Ultrasounds during pregnancy The following limits do not apply to high-risk pregnancies. For example, a multiple pregnancy is considered high risk. Contact UMP Customer Service to learn what is covered for high-risk pregnancies. Routine ultrasounds during pregnancy are covered as follows: • One in week 13 or earlier • One during weeks 13-28 Adding a new dependent to your coverage For information about how to enroll new dependents in your health plan, refer to the Employee Enrollment Guide or the Retiree Enrollment Guide on the HCA website at hca.wa.gov/employee-retiree-benefits/forms-and-publications. You can also refer to “Making changes” in the “Eligibility and Enrollment” and in the “Eligibility and enrollment for a retiree or survivor” sections of this certificate of coverage for more information. Office visits The plan pays for office visits for covered conditions under the medical benefit. Preventive care visits with network providers as described under the definition of “Preventive care” are covered in full and are not subject to your medical deductible. Orthognathic and Telegnathic surgery Orthognathic and telegnathic surgery must be preauthorized by the plan. Contact UMP Customer Service if you have questions. See page 72 for treatment of temporomandibular joint (TMJ) disorder. Pain and joint management, interventional Interventional pain management is a medical subspecialty that treats pain with invasive interventions like injections, spinal cord stimulations, and implantable drug delivery systems. The purpose of interventional pain management is to help members have less pain, so they can return to normal activities, when possible. Preauthorization is required for interventional pain and joint management, such as: • Epidural injections • Radiofrequency ablations • Facet blocks • Sacroiliac joint injections • Pain pumps Preauthorization is not required for post-procedural pain management in an inpatient setting, including, but not limited to, treating acute pain due to trauma, acute post-thoracotomy pain, and acute postoperative pain. Prescription drugs See the “Your prescription drug benefit” section. Preventive care ALERT! This benefit covers only services that meet the requirements below. If you receive services during a preventive care visit that do not meet these requirements, or your provider bills your visit as medical treatment instead of a preventive service, the services are not covered as preventive. Instead, when medically necessary, they are covered under the standard rate. 66 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage