• Provide a booklet to participants describing their journey through the program. • Assign participants a dedicated case manager who will walk participants through each step of the journey. • Gather relevant medical records to supply to the participant’s COE care team as part of the referral process. This information helps the care team assess next steps. After Premera’s referral, Virginia Mason Medical Center will: • Review the participant’s medical records and schedule an evaluation appointment to determine whether the surgery is medically appropriate for the participant under the COE Program. • Provide a list from which participants may select their surgeon if the participant is approved for surgery. Virginia Mason Medical Center must determine if surgery for joint replacement is appropriate based on established medical guidelines. You may find these guidelines on the Policies that affect your care webpage (see Directory for link). What is included in the COE Program In general, all eligible expenses associated with single knee or single hip replacement surgery (if determined surgically appropriate) under the COE Program are covered. If surgery is recommended, this includes expenses from the day you arrive for your pre-operative visit through discharge, including your: • Assessment(s). • Surgery. • Hospital stay. • Hospital discharge (excluding take-home prescription drugs, which are covered under your UMP prescription drug benefit). Travel benefits Members participating in the COE Program may qualify for assistance with travel and lodging expenses. These expenses may include partial coverage by Premera for mileage, flights, parking, and lodging. To be covered by the program, all travel must be arranged through Premera. This travel may be arranged by calling Premera at 1-855-784-4563 (TRS: 711). You must have an approved adult care companion, whose travel expenses will be covered as described below. You may be partially reimbursed for expenses related to: • Mileage for driving within Washington. To qualify for reimbursement for mileage, members must live at least 60 driving miles from Virginia Mason Medical Center, located at 1100 9th Ave., Seattle, WA 98101. • Flights departing from and arriving at airports within Washington or Portland International Airport. You must depart from the airport closest to your residence. • Ground transportation from Seattle-Tacoma International Airport to Virginia Mason Medical Center. • Lodging expenses (excluding meals) at a COE-designated hotel. Premera must arrange all lodging. • Parking at Virginia Mason Medical Center and parking at your departing airport. TIP: Reimbursement for travel expenses is based on cost or current IRS rates for medical expenses, whichever is less, and may not cover all of your costs. For the IRS rates, visit the IRS website at irs.gov/tax-professionals/standard-mileage-rates. 2024 UMP CDHP (PEBB) Certificate of Coverage 59