UMP Classic Medicare SBC (2024)

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2024 – 12/31/2024 Washington State – Uniform Medical Plan (UMP) Classic (Medicare) (PEBB) Coverage for: Individual and Eligible Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit ump.regence.com/pebb or call 1 (888) 849-3681 (TRS: 711). For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1 (888) 849-3681 (TRS: 711) to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount What is the overall $250 individual / $750 family per calendar before this plan begins to pay. If you have other family members on the plan, each deductible? year. family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven't yet met the Are there services covered Yes. Certain preventive care and those deductible amount. But a copayment or coinsurance may apply. For example, before you meet your services listed below as "deductible does not this plan covers certain preventive services without cost sharing and before you deductible? apply." meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles Yes. $100 individual / $300 family per calendar You must pay all of the costs for these services up to the specific deductible amount for specific services? year for prescription drug coverage. There are before this plan begins to pay for these services. no other specific deductibles. $2,500 individual / $5,000 family per calendar The out-of-pocket limit is the most you could pay in a year for covered services. If you What is the out-of-pocket year. have other family members in this plan, they have to meet their own out-of-pocket limits limit for this plan? Prescription drugs: $2,000 individual / $4,000 until the overall family out-of-pocket limit has been met. family per calendar year Premiums, balance-billing charges, member coinsurance paid to out-of-network providers What is not included in the and non-network pharmacies, and health care Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? this plan doesn't cover. Prescription drugs do not apply to the medical out-of-pocket limit and are subject to their own out-of-pocket limit. Page 1 of 7 Claims Administrator: Regence BlueShield

Yes. Find a doctor at ump.regence.com/go/pebb/ump-classic or call This plan uses a provider network. You will pay less if you use a provider in the plan's 1- 888-849-3681 (TRS: 711) for a list of network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use network providers (preferred providers). receive a bill from a provider for the difference between the provider's charge and what a network provider? For a list of network pharmacies, visit the your plan pays (balance billing). Be aware, your network provider might use an out-of- pharmacy-locator webpage at network provider for some services (such as lab work). Check with your provider before ump.regence.com/go/2024/pharmacy-locator you get services. or call 1-888-361-1611 (TRS: 711). Do you need a referral to No. You can see the specialist you choose without a referral. see a specialist? All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Primary care visit to 15% coinsurance 40% coinsurance treat an injury or illness None If you visit a health Specialist visit 15% coinsurance 40% coinsurance care provider's office Coinsurance and deductible do not apply for childhood or clinic Preventive No charge, deductible does 40% coinsurance, immunizations from out-of-network providers. You may care/screening/ not apply deductible does not apply have to pay for services that aren't preventive. Ask immunization your provider if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, 15% coinsurance 40% coinsurance Certain tests aren’t covered, and other tests require If you have a test blood work) preauthorization. Please refer to your plan document. Imaging (CT/PET scans, 15% coinsurance 40% coinsurance *See section Radiology. MRIs) *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 2 of 7

Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Value Tier (Specific high 5% coinsurance or Deductible does not apply for insulin. value prescription drugs $10 copay, whichever is 5% coinsurance, deductible *Coinsurance for Tier 2 covered insulins are capped at used to treat certain less / prescription, does not apply $35 per 30-day supply. chronic conditions) deductible does not apply Preauthorization may be required. Please refer to your 10% coinsurance or plan document. *See section Your prescription drug If you need drugs to Tier 1 (Low-cost generic $25 copay, whichever is 10% coinsurance, benefit. treat your illness or prescription drugs) less / prescription, deductible does not apply Up to a 90-day supply / retail prescription (your cost condition deductible does not apply share is per 30-day supply) More information about Tier 2 (Preferred brand 30% coinsurance or $75 90-day supply / mail-order prescription prescription drug drugs and high-cost copay, whichever is less, 30% coinsurance Postal Prescription Services (PPS) and Costco Mail coverage is available at generic drugs) up to 30 day supply / Order Pharmacy are the plan's only network mail-order ump.regence.com/pebb/ prescription* pharmacies. benefits/prescriptions Specialty drugs must be filled from the specialty pharmacy, Ardon Health, except when a drug can only Refer to Value Tier, Tier 1, Refer to Value Tier, Tier 1, be dispensed by a certain pharmacy. Specialty drugs and Tier 2 drugs above. and Tier 2 drugs above. Covers up to a 30-day supply for most specialty prescription drugs. Prescription drugs filled at excluded pharmacies are not covered. Facility fee (e.g., If you have outpatient ambulatory surgery 15% coinsurance 40% coinsurance None surgery center) Physician/surgeon fees 15% coinsurance 40% coinsurance Preauthorization may be required. *See section Surgery. 15% coinsurance after $75 15% coinsurance after $75 Copayment applies to facility charge for each visit Emergency room care copay / visit copay / visit (waived if admitted), whether or not the deductible has been met. If you need immediate Coverage is not provided for air or water ambulance if medical attention Emergency medical 20% coinsurance 20% coinsurance ground ambulance would serve the same purpose. transportation Ambulance services for personal or convenience purposes are not covered. Urgent care 15% coinsurance 40% coinsurance None *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 3 of 7

Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) Facility fee (e.g., $200 copay per day up to If you have a hospital hospital room) $600 per individual per 40% coinsurance Provider must notify plan on admission. stay admission Physician/surgeon fees 15% coinsurance 40% coinsurance Preauthorization may be required. *See section Surgery. Outpatient services 15% coinsurance 40% coinsurance Preauthorization may be required. *See section Behavioral health. If you need mental $200 copay per day up to health, behavioral $600 per individual per Preauthorization required for inpatient admissions. health, or substance Inpatient services admission; 40% coinsurance Provider must notify the plan for detoxification, abuse services intensive outpatient program, and partial Professional services: hospitalization. *See section Behavioral health. No charge Office visits 15% coinsurance 40% coinsurance Cost sharing does not apply for preventive services. Childbirth/delivery 15% coinsurance 40% coinsurance Depending on the type of services, a copayment, If you are pregnant professional services coinsurance or deductible may apply. Maternity care Childbirth/delivery $200 copay per day up to may include tests and services described elsewhere in facility services $600 per individual per 40% coinsurance the SBC (i.e. ultrasound). admission Home health care 15% coinsurance 40% coinsurance None Inpatient: $200 copay per 60 inpatient days / year day up to $600 per 60 outpatient visits / year (combined with habilitation individual per admission; services) If you need help Professional and outpatient services are covered at the recovering or have Rehabilitation services Professional services: 15% 40% coinsurance coinsurance specified, after deductible. other special health coinsurance Includes physical therapy, occupational therapy and needs speech therapy. Outpatient services: 15% Inpatient admissions for rehabilitation services must be coinsurance preauthorized. *See section Therapy: Habilitative and rehabilitative. 60 professional neurodevelopmental visits / year Habilitation services 15% coinsurance 40% coinsurance (combined with outpatient rehabilitation services) Includes physical therapy, occupational therapy and *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 4 of 7

Common Medical Services You May What You Will Pay Limitations, Exceptions, & Other Important Event Need In-Network Provider Out-of-Network Provider Information (You will pay the least) (You will pay the most) speech therapy. Preauthorization is required. *See section Therapy: Habilitative and rehabilitative. Inpatient: $200 copay per day up to $600 per 150 inpatient days / year Skilled nursing care individual per admission 40% coinsurance Preauthorization is required. *See section Skilled Professional services: 15% nursing facility. coinsurance Durable medical 15% coinsurance 40% coinsurance None equipment Hospice services No charge 40% coinsurance Hospice care / 6 months 14 respite inpatient or outpatient days / lifetime Children's eye exam No charge, deductible does Not covered 1 routine eye exam / year not apply Limited to individuals under age 19. 1 pair of standard lenses and frames / year If your child needs Children's glasses No charge, deductible does Not covered 1 year supply of contact lenses in lieu of standard dental or eye care not apply lenses and frames Limited to individuals under age 19. Children's dental check- Not covered Not covered None up *For more information about limitations and exceptions, see the plan or policy document at hca.wa.gov/ump-pebb-coc. Page 5 of 7

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Cosmetic surgery, except congenital anomalies • Infertility treatment • Private-duty nursing • Dental care • Long-term care • Weight loss programs Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) • Acupuncture, 24 visits / year • Hearing aids, $3,000 per ear / 3 calendar years • Routine eye care (Adult) • Bariatric surgery • Non-emergency care when traveling outside the • Routine foot care • Chiropractic care, 24 spinal manipulations / year U.S. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform, or the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1 (877) 267-2323 ext. 61565 or cciio.cms.gov or your state insurance department. You may also contact the plan at 1 (888) 849-3681 (TRS: 711). Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call 1 (800) 318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the plan at 1 (888) 849-3681 (TRS: 711) or visit regence.com or the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform. You may also contact the Office of the Insurance Commissioner of Washington State by calling 1 (800) 562-6900, or through the Internet at: www.insurance.wa.gov. Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1 (866) 240-9580. To see examples of how this plan might cover costs for a sample medical situation, see the next section. Page 6 of 7

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby Managing Joe's Type 2 Diabetes Mia's Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up hospital delivery) controlled condition) care)  The plan's overall deductible $250  The plan's overall deductible $250  The plan's overall deductible $250  Specialist coinsurance 15%  Specialist coinsurance 15%  Specialist coinsurance 15%  Hospital (facility) copayment $200  Hospital (facility) copayment $200  Hospital (facility) copayment $200  Other coinsurance 15%  Other coinsurance 15%  Other coinsurance 15% This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter) Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $250 Deductibles $250 Deductibles $250 Copayments $200 Copayments $0 Copayments $80 Coinsurance $700 Coinsurance $1,200 Coinsurance $400 What isn't covered What isn't covered What isn't covered Limits or exclusions $60 Limits or exclusions $200 Limits or exclusions $0 The total Peg would pay is $1,210 The total Joe would pay is $1,650 The total Mia would pay is $730 The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 7

NONDISCRIMINATION NOTICE Regence complies with applicable Federal and Washington state civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, gender identity or sexual identity. Regence does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity or sexual orientation. Regence: Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, and accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services listed above, You can also file a civil rights complaint with: please contact: Medicare Customer Service • The U.S. Department of Health and Human 1-800-541-8981 (TTY: 711) Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal Customer Service for all other plans at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or 1-888-344-6347 (TTY: 711) by mail or phone at: If you believe that Regence has failed to U.S. Department of Health and Human Services provide these services or discriminated in 200 Independence Avenue SW, another way on the basis of race, color, Room 509F HHH Building national origin, age, disability, sex, gender Washington, DC 20201 identity or sexual orientation, you can file a 1-800-368-1019, 800-537-7697 (TDD). grievance with our civil rights coordinator below: Complaint forms are available at Medicare Customer Service http://www.hhs.gov/ocr/office/file/index.html. Civil Rights Coordinator • The Washington State Office of the Insurance MS: B32AG, PO Box 1827 Commissioner, electronically through the Office of Medford, OR 97501 the Insurance Commissioner Complaint portal 1-866-749-0355, (TTY: 711) available at https://www.insurance.wa.gov/file- Fax: 1-888-309-8784 complaint-or-check-your-complaint-status, or by [email protected] phone at 800-562-6900, 360-586-0241 (TDD). Customer Service for all other plans Complaint forms are available at Civil Rights Coordinator https://fortress.wa.gov/oic/onlineservices/cc/pub/c MS CS B32B, P.O. Box 1271 omplaintinformation.aspx Portland, OR 97207-1271 1-888-344-6347, (TTY: 711) [email protected] 01012022.04PF12LNoticeNDMARegence-WA

Language assistance ATENCIÓN: si habla español, tiene a su disposición ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, servicios gratuitos de asistencia lingüística. Llame al បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ 1-888-344-6347 (TTY: 711). គឺអាចមានសំរារ់រំបរអ្ើ នក។ ចូរ ទូរស័ព្ទ 1-888-344- 6347 (TTY: 711)។ 注意：如果您使用繁體中文，您可以免費獲得語言 援助服務。請致電1-888-344-6347 (TTY: 711)。 ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱਚ CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-888-344- trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888- 6347 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ। 344-6347 (TTY: 711). 주의: 한국어를 사용하시는 경우, 언어 지원 ACHTUNG: Wenn Sie Deutsch sprechen, stehen 서비스를 무료로 이용하실 수 있습니다. 1-888- Ihnen kostenlose Sprachdienstleistungen zur 344-6347 (TTY: 711) 번으로 전화해 주십시오. Verfügung. Rufnummer: 1-888-344-6347 (TTY: 711) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari ማስታወሻ:- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ kang gumamit ng mga serbisyo ng tulong sa wika nang ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፤ በሚከተለው ቁጥር walang bayad. Tumawag sa 1-888-344-6347 (TTY: ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው:- 711)፡፡ 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної ВНИМАНИЕ: Если вы говорите на русском языке, служби мовної підтримки. Телефонуйте за то вам доступны бесплатные услуги перевода. номером 1-888-344-6347 (телетайп: 711) Звоните 1-888-344-6347 (телетайп: 711). ध्यान दिनहोस: तपा्ሷलें नेपाली बोल्नहन्छ भने तपा्ሷकों दनदतत भाषा सहायता सेवाहरू ु ् ATTENTION : Si vous parlez français, des services ु ु दनिःशल्क रूपमा उपलब्ध छ । फोन गनुहोस 1-888-344-6347 (दिदिवा्ሷ: ् d'aide linguistique vous sont proposés gratuitement. ु ु Appelez le 1-888-344-6347 (ATS : 711) 711 ATENȚIE: Dacă vorbiți limba română, vă stau la 注意事項：日本語を話される場合、無料の言語支 援をご利用いただけます。1-888-344-6347 dispoziție servicii de asistență lingvistică, gratuit. （TTY:711）まで、お電話にてご連絡ください。 Sunați la 1-888-344-6347 (TTY: 711) ti’go Diné MAANDO: To a waawi [Adamawa], e woodi ballooji- Bizaad, saad ma to ekkitaaki wolde caahu. Noddu 1-888-344-6347 1-888-344-6347 (TTY: 711.) (TTY: 711) ่ FAKATOKANGA’I: Kapau ‘oku ke Lea- โปรดทราบ: ถา้ คุณพดู ภาษาไทย คุณสามารถใชบร้ ิการชวยเหลือทางภาษาไดฟ้ รี โทร 1-888-344-6347 (TTY: 711) Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea te ke lava ‘o ma’u ia. ້ ໂປດຊາບ: ຖາວາ ທານເວາພາສາ ລາວ, ້ ່ ່ ha’o telefonimai mai ki he fika 1-888-344-6347 (TTY: ່ ການບລການຊວຍເຫອດານພາສາ, ໂດຍບເສຽຄາ, ແມນມພອມໃຫທານ. ໍ ່ ້ ໍ ່ ່ ້ ້ ່ ິ ຼື ີ 711) ັ ໂທຣ 1-888-344-6347 (TTY: 711) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa usluge jezičke pomoći dostupne su vam besplatno. afaanii tola ni jira. 1-888-344-6347 (TTY: 711) tiin Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa bilbilaa. oštećenim govorom ili sluhom: 711) امش یارب ناگیار تروصب ینابز تلایهست ،دینک یم تبحص یسراف نابز هب رگا :هجوت .دیریگب سامت 1-888-344-6347 (TTY: 711) اب .دشاب یم مهارف 1-888-344-6347 مقرب لصتا .ناجملاب كل رفاوتت ةیوغللا ةدعاسملا تامدخ نإف ،ةغللا ركذاف ثدحتت تنك اذإ :ةظوحلم (TTY: 711 مكبلاو مصلا فتاه مقر( 01012022.04PF12LNoticeNDMARegence-WA