UMP Classic 2012 Summary of Benefits

This summary of benefits does not include all benefit limitations or special requirements. Copays, coinsurance, and deductibles (both medical and prescription drug) must be met except as indicated before the plan pays benefits. Percentages shown below apply to the allowed amount, which is the fee accepted as payment in full by network providers.

For more information about your benefits, refer to the UMP Classic 2012 Certificate of Coverage. You can also call Customer Service at 1-888-849-3681 (TTY: 711). Use www.myRegence.com for 24-hour access to your medical claims and other online resources.

UMP Classic 2012 Summary of Benefits
All covered benefits are subject to the medical deductible unless noted. Percentages shown apply to the allowed amount (the fee accepted as payment in full by network providers). Some exclusions may apply to all benefits; see "What the Plan Doesn't Cover."
Benefits	You pay for services by network providers (percentage of the allowed amount)	You pay for services by non-network providers (percentage of the allowed amount)	Preauthorization or notification¹ required?
¹ Notification required: Your provider must notify the plan when you receive services. ² Inpatient copay: What you pay for facility charges at network facilities. ³ You will pay any difference between the plan's allowed amount and the provider's billed charge in addition to this percentage. This difference does not count toward your medical deductible or medical out-of-pocket limit. ⁴ Not subject to the medical deductible.
Ambulance Air, ground, or water	20%	20%	Some services require preauthorization; call 1-888-849-3681
Chemical Dependency Treatment Facility (hospital) charges and professional (doctor) charges may be billed separately.
Inpatient	Facility: Inpatient copay² Professional: 15%	Facility: 40%³ Professional: 40%³	Notification¹ Residential treatment requires preauthorization
Outpatient	Facility: 15% Professional: 15%	Facility: 40%³ Professional: 40%³	Some services
Chiropractic Treatment See "Spinal and Extremity Manipulations"
Diagnostic Tests, Laboratory, and X-Rays	15%	40%³	Computed Tomographic Angiography
Durable Medical Equipment, Supplies, and Prostheses	15%	40%³	A few supplies
Emergency Room (ER) You do not have to pay the ER copay if admitted to the hospital directly from the ER. If the patient didn't have access to network providers, you pay 15% of the allowed amount, plus any amount the provider charges over the allowed amount.
Facility (hospital) charges and professional (doctor) charges may be billed separately.	Facility: 15% after you pay $75 copay per visit Professional: 15%	Facility: 15%³ after you pay $75 copay per visit Professional: 15%³	No
Hospice Care	$0	40%³	No
Respite Care $5,000 lifetime maximum	$0	$0	No
Hospital Services Facility (hospital) charges and professional (doctor) charges may be billed separately.
Inpatient	Facility: Inpatient copay² Professional: 15%	Facility: 40%³ Professional: 40%³	Notification¹
Outpatient	Facility: 15% Professional: 15%	Facility: 40%³ Professional: 40%³	Some services
Mammograms
Screening mammograms⁴ Beginning at age 40, one per calendar year	$0	40%³	No
Diagnostic mammograms	15%	40%³	No
Massage Therapy 16-visit maximum per calendar year	15%	No coverage for non-network providers	No
Mental Health Treatment Facility (hospital) charges and professional (doctor) charges may be billed separately.
Inpatient	Facility: Inpatient copay² Professional: 15%	Facility: 40%³ Professional: 40%³	Notification¹ Residential treatment requires preauthorization
Outpatient	15%	40%³	Some services
Naturopathic Physician Services	15%	40%³	No
Obstetric and Newborn Care - Also see Well-Baby Care below Facility (hospital) charges and professional (doctor) charges may be billed separately.
Inpatient	Facility: Inpatient copay² Professional: 15%	Facility: 40%³ Professional: 40%³	No
Outpatient	15%	40%³	No
Office Visits	15%	40%³	No
Physical, Occupational, Speech, and Neurodevelopmental Therapy
Inpatient: 60 days maximum per calendar year for all types of therapy combined	Included in inpatient copay²	40%³	Some services
Outpatient: 60-visit maximum per calendar year for all types of therapy combined	15%	40%³	No
Prescription Drugs See Prescription Drug Benefits for information on prescription drug coverage
Preventive Care (including immunizations)⁴	$0	40%³	No
Spinal and Extremity Manipulations 10-visit maximum per calendar year	15%	40%³	No
Surgery Facility (hospital) charges and professional (doctor) charges may be billed separately. Inpatient admissions may require notification.
Inpatient	Facility: Inpatient copay² Professional: 15%	Facility: 40%³ Professional: 40%³	Some services
Outpatient	Facility: 15% Professional: 15%	Facility: 40%³ Professional: 40%³	Some services
Tobacco Cessation Program⁴ Quit for Life program only	$0	Not covered	No
Vision Care (Routine)⁴
Eye exams (routine) One exam per calendar year	$0	40%³	No
Vision hardware (eyeglasses, contact lenses)	$150 maximum plan payment every two calendar years	$150 maximum plan payment every two calendar years	No
Well Baby/Well Child Care See Preventive Care