UMP CDHP Out-of-Pocket Provider Network Out-of-Network Prescription Premiums Deductibles Special Limits Networks Reimbursement Reimbursement Drugs Charges Lowest of Combined: Combined: Same as UMP Plan pays 85% of Plan pays 60% of Once Member pays HSA: Subject UMP Plans Classic allowed amount, allowed amount. deductible is facility charges to IRS rules Applies to Applies to both Member pays 15%. Member pays 40% met, the on regarding both medical medical remaining, plus Member pays coinsurance; no annual services and services and Preventive care: any amount billed 15% for all contributions. inpatient copay prescription prescription Specific services by the provider covered May use HSA drugs. drugs. covered in full, not over the allowed drugs, up to funds for any subject to amount. the qualified $1,400 for $4,200 for one deductible. limit. medical one (1) (1) person on Preventive care: The same expenses, person on account; Not subject to limits apply as including those account; $8,400 for deductible, but still for UMP not covered by $2,800 for account with pay out-of-network Classic and UMP CDHP. account with more than one coinsurance UMP Plus more than (1) person May not (quantity one (1) participate in limits, step Note: A single person medical therapy, refill person will pay flexible too soon, no more than spending TIP). $6,850 for arrangement under the covered PEBB. services per year IRS rules preclude most Dependents from being enrolled in UMP CDHP and
UMP CDHP Premiums Deductibles Out-of-Pocket Limits Provider Networks Network Reimbursement Out-of-Network Reimbursement Prescription Drugs Charges Special Lowest of UMP Plans Combined: Applies to both medical services and prescription drugs. $1,400 for one (1) person on account; $2,800 for account with more than one (1) person Combined: Applies to both medical services and prescription drugs. $4,200 for one (1) person on account; $8,400 for account with more than one (1) person Note: A single person will pay no more than $6,850 for covered services per year Same as UMP Classic Plan pays 85% of allowed amount, Member pays 15%. Preventive care: Specific services covered in full, not subject to deductible. Plan pays 60% of allowed amount. Member pays 40% remaining, plus any amount billed by the provider over the allowed amount. Preventive care: Not subject to deductible, but still pay out-of-network coinsurance Once deductible is met, the Member pays 15% for all covered drugs, up to the limit. The same limits apply as for UMP Classic and UMP Plus (quantity limits, step therapy, refill too soon, TIP). Member pays facility charges on coinsurance; no inpatient copay HSA: Subject to IRS rules regarding annual contributions. May use HSA funds for any qualified medical expenses, including those not covered by UMP CDHP. May not participate in medical flexible spending arrangement under the PEBB. IRS rules preclude most Dependents from being enrolled in UMP CDHP and