Certificate Of Coverage For Active Employees - Wa

2006Uniform Medical PlanPreferred Provider Organization (PPO)Certificate of Coverage forActive EmployeesSelf-insured by the State of WashingtonEffective January 1, 2006Printed under the direction of the Washington State Health Care Authority Public Employees Benefits BoardHCA 54-550 (10/05)

If you have questions about Contact Customer Service1-800-762-6004 or 425-670-3000 (Seattle area)Monday-Friday, 8 a.m. to 6 p.m.Appeals, First Level;Correspondence, Complaints,Preauthorization, Medical ReviewUniform Medical Plan PPOP.O. Box 34578Seattle, WA 98124-1578Toll-free: 1-800-762-6004Local (Seattle area): 425-670-3000Fax: 425-670-3197Benefit Information, Certificates ofCoverage, I.D. Cards, Claim Forms,Claims StatusUniform Medical PlanP.O. Box 34850Seattle, WA 98124-1850www.ump.hca.wa.govToll-free: 1-800-762-6004Local (Seattle area): 425-670-3000Finding a Network ProviderFor services in:Washington and Idaho border counties of Bonner, Kootenai, Latah, and Nez Perce:1-800-762-6004 or 425-670-3000 (Seattle area) or www.ump.hca.wa.govOther U.S. locations (Beech Street): 1-800-432-1776 or www.beechstreet.comPrescription Drugswww.express-scripts.comExpress Scripts, Inc.Member Services, Network Pharmacies, 1-866-576-3862Preferred Drugs Questions, Complaints Available 24 hours a day, 7 days a weekFirst-Level Appeals,CorrespondenceExpress Scripts, Inc.Attn: Pharmacy Appeals: WA5Mail Route BLO3906625 West 78th StreetBloomington, MN 55439Drug Coverage Managementand Preauthorization1-800-417-8164Provider to call on enrollee’s behalfMail-Service PharmacyFirst prescription, order by mail:Note: Use Web site only for refills.Express Scripts, Inc.P.O. Box 52166Phoenix, AZ 85072-9886Refills:Express Scripts, Inc. 1-866-576-3862Claims from Non-NetworkPharmaciesFax: 1-877-852-4070Enrollee phone: 1-866-576-3862Provider phone: 1-800-417-8164www.express-scripts.comExpress Scripts, Inc. WA5AP.O. Box 390873Bloomington, MN 55439-0873Case Management1-888-759-4855Eligibility and EnrollmentPEBB Benefit Serviceswww.pebb.hca.wa.gov1-800-200-1004 or 360-412-4200 Fax: 360-923-2602Monday-Friday, 8 a.m. to 5 p.m.Preventive Care ov/nip/publications/ACIP-list.htmTobacco CessationFree & Clear 1-800-292-2336Monday-Friday, 8 a.m. to 6 p.m.See pages 18-19 for more information.Contact your personnel, payroll, or insurance officeAddress ChangesWashington Hotline Numbers Alcohol and Substance Abuse 1-800-562-1240Domestic Violence 1-800-562-6025Emergency Contraception 1-888-668-2528Family Planning 1-800-770-4334HIV-AIDS (national) 1-800-342-2437Poison Control 1-800-732-6985www.freeclear.com

To Learn More About See Page Highlights . 1UMP PPO Features . 1How to Use the Plan . 1Your Rights and Responsibilities as a UMP PPO Enrollee.2Information Available To You .3Confidentiality of Your Health Information.4Release of Information .4Your Cost-Sharing Requirements . 5Annual Medical/Surgical Deductible . 5Benefits Not Subject to the Annual Medical/Surgical Deductible .5Annual Prescription Drug Deductible . 5Coinsurance . 5Copayments . 5Annual Medical/Surgical Out-of-Pocket Limit . 5Maximum Plan Payment . 6Summary of Benefits . 7How the UMP PPO Works . 14Your Medical/Surgical Provider Options . 14Network Providers .14Out-of-Network Providers .15Non-Network Providers .15Approved Provider Types .15Coverage Outside Washington State . 16Services Received Outside Washington, Inside the U.S. .16Services Received Outside the U.S. .17Emergency Care . 17Medical Review . 17Preauthorizing Services .17Confirming Benefits .18Medical Review During Claim Processing .18Second Opinions .18Case Management for Serious Illness . 18Optional Case Management.18Required Case Management .19Your Prescription Drug Provider Options . 19Retail Pharmacies .19Mail-Service Pharmacy.20Internet or Other Mail-Order Pharmacies .20Your Prescription Drug Benefit Amount. 20UMP Preferred Drug List .20Prescription Drug Benefits Summary .21Limits on Drug Coverage. 22Limits on Specialty Drugs .22What to Do if Drug Coverage Is Denied .22(continued on next page)

To Learn More About See Page Covered Expenses. 23Acupuncture .23Ambulance .23Biofeedback Therapy .24Blood and Blood Derivatives .24Bone, Eye, and Skin Bank Services.24Cardiac and Pulmonary Rehabilitation .24Chemical Dependency Treatment .24Chiropractic Physician Services .24Dental Services .24Diabetes Education .25Diagnostic Tests, Laboratory, and X-Rays .25Dialysis.26Durable Medical Equipment, Supplies, and Prostheses .26Emergency Room .26Hearing Care .27Home Health Care .27Hospice Care (Including Respite Care) .27Hospital Inpatient Services .28Hospital Outpatient Services .28Massage Therapy .28Mastectomy and Related Services .28Mental Health Treatment .29Naturopathic Physician Services .29Neurodevelopmental Therapy for Children Ages 6 and Younger .29Obstetric and Newborn Care .30Office, Clinic, and Hospital Visits .30Organ Transplants .30Outpatient/Day Surgery, Ambulatory Surgical Center (ASC) .31Phenylketonuria (PKU) Supplements .31Physical, Occupational, and Speech Therapy .31Prescription Drugs, All Insulin, and All Disposable Diabetic Supplies .32Preventive Care .34Radiation and Chemotherapy .40Second Opinions .40Skilled Nursing Facility.40Spinal and Extremity Manipulations.40Telemedicine Services .41Temporomandibular Joint (TMJ) Treatment .41Tobacco Cessation Program .41Vision Care (Routine) .41Expenses Not Covered, Exclusions, and Limitations . 42Filing a Claim . 46For Medical/Surgical Services . 46Calculating Benefits When UMP PPO Is Your Primary Coverage: Some Sample Claims . 47For Prescription Drugs . 48False Claims or Statements . 48

To Learn More About See Page Complaint and Appeal Procedures . 49Complaints. 49What Is a Complaint? .49Prescription Drug Coverage Management .49Appeals . 49What Is an Appeal? .49General Information About Appeals .50Independent Review . 52If You Have Other Medical Coverage . 53Who Pays First? . 53For the Subscriber .53For a Spouse or Same-Sex Domestic Partner Covered by a UMP PPO Subscriber .53For Dependent Children Covered by a UMP PPO Subscriber.53Other Types of Plans.54When UMP PPO Is the Secondary Payer. 54Example: Coordination of Benefits Calculation When UMP PPO Is Secondary .55Coordination of Benefits (COB) Questionnaire .55When Another Party Is Responsible for Injury or Illness . 56How UMP Handles Payment . 56Recovery of Expenses Initially Paid By UMP . 56Eligibility and Enrollment . 57Eligibility . 57Eligible Employees .57Eligible Dependents .57Medicare Entitlement .58Enrollment . 58Waiver of Coverage .59Enrolling a Dependent Acquired After the Subscriber’s Effective Date of Coverage .59When Coverage Begins .60Special Enrollment for Employees and Their Dependents Who Previously Waived Coverage .60Changing Medical Plans Mid-Year.61When Coverage Ends .62Options for Continuing PEBB Benefits .62UMP PPO As “Creditable Coverage” For Medicare Part D. 63Definitions . 64This booklet explains benefit provisions specific to UMP PPO and is the certificate of coverage for UMP PPO enrollees. (This certificate of coveragesupersedes previous certificates.)If provisions in this booklet are inconsistent with any federal or state statute or rule, the language of the statute or rule will govern.This booklet was compiled by the Washington State Health Care Authority/Uniform Medical Plan, PO Box 91118, Seattle, WA 98111-9218. If you have anyquestions about these provisions, please contact UMP PPO (see the Directory).

Highlights 1UMP PPO 2006 Active Certificate of CoverageHighlightsWelcome to the Uniform Medical Plan Preferred ProviderOrganization (UMP PPO)! UMP PPO is a self-insuredplan designed by the Public Employees Benefits Board(PEBB) and administered by the Washington State HealthCare Authority (HCA). Your coverage through UMP PPOgives you access to one of the largest provider networksin Washington State, as well as care from out-of-statenetworks in most other parts of the country.This plan is designed to keep you and your familyhealthy in addition to providing benefits in case of illnessor injury. As you know, your health care coverage canbe one of your most important benefits. Please reviewthis booklet carefully so that you can take advantage ofall this plan has to offer. In addition, you can visit theUMP Web site at www.ump.hca.wa.gov to access thefollowing: Online accounts, where you can access your medical and pharmacy claims information through secureWeb sites. Secure e-mail to submit questions to CustomerService (through your online account). Benefits information. UMP’s preferred drug list. Provider and pharmacy network directories. UMP publications and forms. Although you can select any approved provider type,network providers offer several advantages: Higher level of coverage. No claim forms for you to fill out. Your enrollee coinsurance applies to your annualmedical/surgical out-of-pocket limit. Preventive care, preauthorized hospice services,and tobacco cessation services through Free &Clear are covered at 100% of allowed charges. You’re not responsible for differences betweenthe provider’s billed charge and the UMP allowedcharge. Because the UMP PPO network includes such a largenumber of physicians and other health care professionals, it’s likely your current provider is already anetwork provider. All care must be medically necessary (as defined onpages 67-68) to be covered. Enrolling in UMP PPO also gives you access tonetwork pharmacies nationwide, where you canpurchase retail prescription drugs at discountedrates — with no claim forms to worry about. You mayalso order prescriptions through our mail-servicepharmacy. See pages 19-22 and 32-34 for details onyour prescription drug benefits. Frequently asked questions. Preventive care, routine vision exams and hardware,tobacco cessation services through Free & Clear,and required second opinions are not subject to theannual medical/surgical deductible.UMP PPO FeaturesHow to Use the Plan Links to health resources and Medicare information. Explanations of complaints and appeals processes.Here are a few important plan features: When covered by UMP PPO, you can choose to seenetwork, out-of-network, or non-network providers.These different options are described on pages 14-15,along with the coverage differences. In most cases, UMP PPO allows you to self-refer forservices from network, out-of-network, and nonnetwork providers belonging to any approved provider type (see list beginning on pages 15-16). Worldwide coverage for nonemergency and emergency care is a definite plus when you travel. Referto “Coverage Outside Washington State” on pages16-17 for specific information. Review the UMP PPO’s online provider and pharmacy directories at www.ump.hca.wa.gov, or callUMP Customer Service at 1-800-762-6004 or425-670-3000 in the Seattle area to request thesedirectories. Choose a UMP PPO network provider or UMP network pharmacy. Provider can refer to a person(a doctor or other health care professional) or a facility (such as a hospital, clinic, etc.). Since networkchanges occur daily, when calling for an appointmentask if your provider is a UMP PPO network provider.You may also call UMP to confirm your provider’sstatus. Remember that UMP PPO network providers are covered at a higher benefit level and give you