The plan also excludes prescription drugs to treat conditions that are not covered under the medical benefit. These include, but are not limited to, prescription drugs for: • Cosmetic purposes. • Promoting hair growth. • Fertility or infertility. • Sexual dysfunction. • Obesity (or weight loss). Limits on plan coverage If you receive a service that is not medically necessary, is experimental or investigational, is listed as an exclusion in the “What the plan does not cover” section, or is listed as a noncovered or excluded prescription drug, you are responsible for paying all associated charges. Preauthorizing medical services ALERT! This section does not apply to prescription drugs. See page 98 for how to request preauthorization of drugs covered under the prescription drug benefit. The plan must preauthorize some medical services and supplies to determine whether the service or supply meets the plan’s medical necessity criteria to be covered. The fact that a service or supply is prescribed or furnished by a provider does not, by itself, make it a medically necessary covered service. Preauthorization is not a guarantee of coverage. A change after the plan has approved a preauthorization request — including, but not limited to, a change of provider or different/additional services — requires your provider to submit a new preauthorization request and for the plan to approve it. If your preauthorization is denied, your provider may request a peer-to-peer review where they can talk to a Regence BlueShield provider about your condition prior to submitting an appeal. For more information contact UMP customer service. Your preauthorization role ALERT! Excluded, experimental, and investigational services do not require a preauthorization because they are not covered by the plan. To confirm whether a service is covered, contact UMP Customer Service. To be covered, some services, including, but not limited to, Applied Behavior Analysis (ABA) Therapy for members age 18 or older (see page 43) and bariatric surgery (see page 44), must be preauthorized before services are received. A network provider may be required to request preauthorization before providing services. Contact UMP Customer Service to ask if a service requires preauthorization and how to submit a request. An out-of-network provider is not obligated to obtain preauthorization for services that require a preauthorization because they do not have a contract with Regence. If an out-of-network provider does not obtain a required preauthorization from Regence and an out-of-network consent from the ACP in advance of the service, you will be responsible for all charges billed to you. For more information on how to obtain an out-of-network consent (see the “Network Consent for Out-of-network Services” section). 104 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage