2021 UMP Classic PEBB Certificate Of Coverage - Wa
2021 UMP Classic (PEBB)Certificate of CoverageSelf-insured by the State of Washington·Effective January 1, 2021Printed under the direction of the Washington State Health Care Authority Public Employees Benefits Board (PEBB)HCA 54-550 (8/20)
Directory: medical servicesContact type anddescriptionContact informationUMP Customer Serviceand generalcorrespondenceCall: 1-888-849-3681 (TRS: 711)Monday-Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific)Chat live: Sign in to your Regence account at regence.com to chat liveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Email: Send secure email via your Regence account at regence.comIf you are outside the U.S. and you have questions about your benefits andcoverage, you can use email, chat live, or Skype to contact UMP CustomerService. You may request to have a customer service representative callyou at a scheduled time during normal business hours.Network providerdirectoryIf you are outside the U.S. and need to find a local provider, make anappointment or be hospitalized, call Blue Cross Blue Shield Global Coreat 1-800-810-2583 or call collect at 1-804-673-1177, 24 hours a day, 7 daysa week.Call: 1-888-849-3681 (TRS: 711)Monday-Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific)Chat live: Sign in to your Regence account at regence.com to chat liveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Nurse line (Advice 24)Access to a nurse anytimeMedical appeals,complaints andgrievancesProvider search: ump.regence.com/go/pebb/UMP-ClassicCall: 1-800-267-6729 (TRS: 711)24 hours a day, 7 days a weekCall: 1-888-849-3681 (TRS: 711)Monday-Friday: 5 a.m. to 8 p.m.; Saturday: 8 a.m. to 4:30 p.m. (Pacific)Chat live: Sign in to your Regence account at regence.com to chat liveMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Fax: 1-877-663-7526Secure Online Account: Sign in to your Regence account at regence.comand navigate to Appeals to submit an appeal onlineEmail: memberappeals@regence.comMail:UMP Member AppealsRegence BlueShieldPO Box 91015Seattle, WA 98111-91152021 UMP Classic (PEBB) Certificate of Coverage1
Contact type anddescriptionContact informationPreauthorizationCall: 1-888-849-3682 (TRS: 711)For providers submittingmedical servicepreauthorization requestsAccess to medicalclaimsClaims mailing addressFor members submittingmedical service claimsMedicareEligibility, enrollment,and address changesMonday-Friday: 7 a.m. to 5 p.m. (Pacific)Fax: 1-877-663-7526Visit: availity.comVisit: Sign in to your Regence account at regence.comFax: 1-877-357-3418Mail:Regence BlueShieldPO Box 1106Lewiston, ID 83501-1106Call: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048)24 hours, 7 days a weekVisit: medicare.gov or MyMedicare.govEmployees: Contact your payroll or benefits officeContinuation Coverage: Call the PEBB Program: 1-800-200-1004(TRS: 711)Retirees: Call the PEBB Program: 1-800-200-1004 (TRS: 711)Monday-Friday: 8 a.m. to 4:30 p.m. (Pacific)Tobacco cessationservicesSee page 76Visit: hca.wa.gov/erbAmerican Cancer Society’s Quit for Life programCall: 1-866-784-845424 hours, 7 days a weekVisit: quitnow.net22021 UMP Classic (PEBB) Certificate of Coverage
Directory: vision servicesContact type anddescriptionContact informationVision Service Plan (VSP)Member ServicesCall: 1-844-299-3041Monday-Friday: 5 a.m. to 8 p.m.; Saturday 7 a.m. to 8 p.m.;Sunday 7 a.m. to 7 p.m. (Pacific)Deaf, DeafBlind, Late Deafened and Hard of Hearing members call:1-800-428-4833Calling from outside the US: Dial exit code of your country (typically 00)plus the country code (1 for USA), then the area code (916), then theseven-digit US local phone number 635-7373.Example: 001-916-635-7373Visit: VSP website at www.vsp.comMail:Vision Service PlanP.O. Box 997100Sacramento, CA 95899-7100VSP provider directoryProvider search: Create an account on the VSP website atwww.vsp.com and log in to find a VSP Choice network provider.Call: 1-844-299-3041Monday-Friday: 5 a.m. to 8 p.m.; Saturday 7 a.m. to 8 p.m.;Sunday 7 a.m. to 7 p.m. (Pacific)VSP appeals andgrievances mailingaddressClaims mailing addressTo submit out of countryclaims, call VSP MemberServicesDeaf, DeafBlind, Late Deafened and Hard of Hearing members call:1-800-428-4833Mail:Vision Service PlanAttention: Complaint and Grievance UnitP.O. Box 997100Sacramento, CA 95899-7100Mail:Vision Service PlanP.O. Box 385018Birmingham, AL 35238-50202021 UMP Classic (PEBB) Certificate of Coverage3
Directory: prescription drug servicesContact type and descriptionContact informationPrescription drugsWashington State Rx Services (WSRxS)Contact customer service, locatenetwork pharmacies, ask prescriptiondrug questions, access prescriptiondrug claimsNetwork mail-order pharmacyOrder new prescriptions and refills,check order status, manageprescriptions, track your packageCall: 1-888-361-1611 (TRS: 711)Monday-Friday: 7:30 a.m. to 5:30 p.m. (Pacific)Available outside these hours with limited services.Visit: Find a link to yourWSRxS account l Prescription Services (PPS)Call: 1-800-552-6694Monday-Friday: 6 a.m. to 6 p.m. (Pacific)Saturday: 9 a.m. to 2 p.m. (Pacific)Providers fax: 1-800-723-9023Mailing a prescription order:Postal Prescription ServicesPO Box 2718Portland, OR 97208-2718Network specialty pharmacyOrder new prescriptions and refills forspecialty drugsVisit: Sign in to your PPS account at ppsrx.comArdon HealthCall: 1-855-425-4085 (TRS: 711)Monday-Friday: 8 a.m. to 7 p.m. (Pacific)Saturday: 8 a.m. to 12 p.m. (Pacific)Closed Sundays and all major holidaysProviders fax: 1-855-425-4096Prescription drug paper claims,complaints and appealsSee instructions for submitting a claimon page 137Visit: ardonhealth.comWSRxSCall: 1-888-361-1611 (TRS: 711)Monday-Friday: 7:30 a.m. to 5:30 p.m. (Pacific)Fax claims to: 1-800-207-8235Fax appeals to: 1-866-923-0412Email: Send secure email through your WSRxS account WSRxSPO Box 40168Portland, OR 97240-0168Visit: Find claim forms on the HCA website athca.wa.gov/ump-forms-pubs42021 UMP Classic (PEBB) Certificate of Coverage
Contact type and descriptionContact informationPrescription drug preauthorizationWSRxSFor providers and pharmacistssubmitting prescription drugpreauthorization requestsCall: 1-888-361-1611 (TRS: 711)Monday-Friday: 7:30 a.m. to 5:30 p.m. (Pacific)Fax: 1-800-207-8235Visit: covermymeds.com (see page 102)HCA is committed to providing equal access to our services. If you need an accommodation, or requiredocuments in another format, please contact the following: Employees: Your payroll or benefits office. Retirees and PEBB Continuation Coverage members: Call us at 1-800-200-1004 (TRS: 711).2021 UMP Classic (PEBB) Certificate of Coverage5
Table of ContentsDirectory: medical services . 1Directory: vision services. 3Directory: prescription drug services . 4Online services . 11How to use this certificate of coverage . 12Section for Medicare retirees . 12If you still have questions . 12About UMP Classic . 13Finding a health care provider . 13Sample payments to different provider types. 15How to find a preferred provider . 16Covered provider types. 16When you do not have access to a preferred provider: network waiver . 17When and how to request a network waiver . 17Out-of-area services . 18Services received outside the United States . 20What you pay for medical services . 21Deductibles . 21Coinsurance . 23Copay . 24When you pay . 24Medical out-of-pocket limit. 25Summary of services and payments . 26Deductibles and limits . 26Types of services . 27What else you need to know . 31Benefits: what the plan covers . 31Guidelines for coverage . 31Health Technology Clinical Committee (HTCC) . 32Summary of benefits . 35List of benefits. 38Acupuncture . 38Ambulance . 3862021 UMP Classic (PEBB) Certificate of Coverage
Applied Behavior Analysis (ABA) Therapy . 39Autism treatment . 39Bariatric surgery. 40Behavioral health . 40Breast health screening tests . 43Care Gap Closure Program . 43Care management . 43Chiropractic physician services . 44Dental services. 44Diabetes care supplies . 46Diabetes Control Program . 47Diabetes education . 47Diabetes Prevention Program (DPP) . 47Diagnostic tests, laboratory, and x-rays . 48Dialysis . 48Durable medical equipment (DME), supplies, and prostheses. 49Emergency room . 51End-of-life counseling . 51Family planning services . 51Foot care, maintenance . 53Genetic services . 53Headaches, chronic migraine or chronic tension type . 53Hearing care (diseases and disorders of the ear) . 53Hearing exam and hearing aids. 53Home health care . 54Hospice care . 55Hospital services . 56Infusion drug site of care program . 57Joint replacement surgery, knees and hips in the Centers of Excellence (COE) Program . 58Knee arthroplasty, total . 61Mammogram and Digital Breast Tomosynthesis (DBT) . 61Massage therapy . 62Mastectomy and breast reconstruction . 62Mental health . 62Naturopathic physician services . 632021 UMP Classic (PEBB) Certificate of Coverage7
Nurse line . 63Nutrition counseling and therapy . 63Obstetric and newborn care. 63Office visits. 65Orthognathic surgery . 65Pain and joint management, interventional . 65Prescription drugs. 66Preventive care . 66Radiology . 68Second opinions . 69Skilled nursing facility . 69Sleep therapy . 70Spinal and extremity manipulations. 70Spinal injections . 70Spinal surgery . 71Spine Care in the Centers of Excellence (COE) Program . 71Substance use disorder . 74Surgery . 74Temporomandibular joint (TMJ) treatment . 75Therapy: Neurodevelopmental, occupational, physical, and speech . 75Tobacco cessation services . 76Transgender services . 78Transplants . 78Urgent care . 78Virtual care . 78Vision care (diseases and disorders of the eye) . 80Your routine vision benefits . 81Finding a routine vision provider . 81Adults (ages 19 and over) . 81Children (under the age of 19) . 84Claims administration . 85Your prescription drug benefit . 86The UMP Preferred Drug List . 87How UMP decides which prescription drugs are preferred . 88What you pay for prescription drugs . 8882021 UMP Classic (PEBB) Certificate of Coverage
How the prescription drug cost-limit works . 92Your prescription drug out-of-pocket limit. 92Where to buy your prescription drugs . 95Guidelines for prescription drugs UMP covers . 98Limits on your prescription drug coverage . 101What to do if the plan denies coverage . 107Prescription drugs UMP does not cover . 107Limits on plan coverage . 108Preauthorizing medical services . 108General information from UMP Customer Service. 111What the plan does not cover . 112If you have other medical coverage . 122Coordination of benefits . 122Contact UMP and WSRxS . 123Who pays first . 123For retirees enrolled in Medicare and UMP Classic . 128Are you a Medicare retiree? . 128How UMP Classic and Medicare work together . 128When you pay: How billing works . 133Why you might get a COB savings check from UMP Classic . 133How UMP Classic prescription drug coverage works with Medicare . 133Where to go for more information . 134Billing & payment: filing a claim. 135Submitting a claim for medical services. 135Submitting a claim for prescription drugs . 137False claims or statements . 138Complaint and appeal procedures . 139What is a complaint or grievance? . 139How to submit a complaint or grievance . 139What is an appeal? .
Jan 01, 2021 · HCA website at hca.wa.gov/ump-forms-pubs . 2021 UMP Classic (PEBB) Certificate of Coverage 5 . Contact type and description . Contact information . Prescription drug preauthorization . For providers and pharmacists . submitting prescription drug . preauthorization requests WSRxS . Call:
hca.wa.gov/ump-pebb-coc for full benefit details. To get the most out of your . Service at 1-888-849-3681 (TRS: 711). Hearing aid benefit The hearing aid benefit for UMP members is changing. Starting in 2021, you pay 0 of the allowed amount every five calendar . full preventive care list on HealthCare.gov . 4 2021 UMP (PEBB) Open .
hca.wa.gov/pebb-employee . hca.wa.gov/pebb-rules . 2023 PEBB employee medical monthly premiums. Effective January 1, 2023, for state agency and higher-education employees. . During open enrollment, you can learn more about your health plan and other insurance options by attending one of the PEBB Program benefits fairs. All are from noon to 3 .
Kaiser WA SoundChoice Kaiser WA CDHP UMP Classic UMP Plus UMP Select UMP CDHP. Non-Medicare Retirees & Split Accounts. 4 Split Account is defined as non-Medicare and Medicare members enrolled under one Subscriber account. For Example: . Sara.Whitley@hca.
limited to a single enrollment in medical and dental plans (PEBB Program) or medical, dental, and vision (SEBB Program). If they are a PEBB employee who waives PEBB medical and dental for SEBB medical, they must also enroll in SEBB dental and vision. Relationship to subscriber 1 This field is required for health care services.
, select “Forms & publications” in the blue bar at the top of the page, and type “UMP: pr
PEBB Retiree Enrollment Guide Acronyms used in this segment – HCA Health Care Authority – PEBB Public Employees Benefits Board – FSA Flexible Spending Account – CDHP Consumer Directed Health Plan – HSA Health Savings Account – VEBA Voluntary Employee Beneficiary Assoc
https://hca.wa.gov/ PEBB Health Benefit Plan –Cost and Utilization Trends November 30, 2018 1 . Overall our analysis continues to demonstrate that subscribers in the Uniform Medical Plan (UMP) CDHP pay a higher monthly premi
Waves API 550 User Manual - 3 - 1.2 Product Overview . The Waves API 550 consists of the API 550A, a 3-Band parametric equalizer with 5 fixed cutoff points per band and the API 550B, a 4-Band parametric equalizer with 7 fixed cutoff points per band. Modeled on the late 1960’s legend, the API 550A EQ delivers a sound that has been a hallmark of high end studios for decades. It provides .