contacting 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, contact 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 (see “Requesting an exception for noncovered prescription drugs”). 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). 88 2024 UMP Classic (PEBB) Certificate of Coverage
ALERT! When a generic equivalent for a brand-name prescription drug becomes available, the brand-name drug immediately becomes noncovered. An exception must be requested and approved for coverage of the brand-name drug if you want to continue using the brand-name drug. Always ask your provider to allow substitution on your prescriptions to save you money. See the “Substitution under Washington State law” section for information on transitioning from a brand-name to generic prescription drug, 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. 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 contacting 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). Preferred drug list exceptions and coverage determinations require medical information and are based on medical necessity. Therefore, your prescribing provider must submit clinical information for review and 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 2024 UMP Classic (PEBB) Certificate of Coverage 89
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. ▪ If the plan determines the information submitted confirms 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, then your exception request may be approved. When the plan approves an exception, you will pay the Tier 2 cost-share (see “what you pay for prescription drugs”). If your exception request is denied, the plans response letter will include the reason for the denial and the steps you can take next. 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. 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 To be covered, a prescription drug must meet all of the following: • Is listed on the UMP Preferred Drug List (The Preferred Drug List is subject to change). • 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 or WSRxS P&T Committee (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. 90 2024 UMP Classic (PEBB) Certificate of Coverage
• 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. The plan may cover FDA-approved prescription drugs for off-label use (prescribed for a use other than its FDA-approved label) only if they are not excluded, the use is not considered experimental or investigational by WSRxS, and the use 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. Note: The plan may require that you try standard treatment(s) before it covers 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. Nonprescription drugs and supplies Your prescription drug benefit also includes the following nonprescription drugs and supplies: • 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. • Each month, up to two over-the-counter COVID test kits will be covered as described in the UMP Preferred Drug List 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.” 2024 UMP Classic (PEBB) Certificate of Coverage 91
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 • Conform to coverage guidelines (see the "How UMP decides which prescription drugs are preferred" section). The brands and types of products covered are limited. For a list of covered preventive care products, check the Preferred Drug List or contact WSRxS Customer Service. 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. Injectable drugs available under the pharmacy benefit Certain injectable drugs may only be available through your pharmacy benefit. You can check the UMP Preferred Drug List to see if an injectable drug is covered through your pharmacy benefit. Some injectable drugs may need to be administered by a health care provider, and these drugs are typically available through your medical benefit. Vaccines administered at network pharmacies may be covered under your pharmacy benefit. 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. There may be additional limits (such as needing preauthorization) for your compound. Contact WSRxS to find out whether a preauthorization is required. 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 Nonspecialty drugs Specialty drugs* description All network pharmacies (retail and mail-order) Preventive • No deductible • No deductible (Preventive)*** • 0% coinsurance • 0% coinsurance Value Tier • No deductible • No deductible (Value) • 0–30-day supply: • 0–30-day supply: 92 2024 UMP Classic (PEBB) Certificate of Coverage
Tier and Nonspecialty drugs Specialty drugs* description All network pharmacies (retail and mail-order) ▪ 5% coinsurance or $10, whichever ▪ 5% coinsurance or $10, whichever is less is less • 31–60-day supply: ▪ 5% coinsurance or $20, whichever is less • 61–90-day supply: ▪ 5% coinsurance or $30, whichever is less Tier 1 (Tier • No deductible • No deductible 1/Tier 1 • 0–30-day supply: • 0–30-day supply: Specialty) ▪ 10% coinsurance or $25, whichever ▪ 10% coinsurance or $25, whichever Select generic is less is less drugs • 31–60-day supply: ▪ 10% coinsurance or $50, whichever is less • 61–90-day supply: ▪ 10% coinsurance or $75, whichever is less Tier 2 (Tier • Deductible applies • Deductible applies 2/Tier 2 • 0–30-day supply: • 0–30-day supply: Specialty) ▪ 30% coinsurance or $75, whichever ▪ 30% coinsurance or $75, whichever Preferred drugs is less** is less • 31–60-day supply: ▪ 30% coinsurance or $150, whichever is less** • 61–90-day supply: ▪ 30% coinsurance or $225, 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 contacting WSRxS Customer Service (see Directory for link and contact 2024 UMP Classic (PEBB) Certificate of Coverage 93
information). You may purchase up to a 90-day supply for most prescription drugs. For most 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. 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 are not covered. See the definition of “Excluded pharmacy.” Prescription drug deductible Your 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 your prescription drug deductible. How your deductible works Note: Your medical deductible and prescription drug deductible are separate. You pay your prescription drug deductible for Tier 2 drugs. Until you meet your prescription drug deductible, you pay your 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 your 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 2024 UMP Classic (PEBB) Certificate of Coverage
What does not apply to your deductible 1 • 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 “Prescription drugs and products UMP does not cover”). • Costs for prescription drugs purchased from excluded pharmacies (see “Excluded pharmacy” in the “Definitions” section). What you will pay for after reaching your deductible • Any prescription drugs or other products not covered by the plan (see “Prescription drugs and products UMP does not cover”). • 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 your deductible You pay your prescription drug deductible at any pharmacy. Your 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 allowed amount. Prescriptions purchased from an excluded pharmacy are not covered (see “Excluded pharmacy” in the “Definitions” section). Your coinsurance for prescription drugs ALERT! See page 55 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 most specialty drugs, you may purchase up to a 30-day supply. 1 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 are not covered. 2024 UMP Classic (PEBB) Certificate of Coverage 95
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. 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 96 2024 UMP Classic (PEBB) Certificate of Coverage
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 Normal You pay Prescription amount coinsurance cost-limit for a 30-day supply Value Tier (Value) $100 5% $5 $10 (5% x $100=$5) Tier 1 (Tier 1/Tier 1 $300 10% $25 $25 Specialty) (10% x $300=$30) Tier 2 (Tier 2/Tier 2 $500 30% $75 $75 Specialty) (30% x $500=$150) Must meet your prescription drug deductible first 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 are not covered. Your prescription drug out-of-pocket limit Expenses are counted from January 1, 2024, or your first day of enrollment, whichever is later, to December 31, 2024, 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 are not covered (see the definition of “Excluded pharmacy”) 2024 UMP Classic (PEBB) Certificate of Coverage 97
How the prescription drug out-of-pocket limit works What applies to this limit The following are 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. 2 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. 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 are not covered. Pharmacies are contracted through a different network than medical providers. 2 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 are not covered. 98 2024 UMP Classic (PEBB) Certificate of Coverage
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 contact 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 your 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. Contact 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, contact UMP’s network mail-order pharmacies, or contact 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. 2024 UMP Classic (PEBB) Certificate of Coverage 99
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 your 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 plan 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 Be sure to fill your prescriptions at a network pharmacy and show your ID card at the pharmacy counter. If you do, you pay for covered prescription drugs based on the allowed amount (WSRxS’ standard reimbursement). If you do not show your UMP member ID card at a network pharmacy or you use a non- network pharmacy, then you may be charged a higher amount. If the amount charged is more than the UMP allowed amount, you will pay the difference in addition to your coinsurance. Prescriptions purchased from an excluded pharmacy are not covered. If you have more than one insurance plan and UMP is your secondary insurance, 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: 100 2024 UMP Classic (PEBB) Certificate of Coverage
• You need to submit your claim to WSRxS for reimbursement (see the “Submitting a claim for prescription drugs” section). • 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. 2024 UMP Classic (PEBB) Certificate of Coverage 101
• A nonprescription alternative, including an over-the-counter alternative, becomes available. • A prescription drug receives FDA approval for a new use. • A prescription drug is used off label to treat an indication that is not determined to be medically necessary by WSRxS. • 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 listed on the UMP Preferred Drug List, and are medically necessary for your health condition; or • You received an exception to cover a noncovered drug Although your provider may prescribe a prescription drug that is not considered medically necessary, the above conditions must be met in order for a prescription drug to be covered. 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 contacting 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. 102 2024 UMP Classic (PEBB) Certificate of Coverage
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 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 contacting 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 contact 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. Contact 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. Contact 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. 2024 UMP Classic (PEBB) Certificate of Coverage 103
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 contact 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. 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 contacting 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 103 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). 104 2024 UMP Classic (PEBB) Certificate of Coverage
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. 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 contact 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 contact 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. 2024 UMP Classic (PEBB) Certificate of Coverage 105
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 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 90. 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 contacting 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. 106 2024 UMP Classic (PEBB) Certificate of Coverage
To request a travel override, contact 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 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, contact WSRxS Customer Service. What to do if the plan denies coverage TIP: If your prescription coverage is denied by the pharmacy due to plan enrollment issues, contact: Employees: Your employer’s payroll or benefits office. Retirees, PEBB Continuation Coverage, and retired employees of a former employer group: PEBB Program at 1-800-200-1004 (TRS: 711). If a network pharmacy (including mail-order or specialty drug) tells you that preauthorization is required, coverage is denied, or quantities are limited, you, your pharmacist, or your prescribing provider may contact 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 are not covered without an approved UMP Preferred Drug List exception request 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. 2024 UMP Classic (PEBB) Certificate of Coverage 107
• 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 91, or otherwise listed on the UMP Preferred Drug List. 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 prescribed for excluded conditions. • 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. 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 103 for how to request preauthorization of drugs covered under the prescription drug benefit. 108 2024 UMP Classic (PEBB) Certificate of Coverage
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. If your preauthorization is denied, your provider may request a peer-to-peer review where they can talk to a Regence BlueShield provider about your condition prior to submitting an appeal. For more information contact UMP customer service. Your preauthorization role ALERT! Excluded, experimental, and investigational services do not require preauthorization because they are not covered by the plan. To confirm whether a service is covered, contact UMP Customer Service. To be covered, some services, including, but not limited to, Applied Behavior Analysis (ABA) Therapy for members age 18 or older (see page 38) 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. Contact UMP Customer Service to ask if a service requires preauthorization and how to submit a request. An out-of-network provider is not obligated to obtain preauthorization 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. 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. • Contact 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. 2024 UMP Classic (PEBB) Certificate of Coverage 109
ALERT! The UMP preauthorization list is updated throughout the year. 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 contacting 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. Contact 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 The plan will respond to standard preauthorization requests submitted by contracted providers within 5 days of receipt for non-electronic requests and within 3 days of receipt for electronic requests. For expedited preauthorization requests, the plan will respond within 1 to 2 days of receipt. If additional information is required, the plan will notify the provider within the timelines described in this section. You will also be notified of the decision. If your provider believes that waiting for a decision under the standard preauthorization timeframe could place your life, health, or ability to regain maximum function in serious danger, they can request an expedited preauthorization request. 110 2024 UMP Classic (PEBB) Certificate of Coverage
General information from UMP Customer Service For services not requiring preauthorization, you may contact 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 are 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, contact 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; ◦ Music; ◦ Play; ◦ Recreational or similar therapy; and 2024 UMP Classic (PEBB) Certificate of Coverage 111
◦ 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 184) 20. Deep brain stimulation and transcranial direct current stimulation when used as nonpharmacological treatments for treatment-resistant depression 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 112 2024 UMP Classic (PEBB) Certificate of Coverage
◦ 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 ◦ Residential accessibility modifications ◦ Arch supports ◦ Sanitary supplies ◦ Communication aids ◦ Telephone alert systems ◦ Elevators ◦ Vision aids except when covered ◦ Exercise equipment through VSP ◦ Massage devices ◦ Whirlpools, portable whirlpool pumps, ◦ Overbed tables or sauna baths 31. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals 32. Experimental or investigational services, supplies, or drugs (see page 187) 2024 UMP Classic (PEBB) Certificate of Coverage 113
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: ◦ Over-the-counter hearing aids that are not prescribed, except for initial assessment, fitting, adjustment, auditory training, and ear molds as necessary to maintain an optimal fit ◦ 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 45. Home health care, except as described on page 54. The plan does not cover the following services: ◦ Housekeeping or meal services 114 2024 UMP Classic (PEBB) Certificate of Coverage
◦ 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 192) 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, physical exams and associated services (laboratory or similar tests) 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 38; ◦ “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. INTENTIONALLY LEFT BLANK. 59. Lumbar artificial disc replacement 60. Lumbar fusion for degenerative disc disease 2024 UMP Classic (PEBB) Certificate of Coverage 115
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 191) 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 82. Prescription drug charges over the allowed amount, regardless of where purchased 83. Prescription drugs that require preauthorization, unless the request is: 116 2024 UMP Classic (PEBB) Certificate of Coverage
◦ 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 68 86. Proton beam therapy for individuals age 21 or older for conditions other than: ◦ Brain/spinal ◦ Skull-based ◦ Esophageal ◦ Other primary cancers where all other ◦ Head/neck treatment options are contraindicated ◦ Hepatocellular carcinoma after review by a multidisciplinary tumor board ◦ Ocular 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 ◦ Expired other authorities ◦ Lost or stolen ◦ Contaminated ◦ Ruined ◦ Damaged 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, age 18 or 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 99. Services covered by other insurance, including, but not limited to: ◦ Automobile no-fault ◦ Commercial premises 2024 UMP Classic (PEBB) Certificate of Coverage 117
◦ General no-fault ◦ Personal injury protection (PIP) ◦ Homeowner’s ◦ Renter’s ◦ Medical payments (Med-Pay) ◦ Underinsured or uninsured motorist ◦ Motor vehicle See page 145 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 ◦ When treatment is primarily custodial 118 2024 UMP Classic (PEBB) Certificate of Coverage
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 body radiation therapy for the treatment of primary tumor of the following cancer types: ◦ Bone ◦ Head and neck ◦ Adrenal ◦ Melanoma ◦ Merkel cell ◦ Breast ◦ Ovarian ◦ Cervical 116. Stereotactic radiation surgery for conditions other than central nervous system primary and metastatic tumors 117. Surrogacy 118. Telephone or virtual consultations or appointments, except as described under “Telemedicine services” on page 77 119. Tinnitus specific therapies including, but not limited to: ◦ Tinnitus retraining therapy (TRT) ◦ Neuromonics tinnitus treatment (NTT) ◦ Tinnitus activities treatment (TAT) 2024 UMP Classic (PEBB) Certificate of Coverage 119
◦ Tinnitus-masking counseling 120. Transcutaneous vagal nerve stimulation (does not include or apply to support of previous implanted VNS) 121. Transcutaneous vagal nerve stimulation for epilepsy or depression 122. Travel, transportation, and lodging expenses, except as specified for ambulance services covered by the plan (see page 37), 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) 123. 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) 124. Upright magnetic resonance imaging (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading” 125. Vagal nerve stimulation (VNS) for treatment-resistant depression 126. Vagal nerve stimulation (VNS) for the treatment of depression (does not include or apply to support of previously implanted VNS) 127. Vision hardware replacements: ◦ The plan does not cover the replacement of any lost, stolen or broken lenses and/or frames. 128. 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 age 19. Impact-resistant coating is also covered for dependent children age 19 or older. 120 2024 UMP Classic (PEBB) Certificate of Coverage
◦ Medical or surgical treatment of the eyes 129. 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. 130. Vitamin D screening and testing as part of routine screening 131. 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. 132. 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. 133. 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 134. Transcranial Magnetic Stimulation (TMS) for treatment of: ◦ Obsessive-compulsive disorder (OCD) ◦ Generalized anxiety disorder (GAD) ◦ Posttraumatic stress disorder (PTSD) ◦ Smoking cessation ◦ Substance use disorder (SUD) If you have questions about whether a certain service or supply is covered, contact 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 “How UMP Classic and Medicare work together”). 2024 UMP Classic (PEBB) Certificate of Coverage 121
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. 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, contact 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. 122 2024 UMP Classic (PEBB) Certificate of Coverage
• 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. 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. 2024 UMP Classic (PEBB) Certificate of Coverage 123
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. 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 128. 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. 124 2024 UMP Classic (PEBB) Certificate of Coverage
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 network status” section for examples. The examples in the table below assume that you have met your medical deductible. Situation Example Preferred UMP UMP Other UMP You pay provider allowed normal plan pays your charge amount benefit pays provider UMP is EXAMPLE 1: $200 $100 $85 N/A $85 $15 primary, When UMP (85% of other plan is pays first (or is $100) secondary the only plan) UMP is EXAMPLE 2: $200 $100 $85 $80 $5 $15 secondary, The other plan other plan is pays less than primary the normal UMP benefit UMP is EXAMPLE 3: $200 $100 $85 $85 $0 $15 secondary, The other plan other plan is pays as much primary as (or more than) the normal UMP benefit 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 2024 UMP Classic (PEBB) Certificate of Coverage 125
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. 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. 126 2024 UMP Classic (PEBB) Certificate of Coverage
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). Alert! If you are the subscriber and are an employee, see “When UMP Classic pays first and Medicare pays second” 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. 2024 UMP Classic (PEBB) Certificate of Coverage 127
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. • 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 your 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 your UMP Classic and Medicare deductibles If you meet your UMP Classic deductible, you do not pay both the Medicare Part B and your UMP Classic deductible. Your 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) = $297.50 128 2024 UMP Classic (PEBB) Certificate of Coverage
Benefit calculation Amount Since the UMP Classic benefit available (dollar amount) is greater than the balance, UMP $266.40 pays the balance remaining after Medicare pays: The difference between the normal UMP Classic benefit and the amount UMP paid is: $31.10 This amount is considered “COB savings” (see page 131). 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 $100 amount UMP Classic normal $85 (85% of $100) benefit UMP Classic pays $20 You pay $0 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 2024 UMP Classic (PEBB) Certificate of Coverage 129
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). • 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 Important information preferred provider? Services covered by Medicare No You should see a provider who accepts Medicare. See “When providers do not accept 130 2024 UMP Classic (PEBB) Certificate of Coverage
Type of service Higher benefits with UMP Important information preferred provider? Medicare” on page 131 to learn why this is important. Services covered by UMP Yes See “What UMP Classic covers Classic but not by Medicare that Medicare does not” starting on page 130 to see which services apply. Use the provider search on the UMP website (see Directory for link) or contact 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. 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. 2024 UMP Classic (PEBB) Certificate of Coverage 131
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, contact 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 contact 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. 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 your 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 contact WSRxS Customer Service (see Directory for link and contact information). 132 2024 UMP Classic (PEBB) Certificate of Coverage
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 (X) for 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 Medicare What Medicare covers Whether your claim has been processed by Medicare Your Medicare deductibles and coinsurance amounts What UMP Classic covers UMP Customer Service or visit the Your UMP Classic copays, coinsurance, and deductible UMP website amounts 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 PEBB Program Address changes Changing your PEBB medical coverage UMP Classic premiums If the member responsibility dollar amount on your UMP Your provider’s billing office Classic Explanation of Benefits does not match your provider’s bill Whether your claim has been submitted to Medicare Billing and payment: submitting a claim FOR MEDICARE RETIREES: Read the “For Retirees Enrolled in Medicare and UMP Classic” section. 2024 UMP Classic (PEBB) Certificate of Coverage 133
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 contact 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: • 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 contacting 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. 134 2024 UMP Classic (PEBB) Certificate of Coverage
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. Contact 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. 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., contact 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 your 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 123) 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. 2024 UMP Classic (PEBB) Certificate of Coverage 135
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 contacting WSRxS Customer Service. Send the completed claim form, along with your pharmacy receipt(s), to: 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 (see the “Refill too soon” section). 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 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. 136 2024 UMP Classic (PEBB) Certificate of Coverage
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. 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 (aka: grievance)? A complaint 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 (aka: grievance) For all medical complaints, it’s recommended that you first contact UMP Customer Service. For prescription drug complaints or grievances, we recommend contacting WSRxS Customer Service. Many issues may be resolved with a phone call. If an initial phone call does not resolve your complaint, you may submit your complaint: • 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. 2024 UMP Classic (PEBB) Certificate of Coverage 137
• A retroactive decision to deny coverage based on eligibility (see the “Appeals related to eligibility” section below). • 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 contacting 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. 138 2024 UMP Classic (PEBB) Certificate of Coverage
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. 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 contacting 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 your 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 2024 UMP Classic (PEBB) Certificate of Coverage 139
review). You may authorize a representative to submit an appeal on your behalf in writing or by contacting 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 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 contacting 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: 1-888-849-3681 (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 contacting 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 140 2024 UMP Classic (PEBB) Certificate of Coverage
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). 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 2024 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 2024 UMP Classic (PEBB) Certificate of Coverage 141
a representative to submit a request for an external review on your behalf in writing or by contacting 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. 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, contact 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. 142 2024 UMP Classic (PEBB) Certificate of Coverage
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 contact UMP Customer Service if you have questions. 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 2024 UMP Classic (PEBB) Certificate of Coverage 143
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: ▪ 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. 144 2024 UMP Classic (PEBB) Certificate of Coverage
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 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 equals the third-party recovery. General provisions UMP is administered by Regence BlueShield and Washington State Rx Services under contract with HCA. 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 contacting 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. 2024 UMP Classic (PEBB) Certificate of Coverage 145
• 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. ▪ 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 currently retired, or are in the process retiring, and become eligible for Medicare. 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, PEBB Continuation Coverage members, and retired employees of a former employer group: 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. 146 2024 UMP Classic (PEBB) Certificate of Coverage
• 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. • 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 91) • Process for preauthorization, notice, or review (see the “Limits on plan coverage” section and page 103) You may find the following on the UMP website or by contacting 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) 2024 UMP Classic (PEBB) Certificate of Coverage 147
• When the plan may retroactively deny coverage for preauthorized medical services The following are available through your Regence account or by contacting UMP Customer Service: • Medical claims history and medical deductible status • Online directory of preferred providers, including both primary care providers and specialists The following are available on the UMP Prescription drug coverage webpage or by contacting 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 contact 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 contact 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 contacting 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. 148 2024 UMP Classic (PEBB) Certificate of Coverage
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: Contact UMP Customer Service or use your Regence account (see Directory for link and contact information). • Prescription drug benefits: Contact 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 HCA 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 2024 UMP Classic (PEBB) Certificate of Coverage 149
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. 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 HCA’s authorized officers. 150 2024 UMP Classic (PEBB) Certificate of Coverage
Acronyms ABA – Applied Behavior Analysis [Therapy] HSA – Health savings account ACP – Accountable Care Program HTCC – Health Technology Clinical Committee ASC – Ambulatory surgery center IRC – Internal Revenue Code CDC – Centers for Disease Control and IRO – Independent review organization Prevention IRS – Internal Revenue Service CDHP – Consumer-directed health plan MSN – Medicare Summary Notice CHIP – Children’s Health Insurance Program NMSN – National Medical Support Notice CMS – Centers for Medicare and Medicaid P – Preventive Services P&T – Pharmacy and Therapeutics Committee COB – Coordination of benefits PCP – Primary care provider COBRA – Consolidated Omnibus Budget PEBB – Public Employees Benefits Board Reconciliation Act COC – Certificate of coverage PFML – Paid Family and Medical Leave COE – Centers of Excellence Program PPACA – Patient Protection and Affordable Care DME – Durable medical equipment Act DPP – Diabetes Prevention Program PPO – Preferred Provider Organization EOB – Explanation of benefits PPS – Postal Prescription Services EOMB – Explanation of Medicare benefits RCW – Revised Code of Washington ER – Emergency room REMS – Risk Evaluation and Mitigation Strategies ERB – Employee and Retiree Benefits [Division] SBC – Summary of Benefits and Coverage FDA – Food and Drug Administration SEBB – School Employees Benefits Board FMLA – Family Medical Leave Act TMJ – Temporomandibular joint FSA – Flexible spending arrangement TRS – Telecommunications Relay Service HCA – Health Care Authority UMP – Uniform Medical Plan HDHP – High-deductible health plan V – Value tier HIPAA – Health Insurance Portability and WAC – Washington Administrative Code Accountability Act WSRxS – Washington State Rx (prescription HRA – Health reimbursement arrangement drug) Services HRSA – Health Resources and Services Administration 2024 UMP Classic (PEBB) Certificate of Coverage 151
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 their election to enroll in PEBB Continuation Coverage (COBRA or Unpaid Leave). 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.” Retired employee of a former employer group eligibility The PEBB Program determines whether a retired employee or a retired school employee of a former employer group is eligible to self-pay coverage upon receipt of their election to enroll. If the retired employee or the retired school employee requests to enroll and is not eligible, 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. 152 2024 UMP Classic (PEBB) Certificate of Coverage
▪ 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. ◦ 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. Exceptions apply for non-Medicare enrollees when a subscriber selects a Medicare Supplement, Medicare Advantage, or Medicare Advantage Prescription Drug plan. Employee enrollment An employee must use Benefits 24/7, the online enrollment system (once available), or 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 online enrollment must be completed or the form must be received no later than 31 days after the date the employee becomes eligible or regains eligibility. 2024 UMP Classic (PEBB) Certificate of Coverage 153
If the employee does not enroll online or 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. Waiving medical enrollment An eligible employee may waive enrollment in PEBB medical 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 using Benefits 24/7, the online enrollment system (once available), or by submitting the applicable PEBB Continuation Coverage Election/Change form and any supporting documents to the PEBB Program. The online enrollment must be completed or 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. Retired employee of a former employer group enrollment A retired employee or a retired school employee of a former employer group may enroll and self-pay premiums using Benefits 24/7, the online enrollment system (once available), or by submitting the PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The online enrollment must be completed or the PEBB Program must receive the required form no later than 60 days after the employer group ended their participation. 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. Note: Enrollment in the PEBB Program’s Medicare Advantage Prescription Drug (MAPD) plan may not be retroactive. If a subscriber elects a MAPD plan and the online enrollment or the required forms are received by the PEBB Program after the date PEBB health plan 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 MAPD plan begins. Dependent enrollment To enroll an eligible dependent, the subscriber must include the dependent’s information online using Benefits 24/7 (once available) or 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. 154 2024 UMP Classic (PEBB) Certificate of Coverage
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 must use Benefits 24/7 (once available) or submit the required form(s) to their employing agency. • Any other subscriber must use Benefits 24/7 (once available) or submit 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. 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. 2024 UMP Classic (PEBB) Certificate of Coverage 155
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. 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, a retired employee of a former employer group, or their dependent If a continuation coverage subscriber, a retired employee of a former employer group, 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. 156 2024 UMP Classic (PEBB) Certificate of Coverage
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, including 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 subscribers 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. Retired employees of a former employer group and dependents For a retired employee of a former employer group and their eligible dependents enrolling when newly eligible, medical coverage begins the first day of the month following the day they lost eligibility for PEBB retiree insurance 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 online enrollment election using Benefits 24/7 (once available) or the required form is received. If that day is the first of the month, medical coverage begins on that day, except for a Medicare Advantage or Medicare Advantage Prescription Drug plan, which will begin the first day of the month following the date the enrollment election is received online or the required form is received by the PEBB Program. 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. 2024 UMP Classic (PEBB) Certificate of Coverage 157
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 provide notice online using Benefits 24/7 (once available) or by submitting a written request to their employing agency. • Any other subscriber must provide notice online using Benefits 24/7 (once available) or by submitting a written request to 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 or retired employees of a former employer group A continuation coverage subscriber or a retired employee of a former employer group may voluntarily terminate enrollment in a medical plan at any time by submitting a request online using Benefits 24/7 (once available) or in writing to the PEBB Program. Enrollment in the medical plan will be terminated the last day of the month in which the request was received online or by the PEBB Program, 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. Exception: When a subscriber or their dependent is enrolled in a Medicare Advantage or Medicare Advantage Prescription Drug plan, then medical plan enrollment will terminate on the last day of the month when the PEBB Medicare Advantage Plan Disenrollment form (form D) is received. 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. 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 158 2024 UMP Classic (PEBB) Certificate of Coverage
• Waive their medical plan enrollment • Enroll after waiving medical plan enrollment • Enroll or remove eligible dependents An employee must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Employee Enrollment/Change form and any supporting documents to their employing agency. The change must be completed online, 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. Any other 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 using PEBB My Account or Benefits 24/7 (once available) or 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. The change must be completed online, 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 retired employee of a former employer group must submit the election change online using PEBB My Account or Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The change must be completed online, 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 make the change online using Benefits 24/7 (once available) or submit the required PEBB Employee Enrollment/Change form and any supporting documents to their employing agency. • A continuation coverage subscriber must make the change online using Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (COBRA) Election/Change, or PEBB 2024 UMP Classic (PEBB) Certificate of Coverage 159
Continuation Coverage (Unpaid Leave) Election/Change form (as appropriate) and any supporting documents to the PEBB Program. • A retired employee of a former employer group must make the change online using Benefits 24/7 (once available) or submit the required PEBB Continuation Coverage (Employer Group Ended Participation) Election/Change form and any supporting documents to the PEBB Program. The change must be completed online, or 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: • 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 complete the request online or 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 request must be received online, or 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. A continuation coverage subscriber or a retired employee of a former employer group: • 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 change must be made online using Benefits 24/7 (once available) or 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 they or their dependent is enrolled in a Medicare Advantage (MA) or Medicare Advantage Prescription Drug (MAPD) 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 PEBB Medicare Advantage Plan Disenrollment Form (form D) is received. • Has seven months to enroll in an MA or MAPD 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 an MA or MAPD plan before their last day of the Medicare Part B initial enrollment period. The change must be made online in Benefits 24/7 (once available), or the forms must be received by the PEBB Program, no later than the last day of the month prior to the month they or their dependent enrolls in the MA or MAPD plan. Special open enrollment events that allow for a change in health plans A subscriber may not change their health plan during a special open enrollment 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). 160 2024 UMP Classic (PEBB) Certificate of Coverage
• 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 has a change in residence and their current medical plan is no longer available, the subscriber must select a new medical plan as described in PEBB Program rules. If the subscriber does not elect a new medical plan as required, they will be enrolled in a PEBB medical plan designated by the director of HCA or their designee. • 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 ▪ The PEBB Program determines that there has been a substantial decrease in the providers available under a PEBB medical plan. 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 or there has been a substantial decrease in the providers available under the plan. 2024 UMP Classic (PEBB) Certificate of Coverage 161
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. • 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 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. 162 2024 UMP Classic (PEBB) Certificate of Coverage
• 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. • 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. 2024 UMP Classic (PEBB) Certificate of Coverage 163
• For a continuation coverage subscriber or a retired employee of a former employer group who submits a request to terminate medical coverage, enrollment in medical coverage will be terminated the last day of the month in which the request was received online using Benefits 24/7 (once available) or by the PEBB Program, 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. Exception: When a subscriber or their dependent is enrolled in a Medicare Advantage or Medicare Advantage Prescription Drug plan, the medical plan enrollment will terminate on the last day of the month when the PEBB 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 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. 164 2024 UMP Classic (PEBB) Certificate of Coverage
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: • 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.” 2024 UMP Classic (PEBB) Certificate of Coverage 165
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.” 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 us at 1-888-849-3681 (TRS: 711). 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: 166 2024 UMP Classic (PEBB) Certificate of Coverage
▪ 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. 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 a retiring employee from a Public Employees Benefits Board (PEBB) employing agency or employer group, and an elected or full-time appointed official of the legislative and executive branch of state government eligible to continue enrollment in PEBB retiree insurance coverage. The term “retiree” or “retiring school employee” includes a retiring school employee from a School Employees Benefits Board (SEBB) organization or employer group. 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 their election to enroll. 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.” 2024 UMP Classic (PEBB) Certificate of Coverage 167
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 their election to enroll. 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.” 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. 168 2024 UMP Classic (PEBB) Certificate of Coverage
◦ 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. 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 electing to defer enrollment using Benefits 24/7, the online enrollment system (once available), or 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. 2024 UMP Classic (PEBB) Certificate of Coverage 169
• 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 or School Employees Benefits Board (SEBB), including such coverage under COBRA or continuation coverage. They do not need to elect to defer enrollment online or submit a PEBB Retiree Election Form. 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 elect to defer enrollment online or 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 enroll using Benefits 24/7, the online enrollment system (once available), or submit a PEBB Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB Program. The online enrollment must be completed or the forms must be received no later than 60 days after the employee’s or the school employee’s own 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 enroll using Benefits 24/7, the online enrollment system (once available), or submit a PEBB Retiree Election Form (form A) along with any other required forms and supporting documents to the PEBB Program. The online enrollment must be completed or the forms 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 enroll using Benefits 24/7, the online enrollment system (once available), or 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. The online enrollment must be completed or the forms 170 2024 UMP Classic (PEBB) Certificate of Coverage
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. A retiree or a survivor who deferred enrollment and is enrolling in a PEBB retiree health plan, must enroll using Benefits 24/7, the online enrollment system (once available), or 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. The online enrollment must be completed or the forms 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 (MAPD) plan may not be retroactive. If a subscriber elects an MAPD plan and the online enrollment or 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 MAPD plan begins. Dependent enrollment To enroll an eligible dependent, the subscriber must include the dependent’s information online using Benefits 24/7 (once available) or 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. 2024 UMP Classic (PEBB) Certificate of Coverage 171
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 by uploading it online using Benefits 24/7 (once available) or providing it 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 upload or provide 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. 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 retiring employee’s or retiring school employee’s own 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. 172 2024 UMP Classic (PEBB) Certificate of Coverage
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 online enrollment election using Benefits 24/7 (once available) or the required form is received. If that day is the first of the month, medical coverage begins on that day, except for a Medicare Advantage or Medicare Advantage Prescription Drug plan, which will begin the first day of the month following the date the enrollment election is received online or the required from is received by the PEBB Program. 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. 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 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 online using Benefits 24/7 (once available) or by written request to the PEBB Program 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 online using Benefits 24/7 (once available) or in writing to the PEBB Program. Enrollment in the medical plan will be terminated the last day of the month in which the request is received online or by the PEBB Program, 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 or Medicare Advantage Prescription Drug plan, medical plan enrollment will be terminated on the last day of the month when the PEBB Medicare Advantage Plan Disenrollment Form (form D) is received. 2024 UMP Classic (PEBB) Certificate of Coverage 173
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 request online using Benefits 24/7 (once available) or 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 request is received online or by the PEBB Program. If the request is 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 or Medicare Advantage Prescription Drug plan, medical plan enrollment will be deferred the first of the month following the date the PEBB 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: • 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 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 or SEBB ends, or such coverage under COBRA or continuation coverage ends. The evidence of continuous enrollment required to enroll as described below may include a health plan sponsored by a Washington State educational service district if enrollment was deferred prior to January 1, 2024. Note: Enrollment in the PEBB Program’s Medicare Advantage Prescription Drug (MAPD) plan may not be retroactive. If a subscriber elects an MAPD plan and the online enrollment or the required forms are received by the PEBB Program after the date PEBB retiree insurance coverage is to begin, the subscriber 174 2024 UMP Classic (PEBB) Certificate of Coverage
and their enrolled dependents will be enrolled in the Uniform Medical Plan Classic during the gap month(s) prior to when the MAPD plan begins. For a retiree or a survivor to enroll in a PEBB medical plan, the enrollment must be completed online using Benefits 24/7 (once available) or 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. 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 using PEBB My Account or Benefits 24/7 (once available) or submit 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 online 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 (MA) plan or Medicare Advantage Prescription Drug (MAPD) plan, the change in enrollment must be allowable under federal regulations. To make an enrollment change, the subscriber must submit the change online using Benefits 24/7 (once available) or submit the required PEBB Retiree Change Form (form E) along with any other required forms to the PEBB Program. The change must be completed online or 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 2024 UMP Classic (PEBB) Certificate of Coverage 175
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 change must be made online or 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 an MA or MAPD 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 PEBB Medicare Advantage Plan Disenrollment Form (form D) is received. • A subscriber enrolled in PEBB retiree insurance coverage has seven months to enroll in an MA or MAPD 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 an MA or MAPD plan before their last day of the Medicare Part B initial enrollment period. The change must be made online or 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 MA or MAPD 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 complete the request online or notify the 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 request must be received online, or 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 during a special open enrollment 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: o Marriage or registering a state-registered domestic partnership. o Birth, adoption, or assuming a legal obligation for total or partial support in anticipation of adoption. o 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 has a change in residence and their current medical plan is no longer available, the subscriber must select a new medical plan, as described in PEBB Program rules. If the subscriber does 176 2024 UMP Classic (PEBB) Certificate of Coverage
not elect a new medical plan as required, they will be enrolled in a PEBB medical plan designated by the director of HCA or their designee. • 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 ▪ The PEBB Program determines that there has been a substantial decrease in the providers available under a PEBB medical plan. 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 or there has been a substantial decrease in the providers available under the plan. 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. 2024 UMP Classic (PEBB) Certificate of Coverage 177
• 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. • 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. When a subscriber is enrolled in a Medicare Advantage (MA) or a Medicare Advantage Prescription Drug (MAPD) plan, medical coverage ends at the end of the month after a termination notice is sent. The first of the month following the date the election is received online using Benefits 24/7 (once available) or the required forms are received by the PEBB Program when an enrolled retiree or survivor requests to defer enrollment in PEBB retiree insurance coverage. If the election is 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 an MA or a MAPD plan, medical plan enrollment will be deferred the first of the month following the date the PEBB Medicare Advantage Plan Disenrollment Form (form D) is received. The last day of the month in which the request is received online using Benefits 24/7 (once available) or 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 178 2024 UMP Classic (PEBB) Certificate of Coverage
retiree, a survivor, or their dependent is enrolled in an MA or MAPD plan, medical plan enrollment will be terminated on the last day of the month when the PEBB 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: • 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. Refer to the PEBB Continuation Coverage Election Notice for details. 2024 UMP Classic (PEBB) Certificate of Coverage 179
A subscriber and their dependents covered by this medical plan who lose eligibility for PEBB retiree insurance coverage when their employer group ends participation with the Health Care Authority, may be eligible to continue their enrollment under PEBB Continuation Coverage (Employer Group Ended Participation). The PEBB Program administers these coverages. Call the PEBB Program at 1‑800‑200‑1004 (TRS: 711) 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 us at 1-888-849-3681 (TRS: 711). 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. 180 2024 UMP Classic (PEBB) Certificate of Coverage
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, call the PEBB Program at 1-800-200-1004 (TRS:711) or visit hca.wa.gov/pebb-retirees. For questions about Medicare, 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. 2024 UMP Classic (PEBB) Certificate of Coverage 181
• 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. 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, contact 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 182 2024 UMP Classic (PEBB) Certificate of Coverage
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" section 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 network status” 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. 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. Biosimilar A biosimilar, or biosimilar drug, is a medicine approved by the US Food and Drug Administration that is highly similar in structure to and has no clinical difference to a reference biologic medicine. Brand-name drug A brand-name drug is a prescription drug sold under the proprietary name or trade name selected by the manufacturer. 2024 UMP Classic (PEBB) Certificate of Coverage 183
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. 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 184 2024 UMP Classic (PEBB) Certificate of Coverage
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 Your 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 not subject to this deductible (see the “Summary of benefits” section). See the “What you pay for medical services” section for details on how your medical deductible works. Your 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 94. Deductible, prescription drugs Your 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 your 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. Your 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 94. 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 153 and 168) for information about dependents of a retiree or survivor that is either covered by or eligible to be covered by the plan under the subscriber’s account. 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: 2024 UMP Classic (PEBB) Certificate of Coverage 185
• 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. Employer group Employer group for the Public Employees Benefits Board (PEBB) Program means those counties, municipalities, political subdivisions, the Washington health benefits exchange, tribal governments, and employee organizations representing state civil service employees obtaining employee benefits through a contractual agreement with the health care authority (HCA) to participate in benefit plans developed by the PEB board. Employer group for the School Employees Benefits Board (SEBB) Program means an employee organization representing school employees and a tribal school as defined in RCW 28A.715.010, obtaining employee benefits through a contractual agreement with the health care authority (HCA) to participate in benefit plans developed by the SEB board. 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. 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. 186 2024 UMP Classic (PEBB) Certificate of Coverage
Excluded pharmacy Excluded pharmacies are pharmacies or pharmacy chains that are prohibited from contracting with the Pharmacy Network, and that are not eligible to be reimbursed for Prescription Drug Claims. Prescriptions filled at excluded pharmacies are not covered. 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. ▪ 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 2024 UMP Classic (PEBB) Certificate of Coverage 187
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 contact 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 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. 188 2024 UMP Classic (PEBB) Certificate of Coverage
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 • Is Medicare-certified, accredited by the Joint Commission on Accreditation of Healthcare Organizations, or a preferred provider. 2024 UMP Classic (PEBB) Certificate of Coverage 189
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. 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. 190 2024 UMP Classic (PEBB) Certificate of Coverage
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 HCA. 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). For benefits limited to a certain dollar amount (e.g., hearing aids), you pay all charges billed to you above the maximum dollar amount. Any amounts billed above the maximum dollar limit do not apply to your out-of-pocket limit. 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. 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. 2024 UMP Classic (PEBB) Certificate of Coverage 191
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 your 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. • 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. 192 2024 UMP Classic (PEBB) Certificate of Coverage
• 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 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. 2024 UMP Classic (PEBB) Certificate of Coverage 193
Member A member is an eligible employee, retiree, former employee or former dependent in Continuation Coverage, survivor, retired employee of a former employer group, 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 the plan pays 85 percent of the allowed amount for preferred providers after you meet your medical deductible. 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 contacting 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 contacting 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. 194 2024 UMP Classic (PEBB) Certificate of Coverage
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 125. 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 2024 UMP Classic (PEBB) Certificate of Coverage 195
• 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, continuation coverage subscribers, retired employees of a former employer group, and retirees or survivors 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. 196 2024 UMP Classic (PEBB) Certificate of Coverage
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 not in your plan’s preferred network, and they cannot balance bill you. • Considered out of network for your plan, except for the following services: ▪ Covered preventive services. ▪ Mental health or substance use disorder. ▪ Emergency services for a medical emergency (including air ambulance). 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. 2024 UMP Classic (PEBB) Certificate of Coverage 197
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). 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 153 or 167) for information about retiree or survivor eligibility, “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 contacting UMP Customer Service (see Directory for link and contact information). See page 103 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 198 2024 UMP Classic (PEBB) Certificate of Coverage
• 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). 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 your 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). 2024 UMP Classic (PEBB) Certificate of Coverage 199
• Services with an A or B rating by the U.S. Preventive Services Task Force. Preventive rate Covered preventive services are not subject to your 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. 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 2024 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 200 2024 UMP Classic (PEBB) Certificate of Coverage
dependents in Continuation Coverage, retirees, survivors, retired employees of a former employer group, 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. Retired employee of a former employer group A retired employee of a former employer group includes a retired employee from a PEBB employer group and a retired school employee of a SEBB employer group who is continuing enrollment in PEBB health plan coverage by self-paying premiums after losing eligibility for PEBB retiree insurance coverage 2024 UMP Classic (PEBB) Certificate of Coverage 201
upon the employer group ending participation in insurance plans and contracts with the health care authority (HCA). 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). 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. 202 2024 UMP Classic (PEBB) Certificate of Coverage
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. 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 2023 plan year reduces the subscriber’s 2024 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 2024 plan year reduces the subscriber’s 2025 plan year deductible by $125 if the subscriber is still eligible to participate in the wellness incentive program and is enrolled in the 2025 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 2024 UMP Classic (PEBB) Certificate of Coverage 203
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. 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, retired employee of a former employer group, 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. 204 2024 UMP Classic (PEBB) Certificate of Coverage
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. 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 UMP nondiscrimination and language assistance notice by visiting hca.wa.gov/ump- 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. 2024 UMP Classic (PEBB) Certificate of Coverage 205
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. myStrength is a separate company that provides virtual behavioral health care services. 206 2024 UMP Classic (PEBB) Certificate of Coverage