Locations where sleep therapy services are not covered Sleep therapy services are not covered: • In the emergency room • At urgent-care facilities • During inpatient hospitalization Spinal and extremity manipulations The plan covers up to 24 visits per calendar year for manipulations (adjustments) of the spine and extremities (arms and legs). See the definition of “Limited benefit.” You pay the special rate (a $15 copay) for up to 24 visits for spinal and extremity manipulations when you see a preferred provider after you meet your deductible. The copay will apply toward the out-of-pocket limit. All visits apply to the 24-visit limit. You may receive an office visit (see the “Office visits” benefit for more details) and/or x-ray (see the “Diagnostic tests, laboratory, and x-rays” benefit for more details) at the time of your spinal and extremity manipulation service. Note: For participating providers and out-of-network providers, services are paid at the standard rate up to 24 visits per calendar year. Spinal injections The plan must preauthorize some spinal injections (see the “Limits on plan coverage” section for how this works). The following therapeutic injections are covered for treatment of chronic pain: • Cervical-thoracic epidural injections • Lumbar epidural injections • Sacroiliac joint injections Note: See page 114 for a list of spinal injections that are not covered by the plan. Spinal injections not specified in this section may be covered subject to the plan’s medical policy. Contact UMP Customer Service for more information. Spinal surgery The plan must preauthorize inpatient and outpatient spinal surgery performed outside of the Centers of Excellence (COE) Program. Spine care in the Centers of Excellence (COE) Program The Centers of Excellence (COE) Program covers 100 percent of the allowed amount for covered services after you meet your deductible related to lumbar fusion. The program includes, but is not limited to: • An evaluation to determine if surgery is appropriate. • Presurgical consultations. • Travel costs (see the “Travel benefits” section below). • Hospitalization and surgery, if surgery is determined to be appropriate. • Postsurgical check-ups. In the COE program, members work with Premera Blue Cross (the administrator of the program) and Virginia Mason Medical Center (the Center of Excellence) to make sure that their treatment is consistent with established standards of medical care. 70 2024 UMP CDHP (PEBB) Certificate of Coverage