Medical benefit Medical benefit refers to services subject to your medical deductible, and copay or coinsurance. See the “What you pay for medical services” section for a description of how this works. Medical emergency A medical emergency means a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson who has an average knowledge of medicine and health would reasonably expect that not seeking immediate medical treatment at an emergency room would result in any one of the following: • Places the member’s health, or with respect to pregnancy, the health of an unborn child, in serious jeopardy; • Causes serious impairment to bodily functions; or • Causes serious dysfunction of any bodily organ or part. Medical food Medical food is food administered under the supervision of a provider, intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements. Medically necessary or medical necessity ALERT! The provider or member must provide documentation demonstrating medical necessity when requested by the plan, or the plan may deny services as not medically necessary. The plan may not cover some medically necessary services. All benefits or services that are medically necessary are subject to the plan’s coverage limitations, exclusions, and provisions of the plan. It is important to review this COC or verify coverage with UMP Customer Service before receiving services. Medically necessary or medical necessity means health care services, supplies, prescription drugs, or interventions that a licensed health care provider recommends and all the following conditions are met: • The purpose of the service, supply, intervention, or prescription drug is to prevent, evaluate, treat, or diagnose an illness, injury, disease, or its symptoms. • The level of service, supply, intervention, prescription drug, or prescription drug dose is appropriate considering the potential benefits and harm to the member. • The level of service, supply, intervention, prescription drug, or prescription drug dose is known to be effective in improving health outcomes. • The level of service, supply, intervention, prescription drug, or prescription drug dose recommended for this condition is cost-effective compared to alternative interventions, including no intervention. • The service, supply, or intervention is not being recommended for reasons of convenience to the patient or health care provider. • For services that the HTCC has reviewed, and that UMP has implemented, medical necessity is established only when HTCC’s coverage conditions are met. 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 179