Columbia United Providers

Benefit/service	Member’s payment responsibility	Notes
Preventive care	No copay	Includes routine physicals, immunizations, PAP tests, mammograms, and other screening and testing when provided as part of the preventive care visit.
Office visits	$15 copay	Copay is for office visit only and includes consultations, mental health and chemical dependency outpatient visits, office-based surgeries, and follow-up visits. Copays do not apply to preventive care, laboratory, radiology services, radiation, and chemotherapy. Some services will be subject to coinsurance.
Pharmacy*	Tier 1 – $10 copay Tier 2 – 50% of the drug cost	30-day supply Tier 1 includes generic drugs in health plan’s preferred drug list (formulary). Tier 2 includes brand-name drugs in health plan’s preferred drug list (formulary).
Emergency room visit	$100 copay	No copay if admitted; hospital coinsurance and deductible would apply.
Out-of-area emergency services	$100 copay	No copay if admitted; hospital coinsurance and deductible would apply.
Urgent care	$15 copay	Copay is for office visit only, when provided in an urgent care setting. Deductible and coinsurance apply to all other services.
Skilled nursing, hospice, and home health care	No copay	Covered as an alternative to hospital care at the health plan’s discretion.
Maternity care	No copay	If the member is eligible for the Maternity Benefits Program, maternity services can only be covered under Basic Health for 30 days following diagnosis of pregnancy. All other maternity services are covered through the Department of Social and Health Services.
Oxygen	No copay	Includes equipment and supplies. Not subject to copays, coinsurance, or deductible. Requires health plan authorization.

*Different health plans have different lists of approved prescription drugs (formularies). To find out if a drug is covered in your pharmacy benefit, contact your health plan.

The benefits information in this booklet is a brief summary. For complete information, read the Schedule of Benefits in your Member Handbook, which you will receive from the health plan after you enroll.

Benefits and services subject to the deductible and coinsurance [Back to Top]

Before your health plan pays the 80% coinsurance for the following benefits, you must pay your $150 annual deductible. Once you meet your deductible, all coinsurance payments will be applied toward your $1,500 annual out-of-pocket maximum. Deductibles and out-of-pocket maximums are per person, per year. Once the $1,500 per person out-of-pocket maximum has been reached, the health plan pays for all covered benefits and services with a coinsurance. Members are only responsible for copays for benefits and services listed on page 6 of the handbook. If you change health plans any time during the year, the amount you’ve paid toward your deductible and out-of-pocket maximum for covered family members will start over with your new health plan.

Benefit/service	Member’s payment responsibility	Description
Hospital, inpatient Hospital, outpatient	20% coinsurance; deductible applies. $300 maximum facility charge per admittance. 20% coinsurance; deductible applies.	Facility charges may include, but are not limited to, room and board, prescription drugs provided while an inpatient, and other services received as an inpatient. No charges for maternity care or when readmitted for the same condition within 90 days. If the member is eligible for the Maternity Benefits Program, maternity services can only be covered under Basic Health for 30 days following diagnosis of pregnancy. All other maternity services are covered through the Department of Social and Health Services. See “Other professional services” below.
Other professional services	20% coinsurance; deductible applies.	Includes services received as an inpatient, including, but not limited to, surgeries, anesthesia, chemotherapy, radiation, and other types of inpatient and outpatient services.
Mental health	20% coinsurance; deductible applies to inpatient. $300 maximum facility charge per admittance.	Limited to 10 inpatient days a year and 12 outpatient visits a year. Office visits to manage medication do not count towards 12-visit maximum. Outpatient visits are subject to $15 copay (see “Office visits”).
Laboratory	No copay or coinsurance for outpatient services. 20% coinsurance for inpatient hospital-basedlaboratory services.	Deductible applies to services with coinsurance.
Radiology	20% coinsurance, except for outpatient x-ray and ultrasound.	Deductible applies to services with coinsurance.
Ambulance services	20% coinsurance; deductible applies.	Includes approved transfers from one facility to another. No coinsurance if transfer is required by the health plan.
Chiropractic/physical therapy/occupational therapy	20% coinsurance; deductible applies.	Up to a combined maximum of 12 visits per year. (Of those, no more than six can be for chiropractic care.) Visits qualify only when used as post-operative treatment following reconstructive joint surgery. Visits must be within one year of surgery.
Chemical dependency	20% coinsurance and deductible apply to inpatient. $300 maximum facility charge per admittance.	Limited to $5,000 every 24-month period; $10,000 lifetime maximum. Outpatient visits are subject to $15 copay (see“Office visits”).
Organ transplants	Deductible, coinsurance, and copays apply by specific service.	12-month waiting period, except for newborns or for a condition that is not pre-existing.

What is not covered? [Back to Top]

This is a brief summary of exclusions. For details see the Basic Health Member Handbook created by Basic Health or call CUP Member Services at (360) 891-1520, (800) 315-7862 or TDD (866) 287-9962.

Services that do not meet the Basic Health definition of “Medical Necessity” for the diagnosis, treatment or prevention of injury or illness, or to improve the functioning of a malformed body member, even though such services are not specifically listed as exclusions.
Services not provided, ordered, or authorized by CUP or our contracted providers, except in an emergency.
Maternity care beyond 30 days of diagnosis (unless determined ineligible for maternity benefi ts program). IF YOU ARE COVERED UNDER THE HEALTH CARE TRADE ACT, YOUR MATERNITY BENEFITS ARE PAID IN FULL. SEE HANDBOOK FOR A DESCRIPTION OF YOUR MATERNITY BENEFITS.
Services received before your effective date of coverage.
Custodial or domiciliary care, or rest cures for which facilities of an acute care general hospital are not medically required.
Hospital charges for personal comfort items; a private room unless authorized by CUP; and services such as telephones, televisions, and guest trays.
Emergency facility services for nonemergency conditions.
Charges for missed appointments or for failure to provide timely notice for cancellation of appointments.
Charges for completing or copying records or forms.
Transportation except as specified under “Organ Transplants” and “Emergency Care” in the Basic Health Member Handbook provided by Basic Health.
Implants, except: cardiac devices, artificial joints, intraocular lenses (limited to the fi rst intraocular lens following cataract surgery), and implants as defined in the “Plastic and Reconstructive Surgery” benefi t in the Basic Health Member Handbook provided by Basic Health.
Sex change operations; investigation of or treatment for infertility or impotence; reversal of sterilization; artificial insemination; in vitro fertilization.
Eyeglasses; contact lenses (except the first intraocular lens following cataract surgery); routine eye exams, including eye refraction.
Hearing aids.
Orthopedic shoes and routine foot care.
Speech and recreational therapy.
Immunizations, except as covered under preventive care. Immunizations for the purpose of travel, employment, or required because of where you reside are not covered.
Dental services.
Obesity services, drugs, supplies, and weight-loss programs.
Cosmetic surgery, including treatment for complications of cosmetic surgery, except as described in the Basic Health Member Handbook provided by Basic Health.
Medical services received from or paid for by the Veterans Administration or by state or local government, except where in conflict with the Revised Code of Washington or federal law.
Conditions resulting from acts of war (declared or not).
Direct complications from excluded services.
Evaluation and treatment of learning disabilities.
Any service or supply not specifically listed as a covered service, unless prescribed by a contracting provider and authorized in advance by CUP.
Medical equipment and supplies not specifically listed in the Basic Health Schedule of Benefits except while in the hospital (including, but not limited to, hospital beds, wheelchairs, and walk aids.