Summary of benefits

Some benefits are affected by Health Technology Clinical Committee (HTCC) decisions.

How does this work?

The summary of benefits table below applies to both UMP Plus networks: Puget Sound High Value Network (PSHVN) and UW Medicine Accountable Care Network (UW Medicine ACN).

Only certain services are listed in the table. For those not listed, see the alphabetical list of covered benefits in your certificate of coverage (PSVHN or UW Medicine ACN).

Not all details, such as benefit limitations or exclusions, are included in the table. Also review:

If you have questions about your benefits, services that require preauthorization or plan notification, or services not covered by the plan, call UMP Customer Service at 1-888-849-3681 (TRS: 711).

If you would like more information about the benefits listed below, you can read your UMP Plus 2019 Certificate of Coverage (see below), the Summaries of Benefits and Coverage, or the medical policies

Benefit
Select link for benefit details
How much I'll pay
(See descriptions of service types listed below)

Acupuncture: PSHVN and UW Medicine ACN

Standard
Ambulance: PSHVN and UW Medicine ACN Special: Select link on left for benefit details.
Applied Behavior Analysis (ABA) Therapy: PSHVN and UW Medicine ACN
Other providers (see benefit link).
Standard
Breast health screening tests: PSHVN and UW Medicine ACN See "Mammograms" below
Chiropractic physician services  See “Spinal and extremity manipulations” below. 
Contraceptive services: PSHVN and UW Medicine ACN Preventive
Dental services: PSHVN and UW Medicine ACN Special: Select link on left for benefit details.
Diabetes care supplies: PSHVN and UW Medicine ACN Special: Select link on left for benefit details.
Diabetes Control Program: PSHVN and UW Medicine ACN Preventive
Diabetes Prevention Program: PSHVN and UW Medicine ACN Preventive

Diagnostic tests, laboratory, and X-rays: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN

Standard

Durable medical equipment, supplies, and prostheses: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN

Standard
Emergency room (ER) : PSHVN and UW Medicine ACN

Standard plus an ER copay of $75, medical deductible, and coinsurance.
You are usually billed separately for:

  • Facility charges
  • Professional (physician) services
  • Lab tests, x-rays, and other imaging tests
End-of-life counseling: PSHVN and UW Medicine ACN If received as part of hospice services: paid at 100% after meeting medical deductible.
If received outside of hospice services: standard.
Family planning services: PSHVN and UW Medicine ACN

Standard
Office visits may be covered as primary care services when you see a primary care provider in the core network.
For more information see your certificate of coverage (PSHVN and UW Medicine ACN).

Headaches, chronic migraine or tension: PSHVN and UW Medicine ACN

Standard: Covered Botox injections for migraines
All other specified treatments not covered

Hearing aids (not subject to the medical deductible): PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Special: Select link on left for benefit details.
Hearing exams, routine: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Preventive

Home health care: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN

Standard

Hospice care (inpatient, outpatient, and respite care): PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN

Special: Select link on left for benefit details.

Hospital services (Inpatient services): PSHVN and UW Medicine ACN
Other providers: children's hospitals
Inpatient
Hospital services (Outpatient services): PSHVN and UW Medicine ACN Standard
Immunizations (Vaccines): PSHVN and UW Medicine ACN Preventive (usually)
Mammograms (Diagnostic): PSHVN and UW Medicine ACN Standard
Mammograms (Screening): PSHVN and UW Medicine ACN Preventive

Massage therapy: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN

Standard
Mastectomy and breast reconstruction: PSHVN and UW Medicine ACN Inpatient (Standard for related outpatient visits)
Mental health treatment (Inpatient services): PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Inpatient
Mental health treatment (Outpatient services): PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Standard
Naturopathic physician services: PSHVN and UW Medicine ACN Primary care
Obstetric and newborn care: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN

Inpatient
Some breast pumps are covered as preventive.
Standard or Inpatient
Some ancillary providers. Examples include birth centers and licensed midwives.

Office visits, nonprimary care: PSHVN and UW Medicine ACN Standard
Office visits, primary care: PSHVN and UW Medicine ACN

Primary care, only when you see a primary care provider in the core network.
For more information see your certificate of coverage: PSHVN and UW Medicine ACN.

Physical, occupational, speech, and
neurodevelopmental therapy: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Standard
Charges for inpatient services are not included in the inpatient copay.
 
Prescription drugs See What you pay for drugs

Preventive care (includes vaccines, routine exams,
some screening tests): PSHVN and UW Medicine ACN

Preventive
Primary care services: PSHVN and UW Medicine ACN

Primary care or standard
Although there is no cost for office visit charges for primary care services, other services provided at a primary care visit
may be subject to the medical deductible and coinsurance. 

Skilled nursing facility: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Inpatient
Some services may be billed separately, such as physical therapy.
Spinal and extremity manipulations: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Standard
Substance use disorder treatment (Inpatient services): PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Inpatient
Substance use disorder treatment (Outpatient services): PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN
Standard
Surgery: PSHVN and UW Medicine ACN
For ancillary provider information: PSHVN and UW Medicine ACN

See link on left for benefit details.
Some ancillary providers.
Examples include anesthesiologists, pathologists, and maxillofacial surgeons.

Surgery (Inpatient services): PSHVN and UW Medicine ACN Inpatient
Surgery (Outpatient services: PSHVN and UW Medicine ACN Standard
Telemedicine services: PSHVN and UW Medicine ACN Standard
Tobacco cessation services: PSHVN and UW Medicine ACN Preventive
Transgender health: PSHVN and UW Medicine ACN
Other providers (see benefit link).
Standard
Urgent care: PSHVN and UW Medicine ACN
Other providers (see benefit link).

Special: Select link on left for benefit details.

Vision care (Diseases and disorders of the eye): PSHVN and UW Medicine ACN Standard
Vision exams, routine: PSHVN and UW Medicine ACN Preventive
Vision hardware (eyeglasses and contact lenses): PSHVN and UW Medicine ACN Special: Select link on left for benefit details.
Well-child visits Preventive

Contact

UMP Customer Service
Online: 
Your Regence account
Phone: 1-888-849-3681
TRS: 711
Business hours: Monday through Friday 5 a.m. to 8 p.m. and Saturday 8 a.m. to 4:30 p.m. (Pacific)

Washington State Rx Services
Online: 
Your pharmacy account
Phone: 1-888-361-1611
TRS: 711
Business hours: 24 hours a day, 7 days a week