• Your provider ordered a blood sugar test in the last 12 months; and • Laboratory results showed you are in the prediabetes range DPP provides access to a virtual (online) program through Omada Health. You may take an online screening questionnaire to see if you meet the program’s criteria by visiting the DPP website at go.omadahealth.com/wapebb, creating an account, and signing in. If you meet the criteria, you may participate in the program at no cost to you. The virtual program includes a professional health coach, a wireless scale, and weekly online classes with a small group of participants who provide real-time support. You may also contact UMP Customer Service for more information. Diagnostic tests, laboratory, and x-rays You pay the standard rate for covered diagnostic tests, laboratory tests, and x-rays when medically necessary. If there are alternative diagnostic approaches with different fees, the plan will cover the least expensive, evidence-based diagnostic method. Visit the UMP Policies that affect your care webpage or contact UMP Customer Service for a list of services requiring preauthorization (see Directory for link and contact information). Covered services include: • All prostate cancer screening (prostate-specific antigen [PSA testing]), which is subject to your deductible and coinsurance, even if billed as preventive. • Colonoscopy performed to diagnose disease or illness. See the list on page 65 for coverage of preventive or screening colonoscopy. • Diagnostic laboratory tests, x-rays (including diagnostic mammograms), and other imaging studies. • Electrocardiograms (EKG, ECG). • Skin allergy testing. TIP: See page 61 to learn how the plan covers mammograms. The plan does not pay for the following tests (this list does not include all tests not covered by the plan): • Carotid Intima Media Thickness testing. • Computed Tomographic Colonography (CTC) (also called a virtual colonoscopy) for routine screening. • Upright Magnetic Resonance Imaging (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading.” Dialysis You pay the standard rate for covered dialysis services. The plan pays based on the allowed amount and the network status of the provider. Other professional providers may bill separately from the facility. Durable medical equipment (DME), supplies, and prostheses TIP: The plan pays for covered DME at the standard rate. To receive the highest benefit, you must get the equipment or supply from a preferred DME supplier or other preferred medical provider. To find preferred DME providers, see the “Finding a preferred DME supplier” section below. 48 2024 UMP CDHP (PEBB) Certificate of Coverage