Spinal and extremity manipulations Support network provider type: You must use a UMP Plus–UW Medicine ACN provider or a covered provider within the support network to receive network level benefits (see description in the “Support network providers” section). The plan covers up to 24 visits per calendar year for manipulations (adjustments) of the spine and extremities (arms and legs). See the definition of “Limited benefit.” You pay the special rate (a $15 copay) for up to 24 visits for spinal and extremity manipulations when you see a network provider. The copay will not apply toward your medical deductible, but the copay will apply to the out-of-pocket limit. All visits apply to the 24-visit limit. You may receive an office visit (see the “Office visits” benefit for more details) and/or x-ray (see the “Diagnostic tests, laboratory, and x-rays” benefit for more details) at the time of your spinal and extremity manipulation service. Note: For out-of-network providers, services are paid at the standard rate up to 24 visits per calendar year. Spinal injections The plan must preauthorize some spinal injections (see the “Limits on plan coverage” section for how this works). The following therapeutic injections are covered for treatment of chronic pain: • Cervical-thoracic epidural injections • Lumbar epidural injections • Sacroiliac joint injections Note: See page 114 for a list of spinal injections that are not covered by the plan. Spinal injections not specified in this section may be covered subject to the plan’s medical policy. Contact UMP Customer Service for more information. Substance use disorder See the “Behavioral health” benefit. Surgery Note: When you receive nonemergency services at a network hospital, network hospital outpatient department, network critical access hospital, or network ambulatory surgical center in Washington State, you pay the network rate and cannot be balance billed regardless of the network status of the provider. For nonemergency services performed at one of these facilities outside of Washington State, you still pay the network rate, but in some states, an out-of- network provider may be allowed to ask you to waive some of your balance billing protections. You pay the standard rate for covered surgical services. The plan pays for covered surgical services according to the network status of the provider. The surgeon and other professional providers may bill separately from the facility. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 71