Medical out-of-pocket limit

Prescription drugs do not count toward your medical out-of-pocket limit.

What you pay for drugs

How your medical out-of-pocket limit works

The medical out-of-pocket limit is the most you pay during a calendar year for covered services from network providers. After you meet this limit for the year, the plan pays 100 percent of the allowed amount for covered services from network providers.

The UMP Plus medical out-of-pocket limit is $2,000 per person, with a maximum of $4,000 per family (two or more enrolled under one account).

What counts toward this limit?

  1. Your coinsurance paid to covered providers in the core and support networks, and to other providers approved for certain services.
  2. Inpatient and emergency room copays.
  3. Your medical deductible.

What doesn’t count toward this limit?

  1. Amounts paid by the plan, including services covered in full.
  2. Your monthly premiums.
  3. Prescription drug costs. See how the prescription drug out-of-pocket limit works, which is counted separately by Washington State Rx Services.
  4. Your coinsurance paid to out-of-network providers. Note that out-of-network coinsurance does count toward your medical deductible.
  5. Balance billed amounts.
  6. Services not covered by the plan (see examples).
  7. Amounts that are more than a maximum dollar amount paid by the plan. For example, the plan pays a maximum of $150 for adult vision hardware once every two calendar years. Any amount you pay over $150 does not count toward the medical out-of-pocket limit.
  8. Amounts paid for services exceeding a benefit limit. For example, the benefit limit for acupuncture is 16 visits. If you have more than 16 acupuncture visits in one year, you will pay in full for those visits. What you pay will not count toward this limit. See Limited benefit for more benefits with this type of limit.

For exceptions, see “Exceptions: Out-of-network provider services that count...” below.

Note: You will still be responsible for paying numbers 2–8 above after you meet your medical out-of-pocket limit.

You still pay for out-of-network provider services

Services by out-of-network providers are paid at 50 percent of the allowed amount, unless noted under "Specific services" or listed below as an exception. Even after you meet your medical out-of-pocket limit, you will still pay 50 percent coinsurance for out-of-network provider services, and the provider may balance bill you.

The 50 percent you pay and balance billed amounts do not count toward your medical out-of-pocket limit. However, coinsurance paid to out-of-network providers does count toward your medical deductible. Balance billed amounts never apply toward your medical deductible.

Exceptions: out-of-network provider services that count toward your medical out-of-pocket limit

For dialysis, the plan will pay 100 percent of the network rate after you meet your medical out-of-pocket limit.

For the services listed below only, your coinsurance and balance billed amounts for out-of-network provider services will count toward your out-of-pocket limit. In addition, the plan will pay 100 percent of billed charges for these services after you meet your medical out-of-pocket limit.

  • Ambulance.
  • Cochlear implant processor supplier.
  • Ocularists (creation and fitting of prosthetic eyes).

In addition to the services above, your coinsurance for out-of-network provider services related to an approved network consent will count toward your medical out-of-pocket limit. The plan will pay 100 percent of the allowed amount for these services after you meet your medical out-of-pocket limit.

Contact

UMP Customer Service 
Phone: 1-888-849-3681
TRS: 711

Washington State Rx Services
Phone: 1-888-361-1611
TRS: 711