Uniform Medical Plan Classic 2019 Certificate of Coverage ... Uniform Medical Plan Classic 2019...

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  • 2019 Uniform Medical Plan Classic

    Certificate of Coverage

    HCA 54-550 (11/18)

    MEDICARE RETIREES: See pages

    104–111 for Medicare

    section

    Printed under the direction of the Washington State Health Care Authority Public Employees Benefits Board

    Self-Insured by the State of Washington · Effective January 1, 2019

  • Directory: Medical services Contact type and description Contact information

    UMP Customer Service Call: 1-888-849-3681 (TRS: 711) Monday–Friday: 5 a.m. to 8 p.m. Pacific Time (PT) Saturday: 8 a.m. to 4:30 p.m. PT

    Network provider directory Call: 1-888-849-3681 (TRS: 711) Monday–Friday: 5 a.m. to 8 p.m. PT Saturday: 8 a.m. to 4:30 p.m. PT Use the provider search at www.hca.wa.gov/ump-providers-classic Live Chat: Sign into your Regence account at www.regence.com Monday-Friday: 7 a.m. to 5 p.m. PT

    Medical appeals, complaints, grievances, and general correspondence

    Call: 1-888-849-3681 (TRS: 711) Monday–Friday: 5 a.m. to 8 p.m. PT Saturday: 8 a.m. to 4:30 p.m. PT Fax: 1-877-663-7526 Email: Send secure email via your Regence account at www.regence.com Mail: Uniform Medical Plan Attn: Appeals and Grievances PO Box 2998 Tacoma, WA 98401-2998

    Preauthorization For providers submitting medical service preauthorization requests

    Providers call: 1-888-849-3682 (TRS: 711) Monday-Friday: 7 a.m. to 5 p.m. PT Providers fax: 1-877-663-7526

    Online access to medical claims Sign in to your Regence account at www.regence.com

    Claims mailing address For members submitting medical service claims

    Mail: Regence BlueShield PO Box 1106 Lewiston, ID 83501-1106 Fax: 1-877-357-3418

    Medicare Call: 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048) 24 hours, 7 days a week Visit: www.medicare.gov or www.MyMedicare.gov

    Eligibility and enrollment, address changes

    Employees: Contact your personnel, payroll, or benefits office All other members: Call the PEBB Program: 1-800-200-1004 (TRS: 711) Monday–Friday: 8 a.m. to 4:30 p.m. PT Visit: www.hca.wa.gov/erb

    Tobacco cessation American Cancer Society’s Quit for Life program See “Tobacco cessation services” in the Benefits: what the plan covers section for detailed information. Call: 1-866-784-8454 - 24 hours, 7 days a week Visit: www.quitnow.net/ump

    To obtain this booklet in another format (such as Braille or audio), call 1-888-849-3681 (TRS: 711).

  • Uniform Medical Plan Classic 2019 Certificate of Coverage 1

    Directory: Prescription drug services Contact type and description Contact information

    Prescription drugs Contact customer service, find network pharmacies, ask preferred drug questions

    Washington State Rx Services

    Call: 1-888-361-1611 (TRS: 711) - 24 hours a day, 7 days a week

    See end of Prescription drug section for more detailed contact information

    Network mail-order pharmacy Order new prescriptions and refills, check order status, manage prescriptions, track your package

    Postal Prescription Services (PPS)

    Call: 1-800-552-6694 Monday-Friday: 6 a.m. to 6 p.m. PT Saturday-Sunday: 9 a.m. to 2 p.m. PT

    Sign in to your account at www.ppsrx.com

    Network specialty pharmacy Order new prescriptions and refills for specialty drugs

    Ardon Health

    Call: 1-855-425-4085 (TRS: 711) Monday-Friday: 8 a.m. to 7 p.m. PT Saturday: 8 a.m. to 12 p.m. PT

    Prescription drug paper claims, complaints and appeals Call: 1-888-361-1611 (TRS: 711) Monday-Friday: 7:30 a.m. to 5:30 p.m. PT

    Fax claims to: 1-800-207-8235

    Fax appeals to: 1-866-923-0412

    Mail: Washington State Rx Services PO Box 40168 Portland, OR 97240-0168

    Prescription drug preauthorization For providers and pharmacists submitting prescription drug preauthorization requests.

    Washington State Rx Services

    Call: 1-888-361-1611 (TRS: 711) Monday-Friday: 7:30 a.m. to 5:30 p.m. PT

    Fax: 1-800-207-8235

    Online access to prescription drug claims Find a link to your pharmacy account at www.hca.wa.gov/ump/log-your-accounts

    To obtain this booklet in another format (such as Braille or audio), call 1-888-849-3681 (TRS: 711).

  • Uniform Medical Plan Classic 2019 Certificate of Coverage 2

    How to use this book For general topics, check the table of contents. For an overview of the most common benefits, see the “Summary of benefits” (see pages 26–34). The table shows:

     How much you will pay.  Any limits on the benefit (such as number of visits or dollar amount).  Whether preauthorization or notification is required.  The page numbers where you can find more about a benefit. To look up unfamiliar terms, see the “Definitions” section beginning on page 156.

    Section for Medicare retirees See our section just for retirees enrolled in Medicare on pages 104–111. In addition, throughout the rest of the book, look for the symbol below with accompanying blue text. This indicates information specific to Medicare retirees.

    FOR MEDICARE RETIREES: Information especially for Medicare retirees.

    If you still have questions If you have specific questions, try these options:

     Search our website at www.hca.wa.gov/ump.  Call UMP Customer Service for questions about medical services at 1-888-849-3681 (TRS: 711) Monday–Friday

    5 a.m. to 8 p.m. and Saturday 8 a.m. to 4:30 p.m. Pacific Time.

     Call Washington State Rx Services for questions about pharmacy services at 1-888-361-1611 (TRS: 711). Calls are taken 24 hours a day, 7 days a week.

    See the Directory page on the inside front cover for more contact information.

    file://hcasanfloly002/design/54%20UMP/54-0001%20218%20UMP%20CoC%20Redesign%20Template/www.hca.wa.gov/ump

  • Uniform Medical Plan Classic 2019 Certificate of Coverage 3

    Table of contents About Uniform Medical Plan Classic ----------------------------------------------------------- 7

    Online services...................................................................................................................................................... 7 Finding a health care provider ------------------------------------------------------------------ 8

    How to find a preferred provider ................................................................................................................... 8 Why choose a preferred provider? ................................................................................................................ 8 Sample payments to different provider types ........................................................................................10 Covered provider types ...................................................................................................................................10 What is a primary care provider? .................................................................................................................10 When you don’t have access to a preferred provider: network waivers .......................................11 Services received outside the U.S. ...............................................................................................................12

    What you pay for medical services ----------------------------------------------------------- 15 Deductibles ..........................................................................................................................................................15

    If you qualified for the SmartHealth wellness incentive ................................................................................. 15 Coinsurance .........................................................................................................................................................16 Copayment ..........................................................................................................................................................17

    Inpatient copay ............................................................................................................................................................... 17 When do I pay? ...................................................................................................................................................17 Medical out-of-pocket limit ...........................................................................................................................17

    Summary of payment ---------------------------------------------------------------------------- 19 Deductibles and limits .....................................................................................................................................19 Types of services ................................................................................................................................................20 What else do I need to know? .......................................................................................................................21

    Benefits: what the plan covers ----------------------------------------------------------------- 22 Guidelines for coverage ..................................................................................................................................22 Health Technology Clinical Committee (HTCC) ......................................................................................22 Summary of benefits ...............................................................................................................