UMP CDHP 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) Consumer-Directed Health Plan (CDHP) Coverage for: Individual and Eligible Family | Plan Type: PPO (PEBB) 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: What is the overall $1,600 individual (single coverage) / $3,200 Generally, you must pay all of the costs from providers up to the deductible amount deductible? family per calendar year. before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay. 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 No. You don't have to meet deductibles for specific services. for specific services? $4,200 individual (single coverage) / $8,400 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 family* per calendar year. have other family members in this plan, the overall family out-of-pocket limit must be limit for this plan? *An individual on family coverage will not have met. their out-of-pocket limit exceed $7,000. Premiums, balance-billing charges, member What is not included in the coinsurance paid to out-of-network providers Even though you pay these expenses, they don't count toward the out-of-pocket limit. out-of-pocket limit? and non-network pharmacies, and health care this plan doesn't cover. Yes. Find a doctor at ump.regence.com/go/pebb/ump-cdhp or call 1- This plan uses a provider network. You will pay less if you use a provider in the plan's 888-849-3681 (TRS: 711) for a list of network network. You will pay the most if you use an out-of-network provider, and you might Will you pay less if you use 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). Page 1 of 6 Claims Administrator: Regence BlueShield