The fact that a physician or other provider prescribes, orders, recommends, or approves a service or supply, prescription drug, or prescription drug dose does not make it medically necessary. The plan may require proof that services, interventions, supplies, or prescription drugs (including court- ordered care) are medically necessary. Depending on the circumstances, such proof may be documentation about the member’s condition or scientific evidence about the effectiveness of the treatment. The plan will not provide benefits if the required proof is not received, or does not adequately justify the medical necessity of the service, supply, prescription drug, or prescription drug dose. Claims processing may be delayed if proof of medical necessity is required but not adequately provided by the health service provider. The plan uses scientific evidence from peer-reviewed medical literature to determine effectiveness for services and interventions not yet in widespread use for the medical condition and member indications being considered. For services that the HTCC has reviewed, and that UMP has implemented, state law requires that UMP use the HTCC’s coverage criteria in determining whether the service is medically necessary. When the HTCC determines that a service is not covered, then the service is not covered by the plan. If the HTCC determines that a service is covered, then the HTCC’s criteria (if any) determine medical necessity. The HTCC’s decisions and related documentation are available on the HCA website at hca.wa.gov/hta. For services, interventions, supplies, prescription drugs, or prescription drug doses not related to an HTCC review, the plan first uses scientific evidence, then professional standards, then expert opinion to determine coverage. Scientific evidence consists primarily of controlled clinical trials that either directly or indirectly demonstrate the effect of the intervention on health outcomes. If controlled clinical trials are not available, observational studies that demonstrate a causal relationship between the intervention and health outcomes may be used. Partially controlled observational studies and uncontrolled clinical series may be suggestive, but do not by themselves demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the medical condition or potential experimental biases. Interventions for which clinical trials have not been conducted because of epidemiological reasons (that is, rare or new diseases or orphan populations) shall be evaluated based on professional standards of care or expert opinion. A level of service, supply, prescription drug, prescription drug dose, or intervention is considered cost effective if the benefits and harms relative to the costs represent an economically efficient use of resources for members with this condition. The plan applies this criterion based on the individual member’s medical situation and characteristics. Cost-effective does not always mean the lowest price. Preventive services not covered by the plan’s preventive care benefit will still be covered under the medical benefit or prescription drug benefit if the outlined criteria are met for medical necessity. Member A member is an eligible employee, retiree, former employee or former dependent in Continuation Coverage, survivor, retired employee of a former employer group, or dependent enrolled in the plan (see also the “Enrollee” definition). 180 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage