• Covered surgical services • Non-surgical services, including, but not limited to, hormone therapy, office visits, mental health counseling, and tests This is not a complete list of medical and surgical treatments of gender dysphoria in transgender individuals. For more information on gender affirming care, visit the UMP Policies that affect your care webpage (see Directory for link) to find the clinical criteria for gender affirming care. Some services and prescription drugs associated with gender dysphoria may require preauthorization. Genetic services Covered genetic tests require preauthorization. With preauthorization, the plan covers medically necessary, evidence-based genetic testing services. Some genetics tests are not covered. For information about genetic services related to the fetus during pregnancy, see “Services for obstetric and newborn care” on page 63. Contact UMP Customer Service with any questions. Headaches, chronic migraine or chronic tension type The plan only covers the treatment of chronic migraine with OnabotulinumtoxinA (Botox) when both the following criteria are met: • The condition has not responded to at least three prior pharmacological prophylaxis therapies from two different classes of prescription drugs; and • The condition is appropriately managed for medication overuse. Botox injections must be discontinued when: • The condition has shown inadequate response to treatment (defined as less than 50 percent reduction in headache days per month after two treatment cycles); or • The member has received a maximum of five treatment cycles. The following treatments are not covered: • Treatment of chronic tension-type headaches with Botox or acupuncture; and • Treatment of chronic migraine or chronic tension-type headaches with massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (such as chiropractic services). Hearing care (diseases and disorders of the ear) The plan pays under the medical benefit for covered services for treatment of diseases and disorders of the ear or auditory canal not related to routine hearing loss. These services are not part of “Hearing exam (routine)” and “Hearing aids” below. Hearing exam (routine) ALERT! The plan pays for a hearing exam performed as part of a newborn screening at the preventive rate. You pay the standard rate for one routine hearing exam per calendar year. 2024 UMP CDHP (PEBB) Certificate of Coverage 53