• The condition is appropriately managed for medication overuse. Botox injections must be discontinued when: • The condition has shown inadequate response to treatment (defined as less than 50 percent reduction in headache days per month after two treatment cycles); or • The member has received a maximum of five treatment cycles. The following treatments are not covered: • Treatment of chronic tension-type headaches with Botox or acupuncture; and • Treatment of chronic migraine or chronic tension-type headaches with massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (such as chiropractic services). Hearing care (diseases and disorders of the ear) The plan pays under the medical benefit for covered services for treatment of diseases and disorders of the ear or auditory canal not related to routine hearing loss. These services are not part of the “Hearing exam and hearing aids” benefit. Hearing exam and hearing aids (instruments) 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). This benefit is not subject to your medical deductible and includes the services and supplies outlined below. Hearing exam (routine) ALERT! The plan pays for a hearing exam performed as part of a newborn screening at the preventive rate. You pay $0 for one routine hearing exam per calendar year when you see a network provider. However, if you see an out-of-network provider, you pay 50 percent of the allowed amount and the provider may balance bill you. Hearing aids You pay $0 of the $3,000 benefit limit per ear every 3 calendar years for prescribed hearing aids. You are responsible for hearing aid charges exceeding the $3,000 hearing aid benefit limit. See the definition of “Limited Benefit”. You pay the standard rate for the following hearing-related services: ▪ Ear mold(s) ▪ Initial battery, cords, and other ancillary equipment ▪ Warranty (only as included with the initial purchase) 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 57