You must have a prescription for occupational, physical, and speech therapy services from a covered provider type (see the “Covered and noncovered provider types” section), such as a physician. Inpatient habilitative services Preauthorization is required for inpatient habilitative admissions. The plan covers therapy services when they are provided during inpatient habilitative admission, up to 60 days combined per calendar year, counting all types of therapies listed here (see definition of “Limited benefit”). You must pay the inpatient copay and your coinsurance for inpatient services. Outpatient habilitative services The plan covers medically necessary outpatient occupational, physical, and speech therapy services up to 60 visits combined per calendar year, counting all types of therapies listed here (see definition of “Limited benefit”). Rehabilitative Services The plan covers inpatient and outpatient services to improve or restore function lost due to issues such as: • An illness. • An acute injury. • Worsening or aggravation of a chronic injury. You must have a prescription for occupational, physical, and speech therapy services from a covered provider type (see the “Covered and noncovered provider types” section, such as a physician. Inpatient rehabilitation services Preauthorization is required for inpatient rehabilitation admissions. The plan covers therapy services when they are provided during inpatient rehabilitation admission, up to 60 days combined per calendar year, counting all types of therapies listed here (see definition of “Limited benefit”). You must pay the inpatient copay and your coinsurance for inpatient services. Outpatient rehabilitation services The plan covers medically necessary outpatient neurodevelopmental, occupational, physical, and speech therapy services up to 60 visits combined per calendar year, counting all types of therapies listed here (see definition of “Limited benefit”). Tobacco cessation services ALERT! If you get nicotine replacement therapy or prescription drugs for tobacco cessation at a non-network pharmacy, or purchase at a cash register other than the pharmacy counter, and submit a claim, you may not receive full reimbursement from the plan. See the “Where to buy your prescription drugs” section for how to locate a network pharmacy. Prescriptions purchased from an excluded pharmacy will not be covered. See the definition of “Excluded pharmacy.” The services described in this section are covered only for tobacco cessation. Nicotine replacement therapy and prescription drugs for tobacco cessation that are listed as “Preventive” in the Tier column on the UMP Preferred Drug List are not subject to coinsurance. If you purchase an over-the-counter tobacco cessation product without a valid prescription, the plan will not cover it and you will pay the full cost. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 73