TIP: If you get a vaccine from an out-of-network provider, submit your claim to Regence BlueShield as a medical claim (see the “Billing and payment: submitting a claim” section). If you get a vaccine from an out-of-network pharmacy, submit your prescription drug claim to WSRxS (see the "Submitting a claim for prescription drugs" section). If you use an out-of-network provider or an out-of-network pharmacy, services will be paid at the out-of-network rate and you may be balance billed. Vaccines from an excluded pharmacy will not be covered. See the definition of “Excluded pharmacy.” Radiology Preauthorization is required for all non-emergency diagnostic imaging. Providers should obtain preauthorization before scheduling or performing any elective outpatient imaging service. Examples of imaging tests that require a preauthorization are: • Computed tomography (CT) • Computed tomography angiography (CTA) • Magnetic resonance angiography (MRA) • Magnetic resonance imaging (MRI) • Myocardial perfusion imaging (MPI) • Nuclear cardiology: ▪ Blood pool imaging ▪ First pass ventriculography ▪ Infarct imaging ▪ Multiple-gated acquisition (MUGA) scan • Positron emission tomography (PET and PET-CT) Second opinions This benefit covers: • Second opinions you choose to get. The plan covers these under the medical benefit, once you meet your medical deductible and pay the coinsurance. • Second opinions required by the plan. The plan covers these at 100 percent (you do not have to meet your medical deductible or pay the coinsurance). If you do not get a second opinion when required by the plan, coverage for services may be denied. Skilled nursing facility 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). 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 69