Document klickitatcounty_gov_doc_d38c416a3a

HCA 54-549 (11/17) 2018 UMP Consumer-Directed Health Plan with Health Savings Account Certificate of Coverage Printed under the direction of the Washington State Health Care Authority Public Employees Benefits Board Self-Insured by the State of Washington · Effective January 1, 2018 ---PAGE BREAK--- Directory UMP Customer Service 1-[PHONE REDACTED] (TRS: 711) Monday–Friday: 5 a.m. to 8 p.m. Pacific Time (PT) Saturday: 8 a.m. to 4:30 p.m. PT Network provider directory Use any of the options shown Use the Provider Search at www.hca.wa.gov/ump 24 hours, 7 days a week Call 1-[PHONE REDACTED] (TRS: 711) Monday–Friday: 5 a.m. to 8 p.m. PT Saturday: 8 a.m. to 4:30 p.m. PT Live chat via www.regence.com Monday-Friday: 7 a.m. to 5 p.m. PT Medical appeals, grievances, and general correspondence Uniform Medical Plan Attn: Appeals and Grievances PO Box 2998 Tacoma, WA 98401-2998 Fax 1-[PHONE REDACTED] Preauthorization (medical services) Providers call 1-[PHONE REDACTED] Fax 1-[PHONE REDACTED] Online access to medical claims Your account at www.regence.com Claims mailing address (medical services; member submitted) Regence BlueShield PO Box 1106 Lewiston, ID 83501-1106 Fax 1-[PHONE REDACTED] Prescription drugs (Customer service, network pharmacies, preferred drug questions, complaints) Washington State Rx Services 1-[PHONE REDACTED] (TRS: 711) See end of prescription drug section for more detailed contact information Network mail-order pharmacy Postal Prescription Services (PPS) 1-[PHONE REDACTED] Paper claims Prescription drug appeals Washington State Rx Services PO Box 40168 Portland, OR 97240-0168 1-[PHONE REDACTED] (TRS: 711) Fax claims 1-[PHONE REDACTED] Fax appeals 1-[PHONE REDACTED] Drug preauthorization Providers and pharmacists only Washington State Rx Services 1-[PHONE REDACTED] (TRS: 711) Fax 1-[PHONE REDACTED] Online access to prescription drug claims Find a link to your pharmacy account at www.hca.wa.gov/ump/log-your-accounts HealthEquity Health Savings Account trustee www.healthequity.com/pebb 1-[PHONE REDACTED] 24 hours, 7 days a week Medicare www.medicare.gov www.MyMedicare.gov 1-800-MEDICARE (1-[PHONE REDACTED]) Eligibility and enrollment, address changes www.hca.wa.gov/pebb Employees: Contact your personnel, payroll, or benefits office All other members: PEBB Program 1-[PHONE REDACTED] (TRS: 711) Monday–Friday: 8 a.m. to 5 p.m. PT Tobacco cessation Quit for Life See “Tobacco cessation services” in the Benefits: what the plan covers section for detailed information. www.quitnow.net/ump 1-[PHONE REDACTED] Monday–Friday: 8 a.m. to 6 p.m. PT To obtain this booklet in another format (such as Braille or audio), call 1-[PHONE REDACTED] (TRS: 711). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 1 How to use this book For general topics, check the Table of Contents. For an overview of the most common benefits, see the “Summary of benefits” (pages 24–38). The table also shows how much you will pay, any limits on the benefit (such as number of visits or dollar amount), whether preauthorization or notification is required, and the page numbers where you can find more about that benefit. To look up unfamiliar terms, see the “Definitions” section beginning on page 157. Helpful symbols The symbols below provide important information you may find helpful as you read. TIP: Indicates information that may be helpful in understanding a subject. FOR MORE INFORMATION: Refers you to information found elsewhere. ALERT! Important information you should know or something you need to do. If you still have questions If you have a specific question for which you can’t find the answer:  Use our online search function at www.hca.wa.gov/ump.  Call Customer Service at 1-[PHONE REDACTED] (TTY: 711) Monday–Friday 5 a.m. to 8 p.m. and Saturday 8 a.m. to 4:30 p.m. Pacific Time. See the Directory page on the inside front cover of this document for more contact information. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 2 Table of contents About the UMP Consumer-Directed Health Plan 8 Online services 9 What is UMP CDHP? 10 Finding a health care provider 11 How to find a preferred provider 11 Why choose a preferred provider? 11 When you don’t have access to a preferred provider: network waiver 13 Sample payments to different provider types 15 Covered provider types 15 What is a primary care provider? 16 How does a health savings account work? 16 Services received outside the U.S. 17 What you pay for medical services 19 Deductible 19 Coinsurance 20 How do I pay my claims? 20 Out-of-pocket 21 Health savings account (HSA) 23 If you qualified for the SmartHealth wellness incentive 23 Summary of payment 24 Deductibles and limits 24 Types of services 25 Benefits: what the plan covers 27 Guidelines for coverage 27 Health Technology Clinical Committee (HTCC) 27 What is the HTCC? 27 How does HTCC affect my UMP benefits? 28 Where do I find HTCC decisions? 28 List of HTCC decisions 29 Summary of benefits 31 List of benefits ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 3 Acupuncture 39 Ambulance 39 Applied Behavior Analysis (ABA) Therapy 39 Autism treatment 40 Bariatric surgery 40 Breast health screening tests 41 Chemical dependency treatment 42 Chiropractic physician services 43 Dental services 43 Diabetes care supplies 45 Diabetes Control Program 45 Diabetes education 46 Diabetes Prevention Program 46 Diagnostic tests, laboratory, and x-rays 46 Dialysis 47 Durable medical equipment, supplies, and prostheses 47 Emergency room 49 End-of-life counseling 49 Family planning services 49 Foot care, maintenance 51 Genetic 51 Headaches 51 Hearing care (diseases and disorders of the ear) 52 Hearing exams and hearing aids 52 Home health care 53 Hospice care (inpatient, outpatient, and respite care) 54 Hospital services 55 Joint replacement surgery, knees and hips–Center of Excellence (COE) Program 56 Knee arthroplasty 59 Mammograms 59 Massage therapy 60 Mastectomy and breast reconstruction 60 Mental health treatment 61 Naturopathic physician services 61 Nutrition counseling and therapy 62 Obstetric and newborn care 62 Office visits 64 Orthognathic surgery 64 Physical, occupational, speech, and neurodevelopmental therapy 65 Prescription 65 Preventive care 65 Second opinions 68 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 4 Skilled nursing facility 68 Spinal and extremity manipulations 68 Spinal injections 68 Surgery 69 Telemedicine services 69 Temporomandibular joint (TMJ) treatment 71 Tobacco cessation services 71 Transgender health 73 Transplants 73 Urgent care 73 Vision care (diseases and disorders of the eye) 73 Vision exams (routine) 74 Vision hardware (eyeglasses and contact lenses) 74 Your prescription drug benefit 75 What drugs are covered? The UMP Preferred Drug List 75 How much will I pay for prescription drugs? 76 Where to purchase your prescription drugs 77 Guidelines for drugs UMP covers 80 Exceptions covered 81 Products covered under the preventive care benefit 82 Some injectable drugs are covered only under the prescription drug benefit 82 Compounded prescription drugs 82 Limits on your prescription drug coverage 83 Programs limiting drug coverage 83 Can the pharmacist substitute one drug for another? 86 Travel overrides for prescription drugs 87 Refill too soon 87 What can I do if coverage is denied? 87 Guidelines for drugs UMP does not cover 88 Prescription drug contacts 89 Limits on plan coverage 90 Preauthorizing medical services 90 Your preauthorization role 90 Where can I find the list of services requiring preauthorization or notification? 91 Notification for facility admissions 91 What is the difference between preauthorization and notification? 91 How long does the plan have to make a decision? 92 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 5 General information from customer service is not a guarantee that a service is covered 92 Case management 93 What the plan doesn’t cover 94 If you have other high-deductible health plan medical coverage 102 Coordination of benefits 102 Whom do I inform if I have other coverage? 102 Who pays first? 103 When UMP CDHP pays first 104 How UMP CDHP coordinates benefits when it pays 105 How does coordination of benefits work with prescription drugs? 107 Does UMP coordinate with occupational injury or illness (workers’ compensation) claims? 108 Billing & payment: filing a 109 Submitting a claim for medical services 109 Submitting a claim for prescription drugs 111 False claims or statements 112 What you need to know as a plan member 113 Your rights and responsibilities 113 Information available to you 114 Confidentiality of your health information Release of information 116 Complaint and appeal procedures 117 What is a complaint or grievance? 117 What is an appeal? 118 The appeals process 118 Complaints about quality of care 123 Appeals related to 123 When another party is responsible for injury or illness 124 What are my and the plan’s legal rights and responsibilities? 124 Services covered by other insurance 126 Motor vehicle coverage 126 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 6 Fees and expenses 126 Future medical expenses 126 Eligibility and enrollment for active employees 127 Who can enroll in UMP CDHP with an HSA? 127 Eligibility 128 Eligible employees 128 Eligible dependents 128 Enrollment 130 How to enroll 130 When medical enrollment begins 131 Annual open enrollment 132 Special open enrollment 132 National Medical Support Notice (NMSN) 136 Medicare entitlement 137 When medical coverage ends 137 Options for continuing PEBB medical coverage 138 Family and Medical Leave Act of 1993 139 Payment of premiums during a labor dispute 139 Conversion of coverage 139 Appeals of determinations of PEBB eligibility 139 Relationship to law and regulations 140 Eligibility and enrollment for retirees and surviving dependents 141 Eligibility 141 Eligible dependents 141 Enrollment 143 Deferring enrollment in PEBB retiree coverage 143 How to enroll 144 When medical coverage begins 145 Enrollment following deferral 146 Annual open enrollment 146 Special open enrollment 147 Medicare entitlement 149 Medicare Part A and Medicare Part B 149 Medicare Part D 149 When medical coverage ends 150 Options for continuing PEBB medical coverage 151 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 7 Conversion of coverage 152 Appeals of determinations of PEBB eligibility 152 Relationship to law and regulations 152 Customer service 152 General provisions 153 Definitions 157 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 8 About the UMP Consumer-Directed Health Plan The UMP Consumer-Directed Health Plan (UMP CDHP) is a self-insured health plan offered through the Washington State Health Care Authority’s Public Employees Benefits Board (PEBB) Program and administered by Regence BlueShield in partnership with HealthEquity, the trustee (manager) of your health savings account (HSA), and Washington State Rx Services. All prescription drugs, services, or other benefit changes may require approval by the PEB Board at the time of procurement of benefits for the next calendar year. UMP CDHP is a high-deductible health plan that meets the requirements of Section 223 of the Internal Revenue Code. The health care coverage described in this certificate of coverage is designed to be compatible for use with a Health Savings Account (HSA) under federal tax law. UMP CDHP is available only to people eligible for coverage through the PEBB Program, including employees and retirees of state government and higher-education institutions, school district retirees, and employees of certain local governments and school districts that participate in the PEBB Program, as well as their eligible dependents. If you or your dependents are enrolled in UMP CDHP and want to enroll in another health plan, you and your dependents can only enroll in other high-deductible health plans. The second high- deductible health plan cannot include an HSA. You cannot be enrolled in:  Medicare Part A or Part B.  Medicaid (called Apple Health in Washington).  Another comprehensive medical plan, such as a spouse or state-registered domestic partner’s plan.  A Voluntary Employees’ Beneficiary Association Medical Expense Plan (VEBA MEP) account, unless you convert it to a limited VEBA MEP.  TRICARE.  A medical flexible spending arrangement (FSA) or health reimbursement arrangement (HRA). This also applies if your spouse has a medical FSA, even if you are not covering your spouse on UMP CDHP. This does not apply if the medical FSA or HRA is a limited purpose account, or for a post-deductible medical FSA. This plan is designed to keep you and your family healthy, as well as provide benefits in case of injury or illness. Please review this booklet carefully so you can get the most from your health care benefits. UMP CDHP is a “non-grandfathered health plan” under the Patient Protection and Affordable Care Act (PPACA). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 9 Online services You can access plan information online at the UMP website, the Health Care Authority (HCA) website, the Regence website, and the HealthEquity website. Visit the UMP website at www.hca.wa.gov/ump to:  Review complaints and appeals procedures.  Access UMP medical policies.  Find a preferred provider.  Find a network pharmacy.  Find out what your prescription will cost.  Order prescription refills through your mail-order pharmacy account.  Download or print documents and forms.  Find your certificate of coverage.  Access wellness tools.  Access the Summary of Benefits and Coverage (SBC) and Uniform Glossary of Terms (UGT). Visit the Health Care Authority home page at www.hca.wa.gov to:  Learn more about the Health Technology Clinical Committee.  Find health technology reviews.  Compare medical plans.  Change your address. Visit the Regence website, regence.com, to:  Find a preferred provider.  Access your personal member portal.  View your Explanation of Benefits (medical claims processing details).  Access customer service via live chat.  Access wellness tools.  Get cost estimates for treatment of common medical conditions.  View or order your UMP ID card.  Access information on the BlueCard (Global Core) program. Visit http://blue.regence.com/trgmedpol to view Regence medical policies. Visit the HealthEquity member portal at www.healthequity.com/pebb to:  Log in to your personal member portal.  Check your Health Savings Account balance.  View and pay a medical provider’s claim that’s already been processed by UMP CDHP.  Make deposits directly from your bank account using electronic funds transfer.  Manage your investments (for accounts with more than $2,000).  Check your transaction history.  Find forms to get reimbursed for expenses you paid out of pocket.  View and print account statements. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 10 What is UMP CDHP? UMP CDHP is a health plan that covers the same services as UMP Classic. For a lower premium, you have a higher deductible for covered services. Families have one combined deductible. Families must pay their total family deductible before the plan begins to pay for services, including drugs. Some services, including covered preventive care, are exempt from the deductible (see page 19), which means the plan will pay for some services even before you meet your deductible. A plan becomes a family plan once the subscriber adds a dependent. A major feature of UMP CDHP is a Health Savings Account (HSA), which allows you and your employer to deposit money into a savings account to use toward qualified medical expenses. Unlike a medical flexible spending arrangement (FSA), you don’t have to spend all the money in your account each year. It rolls over into the next year. And if you use your HSA funds only to cover qualified medical expenses, you will achieve a tax savings. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 11 Finding a health care provider As a UMP CDHP member, you may see a preferred, participating, or out-of-network provider. The amount you pay for services will depend on which network provider type you choose to see.  Preferred provider: preferred under the preferred provider organization (PPO) network that applies to UMP CDHP members.  Most covered services are paid at 85%.  The provider will not bill you for charges that exceed the allowed amount.  Labelled in the online provider directory with a bar icon and category 1.  Participating provider: contracts with Regence BlueShield or another BlueCard network as a participating provider.  Most covered services are paid at 60%.  The provider will not bill you for charges that exceed the allowed amount.  Labelled in the online provider directory with a bar icon and category 2.  Out-of-network provider: not contracted with Regence BlueShield or another BlueCard network.  Most covered services are paid at 60%.  The provider may bill you for charges that exceed the allowed amount. This is called balance billing. How to find a preferred provider As a UMP CDHP member, you have access to Regence BlueShield preferred providers and Blue Cross and Blue Shield Plan providers worldwide through the BlueCard® and BlueCard (Global Core) programs (see page 17), so 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 Provider Search at www.hca.wa.gov/ump.  Call Customer Service at 1-[PHONE REDACTED].  Log in to your account on regence.com, where you have access to more information about providers, as well as other tools (see page To find a network pharmacy, see pages 77–79. Why choose a preferred provider? A preferred provider costs you the least You get the most from your plan when you choose a preferred provider. Here’s why:  You pay 15% of the allowed amount for most services, after you pay your deductible.  You pay nothing for covered preventive care services and immunizations. See “Preventive care” on page 65 for examples of such services.  These providers can’t bill you for charges that exceed the plan’s allowed amount.  You won’t have to file a claim if the plan is your primary coverage. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 12 Note: Some services and supplies are not covered by the plan (see page 94) or have benefit limits. If you receive service that are not covered by the plan or you exceed your benefit limit, you will have to pay for those services or supplies, even if you see a preferred provider. You may call UMP Customer Service at 1-[PHONE REDACTED] to find out if a service or supply is covered. ALERT! Some providers are considered preferred at one practice location but not another. If you see a provider at an out-of-network location, services will be covered as out-of-network, even if the provider is preferred elsewhere. If you see a provider at a new or different location than usual, make sure he or she is a preferred provider at the alternate location as well. Participating providers cost you more than preferred providers When you visit preferred providers, you pay 15% of the plan allowed amount for covered services. With participating providers, you pay 40% of the plan allowed amount for covered services. See page 13 under “Sample payments to different provider types” for examples. How are preferred and participating providers the same? The following rules apply to both preferred and participating providers:  Balance billing: These providers may not charge you more than the plan allowed amount.  Preventive care: Services covered as preventive by the plan are paid at 100%.  Medical out-of-pocket limit: Once you meet your medical out-of-pocket limit (see page 21), covered services are paid at 100%. Out-of-network providers cost you the most money When you see an out-of-network provider:  You pay 40% of the allowed amount for most services after you pay your deductible, plus 100% of any amount the out-of-network provider charges above the allowed amount.  The 40% coinsurance you pay to out-of-network providers does not count toward your out- of-pocket limit.  You still have to meet your deductible before the plan begins to pay. Any amount you pay above the allowed amount does not count toward your deductible or out-of-pocket limit.  You may have to pay for the service upfront and send the claim form to the plan for reimbursement.  The provider may not request preauthorization for services that require it. As a result, payment may be delayed or denied.  The provider may not be familiar with UMP prescription drug guidelines and prescribe drugs subject to higher cost or that aren’t covered by the plan. Note: Payment for out-of-network services may be sent to you or the provider. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 13 TIP: The allowed amount is the payment amount preferred and participating providers agree to accept from the plan. Out-of-network providers may charge more than this amount, and you are responsible for paying that difference between the billed amount and the allowed amount. This is called balance billing. When you don’t have access to a preferred provider: network waiver ALERT! When requesting a network waiver after services are processed, you must submit your request within 180 days of receiving notice of payment included in your Explanation of Benefits, (see page 162) for the related services. See below for details. An approved network waiver allows the plan to pay for 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 medically necessary services within 30 miles of the patient’s residence. When should I request a network waiver? Before your visit When services require preauthorization, you may request a network waiver before services are provided. See page 91 for how to find the list of services requiring preauthorization. Your network waiver request should be included with the preauthorization request. See “Information needed to submit a network waiver request” below to learn what to include in your request. When the plan approves the network waiver prior to your receiving medical services from an out- of-network provider:  For most medical services, you will pay your cost share as though the provider was preferred.  For preventive services, the plan covers services at 100%. After your visit When you receive any service, except those that require a preauthorization, you may request a network waiver after related claims have been processed. Network waiver requests that are not approved in advance are considered an appeal and must be submitted within 180 days of receiving an Explanation of Benefits. See “Complaint and appeal procedures” beginning on page 117 for information about your appeal rights. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 14 Information needed to submit a network waiver request The circumstances under which you may request a network waiver are described above. You should include all of the following documentation in your request:  A letter of explanation from you or your provider stating why the patient saw or needs to see the out-of-network provider.  Details of the research conducted by you or your provider to locate a preferred provider (in effect, dates 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 of the following information should also be included:  Performing provider’s name, address, phone number, and National Provider Identifier (NPI) or Tax ID number (TIN).  Diagnosis codes.  Procedure codes.  Length of treatment requested or required for services.  Estimated charges. See the “Preauthorizing medical services” section on pages 90-92 for more information about requesting medical services preauthorization from the plan. Where to send your network waiver request Regence BlueShield Attn: Correspondence, Intake, and Appeals PO Box 2998 Tacoma, WA 98401-2998 ALERT! If a network waiver is approved, you must still pay your cost share for most medical services. See page 13 for more information. Services provided under an approved network waiver do count toward your deductible and out-of-pocket limit. Network waivers for ongoing services may require periodic review. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 15 Sample payments to different provider types The chart below shows how much you pay for professional services from preferred, participating, and out-of-network providers when UMP CDHP is your primary insurance. For these examples, assume you have paid your deductible and haven’t reached your out-of-pocket limit. Please note that these are examples only and may not reflect your specific situation. Provider type Must provider accept allowed amount? Balance billing allowed? Itemized payments You owe provider Preferred provider Yes. You pay 15% of the allowed amount (coinsurance). No. Billed charge: $1,000 Allowed amount: $900 Plan pays 85%: -$765 You pay 15%: $135 $135 Participating provider Yes. You pay 40% of the allowed amount (coinsurance). No. Billed charge: $1,000 Allowed amount: $900 Plan pays 60%: -$540 You pay 40%: $360 $360 Out-of-network provider No. You pay 40% of the allowed amount (coinsurance), plus all charges that exceed the allowed amount. Yes. Billed charge: $1,000 Allowed amount: $900 Plan pays 60%: -$540 You pay 40%: $360 plus $100 exceeding allowed amount. You pay $460. $460* *This amount does not apply to your deductible or out-of-pocket limit. Covered provider types The plan pays for covered services only when performed by covered provider types performing services within the scope of their licenses. When a facility charges facility fees, the services must be covered services and within the scope of the facility’s license to be covered. All preferred providers are covered provider types. If you see an out-of-network provider that is not a covered provider type, the plan will not pay for any of the services received and you will be responsible for all charges. As with all noncovered services, any payments you make to a noncovered provider type will not apply toward your deductible or out-of-pocket limit. See the list of covered provider types at www.hca.wa.gov/ump-providers-cdhp. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 16 What is a primary care provider? A primary care provider (PCP) is a physician (see “Physician services” on page 171), nurse practitioner, or physician assistant who provides, coordinates, or helps a patient access a range of health care services. You are not required to choose a PCP, but doing so may be helpful. To be designated as a PCP, a provider must be one of the provider types and practice under one of the specialties listed in the table below. Provider Type Specialties Medical Doctor Doctor of Osteopathic Medicine Naturopathic Physician Nurse Practitioner (A.R.N.P.) Physician Assistant Adult Medicine Family Practice General Practice Geriatrics Gynecology Internal Medicine OB/GYN or Obstetrics Pediatrics (for patients under age 18) Preventive Medicine Women’s Health How does a health savings account work? ALERT! If you enroll in a consumer-directed health plan with a Health Savings Account (HSA), you may not have a medical flexible spending arrangement (FSA). If you have both an HSA and a medical FSA, you may be subject to tax penalties. The subscriber is the owner of the health savings account (HSA). He or she gets the tax advantages associated with an HSA and pays any taxes or penalties that result if the HSA does not comply with IRS rules. You can contribute funds to the HSA within certain limits. Money from the HSA can be used tax-free to pay for qualified medical expenses of the subscriber and his or her IRS dependents (able to be claimed as a tax dependent). See page 23 for details of how this works with UMP CDHP. The trustee (manager) of your HSA, HealthEquity, features a member portal at www.healthequity.com/pebb. When you log in to your regence.com account, you can also find a link to the HealthEquity portal. Find out which services are available in the portal by reading the “Online services” section on page 9. ALERT! You and your dependents can only enroll in other high-deductible health plans. The second high-deductible health plan cannot include an HSA. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 17 Services received outside the U.S. ALERT! The plan does not cover prescription drugs ordered through mail-order pharmacies located outside the U. S. See “Drugs purchased outside the U.S.” on page 80 for to learn more. Contact BlueCard (Global Core) to learn about services received outside the United States find a provider internationally, or submit a claim. Contact BlueCard (Global Core) BlueCard (Global Core) Service Center Available 24 hours a day, 7 days a week 1-800-810-BLUE (2583), or call collect 1-[PHONE REDACTED] Online provider search Go to Website  Register online to get an international claim form and submit claims electronically.  Find BlueCard information. When are services outside the U.S. covered? The plan covers the same benefits as described in this certificate of coverage that are received outside the U.S. when the services are:  Medically necessary (see definition on page 165).  Appropriate for the condition being treated.  Not considered to be experimental or investigational by U.S. standards.  Meeting all medical policy criteria.  Covered by the plan. Finding a preferred provider outside the U.S. Under BlueCard (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., go to or call the BlueCard Service Center: 1-800-810-BLUE (2583) or collect at 1-[PHONE REDACTED]. Important tips for receiving care outside the U.S.  Always carry your UMP identification (ID) card.  If you need emergency medical care, go to the nearest hospital.  If you are admitted to the hospital, call the BlueCard Service Center (see above) to notify the plan of your admission.  For non-emergency medical care outside the U.S., call the BlueCard Service Center (see above) to help you find a provider for the care you need. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 18 Paying for care outside the U.S. Inpatient services at a BlueCard contracted hospital When you receive inpatient care at a hospital contracted with BlueCard (Global Core), you will pay your normal out-of-pocket costs, such as deductible, copayment, coinsurance, and any services not covered by the plan. Contracted hospitals will verify your benefits and eligibility with BlueCard and submit a claim. You will pay the provider after the plan processes the claim. Services at a non-contracted hospital When you receive services at a hospital not contracted with BlueCard, you pay the hospital at the time of service, then submit a claim with an itemized bill from the hospital to the plan for reimbursement (see “How do I submit a claim?” on page 109). You may ask the non-contracted hospital if they will submit a claim on your behalf. Outpatient and professional provider services If you receive outpatient care outside the U.S., you pay the facility or professional provider at the time of service, then submit a claim to the plan for reimbursement (see “How do I submit a claim?” on page 109). Covered services by BlueCard contracted providers are reimbursed at the network rate. Submitting a claim for services outside the U.S. If you receive inpatient services at a contracted hospital, the hospital will submit claims on your behalf. See “Inpatient services at a BlueCard contracted hospital” above. For care from non-contracted hospitals and all outpatient care, you pay the provider at the time of service. To receive reimbursement from the plan for covered services, you must submit an international claim to the BlueCard Service Center. See “Contact BlueCard (Global Core)” on page 17 for contact information and where to find a claim form. For all claims submitted either by the member or by the provider, Regence works with the BlueCard Service Center to translate claims, services, and account for currency differences. Specific services, charges, drugs and dosage must be documented. If you have questions about submitting a claim for services outside the U.S., call UMP Customer Service at 1-[PHONE REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 19 What you pay for medical services Deductible ALERT! Prescription drug costs do count toward your deductible. You pay the entire cost of your drugs, even those covered by the plan, until you have met your entire deductible. See “Products covered under the preventive care benefit” on page 82 for exceptions. A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying most benefits. For this plan, the deductible for a single person on an account is $1,400; for more than one person on an account, the deductible is $2,800. See “How does the deductible work with more than one person?” on page 20 for more information. You pay your providers until you meet your deductible for the year, then the plan begins to pay benefits for your care. See below for services that are exempt from the deductible. What doesn’t count toward my deductible? The following out-of-pocket expenses do not count toward your deductible:  Services you pay for that aren’t covered by the plan (see pages 94–101 for some examples).  Services that are exempt from the deductible, even if you had out-of-pocket costs preventive care received from an out-of-network provider).  Charges for services exceeding benefit maximums. For example, the maximum for adult vision hardware is $150 every two calendar years. Charges over this amount do not count toward your deductible.  Charges for services beyond benefit limits. For example, the annual benefit limit for acupuncture is 16 visits. Costs for more than 16 visits are not covered by the plan and do not count toward your deductible.  Out-of-network provider charges that exceed the allowed amount (see table on page 13), including non-network pharmacies. TIP: You can use money from your HSA to pay for noncovered services as long as they are qualified medical expenses (see definition on page 173). Which services are exempt from the deductible? You do not have to pay the deductible before the plan pays for these services:  Preventive care and immunizations as described on pages 65–67.  Routine vision care: exams, glasses, and contacts (page 74).  Select contraceptive supplies and services (pages 49–51).  Certain products available from network pharmacies (page 82).  Diabetes Control Program (page 45). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 20  Diabetes Prevention Program (page 46).  Tobacco cessation services (page 71).  Required second opinions. TIP: The plan pays the services and drugs (subject to cost share) listed above even if you have not met your deductible. This means that you do not have to pay the first $1,400 or $2,800 of covered services before the plan begins to pay. How does the deductible work with more than one person?  If you cover only yourself, your deductible is $1,400. You must pay this amount for covered services not exempt from the deductible (including covered drugs) before the plan begins to pay for your care.  If you cover yourself and at least one other person, your deductible is $2,800. You must pay this amount for covered services for all covered persons combined before the plan pays for any services, including drugs (other than those exempt from the deductible). ALERT! If you receive services with a benefit limit (such as massage therapy or physical therapy) before meeting your deductible, those visits will count toward the benefit limit. See definition of “Limited benefit” on page 164 for more information. Note: If a dependent has other primary coverage, visits paid by the primary plan also count toward UMP CDHP benefit limits. Coinsurance Coinsurance refers to the percentage of the allowed amount that you pay for most medical services and for prescription drugs, when the plan pays less than 100%. After you’ve paid your deductible, you pay the following percentages for most medical services:  For preferred providers: 15% of the allowed amount.  For participating providers: 40% of the allowed amount. See table on page 13 for details.  For out-of-network providers: 40% of the allowed amount and you may be balance billed, which means you will pay any amount an out-of-network provider bills that is above the allowed amount. See pages 75–89 for how much you pay for prescription drugs. How do I pay my claims? To ensure you pay the correct amount, it’s best to pay after claims are processed by the plan. Your provider should bill the plan first. When the plan processes a claim, it applies any network provider discount, checks the benefits for the service, and confirms if you’ve met your deductible ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 21 in order to calculate what you owe on the claim. Both you and your provider will receive an Explanation of Benefits (EOB) that provides the detail on what the plan pays and what amount, if any, is the member’s responsibility. Your provider should then bill you the same amount that is shown in the “member responsibility” column on the EOB. Note: The provider may ask you to pay your copayment, when applicable, at the time of service. Your coinsurance will be billed after services are provided. In these cases, you should check your EOB when it arrives to make sure that the amount you paid is reflected accurately in the Member Responsibility section. You may call UMP Customer Service at 1-[PHONE REDACTED] for assistance. How to use your Health Savings Account to pay After a claim is processed, you may log into your HealthEquity health savings account (HSA) to view your medical claims. You may pay for qualified medical expenses (see page 173) by:  Using your HealthEquity debit card at the time of service.  Logging in to your HSA and designating payment to be sent by HealthEquity directly to the provider. Note: You can make a partial payment using this method.  Logging in to your HSA and paying yourself back for a qualified medical expense you paid using non-HSA funds. For example, if you paid cash at your provider’s office for qualified medical expenses, you can reimburse yourself from your HSA. Out-of-pocket limit The out-of-pocket limit is the most you pay during a calendar year for covered services from preferred and participating providers. After you meet your out-of-pocket limit for the year, the plan pays for covered services by preferred and participating providers at 100% of the allowed amount. Expenses are counted from January 1, 2018, or your first day of enrollment (whichever is later); through December 31, 2018, or your last day of enrollment (whichever is first). Your out-of-pocket limit depends on the number of person covered on the account.  One person covered: $4,200.  Two or more persons covered: $8,400. Once an individual meets $6,850 in covered out-of- pocket expenses annually, the plan will pay for covered services at 100% for that individual. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 22 What counts toward this limit? What doesn’t? What counts toward the out-of-pocket limit? 1. Your coinsurance paid to preferred and participating providers (see page 13). 2. Your out-of-pocket costs for covered prescription drugs and products purchased from a network pharmacy. 3. Your deductible. What doesn’t count toward the out-of- pocket limit? See “Exceptions: out-of- network provider services that count” below. 1. Amounts paid by the plan, including services covered in full. 2. Your premiums. 3. Non-network pharmacy charges that exceed the allowed amount (see page 158). 4. Balance billed amounts (see definition on page 158). 5. Your coinsurance paid to out-of-network providers (note that out-of-network coinsurance does count toward your deductible; see page 13). 6. Services not covered by the plan; for examples, see pages 94–101. 7. Amounts that are more than a maximum dollar amount paid by the plan. For example, the plan pays a maximum of $150 for adult vision hardware once every two calendar years. Any amount you pay over $150 does not count toward the out-of-pocket limit. 8. Amounts paid for services exceeding a benefit limit. For example, the benefit limit for acupuncture is 16 visits. If you have more than 16 acupuncture visits in one year, you will pay in full for those visits, and what you pay will not count toward this limit. See “Limited benefit” on page 164 to learn more. What will I pay for after reaching my out-of-pocket limit? You will still be responsible for paying numbers 2–8 above after you meet your out-of- pocket limit. You still pay for out-of-network provider services Services by out-of-network providers are paid by the plan at 60% of the allowed amount (unless noted under “Exceptions: out-of-network provider services that count” below). Even after you meet your out-of-pocket limit, you will pay 40% coinsurance for out-of-network provider services and the provider may still balance bill you (see definition on page 158). Note: The 40% you pay and balance billed amounts do not count toward your out-of-pocket limit. However, coinsurance paid to out-of-network providers does count toward your deductible. Balance billed amounts never apply toward your deductible. Exceptions: out-of-network provider services that count For dialysis (see page 47), the plan will pay 100% of the network rate after you meet your medical out-of-pocket limit. For the services listed below only, your coinsurance and balance billed amounts for out-of- network provider services will count toward your out-of-pocket limit. In addition, the plan will pay 100% of billed charges for these services after you meet your out-of-pocket limit.  Ambulance (see page 39).  Services for which you have an approved network waiver (see page 13). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 23  Cochlear Implant Processor Supplier.  Ocularists (creation and fitting of prosthetic eyes). Health savings account (HSA) PEBB will deposit $700.08 for one person, and $1,400.04 for more than one person on an account, deposited in equal amounts over the calendar year. Employer contributions are made only during those months you are enrolled in UMP CDHP. You may also make deposits to your account. See page 25 for this year’s contribution limits. Subscribers age 55 and older can contribute an additional $1,000 per year. The PEBB contributions count toward the limit, as does the SmartHealth incentive (see below). You can use your HSA to pay for member cost-sharing and other qualified medical expenses as described in Internal Revenue Code 223(d) including those not normally covered by the plan. You can use HSA funds to pay for expenses for your spouse or tax dependents, even if they are not covered by UMP CDHP. The Internal Revenue Service determines which services are eligible for reimbursement through an HSA, and who can pay for services using HSA funds. For a list of items and services that you can pay for with your HSA funds, see www.healthequity.com/pebb or call 1- [PHONE REDACTED]. FOR MORE INFORMATION: See the HealthEquity website at www.healthequity.com/pebb or call 1-[PHONE REDACTED] for details on how to use your HSA. If you qualified for the SmartHealth wellness incentive The subscriber is the only family member eligible to earn the SmartHealth wellness incentive. A federal requirement mandates a minimum deductible for Therefore, the PEBB Program is not allowed to reduce the UMP CDHP deductible by $125. If you earned the wellness incentive for 2018, the PEBB Program will deposit $125 into your HSA in January. This counts toward your maximum annual contribution. You may need to adjust your payroll contributions to make sure you don’t exceed your maximum allowed contribution for the year. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 24 Summary of payment ALERT! Even if a provider orders a test or prescribes a treatment, the plan may not cover it. Please review this certificate of coverage or call Customer Service at 1-[PHONE REDACTED] if you have questions about benefits or limitations. On the next several pages, you’ll find a summary of your plan benefits and what you’ll pay for them. For a complete understanding of how a benefit works, it is important that you also read the pages listed in the “For more information” column. Not all benefits are listed. For services not listed, see the Table of Contents or call UMP Customer Service at 1-[PHONE REDACTED]. In order to be covered, all services must be medically necessary (see definition on page 165). If you see an unfamiliar term, see the alphabetical list of definitions on pages 157–176. This certificate of coverage applies only to dates of service between the day your coverage begins (no earlier than January 1, 2018) and the day your coverage ends (no later than December 31, 2018). ALERT! If a dependent has coverage under another health plan, see pages 102–108. Deductibles and limits What is it? How much is it? What else do I need to know? For details: See page(s) Deductible  $1,400 for one person on the account  $2,800 for two or more persons on an account  If you qualified for the 2018 SmartHealth wellness incentive, see page 23 to learn more.  This deductible applies to all services, including prescription drugs, unless specifically stated the services are not subject to the deductible.  For a family account, you must meet the entire $2,800 deductible.  You pay toward this deductible before the plan pays for most covered services.  You don’t have to pay the deductible for some services.  Not all services count toward this deductible. 19–20 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 25 What is it? How much is it? What else do I need to know? For details: See page(s) Out-of-pocket limit  $4,200 for one person on the account  $8,400 for two or more persons on an account (family)  Your deductible and prescription drug costs count toward this limit.  Not all services count toward this limit.  Once one person meets $6,850 in covered out-of-pocket expenses annually, the plan will pay for covered services at 100% for that person. 21–23 Health Savings Account (HSA) If the subscriber is age 55 or older, may contribute up to an additional $1,000.  Maximum annual contribution: - Account with one person $3,450 - Account with two or more persons: $6,900  You may pay for any qualified medical expenses (see definition on page 173) from your HSA, including:  Services that apply to your deductible.  Services that are not covered by the plan, but are still qualified medical expenses 23 Annual plan payment limit None No limit to how much the plan pays per calendar year. Not applicable Lifetime plan payment limit None No limit to how much the plan pays over a lifetime. Not applicable Types of services The table below describes how much you’ll pay for services. Unless otherwise noted, all payment is based on the allowed amount and services are subject to the deductible. See the “Summary of benefits” table on pages 31–38 to find out which services fall under the standard, preventive, outpatient, inpatient, facility fees, and special categories. Type of service How much you pay Standard Subject to the deductible; see pages 19–20. You must pay your deductible before the plan begins to pay. How much you pay (your coinsurance) depends on the provider’s network status:  Preferred providers—You pay 15% of the allowed amount. The provider may not balance bill.  Participating providers—You pay 40% of the allowed amount. The provider may not balance bill.  Out-of-network providers—You pay 40% of the allowed amount. The provider may balance bill (see page 158). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 26 Type of service How much you pay Preventive Not subject to the deductible. See page 66 for a description of preventive services. How much you pay (your coinsurance) depends on the provider’s network status:  Preferred and participating providers—You pay the plan pays in full.  Out-of-network providers—You pay 40% of the allowed amount. The provider may balance bill (see page 158). Outpatient Subject to the medical deductible and coinsurance. If you receive services at a facility that offers inpatient services (like a hospital) but you are not admitted, you pay for outpatient services. See the specific benefit emergency room or diagnostic tests) for how much you pay. You may be billed separately for facility fees in addition to the provider fees. Inpatient Subject to the deductible; see pages 19–20. Most inpatient services require both preauthorization (see page 90) and notification (your provider must notify the plan upon admission to a facility; see page 91). How much you pay (your coinsurance) depends on the provider’s network status:  Preferred providers—You pay 15% of the allowed amount.  Participating providers—You pay 40% of the allowed amount; the provider may not balance bill.  Out-of-network providers—You pay 40% of the allowed amount; the provider may balance bill (see page 13). Services are considered inpatient only when you are admitted to a facility. See definition of “Inpatient stay” on page 164. Facility fees Facility fees may be charged in addition to provider fees when accessing hospitals or clinics. How much you pay (your coinsurance) depends on the provider’s* network status:  Preferred providers—You pay 15% of the allowed amount.  Participating providers—You pay 40% of the allowed amount; the provider may not balance bill.  Out-of-network providers—You pay 40% of the allowed amount; the provider may balance bill (see page 13). *A facility, such as a hospital, may be referred to as a “provider” on Explanation of Benefits or facility bills. Special (for example, ambulance) Subject to the deductible; see page 19. These services have unique payment rules, which are described in the “How much will I pay?” column on pages 31–38. What else do I need to know?  Some services aren’t covered; see pages 94–101 for a list of exclusions.  You don’t need a referral from the plan to see a specialist for most services. However, you will save money by seeing preferred providers, especially for preventive services. See page 11 for more information.  Preexisting conditions: There is no waiting period; medically necessary covered services are eligible for benefits from the effective date of your medical enrollment. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 27 Benefits: what the plan covers Guidelines for coverage ALERT! The fact that a physician or other provider prescribes, orders, recommends, or approves a service or supply does not mean it is covered or medically necessary (see page 165). For this plan to cover a service or supply, it must meet all of the following conditions. The service or supply must:  Be received by an enrolled member on a day between the date your coverage begins (but no sooner than January 1, 2018) and the date your coverage ends (but no later than December 31, 2018); and  Be listed as covered; and  Match the plan’s coverage policies and preauthorization requirements; and  Be medically necessary (see definition on page 165). Limits and exclusions may apply to plan benefits. See both the benefit description and “What the plan doesn’t cover” starting on page 94. Some services require preauthorization and/or plan notification prior to receiving treatment. See page 91 for how to find the list at www.hca.wa.gov/ump or call UMP Customer Service to ask if a particular service is covered. The following sections describe the benefits provided by this plan. Be sure to read them carefully for important information that can help you get the most from your health coverage. If you do not understand the benefits, it is your responsibility to ask for help before receiving services by calling Customer Service at 1-[PHONE REDACTED]. Health Technology Clinical Committee (HTCC) ALERT! HTCC decisions are usually implemented by UMP at the beginning of the next calendar year after the HTCC decision is issued. If UMP implements an HTCC decision mid-year, the plan will notify you in writing before the change in coverage becomes effective. What is the HTCC? Created by Washington State law chapter 70.14 RCW, the Health Technology Clinical Committee (HTCC) is a committee of eleven 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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 28 In public meetings, the HTCC considers public comments and scientific evidence regarding the safety, medical effectiveness, and cost-effectiveness of the services in making its determination. How does HTCC affect my UMP benefits? Under state law, UMP must comply with an HTCC determination. Determinations will either be covered, covered with conditions, or not covered. The HTCC determines the conditions, if any, under which the health technology will be included as a covered benefit and, if covered, the criteria the plan must use to decide whether the technology is medically necessary. When the HTCC determines that a service is not covered, that means the service is not medically necessary in any circumstance. Some HTCC decisions include a requirement to follow Food and Drug Administration (FDA) or Centers for Medicare and Medicaid Services (CMS) guidelines. You may review these guidelines at www.fda.gov or www.cms.gov. Where do I find HTCC decisions? ALERT! HTCC decisions implemented by the plan take precedence over any other coverage policies. This certificate of coverage contains a summary of how HTCC decisions are covered. You may view the list of services that have been reviewed or are currently under review by the HTCC at www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews. The website includes:  The decisions and criteria for coverage  Evidence reports  Public comments  The public meeting schedule  Instructions on providing public comments on pending reviews or re-reviews You may also call UMP Customer Service at 1-[PHONE REDACTED] with questions about coverage of conditions, if any, for HTCC technologies. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 29 List of HTCC decisions Topic Coverage level Topic Coverage level Applied Behavioral Analysis Covered with limitations Hyperbaric oxygen therapy for tissue damage including wound care and treatment of central nervous system conditions Covered with limitations Appropriate imaging for breast cancer screening in special populations Covered with limitations Imaging for rhinosinusitis Covered with limitations Artificial disc replacement Covered with limitations Implantable drug delivery system for chronic non-cancer pain Not a covered benefit Autologous blood and platelet-rich plasma injections Not a covered benefit Intensity modulated radiation therapy Covered with limitations Bariatric surgery Covered with limitations Knee arthroscopy for osteoarthritis of the knee Not a covered benefit Bone growth stimulators Covered with limitations Lumbar fusion for degenerative disc disease Not a covered benefit Bone morphogenic proteins for use in lumbar fusion Covered with limitations Microprocesser-controlled lower limb prosthesis Covered with limitations Breast MRI Covered with limitations Negative pressure wound therapy Covered with limitations Bronchial thermoplasty for asthma Not a covered benefit Nonpharmacological treatments for treatment- resistant depression Covered with limitations Cardiac nuclear imaging Covered with limitations Novocure (tumor treating fields) Not a covered benefit Cardiac stents Covered with limitations Osteochondral allograft and autograft transplantation Covered with limitations Carotid artery stenting Covered with limitations Pharmacogenomic testing for selected conditions Not a covered benefit Catheter ablation proce- dures for supraventricular including atrial flutter and atrial fibrillation Covered with limitations Positron emission tomography scans for Covered with limitations ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 30 Topic Coverage level Topic Coverage level Cervical spinal fusion for degenerative disc disease Covered with limitations Proton beam therapy Covered with limitations Chronic migraine and chronic tension-type headache Covered with limitations Robotic assisted surgery Covered with limitations Cochlear implant Covered with limitations Routine ultrasound for pregnancy Covered with limitations Computed tomographic angiography for detection of coronary artery disease Covered with limitations Screening and monitoring tests for osteopenia/osteoporosis Covered with limitations Computed tomographic colonography Not a covered benefit Sleep apnea diagnosis and treatment in adults Covered with limitations Coronary artery calcium scoring Not a covered benefit Spinal cord stimulation for chronic neuropathic pain Not a covered benefit Discography Covered with limitations Spinal injections Covered with limitations Electrical neural stimulation Not a covered benefit Stereotactic radiation surgery and stereotactic body radiation therapy Covered with limitations Extracorporeal membrane oxygenation in adults Covered with limitations Testosterone testing Covered with limitations Extracorporeal shock wave therapy for musculoskeletal conditions Not a covered benefit Total knee arthroplasty Covered with limitations Facet neurotomy Covered with limitations Tympanostomy tubes in children Covered with limitations Fecal microbiota transplantation Covered with limitations Upper endoscopy for GERD and GI Covered with limitations Functional neuroimaging for primary degenerative dementia or mild cognitive impairment Not a covered benefit Upright/positional MRI Not a covered benefit Glucose monitoring Covered with limitations Vagal nerve stimulation Covered with limitations Hip resurfacing Not a covered benefit Varicose veins Covered with limitations ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 31 Topic Coverage level Topic Coverage level Hip surgery for femoroacetabular impingement Not a covered benefit Vertebroplasty, kyphoplasty, sacroplasty Not a covered benefit Hyaluronic acid/viscosupplementation Covered with limitations Vitamin D screening and testing Covered with limitations Summary of benefits Only certain services are listed in the table. For those not listed, see the alphabetical list of covered benefits on pages 27–74. Please read the pages listed in the “For more information” column for each benefit. Not all details are included in the table. Also review:  Services that require preauthorization. See page 91 for details.  Services for which your provider must notify the plan. See page 91 or call 1-[PHONE REDACTED].  Services that aren’t covered (exclusions). See pages 94–101. If you have questions about your benefits, services that require preauthorization or plan notification, or services not covered by the plan, call UMP Customer Service at 1-[PHONE REDACTED]. Benefit/service How much will I pay? (See pages 25–26 for description of payment types) For more information: See page(s) Any limitations or exclusions? Ambulance Special: 20% of the allowed amount for any provider. Out-of-network providers may balance bill. 39, 94, 100 Covered only for a medical emergency (see definition on page 165) or when other means of transportation are considered unsafe due to your medical condition. Acupuncture Standard 39 Up to 16 visits per calendar year. Applied Behavior Analysis (ABA) Therapy Standard 39 Specific preauthorization requirements. Only specified providers are covered. Breast health See “Mammograms” below ---PAGE BREAK--- *For services requiring preauthorization or plan notification: See the list of services at www.hca.wa.gov/ump- preauth-cdhp or call 1-[PHONE REDACTED]. Many services require both preauthorization and plan notification. See page 91 for how this works. UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 32 Benefit/service How much will I pay? (See pages 25–26 for description of payment types) For more information: See page(s) Any limitations or exclusions? Chemical dependency treatment Inpatient services Inpatient 42, 99 See page 42 for preauthorization of inpatient services. Plan notification is required at the time of admission.* Outpatient services Standard 42, 99 See page 42 for services that may require preauthorization.* Chiropractic physician services 68 See “Spinal and extremity manipulations” on page 37. Contraceptive services Preventive or standard 49–51, 66 See page 50 for services that are covered as preventive. Some contraceptive services may be covered as standard. For sterilization, see page 51. Dental services Special: You pay 20% of the allowed amount when you see a preferred provider for covered medical services. Dentists and other dental providers are not included in the UMP provider network. 43, 95 See “Dental services” on page 43 for limitations on covered services. Diabetes care supplies Special: Most diabetic care supplies are paid under the prescription drug benefit. Insulin pump and pump supplies are covered under the medical benefit as durable medical equipment. 45, 48, 107 See “How are diabetes care supplies covered when UMP CDHP pays second?” on page 107 if another plan pays first. Diabetes Control Program Preventive 45 Only this plan’s diabetes control program is covered. ---PAGE BREAK--- *For services requiring preauthorization or plan notification: See the list of services at www.hca.wa.gov/ump- preauth-cdhp or call 1-[PHONE REDACTED]. Many services require both preauthorization and plan notification. See page 91 for how this works. UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 33 Benefit/service How much will I pay? (See pages 25–26 for description of payment types) For more information: See page(s) Any limitations or exclusions? Diabetes Prevention Program Preventive 46 Only this plan’s diabetes prevention program is covered. Diagnostic tests, laboratory, and x-rays Standard 46, 63, 94, 97, 100 Usually billed separately from related office visits or inpatient services. Durable medical equipment, supplies, and prostheses Standard 47–49, 73, 96, 98, 160 May require preauthorization.* Some breast pumps are covered as preventive; see “Services covered as preventive” on page 63. Emergency room (ER) See page 165 for coverage of emergency services at out- of-network facilities. Standard 49, 165 Services determined not to be due to a medical emergency (page 165) may not be covered in an ER setting. If your ER visit is determined to be a medical emergency, it will be paid at the network rate for both preferred and out-of-network facilities. End-of-life counseling  If received as part of hospice services: Paid at 100% after meeting your deductible.  If received outside of hospice services: standard. 49 Total of 30 visits, all services combined per calendar year. Family planning services Standard Some contraceptive services are covered as preventive. 49–51, 97 Not covered:  Fertility or infertility services  Reversal of sterilization ---PAGE BREAK--- *For services requiring preauthorization or plan notification: See the list of services at www.hca.wa.gov/ump- preauth-cdhp or call 1-[PHONE REDACTED]. Many services require both preauthorization and plan notification. See page 91 for how this works. UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 34 Benefit/service How much will I pay? (See pages 25–26 for description of payment types) For more information: See page(s) Any limitations or exclusions? Headaches, chronic migraines or tension Standard: Covered Botox injections for migraines All other specified treatments not covered 51 Botox injections for migraines covered with limitations. Not covered:  Botox injections for tension-type headaches.  Treatment of chronic migraines with acupuncture, massage, trigger point injections, transcranial magnetic stimulation, or manipulation therapy. Hearing aids Special: Plan pays up to $800. 52 Limited to $800 plan payment per three calendar years. Hearing exams, routine Standard 52, 66 Newborn hearing screening is covered as preventive. Home health care Standard 53, 69, 96, 159, 163, 165 See page 53 for what is covered. Specific services are not covered; see exclusion 40 on page 96. Maintenance care (page 165) and custodial care (page 159) are not covered. Hospice care (Includes respite care and prescription drugs) Special: Medical services paid at 100% after meeting the deductible. Prescription drugs paid at 100% after meeting the deductible. End-of-life counseling while in hospice paid at 100% after meeting medical deductible. 54, 164, 174 Covered for terminally ill members for up to six months. Respite care is limited to 14 visits per lifetime. Prescription drugs limited to covered drugs purchased through network pharmacies (including the network specialty pharmacy). ---PAGE BREAK--- *For services requiring preauthorization or plan notification: See the list of services at www.hca.wa.gov/ump- preauth-cdhp or call 1-[PHONE REDACTED]. Many services require both preauthorization and plan notification. See page 91 for how this works. UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 35 Benefit/service How much will I pay? (See pages 25–26 for description of payment types) For more information: See page(s) Any limitations or exclusions? Hospital services Inpatient services Inpatient 55, 62–64, 97 Plan notification is required for all hospital admissions within 24 hours of admission.* Inpatient rehabilitation services require preauthorization.* Outpatient services Standard 55 Some services require preauthorization.* Immunizations (vaccines) Preventive (usually) 67, 97, 167 Covered under CDC recommendations; see page 67. Not covered for travel or employment. Joint replacement surgery, knees and hips–Center of Excellence (COE) Program Special: When approved for the program, services are covered at 100%. 56–59 Must be 18 years old or older. Mammograms (diagnostic) Standard 60 Must be billed as diagnostic by the provider. Mammograms (screening) Preventive 41, 59 Women age 40 and older: Covered every year. Women under age 40: Covered as preventive only for women at increased risk. Covered with limitations for women not at increased risk. See “Breast health screening tests” (page 41) for other diagnostic tests. Massage therapy Standard 60, 98 Limited to 16 visits per calendar year. Only preferred massage therapists are covered. ---PAGE BREAK--- *For services requiring preauthorization or plan notification: See the list of services at www.hca.wa.gov/ump- preauth-cdhp or call 1-[PHONE REDACTED]. Many services require both preauthorization and plan notification. See page 91 for how this works. UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 36 Benefit/service How much will I pay? (See pages 25–26 for description of payment types) For more information: See page(s) Any limitations or exclusions? Mastectomy and breast reconstruction Standard 47, 60 All inpatient services require plan notification.* Mental health treatment Inpatient services Inpatient 61, 99 See page 61 about preauthorization of inpatient services. Plan notification is required at the time of admission.* Outpatient services Standard 61, 98, 99 See page 61 for services that require plan notification.* Naturopathic physician services Standard 16, 61, 88, 95 Herbs, vitamins, and other supplements are not covered. See “Exceptions covered” on page 81 for exceptions. Obstetric and newborn care Inpatient (standard for related outpatient visits) Some breast pumps are covered as preventive. 62–64, 100 For non-routine services for a newborn, you may pay an additional deductible or separate coinsurance; see page 64. See page 62 for coverage of circumcision for males, which is not a preventive service. Office visits Standard 64, 98 See pages 65–67 for routine exams covered as preventive. Physical, occupational, speech, and neurodevelopmental therapy Standard Inpatient services are usually charged separately from facility charges. 65, 97, 165 Inpatient: 60 days maximum per calendar year. Outpatient: 60 visits maximum per calendar year. Prescription drugs 15% after deductible is met. 75–89 See exclusions on pages 94– 101, and other limits on pages 80–85. ---PAGE BREAK--- *For services requiring preauthorization or plan notification: See the list of services at www.hca.wa.gov/ump- preauth-cdhp or call 1-[PHONE REDACTED]. Many services require both preauthorization and plan notification. See page 91 for how this works. UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 37 Benefit/service How much will I pay? (See pages 25–26 for description of payment types) For more information: See page(s) Any limitations or exclusions? Preventive care Includes vaccines, routine exams, some screening tests Preventive 59, 63, 65–67, 82, 172 Only certain services are covered as preventive; see pages 65–67. See page 63 for contraception covered as preventive. Skilled nursing facility Inpatient Some services may be billed separately (such as physical therapy). 68, 97, 100, 174 Maintenance care (page 165) and custodial care (page 159) are not covered. Spinal and extremity manipulations Standard 68, 98 Limited to 10 visits per calendar year. Surgery 44, 55, 60, 64, 69, 73, 96, 100, 158, 169, 173 Bariatric surgery: page 40. Transgender surgery: page 73. Inpatient services Inpatient Some services require preauthorization and/or plan notification.* Outpatient services Standard Some services require preauthorization.* Telemedicine services Standard 69 Tobacco cessation services Preventive 71 See page 71 for coverage of drugs and nicotine replacement supplies. See page 72 for tobacco cessation services for members ages 17 and under. Transgender services Standard 73 Some services require preauthorization and/or plan notification. See page 73 for covered services. Urgent care Standard 73 ---PAGE BREAK--- *For services requiring preauthorization or plan notification: See the list of services at www.hca.wa.gov/ump- preauth-cdhp or call 1-[PHONE REDACTED]. Many services require both preauthorization and plan notification. See page 91 for how this works. UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 38 Benefit/service How much will I pay? (See pages 25–26 for description of payment types) For more information: See page(s) Any limitations or exclusions? Vision care (Diseases and disorders of the eye) Standard 73, 94, 96, 98 Vision exams, routine Preventive 74, 96, 98 One per calendar year. The plan pays up to $65 per year for contact lens fitting fees. You pay any additional charges. Vision hardware, adults (over age 18) Glasses, contact lenses Special: You pay any amount over $150; network status of provider does not matter. No deductible. 74 Plan pays up to $150 per two calendar years (resets every even year). Vision hardware, children (age 18 and under) Glasses, contact lenses Special: No deductible. Eyeglasses: You pay $0 for one set of standard or deluxe frames and lenses per year. Contact lenses: You pay 15% of the allowed amount. 65–67 Plan pays for one pair of eyeglasses per year at 100% of the allowed amount. See page 74 for options that aren’t covered. No limit on number of contact lenses covered. Well-child visits Preventive 65–67 See pages 65–67. [end of SOB table ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 39 List of benefits Acupuncture The plan covers up to 16 visits for acupuncture treatment per calendar year. See definition of “Limited benefit” on page 164. Ambulance You pay 20% for ambulance services, which must be medically necessary; see definition on page 165. Out-of-network providers may balance bill you. See page 158 for how this works. For these services, balance billed amounts will count toward your out-of-pocket limit. Ambulance services for personal or convenience purposes are not covered. Ground ambulance Professional ground ambulance services are covered in a medical emergency:  From the site of the medical emergency to the nearest facility equipped to treat the medical emergency (see definition of medical emergency on page 165).  From one facility to the nearest other facility equipped to give further treatment. In addition, 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.  From a facility to your home. Air or water ambulance  Air and water professional ambulance services are covered only when all of the following conditions are met:  Ground ambulance is not appropriate.  The situation is a medical emergency (see definition on page 165).  Air or water ambulance is medically necessary (see definition on page 165).  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 residence. If you travel outside the U.S., consider getting separate insurance that covers such air ambulance services. Applied Behavior Analysis (ABA) Therapy The plan covers Applied Behavior Analysis (ABA) Therapy only for a diagnosis of autism spectrum disorder. ABA Therapy services must be preauthorized by the plan before services are performed, or all claims will be denied. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 40 Like other preauthorized services, approved preauthorization is specific to the provider who made the preauthorization request. ABA therapy hours preauthorized for one provider are not automatically transferable to another provider. A change in the provider requires a new preauthorization. Providers of ABA Therapy services must be appropriately credentialed and qualified to prescribe or perform ABA Therapy services. As for other covered services, you receive the best benefit by using preferred providers. See page 13 for differences in your cost for preferred, participating, and out-of-network providers. To find a preferred provider, call UMP Customer Service at 1-[PHONE REDACTED]. More information on ABA Therapy, including how to request preauthorization, is available at www.hca.wa.gov/ump by typing “ABA Therapy” in the Search box at the upper right. ALERT! All ABA Therapy services must be preauthorized before services are provided, including those by plan-approved out-of-network providers. The plan will deny coverage when services are not preauthorized, or when preauthorization is requested but is denied by the plan. You will pay all charges associated with noncovered ABA Therapy services, and these noncovered services do not count toward your deductible or out-of-pocket limit. Autism treatment To determine how a particular service, supply, or intervention is covered, please see that specific benefit. For example, speech or occupational therapy is addressed on page 65 under the “Physical, speech, occupational, or neurodevelopmental therapy” benefit, while mental health coverage is found under “Mental health treatment” on page 61. If a specific benefit is subject to limits, such as number of visits, these limits apply to services, supplies, or interventions for an autism diagnosis the same as for any other diagnosis. TIP: This description does not apply to applied behavior analysis (ABA) therapy. See “Applied Behavior Analysis (ABA) Therapy” on page 39 for details. Bariatric surgery For the plan to cover bariatric surgery, you must get preauthorization from the plan and follow all of your chosen facility’s bariatric surgery requirements. This includes working with a multidisciplinary bariatric surgery team, ensuring that 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 and over are covered for Roux-en-Y, sleeve gastrectomy, and laparoscopic adjustable gastric banding procedures. No other procedure will be considered for coverage. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 41 If you are Medicare-eligible or close to becoming eligible for Medicare and are considering bariatric surgery coverage, contact Customer Service at 1-[PHONE REDACTED]. Related care following bariatric surgery If you need surgical follow-up care related to bariatric surgery, any follow-up surgery must be appropriate and essential to the long-term success of the initial bariatric surgery. Such follow-up surgery must be preauthorized by the plan as meeting plan medical policy and criteria. Panniculectomy (removal of loose skin) is covered following bariatric surgery only when specific medical criteria are met. Most panniculectomies are considered cosmetic and are not covered. UMP will cover surgical follow-up care related to a bariatric procedure such as complications, needed revisions, and Lap Band fills to prior bariatric surgery if the follow-up surgery is appropriate and essential to the long-term success of the initial bariatric surgery. Members who had a bariatric procedure prior to coverage under a UMP plan and have complications, need for revision, or require Lap Band fills for ongoing medically necessary services are not required to verify prior coverage or that they met Regence medical policy criteria for the initial bariatric procedure. However, you must follow plan requirements for follow-up care, including requesting preauthorization. Breast health screening tests See also “Mammograms” on page 59 for more information about breast health testing. The tests listed below may be covered for diagnostic purposes as indicated under plan medical policy. Services covered Women ages 40 and older: Covered as preventive in addition to a digital mammogram. See “How much will I pay?” on page 59. See For women under age 40 on page 59 under “Screening (preventive)” for how preventive breast health testing is covered for high-risk women. Services not covered When performed supplementary to digital mammography for screening purposes for women with or without dense breasts, the following procedures are not covered by the plan: Non-high-risk patients:  Magnetic Resonance Imaging (MRI)  Hand Held Ultrasound (HHUS)  Automated Breast Ultrasound (ABUS) High-risk patients:  Hand Held Ultrasound (HHUS)  Automated Breast Ultrasound (ABUS) ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 42 Chemical dependency treatment Chemical dependency is defined as an illness characterized by a physiological or dependence on a controlled substance or alcohol. Chemical dependency does not include dependence on tobacco, caffeine, or food. Non-emergency inpatient services must be preauthorized by the plan. See page 90 for details. Contact UMP Customer Service at 1-[PHONE REDACTED] about preauthorization requirements. To be covered, residential treatment programs must be licensed to provide residential treatment solely to persons requiring residential chemical dependency or to persons diagnosed with a mental health condition requiring residential treatment. See page 61 for more information on mental health treatment. Your provider must notify the plan upon admission when you receive the following services:  Detoxification.  Inpatient admission, including to a residential treatment facility.  Intensive Outpatient Program (IOP).  Partial Hospitalization Program (PHP). Inpatient ALERT! Your provider must notify the plan upon admission when you receive inpatient services for chemical dependency treatment. Inpatient services for which the plan is not notified may not be covered. Inpatient chemical dependency treatment is subject to clinical review (see definition on page 159). Services are considered “inpatient” when you are admitted to a facility. The plan pays for these services according to the network status of the provider, unless your condition is a medical emergency (see definition on page 165). Professional services (for example, doctors or lab tests) may be billed separately from the facility charges. Outpatient Outpatient chemical dependency services are covered the same as any other medical service. The plan pays based on the allowed amount and the network status of the provider. Preauthorization for outpatient chemical dependency services is not required in most cases. However, the plan may require that your provider submit a treatment plan in order to determine medical necessity. The plan will review your provider’s treatment plan to determine if it meets all of the following conditions:  The purpose of the service is to treat or diagnose a medical condition.  Outpatient services are the appropriate level of services considering the potential benefits of the services.  The level of service is known to be effective in improving health outcomes. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 43  The level of service recommended for your condition is cost-effective compared to alternative interventions, including no intervention. See the definition of “Medically necessary services, supplies, drugs, or interventions” on page 165. Chiropractic physician services See “Spinal and extremity manipulations” on page 68. 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. Most dental services are not covered. For example, dental implants, orthodontic services, and treatment for damage to teeth or gums caused by biting, chewing, grinding, or any combination of these is not covered. However, your PEBB dental plan may cover these services. Under certain circumstances, the plan may cover fluoride supplements; see page 81. The application of fluoride varnish may be covered for infants and children starting at the age of primary tooth eruption in primary care practices, for prevention of dental caries (tooth decay); coverage depends on the network status of the provider as described on pages 25–26. Note that health care providers other than dentists may apply fluoride varnish. For dental services that are covered by the plan, you pay 20% of the allowed amount and the provider may balance bill you (see definition on page 158). Only the following dental services are covered: General anesthesia during a dental procedure General anesthesia performed during a dental procedure is covered only when:  It is provided by an anesthesiologist in a hospital or ambulatory surgery center, and  The charges for the hospital or ambulatory surgery center are covered by the plan (see below). Dental procedures performed in a hospital or ambulatory surgery center Dental procedures performed in a hospital or ambulatory surgery center are covered only when the enrollee:  Is under age 7 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 enrollee at undue risk if the procedure were performed in a dental office. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 44 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, and you must be currently enrolled in UMP CDHP during the entire course of treatment. The plan does not cover treatment after UMP coverage ends. Example: You have an accident on March 12, 2018, resulting in injuries that are covered by the plan. Your treatment plan must be finalized no later than April 11, 2018. All related treatment must be completed by December 31, 2019 (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, or  Extends past the end of the calendar year following the accident or your enrollment in UMP CDHP. Oral surgery TIP: See page 71 for information about TMJ disorder treatment. Only the following oral surgery procedures are covered, whether performed by a dentist or a medical professional:  Excision of tumors or of the jaw, cheeks, lips, tongue, gums, roof and floor of the mouth, or restorative surgery required by the excision.  Incision of salivary glands or ducts.  Obturator maintenance for cleft palate.  Gum reduction for gingival hyperplasia due to Dilantin® or phenytoin use.  Services related to cancer and treatment of cancer, including but not limited to jaw reconstruction.  Treatment of a fracture or dislocation of the jaw or facial bones.  Treatment related to chronic conditions that result in loss or damage of teeth. Note: UMP CDHP is not affiliated with the Uniform Dental Plan (UDP). If you are enrolled in UDP, please contact UDP for information. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 45 Diabetes care supplies FOR MORE INFORMATION: If a health plan other than UMP CDHP is the primary payer (see definition on page 172) for a dependent, claims for diabetes care supplies may be paid differently. See page 107 for more information. Diabetic supplies listed below are covered under your plan’s prescription drug benefit (15% of the cost after you meet your deductible). To be covered, you must get a written prescription for these medications and supplies. You avoid having to submit your own claims when you purchase these diabetic supplies from a Washington State Rx Services network pharmacy. Find a network pharmacy at www.hca.wa.gov/ump/find-drugs or call 1-[PHONE REDACTED]. The following diabetes care supplies are covered under the prescription drug benefit as described on pages 75–89:  Preferred glucose meters  Preferred test strips  Insulin syringes  Lancets Insulin pump and pump supplies are covered under the medical benefit as durable medical equipment. See page 48 for coverage of insulin pumps and related supplies. Continuous glucose monitors must be preauthorized and are covered only under the medical benefit. See the definition of medical benefit on page 165. Certain nonpreferred test strips and nonpreferred glucometers may be available through preauthorization (see page 83). Diabetes Control Program TIP: The Diabetes Control Program is exempt from the medical deductible and is free for UMP members ages 18 and older. For non-Medicare members ages 18 and older with a diagnosis of diabetes, the plan covers 100% for Diabetes Control Program administered by the Case 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. If you qualify for the Diabetes Control Program, you can self-refer by calling [PHONE REDACTED]. You can find out if you qualify for the program at screening events scheduled at your employer worksite, or you can visit your primary care provider for a blood sugar laboratory test. If you see a screening vendor, they will tell you if you meet criteria to participate in the program at the time of ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 46 the screening. If you see your primary care provider, they will tell you if you meet criteria once the laboratory results are available. Diabetes education The plan covers diabetic 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 three-visit lifetime limit stated under “Nutrition counseling and therapy” on page 62. Diabetes Prevention Program Screening events are scheduled at your employer worksite, or you can visit your primary care provider for a blood sugar test. If you see a screening vendor, they will tell you if you meet criteria to participate in the program at the time of the screening. If you see your primary care provider, they will tell you if you meet criteria once the test results are available. If you meet the program’s screening criteria, you will be encouraged to participate in the program at no cost to you. The PEBB Program may schedule screening events at sites around the state. You may also qualify for classes if a blood sugar test ordered by your provider in the previous 12 months is in the prediabetes range. Contact Customer Service at 1-[PHONE REDACTED] for more information. Diagnostic tests, laboratory, and x-rays This benefit covers tests that are appropriate for your diagnosis or reported by the ordering provider and must be medically necessary as defined on page 165. If there are alternative diagnostic approaches with different fees, the plan will cover the least expensive, evidence-based diagnostic method. See www.hca.wa.gov/ump-preauth-cdhp or call 1-[PHONE REDACTED] for a list of services requiring preauthorization. Covered services include:  Diagnostic laboratory tests, X-rays (including diagnostic mammograms), and other imaging studies.  Colonoscopy performed to diagnose disease or illness. See the list on page 66 for coverage of preventive or screening colonoscopy.  Electrocardiograms (EKG, ECG).  Prostate cancer screening (prostate-specific antigen [PSA] testing): All PSA testing is covered under the medical benefit (subject to the deductible and coinsurance), even if billed as preventive.  Skin allergy testing. FOR MORE INFORMATION: See page 59 to learn how the plan covers mammograms. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 47 Tests not covered 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 For covered professional and facility services necessary to perform dialysis, you pay:  15% for preferred facilities.  20% for out-of-network facilities. For dialysis services, amounts paid to out-of-network facilities (including balance-billed amounts; see page 158) will count toward your out-of- pocket limit. Durable medical equipment, supplies, and prostheses TIP: The plan covers durable medical equipment (DME) at the preferred benefit rate only if you get the equipment or supply from a preferred DME supplier or other preferred medical provider. To find preferred DME providers see “Finding a preferred DME supplier” below. If you receive a higher-cost (DME) item when a less expensive, medically appropriate option is available, the plan may not pay for the more expensive item. Some items require preauthorization. See page 91 for how to find the list at www.hca.wa.gov/ump or call 1-[PHONE REDACTED]. The DME benefit covers services and supplies that are prescribed by a provider practicing within his/her scope of practice, medically necessary, and used to treat a covered condition, including:  Artificial limbs or eyes (including implant lenses prescribed by a physician and required as a result of cataract surgery or to replace a missing portion of the eye).  Automatic positive airway pressure (APAP) devices and related supplies.  Bilevel positive airway pressure (BiPAP) devices and related supplies.  Bone growth (osteogenic) stimulators (requires preauthorization).  Breast prostheses and bras as required by mastectomy. (See “Mastectomy and breast reconstruction” on page 60.)  Breast pumps for pregnant and nursing women (see page 63).  Casts, splints, crutches, trusses, and braces.  Continuous Positive Airway Pressure (CPAP) devices and related supplies.  Diabetic shoes, only as prescribed for a diagnosis of diabetes (see “Orthotics” on page 48).  Elemental formulas for Eosinophilic Gastrointestinal Disorders (EGIDs). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 48  Insulin pumps and related pump supplies (see “Insulin pumps and related pump supplies” below).  Ostomy supplies.  Oxygen and rental equipment for its administration.  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 option) of DME such as wheelchairs, hospital beds, and respiratory equipment. (The combined rental fees cannot exceed full purchase price; may require preauthorization.)  Wig or hairpiece to replace hair lost due to radiation therapy or chemotherapy for a covered condition, up to a lifetime maximum of $100. Other wigs and hairpieces are not covered. The plan limits coverage of DME to one item of a particular type of equipment and the accessories needed to operate the item. The plan also covers the repair or replacement of DME due to normal use or a change in the patient’s condition (including the growth of a child). You are responsible for the entire cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility. Note: The plan does not cover replacement of lost, stolen, expired, or damaged DME equipment. Orthotics Coverage of orthotics: Items such as shoe inserts, foot orthotics, and other shoe modifications are covered only when both of the following conditions are met:  The patient has been diagnosed with diabetes.  Specialized (including customized) orthotics are prescribed to treat or reduce the risk of diabetic complications. If you have questions about what services are covered, call UMP Customer Service at 1-[PHONE REDACTED]. 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. Finding a preferred DME supplier To find a preferred DME supplier, go to www.hca.wa.gov/ump-providers-cdhp and click on the preferred providers link. In the “Search for a doctor, hospital name, or specialty box,” begin typing “durable medical”; a drop down list will appear. Select “Durable Medical Equipment & Supplies Supplier” and click “Search.” Note: You do not have to log in to the Regence member site to search for a provider, but you will get more relevant results if you do. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 49 You should now have a list of preferred DME suppliers. Note that different DME suppliers carry different types of supplies; you may need to call to confirm that a particular supplier has what you need. These supplies are not available through PPS, the network mail-order pharmacy. Emergency room TIP: If you need immediate care but your situation isn’t a medical emergency (see page 165), see “Urgent care” on page 73 for how to get treatment at a lower cost than in an emergency room. Facility charges for emergency room treatment are covered for diagnosis and treatment of an injury or illness covered by the plan. Charges for professional services (provided by doctors and other provider types) may be billed separately from facility (hospital or emergency room) charges. The plan pays these professional services based on the allowed amount, payment rules, and services provided. If your emergency room visit is determined to be a medical emergency, it will be paid at the network rate for both preferred and out-of-network facilities. If your emergency room visit is not the result of a medical emergency (see definition on page 165), the plan may not pay for emergency services. ALERT! Medical emergencies treated at an out-of-network hospital will be paid at the network rate. However, you may still be balance billed (see definition on page 158). Non-medical emergencies treated at an out-of-network hospital may not be covered by the plan. If the plan does pay, it will be at the out-of-network rate. End-of-life counseling 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% after you meet your deductible. Outside of hospice, these services are paid as a medical benefit (see page 165), subject to the deductible and coinsurance. For more information on hospice care, see page 54. Family planning services The plan covers a variety of contraceptive drugs and devices. Some are covered as preventive— you don’t pay your deductible or coinsurance. Others are covered under either the medical or prescription drug benefits, depending on the service. Services related to voluntary and involuntary termination of pregnancy (abortion or miscarriage) are covered under the medical benefit (see definition on page 165). Education and counseling related to contraception are covered as preventive (see page 65). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 50 If you receive care from an out-of-network provider or non-network pharmacy, you may have to pay upfront and submit a claim for reimbursement (see pages 109–112). However, note that you must get over-the-counter contraceptive supplies from a network pharmacy for these items to be covered (see “Over-the-counter products” on page 50). Contraceptive drugs ALERT! Visits for placement and removal of contraceptive devices that require professional insertion and removal are covered as preventive. Contraceptives include birth control pills, emergency contraception (the “morning after” pill), vaginal rings, patches, implants, and injectables (such as Depo-Provera). Contraceptive drugs are covered under the prescription drug benefit; those not covered as preventive are subject to the deductible and coinsurance as described on page 76. Generally, only generic drugs are covered as preventive, which are indicated on the UMP Preferred Drug List posted on www.hca.wa.gov/ump/find-drugs, or you can call Washington State Rx Services at 1-[PHONE REDACTED]. Brand-name contraceptive drugs are covered as preventive only when authorized by the plan (see “Preauthorizing drugs” on page 83). Otherwise, they are covered subject to the deductible and coinsurance. You may purchase up to a 12-month supply for contraceptives. Call Washington State Rx Services at 1-[PHONE REDACTED] for information on how to obtain a 12-month supply. Lost, expired, or stolen contraceptives are not covered. Women may receive emergency contraception over the counter without a prescription. Only the generic version of emergency contraception is covered under the preventive benefit. If you choose a brand-name version, you will pay 15% coinsurance. Requesting an exception The plan requires preauthorization to cover brand-name contraceptives covered under the prescription drug benefit as preventive when a generic alternative is available. If you have a medical condition that prevents you from using a generic drug that is covered as preventive, call Washington State Rx Services at 1-[PHONE REDACTED] for how to request an exception. Barrier devices All barrier devices requiring a prescription or fitting are covered as preventive when you see a preferred provider or use a network pharmacy. Barrier devices requiring a prescription or fitting include intrauterine devices (IUDs), diaphragms, and cervical caps. Fitting, insertion, and removal of barrier devices that require it are also covered as preventive. Over-the-counter products Only over-the-counter products that are approved by and registered with the U.S. Food and Drug Administration (FDA) and intended for use by females are covered. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 51 For the plan to cover FDA-registered over-the-counter contraceptives, you must present a prescription from a covered provider type (see page 13) to the pharmacist at the time of purchase. ALERT! To receive plan coverage for an approved over-the-counter contraceptive, you must:  Purchase from a network pharmacy, and  Present a prescription from a covered provider type at the time of purchase. Sterilization When you see a preferred provider, sterilization procedures such as tubal ligation or vasectomy are covered as follows:  For females: Covered as preventive (not subject to the deductible and paid at 100%).  For males: Paid at 100% after meeting the deductible. What is not covered under the family planning benefit? The following services and products are not covered by the plan as a family planning benefit:  Over-the-counter products not approved by and registered with the FDA.  Over-the-counter products for use by males, such as male condoms.  Reversal of voluntary sterilization.  Treatment of fertility or infertility, including direct complications resulting from such treatment. Foot care, maintenance Maintenance foot care includes services such as trimming of toenails and removal or trimming of corns or calluses. These services are covered only for a diagnosis of diabetes, and when provided by an approved provider type. Maintenance foot care provided outside the diagnosis of diabetes is not covered. 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 page 62. Call UMP Customer Service at 1-[PHONE REDACTED] with any questions. Headaches The treatment for chronic migraine headaches is limited. Treatment of chronic migraine with OnabotulinumtoxinA (Botox) is only covered 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 drugs.  The condition is appropriately managed for medication overuse. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 52 Botox injections must be discontinued when:  The condition has shown inadequate response to treatment (defined as less than 50% reduction in headache days per month after two treatment cycles) or has changed to episodic migraine (defined as less than 15 headache days per month) for three consecutive months.  The patient has received a maximum of five treatment cycles. The following treatment is not covered:  Treatment of chronic tension-type headache with Botox is not covered.  Treatment of chronic migraine or chronic tension-type headache with acupuncture, massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (such as chiropractic services) are not covered. Hearing care (diseases and disorders of the ear) The plan covers treatment for diseases and disorders of the ear or auditory canal not related to routine hearing loss under the medical benefit. Routine hearing care benefit limits (see “Hearing exams and hearing aids” below) do not apply. Hearing exams and hearing aids Hearing exams (routine) ALERT! The plan pays for a hearing exam performed as part of a newborn screening as preventive (not subject to the deductible and paid at 100% for preferred providers). One routine hearing exam is covered per calendar year and is subject to the deductible. When you see a preferred provider, these services are paid at 85% of the allowed amount. However, if you see an out-of-network provider, you pay 40% of the allowed amount and the provider may balance bill you. Hearing aids Hearing aids and related items are subject to the deductible. The plan pays up to $800 per member every three calendar years for:  Purchase of a hearing aid (monaural or binaural) prescribed as a result of an exam when necessary for the treatment of hearing loss, including:  Ear mold(s).  Hearing aid instrument.  Initial battery, cords, and other ancillary equipment.  Warranty (only as included with the initial purchase).  Follow-up consultation within 30 days after delivery of hearing aid.  Rental charges up to 30 days, if you return the hearing aid before actual purchase.  Repair of hearing aid equipment. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 53 The maximum benefit of $800 applies no matter where you shop for your hearing aids and supplies. Hearing aid items not covered The following hearing-related items are not covered:  Charges incurred after your UMP 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. Hearing aids and your deductible If you purchase a hearing aid before you meet your deductible:  You may pay the entire cost of the hearing aid and related items (as long as they are qualified medical expenses; see page 173) out of your HSA. However, only up to the $800 limit will apply toward your deductible and out-of-pocket limit.  You or the provider must submit a claim to UMP CDHP, even if you are paying the entire cost out of pocket. The plan must have a claim to count the amount paid (up to the $800 limit) toward your deductible and out-of-pocket limit.  Even if you pay the entire cost of the hearing aid, you have used your hearing aid benefit for the next three years. The plan will not cover another hearing aid for you for three years. Call 1-[PHONE REDACTED] to ask when your benefit will renew. Home health care ALERT! See exclusion 40 on page 96 for services not covered by the plan. UMP CDHP covers medically necessary services provided and billed by a licensed home health agency for medical treatment of a covered illness or injury. These services must be part of a treatment plan written by your provider (such as a physician or advanced registered nurse practitioner [ARNP]). The provider must certify that you are homebound and would require hospital or skilled nursing facility care if you did not receive home health care. Examples of covered services are:  Visits for part-time or occasional skilled nursing care and for physical, occupational, and speech therapy.  Related services such as occasional care (less frequently than daily visits, and under two hours per visit) from 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.  End-of-life counseling (see page 49). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 54 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 book for coverage rules and limitations. These limitations apply even if the services are provided in the home or by a home health provider. Call Customer Service at 1-[PHONE REDACTED] if you have questions. Hospice care (inpatient, outpatient, and respite care) Hospice 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 patients and their families without intent to cure. Medical Services received from preferred and participating providers are covered at 100% of the allowed amount after you meet your deductible. The plan covers hospice care for terminally ill enrollees for no more than six months. See page 49 for coverage of end-of-life counseling. If you need hospice care, your provider will refer you to the program. For alternative caregivers, you may call UMP Customer Service at 1-[PHONE REDACTED]. Prescription drugs For covered prescription drugs, UMP CDHP members in hospice care receive special coverage when using network pharmacies, including the network specialty pharmacy and the network mail-order pharmacy.  Until the deductible is met, the member pays the full cost (allowed amount) for covered drugs.  After the deductible is met, the plan pays for all covered prescription drugs purchased through a network pharmacy at 100% for members in hospice care. This applies only to the member in hospice care. Other family members covered under the same account will pay for their covered prescription drugs as described on pages 75-89. All quantity limits, preauthorization requirements, and coverage limits apply. ALERT! The member still pays the full cost for noncovered drugs. If the member purchases covered prescription drugs from a non-network pharmacy (see page 79), the plan covers under normal benefits as described on page 76. Respite care Respite care is continuous care of more than four hours a day to give family members temporary relief from caring for a homebound hospice patient. The plan covers these services at 100% of the allowed amount after you pay the deductible, up to 14 visits per the patient’s lifetime. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 55 Hospital services ALERT! Many services provided in a hospital setting require preauthorization or plan notification, or both. Failure to request or receive preauthorization, or to notify the plan, may result in complete denial of claims. See pages 90–92 for a description of how preauthorization and plan notification 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 (see definition on page 165). Some services require preauthorization. See page 91 for how to find the list at www.hca.wa.gov/ump or call 1-[PHONE REDACTED]. 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 can’t 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 will be provided 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 upon admission. The plan pays these services according to the network status of the providers (including the hospital), unless your condition is a medical emergency (see page 165). All covered professional services are paid based on the allowed amount. 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. Some services require preauthorization. See page 91 for how to find the list at www.hca.wa.gov/ump or call 1-[PHONE REDACTED]. Not all providers at a preferred hospital are preferred providers Some hospital-based physicians (such as anesthesiologists and emergency room doctors) who work in a preferred hospital, or other preferred facility, may not be preferred providers. If a participating or out-of-network provider bills separately from the hospital, you will pay 40% of the allowed amount. For out-of-network providers, you may also be balance billed (see definition on page 158). For examples of how much you pay, see “Sample payments to different provider types” on page 13. To see the network status of anesthesiologists and emergency room doctors in Washington State hospitals, call UMP Customer Service at 1-[PHONE REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 56 Joint replacement surgery, knees and hips–Center of Excellence (COE) Program ALERT! You must meet your deductible before the plan begins to pay for this benefit. The Center of Excellence (COE) Program covers services related to knee or hip total joint replacement surgery. The Program includes, but is not limited to:  Presurgical consultations.  Travel costs. See “What is my travel benefit?” below.  Hospitalization and surgery.  Postsurgical check-ups. Patients work with Premera Blue Cross (Premera)—the administrator of the program—and Virginia Mason—the Center of Excellence—to ensure that their treatment is consistent with established standards of medical care. If you receive services related to joint replacement that are not covered under the COE Program, 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 (page 19), coinsurance (page 20), or amounts not covered by the plan. Center of Excellence: Virginia Mason Virginia Mason is the only provider approved to perform knee and hip replacement under the COE Program. Virginia Mason has proven that they can provide high-quality joint replacements at predictable costs, using the most up-to-date medical guidelines and services. Who is eligible to participate in the COE Program? You are a candidate for the COE Program if you are:  A UMP CDHP member.  Not enrolled in Medicare as your primary coverage.  Age 18 or older. Virginia Mason must determine if surgery for joint replacement is appropriate based on established medical guidelines. You can find these guidelines at www.breecollaborative.org/wp- How do I 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-[PHONE REDACTED].  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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 57 After applying:  Premera screens applicants to initially determine whether they are eligible to be considered for the COE Program.  Premera refers eligible applicants to Virginia Mason for further assessment.  Virginia Mason will review medical records of eligible applicants to determine if they are medically appropriate candidates for surgery under the COE Program.  If you are approved for surgery, Virginia Mason will provide you with a list of Virginia Mason surgeons to choose from. Note: You may be required to follow a plan Virginia Mason gives you as a condition of approval for surgery, such as for weight loss or tobacco cessation. What happens after I’m approved to participate in the program? Premera will provide a booklet describing your journey through the program. Premera will assign you a dedicated case manager who will walk you through each step of the process. What is my travel benefit? Members having surgery under 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. You must have an approved adult travel companion, whose travel expenses are also covered as described below. FOR MORE INFORMATION: 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. Visit www.hca.wa.gov/ump-coe-program-cdhp for links to IRS rates. Premera may partially reimburse expenses related to:  Mileage for driving within Washington. To qualify for reimbursement, members must live at least 60 driving miles from Virginia Mason, 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. See a list of airports at www.hca.wa.gov/ump-coe-program-cdhp.  Ground transportation from Seattle-Tacoma International Airport to Virginia Mason.  Lodging expenses (excluding meals) at The Inn at Virginia Mason. You may qualify for lodging reimbursement even if you do not live more than 60 driving miles from Virginia Mason in Seattle. Premera must arrange all lodging. If The Inn at Virginia Mason is full, Premera will make other hotel arrangements for you.  Parking at Virginia Mason and parking at your departing airport, even if you do not live more than 60 driving miles from Virginia Mason. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 58 What is included in the COE Program? Premera will work with you to help you understand how the COE Program works, what’s covered and what isn’t, connect you with Virginia Mason providers, and resolve any questions or issues you may have. In general, all eligible expenses associated with knee or hip replacement surgery under the COE Program are covered. 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 drugs, which are covered under your UMP prescription drug benefit). What is not included in the COE Program? If you receive services not arranged through Premera, or choose to receive services at Virginia Mason that are not related to your hip or knee replacement surgery, the services will be covered under your normal UMP CDHP benefits. The following services are not included in the COE Program:  Care received as part of the plan Virginia Mason gives you as a condition of program approval, regardless of where you receive care. Examples of plan requirements include smoking cessation and medical tests.  Physical therapies that are not provided during your hospitalization.  Follow-up care other than the initial postsurgical checkup at Virginia Mason. An example of follow-up care is a visit with your regular doctor.  Medications received from a pharmacy upon discharge from the hospital.  Convenience items, such as a personal phone. What happens if I don’t qualify for the program? If the COE Program determines you are not an appropriate candidate for joint replacement surgery, you may choose a provider other than Virginia Mason for your total joint replacement, and services will be covered under the standard rate (see page 25). Appeals related to the COE Program UMP members can appeal denials made by Premera. Appeals must be submitted to Premera. Decisions made by your Virginia Mason provider(s) regarding your medical appropriateness for surgery are not made by the plan and are therefore not appealable to the plan. TIP: Deadlines and other rules remain the same. See page 117 for details of how appeals work. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 59 An appeal for services related to the COE Program must be submitted to Premera at the address below (rather than to Regence): Eligibility Appeals Attn: Appeals Department - MS 123 PO Box 91102 Seattle, WA 98111-9102 Knee arthroplasty Treatment of late-stage osteoarthritis and rheumatoid arthritis of the knee is covered only as follows:  Total knee arthroplasty, performed with or without 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 knee or hip joint replacement surgery covered in full. See “Joint replacement surgery, knees and hips–Center of Excellence (COE) Program” on page 56. Mammograms ALERT! Not all mammograms are paid at 100% (preventive). Only screening mammograms are considered preventive. Diagnostic mammograms are subject to the medical deductible and coinsurance. Claims will be paid based on how the service is billed by your provider. Screening (preventive) mammograms For women ages 40 and older, with or without a clinical breast exam, the plan covers screening mammograms every year, not subject to the deductible. For women under age 40, the plan covers screening mammograms for women who are at an increased risk for breast cancer. The service must be ordered by a health care provider, and the claim must be billed with an “at risk” diagnosis to be covered under the preventive care benefit. How much will I pay? For all women, if you see a:  Preferred provider: You pay nothing.  Participating provider: You pay nothing.  Out-of-network provider: You pay 40% of the allowed amount and the provider may balance bill you. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 60 Diagnostic (medical) mammograms The plan pays for medically necessary mammograms to diagnose a medical condition under the “Diagnostic tests, laboratory, and x-rays” benefit, subject to the deductible and coinsurance. Coverage of diagnostic mammograms is not related to age. Women under age 40 who receive a mammogram that is not for an “at risk” diagnosis may have services paid as a diagnostic (medical) mammography under the “Diagnostic tests, laboratory, and x-rays” benefit, subject to the deductible and coinsurance. The service must be ordered by a health care provider and billed as a diagnostic mammogram. ALERT! See “Breast health screening tests” on page 41 for coverage of diagnostic testing other than mammograms. Massage therapy The plan covers up to 16 massage therapy visits per calendar year for covered diagnoses. If you pay for visits before you meet your deductible, those visits count toward the 16-visit limit. See the definition of “Limited benefit” on page 164. You must have a prescription for massage therapy treatment from another covered provider type, such as a physician. ALERT! Only preferred massage therapists are covered. To find a preferred massage therapist, use the Provider Search at www.hca.wa.gov/ump-providers-cdhp or call Customer Service at 1-[PHONE REDACTED]. Mastectomy and breast reconstruction ALERT! See page 73 for coverage of breast reconstruction or mastectomy services related to transgender services. This benefit covers mastectomy as treatment for disease, illness, or injury, as well as:  Reconstruction of the breast on which the mastectomy was performed.  Surgery and reconstruction of the other breast to produce a symmetrical appearance.  Prostheses.  Physical complications of all stages of mastectomy. Please note that you must use a covered provider type (see page 13) for services to be covered. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 61 Mental health treatment The plan covers mental health services for treatment of mental, and personality disorders, including eating disorders. Marriage or family counseling is not covered. The amount the plan pays depends on the provider’s network status (see the table on page 36). Your provider must notify the plan upon admission when you receive the following services:  Inpatient admission, including to a residential treatment facility.  Partial Hospitalization Program (PHP). Inpatient Services are considered “inpatient” when you are admitted to a facility. To be covered, residential treatment programs must be licensed to provide residential treatment solely to persons requiring residential chemical dependency or to persons diagnosed with a mental health condition requiring residential treatment. Non-emergency inpatient services must be preauthorized by the plan; see page 90 for details. Contact UMP Customer Service at 1-[PHONE REDACTED] about preauthorization requirements. See the bullets above for services that require plan notification. The plan pays for these services according to the network status of the provider, unless your condition is a medical emergency (see page 165). All covered professional services are paid based on the allowed amount. Outpatient ALERT! See page 39 for preauthorization requirements related to Applied Behavior Analysis (ABA) Therapy services. Outpatient mental health services are covered the same as any other medical service. The plan pays based on the allowed amount and the network status of the provider. Most outpatient mental health services do not require preauthorization. See bullets above for services requiring plan notification. Naturopathic physician services While naturopaths are a covered provider type, naturopaths may recommend services that the plan doesn’t cover. You will pay all costs for excluded and non-medically necessary services, even if your naturopathic physician recommends or prescribes them (see definition of medical necessity on pages 165–167). The plan does not cover herbal, homeopathic, or other dietary supplements (including vitamins and minerals, except as described on page 81), even if prescribed by a covered provider type. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 62 Nutrition counseling and therapy TIP: See “Diabetes education” on page 46 for how these services are covered for diabetics. The plan covers up to three visits per lifetime for nutrition counseling and therapy services. Similar services may be covered under other benefits that are not subject to the three-visit limit, including but not limited to “Diabetes Control Program (page 45), “Diabetes education” (page 46) and the “Diabetes Prevention Program” (page 46). Obstetric and newborn care Services for pregnancy and its complications are covered. See “Covered provider types” on page 13 for providers whose services are covered by the plan. Covered professional services include:  Prenatal and postnatal care.  Amniocentesis and related genetic counseling and testing during pregnancy.  Prenatal testing (follows state regulations in Washington Administrative Code 246-680-020).  Vaginal or Cesarean delivery.  Care of complications associated with pregnancy, including pregnancies resulting from fertility or infertility treatment. Early elective deliveries may not be covered. See “When deliveries before 39 weeks gestation may not be covered” on page 63. For inpatient hospital charges related to a routine childbirth, you pay:  Any remaining deductible for the mother.  Coinsurance for facility charges and professional services for the mother while hospitalized.  The deductible for the newborn; however, if only preventive care services (see page 65) are billed for the newborn, you will not pay the newborn’s deductible or coinsurance when you see a preferred provider. For non-routine hospitalization of the newborn, you will also pay coinsurance for facility and professional services for the newborn. Circumcision is covered as a medical benefit for males only (subject to the deductible and coinsurance). As this is not a preventive service, you will pay the newborn’s deductible and coinsurance for this service. A newborn dependent of a female enrollee is covered 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 mother’s UMP coverage for the first 21 days. See “Adding a new dependent to your coverage” on page 64 for what you need to do for continued coverage. If your obstetric care began while covered under another health plan, and the providers are not part of the plan network, call Customer Service at 1-[PHONE REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 63 When deliveries before 39 weeks gestation may not be covered Vaginal or Cesarean deliveries before 39 weeks of gestation are covered when the services are medically necessary; examples include:  Due to a medical emergency (see definition on page 165) affecting the mother or baby.  Indicated due to a medical condition of the mother or baby for which a delivery is medically necessary (see definition on page 165).  Labor begins spontaneously (without medical intervention) before the mother 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 mother or baby.  Neither the mother nor baby has a medical condition for which immediate delivery is medically necessary. Talk to your doctor about whether early delivery is for a medically necessary reason. For questions about this policy, call UMP Customer Service at 1-[PHONE REDACTED]. Services covered as preventive The following services are covered as preventive (not subject to the deductible or coinsurance when you see a preferred provider):  Screening for gestational diabetes during pregnancy.  Counseling and HIV screening.  Purchase of manual and electric breast pumps for pregnant and nursing women, plus supplies included with the initial purchase. Hospital-grade pumps are not covered.  Use of low dose aspirin (81 mg/day) after 12 weeks’ gestation in women at high risk of preeclampsia. You must have a prescription from your provider and purchase from a network pharmacy to get the medication at no cost; see “Products covered under the preventive care benefit” on page 82. See pages 65–67 for more prenatal, newborn, and well-baby services that are covered as preventive. See page 81 for coverage of prenatal vitamins. Lactation (breastfeeding) counseling Lactation counseling is covered under the preventive benefit during pregnancy and after birth to support breastfeeding when services are received by a covered provider type. Limitations on ultrasounds during pregnancy The following limits do not apply to high-risk pregnancies. For example, a multiple pregnancy is considered high risk. Call UMP Customer Service at 1-[PHONE REDACTED] for more information or to understand what is covered for high-risk pregnancies. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 64 Ultrasounds during pregnancy are covered as follows:  One in week 13 or earlier.  One during weeks 16-22. Adding a new dependent to your coverage For information about how to enroll new dependents in your health plan, read the Employee Enrollment Guide at www.hca.wa.gov/pebb. How does the deductible work when you add a dependent? When only one person is enrolled in UMP CDHP If you are the only member enrolled in UMP CDHP and a new member enrolls under your account during the plan year:  You will have to satisfy an additional $1,400 deductible when the new member enrolls.  You must meet the entire deductible ($2,800) even if the new member enrolls later in the year. Even if you have already met your $1,400 deductible before the new member enrolls, you will need to meet the additional $1,400 deductible before UMP CDHP begins paying for services. Once a new member enrolls, PEBB will contribute to your HSA on his or her behalf. These contributions are equal amounts, up to a maximum of $700 per year for those enrolled in UMP CDHP for the entire 12 months. When more than one person is enrolled in UMP CDHP For two or more members enrolled in UMP CDHP, the maximum deductible is $2,800. The maximum PEBB contribution to your HSA is $1,400. Note: Receiving the $125 SmartHealth wellness incentive does not change how much PEBB contributes to your HSA. However, it does count toward your maximum annual HSA contribution limit. ALERT! You may be eligible to change plans when a newly eligible member enrolls. See page 132 or page 147 for details. Office visits The plan pays for office visits for covered conditions under the medical benefit (see page 165). Preventive care visits to preferred providers as described under “Preventive care” on page 65 are covered in full and are not subject to the deductible. Orthognathic surgery Orthognathic surgery (see definition on page 169) must be preauthorized by the plan according to the plan’s medical policy. Call UMP Customer Service at 1-[PHONE REDACTED] if you have questions. See page 71 for treatment of temporomandibular joint (TMJ) disorder. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 65 Physical, occupational, speech, and neurodevelopmental therapy The plan covers inpatient and outpatient services to improve or restore function lost due to:  An acute injury or illness.  Worsening or aggravation of a chronic injury.  A congenital anomaly (such as cleft lip or palate).  Conditions of developmental delay, including autism. You must have a prescription for the above therapies from another covered provider type (see page 13), such as a physician. Inpatient services Preauthorization is required for inpatient admissions for physical, occupational, speech, and neurodevelopmental therapy services. The plan covers rehabilitation therapy services provided during inpatient hospitalization up to 60 days per calendar year (see definition of “Limited Benefit” on page 164). Outpatient services The plan covers outpatient physical, occupational, speech, and neurodevelopmental therapy services up to 60 visits per calendar year, counting all types of therapies listed here (see definition of “Limited benefit” on page 164). For the purposes of this benefit, developmental delay (see definition on page 160) means a significant lag in achieving skills such as:  Language (speech, reading, writing).  Motor (crawling, walking, feeding oneself).  Cognitive (thinking).  Social (getting along with others). Prescription drugs Please see “Your prescription drug benefit” starting on page 75. Preventive care ALERT! This benefit covers only services that meet the criteria below. If you receive services during a preventive care visit that don’t meet these requirements, or your provider bills your visit as medical treatment instead of a preventive service, the services will not be covered as preventive. Instead, when medically necessary, they are covered under the standard rate (see page 25). You don’t have to meet your deductible before the plan pays for services covered under the preventive care benefit. When you see a preferred provider for these services, you pay nothing. If ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 66 you see an out-of-network provider, you pay 40% of the allowed amount (definition on page 157), and the provider may balance bill you. However, if you do not have access to a preferred provider for preventive services, the plan may pay 100% of billed charges. See page 13 for how to request a network waiver. For a list of services covered as preventive, see www.healthcare.gov/preventive-care- benefits/adults. This site also features links to specific preventive services covered for women and children. Note that recommendations added during the calendar year may not be covered as preventive until later years. For a list of immunizations covered as preventive, see “Covered immunizations” on page 67. Examples of services covered under the preventive care benefit include:  Preventive visits such as well-baby care and annual physical exams.  Preventive vision acuity screening from birth through 18 years of age.  Intensive behavioral counseling for adults who are overweight or obese and have additional cardiovascular disease risk factors.  Screening for hepatitis B for non-pregnant adolescents and adults at high risk.  Routine screenings for women (see list below for examples).  Certain radiology and lab tests such as screening mammograms (see page 59).  Screening procedures such as colonoscopy. See page 46 for coverage of colonoscopy performed to diagnose or treat disease or illness.  One-time screening by ultrasound for abdominal aortic aneurysm, for men ages 65-75 who have ever smoked.  Immunizations as specified under “Covered immunizations” on page 67.  Hearing tests as part of a newborn screening.  Fluoride for prevention of caries (dental decay): prescribed by primary care provider to children age 6 months and older, when water is fluoride deficient; see page 81 for coverage. See page 43 for coverage of fluoride varnish.  Certain screening tests performed during pregnancy. See page 62 for more on prenatal care.  Low to moderate dose of statin medications to adults ages 40 and over (statin medications that are designated as preventive on the UMP Preferred Drug List (with a “PV” in the Limitation column). You may call Customer Service at 1-[PHONE REDACTED] to ask if a service is covered as preventive. The following specific services for women are covered as preventive:  Human Papillomavirus (HPV) testing for women ages 30 and over, once every three years.  Chlamydia and gonorrhea testing in sexually active women age 24 years and younger, and for women age 25 and older who are at increased risk for infection.  Education and counseling regarding contraception.  Counseling and screening for HIV, counseling and screening for interpersonal and domestic violence, and counseling for sexually transmitted infections. For additional services covered as preventive for women, see “Family planning services” on page 49, “Mammograms” on page 59, and “Obstetric and newborn care” on page 62. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 67 Note: Prostate cancer screening (prostate-specific antigen [PSA] testing) is not covered under the preventive care benefit, but is covered as a medical benefit (subject to the deductible and coinsurance). ALERT! Follow-up visits or tests are not covered under the preventive care benefit. If the test or visit is normally covered by the plan and is medically necessary, the plan pays under the medical benefit (see definition on page 165). Covered immunizations The plan covers immunizations as included on the applicable immunization schedule (children, adolescents, adults) for U.S. residents by the Centers for Disease Control and Prevention (CDC). Visit www.hca.wa.gov/ump/find-drugs to find a link to the CDC schedules or call Customer Service at 1-[PHONE REDACTED]. Note that some 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 care benefit are not subject to the deductible. Immunizations given by the providers listed under “Where can I get immunizations?” below are paid under the preventive care benefit. If you see an out-of-network provider for covered immunizations, you pay 40% of the allowed amount and the provider may balance bill you. FOR MORE INFORMATION: For a list of immunizations covered as preventive, find a link to the CDC immunization schedules at www.hca.wa.gov/ump/find-drugs or call 1-[PHONE REDACTED]. Where can I get immunizations? Immunizations covered under the preventive care benefit are covered at 100% when received from a:  Preferred provider.  Network vaccination pharmacy (see definition on page 167); check at www.hca.wa.gov/ump/ find-drugs or call Washington State Rx Services at 1-[PHONE REDACTED] to find a pharmacy.  Public health department. The plan does not cover immunizations for travel or employment, even when recommended by the CDC or required by travel regulations. TIP: Flu shots are covered as included on the applicable CDC immunization schedule. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 68 Second opinions The plan covers second opinions under the medical benefit (subject to the deductible and coinsurance). This benefit covers:  Second opinions you choose to get. The plan covers these under the medical benefit subject to the deductible and coinsurance.  Second opinions required by the plan. The plan covers these at 100% (you don’t pay toward your deductible or coinsurance). If you don’t get a second opinion when required by the plan, coverage for services may be denied. Skilled nursing facility Services must be preauthorized by the plan before you are admitted to a skilled nursing facility; see page 90. The facility must also notify the plan within 24 hours of your admission; see page 91. 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. UMP CDHP 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 (see definition on page 165). Skilled nursing facility confinement that is primarily convalescent or custodial in nature is not covered. Spinal and extremity manipulations Up to 10 visits per calendar year for manipulations (adjustments) of the spine and extremities (arms and legs) are covered. When you have reached your 10-visit limit, no further payment for manipulations of the spine and extremities will be made. Visits that count toward your deductible also count toward your 10-visit limit (see “Limited benefit” on page 164). Spinal injections Some spinal injections must be preauthorized by the plan. See page 90 for how this works. The following therapeutic injections are covered for treatment of chronic pain:  Lumbar epidural injections  Cervical-thoracic epidural injections  Sacroiliac joint injections See exclusion 96 on page 100 for a list of spinal injections that are not covered by the plan. Spinal injections not specified above may be covered subject to the plan’s medical review. Call 1-[PHONE REDACTED] for more information. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 69 Surgery ALERT! Even if your doctor is preferred, the facility or other providers such as anesthesiologists might not be. Make sure you confirm that all of the providers who will participate in your care and the facility are preferred before you receive services. Out-of-network providers and facilities can bill you for all charges not paid by the plan, while preferred providers and facilities agree to accept the payment amounts negotiated by the plan, which saves you money. The plan pays for covered surgical services according to the network status of the provider (see page 13 for coinsurance amounts). The surgeon and other professional providers may bill separately from the facility. Some outpatient procedures require preauthorization (see page 90). Your provider must also notify the plan (see page 91) when you receive certain services, including admission as an inpatient. See the list of services that require preauthorization at www.hca.wa.gov/ump-preauth- cdhp. Call Customer Service at 1-[PHONE REDACTED] if you have questions. The plan covers the following services as outpatient:  Outpatient surgery at a hospital.  Surgery and procedures performed at an ambulatory surgery center.  Short-stay obstetric (childbirth) services (released within 24 hours of admission). ALERT! All surgeries must follow the plan’s coverage rules. We recommend that you contact UMP Customer Service at 1-[PHONE REDACTED] before any procedure to ask if it’s covered or requires preauthorization. Telemedicine services Telemedicine is the delivery of health care services through audio-visual technology, allowing real-time communication between the patient at the originating site and a provider for the purpose of diagnosis, consultation, or treatment. Telemedicine does not include the use of audio- only telephone, facsimile, or email. Store and forward technology is a term used for the transfer of a covered person’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 patient. It does not include the use of audio-only telephone, facsimile, or email. If you see a network provider, telemedicine services will be paid at the network rate. If you see an out-of-network provider, telemedicine services will be 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: ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 70  The plan provides coverage for the service when provided in person by the provider, and  The health care services are medically necessary, and  The health care 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, and  The technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information, and  The health care services are 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 can be in person or via telemedicine. The originating site (the physical location where the patient is) for a telemedicine health care services must be one of the following sites:  Hospitals.  Rural health clinics.  Federally qualified health centers.  Physician's or other health care provider's offices.  Community mental health centers.  Skilled nursing facilities.  Home.  Renal dialysis centers (except independent renal dialysis centers). Any originating site except h0me may charge a facility fee for infrastructure and preparation of the patient. Telemedicine and store and forward technology are subject to all terms and conditions of the plan, including utilization review, preauthorization requirements, deductibles, and copayment requirements. Services obtained from non-network providers will be reimbursed at the out-of- network rate. The following are not covered by the plan:  Audio-only telephone, email or facsimile transmissions between doctor and patient.  Originating sites’ professional fees.  Installation or maintenance of any telecommunication devices or systems.  Home health monitoring.  Store and forward technology without an associated office visit between the covered person and the referring health care provider.  Telemedicine visits originating from a location other than the specified originating sites.  Services that would not be covered if delivered in person.  Services that are not medically necessary.  Telemedicine or store and forward services that cannot be safely and effectively provided through telemedicine or store and forward technology. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 71  Telemedicine or store and forward services that use technology that does not meet state and federal requirements for privacy and security of protected health information.  Telemedicine 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. Temporomandibular joint (TMJ) treatment The plan covers diagnosis and medically necessary treatment of temporomandibular joint (TMJ) disorders, including surgery and non-surgical services. Treatment must follow plan medical policy and requires preauthorization. Treatment that is experimental or investigational, or primarily for cosmetic purposes, is not covered. 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 regular register and submit a claim, you may not receive full reimbursement from the plan. See page 77 for how to find a network pharmacy. The services described below are covered only for tobacco cessation. Nicotine replacement therapy and prescription drugs for tobacco cessation that are designated as preventive on the UMP Preferred Drug List (with a “PV” in the Limitation column) are not subject to the deductible or coinsurance. TIP: You do not have to enroll in the Quit for Life program to get coverage of nicotine replacement therapy or prescription drugs for tobacco cessation. See below for limits and rules on accessing these services. Nicotine replacement therapy The plan covers only certain nicotine replacement therapy products as preventive (at no cost to you), designated on the UMP Preferred Drug List with “PV” in the Limitation column. Over-the- counter drugs are normally not covered by UMP, but nicotine replacement products are covered when they are purchased at a pharmacy using your UMP ID card. You may get nicotine replacement therapy directly from the Quit for Life program (see “Quit for Life program” 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 the network pharmacy. Give your prescription along with your UMP ID card to the pharmacist. The purchase must be submitted through the prescription drug system to be covered. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 72 If you get a nicotine replacement therapy product not designated as preventive, you will pay any remaining deductible and 15% coinsurance. 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 (see table on pages 25–26) when you see a preferred or participating provider. Phone or online counseling is covered only through the Quit for Life program described below. UMP CDHP members age 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 “Preauthorizing drugs” on page 83 for how to request an exception. If your exception is approved, you will receive the approved product or drug at no cost. Quit for Life program TIP: UMP CDHP members age 17 and under may access similar support services through the Smokefree Teen program at www.teen.smokefree.gov, in addition to the services listed above. UMP CDHP members age 18 and older may participate in the Quit for Life tobacco cessation program. This program offers phone counseling in addition to the services described above at no cost to members. If you get nicotine replacement therapy or prescription drugs for tobacco cessation that are not designated as preventive on the UMP Preferred Drug List (“PV” in the Limitation column), you will pay as described above. For nicotine replacement therapy, you may get supplies sent to you from Quit for Life, or get a prescription from your provider and purchase as described under “Nicotine replacement therapy” above. FOR MORE INFORMATION: The general rule about the PEBB tobacco premium surcharge is you can only reattest for an exemption if you are tobacco-free for two months, enroll in Quit for Life (for members over age 18), or access the information and resources in Smokefree Teen (for members under age 18). Contact the PEBB Program at 1-[PHONE REDACTED] or visit www.hca.wa.gov/pebb for details. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 73 Transgender health The following services associated with a diagnosis of gender are covered.  Non-surgical services, including but not limited to hormone therapy, office visits, mental health/counseling, and tests.  Covered surgical services. Visit www.hca.wa.gov/ump/ump-administration/clinical-policies to find a link to the clinical criteria for transgender services. Some services and drugs may require preauthorization. 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 CDHP member receives an organ, eye, or tissue donation from a live donor, UMP CDHP pays 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 “Emergency room services” on page 49 for care during a medical emergency (definition on page 165). 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. These services are paid at the standard rate as described in the table on page 25, according to the provider’s network status. Go to www.hca.wa.gov/ump-providers-cdhp to find preferred urgent care facilities. Vision care (diseases and disorders of the eye) The plan covers treatment for diseases and disorders of the eye that are not part of a routine vision exam under the medical benefit. 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 durable medical equipment (page 47). These services are subject to the deductible, and coinsurance depends on the network status of the provider. Contact the plan at 1-[PHONE REDACTED] if you have questions. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 74 Vision exams (routine) The plan covers one routine eye exam for each enrollee per calendar year, which is exempt from the deductible and will be paid at the preventive rate (see page 25). ALERT! The plan pays up to $65 per year for contact lens fitting fees; you may pay for charges exceeding that amount. For example, if the additional charge for a contact lens fitting is $100, you will pay $35 for the vision exam (the amount over $65). Vision hardware (eyeglasses and contact lenses) Adults (over age 18) The plan pays up to $150 every two calendar years for prescription eyeglass lenses, frames, and contact lenses, including repairs; you do not need to meet your deductible. This $150 limit is renewed on January 1 of even years (2016, 2018, etc.). Any unused amount does not carry over into the next even plan year. The plan will not pay more than your actual cost for these items and services. You are responsible for any costs above the $150 limit. Note: See “Vision care (diseases and disorders of the eye)” on page 73 for vision hardware coverage following cataract surgery. You can buy your vision hardware anywhere. The maximum benefit of $150 applies no matter where you shop. If you go to a provider that does not bill the plan directly, you can submit a claim for glasses or contacts; see “Billing & payment: filing a claim” starting on page 109 for instructions. Children ages 18 and under Vision hardware (eyeglasses: frames and lenses; contact lenses) is not subject to the deductible. The following services are covered each calendar year for children ages 18 and under:  Eyeglasses: The plan pays 100% of the allowed amount for one pair of standard or deluxe frames plus lenses (including high-index). The only added feature covered under this benefit is scratch-resistant coating. You will pay for any other additional features, such as but not limited to anti-reflective coating or tints.  Contact lenses: No limit to number purchased, but the plan pays 85% of the allowed amount, and you pay 15% coinsurance. TIP: For members with other primary coverage: If your primary coverage has a vision hardware benefit and you submit a claim to UMP CDHP as your secondary coverage, any charges paid by your primary plan will also count against your UMP CDHP vision hardware limit. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 75 Your prescription drug benefit See page 89 for prescription drug contact information. Your plan’s drug benefit is managed by a partnership of companies known as Washington State Rx Services. These companies are:  Moda Health—Administration and customer service.  MedImpact Healthcare Systems Inc.—Pharmacy network management and prescription drug claims processing.  Mail-order pharmacy—Postal Prescription Services (PPS).  Specialty drug pharmacy—Ardon Health. When you have questions about your prescription drug coverage or need help finding a network vaccinating pharmacy, call Washington State Rx Services at 1-[PHONE REDACTED]. Contact the mail-order or specialty pharmacy directly for help placing or tracking prescription orders. Note: Regence BlueShield does not provide prescription drug benefits for UMP CDHP. Always contact Washington State Rx Services with questions about your prescription drug coverage. TIP: The UMP Preferred Drug List is available at www.hca.wa.gov/ump/find-drugs. You can also check drug prices online with the Prescription Price Check tool. What drugs are covered? The UMP Preferred Drug List ALERT! Not all drugs are listed on the UMP Preferred Drug List. If your drug isn’t listed, call 1-[PHONE REDACTED]. The UMP Preferred Drug List (sometimes called a “formulary”) lists the following:  If a drug is covered by the plan.  If the drug must be preauthorized (see “Preauthorizing drugs” on page 83).  If the drug must be purchased from the plan’s specialty pharmacy (see page 85).  If there are any limits on a drug’s coverage (see page 80).  If there are less expensive alternatives. The UMP Preferred Drug List is updated online at least You can look up your prescription drugs online at www.hca.wa.gov/ump/find-drugs or by calling Washington State Rx Services. New brand-name drugs may not be covered during the first 180 days they are available. To check if a new drug is covered, call Washington State Rx Services at 1-[PHONE REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 76 ALERT! When a generic equivalent for a brand-name drug becomes available, the brand-name drug immediately becomes nonpreferred. Always ask your doctor to allow substitution on your prescriptions to save you money. Who decides which drugs are preferred? As a state-sponsored health plan, UMP CDHP must follow coverage decisions made by the Washington State P&T Committee, which consists of Washington health care professionals, including physicians and pharmacists. The UMP Preferred Drug List includes these coverage recommendations. Not all drug classes are reviewed by the Washington State P&T Committee. For these drugs, the Washington State Rx Services P&T Committee makes coverage recommendations for UMP’s review and final determination of a drug’s coverage level (preferred or nonpreferred). For the plan to approve a drug for you, it must be medically necessary (see page 165) for your health condition. Your provider may prescribe a drug or drug dose that is not medically necessary. How much will I pay for prescription drugs? ALERT! Hospice care: See page 54 for special prescription drug coverage while in hospice. Until you meet your deductible (see page 19), you will pay the entire cost of your prescription drugs. Once you have met your deductible for the year, you pay 15% of the drug’s cost for covered prescription drugs. You can get up to a 90-day supply for most drugs (except for specialty drugs; see page 85). For drugs covered as preventive (see page 82), you don’t pay the deductible or coinsurance when you use a network pharmacy. If a prescription drug isn’t covered by the plan, it does not count toward either your deductible or your out-of-pocket limit. Note: You may use your Health Savings Account (HSA) to pay for many drugs not covered by the plan; see “Your health savings account” on page 23 for more information. ALERT! When you use network pharmacies, retail or mail-order, you pay based on the drug’s allowed amount, a discounted price negotiated for the plan. If you use a non-network pharmacy of any type, the pharmacy may charge more than the allowed amount. You will have to pay this amount, which doesn’t count toward your deductible or out-of-pocket limit and is not payable by the plan. NOTE: Prescriptions ordered through mail-order pharmacies located outside the U.S. are not covered, even if you send in a claim. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 77 If a dependent has other medical coverage If a dependent has primary medical coverage through another plan that covers prescription drugs, some of the limits and restrictions to prescription drug coverage listed on pages 80–85 will apply when UMP CDHP pays secondary to another plan. See “Submitting a claim for prescription drugs” beginning on page 111 for how to submit a prescription drug claim. Using network pharmacies when UMP CDHP is secondary If a dependent has 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 CDHP is secondary If a dependent’s primary plan uses PPS, the plan’s network mail-order pharmacy, PPS can process payments for both plans and charge only what’s left. Make sure that PPS has the information for both plans and knows which plan is primary. However, if the primary plan uses a different mail-order pharmacy, the member must use the primary plan’s mail order, then submit a paper claim for payment by UMP CDHP. See “Submitting a claim for prescription drugs” on page 111 for how to do this. Where to purchase your prescription drugs ALERT! If you use a non-network pharmacy of any type, you will pay the entire cost of the drug upfront and must submit a claim. However, only the allowed amount for covered drugs (see page 158) will count toward your deductible or out-of-pocket limit. Pharmacies are contracted through a different network than medical providers. See above through page 79 for how to confirm a pharmacy is network. Retail pharmacies Washington State Rx Services has a large network of retail pharmacies, which includes many independent and regional pharmacies in Washington State as well as national chains. Search for a network pharmacy at www.hca.wa.gov/ump/find-drugs or call 1-[PHONE REDACTED]. You can use any pharmacy, but you will save money if you use a network pharmacy. When you get your prescriptions at a network pharmacy, the pharmacy sends the claim to the plan for you, and you pay only what you owe. Before meeting your deductible, this will be the allowed amount for a covered drug. After you have met your deductible, you will pay 15% of a covered drug’s allowed amount. Note: You will pay the entire cost for any drug not covered by the plan, which will not apply toward either your deductible or your out-of-pocket limit. Many network retail pharmacies have vaccinating pharmacists able to administer preventive immunizations at no cost to you. Find the list of network vaccination pharmacies (see definition ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 78 on page 167), at www.hca.wa.gov/ump/find-drugs, or call Washington State Rx Services at 1-[PHONE REDACTED]. TIP: If you take an ongoing prescription drug and purchase between an 84- and 90-day supply, you may be able to save money by using a Choice90 network pharmacy or PPS mail-order pharmacy. Search for a network pharmacy at www.hca.wa.gov/ump/find-drugs to find a Choice90 network pharmacy and compare prices. Mail-order pharmacy ALERT! PPS cannot ship outside of the United States. See “Travel overrides for prescription drugs” on page 87 if you will be traveling. Postal Prescription Services (PPS) is the plan’s network mail-order pharmacy. You may call PPS at 1-[PHONE REDACTED] or Washington State Rx Services at 1-[PHONE REDACTED] to learn more about mail order. Steps to get started: 1. Set up an account with PPS by going to or calling PPS at the phone number listed above. 2. Mail your prescription to PPS. Your provider can also electronically send or fax your prescription to PPS at 1-[PHONE REDACTED]. Prescriptions faxed to PPS must:  Be faxed from the provider’s office fax machine.  Be on the provider’s letterhead.  Include the patient’s name, address, phone number, plan ID number, and date of birth. Note: Only a provider can fax in a prescription. You must follow these instructions to avoid a delay in filling your prescription. Refills can be ordered through your online pharmacy account at or by calling PPS directly. Prescriptions are usually delivered within 7 to 10 days after the pharmacy receives your prescription. When using PPS, the same deductible, coinsurance, preauthorization requirements, and limits on coverage apply as for prescription drugs purchased at retail network pharmacies. ALERT! If there is a shortage of a specific drug that PPS cannot control and it doesn’t have the quantity you ordered, PPS will contact you to discuss your options for obtaining your prescription(s). Prescriptions mailed or orders placed in December but not filled until January 1 or after will be subject to the deductible applicable on the date the prescription is processed. Because of ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 79 increased volume at the end of the year, prescriptions submitted to PPS in December may not be processed during the current benefit year. ALERT! Some durable medical equipment (DME) items are not available through PPS. You will need to get them through a network retail pharmacy or preferred DME provider. Use network pharmacies and show your ID card to get the plan discount The plan pays for prescription drugs based on the allowed amount (Washington State Rx Services’ standard reimbursement). If you use a non-network pharmacy or do not show your ID card at a network pharmacy, and the amount charged is more than the allowed amount, you will pay the difference in addition to your coinsurance. Non-network pharmacies —retail or mail-order ALERT! The plan does not cover prescription drugs ordered through mail-order pharmacies located outside the U.S. You can purchase your prescriptions (except specialty drugs) at a non-network pharmacy, but you’ll pay more if you do. If you get your prescriptions filled at a non-network pharmacy, whether a retail, internet, or mail-order pharmacy (other than PPS), the following applies:  You will need to submit your own claim to Washington State Rx Services for reimbursement (see “Submitting a claim for prescription drugs” starting on page 111).  You don’t get the plan discount.  You’ll pay the difference between the allowed amount (see page 158) and what the pharmacy charges, and it won’t count toward your deductible or out-of-pocket limit.  Non-network pharmacies will not know if a 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 it.  Unless noted on the UMP Preferred Drug List, specialty drugs purchased anywhere but through the plan’s network specialty drug pharmacy are not covered (see “Specialty Drugs” on page 85). TIP: To submit claims for prescriptions purchased from non-network pharmacies (U.S. retail, internet, or mail-order pharmacies, or foreign retail pharmacies), see “Submitting a claim for prescription drugs” on page 111. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 80 Drugs purchased outside the U.S. If you purchase drugs outside the U.S. for any reason, the following rules apply:  If the 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 his/her scope of practice.  If you get a 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 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 his/her scope of practice. The plan does not cover over-the-counter drugs except for certain preventive medicines as required by the Accountable Care Act. These drugs are indicated with a “PV” in the UMP Preferred Drug List.  If you get a drug that is designated as not covered in the UMP Preferred Drug List, the plan will not cover the drug. To submit a claim for a prescription drug purchased outside the U.S., see “Submitting a claim for prescription drugs” beginning on page 111. All necessary information must be included on the prescription drug claim form with drugs and dosage documented. Regence works with the BlueCard (Global Core) Service Center to translate claims, services, and account for currency differences on all claims submitted by you or your provider. ALERT! The plan does not cover prescription drugs purchased through mail-order pharmacies located outside the U.S. Guidelines for drugs UMP covers To be covered, a prescription drug must meet all of the following criteria:  Has been reviewed by one of the following: the Washington State Pharmacy & Therapeutics (P&T) Committee or Washington State Rx Services (see list on page 75) and has been placed on the UMP Preferred Drug List.  Be medically necessary (see definition on page 165).  Can be legally obtained in the United States only with a written prescription.  Is approved by the Food and Drug Administration (FDA).  Does not have a nonprescription alternative (see definition on page 168), including an over- the-counter alternative with similar safety, efficacy, and ingredients. (See “Exceptions covered” on page 81.)  Is not classified as a vitamin (except as listed below), mineral, dietary supplement, homeopathic drug, or medical food.  Has been prescribed by a provider prescribing within his/her scope of practice (is licensed to prescribe).  Has been dispensed from a licensed pharmacy employing licensed, registered pharmacists.  Meets plan coverage criteria. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 81 The plan may require that you try standard treatment(s) before it will cover a drug for off- label use (prescribed for a use other than its FDA-approved label). The plan will not cover any drug when the FDA has determined its use to be unsafe. Exceptions covered ALERT! Only select generic prenatal vitamins and generic fluoride supplements are covered; the plan does not cover brand-name prenatal vitamins and fluoride supplements. The plan also does not cover prescriptions that contain DHA (docosahexaenoic acid). DHA is a dietary supplement, and dietary supplements are not covered by the plan. The plan covers the following prescription drugs as exceptions to the above rules when you have a written prescription from your provider:  Activated vitamin D for patients on renal dialysis or with parathyroidism.  Select generic fluoride supplements for prevention of dental caries for children ages 6 months to 18 years.  Select generic prescription prenatal vitamins without docosahexaenoic acid (DHA) for women of childbearing age; and  Limited products for the treatment of congenital metabolic disorders such as generic phenylketonuria (PKU) detected by newborn screening when specialized formulas are medically necessary. Your pharmacy benefit also includes the following nonprescription drugs and supplies:  Insulin and diabetic supplies such as blood glucometers, test strips, lancets, and insulin syringes used in the treatment of diabetes. See “Diabetes care supplies” on page 45 for more information.  Select contraceptive devices and drugs (see pages 49–51).  Low-dose aspirin for pregnant women (see page 63 for coverage details).  Select generic over-the-counter prenatal vitamins without DHA for women of childbearing age.  Certain nicotine replacement therapy products (see page 71).  Other over-the-counter products that are specifically noted in the UMP Preferred Drug List as covered by the plan. The plan covers FDA-approved drugs used for off-label indications (prescribed for a use other than its FDA-approved label) only if recognized as effective for treatment:  In a standard reference compendium (defined on page 175) as supported by peer-reviewed clinical evidence;  In most relevant peer-reviewed medical literature (defined on page 170), if not recognized in a standard reference compendium; or  By the federal Secretary of Health and Human Services. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 82 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 purchase at a network pharmacy to receive 100% reimbursement. You may not receive full reimbursement for claims from register receipts and non-network pharmacies. Some products are covered under the preventive care benefit, if they:  Are recommended by the U.S. Preventive Services Task Force as described on pages 65–67, and  Conform to coverage guidelines stated above. The brand and type of products covered are limited. Call 1-[PHONE REDACTED] for more information on which ones are covered. You pay nothing 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. Some contraceptive drugs and supplies are covered as preventive; see “Family planning services” on page 49 for details. See “Tobacco cessation services” on page 71 for products covered as preventive for tobacco cessation. Some injectable drugs are covered only under the prescription drug benefit Certain drug classes, including but not limited to those listed below, are covered only under the prescription drug benefit and not the medical benefit:  Growth hormones  Self-administered drugs for multiple sclerosis  Self-administered drugs for rheumatoid arthritis  Drugs to treat hepatitis C Your pharmacy may submit a claim for these drug classes to Washington State Rx Services. A drug may be approved for use for another condition, but is still available only through the prescription drug benefit. Call 1-[PHONE REDACTED] if you have questions. Compounded prescription drugs Compounded prescription drugs are the result of combining, mixing, or altering of 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 patient. Traditional compounding typically occurs when an FDA-approved drug is unavailable or a licensed health care provider decides that an FDA-approved drug is not appropriate for a patient’s medical needs. Compounded drugs costing more than $150 require preauthorization. Claims for compounded drugs require additional ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 83 information submitted on the claim form; this information is available from the compounding pharmacy. Limits on your prescription drug coverage Washington State Rx Services may exclude, discontinue, or limit coverage for any drug manufacturer’s version of a drug for any of the following reasons:  New drugs are developed.  Generic, biosimilar, interchangeable biosimilar, or follow-on biologic drugs become available.  A nonprescription alternative (see definition on page 168), including an over-the-counter alternative (see definition on page 169) becomes available.  There is a sound medical reason.  There is lack of scientific evidence a drug is as safe and effective as existing drugs used to treat the same or similar conditions.  One of the following recommends a change: The Washington State Pharmacy & Therapeutics (P&T) Committee, or Washington State Rx Services (see list on page 75).  A drug receives Food and Drug Administration (FDA) approval for a new use.  A drug is found to be less than effective by the FDA’s Drug Efficacy Study Implementation (DESI) classifications.  The FDA denies, withdraws, or limits the approval of a product.  A more cost-effective alternative is available to treat the same condition. For approval, the drug must be covered by the plan and be medically necessary for your health condition. Your provider may prescribe a drug or drug dose that is not medically necessary (see definition on page 165). Programs limiting drug coverage The limits and restrictions described from “Limits on your prescription drug coverage” on page 80 through “Refill too soon” on page 87 help us monitor drug usage, safety, and costs. Drugs may be added to any of these programs at any time. You can find out if your drug falls under any of these limits and restrictions by checking the UMP Preferred Drug List or calling Washington State Rx Services at 1-[PHONE REDACTED]. Risk Evaluation and Mitigation Strategies (REMS) program Risk Evaluation and Mitigation Strategies (REMS) programs make sure drugs are used safely. The Food and Drug Administration (FDA) requires a REMS program for a drug if they determine that safety measures are needed to ensure that the drug’s benefits outweigh its risks. Some REMS programs require the drug to be prescribed, dispensed, and used according to the REMS program guidelines to ensure safe use. If the REMS program is not followed, UMP may not cover the restricted drug. Preauthorizing drugs Some medications require preauthorization to determine whether they are medically necessary and meet criteria, or the plan will not cover them. You can find out if your drug requires ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 84 preauthorization by calling Washington State Rx Services, or checking the UMP Preferred Drug List at www.hca.wa.gov/ump/find-drugs. You and your prescribing provider can also find the coverage criteria for your drug at www.hca.wa.gov/ump. Some examples (not a complete list) of the drugs requiring preauthorization include:  Certain injectable drugs when purchased through a retail or network mail-order pharmacy.  Compounded drugs costing more than $150. If your drug requires preauthorization, your pharmacist or prescribing provider must call Washington State Rx Services at 1-[PHONE REDACTED] to request it. Note: Drugs covered under the medical benefit rather than the prescription drug benefit have different rules for preauthorization. Call UMP Customer Service at 1-[PHONE REDACTED] for details. Emergency fill Emergency fill lets you get a limited quantity of certain 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. A list of emergency medications is available at www.hca.wa.gov/ump/ump-cdhp/what-you-pay- drugs or by calling 1-[PHONE REDACTED].  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 15% of the medication’s allowed amount after you meet your deductible. You pay the full amount of the medication before you meet your deductible.  The plan will cover an emergency fill of up to a 7-day medication supply; preauthorization requests are usually resolved within three to five business days.  If your preauthorization request is denied, you will pay the full cost of the drug for any quantity you receive after the emergency fill. Emergency fill limits Note that the following limits still apply to emergency fill medications:  Refill too soon: If you have a filled prescription for a medication (or its therapeutic equivalent), you cannot get an emergency fill until you have used 84% or more of the filled prescription.  Quantity limits: You cannot get more than the stated quantity limit under an emergency fill. If you have a current filled prescription for a medication (or its therapeutic equivalent) and it was filled to the quantity limit, you cannot get an emergency fill until you have used 84% or more of the filled prescription. Quantity limits Certain drugs have a quantity limit per prescription (how much or how many you get). If you need more than this limit allows, your pharmacist or prescribing provider must call Washington State Rx Services at 1-[PHONE REDACTED]. If Washington State Rx Services denies your request or your provider or pharmacist does not get preauthorization, we will cover the drug only up to the quantity limit amount. You will pay for any extra amount. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 85 Specialty drugs ALERT! Ardon Health, the plan’s network specialty pharmacy, is unable to ship outside the U.S. See “Travel overrides for prescription drugs” on page 87 if you will be traveling. Specialty drugs are high-cost injectable, infused, oral, or inhaled drugs or products that require special handling and storage and are subject to additional rules. You can find out if a drug is a specialty drug by checking the UMP Preferred Drug List at www.hca.wa.gov/ump/find-drugs, or by calling Washington State Rx Services. 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, Ardon Health, (1-[PHONE REDACTED] Monday through Friday, 8 a.m. to 7 p.m., or Saturday 8 a.m. to 12 p.m. Pacific Time). You may receive up to a 30-day supply for most specialty medications per prescription or refill. However, some may be limited to a 15-day supply due to high discontinuation rate or a short duration of use, or to ensure that the medication is not causing harmful side effects. Specialty drugs require preauthorization. See “Preauthorizing drugs” (page 106) on how to request preauthorization. A Patient Care Coordinator will work with you to schedule a delivery time for the medication. The specialty pharmacy will deliver your medications anywhere in the country you choose, such as to your workplace or to a neighbor if you cannot be home for the delivery. Specialty medications often require special handling and storage. The plan is not responsible for replacement of lost, stolen, expired, or damaged prescription drugs or products (see exclusion 79 on page 99). If your provider will be administering a medication, you can have it shipped to the provider’s office. However, once the provider’s office receives the drug, the provider takes responsibility for the drug. Step therapy When a drug is part of the step therapy program, you have to try certain drugs (Step 1) before the prescribed Step 2 drug will be covered. When a prescription for a step therapy drug is submitted “out of order,” meaning you haven’t first tried the Step 1 drug before submitting a prescription for a Step 2 drug, your prescription will not be covered. 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 can call Washington State Rx Services at 1-[PHONE REDACTED] and request coverage. You will have to pay the entire cost of the drug if you have not tried the Step 1 drug and coverage hasn’t 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 at www.hca.wa.gov/ump/find-drugs, or call Washington State Rx Services at 1-[PHONE REDACTED]. 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 drug may not be covered. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 86 Can the pharmacist substitute one drug for another? ALERT! New generic 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 isn’t available now. That way, when one becomes available, the pharmacist can automatically refill with the generic. Substitution under Washington State law When a brand-name or biological drug has a generic equivalent or interchangeable biosimilar (see definition on page 162), pharmacists in Washington State must substitute the generic equivalent or interchangeable biosimilar drug for the brand-name or biologic drug. Your provider may write the prescription “dispense as written” if he or she wants you to get only the prescribed brand-name or biologic drug, or you can tell the pharmacist you want the brand-name or biologic drug. Therapeutic Interchange Program (TIP) The Washington State Therapeutic Interchange Program (TIP) allows a pharmacist to substitute a “therapeutic alternative” drug for a nonpreferred brand-name drug in certain cases. Therapeutic alternatives are drugs that are chemically different from your prescribed drug but provide the same therapeutic benefit. You can find out if your drug is affected by TIP by checking the UMP Preferred Drug List at www.hca.wa.gov/ump/find-drugs or by calling Washington State Rx Services at 1-[PHONE REDACTED]. Not all nonpreferred drugs are affected by TIP. 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 PPS.  Your prescribing provider allows substitution on your prescription. If you do not want your drug to be changed, simply ask the pharmacist to fill the prescription as written. Regardless of whether you or your prescriber ask the pharmacist to “dispense as written,” if you get the nonpreferred drug, you will pay the applicable cost-share for the nonpreferred brand- name drug. How does TIP work at the network mail-order pharmacy? 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 for the nonpreferred brand-name drug. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 87 Travel overrides for prescription drugs You may request a travel override to get an extra supply of medications 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 United States:  Within the United States, you may request up to a 90-day supply per prescription, or as allowed under that prescription.  Outside the United States, you may request up to a 6-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 drugs past the time when your enrollment in the plan ends.  You will pay applicable charges (deductible and coinsurance) for each extra supply received. To request a travel override, call Washington State Rx Services at 1-[PHONE REDACTED]. Refill too soon The plan will not cover a refill until 84% of the previous 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 destroyed, lost, expired, 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. What can I do if coverage is denied? TIP: If your prescription claims are denied by the pharmacy due to plan eligibility issues or termination of coverage, contact:  Employees—Your employer’s personnel, payroll, or benefits office.  All other members—PEBB Benefits Services at 1-[PHONE REDACTED]. If a network pharmacy (including a mail-order or specialty pharmacy) tells you that preauthorization is required, coverage is denied, or quantities are limited, you, your pharmacist, or your prescribing physician may contact Washington State Rx Services at 1-[PHONE REDACTED] to request a coverage review or preauthorization. If Washington State Rx Services denies the coverage request, you have the right to submit an appeal. See instructions for appealing on pages 118–121. If your provider thinks that you need the medication immediately, he or she 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. Washington State Rx Services will decide regarding coverage of the drug within 72 hours of the request. In this case, you may choose to purchase a three-day supply at your own expense. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 88 Guidelines for drugs UMP does not cover Drugs not covered under the plan include but are not limited to:  Drugs that are not medically necessary (see definition on page 165).  Experimental or investigational drugs  Dietary supplements, vitamins, minerals, herbal supplements, and medical foods  Homeopathic drugs, including FDA-approved prescription products  Dental preparations, such as rinses and pastes  Over-the-counter drugs or prescription drugs that have a nonprescription alternative (see page 168), except for the drugs specified under “Guidelines for drugs covered” on page 81. Note: Prescription drugs with a nonprescription alternative—including an over-the-counter alternative having similar safety, efficacy, and ingredients—are not covered.  Drugs under a REMS program required by the Food and Drug Administration (FDA) when prescribed outside REMS guidelines; see page 83 for details.  Drug costs covered by other insurance. See page 107 for coordination with other plans. The plan also does not cover drugs to treat conditions that are not covered under the medical benefit. These include, but aren’t limited to, drugs for:  Cosmetic purposes  Fertility or infertility  Obesity (or weight loss)  Sexual dysfunction ALERT! Drugs classified as proton pump inhibitors (PPIs) and nasal sprays for treatment of allergy have over-the-counter alternatives and are not covered for adults age 18 and over. The plan does cover PPIs or nasal sprays for children under age 18 with a prescription. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 89 Prescription drug contacts Washington State Rx Services 1-[PHONE REDACTED] 7:30 a.m. to 5:30 p.m. Pacific Time, Monday through Friday Postal Prescription Services (PPS) Mailing a prescription order Postal Prescription Services PO Box 2718 Portland, OR 97208-2718 1-[PHONE REDACTED] Fax: 1-[PHONE REDACTED] (providers only) Contact PPS for how to place a mail order. Specialty Pharmacy (Ardon Health) (see page 85) 1-[PHONE REDACTED] Fax: 1-[PHONE REDACTED] (providers only) To request preauthorization for prescription drugs (providers only) 1-[PHONE REDACTED] Fax: 1-[PHONE REDACTED] Submit paper claims Find claim forms at www.hca.wa.gov/ump-forms See instructions on pages 111–112. Washington State Rx Services Attn: Pharmacy Claims PO Box 40168 Portland, OR 97240-0168 Fax: 1-[PHONE REDACTED] Send appeals/complaints for prescription drugs Washington State Rx Services Attn: Appeals PO Box 40168 Portland, OR 97240-0168 Fax: 1-[PHONE REDACTED] Online services  Find a network pharmacy  Find a Choice90 pharmacy  Find a network vaccination pharmacy  Refill mail-order prescriptions  Get estimates of drug costs at retail versus mail order  Review the UMP Preferred Drug List tier levels, covered or not, quantity limits, preauthorization coverage criteria, whether subject to TIP. www.hca.wa.gov/ump-drugs-cdhp [end of pres drugs] ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 90 Limits on plan coverage If you receive a service that is not medically necessary, is experimental or investigational, or is listed as an exclusion in the “What the plan doesn’t cover” section on pages 94–101, you are responsible for paying all associated charges. Preauthorizing medical services ALERT! This section does not apply to prescription drugs. See page 83 for how to request preauthorization of covered drugs under the prescription drug benefit. Some medical services and supplies require preauthorization by Uniform Medical Plan to determine whether the service or supply meets the plan’s medical necessity criteria in order 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 (see definition on pages 165). A change after the plan has approved a preauthorization request—such as but not limited to a change of provider, or different/additional services—requires a new preauthorization request be submitted to and approved by the plan. Your preauthorization role ALERT! Excluded, experimental, and investigational services do not require a preauthorization because they are not covered by the plan. To confirm whether your procedure is a covered benefit, call UMP Customer Service. To be covered, some services—including but not limited to Applied Behavior Analysis (ABA) Therapy (page 39) and bariatric surgery (page 40)—must be preauthorized before services are received.  A preferred or participating provider may be required to request preauthorization before performing services.  An out-of-network provider is not required to obtain preauthorization in advance of some services because they do not have a contract with Regence. A preauthorization may still be required. Because your provider has the clinical details and technical billing information needed for the preauthorization request, it is to your benefit that they submit a preauthorization request on your behalf. You are encouraged to request that an out-of-network provider preauthorize certain services on your behalf to determine medical necessity prior to the services being rendered. Call UMP Customer Service at 1-[PHONE REDACTED] to ask if a service requires preauthorization and how to submit a request. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 91 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 “What the plan doesn’t cover” section on pages 94–101). ALERT! For how to appeal denial of a preauthorization request before receiving services see pages 118–121. Where can I find the list of services requiring preauthorization or notification? For a list of services and treatments requiring preauthorization or plan notification:  Visit www.hca.wa.gov/ump-preauth-cdhp.  Call UMP Customer Service at 1-[PHONE REDACTED].  Request a printed list by calling UMP Customer Service at 1-[PHONE REDACTED]. ALERT! The UMP preauthorization list is updated throughout the year. You may view the current list of services that require preauthorization at www.hca.wa.gov/ump-preauth-cdhp or call Customer Service at 1-[PHONE REDACTED] to determine if services require preauthorization or notification. The fact that a service doesn’t require preauthorization or notification does not guarantee coverage. Notification for facility admissions Your provider must notify the plan upon your admission to a facility for services requiring notification as listed at www.hca.wa.gov/ump-preauth-cdhp, or call UMP Customer Service at 1-[PHONE REDACTED]. Facility admissions for which the plan is not notified may not be covered. Notification is usually done by the facility at the time you are admitted. Notification is not the same as preauthorization, and many services require both. What is the difference between preauthorization and notification? ALERT! Many services, including but not limited to inpatient services, require both preauthorization and notification. Call 1-[PHONE REDACTED] or talk to your provider if you have questions about services needing preauthorization or notification by the plan. “Preauthorization” is when your provider sends a request for coverage of a service on the Uniform Medical Plan preauthorization list at www.hca.wa.gov/ump-preauth-cdhp, and the plan sends ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 92 either an approval or denial of coverage. If services that require preauthorization are not approved before being provided, coverage may be denied. The plan does not approve or deny preauthorization for services that are not on the Uniform Medical Plan preauthorization list. Preauthorization is usually requested by the provider performing the services. “Notification” means that your provider must contact the plan to let us know when you receive services. Notification is usually done by the facility at the time you receive these services. ALERT! If the plan denies preauthorization and you receive those services anyway, you (the patient) are responsible for the provider’s entire billed charge. How long does the plan have to make a decision? You will be notified in writing within 15 calendar days of the plan’s receipt of the preauthorization request whether the request has been approved, denied, or if more information is needed to make a determination. If additional information is requested:  You are allowed up to 45 calendar days of the date on the letter to submit the information requested.  You will be notified in writing of the determination within 15 calendar days of either the plan’s receipt of the additional information or the end of the 45-day period if no additional information is received. If you or your physician believes that waiting for a determination under the standard time frame could place your life, health, or ability to regain maximum function in serious jeopardy, your physician should notify the plan by phone or fax as a shorter time limit may apply. General information from customer service is not a guarantee that a service is covered For services not requiring preauthorization, you may call 1-[PHONE REDACTED] 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, the plan cannot guarantee that your service will be covered or give 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 developed by independent organizations (not affiliated with the plan). Each code describes a particular 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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 93 Case management Case management is a free service offered by the plan to help enrollees with serious or complex health care needs coordinate their care. A nurse case manager helps you find health care providers and services appropriate for your treatment. When preauthorization is requested for a condition that may benefit from case management services, or when the plan receives a claim for services indicating complex health needs, you will be contacted by case management staff to discuss your options. This free service helps you:  Ensure you get the most out of your UMP CDHP benefits.  Find preferred providers, facilities, and other resources to assist in the coordination of your medical care.  Keep your health care costs down negotiating rates when no preferred providers are available). You, your family, or any provider or facility (such as a hospital) involved in your treatment may call 1-[PHONE REDACTED] to request evaluation and consideration of case management services. Alternative benefits Alternative benefits means benefits for services or supplies that are not otherwise covered as specified in this certificate of coverage, but for which the plan may approve coverage after case management evaluation. The plan may cover alternative benefits through case management if the plan determines that alternative benefits are medically necessary and will result in overall reduced covered costs and improved quality of care. Before alternative benefits will be covered, the plan, you (or your legal representative), and, if required by the plan, your physician or other provider must enter into a written agreement to 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 as specified in the written agreement. The rest of this certificate of coverage remains in force. 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. Case management may include assigning a primary physician (MD or DO) to coordinate care if you do not already have one, and assigning a single hospital and pharmacy to provide covered services or medications. The plan may deny payment for any services and providers or facilities not included in your required case management plan, except medically necessary emergency services. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 94 What the plan doesn’t cover Expenses not covered, exclusions, and limitations TIP: If you have any questions about services not covered by the plan, call Customer Service at 1-[PHONE REDACTED]. You may pay all costs associated with a noncovered service. This plan covers only the services and conditions specifically identified in this certificate of coverage. Unless a service or condition fits into one of the specific benefit definitions, it is not covered. 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. Air ambulance, if ground ambulance would serve the same purpose. 2. Autologous blood and platelet-rich plasma injections. 3. Bariatric surgery under the following circumstances:  BMI 30 to 34 without Type II Diabetes Mellitus.  BMI less than 30.  Patients younger than 18 years of age. 4. Bone growth stimulators for:  Nonunion of skull, vertebrae or tumor related.  Ultrasonic stimulator – delayed fractures and concurrent use with other noninvasive stimulator. 5. Bone morphogenetic protein-7 for use in lumbar fusion. 6. Bronchial thermoplasty for asthma. 7. Cardiac nuclear imaging for:  patients: Does not apply to pre-operative evaluation of patients undergoing high-risk non-cardiac surgery or patients who have undergone cardiac transplant.  Patients with known coronary artery disease and no changes in 8. Carotid artery stenting of intracranial arteries. 9. Carotid intima media thickness testing. 10. Complications arising directly from services that would not be covered by the plan during the current plan year. The plan will, however, cover complications arising directly from services that a PEBB plan paid for you in the past. 11. Computed tomographic colonography (CTC) (also called a virtual colonoscopy) for routine colorectal cancer screening. 12. Corneal refractive therapy (CRT), also called Orthokeratology. 13. Coronary or cardiac artery calcium scoring. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 95 14. Coronary artery tomographic angiography for:  Patients who are or at high risk of coronary artery disease;  CCTA used for coronary artery disease investigation outside of the emergency department or hospital setting; and  CT scanners that use lower than 64-slice technology. 15. Cosmetic services or supplies, including drugs and pharmaceuticals. However, the plan does cover:  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. 16. Court-ordered care, unless determined by the plan to be medically necessary and otherwise covered. 17. Custodial care (see definition on page 159). 18. Deep brain stimulation and transcranial direct current stimulation when used as nonpharmacological treatments for treatment-resistant depression. 19. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services listed on pages 43–44. 20. Dietary or food supplements, including but not limited to:  Herbal supplements, dietary supplements, medical foods, and homeopathic drugs.  Infant or adult dietary formulas (see “Exceptions covered” by the plan on page 81).  Medical foods.  Minerals.  Prescription or over-the-counter vitamins (see exceptions on page 81). 21. Dietary programs. 22. Discography for patients with chronic low back pain and lumbar degenerative disc disease. This does not apply to patients with the following conditions:  Radiculopathy  Functional neurologic deficits (motor weakness or EMG findings of radiculopathy)  Spondylolisthesis greater than Grade 1  Isthmic spondylolysis  Primary neurogenic claudication associated with stenosis  Fracture, tumor, infection, inflammatory disease  Degenerative disease associated with significant deformity 23. Drugs or medicines not covered by the plan as described in the “Your prescription drug benefit” section, pages 75–89. 24. Drugs or medicines obtained through mail-order pharmacies located outside the U.S. 25. Educational programs, except as described under:  “Diabetes Control Program” on page 45.  “Diabetes education” on page 46.  “Diabetes Prevention Program” on page 46. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 96  “Tobacco cessation services” on page 71. 26. Electrical neural stimulation (ENS), which includes transcutaneous electrical nerve stimulation (TENS) Units. 27. Email consultations or e-visits. 28. Equipment not primarily intended to improve a medical condition or injury, including but not limited to:  Air conditioners or air purifying systems  Arch supports  Communication aids  Elevators  Exercise equipment  Massage devices  Overbed tables  Residential accessibility modifications  Sanitary supplies  Telephone alert systems  Vision aids  Whirlpools, portable whirlpool pumps, or sauna baths 29. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals. 30. Experimental or investigational services, supplies, or drugs. 31. Extracorporeal shock wave therapy for musculoskeletal conditions. 32. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy, photokeratectomy, or LASIK surgery. 33. Facet neurotomy for the thoracic spine or headache. 34. Fecal microbiota transplantation for treatment of inflammatory bowel disease. 35. Foot care not related to diabetes: cutting of toenails; treatment for diagnosed corns and calluses; or any other maintenance-related foot care. 36. Functional neuroimaging for primary degenerative dementia or mild cognitive impairment. 37. Headaches, chronic migraines and tension (see page 51): Treatment of chronic tension-type headache with Botox. Treatment of chronic migraine or chronic tension-type headache with acupuncture, massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (example: chiropractic services). 38. Hip resurfacing. 39. Hip surgery for treatment of Femoroacetabular impingement (FAI) 40. Home health care, except as described on page 53. The plan does not cover the following services:  Private duty or continuous care in the member’s home.  Housekeeping or meal services.  Care in any nursing home or convalescent facility.  Care provided by or for a member of the patient’s family. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 97  Any other services provided in the home that do not meet the definition of skilled home health care as described on page 53 or not specifically listed as covered in this certificate of coverage. 41. Hospital inpatient charges for non-essential services or features such as:  Admissions solely for diagnostic procedures that could be performed on an outpatient basis.  Reserved beds.  Services and devices that are not medically necessary (see definition of “Medically necessary services, supplies, drugs, or interventions” on page 165).  Personal or convenience items. 42. Hyaluronic acid injections (viscosupplementation) for treatment of pain in any joint other than the knee. 43. Hyperbaric oxygen therapy treatment for:  Brain injury including traumatic (TBI) and chronic brain injury  Cerebral palsy  Multiple sclerosis  Migraine or cluster headaches  Acute and chronic sensorineural hearing loss  Thermal burns  Non-healing venous, arterial and pressure ulcers 44. Imaging of the sinus for rhinosinusitis using X-ray or ultrasound. 45. Immunizations for the purpose of travel or employment, even if recommended by the Centers for Disease Control and Prevention. 46. Implantable drug delivery systems (infusion pumps or IDDS) for chronic non-cancer pain. 47. In vitro fertilization and all related services and supplies, including all procedures involving selection of embryo for implantation. 48. Incarceration: Services and supplies provided while confined in a prison or jail. 49. 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 selective fetal reduction), or visits for infertility. 50. Knee arthroscopy for osteoarthritis of the knee. 51. Late fees, finance charges, or collections charges. 52. Learning disabilities treatment after diagnosis, except as covered under the following benefits:  “Applied Behavior Analysis (ABA) Therapy” on page 39.  “Physical, occupational, speech, and neurodevelopmental therapy” on page 65; or  When part of treating a mental health disorder as described on page 61. 53. Lumbar artificial disc replacement. 54. Lumbar fusion for degenerative disc disease. 55. Magnetic resonance imaging, upright (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading.” 56. Maintenance care (see definition on page 165). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 98 57. Manipulations of the spine or extremities, except as described under “Spinal and extremity manipulations” on page 68. 58. Marriage, family, or other counseling or training services, except as provided to treat an individual member’s mental, or personality disorder. 59. Massage therapy services when the massage therapist is not a preferred provider. 60. Microprocessor-controlled lower limb prostheses (MCP) for the feet and ankle. 61. Migraine headaches (chronic migraines and tension) (see page 51): Treatment of chronic tension-type headache with Botox. Treatment of chronic migraine or chronic tension-type headache with acupuncture, massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (example: chiropractic services). 62. Missed appointment charges. 63. Noncovered provider types: Services delivered by providers not listed as a covered provider type (see page 13). 64. Novocure (tumor treating fields). 65. Orthoptic therapy except for the diagnosis of strabismus, a muscle disorder of the eye. 66. Orthotics, foot or shoe: Items such as shoe inserts and other shoe modifications, except as specified on page 48. 67. Osteochondral allograft/autograft transplantation for joints other than the knee. 68. Out-of-network provider charges that are above the allowed amount. 69. Over-the-counter contraceptive supplies intended for use by males. 70. Pharmacogenomics testing for depression, mood disorders, anxiety, ADHD, and substance use disorder. 71. Positron emission tomography (PET) scans for routine surveillance of 72. Postage and handling related to medical services and supplies. 73. Prescription drug charges over the allowed amount, regardless of where purchased. 74. Prescription drugs that require preauthorization unless the request is:  Supported by medical justification from a clinician other than the patient or member of the patient’s family.  Approved by the plan. 75. Proton beam therapy for conditions other than:  Ocular cancers.  Pediatric cancers medulloblastoma, retinoblastoma, Ewing’s sarcoma).  Central nervous system tumors.  Other non-metastatic cancers with the following conditions: patient has had prior radiation in the expected treatment field with contraindication to all other forms of therapy, and at agency discretion. 76. Provider administrative fees—Any charges for completing forms, copying records, or finance charges, except for records requested by the plan to perform retrospective (postpayment) review. 77. Recreation therapy. 78. Replacement of lost, stolen, or damaged durable medical equipment. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 99 79. Replacement of medications that are any of the following:  Confiscated or seized by Customs or other authorities  Contaminated  Damaged  Expired  Lost or stolen  Ruined 80. Residential treatment programs that are not licensed to provide residential treatment, solely to persons: Requiring residential chemical dependency treatment, or diagnosed with a mental health condition and requiring residential treatment. 81. Reversal of voluntary sterilization (vasectomy, tubal ligation, or similar procedures). 82. 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. 83. Separate charges for records or reports. 84. Service animals: Any expenses related to a service animal. 85. Services covered by other insurance, including but not limited to motor vehicle, homeowner’s, renter’s, commercial premises, personal injury protection (PIP), medical payments (Med-Pay), automobile no-fault, general no-fault, underinsured or uninsured motorist coverage. See page 108 for more about how this works. 86. Services delivered by providers or facilities delivering services outside the scope of their licenses. 87. Services or supplies:  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.  For which no charge is made, or for which a charge would not have been made if you had no health care coverage.  Provided by a family member or any household member.  Provided by a resident physician or intern acting in that capacity.  That are solely for comfort.  For which you are not obligated to pay. 88. Services performed during a noncovered service. 89. 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. 90. Services supplemental to digital mammography. When performed supplementary to digital mammography for screening purposes for women with or without dense breasts, the following procedures are not covered:  Non-high-risk patients: • Magnetic Resonance Imaging (MRI) ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 100 • Hand Held Ultrasound (HHUS) • Automated Breast Ultrasound (ABUS)  High-risk patients: • Hand Held Ultrasound (HHUS) • Automated Breast Ultrasound (ABUS) 91. Services, supplies, or drugs related to occupational injury or illness (see page 168). 92. Services, supplies, or items that require preauthorization unless the request is:  Supported by medical justification from a clinician other than the patient or member of the patient’s family.  Approved by the plan. 93. Skilled nursing facility services or confinement:  When primary use of the facility is as a place of residence.  When treatment is primarily custodial. 94. Sleep apnea diagnosis and treatment as indicated in referenced Medicare national and local coverage determinations. 95. Spinal cord stimulator for chronic neuropathic pain. 96. Spinal injections, therapeutic (except as described under “Spinal injections” on page 68) of the following types:  Medial branch nerve block  Intradiscal  Facet injections 97. Spinal surgical procedures known as vertebroplasty, kyphoplasty, and sacroplasty. 98. Stereotactic radiation surgery and stereotactic body radiation therapy. 99. Telephone or virtual consultations or appointments, except as described under “Telemedicine services” on page 69. 100. Travel, transportation, and lodging expenses, except as specified for ambulance services covered by the plan (see page 39), or approved travel and lodging expenses related to the Center of Excellence (COE) Program for knee and hip replacement (see page 56). 101. Ultrasounds during pregnancy, except as described on page 63. 102. Upright magnetic resonance imaging (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading.” 103. Vagal nerve stimulation for the treatment of depression. 104. Vitamin D screening and testing is not covered as part of routine screening. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 101 105. 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 associated with non-surgical or surgical services are not covered. Such treatment is not covered even if prescribed by a provider, except as covered under “Diabetes Control Program (see page 45),” “Diabetes Prevention Program” (see page 46), “Nutrition counseling and therapy” (see page 62), or “Preventive care” on 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. 106. Workers’ compensation: When a claim for workers’ compensation is accepted as being caused by a work-related injury or illness, all services related to that injury or illness are not covered, even if some services are denied by workers’ compensation. If you have questions about whether a certain service or supply is covered, call Customer Service at 1-[PHONE REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 102 If you have other high-deductible health plan medical coverage 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 “Who pays first?” on page 103 determine which plan pays first (“primary payer”) and which pays second (“secondary payer”). See page 105 for a description of how UMP CDHP coordinates benefits when it pays second. Uniform Medical Plan processes claims differently depending on whether it pays first or second. The differences are described in the next several pages. TIP: If you have other health coverage, it is important that you let all of your providers know, including the pharmacies where you get your prescription drugs. Whom do I inform if I have other coverage? If you or your dependents have other insurance, you must let Regence BlueShield and Washington State Rx Services know so claims are paid correctly. To do this, you must complete and submit a separate form for medical services and prescription drugs. See the table below for how to find the forms. Medical services Prescription drugs Phone Call 1-[PHONE REDACTED] (TTY: 711) to request a form. 1-[PHONE REDACTED] (TRS: 711) Online Go to www.hca.wa.gov/ump-forms. Or log in to regence.com  In the Search box, type Coordination of Benefits.  Choose “UMP Multiple Coverage Inquiry– Coordination of Benefits.”  You may fill out and submit online, or print out and mail or fax in. Go to www.hca.wa.gov/ump-forms and select “Prescription Drug Multiple Coverage Inquiry Form.” Or submit through your pharmacy account at www.hca.wa.gov/ump/find-drugs. Fax 1-[PHONE REDACTED] [PHONE REDACTED] Mail Regence BlueShield Attn: UMP Claims PO Box 91015 MS BU386 Seattle, WA 98111-9115 Washington State Rx Services PO Box 40168 Portland, OR 97240-0168 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 103 Each person claiming payment for benefits under UMP CDHP is required to give Regence and Washington State Rx Services any facts needed to apply these coordination of benefits rules and determine the correct benefits payable. If your coverage under other plans changes, please call Customer Service right away. Who pays first? Note: If you cannot determine which plan pays first, call Customer Service at 1-[PHONE REDACTED]. When UMP CDHP coordinates benefits with other group 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: 1. Any plan that does not coordinate benefits. 2. The plan that covers the patient as a subscriber, not a dependent. 3. The plan that covers the patient (or their spouse or state-registered domestic partner) as an active employee pays before a plan that covers the patient as a retired employee. 4. The plan that has covered the patient (or their spouse or state-registered domestic partner) as a subscriber the longest, if there are two plans and numbers 1–3 in the list above do not determine which plan pays first. 5. A plan covering the patient as an employee, subscriber, retiree, or the dependent of such a patient will pay before a COBRA or a state right of continuation plan. For dependent children If a dependent child has coverage through his or her employment, the child’s coverage pays before the parent’s. Dependent children of married parents The plan of the parent whose birth month and day 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 covered either parent longer is primary. Exception for newborn children: Under Washington State law, the mother’s health plan must provide newborns with coverage that is no less than 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 life, unless there is other primary coverage. Dependent children of legally separated or divorced parents When there is no court order that specifies which parent is responsible for providing health insurance coverage, the following standard coordination of benefits 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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 104 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 orders 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 mention responsibility for health coverage or health care expenses, the plan of the parent assuming financial responsibility is the primary payer. In some cases, a court order determines payment for health care expenses and standard coordination of benefits rules may not apply. In these cases, you must provide UMP CDHP with copies of legal documents needed to decide 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 a grandparent or other guardian), use the birthday rule to determine which plan pays first. If none of the preceding rules determines who pays first, then each plan covers half of the allowed expenses. When UMP CDHP pays first If you have UMP CDHP as your primary payer (see definition on page 172), UMP CDHP pays the normal benefit as described elsewhere in this book. If you are enrolled in another high-deductible health plan (HDHP) (see definition on page 163) and have questions about how that plan coordinates benefits, you should contact that plan. If you are unsure about which plan is primary, contact UMP Customer Service at 1-[PHONE REDACTED]. Note: If you or your dependents are enrolled in UMP CDHP and want to enroll in another health plan, you and your dependents can only enroll in other high-deductible health plans. The second high-deductible health plan cannot include an HSA. You cannot be enrolled in:  Medicare Part A or Part B.  Medicaid (called Apple Health in Washington).  Another comprehensive medical plan, such as a spouse or state-registered domestic partner’s plan.  A Voluntary Employees’ Beneficiary Association Medical Expense Plan (VEBA MEP) account, unless you convert it to a limited VEBA MEP.  TRICARE.  A medical flexible spending arrangement (FSA) or health reimbursement arrangement (HRA). This also applies if your spouse has a medical FSA, even if you are not covering your ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 105 spouse on UMP CDHP. This does not apply if the medical FSA or HRA is a limited purpose account, or for a post-deductible medical FSA. Other exclusions apply. Check IRS Publication 969–Health Savings Accounts and Other Tax Favored Health Plans at www.irs.gov, contact your tax advisor, or call Health Equity at 1-[PHONE REDACTED] to verify whether you qualify. What happens when UMP CDHP is supposed to pay first, but another HDHP actually paid first? If another HDHP pays first on claims where UMP CDHP should have paid first:  UMP CDHP may pay the other plan the amount UMP CDHP should have paid.  Amounts paid by UMP CDHP to the other plan are considered benefits paid by UMP CDHP. How UMP CDHP coordinates benefits when it pays second UMP CDHP uses a type of coordination of benefits called nonduplication of benefits (see examples on page 105). When UMP CDHP pays second to another group HDHP that covers you, we will pay only an amount needed to bring the total benefit up to the amount UMP CDHP would have paid if you did not have another plan. The intent of this type of coordination of benefits is to maintain the level of benefits available through the UMP CDHP plan. The nonduplication of benefits type of coordination is not designed to pay your covered expenses in full. How much will I pay when UMP CDHP pays second? When you see providers preferred under UMP CDHP (see definition on page 11), you will owe only the balance of the UMP CDHP allowed amount after your primary plan and UMP CDHP pay benefits for covered services. Your cost will usually be higher if you see out-of-network providers. See “Sample payments to different provider types” on page 13 for examples. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 106 The examples in the table below assume that you have met your deductible. Preferred Provider Charge UMP CDHP Allowed Amount UMP CDHP Normal Benefit Other HDHP UMP CDHP Pays You Pay Your Provider UMP CDHP is primary, other plan is secondary EXAMPLE 1: When UMP CDHP pays first (or is the only plan) $200 $100 $85 (85% of $100) N/A $85 $15 UMP CDHP is secondary, other plan is primary EXAMPLE 2: The other plan pays less than the normal UMP CDHP benefit $200 $100 $85 $80 $5 $15 EXAMPLE 3: The other plan pays as much (or more than) the normal UMP CDHP benefit $200 $100 $85 $85 $0 $15 Please contact UMP Customer Service at 1-[PHONE REDACTED] for help with any questions when you or a family member is covered by more than one plan. Submit secondary claims All health plans have deadlines for filing a claim, called a “timely filing” requirement. The timely filing deadline for UMP CDHP is 12 months from the date of service. If a claim is not submitted within a plan’s timely filing deadline, the plan will deny it. If your primary plan delays payment on a claim, the claim should be submitted to Uniform Medical Plan within the timely filing deadline to prevent denial of the claim. UMP will try to contact your primary plan for their benefit payment information or may estimate it in order to provide you with timely processing of your secondary benefit. Adjustments may be made when the primary plan finally 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 pages 109–112 for how to submit claims. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 107 How are diabetes care supplies covered when UMP CDHP pays second? UMP CDHP 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 CDHP. If your pharmacy does, you don’t need to do anything further. If not, you will need to send a claim to Washington State Rx Services for secondary payment. See pages 111–112 for instructions.  If you get your supplies from a diabetic care supplier, the primary plan may process the claim as medical. In this case, you will need to send your Explanation of Benefits and a claim form to Washington State Rx Services for secondary payment; see pages 111–112 for instructions. Note: Nonduplication of benefits applies to these claims (see “How UMP CDHP coordinates benefits when it pays second” on page 105), which means that UMP CDHP may pay nothing after your primary plan pays. See “Diabetes care supplies” on page 45 for more about this benefit. ALERT! A secondary claim for diabetes care supplies submitted to Regence BlueShield will be denied. The claim must be submitted to Washington State Rx Services. How does coordination of benefits work with prescription drugs? Some of the limits and restrictions to prescription drug coverage listed on pages 80–85 will apply when UMP CDHP pays second to another plan. See “Submitting a claim for prescription drugs” beginning on page 111 for how to submit your prescription drug claim. Note: If UMP CDHP pays second to another HDHP, nonduplication of benefits applies (see “How UMP CDHP coordinates benefits when it pays second” on page 105). This means that UMP CDHP may pay nothing after your primary plan pays. Using network pharmacies when UMP CDHP is your secondary coverage If you have primary coverage through another HDHP that covers prescription drugs, show both plan cards to the pharmacy and make sure they know which plan pays first. 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 CDHP is secondary If your primary HDHP also uses PPS as the plan’s network mail-order pharmacy, PPS can process payments for both plans and charge only what’s left. Make sure that PPS has the information for both plans and knows which plan is primary. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 108 However, if your primary HDHP uses a different mail-order pharmacy, you will have to use your primary plan’s mail order, then submit a paper claim for payment by UMP CDHP. See “Submitting a claim for prescription drugs” on page 111 for how to do this. Does UMP coordinate with occupational injury or illness (workers’ compensation) claims? No. When a claim for workers’ compensation is accepted as being caused by a work-related injury or illness, all services related to that injury or illness are not covered, even if some services are denied by workers’ compensation. . 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 CDHP will pay for covered services under the terms of this certificate of coverage. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 109 Billing & payment: filing a claim Submitting a claim for medical services When UMP CDHP is your primary insurance and your provider is preferred, you don’t 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, log in to your account at regence.com or call Customer Service at 1-[PHONE REDACTED]. TIP: In the following section, Uniform Medical Plan refers to the administrative functions for submitting claims for UMP CDHP. Medical claims are handled by Regence BlueShield, and claims involving prescription drugs are handled by Washington State Rx Services. When do I need to submit a claim? You may need to submit a claim to Uniform Medical Plan for payment if:  You receive services from an out-of-network provider.  You have other HDHP insurance that pays first and UMP CDHP is secondary. Dependents with other HDHP coverage see pages 102–108. Out-of-network providers may submit a claim on your behalf; ask the provider. How do I submit a claim? TIP: If you purchase contact lenses or eyeglasses from an out-of-network provider that doesn’t bill your plan, you will need to submit a claim for reimbursement. You can download the Vision Claim Form at www.hca.wa.gov/ump-forms or call Customer Service for a copy. To submit a claim yourself, you’ll need to obtain and mail the following documents: 1. Medical Claim Form—You can find the form online at www.hca.wa.gov/ump-forms or you may request a form by calling Customer Service at 1-[PHONE REDACTED]. 2. 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:  Patient’s name and plan ID number, including the alpha prefix (three letters before ID number).  Description of the injury or illness.  Date and type of service.  Provider’s name, address, and phone number.  For ambulance claims, please also include the zip code of where the patient was picked up and where he or she was taken. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 110 3. If UMP CDHP 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 Uniform Medical Plan, unless the primary plan’s processing of the claim is delayed. Claims not submitted to Uniform Medical Plan within 12 months of the date of service will not be paid. If we have to request additional information, the processing of your claim may be delayed. Reimbursement for services received from an out-of-network provider may be sent to the provider or to you in the form of a check listing both you and the provider as payees. Be sure to make copies of your documents for your records. Mail both the claim form and the provider’s claim document (or bill) to: Regence BlueShield PO Box PO Box 1106 Lewiston, ID 83501-1106 Call Customer Service at 1-[PHONE REDACTED] if you have a question about the processing of your claim. 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 filing” deadline. The plan will not pay claims submitted more than 12 months after the date of service. See “Submit secondary claims on page 106 for how this works when you have other coverage that pays first. For information about submitting claims for services outside of the United States, see www.hca.wa.gov/ump/ump-administration/access-coverage-while-traveling or call UMP Customer Service at 1-[PHONE REDACTED]. You may have to pay services upfront and submit a claim for reimbursement. If you or a family member has other HDHP coverage, see “If you have other medical coverage” on pages 102–108 for information on how the plan coordinates benefits with other plans. Claims reimbursement Most of the time, the plan will pay preferred 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 136) the plan may pay the custodial parent or legal guardian of the child. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 111 Claims determinations You will be notified 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. Notification will include an explanation why an extension is necessary and when the plan expects to take action 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 as well as why it is needed. If the plan is asking you for additional information, you will be allowed at least 45 days to provide it. If the plan doesn’t receive the information requested within the time allowed, the claim will be denied. Submitting a claim for prescription drugs ALERT! See “Products covered under the preventive care benefit” on page 82 for coverage of products such as contraceptive drugs, tobacco cessation drugs, nicotine replacement, or over-the- counter products covered as preventive. You may need to submit your own prescription drug claim to Washington State Rx Services for reimbursement if you:  Purchase drugs at a non-network pharmacy.  Fail to show your ID card at a network pharmacy.  Get a prescription from a mail-order or internet pharmacy other than PPS, the plan’s network mail-order pharmacy.  Have other prescription coverage that pays first and UMP CDHP is secondary. TIP: If you get a vaccine from an out-of-network provider, make sure that you submit your claim to Regence BlueShield as a medical claim (see page 109). Member-submitted vaccine claims sent to Washington State Rx Services will be denied. Prescription drug claim forms are available online at www.hca.wa.gov/ump-forms or by calling Washington State Rx Services at 1-[PHONE REDACTED]. Send the completed claim form, along with your pharmacy receipt(s), to: Washington State Rx Services Attn: Pharmacy Claims PO Box 40168 Portland, OR 97240-0168 Fax 1-[PHONE REDACTED] It’s a good idea to keep copies of all your paperwork for your records. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 112 When you submit a prescription drug claim to Washington State Rx Services, 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 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, based on coinsurance; see page 76.  If your claim exceeds the quantity limit allowed by the plan or the maximum days’ supply, the plan will pay only for the amount of the drug up to the quantity limit or maximum days’ supply.  If you receive a refill before 84% of the last supply you received should have been taken, the plan will not pay for it. This is called a “refill too soon” (see page 87). You must submit prescription drug claims within 12 months of purchase. Claims for prescription drugs submitted more than 12 months after purchase will not be paid. ALERT! If you do not show your plan ID card when purchasing a prescription at a Washington State Rx Services’ network pharmacy, you will have to pay the full cash price and submit a Prescription Drug Claim Form. You won’t 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 on any document for your plan coverage. The plan may recover any payments or overpayments made as a result 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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 113 What you need to know: your rights and responsibilities To ensure UMP CDHP offers 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:  Be treated with respect.  Be informed by your providers about all appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.  On request, receive information from the plan about:  How new technology is evaluated for inclusion as a covered benefit.  Technologies and treatments currently under review by the Health Technology Clinical Committee (HTCC).  Services and treatments that have completed HTCC review and how that affects coverage by Uniform Medical Plan.  How the plan reimburses providers.  Preauthorization and review requirements.  Providers you select and their qualifications.  The plan and preferred providers.  Your covered expenses, exclusions, reductions, and maximums or limits.  Keep your medical records and personal information confidential as described in Notice of Privacy Practices, available online at www.hca.wa.gov/ump.  Get a second opinion about your provider’s care recommendations.  Make decisions with your providers about your health care.  Make recommendations about member rights and responsibilities.  Have a translator’s assistance, if required, when calling the plan.  Complain about or appeal plan services or decisions, or the care you receive.  Receive:  All covered services and supplies determined to be medically necessary as described in this certificate of coverage, subject to the maximums, limits, exclusions, deductibles, and coinsurance.  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, or religion.  Written explanation from the plan about any request to refund an overpayment. As a plan member, you have the responsibility to:  Understand your plan benefits, including what’s covered, preauthorization and notification requirements, and other information described in this certificate of coverage.  Understand how to contact the plan for additional information and assistance about any covered benefit or information described in this certificate of coverage. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 114  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.  Confirm your provider’s network status before every visit.  Understand how Uniform Medical Plan coverage coordinates with other insurance coverage you may have.  Enroll in Medicare Part A and Part B as soon as you are entitled, if you are retired. You must notify the PEBB program when you enroll.  Comply with requests for information by the date given.  Follow your providers’ instructions about your health care.  Give your providers complete information about your health to get the best possible care.  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 coinsurance and deductibles  Refund 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 questionnaire you receive from the plan in a timely manner to prevent delay in claims payment.  Use preferred providers when available. 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. You can find the following information in this certificate of coverage:  List of covered expenses (pages 27–74).  Benefit exclusions, reductions, and maximums or limits (pages 94–101).  Clear explanation of complaint and appeal procedures (pages 117–123).  Preventive health care benefits that are covered (pages 65–67, page 82).  Definition of terms (pages 157–176).  Process for preauthorization, notification, or review (page 83 and pages 90–92).  Policies regarding drug coverage and how the plan adds and removes drugs from the UMP Preferred Drug List (pages 76 and 80). You can find the following at www.hca.wa.gov/ump, or by calling UMP Customer Service at 1-[PHONE REDACTED]:  Online directory of preferred providers, including both primary care providers and specialists.  The Summary of Benefits and Coverage (SBC) and Uniform Glossary of Terms (UGT).  Notice of privacy practices (includes plan policy for protecting the confidentiality of health information; see “Confidentiality of your health information” on page 115).  Clinical coverage criteria applicable to health care services and supplies that require preauthorization.  When the plan may retroactively deny coverage for preauthorized medical services. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 115  Information on the plan’s care management programs.  Procedures to follow for consulting with providers.  General reimbursement or payment arrangements between the plan and preferred providers.  Description and justification for provider compensation programs, including any incentives or penalties intended to encourage providers to withhold services.  Accreditation information, including measures used to report the plan’s performance such as consumer satisfaction survey results or Health Plan Employer Data and Information Set (HEDIS) measures. The following are available through your medical online account at regence.com or by calling UMP Customer Service at 1-[PHONE REDACTED]:  Medical claims history and medical deductible status.  Online directory of preferred providers, including both primary care providers and specialists. The following are available at www.hca.wa.gov/ump or by calling Washington State Rx Services at 1-[PHONE REDACTED]:  The UMP Preferred Drug List.  Prescription drug claims history and deductible status (through your online prescription drug account).  Clinical coverage criteria applicable to prescription drugs that require preauthorization. You may also call 1-[PHONE REDACTED] 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 online account at regence.com. You may call Washington State Rx Services at 1-[PHONE REDACTED] 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 our Notice of Privacy Practices, available online at www.hca.wa.gov/ump or by calling 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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 116 How to designate an authorized representative TIP: Because of privacy laws, the plan usually cannot share information on appeals or complaints with family members or other persons unless the patient is a minor, or the plan has received written authorization to release personal health information to the other person. In most cases, Uniform Medical Plan must have written authorization to communicate with anyone but the member (patient). 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 age 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:  Talk to Uniform Medical Plan about claims or services.  Share your protected health information.  Communicate with the plan on your behalf regarding an appeal in process. 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 appeals: Call Customer Service at 1-[PHONE REDACTED] or use your regence.com account.  Prescription drug appeals: Call Washington State Rx Services at 1-[PHONE REDACTED], or download the form at www.hca.wa.gov/ump-forms. Send the form to the address on the form. Uniform Medical Plan 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 receiving an outcome of an appeal); and  Who is designated to receive or release the information. Release of information The plan or Washington State Health Care Authority may require you to give information when needed to determine eligibility, administer benefits, or process claims. This could include medical and other records. The plan could deny coverage if you don’t provide the information when requested. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 117 Complaint and appeal procedures TIP: In the following section, Uniform Medical Plan refers to the administrative functions for appeals for UMP CDHP. Medical appeals are handled by Regence BlueShield, appeals involving prescription drugs are handled by Washington State Rx Services, and Premera for the COE Program. See page 58 for Premera’s contact information. For more information: If you have any questions about appeals or complaints, you may contact us at: Medical services Prescription drugs 1-[PHONE REDACTED] Uniform Medical Plan Attn: Correspondence, Intake, and Appeals PO Box 2998 Tacoma, WA 98401-2998 1-[PHONE REDACTED] Washington State Rx Services Attn: Appeals PO Box 40168 Portland, OR 97240-0168 ALERT! Appeals procedures may change during the year if required by federal or Washington State law. What is a complaint or grievance? A complaint (also known as a grievance) is an oral or written complaint submitted by or on behalf of a member regarding:  Dissatisfaction with medical care.  Waiting time for medical services.  Provider or staff attitude or demeanor.  Dissatisfaction with service provided by the health plan. Note: If your issue is regarding denial of payment or nonprovision of medical services, it is an appeal (see “How to file an appeal” on page 118). How to file a complaint or grievance For all complaints or grievances, we recommend calling Customer Service first. Many issues can be resolved with a phone call. If an initial phone call does not resolve your grievance, you may submit your complaint or grievance:  Over the phone: If you want a written response, you must request one.  In writing: By mail, fax, or email (see contact information on page 121). You will receive notice of the action on your written request, complaint, or grievance within 30 calendar days of our receiving it. We will notify you if we need more time to respond. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 118 What is an appeal? An appeal is an oral or written request sent by you or your authorized representative to Regence BlueShield or Washington State Rx Services to reconsider a previous decision about:  Claims payment, processing, or reimbursement for health care services or supplies.  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 retroactive decision to deny coverage based on eligibility; see “Appeals related to eligibility” on page 123.  A preauthorization. The appeals process Internal review ALERT! If your appeal is for an urgent or life-threatening condition, see “Expedited appeals” on page 120. You, your treating provider, or an authorized representative (see “How to designate an authorized representative” on page 116) may request an appeal for you. There are three parts to the appeals process: first-level appeal, second-level appeal, and independent 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 coverage for these services during your appeal. However, if the plan or the Health Care Authority upholds the decision to change, reduce, or terminate coverage, you will be responsible for any payments made by the plan during that period. If you request payment for denied claims or approval of services, supplies, or prescription drugs not yet covered by the plan, we do not have to cover the services, supplies, or prescription drugs while the appeal is under consideration. The plan will consult with a health care professional on appeals where the plan’s decision was based in whole or in part on a medical judgment. That includes decisions based on determinations that a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate. In this case, the plan will consult with a health care professional who has appropriate training and experience in the field of medicine involved. You may send written comments, documents, and any other information when you request an 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. Our review will consider any information submitted to us. How to file an appeal You can send an appeal by telephone, mail, fax, or email (see contact information on page 121). The plan will send confirmation upon receipt of your appeal. You will also receive notice of the ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 119 action on your appeal within 30 calendar days. We will ask your permission if we need more time to respond. Information to provide with an appeal Your appeal will be handled more quickly if you provide all the necessary information when you file it. Please include the following information when requesting an appeal:  The subscriber’s full name (the name of the employee or retiree covered by the plan).  The patient’s full name (the name of the employee, retiree, or family member covered by the plan).  The subscriber’s ID number (starting with a on your ID card).  The name(s) of any providers involved in the issue you are appealing.  The dates when services were provided.  Your mailing address.  Your daytime phone number(s).  A statement of what the issue is and what you are asking for.  A copy of the Explanation of Benefits, if applicable.  Medical records from your provider, if applicable. For cases in which the denial of coverage is based on medical necessity or other clinical reasons, your provider should supply clinically relevant information such as medical records or any other relevant information along with your appeal. Because of the time limits on deciding appeals, getting this information in advance will help us make the most accurate decision on your case. First-level appeals You may request a first-level appeal orally or in writing no more than 180 days after you receive notice of the action leading to the appeal. Although you may request an appeal by phone or in person, putting your appeal in writing will help us make more informed decisions. If you don’t request an appeal within this time period, your appeal will not be reviewed and you will not be able to continue further appeals (second-level and independent review). First-level appeals for medical services are handled by Regence BlueShield and first-level appeals for prescription drugs are handled by Washington State Rx Services. Employees from Regence BlueShield and Washington State Rx Services handling the appeals will not have been involved in the initial decision you are appealing. Claim processing disputes will be reviewed by administrative staff. Appeals that involve issues requiring medical judgment about covering, authorizing, or providing health care will be evaluated by the staff of health care professionals at Regence BlueShield or Washington State Rx Services. ALERT! Deadlines for submitting an appeal are based on the first date you are notified of how a claim processed, usually when the plan sends you an Explanation of Benefits (including services that applied to the deductible or were denied). The plan does not waive deadlines based on untimely billing by your provider. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 120 Second-level appeals If you disagree with the decisions made on your first-level appeal, you may request a second-level appeal. Second-level appeals must be submitted no more than 180 days after the date of the letter responding to your first-level appeal. If you don’t request an appeal within this time period, your appeal will not be reviewed and you will not be able to continue further appeals (independent review). Second-level appeals for medical services are reviewed by Regence BlueShield employees, and second-level appeals for prescription drugs are handled by Washington State Rx Services. Employees from Regence BlueShield and Washington State Rx Services handling the appeals will not have been involved in, or subordinate to anyone involved in, the first-level decision. You, or your authorized representative (see page 116), will be given a reasonable opportunity to provide written testimony for the Regence BlueShield panel or Washington State Rx Services to consider. Expedited appeals Expedited appeals for medical service claims involving urgent care If you or the plan denies coverage for services and 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, ask your provider to request an expedited appeal. An expedited appeal replaces the first- and second-level appeals. Regence BlueShield will decide on your expedited appeal within 72 hours of the request. Your provider must submit all clinically relevant information to the plan by phone or fax at: Phone: 1-[PHONE REDACTED] Fax: 1-[PHONE REDACTED] (providers only) If you disagree with the expedited appeal decision, your provider may request an urgent expedited independent review. Expedited appeals for prescription drugs If you or your provider thinks that you need a medication immediately, you or your provider may request an expedited review by submitting all clinically relevant information to the plan by phone or fax at the numbers listed below. An expedited appeal replaces the first- and second-level appeals. Washington State Rx Services will decide regarding coverage of the drug within 72 hours of the request. In this case, you may choose to purchase a three-day supply at your own expense. If Washington State Rx Services’ decision is to cover the drug, Washington State Rx Services will reimburse you up to the allowed amount minus the member cost-share (coinsurance and deductible if applicable). If Washington State Rx Services decides not to cover the drug (denies the appeal), you are responsible for the full cost of the drug. Phone: 1-[PHONE REDACTED] Fax: 1-[PHONE REDACTED] (for providers only) ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 121 Where to send complaints or appeals ALERT! If you are appealing services related to the Center of Excellence (COE) Program for knee and hip joint replacement surgery, including the plan’s denial of your participation in the Program, see page 121 for where to send your appeal. Do not send it to Regence. You cannot appeal to the plan a decision by your physician that you are not medically appropriate for the Program. We recommend calling first with a complaint or appeal about prescription drugs, since many problems can be resolved quickly over the phone. Medical services: Regence Prescription drugs Washington State Rx Services Phone 1-[PHONE REDACTED] (TTY: 711) Monday–Friday 5 a.m. to 8 p.m. and Saturday 8 a.m. to 4:30 p.m. Pacific Time 1-[PHONE REDACTED] (TRS: 711) Monday through Friday, 7:30 a.m. to 5:30 p.m. Pacific Time Mail Uniform Medical Plan Attn: Correspondence, Intake, and Appeals PO Box 2998 Tacoma, WA 98401-2998 Washington State Rx Services Attn: Appeals PO Box 40168 Portland, OR 97240-0168 Email Secure email through your account at regence.com Fax 1-[PHONE REDACTED] 1-[PHONE REDACTED] Time limits for the plan to decide appeals ALERT! The plan will comply with shorter time limits than those below when required by Washington State law. The time limits below apply to both first- and second-level appeals, and are calculated from when the plan receives the appeal.  The plan will decide on your appeal within 14 days of receipt but may take up to 30 days unless a different time limit applies as explained below. We will request written permission from you or your authorized representative (see page 116) when we need an extension to the 30-day timeline, to get medical records or a second opinion. The time limits below apply to expedited appeals.  When your provider determines a delay could seriously jeopardize your life, health, or ability to regain maximum function, or that delay would cause severe pain that could not be adequately managed without the care or treatment you are appealing, we will decide as soon as possible but always within 72 hours. We will notify you (or your authorized representative) ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 122 of our decision verbally within 72 hours, and will mail a written notification within 72 hours of the decision. External review Independent review You may request an external or independent review when the denial is based on the plan’s decision to:  Deny;  Modify;  Reduce; or  Terminate coverage of or payment for a health care service. If you have gone through both a first- and second-level appeal (or expedited appeal) and your appeal was based on one of the issues listed above, you may request an external or independent review. You may also immediately request external review in the following situations:  If the plan has exceeded the timelines for response to your appeal without good cause and without reaching a decision.  If the plan has failed to adhere to the requirements of the appeals process. You must request an independent review no more than 180 days after the date of the letter responding to your second-level appeal (or expedited appeal). Only the member or an authorized representative (see page 116) can request an independent review. TIP: An Independent Review Organization (IRO) will conduct the external review. 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, Washington State Rx Services, or the Health Care Authority. An IRO is intended to provide unbiased, independent clinical and benefit expertise as well as evidence-based decision making while ensuring confidentiality. The IRO reviews your appeal to determine if the plan’s decision is consistent with state law and the UMP CDHP Certificate of Coverage. The plan will pay the IRO’s charges. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 123 Requesting an independent review To request an independent review, contact the plan at: For medical services For prescription drugs Mail Uniform Medical Plan Attn: Correspondence, Intake, and Appeals PO Box 2998 Tacoma, WA 98401-2998 Washington State Rx Services Attn: Appeals PO Box 40168 Portland, OR 97240-0168 Phone 1-[PHONE REDACTED] (TTY: 711) 1-[PHONE REDACTED] (TRS: 711) Fax 1-[PHONE REDACTED] 1-[PHONE REDACTED] The plan—Regence BlueShield for medical services, and Washington State Rx Services for prescription drugs—will send the relevant information and correspondence to the Independent Review Organization. Additional legal options You are required to have exercised the opportunity to seek IRO review (see page 122) of the plan’s decision before you are authorized to bring a cause of action in court against the plan or the Health Care Authority. The IRO decision is binding on both the plan and you except to the extent that other remedies are available under state or federal law. If you prevail at the IRO level, the plan must provide benefits (including by making payment on the claim) following 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 providers only, call UMP Customer Service at 1-[PHONE REDACTED] or send a secure email through your regence.com account. For complaints or concerns about the quality of care you received from any provider (preferred or out-of-network):  Call Washington State Department of Health at [PHONE REDACTED].  Email [EMAIL REDACTED].  Visit www.doh.wa.gov/AboutUs/DepartmentofHealth/Fileacomplaint. Appeals related to eligibility Appeals related to eligibility and enrollment are handled by the Public Employees Benefits Board (PEBB) Program and governed by Washington Administrative Code (WAC) chapter 182-16. Information on how to file an appeal is available:  On the PEBB website at www.hca.wa.gov/pebb.  By contacting the PEBB Appeals Manager at 1-[PHONE REDACTED] or [EMAIL REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 124 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 ensure timely payment of claims, it is important that you respond as directed in the letter, even if the answer is no. If you don’t, coverage may be denied. You may call Customer Service at 1-[PHONE REDACTED] if you have questions. What are my and the plan’s legal rights and responsibilities? Coverage under the plan is not provided for medical, dental, 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; or  Any other source, including no fault automobile medical payments (“Med-Pay”), no fault automobile personal injury protection homeowner’s no-fault coverage, commercial premises no-fault medical coverage, sports policies including excess 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 claims may be denied. However, after expiration or exhaustion of the above no fault 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 advanced by the plan pending the resolution of a claim to the right of recovery if all the following conditions apply:  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.  The plan may choose to recover expenses through subrogation to the extent that the settlement or recovery exceeds full compensation to you for the injury or illness that you sustained. The plan is authorized, but not obligated, to recover any benefits 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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 125  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 the claimant or any third party or the recovery source. The plan is entitled to reimbursement from the first dollars 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 must agree that nothing will be done 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 in accordance with the plan (including, but not necessarily limited to, 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 (notification 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 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 solely to assist you. By paying such benefits, the plan is not waiving any right to reimbursement or subrogation. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 126 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 homeowner’s no fault coverage, commercial premises no fault medical coverage, 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 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 certificate of coverage. 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. 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 incurred by you 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. Future medical expenses Benefits for otherwise covered services may be excluded as follows:  When you have received a recovery from another source relating to an illness or injury for services for which we normally would provide benefits. The amount of any exclusions under this provision, however, will not exceed the amount of your recovery.  Until the total amount excluded under this subrogation provision equals the third-party recovery. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 127 Eligibility and enrollment for active employees Who can enroll in UMP CDHP with an HSA? The UMP CDHP is a health savings account (HSA) qualified high-deductible health plan (HDHP) (see definition on page 163). To be eligible to receive the PEBB contribution to your HSA (see page 23), members enrolling in this plan must establish an HSA. You will be liable for any tax penalties resulting from contributions made to your HSA when you are not HSA-eligible. If you have questions about your eligibility to contribute to an HSA, call HealthEquity at 1-[PHONE REDACTED], or consult with a financial or tax advisor. Generally, to be eligible to contribute to an HSA you must:  Be covered by a HDHP.  Not be covered by any other health plan that is not an HDHP unless the health plan coverage is limited coverage like dental, vision, or disability coverage.  Not be enrolled in Medicare (exception for employees where Medicare is the secondary payer on claims).  Not be claimed as a dependent on another person’s tax return.  Not have received services from the Veterans' Administration during the three months immediately prior to any month in which you contribute to your HSA unless the services are considered disregarded or preventive care, or you have a disability rating from the Veterans' Administration.  Not have received disqualifying medical services from an Indian Health Service facility at any time during the three months immediately prior to any month in which you contribute to your HAS.  Not be enrolled in TRICARE.  Not be enrolled in a medical FSA (if you’re currently enrolled in a medical FSA and want to enroll in a CDHP for the upcoming plan year, you must spend all of your FSA dollars by December 31 of the current plan year).  Not have a spouse who has a general purpose FSA.  Not have a claims-eligible health reimbursement arrangement (a limited purpose health reimbursement arrangement is okay). Note: The general eligibility stated above applies to the PEBB subscriber (employee, retiree, COBRA enrollee, or continuation coverage enrollee) who is establishing an HSA. If you have questions regarding HSA eligibility for your spouse or child, you should call HealthEquity at 1-[PHONE REDACTED], or consult with a financial or tax advisor. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 128 In addition, PEBB will not allow non-Medicare retiree or COBRA subscribers who have a family member enrolled in Medicare to select the CDHP/HSA. If you are a non-Medicare retiree or COBRA subscriber with a Medicare dependent enrolled on your account, you must:  Choose a medical plan that is not a CDHP and keep your Medicare dependent enrolled in PEBB coverage. Your annual deductible and annual out-of-pocket limit will restart with your new plan; or  Disenroll your dependent from your PEBB coverage to enroll in a CDHP. Your disenrolled family member will not qualify for COBRA or other continuation coverage options through the PEBB Program. Eligibility TIP: The following rules apply to the PEBB subscriber, who is the person directly enrolled in UMP CDHP and is an employee or retiree of the sponsoring agency, or other self-pay subscriber (for example, COBRA or Continuation Coverage). Some rules are different for spouses and dependents. Eligible employees In these sections, we may refer to employees as “subscribers” or “enrollees.” The employee’s employing agency will inform the employee whether or not he or she is eligible for benefits upon employment and whenever the employee’s eligibility status changes. The communication will include information about the employee’s right to appeal eligibility and enrollment decisions. Information about an employee’s right to an appeal can be found on page 123 of this certificate of coverage. Eligible dependents To enroll in a health plan, a dependent must be eligible and the employee must follow the procedural requirements for enrolling the dependent. The PEBB Program or employing agency verifies the eligibility of all dependents and requires employees to provide documents that prove a dependent’s eligibility. The following are eligible as dependents: 1. Lawful spouse. 2. State-registered domestic partner as defined in state statute and substantially equivalent legal unions from other jurisdictions as defined in Washington State statute. 3. Children. Children are eligible through the last day of the month in which their 26th birthday occurred except as described in subsection of this section. Children are defined as the subscriber’s: a. Children as defined in state statutes that establish the parent-child relationship; b. Biological children, where parental rights have not been terminated; c. Stepchildren. The stepchild’s relationship to a subscriber (and eligibility as a PEBB dependent) ends on the same date the marriage with the spouse ends through divorce, annulment, dissolution, termination, or death; ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 129 d. Legally adopted children; e. Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child; f. Children of the subscriber’s state-registered domestic partner. The child’s relationship to the subscriber (and eligibility as a PEBB 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; g. Children specified in a court order or divorce decree; h. Extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber’s spouse, or 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. “Children” does not include foster children for whom support payments are made to the subscriber through the state Department of Social and Health Services foster care program; and i. Children of any age with a developmental disability or physical handicap that renders the child incapable of self-sustaining employment and chiefly dependent upon the subscriber for support and maintenance provided such condition occurs before age 26.  The subscriber must provide evidence of the disability and evidence that the condition occurred before age 26.  The subscriber must notify the PEBB Program in writing when his or her dependent is not eligible under this section. The notification must be received by the PEBB Program no later than 60 days after the date that a child age 26 or older no longer qualifies under this subsection.  A child with a developmental disability or physical handicap who becomes self- supporting is not eligible as of the last day of the month in which he or she becomes capable of self-support.  A child with a developmental disability or physical handicap age 26 and older who becomes capable of self-support does not regain eligibility under of this subsection if he or she later becomes incapable of self-support.  The PEBB Program, with input from the medical plan, will periodically certify the eligibility of a dependent child with a disability, but no more frequently than annually after the two-year period following the child’s 26th birthday. ALERT! Don’t forget to notify your employer of changes in dependent status. You may be required to pay for services received by ineligible dependents. 4. Parents of the subscriber. a. Parents covered under PEBB medical before July 1, 1990, may continue enrollment on a self-pay basis as long as:  The parent maintains continuous enrollment in PEBB medical;  The parent qualifies under the Internal Revenue Code as a dependent of the subscriber;  The subscriber continues enrollment in PEBB insurance coverage; and  The parent is not covered by any other group medical plan. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 130 b. Parents eligible under this subsection may be enrolled with a different medical plan than that selected by the subscriber. Parents may not enroll additional dependents to their PEBB insurance coverage. Enrollment TIP: When you retire, be sure to enroll in PEBB retiree insurance coverage within 60 days of your retirement date or the date that your employer-paid coverage, COBRA coverage, or continuation coverage ends. Retirees may defer medical coverage if they have other employment that provides employer-based group medical. If you do not enroll or formally defer PEBB coverage within 60 days of retirement or the date that your employer-paid coverage, COBRA coverage, or continuation coverage ends, you will not be able to return to PEBB coverage later. An employee or dependent is eligible to enroll in only one PEBB medical plan even if eligibility criteria are met under two or more subscribers. For example, a dependent child who is eligible for enrollment under two or more parents working for employers that participate in PEBB coverage may be enrolled as a dependent under only one parent. An eligible employee may waive enrollment in PEBB medical if he or she is enrolled in employer- based group medical, TRICARE, or Medicare. If an employee waives enrollment in PEBB medical, the employee cannot enroll eligible dependents. How to enroll ALERT! Subscribers may change health plans at the following times:  During annual open enrollment: Subscribers may change health plans during the annual open enrollment; see page 132.  During a special open enrollment: Subscribers may change health plans outside of the annual open enrollment if a special open enrollment event occurs; see pages 132–134. Employees must submit an Employee Enrollment/Change form to their employing agency. The form must be received by the employing agency no later than 31 days after the date the employee becomes eligible. To enroll an eligible dependent, the employee must include the dependent’s enrollment information on the form and provide the required document(s) as evidence of the dependent’s eligibility. The dependent will not be enrolled if his or her eligibility is not verified. If the employee does not return the Employee Enrollment/Change form in time to meet the procedural requirements, the employee will be enrolled in Uniform Medical Plan Classic and the tobacco use premium surcharge will be incurred. Any eligible dependents cannot be enrolled until the next open enrollment unless a special open enrollment event occurs. An employee or his or her dependents may enroll during the PEBB Program’s annual open enrollment (see “Annual open enrollment” on page 132) or during a special open enrollment (see “Special open enrollment” beginning on page 132). The employee must provide evidence of the event that created the special open enrollment. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 131 ALERT! Failure to notify your payroll office or the PEBB Program of changes in status affecting eligibility may result in termination of coverage. You are responsible for the cost of any services received when you or your dependent(s) were ineligible. Employees must notify their employing agency to remove dependents no later than 60 days from the last day of the month when dependents no longer meet the eligibility criteria described under “Eligible dependents” on page 128. Consequences for not submitting notice within 60 days may include, but are not limited to:  The dependent may lose eligibility to continue health plan coverage under one of the continuation coverage options described on page 138;  The subscriber may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility;  The subscriber may not be able to recover subscriber-paid insurance premiums for dependents that lost their eligibility; and  The subscriber may be responsible for premiums paid by the state for the dependent’s health plan coverage after the dependent lost eligibility. TIP: Keeping your address and other personal information up-to-date helps ensure that you receive important notices about your benefits. If your address or name changes, notify your personnel, payroll, or benefits office as soon as possible. When medical enrollment begins For an employee and his or her eligible dependents enrolled when the employee is newly eligible, medical plan enrollment 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. For an employee or his or her eligible dependent enrolled during the PEBB Program’s annual open enrollment, medical coverage will begin on January 1 of the following year. For an employee or his or her eligible dependent enrolled during a special open enrollment, medical coverage will begin the first day of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the change in enrollment begins on that day. Exceptions: 1. 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, health plan coverage will begin as follows: a) For the newly born child, health plan coverage will begin the date of birth; b) For a newly adopted child, health plan coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier; ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 132 c) For an employee enrolling in order to enroll a newly born or newly adopted child, medical will begin the first day of the month in which the event occurs. d) For a spouse or state-registered domestic partner of a subscriber, health plan coverage will begin the first day of the month in which the event occurs. 2. If adding a child who becomes eligible as an extended dependent through legal custody or legal guardianship, health plan coverage will begin on the first day of the month following eligibility certification. Annual open enrollment Employees may make a change to their enrollment during the PEBB Program’s annual open enrollment as follows:  Enroll in or waive their enrollment in a medical plan;  Enroll or remove eligible dependents; or  Change medical plan choice. The employee must submit the required enrollment/change form to his or her employing agency. The form must be received no later than the last day of the annual open enrollment (usually November 30). The enrollment change will be effective January 1 of the following year. TIP: You may be eligible to change medical plans if you move during the calendar year. See the list of special open enrollment events below for details. Special open enrollment Employees may change their enrollment outside of the annual open enrollment if a special open enrollment event occurs. However, the change in enrollment must be allowable under Internal Revenue Code and Treasury Regulations, and correspond to and be consistent with the event that creates the special open enrollment for the employee, the employee’s dependent, or both. The special open enrollment may allow an employee to:  Enroll in or change his or her health plan;  Waive his or her health plan enrollment; or  Enroll or remove eligible dependents. To make an enrollment change, the employee must submit the required form(s) to his or her employing agency. Form(s) must be received no later than 60 days after the event that created the special open enrollment. In addition to the required forms, the PEBB Program or employing agency will require the employee to prove eligibility or provide evidence of the event that created the special open enrollment. ALERT! See “Adding a new dependent to your coverage” on page 64. Exception: If an employee wants to enroll a newborn or child whom the employee has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption, the employee should notify his or her employer by submitting an enrollment/change form as soon as ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 133 possible to ensure timely payment of claims. If adding the child increases the premium, the required enrollment/change form must be received no later than 12 months after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. Employees should contact their personnel, payroll, or benefits office for the required forms. ALERT! If an enrollee’s provider or health care facility discontinues participation with this plan, the enrollee may not change medical plans until the next open enrollment period, unless the PEBB Appeals Manager determines that a continuity of care issue exists. The plan cannot guarantee that any one physician, hospital, or other provider will be available or remain under contract with us. Also, if an employee transfers from one employing agency to another during the year, the enrollee cannot change medical plans, except as outlined in this Enrollment section beginning on page 130. When can an employee change his or her health plan? Any one of the following events may create a special open enrollment: 1. Employee acquires a new dependent due to: a. Marriage or registering a domestic partnership; b. Birth, adoption, or when the employee assumes a legal obligation for total or partial support in anticipation of adoption; or c. A child becomes eligible as an extended dependent through legal custody or legal guardianship. 2. Employee or an employee’s 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); 3. Employee has a change in employment status that affects his or her eligibility for the employer contribution toward employer-based group health plan; 4. Employee’s dependent has a change in his or her own employment status that affects his or her eligibility for the employer contribution under his or her employer-based group health plan; 5. Employee or an employee’s dependent has a change in residence that affects health plan availability. If the employee moves and the employee’s current health plan is not available in the new location the employee must select a new health plan; 6. A court order or National Medical Support Notice requires the employee or any other individual to provide insurance coverage for an eligible dependent of the employee (a former spouse or former registered domestic partner is not an eligible dependent); 7. Employee or an employee’s dependent becomes entitled to coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or the employee or the employee’s dependent loses eligibility for coverage under Medicaid or CHIP; 8. Employee or an employee’s dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from Medicaid or a state CHIP; ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 134 9. Employee or an employee’s dependent becomes entitled to coverage under Medicare, or the employee or an employee’s dependent loses eligibility for coverage under Medicare, or enrolls in or terminates enrollment in a Medicare Part D plan. If the employee’s current health plan becomes unavailable due to the employee’s or an employee’s dependent’s entitlement to Medicare, the employee must select a new health plan; 10. Employee or an employee’s dependent’s current health plan becomes unavailable because the employee or enrolled dependent is no longer eligible for a health savings account (HSA); 11. Employee or an employee’s dependent experiences a disruption of care that could function as a reduction in benefits for the employee or the employee’s dependent for a specific condition or ongoing course of treatment. The employee may not change his or her health plan election if the employee’s or dependent’s physician stops participation with the employee’s health plan unless the PEBB Program determines that a continuity of care issue exists. The PEBB Program will consider but is not limited to considering the following: a. Active cancer treatment such as chemotherapy or radiation therapy for up to 90 days or until medically stable; or b. Transplant within the last 12 months; or c. Scheduled surgery within the next 60 days (elective procedures within the next 60 days do not qualify for this continuity of care); or d. Recent major surgery still within the postoperative period of up to 8 weeks; or e. Third trimester of pregnancy. Note: If an enrollee’s provider or health care facility discontinues participation with UMP CDHP, the enrollee may not change medical plans until the next open enrollment period, unless the PEBB Program determines that a continuity of care issue exists. UMP CDHP cannot guarantee that any one physician, hospital, or other provider will be available or remain under contract with us. When can an employee waive his or her medical plan coverage, or enroll after waiving coverage? Any one of the following events may create a special open enrollment: 1. Employee acquires a new dependent due to: a. Marriage or registering a state-domestic partnership; b. Birth, adoption, or when the employee has assumed a legal obligation for total or partial support in anticipation of adoption; or c. A child becoming eligible as an extended dependent through legal custody or legal guardianship. 2. Employee or an employee’s 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); 3. Employee has a change in employment status that affects his or her eligibility for the employer contribution toward employer-based group medical insurance; 4. Employee’s dependent has a change in his or her own employment status that affects his or her eligibility for the employer contribution under his or her employer-based group medical; ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 135 5. Employee or an employee’s dependent has a change in enrollment under an employer-based group medical insurance plan during its annual open enrollment that does not align with the PEBB program’s annual open enrollment; 6. 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; 7. A court order or National Medical Support Notice requires the employee or any other individual to provide insurance coverage for an eligible dependent of the employee (a former spouse or former state-registered domestic partner is not an eligible dependent); 8. Employee or an employee’s dependent becomes entitled to coverage under Medicaid or a state CHIP, or the employee or an employee’s dependent loses eligibility for coverage under Medicaid or CHIP; 9. Employee or an employee’s eligible dependent becomes eligible for a state premium assistance subsidy for PEBB health plan coverage from Medicaid or a state CHIP. 10. Employee or an employee’s dependent becomes eligible and enrolls in TRICARE, or loses eligibility for TRICARE; 11. Employee becomes eligible and enrolls in Medicare, or loses eligibility for Medicare. When can an employee enroll or remove eligible dependents? To enroll a dependent, the employee must include the dependent’s enrollment information and provide any required document(s) as evidence of the dependent’s eligibility. The dependent will not be enrolled if his or her eligibility is not verified. Any one of the following events may create a special open enrollment: 1. Employee acquires a new dependent due to: a. Marriage or registering a state domestic partnership; b. Birth, adoption, or when an employee has assumed a legal obligation for total or partial support in anticipation of adoption; or c. A child becoming eligible as an extended dependent through legal custody or legal guardianship. 2. Employee or an employee’s 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); 3. Employee has a change in employment status that affects his or her eligibility for the employer contribution toward his or her employer-based group health plan; 4. Employee’s dependent has a change in his or her own employment status that affects his or her eligibility for the employer contribution under his or her employer-based group health plan; 5. Employee or an employee’s 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; 6. 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; ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 136 7. A court order or National Medical Support Notice requires the employee or any other individual to provide insurance coverage for an eligible dependent of the employee (a former spouse or former state-registered domestic partner is not an eligible dependent); 8. Employee or an employee’s dependent becomes entitled to coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or the employee or an employee’s dependent loses eligibility for coverage under Medicaid or CHIP; or 9. Employee or an employee’s dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from Medicaid or a state CHIP. National Medical Support Notice (NMSN) When an NMSN requires an employee to provide health plan coverage for a dependent child, the following provisions apply: 1. The employee may enroll his or her dependent child and request changes to his or her health plan coverage as described under subsection of this section. Employees submit the required forms to their employing agency. All other subscribers submit the required forms to the PEBB Program. 2. If the employee 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 subsection of this section upon request of: a. The child’s other parent; or b. Child support enforcement program. 3. Changes to health plan coverage or enrollment are allowed as directed by the NMSN: a. The dependent will be enrolled under the employee’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 employee’s selected health plan 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. 4. Changes to health plan coverage or enrollment as described in subsection through of this section 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 employee’s health plan coverage as described in subsection of this section 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. 5. The employee may be eligible to make changes to his or her health plan enrollment and salary reduction elections during a special open enrollment related to the NMSN. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 137 Medicare entitlement TIP: Retirees, permanently disabled employees, and eligible dependents must enroll in Medicare Part A and Part B if entitled. If an enrollee becomes entitled to Medicare, he or she should contact the nearest Social Security Administration office to ask about the advantages of immediate or deferred Medicare enrollment. For employees and their enrolled spouses age 65 and older, the PEBB medical plan will provide primary insurance coverage, and Medicare coverage will be secondary. However, employees age 65 and older may choose to reject his or her PEBB medical plan and choose Medicare as their primary insurer. If an employee does so, the employee cannot enroll in PEBB medical. The employee can again enroll in PEBB medical during a special open enrollment or annual open enrollment. In most situations, employees and their spouses can elect to defer Medicare Part B enrollment, without penalty, up to the date the employee terminates employment. If Medicare entitlement is due to disability, the enrollee must contact Medicare about deferral of premiums. Upon retirement, Medicare will become the primary insurance, and the PEBB medical plan becomes secondary. Medicare guidelines direct that state-registered domestic partners who are age 65 or older must have Medicare as their primary insurer. When medical coverage ends TIP: If your coverage under this plan ends, you must pay the costs of any services or supplies, except when coverage is required by law. Medical plan enrollment ends on the following dates: 1. On the last day of the month when any individual ceases to be eligible. 2. On the date a plan terminates, if that should occur. Any person losing coverage will be given the opportunity to enroll in another PEBB medical plan. Premium payments and applicable premium surcharges become due the first of the month in which medical coverage is effective. Premium payments and applicable premium surcharges are not prorated during any month, including when an enrollee dies or asks to terminate his or her medical plan before the end of the month. If an enrollee or newborn eligible for benefits under “Obstetric and newborn care” is confined in a hospital or skilled nursing facility for which benefits are provided when PEBB medical coverage ends and the enrollee is not immediately covered by other health plan coverage, benefits will be extended until whichever of the following occurs first:  The enrollee is discharged from the hospital or from a hospital to which the enrollee is directly transferred;  The enrollee is discharged from a skilled nursing facility when directly transferred from a hospital when the skilled nursing facility confinement is in lieu of hospitalization; ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 138  The enrollee is discharged from the skilled nursing facility or from a skilled nursing facility to which the enrollee is directly transferred;  The enrollee is covered by another health plan that will provide benefits for the services; or  Benefits are exhausted. When medical plan enrollment ends, the enrollee may be eligible for continuation of coverage or conversion to other health plan coverage if application is made within the timelines explained in the following sections. The enrollee is responsible for timely payment of premiums and applicable premium surcharges. If the enrollee’s insurance coverage is terminated due to lack of payment, the enrollee’s eligibility to participate in PEBB medical coverage will end retroactive to the last day of the month for which the premium and any premium surcharge was paid. An enrollee who needs the required forms for an enrollment or benefit change may contact the employing agency. TIP: If your coverage under this plan ends, you are responsible for letting your providers know at the time of service. If your provider bills the plan for services you receive after your enrollment has ended, the plan will deny all claims. Options for continuing PEBB medical coverage Employees and their dependents covered by this health plan have options for continuing insurance coverage during temporary or permanent loss of eligibility. There are continuation coverage options for PEBB health plan enrollees: 1. COBRA 2. Continuation Coverage 3. PEBB retiree insurance coverage The first two options temporarily extend group insurance coverage in some cases when the employee or dependent’s PEBB medical plan coverage ends. COBRA coverage is governed by eligibility and administrative requirements under federal law and regulation. Continuation Coverage is an alternative created for PEBB enrollees who are not eligible for COBRA. PEBB retiree insurance coverage is available only to retiring employees and surviving dependents who meet eligibility and procedural requirements. All options are administered by the PEBB Program. Refer to the PEBB Continuation Coverage Election Notice booklet or the PEBB Retiree Enrollment Guide for specific details or call PEBB Customer Service at 1-[PHONE REDACTED]. Employees also have the right of conversion to individual medical insurance coverage when continuation of group medical insurance coverage is no longer possible. The employee’s dependents also have options for continuing insurance coverage for themselves after losing eligibility. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 139 Family and Medical Leave Act of 1993 Employees on approved leave under the federal Family and Medical Leave Act (FMLA) may continue to receive the employer contribution toward insurance coverage in accordance with the FMLA. The employee’s employing agency determines if the employee is eligible for leave and the duration of the leave under FMLA. The employee must continue to pay the employee premium contribution during this period to maintain eligibility. If the employee’s premium or applicable premium surcharge remains unpaid for 60 days from the original due date, insurance coverage will be terminated retroactive to the last day of the month for which the premium and premium surcharge was paid. If an employee exhausts the period of leave approved under FMLA, insurance coverage may be continued by self-paying the premium and applicable premium surcharge set by the HCA, with no contribution from the employer while on approved leave. For more information on continuation coverage, see the section titled “Options for continuing PEBB medical coverage.” Payment of premiums during a labor dispute Any employee or dependent whose premiums are paid in full or in part by the employer may pay premiums directly to Uniform Medical Plan or the HCA if the employee’s compensation is suspended or terminated directly or indirectly as a result of a strike, lockout, or any other labor dispute for a period not to exceed six months. While the employee’s compensation is suspended or terminated, the employee shall be notified immediately by the HCA by mail addressed to the last address of record with the HCA, that the employee may pay premiums as they become due as provided in this section. Conversion of coverage Enrollees (including spouses and dependents of a subscriber terminated for cause) have the right to switch from PEBB group medical to an individual conversion plan offered by Regence BlueShield to UMP CDHP members when they are no longer eligible to continue the PEBB group medical plan, and are not eligible for Medicare or another group insurance coverage that provides benefits for hospital or medical care. Enrollees must apply for conversion coverage 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 our conversion program differ from those of the enrollee’s current group medical plan. To receive detailed information on conversion options under this medical plan, call Customer Service at 1-[PHONE REDACTED]. Appeals of determinations of PEBB eligibility Any current or former employee of a state agency and his or her dependent may appeal a decision by the employing state agency regarding PEBB eligibility, enrollment, or premium surcharge to the employing agency. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 140 Any current or former employee of an employer group or his or her dependent may appeal a decision made by an employer group regarding PEBB eligibility, enrollment, or premium surcharge to the employer group. Relationship to law and regulations Any provision of this certificate of coverage that is in conflict with any governing law or regulation of the state of Washington is hereby amended to comply with the minimum requirements of such law or regulation. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 141 Eligibility and enrollment for retirees and surviving dependents Eligibility FOR MORE INFORMATION: See page 127 for details on who may enroll in UMP CDHP. In these sections, we may refer to retirees and surviving dependents as “subscribers” or “enrollees.” The Public Employee’s Benefits Board (PEBB) Program determines if an employee is eligible to enroll in retiree insurance coverage upon receipt of a completed Retiree Coverage Election/Change form. If the employee does not have substantive eligibility or does not meet the procedural requirements for enrollment in retiree insurance, the PEBB Program will notify the employee of his or her right to an appeal. Information about appealing a decision made by the PEBB Program can be found on page 123 of this certificate of coverage. The PEBB Program will determine if a dependent is eligible to continue enrollment in insurance coverage as a surviving dependent upon receipt of a completed Retiree Coverage Election/Change form. If the dependent does not have substantive eligibility or does not meet the procedural requirements for enrollment in retiree insurance, the PEBB Program will notify the dependent of his or her right to an appeal. Information about appealing a decision made by the PEBB Program can be found on page 123 of this certificate of coverage. Retirees, surviving dependents, and their enrolled dependents are required to enroll in Medicare Part A and Part B, if entitled. This is a condition of their enrollment in PEBB retiree insurance coverage. Medicare-entitled enrollees must provide a copy of their Medicare card or letter from the Social Security Administration with Medicare Parts A and B effective dates to the PEBB Program as proof of enrollment in Medicare. If an enrollee is not entitled to either Medicare Part A or Part B on his or her 65th birthday, the enrollee must provide the PEBB Program with a copy of the required documentation from the Social Security Administration. The only exception to this rule is for employees who retired on or before July 1, 1991. Eligible dependents To be enrolled in a medical plan, a dependent must be eligible and the subscriber must follow the procedural requirements described in the “Enrollment” section beginning on page 143. The PEBB Program verifies the eligibility of all dependents and requires documents from subscribers that prove a dependent’s eligibility. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 142 The following are eligible as dependents: 1. Lawful spouse. 2. State-registered domestic partner as defined in state statute and substantially equivalent legal unions from other jurisdictions as defined in state statute. 3. Children. Children are eligible through the last day of the month in which their 26th birthday occurred except as described in subsection of this section. Children are defined as the subscriber’s: a. Children as defined in state statutes that establish the parent-child relationship; b. Biological children, where parental rights have not been terminated; c. Stepchildren. The stepchild’s relationship to a subscriber (and eligibility as a PEBB dependent) ends on the same date the marriage with the spouse ends through divorce, annulment, dissolution, termination, or death; d. Legally adopted children; e. Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of the child; f. Children of the subscriber’s state-registered domestic partner. The child’s relationship to the subscriber (and eligibility as a PEBB 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; g. Children specified in a court order or divorce decree; h. Extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber’s spouse, or 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. “Children” does not include foster children for whom support payments are made to the subscriber through the state Department of Social and Health Services foster care program; and i. Children of any age with a developmental disability or physical handicap that renders the child incapable of self-sustaining employment and chiefly dependent upon the subscriber for support and maintenance provided such condition occurs before age 26.  The subscriber must provide evidence of the disability and evidence that the condition occurred before age 26.  The subscriber must notify the PEBB Program in writing when his or her dependent is not eligible under this section. The notification must be received by the PEBB Program no later than 60 days after the date that a child age 26 or older no longer qualifies under this subsection.  A child with a developmental disability or physical handicap who becomes self- supporting is not eligible as of the last day of the month in which he or she becomes capable of self-support.  A child with a developmental disability or physical handicap age 26 and older who becomes capable of self-support does not regain eligibility under of this subsection if he or she later becomes incapable of self-support.  The PEBB Program, with input from the medical plan, will periodically certify the eligibility of a dependent child with a disability, but no more frequently than annually after the two-year period following the child’s 26th birthday. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 143 ALERT! Notify the PEBB Program at 1-[PHONE REDACTED] as soon as possible of changes in dependent status. You may be required to pay for services received by ineligible dependents. 4. Parents of the subscriber. a. Parents covered under PEBB medical before July 1, 1990, may continue enrollment on a self-pay basis as long as: • The parent maintains continuous enrollment in PEBB medical; • The parent qualifies under the Internal Revenue Code as a dependent of the subscriber; • The subscriber continues enrollment in PEBB insurance coverage; and • The parent is not covered by any other group medical plan. b. Parents eligible under this subsection may be enrolled with a different medical plan than that selected by the subscriber. Parents may not enroll additional dependents to their PEBB insurance coverage. Enrollment Deferring enrollment in PEBB retiree coverage Retiring employees and surviving dependents (except for survivors of emergency service personnel killed in the line of duty) who want to defer enrollment must submit a Retiree Coverage Election/Change form to the PEBB Program. The forms must be received by the PEBB Program no later than 60 days after the employer paid coverage, Consolidated Omnibus Budget Reconciliation Act (COBRA) coverage, or continuation coverage ends. If a retiree defers enrollment in a PEBB health plan, they also defer enrollment for all eligible dependents. Retiring employees and surviving dependents that do not enroll in a PEBB health plan are only eligible to enroll later if they have deferred enrollment as identified below:  Beginning January 1, 2001, retirees may defer enrollment in a PEBB health plan if they are enrolled in employer-based group medical insurance as an employee or the dependent of an employee, or such medical insurance continued under COBRA coverage or continuation coverage.  Beginning January 1, 2001, retirees may defer enrollment in a PEBB health plan if they are enrolled as a retiree or the dependent of a retiree in a federal retiree medical plan.  Beginning January 1, 2006, retirees may defer enrollment in a PEBB health plan if they are enrolled in Medicare Parts A and B and a Medicaid program that includes payment of medical and hospital benefits.  Beginning January 1, 2014, retirees who are not eligible for Part A and Part B of Medicare may defer enrollment in a PEBB health plan if they are enrolled in coverage through a health care exchange developed under the Affordable Care Act. To defer enrollment, the retiree or surviving dependent must submit a PEBB Retiree Coverage Election/Change form to the PEBB Program indicating his or her desire to defer enrollment in a PEBB health plan within the PEBB Program’s required enrollment time limits. Exception: A retiree may defer enrollment in a PEBB health plan during the period of time he or she is enrolled as a dependent in a medical plan sponsored by PEBB, a Washington state school district, a ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 144 Washington state educational service district, or a Washington state charter school, including such coverage under COBRA or continuation coverage. He or she does not need to submit a Retiree Coverage Election/Change form. If a retiree or surviving dependent defers enrollment in a PEBB medical plan, enrollment must also be deferred for PEBB dental. Enrollees can enroll in only one PEBB medical plan even if eligibility criteria are met under two or more subscribers. Note: PEBB retiree health plan enrollment is deferred if a retiree becomes newly eligible for PEBB benefits as a new employee and enrolls in a PEBB health plan. How to enroll Retirees and surviving dependents must submit a Retiree Coverage Election/Change form to enroll in PEBB retiree insurance coverage. The form must be received no later than 60 days after the employee's employer-paid coverage, COBRA coverage, or continuation coverage ends. Surviving dependents of emergency service personnel killed in the line of duty must submit a Retiree Coverage Election/Change form to the PEBB Program. The completed form must be received no later than 180 days after:  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 he or she is determined to be an eligible survivor; or  The date of the emergency service worker’s death; or  The last day the surviving dependent was covered under a health plan through the emergency service worker’s employer or COBRA coverage from the emergency service worker’s employer. A retiree or surviving dependent who requests to voluntarily terminate his or her PEBB retiree insurance coverage must do so in writing to the PEBB Program. Retirees or surviving dependents who deferred coverage may later enroll in a PEBB health plan if he or she provides evidence of continuous enrollment (see “Enrollment following deferral” on page 146). To enroll a dependent the subscriber must include the dependent’s enrollment information and provide any required document(s) as evidence of the dependent’s eligibility to the PEBB Program. The PEBB Program will not enroll or reenroll dependents if unable to verify a dependent’s eligibility. A subscriber may enroll his or her dependents during the PEBB Program’s annual open enrollment period (see “Annual open enrollment” on page 146) or during a special open enrollment (see “Special open enrollment” on page 147). The subscriber must provide evidence of the event that created the special open enrollment. Subscribers are required to remove dependents no later than 60 days from the last day of the month when dependents no longer meet the eligibility criteria described under “Eligible dependents” on page 141. Consequences for not submitting the notice within 60 days may include, but are not limited to:  The dependent may lose eligibility to continue health plan coverage under one of the continuation coverage options described on page 151; ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 145  The subscriber may be billed for claims paid by the health plan for services that were rendered after the dependent lost eligibility;  The subscriber may not be able to recover subscriber-paid insurance premiums for dependents that lost their eligibility; and  The subscriber may be responsible for premiums paid by the state for the dependent’s medical plan coverage after the dependent lost eligibility. When medical coverage begins ALERT! See “Adding a new dependent to your coverage” on page 64. For eligible employees and their dependents enrolling in PEBB retiree insurance coverage within 60 days of the employee’s employer-paid coverage, COBRA coverage, or continuation coverage ending, PEBB retiree insurance begins the first day of the month following the loss of employer- paid coverage, COBRA coverage, or continuation coverage. For a retiree who deferred enrollment and is enrolling in PEBB retiree insurance no later than 60 days following a loss of other coverage, medical coverage will begin the first day of the month following the loss of other coverage. For an eligible surviving dependent, medical coverage will be continued without a gap subject to payment of premium and any applicable premium surcharges. For a retiree’s or surviving dependent’s dependent enrolled during the PEBB Program’s annual open enrollment, medical coverage will begin on January 1 of the following year. For a retiree’s or surviving dependent’s dependent enrolled during a special open enrollment, medical coverage will begin the first of the month following the later of the event date or the date the required form is received. If that day is the first of the month, the change in enrollment begins on that day. Exceptions:  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, health plan coverage will begin as follows:  For the newly born child, health plan coverage will begin the date of birth;  For a newly adopted child, health plan coverage will begin on the date of placement or the date a legal obligation is assumed in anticipation of adoption, whichever is earlier;  For an employee enrolling in order to enroll a newly born or newly adopted child, medical will begin the first day of the month in which the event occurs.  For a spouse or state-registered domestic partner of a subscriber, health plan coverage will begin the first day of the month in which the event occurs.  If adding a child who becomes eligible as an extended dependent through legal custody or legal guardianship, or a child who becomes eligible as a dependent with a disability, health plan coverage will begin on the first day of the month following eligibility certification. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 146 TIP: Retirees should notify the PEBB Program at 1-[PHONE REDACTED] of address, name, or other changes as soon as possible. This helps ensure that you receive important information about your benefits and helps us serve you better. Enrollment following deferral Retirees or surviving dependents who defer enrollment 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 insurance or such coverage under COBRA coverage or continuation coverage ends, as long as they were continuously enrolled in such coverage. Retirees or surviving dependents who defer enrollment while enrolled in a federal retiree medical plan as a retiree or dependent will have a one-time opportunity to enroll in a PEBB health 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, as long as they were continuously enrolled in such coverage. Retirees or surviving dependents who defer enrollment 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, 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. Retirees or surviving dependents who defer enrollment while enrolled in coverage through a health care 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 by submitting the required forms and evidence of continuous enrollment in exchange coverage to the PEBB Program. Retirees or surviving dependents who defer enrollment may enroll in a PEBB medical plan if he or she receives formal notice that the Health Care Authority (HCA) has determined it is more cost- effective to enroll in PEBB medical than a medical assistance program. To enroll in a PEBB health plan, the retiree or surviving dependent must send a Retiree Coverage Election/Change form and evidence of continuous enrollment to the PEBB Program within the applicable timelines as listed above. Retirees and surviving dependents should contact the PEBB Program to obtain the required forms, information on premiums, and available medical plans. Annual open enrollment Subscribers may make a change to their enrollment during the PEBB Program’s annual open enrollment as follows:  Enroll in or defer enrollment in a medical plan;  Enroll or remove eligible dependents; or  Change medical plan choice. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 147 Special open enrollment TIP: You may be eligible to change medical plans if you move during the calendar year. See “When may a subscriber change his or her health plan?” on page 147 for a list of special open enrollment events. Subscribers may change their enrollment outside of the annual open enrollment if a special open enrollment event occurs. However, the change in enrollment must correspond to and be consistent with the event that creates the special open enrollment for the subscriber or the subscriber’s dependent. Exception: A retiree or surviving dependent may terminate a dependent’s enrollment at any time. Retirees or surviving dependents who have deferred their PEBB retiree insurance coverage may only enroll as described in the “Enrollment following deferral” section on page 146. To make an enrollment change, the subscriber must submit the required form(s) to the PEBB Program. Forms must be received no later than 60 days after the event that created the special open enrollment. In addition to the required forms, the PEBB Program will require the subscriber to prove eligibility or provide evidence of the event that created the special open enrollment. Exception: If a subscriber wants to enroll a newborn or child whom the subscriber has adopted or has assumed a legal obligation for total or partial support in anticipation of adoption, the subscriber should notify the PEBB Program by submitting an enrollment/change form as soon as possible to ensure timely payment of claims. If adding the child increases the premium, the required enrollment/change form must be received no later than 12 months after the date of the birth, adoption, or the date the legal obligation is assumed for total or partial support in anticipation of adoption. When may a subscriber change his or her health plan? Any one of the following events may create a special open enrollment: 1. Subscriber acquires a new dependent due to: a. Marriage or registering a state domestic partnership; b. Birth, adoption, or when the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or c. A child becoming eligible as an extended dependent through legal custody or legal guardianship. 2. Subscriber or a subscriber’s 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); 3. Subscriber has a change in employment status that affects the subscriber’s eligibility for the employer contribution toward employer-based group health plan; ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 148 4. Subscriber’s dependent has a change in his or her own employment status that affects his or her eligibility for the employer contribution under his or her employer-based group health plan; 5. Subscriber or a subscriber’s dependent has a change in residence that affects health plan availability. If the subscriber moves and the subscriber’s current health plan is not available in the new location the subscriber must select a new health plan; 6. A court order or National Medical Support Notice 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); 7. Subscriber or a subscriber’s dependent becomes entitled to coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or the subscriber or the subscriber’s dependent loses eligibility for coverage under Medicaid or a CHIP; 8. Subscriber or a subscriber’s dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from Medicaid or a state CHIP; 9. Subscriber or a subscriber’s dependent becomes entitled to coverage under Medicare, or the subscriber or a subscriber’s dependent loses eligibility for coverage under Medicare, or enrolls in or terminates enrollment in a Medicare Part D plan. If the subscriber’s current health plan becomes unavailable due to the subscriber’s or a subscriber’s dependent’s entitlement to Medicare the subscriber must select a new health plan; 10. Subscriber or a subscriber’s dependent’s current health plan becomes unavailable because the subscriber or enrolled dependent is no longer eligible for a health savings account (HSA); 11. Subscriber or a subscriber’s dependent experiences a disruption of care that could function as a reduction in benefits for the subscriber or the subscriber’s dependent for a specific condition or ongoing course of treatment. The subscriber may not change his or her health plan election if the subscriber’s 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 is not limited to considering the following: a. Active cancer treatment such as chemotherapy or radiation therapy for up to 90 days or until medically stable; b. Transplant within the last 12 months; c. Scheduled surgery within the next 60 days (elective procedures within the next 60 days do not qualify for continuity of care); d. Recent major surgery still within the postoperative period of up to 8 weeks; or e. Third trimester of pregnancy. ALERT! If an enrollee’s provider or health care facility discontinues participation with this plan, the enrollee may not change medical plans until the next open enrollment period, unless the PEBB Appeals Manager determines that a continuity of care issue exists. The plan cannot guarantee that any one physician, hospital, or other provider will be available or remain under contract with us. When can a subscriber enroll or remove eligible dependents? Any one of the following events may create a special open enrollment: ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 149 1. Subscriber acquires a new dependent due to: a. Marriage or registering for a state domestic partnership; b. Birth, adoption, or when a subscriber has assumed a legal obligation for total or partial support in anticipation of adoption; or c. A child becoming eligible as an extended dependent through legal custody or legal guardianship. 2. Subscriber or a subscriber’s 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); 3. Subscriber’s dependent has a change in his or her own employment status that affects his or her eligibility for the employer contribution under his or her employer-based group health plan; 4. Subscriber or a subscriber’s dependent has a change in enrollment under another employer- based group health plan during its annual open enrollment that does not align with the PEBB Program’s annual open enrollment; 5. 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; 6. A court order or National Medical Support Notice requires the subscriber or any other individual to provide insurance coverage for an eligible dependent. (A former spouse or former state-registered domestic partner is not an eligible dependent.); 7. Subscriber or a subscriber’s dependent becomes entitled to coverage under Medicaid or a state Children’s Health Insurance Program (CHIP), or the subscriber or a subscriber’s dependent loses eligibility for coverage under Medicaid or CHIP; 8. Subscriber or a subscriber’s dependent becomes eligible for state premium assistance subsidy for PEBB health plan coverage from Medicaid or a state CHIP. Medicare entitlement Medicare Part A and Medicare Part B If an enrollee becomes entitled to Medicare, he or she should contact the nearest Social Security Administration Office to ask about Medicare enrollment. Unless retirement occurred before July 1, 1991, or the enrollee is a dependent of an employee who retired before July 1, 1991 and is enrolled in PEBB coverage, the enrollee must enroll and maintain enrollment in Medicare Part A and Medicare Part B. Medicare will become the primary insurance coverage, in most cases, and the PEBB retiree medical plan will become the secondary insurance coverage. PEBB rules do not require you to enroll in Medicare’s prescription drug coverage, Medicare Part D. You cannot have both UMP CDHP and Medicare Part D. If you drop your UMP CDHP coverage and sign up for Medicare Part D, you will need to select a Medicare supplement plan offered through the PEBB Program. If you do not sign up with a PEBB Medicare supplement plan, you cannot keep your PEBB health plan coverage. Medicare Part D PEBB has determined that this 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 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 150 coverage”). Therefore, you cannot enroll in Medicare Part D and remain enrolled in this plan. If you choose to enroll in Medicare Part D, you may continue your PEBB retiree insurance coverage only by enrolling in the PEBB-sponsored Medicare supplement plan. FOR MEDICARE RETIREES: PEBB includes an “annual notice of creditable prescription drug coverage” in the fall For Your Benefit newsletter, sent to each subscriber. If sometime in the future you or your covered family member(s) decide to drop your coverage under this plan, you may contact the PEBB Program to request a certificate of creditable coverage. If you do not show that you had creditable coverage, you may have to pay higher Medicare premiums. When medical coverage ends TIP: If your coverage under this plan ends, you must pay the costs of any services or supplies, except when coverage is required by law. Medical plan enrollment ends on the following dates: 1. On the last day of the month when any individual ceases to be eligible. 2. On the date a plan terminates, if that should occur. Any person losing coverage will be given the opportunity to enroll in another PEBB medical plan. 3. For an enrollee who declines the opportunity or is ineligible to continue enrollment under one of the options described in the “Options for continuing PEBB medical coverage” on page 151, coverage ends for the enrollee on the last day of the month in which he or she ceases to be eligible. 4. If the subscriber stops paying premiums, coverage will be terminated for the subscriber and enrolled dependents retroactive to the last day of the month for which the premium and applicable premium surcharges were paid. A full month’s premium is charged for each calendar month of coverage. Premium payments and applicable premium surcharges become due the first of the month in which medical coverage is effective. Premium payments and applicable premium surcharges are not prorated during any month including if an enrollee dies or asks to terminate his or her medical plan before the end of a month. The enrollee is responsible for timely payment of premiums and reporting changes in eligibility or address. The enrollee and his or her covered dependent(s) or beneficiary is responsible for reporting changes no later than 60 days after the event, such as divorce, termination of a state-registered domestic partnership, death, or when a dependent no longer meets the eligibility criteria described under “Eligible dependents.” Failure to report changes can result in loss of premiums and loss of the subscriber and his or her dependent’s right to continue coverage under one of the continuation coverage options described in the “Options for continuing PEBB medical coverage” on page 151 of this certificate of coverage. To obtain forms subscribers can contact the PEBB Program at 1-[PHONE REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 151 If an enrollee, or newborn eligible for benefits under “Obstetric and newborn care” (page 62) is confined in a hospital or skilled nursing facility for which benefits are provided when PEBB coverage ends, and the enrollee is not immediately covered by other health care coverage, benefits will be extended until whichever of the following occurs first:  The enrollee is discharged from the hospital or from a hospital to which the enrollee is directly transferred;  The enrollee is discharged from a skilled nursing facility when directly transferred from a hospital when the nursing facility confinement is in lieu of hospitalization;  The enrollee is discharged from a skilled nursing facility or from a skilled nursing facility to which the enrollee is directly transferred;  The enrollee is covered by another health plan that will provide benefits for the services; or  Benefits are exhausted. When medical plan enrollment ends, the enrollee may be eligible for continuation coverage or conversion to other health care coverage if application is made within the time limits explained in the following sections. TIP: If your coverage under this plan ends, you are responsible for letting your providers know at the time of service. If your provider bills the plan for services you receive after your enrollment has ended, the plan will deny all claims. Options for continuing PEBB medical coverage Subscribers and their dependents covered by this health plan may be eligible to continue enrollment if they lose eligibility and are eligible under one of the following options for continuing coverage: 1. COBRA 2. Continuation Coverage 3. PEBB retiree insurance coverage The first two options above temporarily extend group insurance coverage if certain circumstances occur that would otherwise end your or your dependent’s PEBB medical coverage. COBRA coverage is governed by eligibility and administrative requirements in federal law and regulation. Continuation Coverage is an alternative for PEBB enrollees who are not eligible for COBRA. The third option above is available only to surviving dependents who meet eligibility requirements. Contact PEBB Division Customer Service at 1-[PHONE REDACTED] or refer to the Continuation Coverage Election Notice booklet for details. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 152 Conversion of coverage Enrollees (including spouses and dependents of a subscriber terminated for cause) have the right to switch from PEBB group medical coverage to an individual conversion plan offered by Regence BlueShield to UMP CDHP members when they are no longer eligible to continue the PEBB group medical plan, and are not eligible for Medicare or another group coverage that provides benefits for hospital or medical care. Enrollees must apply for conversion coverage no later than 31 days after their group medical plan ends or within 31 days from the date notice of the 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 our conversion plan differ from those of the enrollee’s current group plan. To obtain detailed information on conversion options under this medical plan, call Customer Service at 1-[PHONE REDACTED]. Appeals of determinations of PEBB eligibility Any enrollee may appeal a decision made by the PEBB Program regarding eligibility, enrollment, premium payments, or premium surcharges (if applicable) to the PEBB appeals committee. Any enrollee may appeal a decision regarding the administration of a health 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 the state of Washington is hereby amended to comply with the minimum requirements of such law or regulation. Customer service If you have questions about your PEBB retiree eligibility and benefit information, please contact the PEBB Program at 1-[PHONE REDACTED] or go to www.hca.wa.gov/pebb-retirees. For questions about Medicare, please contact the Centers for Medicare and Medicaid Services (CMS) at 1-800-MEDICARE or go to www.medicare.gov. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 153 General provisions Relationship to Blue Cross and Blue Shield Association The Washington State Health Care Authority (HCA) on behalf of itself and you expressly acknowledges its understanding that the administrative services contract constitutes an agreement solely between the HCA and Regence BlueShield. Regence BlueShield is 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). The association permits Regence BlueShield to use the Blue Cross and Blue Shield service marks in the state of Washington, for those counties designated in the service area, and that Regence BlueShield is not contracting as the agent of the association. The HCA on behalf of itself and you further acknowledges and agrees that it has not entered into the administrative services contract based upon representations by any person or entity other than Regence BlueShield. The HCA also acknowledges that no person or entity other than Regence BlueShield will be held accountable or liable to HCA or you for any of Regence BlueShield’s obligations to the HCA or you created under such agreement. This paragraph will not create any additional obligations whatsoever on the part of Regence BlueShield other than those obligations created under other provisions of the administrative services contract. Out-of-area services Regence BlueShield has a variety of relationships with other Blue Cross and/or Blue Shield Licensees referred to generally as “BlueCard Programs.” Whenever you obtain health care services outside of Regence’s service area, the claims for these services may be processed through one of these BlueCard Programs, and may include negotiated National Account arrangements available between Regence and other Blue Cross and Blue Shield Licensees. Typically, when accessing care outside the Regence’s service area, you will obtain care from health care providers that have a contractual agreement with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (“Host Blue”). In some instances, you may obtain care from out-of-network providers. Regence’s payment practices in both instances are described below. 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 fulfilling contractual obligations. However, the Host Blue is responsible for contracting with and generally handling all interactions with its network providers. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 154 Whenever you access covered services outside 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 takes into account 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 taking into account 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 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 would then calculate your liability for any covered services according to applicable law. Negotiated National Account arrangements As an alternative to the BlueCard Program, your claims for covered services may be processed through a negotiated National Account arrangement with a Host Blue. The amount you pay for covered services under this arrangement will be calculated based on the lower of either billed covered charges or negotiated price (refer to the description of negotiated price above) made available to Regence by the Host Blue. Out-of-network providers outside Regence’s service area  Member Liability Calculation. 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.  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, as permitted under Inter-Plan Programs Policies, 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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 155 Right to receive and release needed information Regence may need certain facts about your health care coverage or services provided in order 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 UMP CDHP. See page 115 for more information about the confidentiality of your health information. Right of recovery Uniform Medical Plan has the right to a refund of incorrect payments. Uniform Medical 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 the Uniform Medical Plan nor Regence BlueShield provides any health care services, neither can 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 the Uniform Medical Plan or Regence BlueShield. Neither Regence BlueShield nor the Uniform Medical Plan is responsible for the quality of health care you receive, except as provided by law. In addition, Regence BlueShield 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 Regence BlueShield’s control. Governing law and discretionary language The Uniform Medical Plan (the plan) will be governed by and construed in accordance with the laws of the United States of America and by applicable laws of the state of Washington without regard to its conflict of law rules. The Washington State Health Care Authority delegates discretion to Regence BlueShield for the purposes of paying benefits under this coverage only if it is determined that you are entitled to them and of interpreting the terms and conditions of the plan. Final determinations pursuant to this reservation of discretion do not prohibit or prevent a claimant from seeking judicial review of those determinations. The reservation of discretion made under this provision only establishes the scope of review that a court will apply when you seek judicial review of a determination of the entitlement to and payment of benefits or interpretation of the terms and conditions applicable to the plan. Regence BlueShield is not the plan administrator, but does provide claims administration under the plan, and the court will determine the level of discretion that it will accord determinations. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 156 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 reduced to writing and signed by one of the Washington State Health Care Authority’s authorized officers. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 157 Definitions Allowed amount, medical services Allowed amount 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 service area, the preferred provider organization contract with Regence BlueShield is the relevant contract that determines the allowed amount. For preferred providers that are outside the Regence service area, the contract with another Blue Cross or Blue Shield organization in the BlueCard® program for its “Preferred Provider Organization (‘PPO’) network” is the relevant contract that determines the allowed amount.  For participating providers that are within the Regence 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 service area, the contract with another Blue Cross or Blue Shield organization in the BlueCard® program is the relevant contract that determines the allowed amount.  For out-of-network providers (providers not contracted with Regence BlueShield) within the Regence service area, the amount Regence has determined to be reasonable charges for covered services and supplies. The allowed amount may be based upon the billed charges for some services, as determined by Regence or as otherwise required by law. Where, although it does not qualify as a preferred provider hereunder, one of these providers has a contract with Regence, the provider will accept the allowed amount as payment in full.  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 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’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 takes into account 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 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 158 health care providers after taking into account 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 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 would then calculate your liability for any covered services according to applicable law. Charges in excess of the allowed amount are not reimbursable. For questions regarding the basis for determination of the allowed amount, please call Customer Service at 1-[PHONE REDACTED]. Allowed amount, prescription drugs The allowed amount for prescription drugs is based on Washington State Rx Services’ contractually agreed reimbursement, unless other contractual arrangements or terms apply. All covered prescription drug claims are paid based on this allowed amount. Ambulatory surgery center (ASC) An ambulatory surgery center (ASC) is a health care facility that specializes in providing surgery, pain management, and certain diagnostic services in an outpatient setting. ASC-qualified procedures are typically more complex than those done in a doctor’s office but not so complex as to require an overnight stay. Procedures commonly performed in these centers include colonoscopies, endoscopies, cataract surgery, orthopedic, and ENT (ear, nose, and throat) procedures. An ASC may also be known as an outpatient surgery center or same-day surgery center. Appeal See pages 118–121 for an explanation of appeals and how the process works. Authorized representative An authorized representative is someone you have designated in writing to communicate with the plan on your behalf. See page 116 for how this works. Balance billing Balance billing is a provider billing you for the difference between the provider’s or facility’s charge and the allowed amount. For example, if the provider’s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. Preferred and participating providers may not balance bill you for covered services above the allowed amount. See an example of how this works on page 13. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 159 Brand-name drug A brand-name drug is a drug sold under the proprietary name or trade name selected by the manufacturer. Business day Business days are Mondays through Fridays, except for holidays observed by Washington State. Calendar day A calendar day is any day of the week regardless of whether it is observed as a holiday by Washington State. Calendar year A calendar year is January 1 through December 31. Chemical dependency Chemical dependency is an illness characterized by a physiological or dependency on a controlled substance or alcohol. Clinical review Clinical review is when a plan clinical professional reviews medical records related to inpatient treatment in order to determine if inpatient 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% of the allowed amount. This includes most medical services and prescription drugs. Coordination of benefits For members covered by more than one group health plan, coordination of benefits is the method the plan uses to determine which plan pays first, which pays second, and the amount paid by each plan. Please see description and examples in “If you have other medical coverage” on page 102. Cost share Cost share means the amount you pay for a service, supply, or drug. This may be a deductible (pages 19–20), coinsurance (page 20), 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 ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 160 limited to, help in walking, getting into and out of bed, bathing, dressing, feeding and preparing special diets, and supervising medications that are ordinarily self-administered. Deductible The deductible is a dollar amount you must pay each calendar year for health care expenses before the plan starts paying for services. For one person on an account, the annual deductible is $1,400; if there is more than one person, the deductible is $2,800 and applies to all persons collectively. Only expenses covered by the plan count toward your deductible. For example, if you receive LASIK surgery (see exclusion 32 on page 96), the plan does not apply this payment to your deductible. Some services are exempt from this deductible (see the “Summary of benefits” on pages 24–38). See pages 19–20 for details on how the deductible works. Dependent A dependent is a spouse, state-registered domestic partner, child, or other eligible family member covered by the plan under the subscriber’s account (see “Eligible dependents” on pages 128–130 and pages 141–143). 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 can diagnose a developmental delay. Domestic partner For the purposes of this certificate of coverage, a domestic partner is defined as:  A state-registered domestic partner (effective January 1, 2010); or  A person who qualified under PEBB eligibility criteria as a domestic partner before January 1, 2010, and has been continuously enrolled under the subscriber in a PEBB health plan or life insurance. Durable medical equipment Durable medical equipment (DME) is:  Designed for prolonged use.  For a specific therapeutic or clinical purpose, or to assist in the treatment of an injury or illness.  Medically necessary (meeting all plan medical necessity criteria).  Primarily and customarily used only for a medical purpose. See exclusion 78 on page 96 for examples of DME that are not covered. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 161 Efficacy Efficacy is the extent to which a specific intervention, procedure, or service produces the desired effect under ideal conditions (in a controlled environment under lab circumstances). Emergency See “Medical emergency.” Emergency fill Emergency fill is a process where the plan covers a limited quantity of a medication on an emergency basis while the plan processes your drug preauthorization request. Enrollee An enrollee is an employee, retiree, former employee, or dependent enrolled in this plan (see also “Member,” “Subscriber,” and “Dependent”). Experimental or investigational Experimental or investigational means a service, supply, intervention, or drug that the plan has classified as experimental or investigational and therefore, is not covered, even if the service, supply, intervention, or drug 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 service, supply, intervention, or drug to determine if it is investigational. A service, supply, or drug not meeting all of the following criteria is, in the plan’s judgment, investigational:  If a medication or device, the health intervention must have final approval from the United States Food and Drug Administration (FDA) as being safe and efficacious for general marketing. However, if a medication is prescribed for other than its FDA-approved use(s) and is recognized as “effective” for the use for which it is being prescribed, benefits for that use will not be excluded. To be considered “effective” for other than its FDA-approved use, a medication must be so recognized in one of the standard reference compendia (see definition on page 175) or, if not, then in a majority of relevant peer-reviewed medical literature (see definition on page 170); or by the United States Secretary of Health and Human Services.  The scientific evidence must permit conclusions concerning the effect of the service, supply, intervention, or drug on health outcomes, which include the disease process, injury or illness, length of life, ability to function, and quality of life.  The service, supply, intervention, or drug must improve net health outcome.  The scientific evidence must show that the service, supply, intervention, or drug is as beneficial as any established alternatives.  The improvement must be attainable outside the laboratory or clinical research setting.  The service, supply, intervention, or drug is provided by a provider that has demonstrated medical proficiency in the provision of the service, supply, or drug.  The service, supply, intervention, or drug is recognized by the medical community in the service area in which they are received. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 162  The service, supply, intervention, or drug is not considered to be experimental or investigational by U.S. standards. When the plan receives a claim or request for preauthorization that includes all information necessary to make a decision, you will be informed within 20 business days if the service, supply, or drug is considered experimental or investigational. To determine the necessary documentation, call UMP Customer Service at 1-[PHONE REDACTED] (TTY: 711). You may be liable for all charges if you receive services that are determined to be experimental or investigational (see “What the plan doesn’t cover” section on pages 94–101). You may have the right to an expedited appeal; see page 120 for that process. Explanation of Benefits (EOB) An Explanation of Benefits (EOB) is a detailed account of each medical claim processed by the plan, which is sent to you to notify you of claim payment or denial. You can also get this online on your account at regence.com, or call Customer Service to request a copy of an EOB (you will need to provide identifying information). 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 enrollees. See “Allowed amount, medical services” on page 157 for more details. Formulary See “What drugs are covered? The UMP Preferred Drug List” on page 75. Generic drug A generic drug is a 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 drug, which means it works like the brand- name drug in dosage, strength, performance, and use. All generic drugs sold in the United States must be reviewed and approved by the U.S. Food and Drug Administration, and meet the same quality and safety standards as brand-name drugs. Generic equivalent A generic equivalent is a generic 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 “Can the pharmacist substitute one drug for another?” on page 86 for how this works. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 163 Grievance A grievance is also called a complaint. See page 117 for details on how these are handled. Health Care Authority (HCA) The Health Care Authority is the Washington State agency that administers the Uniform Medical Plan (UMP Classic, UMP CDHP, and the UMP Plus Plans: UMP Plus–UW Medicine Accountable Care Network and UMP Plus–Puget Sound High Value Network) in addition to the following health care programs: Washington Prescription Drug Program, Public Employees Benefits Board (PEBB) Program, and Apple Health, formerly called Medicaid. Health intervention Health intervention is a medication, service, or supply provided to prevent, diagnose, detect, treat, or palliate the following: disease, illness, injury, genetic or congenital anomaly, pregnancy or biological or condition that lies outside the range of normal, age-appropriate human variation; or to 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 considered to be new if it is not yet in widespread use for the medical condition and the patient indications being considered. Health Savings Account (HSA) A Health Savings Account (HSA) is a tax-advantaged spending and savings account that can be used to pay for qualified medical expenses. IRS rules govern who can have an HSA and how the funds can be spent. The HSA is funded by pre-tax contributions from you, your employer, or both. See page 25 for the current year’s contribution limits. You can contribute up to the annual limit even if your health plan deductible is lower. The rates are subject to change every year, adjusted for inflation. High-deductible health plan (HDHP) A high-deductible health plan (HDHP) is any plan with a deductible of at least $1,300 for an individual or $2,600 for a family. A consumer-driven health plan (CDHP), also known as a consumer-directed health plan, is a HDHP with a health savings account. Home Where the member is located at the time of service other than facility or other place of origin. 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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 164 Hospice Hospice 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 patients and their families without intent to cure. Hospital A hospital is an institution accredited under the Hospital Accreditation Program of the Joint Commission and licensed by the state where it’s located. Any exception to this must be approved by the plan. The term hospital does not include a convalescent nursing home or institution (or a part of one) that:  Furnishes primarily domiciliary or custodial care (see definition on page 159).  Is operated as a school.  Is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged. Inpatient stay From when you are admitted to a hospital or other medical facility, until you are discharged from that facility. IRO Independent Review Organization (see page 122). Limited benefit TIP: This definition applies only to those benefits in which it is used in this certificate of coverage. Other benefits have additional limits related to medical necessity (see page 165) or preauthorization of services (see page 90). 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. The plan does not make exceptions to benefit limits. For benefits limited to a certain number of visits, any visits that are applied to your deductible (see page 19) 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 six massage therapy sessions to your deductible, you may receive coverage for 10 more sessions in that calendar year, for a total of 16 visits (the visit maximum for massage therapy). Note: These limits apply per enrollee. 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 his/her license provides services coded under a limited benefit spinal manipulation or physical therapy), those services will be counted against ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 165 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 of 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 benefits. Maintenance care Maintenance care is a health intervention after the patient has reached maximum rehabilitation potential or functional level and has shown no significant improvement for one to two weeks, and instruction in the maintenance program has been completed. Maintenance care may apply to a number of 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 certificate of coverage). Medical benefit Medical benefit refers to services subject to the deductible and coinsurance. See pages 19–23 for a description of how this works. Medical emergency A medical emergency means a medical condition that manifests itself by acute of sufficient severity (including severe pain) so that a prudent layperson who has an average knowledge of medicine and health would reasonably expect the absence of immediate medical attention at a hospital emergency room to result in any one of the following:  Placing the person’s health, or with respect to a pregnant female, her health or the health of her unborn child, in serious jeopardy;  Serious impairment to bodily functions; or  Serious dysfunction of any bodily organ or part. Medically necessary services, supplies, drugs, or interventions ALERT! The provider or patient must provide documentation demonstrating medical necessity when requested by the plan, or services may be denied as not medically necessary. Some services that are medically necessary may not be covered by the plan. All benefits or services that are medically necessary are subject to the coverage limitations, exclusions, and provisions of the plan. It is important to review this certificate of coverage or verify coverage with UMP Customer Service at 1-[PHONE REDACTED] (TTY: 711) before receiving services. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 166 Medically necessary or medical necessity means health care services, drugs, supplies, or interventions that a treating licensed health care provider recommends and all of the following conditions are met: 1. The purpose of the service, supply, intervention, or drug is to treat or diagnose a medical condition. 2. It is the appropriate level of service, supply, or intervention, or drug dose considering the potential benefits and harm to the patient. 3. The level of service, supply, intervention, or drug dose is known to be effective in improving health outcomes. 4. The level of service, supply, intervention, or drug recommended for this condition is cost- effective compared to alternative interventions, including no intervention. The fact that a physician or other provider prescribes, orders, recommends, or approves a service or supply, drug, or drug dose does not, in itself, make it medically necessary. The plan may require proof that services, interventions, supplies, or drugs (including court- ordered care) are medically necessary. No benefits will be provided if the proof isn’t received or isn’t acceptable, or if the service, supply, drug, or drug dose is not medically necessary. Claims processing may be delayed if proof of medical necessity is required but not 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 patient indications being considered. State law requires that Uniform Medical Plan determine whether a service or intervention is covered based on decisions made by the Health Technology Clinical Committee (HTCC) (see page 27); these decisions may be referenced at www.hca.wa.gov/about- hca/health-technology-assessment/health-technology-reviews. If the HTCC determines that a health technology will be covered only under certain conditions, the plan is required by law to use the HTCC coverage criteria when evaluating whether the technology is medically necessary. For other services, interventions, or supplies the plan first uses scientific evidence, then professional standards, then expert opinion to determine effectiveness. “Effective” means that the drug, drug dose, intervention, supply, or level of service can reasonably be expected to produce the intended results and to have expected benefits that outweigh potential harmful effects. The scientific evidence should be considered first and, to the greatest extent possible, should be the basis for determining medical necessity. If no scientific evidence is available, professional United States standards of care should be considered. If professional standards of care do not exist, or are outdated or contradictory, decisions about interventions should be based on expert opinion. Giving priority to scientific evidence does not mean that the plan should deny coverage of interventions in the absence of conclusive scientific evidence. Interventions can meet the plan’s definition of medical necessity in the absence of scientific evidence if there is a strong conviction of effectiveness and benefit expressed through up-to-date and consistent professional standards of care, or, in the absence of such standards, convincing expert opinion. A level of service, supply, drug, or intervention is considered “cost effective” if the benefits and harms relative to the costs represent an economically efficient use of resources for the patients with this condition. The plan applies this criterion based on the characteristics of the individual patient. Cost-effective does not necessarily mean the lowest price. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 167 Preventive services not covered by the plan’s preventive care benefit will still be covered under the medical benefit if medically necessary. A “health intervention” is an item or service delivered or undertaken primarily to treat (that is prevent, diagnose, detect, treat, or palliate) a medical condition (such as a disease, illness, injury, genetic or congenital defect, pregnancy, or a biological or condition that lies outside the range of normal, age-appropriate human variation) or to maintain or restore functional ability. For purposes of this definition of “medical necessity” the plan does not consider a health intervention separately from the medical condition and patient indications it is applied to. “Treating provider” means a licensed health care provider who has personally evaluated the patient. “Health outcomes” are results that affect health status as measured by the length or quality (primarily as perceived by the patient) of a person’s life. 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 can 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 on the basis of professional standards of care or expert opinion. Member A member is an employee, retiree, former employee, or dependent enrolled in the plan (see also “Enrollee”). Network Network is the facilities, providers, and suppliers your health plan contracts with to provide health care services. Network pharmacy A network pharmacy contracts with Washington State Rx Services to provide prescription drug coverage to UMP CDHP members at the contracted rate (allowed amount). See page 77 to learn about the advantages of using network pharmacies. Network vaccination pharmacy A network vaccination pharmacy is a pharmacy that contracts with Washington State Rx Services to give immunizations to plan enrollees at the network rate. You can find out which pharmacies are contracted at www.hca.wa.gov/ump/find-drugs or by calling Washington State Rx Services at 1-[PHONE REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 168 Noncovered services Noncovered services refers to any service that is not covered by the plan. Some services may be medically necessary, yet still are not covered. See “What the plan doesn’t cover” on pages 94–101 and “Guidelines for drugs not covered” on page 88 for details. Nonduplication of benefits Nonduplication of benefits is how UMP CDHP coordinates benefits when UMP CDHP is your secondary coverage (see definition on page 174). When another HDHP is primary (pays first), that plan pays their normal benefit. UMP CDHP then pays up to the amount we would have paid if UMP CDHP had been the primary plan. If the primary plan pays as much or more than the normal UMP CDHP benefit, UMP CDHP pays nothing. UMP CDHP does not pay the rest of the allowed amount. See examples on page 105. Non-network pharmacy A non-network pharmacy does not contract with Washington State Rx Services. See page 79 for what happens if you use a non-network pharmacy to purchase covered prescription drugs. Nonpreferred drug A nonpreferred drug is a prescription drug designated as nonpreferred in the UMP Preferred Drug List (see page 75). Nonprescription alternative A nonprescription alternative includes an over-the-counter drug, dietary supplement, herbal supplement, vitamin, mineral, medical food, or medical device that you can 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 can buy without a prescription. Normal benefit The plan’s normal benefit is the dollar amount of the benefit the plan would normally pay if no other group health plan had the primary responsibility to pay the claim. Occupational injury or illness An occupational injury or illness is one resulting from work for pay or profit. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 169 Open enrollment Open enrollment is a period defined by the HCA when you have the opportunity to 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. Orthognathic surgery Orthognathic surgery is surgery to correct conditions of the jaw and face related to structure, growth, sleep apnea, or TMJ disorders; or to correct orthodontic problems that cannot be easily treated with braces. Out-of-network provider(s) An out-of-network provider is a health care provider that is:  In the Regence service area, but is not contracted as part of Regence BlueShield’s preferred provider organization network; or  Outside the Regence service area, but is not 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. Out-of-pocket limit The out-of-pocket limit is the maximum total amount you pay to your providers for covered services and prescription drugs during a calendar year. The limit is $4,200 for one person on an account, or $8,400 if there is more than one person on an account. However, no individual may exceed $6,850 in covered out-of-pocket expenses annually. Once you have reached this limit, the plan pays 100% of the allowed amount for covered services from preferred providers for the rest of the calendar year. See pages 21–23 for what does and doesn’t count toward this limit. Note: Your deductible (see page 19) does count toward this limit. Over-the-counter alternative An over-the-counter alternative drug is a drug that you can 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 can get without a prescription. Over-the-counter equivalent An over-the-counter equivalent is a drug you can buy without a prescription that has identical active ingredients and as a prescription drug or product in a comparable dosage form. P&T Committee See “Pharmacy & Therapeutics Committee.” ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 170 Participating provider A participating provider is contracted but is in another network. The plan pays these providers at the out-of-network rate (most covered services are paid at 60%), but the provider may not balance bill you. Coinsurance paid to a participating provider applies to the out-of-pocket limit. Covered preventive services from participating providers will be paid by the plan at 100% of the allowed amount. Covered mental health or substance abuse services from participating providers will be considered in-network. PEBB The Public Employees Benefits Board is a group of representatives, appointed by the governor, that approves insurance benefit plans for employees and establishes eligibility criteria for participation in insurance benefit plans. PEBB plan A PEBB plan is one of several health benefit plans, including the Uniform Medical Plan (UMP Classic, the UMP Consumer-Directed Health Plan, and the UMP Plus Plans: UMP Plus–UW Medicine Accountable Care Network and UMP Plus–Puget Sound High Value Network), offered through the Public Employees Benefits Board (PEBB) Program to public employees, former employees, retirees, and their dependents. Benefits and eligibility are designed by the PEBB and administered by the Health Care Authority (HCA) as part of a comprehensive benefits package. PEBB Program The PEBB Program is the Washington State Health Care Authority program that administers PEBB benefit eligibility and enrollment. Peer-reviewed medical literature Peer-reviewed medical literature is scientific studies printed in journals or other publications in which original manuscripts are published only after being critically reviewed for scientific accuracy, validity, and reliability by unbiased independent experts. Peer-reviewed medical literature, for example, does not include information from health-related websites or in-house publications of pharmaceutical manufacturers. Pharmacy & Therapeutics (P&T) Committee Pharmacy & Therapeutics Committee: A group of providers and other health care professionals who review prescription drugs and make recommendations on the preferred status of prescription drugs on the Preferred Drug List (see page 76). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 171 Physician services Physician services are health care services provided or coordinated by a licensed medical physician:  Medical Doctor (M.D)  Doctor of Osteopathic Medicine  Naturopathic physician Find the complete list of covered provider types at www.hca.wa.gov/ump-providers-cdhp. Plan Plan as referred to in this document means the UMP Consumer-Directed Health Plan (UMP CDHP) with a Health Savings Account, a self-funded PPO plan offered by the PEBB Program. In the eligibility sections (pages 127–152), “plan” refers to any PEBB-sponsored plan. In the “If you have other medical coverage” section beginning on page 102, “plan” may mean any health insurance coverage. PPO A Preferred Provider Organization (PPO) is a health plan that has a network of providers who have agreed to provide services for the plan’s enrollees at discounted rates. Enrollees may self- refer to most specialists. UMP CDHP is a PPO. Preauthorization Preauthorization is approval by the plan for coverage of specific services, supplies, or 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 drugs, the claim may be denied. See “Preauthorizing medical services” on page 90 for how this works. A list of medical services that require preauthorization is available at www.hca.wa.gov/ump-preauth-cdhp or by calling UMP Customer Service at 1-[PHONE REDACTED]. See page 83 for information on prescription drugs that must be preauthorized. Preferred Drug A preferred drug is a prescription drug that is designated as preferred on the UMP Preferred Drug List. 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 can find out if a 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 pages 80–85). The UMP Preferred Drug List is based on the Washington Preferred Drug List and recommendations by one of the Pharmacy & Therapeutics Committees that partner with Washington State Rx Services (see “Who decides which drugs are preferred?” on page 76 for more information). If your drug is not listed, call Washington State Rx Services at 1-[PHONE REDACTED]. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 172 Preferred provider(s) A preferred provider is a provider:  In the Regence service area and contracted as part of Regence BlueShield’s preferred provider organization 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. Prenatal Prenatal means during pregnancy. Preventive care In this certificate of coverage, preventive care means those services described by the Public Health Services Act, Section 2713:  Services with an A or B rating by the United States Preventive Services Task Force  Evidence-informed preventive care screenings and immunizations for infants, children, and adolescents that are supported by the Health Resources and Services Administration (HRSA).  Evidence-informed preventive care and screenings for women as described in HRSA Guidelines in accordance with 45 CFR 147.131 Primary care provider A primary care provider is a physician (see “Physician services” on page 171), nurse practitioner, or physician assistant who provides, coordinates, or helps a patient access a range of health care services. See page 16 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 means non-facility medical services performed by professional providers such as (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. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 173 Provider network(s) A provider network is a network of providers who are contracted to provide health care services to plan members. These providers have agreed to see members under certain rules, including billing at contracted rates (see “Allowed amount, medical services” on page 157). Preferred providers for UMP CDHP members in 2018 consist of Regence BlueShield preferred providers and Blue Cross and Blue Shield plan providers in the BlueCard® program designated as preferred providers. Qualified medical expense A qualified medical expense is a cost payable through a Health Savings Account, without paying income tax or tax penalties. IRS publication 502 lists the specific types of services and supplies that qualify. You may also access a list at www.healthequity.com/pebb. Quantity limit A quantity limit is a limit on how much of a particular drug you can 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 service area The Regence 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. Please check the website regence.com for up-to-date information. Residential treatment facility A residential treatment facility is a facility licensed to provide residential treatment 24 hours per day to patients requiring residential services such as individual and group counseling and education related to chemical dependency or a mental health diagnosis. Respite care Respite care is continuous care for a homebound hospice patient of more than four hours a day to provide family members temporary relief from caring for the patient. Routine Routine services are those provided as preventive, not as a result of an injury or illness. In the case of immunizations, routine refers to immunizations included on the Centers for Disease Control and Prevention (CDC) schedules (see page 67). ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 174 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; or findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes. However, scientific evidence shall 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 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 “If you have other medical coverage” starting on page 102 for more information on how this plan coordinates benefits. Skilled nursing care Skilled nursing care is services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. Skilled nursing facility A skilled nursing facility is an institution, or part of an institution, that provides skilled nursing care 24 hours a day and is classified as a skilled nursing facility by Medicare. Medicaid-eligible, long-term care facilities are not necessarily skilled nursing facilities. SmartHealth SmartHealth is a wellness program offered by the PEBB Program. SmartHealth offers a $125 wellness incentive in 2018 to eligible non-Medicare subscribers who met eligibility requirements. More details on eligibility and program requirements are at www.hca.wa.gov/pebb-smarthealth. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 175 Specialty drugs Specialty drugs are high-cost injectable, infused, oral, or inhaled drugs or products that generally require special storage or handling and close monitoring of the patient’s drug therapy. Specialty drugs are identified on the UMP Preferred Drug List. See page 85 for information on how specialty drug prescriptions are handled. 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 Subscriber A subscriber is the individual or family member who is the primary certificate holder and plan member. Substance abuse treatment facility A substance abuse treatment facility is an institution, or part of an institution, that specifically treats alcoholism or drug addiction and meets all of these criteria:  Is licensed by the state.  Keeps adequate patient records that contain course of treatment, progress, discharge summary, and follow-up programs.  Provides services, for a fee, to persons receiving alcoholism or drug addiction treatment including room and board as well as 24-hour nursing.  Performs the services under full-time supervision of a physician or registered nurse.  Certified by the Washington State Division of Behavioral Health and Recovery (DBHR), or for facilities outside of the Regence service area (see page 173), contracted with the local BlueCard network. Therapeutic alternative A therapeutic alternative is a drug that isn’t 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 efficacy and toxicity when given in the same doses. ---PAGE BREAK--- UMP Consumer-Directed Health Plan 2018 Certificate of Coverage 176 Therapeutic interchange Therapeutic interchange is substitution of a nonpreferred drug by a pharmacist with a preferred drug that is a therapeutic alternative or equivalent, with the endorsing provider’s permission (see page 86). Tobacco cessation services Tobacco cessation services are provided for the purpose of quitting tobacco use, usually cigarette smoking. UMP CDHP members under age 18 who use tobacco may participate in the online Smokefree Teen program. See page 71 for more information. UMP Consumer-Directed Health Plan (UMP CDHP) The UMP Consumer-Directed Health Plan (UMP CDHP) is a self-insured health plan offered through the Public Employees Benefits Board (PEBB) Program and managed by the Health Care Authority. It features a tax-advantaged Health Savings Account. ---PAGE BREAK---