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- You pay nothing for preventive services when you see a preferred provider.
- If you see an out-of-network provider, you pay 40 percent of the allowed amount, and the provider may balance bill you.
- However, if you do not have access to a preferred provider for preventive services, the plan may pay 100 percent of billed charges. See your UMP Classic or UMP CDHP certificate of coverage for how to request a network waiver.
For the lists of services covered as preventive , visit Healthcare.gov or call UMP at 1-888-849-3681 (TRS: 711). Note that recommendations added during the calendar year may not be covered as preventive until later years.
Alert: This benefit covers only services that meet the criteria below. If you receive services during a preventive care visit that do not meet these requirements, or your provider bills your visit as medical treatment instead of a preventive service, the services will not be covered as preventive. Instead, when medically necessary, they are covered under the standard rate.
- Preventive visits such as well-baby care and annual physical exams.
- Preventive vision acuity screening from birth through 18 years of age.
- Intensive behavioral counseling for adults who are overweight or obese and have additional cardiovascular disease risk factors.
- Screening for hepatitis B for non-pregnant adolescents and adults at high risk.
- Routine screenings for men and women (see list below for examples).
- Certain radiology and lab tests such as screening mammograms.
- Screening procedures such as colonoscopy. For coverage of colonoscopy performed to diagnose or treat disease or illness, see your UMP Classic or UMP CDHP certificate of coverage.
- One-time screening by ultrasound for abdominal aortic aneurysm, for men ages 65-75 who have ever smoked.
- Immunizations as explained below.
- Hearing tests as part of a newborn screening.
- Fluoride for prevention of caries (dental decay): prescribed by primary care provider to children age 6 months and older, when water is fluoride deficient. For more information about this coverage, as well as coverage of fluoride varnish, see your UMP Classic or UMP CDHP certificate of coverage.
- Certain screening tests performed during pregnancy. For more on prenatal care, see your UMP Classic or UMP CDHP certificate of coverage.
- Low to moderate dose of statin medications to adults ages 40 and over (statin medications that are designated as preventive on the UMP Preferred Drug List (with a “PV” in the Tier column)).
You may call UMP Customer Service at 1-888-849-3681 (TRS: 711) to ask if a service is covered as preventive.
- Human Papillomavirus (HPV) testing for women ages 30 and over, once every three years.
- Chlamydia and gonorrhea testing in sexually active women age 24 years and younger, and for women age 25 and older who are at increased risk for infection.
- Education and counseling regarding contraception.
- Counseling and screening for HIV, counseling and screening for interpersonal and domestic violence, and counseling for sexually transmitted infections.
For more services covered as preventive for women, read the following sections in your plan's certificate of coverage:
- UMP Classic: Family planning services, Mammograms, and Obstetric and newborn care.
- UMP CDHP: Family planning services, Mammograms, and Obstetric and newborn care.
Note: Prostate cancer screening (prostate-specific antigen [PSA] testing) is not covered under the preventive care benefit, but is covered as a medical benefit. That means services are subject to the medical deductible (deductible for UMP CDHP) and coinsurance.
Alert: Follow-up visits or tests are not covered under the preventive care benefit. If the test or visit is normally covered by the plan and is medically necessary, the plan pays under the medical benefit.
The plan covers immunizations as included on the applicable immunization schedule (children, adolescents, adults) for U.S. residents by the Centers for Disease Control and Prevention (CDC).
Note that some immunizations are classified as “may be recommended” by the CDC depending on medical condition or lifestyle. For those immunizations to be covered as preventive, you must meet the criteria specified on the CDC schedule.
Immunizations covered under the preventive care benefit are not subject to either the medical or prescription drug deductible (or deductible for UMP CDHP). Covered immunizations given by the providers listed below are paid under the preventive care benefit. If you see an out-of-network provider for covered immunizations, you pay 40 percent of the allowed amount and may be balance billed.
Tip: Flu shots are covered as included on the applicable CDC immunization schedule.
Immunizations covered under the preventive care benefit are covered at 100 percent when received from a:
- Preferred provider.
- Network vaccination pharmacy. To find one, visit the Find drugs page or call Washington State Rx Services at 1-888-361-1611 (TRS: 711).
- Public health department.
The plan does not cover immunizations for travel or employment, even when recommended by the CDC or required by travel regulations.