▪ Follow-up consultation within 30 days after delivery of hearing aid ▪ Rental charges up to 30 days if you return the rented hearing aid before actual purchase ▪ Repair of hearing aid equipment ▪ The initial assessment, fitting, adjustment, auditory training, and other ear molds as necessary to maintain an optimal fit for those who have obtained or intend to obtain a hearing aid The following hearing-related items are not covered: • Over-the-counter hearing aids that are not prescribed, except for initial assessment, fitting, adjustment, auditory training, and ear molds as necessary to maintain an optimal fit • Charges incurred after your plan coverage ends, unless you ordered the hearing aid before that date and it is delivered within 45 days after your coverage ended • Extended warranties, or warranties not related to the initial purchase of the hearing aid(s) • Purchase of replacement batteries or other ancillary equipment, except those covered under terms of the initial hearing aid purchase The following ancillary equipment is not covered: • Alerting devices • Assistive listening devices for FM/DM systems, receivers and transmitters • Assistive listening devices for microphone transmitters • Assistive listening devices for TDD machines • Assistive listening devices for telephones • Assistive listening devices for televisions (including amplifiers and caption decoders) • Assistive listening devices for use with cochlear implants • Assistive listening devices, supplies, and accessories not otherwise specified • Hearing aid batteries Home health care 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). See the “What the plan does not cover” section for services the plan does not cover. In certain circumstances, the plan covers short-term, provider-directed, medically necessary home health services on an intermittent or part-time basis by a licensed home health, hospice, or home care agency, to help a member recover from an acute covered illness, injury, or hospital stay. Home Health care is provided through visits from specialized clinicians, performing specific tasks (rather than time-based shifts), on a short-term basis, until specified individual goals are met. These services must be part of a treatment plan written by your provider (such as your physician or advanced registered practitioner [ARNP]). The provider must certify that you are homebound. These short-term visits may include: • Skilled nursing care, physical, occupational, or speech therapy 58 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage