When other means of transportation are considered unsafe due to your medical condition, the plan covers professional ambulance services: • From one facility to another facility, for inpatient or outpatient treatment; • From home to a facility; or • From a facility to home. Air ambulance You pay 20 percent of the allowed amount for medically necessary ambulance services regardless of network status. You may not be balance billed. Air professional ambulance services are covered only when all the following conditions are met: • Ground ambulance is not appropriate • The situation is a medical emergency • Air ambulance is medically necessary • Transport is to the nearest facility able to provide the care you need ALERT! The plan will not pay for air ambulance or other forms of air transport to move you to a facility closer to your home. If you travel outside the U.S., consider getting separate insurance that covers such air ambulance services. Water ambulance You pay 20 percent of the allowed amount for medically necessary ambulance services. Water professional ambulance services are covered only when all the following conditions are met: • Ground ambulance is not appropriate • The situation is a medical emergency • Water ambulance is medically necessary • Transport is to the nearest facility able to provide the care you need Applied Behavior Analysis (ABA) Therapy The plan covers Applied Behavior Analysis (ABA) Therapy only for a diagnosis of autism spectrum disorder. Providers of ABA Therapy services must be appropriately credentialed and qualified to prescribe or perform ABA Therapy services. The plan must preauthorize ABA Therapy services for members age 18 years old or older before services are performed. No preauthorization is required for members under age 18. Like other preauthorized services, approved ABA preauthorization is specific to the provider who made the ABA preauthorization request. ABA Therapy hours preauthorized for one provider are not automatically transferable to another provider. A change in the provider requires a new ABA preauthorization. The initial assessment and ABA therapy treatment order or prescription do not require preauthorization for members of any age. As for other covered services, you receive the highest-level benefit by using network providers. See the “Types of services” section for differences in your cost for core, support, and out-of-network providers. To find a network provider, visit the UMP Provider search or contact UMP Customer Service. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 43