• Sacroiliac joint injections Note: See page 117 for a list of spinal injections that are not covered by the plan. Spinal injections not specified in this section may be covered subject to the plan’s medical policy. Contact UMP Customer Service for more information. Spinal surgery The plan must preauthorize inpatient and outpatient spinal surgery performed outside of the Centers of Excellence (COE) Program. Spine care in the Centers of Excellence (COE) Program The Centers of Excellence (COE) Program covers 100 percent of the allowed amount for covered services related to lumbar fusion. The program includes, but is not limited to: • An evaluation to determine if surgery is appropriate. • Presurgical consultations. • Travel costs (see the “Travel benefits” section below). • Hospitalization and surgery, if surgery is determined to be appropriate. • Postsurgical check-ups. In the COE program, members work with Premera Blue Cross (the administrator of the program) and Virginia Mason Medical Center (the Center of Excellence) to make sure that their treatment is consistent with established standards of medical care. Premera will help you understand how the COE Program works, what is covered under the Program, connect you with Virginia Mason Medical Center providers if you are eligible, and work to resolve any questions or issues you may have. If you receive services related to spine care that are not covered under the COE Program, but are covered under the plan, you will pay your normal UMP cost-share, depending on the services received and the network status of the provider(s). This may be a deductible, coinsurance, copay, or amounts not covered by the plan. Services billed to the plan outside of the COE Program are subject to the plan’s preauthorization requirements. Centers of Excellence for spine care: Virginia Mason Medical Center Virginia Mason Medical Center is the provider approved to perform spine care evaluations and surgeries under the COE Program. This facility has proven that they provide high-quality spine care using the most up-to-date medical guidelines and services. Who is eligible to participate in the COE Program? You are eligible to participate in the COE Program if you are: • A member enrolled in UMP Select. • Not enrolled in Medicare as your primary coverage. • Age 18 or older. How to apply to participate in the COE Program If you are interested in participating in the COE Program: • You may self-refer by calling Premera at 1-855-784-4563 (TRS: 711). • Your regular provider may refer you. 2024 UMP Select (PEBB) Certificate of Coverage 69