2008 Summary of Benefits

This summary of 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 2008 Certificate of Coverage for details.

Benefits***	UMP pays network providers (percentage of UMP allowed amount)	UMP pays** non-network providers (percentage of UMP allowed amount)	Preauthorization required?
* Not subject to the annual medical deductible. Your enrollee coinsurance for services from non-network providers does not count towards your annual medical out-of-pocket limit, unless UMP pays the claim at the out-of-area rate. You must pay the provider's charges over UMP's allowed amount. * Several exclusions listed in "What UMP Doesn't Cover" may apply to all benefits. Please review carefully.
Acupuncture 16 treatments max/year	90%	60%	No
Ambulance Air and ground	Does not apply (no network providers)	80%	No
Biofeedback (if for mental health diagnosis,see "Mental Health Treatment")	90%	60%	No
Blood and Blood Derivatives	90%	60%	Only for stem cell harvesting for transplant purposes
Bone, Eye, and Skin Bank Services	90%	60%	No
Cardiac and Pulmonary Rehabilitation	90%	60%	Yes
Chemical Dependency Treatment UMP pays up to $14,000 per consecutive 24 calendar month period for inpatient and outpatient treatment combined
• Inpatient Facility services Doctors and other professionals may bill separately for their services	100% after you pay $200 copay/day; $600 max copay/person/year	60%	No
Professional Services	90%	60%	No
• Outpatient	90%	60%	No
Diabetes Education	90%	60%	Only for more than 10 hours per calendar year
Diagnostic Tests, Laboratory, and X-Rays (outpatient)	90%	60%	Certain services
Dialysis	90%	60%	No
Durable Medical Equipment, Supplies, and Prostheses	90%	60%	Yes, for rentals over 3 months and purchases over $1,000
Emergency Room (ER) You do not have to pay the ER copay if the patient is admitted to the hospital directly from the ER. If patient the didn't have access to a network hospital, UMP pays non-network providers at the out-of-area rate (80%).			No
• Facility	You pay $75 copay/visit; UMP pays 90% of remaining amount	You pay $75** copay/visit; UMP pays 60% of remaining amount
•Professional	90%	60% at a non-network hospital
Hearing Exams & Hearing Aids* (Routine)*			No
• Exams, routine	100% once per calendar year	60% once per calendar year
• Hearing aids	$400 max plan payment every 3 calendar years	$400 max plan payment every 3 calendar years
Home Health Care	90%	60%	Yes
Hospice Care Six months maximum benefit
• Inpatient
When preauthorized	100%	60%	Yes
When not preauthorized	90%	60%	No
• Respite care ($5,000 lifetime max)	100%	60%	Yes
Hospital Services
• Inpatient
Facility services Doctors and other professionals may bill separately for their services	100% after you pay $200 copay/day; $600 max copay/person/year	60%	Some services; see "Physical, Occupational, and Speech, Therapy"
Professional services See important information about hospital-based physicians	90%	60%	No
• Outpatient	90%	60%	No
Mammograms
• Screening mammograms* (beginning at age 40, every one or two years)	100%	60%	No
• Diagnostic mammograms	90%	60%	No
Massage Therapy 16 visits max/year	90%	Not applicable; massage therapists must be network providers to be covered.	No, but treatment plan required on file. Exception: Preauthorization required for services exceeding one hour per session.
Mastectomy and Breast Reconstruction	90%	60%	No
Mental Health Treatment
• Inpatient: Facility services Doctors and other professionals may bill separately for their services	100% after you pay $200 copay/day; $600 max copay/person/year	60%	Yes
Professional services	90%	60%	No
• Outpatient: 50 visits max/year	90%	60%	No
Naturopathic Physician Services	90%	60%	No
Neurodevelopmental Therapy See "Physical, Occupational, Speech, and Neurodevelopmental Therapy"
Obstetric and Newborn Care
• Inpatient
Facility services	100% after you pay $200 copay/day; $600 max copay/person/year (No copay for routine newborn nursery care)	60%	No
Professional services	90%	60%	No
• Outpatient	90%	60%	No
Office Visits	90%	60%	No
Organ Transplants
• Inpatient
Facility services	100% after you pay $200 copay/day; $600 max copay/person/year	60%	Yes
Professional services	90%	60%	Yes
• Outpatient Donor searches (bone marrow, stem cell, umbilical cord) are covered	90%	60%	Yes
Out-of-Area Care This is care received in locations without access to network providers	Does not apply	80%	Varies by service/supply
Outpatient Surgery	90%	60%	No
Phenylkentonuria (PKU) Supplements	90%	60%	No
Physical, Occupational, Speech, and Neurodevelopmental Therapy
• Inpatient: 60 days max/year for all types of therapy combined	100% after you pay $200 copay/day; $600 max copay/person/year	60%	Yes
• Outpatient: 60 visits max/year for all types of therapy combined	90%	60%	No, but treatment plan required on file
Prescription Drugs* See Prescription Drug Benefits for information on prescription drug coverage
Preventive Care* See lists of covered services.	100%	60%	No
Skilled Nursing Facility 150 days max/year (see important information regarding Medicare coverage)	100% after you pay $200 copay/day; $600 max copay/person/year	60%	Yes
Spinal and Extremity Manipulations 10 visits max/year	90%	60%	No
Tobacco Cessation Program* Free & Clear program only	100%	Not covered	No
Vision Care*
• Eye exams (routine) One exam per calendar year	90%	60%	No
• Vision hardware Including frames, lenses, contact lenses, and fitting fees combined	$150 max plan payment every two calendar years	$150 max plan payment every two calendar years	No
Well-Baby Preventive Care Services* See specific services covered under "Preventive Care"	100%	60%	No