Contact UMP Customer Service for the drugs covered under the site of care program, more information, or help finding an approved site of care near you. Joint replacement surgery, knees and hips 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 single knee or single hip total joint replacement surgery. The program includes, but is not limited to: • 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. Premera will help you understand how the COE Program works, what is covered under the Program, connect you with Virginia Mason Medical Center providers if you are eligible, and work to resolve any questions or issues you may have. If you receive services related to joint replacement that are not covered under the COE Program, but are covered under the plan, you will pay your normal UMP cost-share, depending on the services received and the network status of the provider(s). This may be a deductible, coinsurance, or amounts not covered by the plan. Services billed to the plan outside of the COE Program are subject to the plan’s preauthorization requirements. COE for knee and hip joint replacement: Virginia Mason Medical Center Virginia Mason Medical Center is the only provider approved to perform single knee and single hip replacement under the COE Program. Virginia Mason Medical Center has proven that it provides high- quality joint replacements using the most up-to-date medical guidelines and services. Who is eligible to participate in the COE Program? You are eligible to participate in the COE Program if you are: • A member enrolled in UMP CDHP. • Not enrolled in Medicare as your primary coverage. • Age 18 or older. How to apply to participate in the COE Program If you are interested in participating in the COE Program: • You may self-refer by calling Premera at 1-855-784-4563 (TRS: 711). • Your regular provider may refer you. You may receive information in the mail about the COE Program, which will explain how the program works and whom to contact for more information. Premera will screen applicants to initially determine whether they are eligible to participate in the COE Program. What happens after you are approved to participate After you are approved to participate in the program, Premera will: 58 2024 UMP CDHP (PEBB) Certificate of Coverage