Over-the-counter contraceptives Over-the-counter contraceptives are covered under the Preventive Tier (P) on the UMP Preferred Drug List (see “The UMP Preferred Drug List” section for more information), only if they are approved by and registered with the FDA. For the plan to cover FDA-registered over-the-counter contraceptives, you must present your UMP member ID card and make your purchase at the pharmacy counter. When possible, it is best to obtain a prescription, since not all pharmacies have prescribing authority. If you go to a pharmacy without a prescription and the pharmacy does not have prescribing authority, you will need to submit a claim to WSRxS. Sterilization When you see a network provider, sterilization procedures, such as tubal ligation or vasectomy, are paid at the preventive rate and are not subject to your medical deductible. Services and products not covered under the family planning benefit The plan does not cover the following services and products as a family planning benefit: • Over-the-counter products not approved by and registered with the FDA • Reversal of voluntary sterilization • Treatment of fertility or infertility, including direct complications resulting from such treatment Foot care, maintenance Maintenance foot care includes services such as toenail trimming and corn or callous removal or trimming. These services are covered only for a diagnosis of diabetes and when provided by an approved provider type. The plan does not cover maintenance foot care provided outside the diagnosis of diabetes. Gender affirming care With a diagnosis of gender dysphoria, the following services are covered at the standard rate for outpatient services and at the inpatient rate for inpatient services: • Covered surgical services • Non-surgical services, including, but not limited to, hormone therapy, office visits, mental health counseling, and tests This is not a complete list of medical and surgical treatments of gender dysphoria in transgender individuals. For more information on gender affirming care, visit the UMP Policies that affect your care webpage to find the clinical criteria for gender affirming care (see Directory for link). Some services and prescription drugs associated with gender dysphoria may require preauthorization. Genetic services Covered genetic tests require preauthorization. With preauthorization, the plan covers medically necessary, evidence-based genetic testing services. Some genetics tests are not covered. For information about genetic services related to the fetus during pregnancy, see “Services for obstetric and newborn care” on page 64. Contact UMP Customer Service with any questions. Headaches, chronic migraine or chronic tension type The plan only covers the treatment of chronic migraine with OnabotulinumtoxinA (Botox) when both the following criteria are met: • The condition has not responded to at least three prior pharmacological prophylaxis therapies from two different classes of prescription drugs; and 56 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage