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A deductible is a fixed dollar amount you pay each calendar year before the plan begins paying most benefits. Your UMP Plus medical deductible is $125 per person, with a maximum of $375 for a family of three or more. When you first get services, you pay the first $125 in charges. After that, the plan begins to pay benefits for your care.
You do not pay a deductible for prescription drugs, and they do not count toward your medical deductible.
If you are a subscriber who earned the SmartHealth wellness incentive, your medical deductible is reduced to $0. The subscriber is the only family member eligible to earn the SmartHealth wellness incentive.
When you see a network provider, you do not have to pay the medical deductible before the plan pays for the following services:
- Office visit charges by network primary care providers
- Covered preventive care and covered immunizations
- Routine vision care (exams, glasses, and contacts)
- Routine hearing care (exams and hearing aids)
- Contraceptive supplies and services
- Certain products available from network pharmacies
- Prescription drugs
- Tobacco cessation services
- Diabetes Control Program
- Diabetes Prevention Program
- Required second opinions
The following out-of-pocket expenses do not count toward your $125 medical deductible:
- Services you pay for that are not covered by the plan.
- Services that are exempt from the medical deductible, even if you had out-of-pocket costs. For example, preventive care received from an out-of-network provider.
- Charges for services exceeding benefit maximums. For example, the maximum for adult vision hardware is $150 every two calendar years. Charges over this amount do not count toward your medical deductible.
- Charges for services beyond benefit limits. For example, the annual benefit limit for acupuncture is 16 visits. Costs for more than 16 visits are not covered by the plan and do not count toward your medical deductible.
- Out-of-network provider charges that exceed the allowed amount.
- Your inpatient hospital copayment.
- Your emergency room copayment.
- Prescription drug costs.
Alert: If you receive services with a benefit limit (such as massage therapy) before meeting your medical deductible, those visits will count toward the benefit limit. For example, if you pay out-of-pocket for a massage therapy visit because you have not met your medical deductible, that visit will count toward the maximum of 16 visits per calendar year. If you have other primary coverage, visits paid by your primary plan also count toward UMP Plus benefit limits.
If you have three or fewer members in your family enrolled in UMP Plus, each family member must meet the $125 medical deductible for a family maximum of $375. Once any one person spends $125 that applies toward the medical deductible, the plan will begin paying benefits for that person only. Because the plan is now paying for this person’s covered services, they are no longer contributing toward the family deductible.
If your family has four or more members, each person has an individual medical deductible of $125 and the maximum the family pays towards medical deductibles is $375. Once a particular individual meets their $125 deductible, the plan begins paying for covered services for that person. Because the plan is now paying for this person’s covered services,they are no longer contributing toward the family deductible. If the combined amount paid toward the deductible for everyone in the family reaches $375—even if no one reached $125 on their own—the plan begins paying for covered services for everyone in the family. No more deductible is owed.