UMP Plus–UW Medicine Accountable Care Network (UW Medicine ACN) 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) Plus-UW Medicine ACN (PEBB) Coverage for: Individual and Eligible Family | Plan Type: ACP 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 $125 individual / $375 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 No. You don’t have to meet deductibles for specific services. for specific services? $2,000 individual / $4,000 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 8 Claims Administrator: Regence BlueShield