2010 Summary of Benefits

See also: 2009 Summary of Benefits

This summary of benefits does not include all benefit limitations or special requirements. Also, copayments, coinsurance, and deductibles (both medical and prescription drug) must be satisfied (except as indicated) before the plan pays benefits. Please refer to the UMP 2010 Certificate of Coverage for details. Important:  See the changes to coinsurance, medical deductible, and out-of-pocket limit for 2010.

Benefits The plan pays network providers (percentage of the allowed amount*) The plan pays non-network providers (percentage of the allowed amount*)

* Allowed amount: The amount network providers agree to accept as payment in full. Non-network providers may charge you more than the allowed amount.
Acupuncture
16 visit max/year; only as an anesthetic or to reduce pain		 85% 60%
Ambulance
Air, ground, or water 		Not applicable 80%
Chemical Dependency Treatment
Facility (hospital) charges and professional (doctor) charges may be billed separately.
  • Inpatient Must be preauthorized
  • Facility: 100% after you pay $200 copay/day; $600 max copay/person/year
 60%
  • Professional: 85%
 60%
  • Outpatient
  • Facility: 85%
 60%
 
  • Professional: 85%
 60%
Chiropractic Treatment
See "Spinal and Extremity Manipulations"		    
Diagnostic Tests, Laboratory, and X-Rays 85% 60%
Durable Medical Equipment, Supplies, and Prostheses 85% 60%
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, the plan pays 85% of the allowed amount.
Facility (hospital) charges and professional (doctor) charges may be billed separately.
  • Facility: 85% after you pay $75 copay per visit
  • Facility: 60% after you pay $75 copay per visit
  • Professional: 85%
  • Professional: 60%
Hospice Care
Must be preauthorized		 100% 60%
  • Respite care
    $5,000 lifetime max
 100% 100%
Hospital Services
Facility (hospital) charges and professional (doctor) charges may be billed separately.
  • Inpatient
  • Facility: 100% after you pay $200 copay/day; $600 max copay/person/year
 60%
  • Professional: 85%
 60%
  • Outpatient
  • Facility: 85%
 60%
  • Professional: 85%
 60%
Mammograms    
  • Screening mammograms
    No deductible
     Beginning at age 40, one per year
 100% 60%
  • Diagnostic mammograms
 85% 60%
Massage Therapy
16-visit max per calendar year; must be prescribed for a medical condition		 85% Not applicable; massage therapists must be network providers to be covered
Mental Health Treatment
Facility (hospital) charges and professional (doctor) charges may be billed separately.
  • Inpatient
    Must be preauthorized
  • Facility: 100% after you pay $200 copay/day; $600 max copay/person/year
 60%
  • Professional: 85%
 60%
  • Outpatient
 85% 60%
Naturopathic Physician Services 85% 60%
Obstetric and Newborn Care
Facility (hospital) charges and professional (doctor) charges may be billed separately.
  • Inpatient
  • Facility: 100% after you pay $200 copay/day; $600 max copay/person/year
 60%
 
  • Professional: 85%
 60%
  • Outpatient
 85% 60%
Office Visits 85% 60%
Physical, Occupational, Speech, and Neurodevelopmental Therapy
  • Inpatient: 60-visit max per calendar year for all types of therapy combined
 Included in inpatient hospital copay 60%
  • Outpatient: 60-visit max per calendar yea for all types of therapy combined
 85% 60%
Preventive Care (including vaccines)
No deductible
Only the services listed in the UMP 2010 Certificate of Coverage are covered under this benefit		 100% 60%
Spinal and Extremity Manipulations
10-visit max per calendar year		 85% 60%
Surgery
Facility (hospital) charges and professional (doctor) charges may be billed separately.
  • Inpatient
  • Facility: 100% after you pay $200 copay/day; $600 max copay/person/year
 60%
  • Professional: 85%
 60%
  • Outpatient
  • Facility: 85%
 60%
  • Professional: 85%
 60%
Tobacco Cessation Program
Free & Clear program only		 100% Not covered
Vision Care
No deductible		    
  • Eye exams (routine)
    One exam per calendar year
 85% 60%
  • Vision hardware
    (eyeglasses, contact lenses)
 $150 max plan payment every two calendar years $150 max plan payment every two calendar years
Well Baby/Well Child Care
See Preventive Care

Prescription Drugs

The prescription drug benefit is administered by Washington State Rx Services.

Tier A Network Retail Pharmacy (up to a 90-day supply) Wellpartner Mail-Order Pharmacy (up to a 90-day supply)
Tier 1 (No deductible)
Generic drugs		 10% coinsurance $10
Tier 2 (Deductible applies)
Preferred brand-name drugs		 30% coinsurance $50
Tier 3 (Deductible applies)
Nonpreferred brand-name drugs
Note: Tier 3 drugs with a generic equivalent have an ancillary charge		 50% coinsurance $100