What is not included in the COE Program If you receive services outside of the COE Program, or choose to receive services at Virginia Mason Medical Center that are not related to your single knee or single hip replacement surgery, covered services will be processed at the standard rate. The following services are not included in the COE Program (but may be covered by other plan benefits): • Care received as part of the plan Virginia Mason Medical Center gives you as a condition of surgery, regardless of where you receive care. Examples include tobacco cessation and weight loss programs. • Physical therapy that is not provided during your hospitalization. • Follow-up care other than the initial postsurgical checkup at Virginia Mason Medical Center. An example of follow-up care is a visit with your regular doctor. • Prescription drugs received from a pharmacy after discharge from the hospital. • Convenience items, such as a personal phone. Contact UMP Customer Service if you have questions about services not included in the COE Program. What happens if you are not an appropriate candidate for joint replacement surgery under the COE program If Virginia Mason Medical Center determines you are not an appropriate candidate for joint replacement surgery, you may still receive joint replacement through other providers under this plan. Services received outside the COE Program are processed according to the plan’s medical policies, benefit structure, and the network status of your provider. Appeals related to the COE Program UMP members may appeal denials made by Premera. Appeals must be submitted to Premera. A decision by your Virginia Mason Medical Center provider regarding whether the provider is willing to perform joint replacement surgery on you is a decision of the provider, not the plan, and cannot be appealed to the plan or Premera. TIP: Appeal deadlines and other rules remain the same. See the “Complaint and appeal procedures” section for details of how non-COE appeals work. An appeal for services related to the COE Program must be submitted within 180 days after you receive notice of the denial to Premera, not to Regence or Virginia Mason Medical Center. Appeals can be submitted to: Premera Blue Cross Attn: Member Appeals PO Box 91102 Seattle, WA 98111-9202 Secure inbound fax: 1-425-918-5592 Knee arthroplasty, total Covered services are paid at the standard rate. Computer navigated and unicompartmental knee arthroplasty for treatment of end-stage osteoarthritis and rheumatoid arthritis of the knee are covered only as follows: • Total knee arthroplasty performed with computer navigation is covered. 60 2024 UMP CDHP (PEBB) Certificate of Coverage