Mammogram and Digital Breast Tomosynthesis (DBT) ALERT! Not all mammograms are paid at 100 percent (preventive rate). Only screening mammograms are considered preventive. Diagnostic mammograms are subject to your medical deductible and coinsurance. Claims are paid based on how your provider bills the service. Screening (preventive) • For members age 40 or older, with or without a clinical breast exam, the plan covers screening mammograms and Digital Breast Tomosynthesis (DBT) every year, and they are not subject to your medical deductible. • For members under age 40, the plan covers screening mammograms and DBT for members who are at an increased risk for breast cancer. A covered health care provider must order the service, and the claim must be billed with an “at risk” diagnosis to be covered under the preventive care benefit. Note: Digital Breast Tomosynthesis (DBT) is only covered when you receive it along with a screening mammogram. How much you will pay For all members, services are covered at the preventive rate. Diagnostic (medical) You pay the standard rate for medically necessary mammograms to diagnose a medical condition under the “Diagnostic tests, laboratory, and x-rays” benefit. There are no age requirements for diagnostic mammograms and DBT. A covered health care provider must order the service, and the claim must be billed as a diagnostic mammogram. ALERT! See the “Breast health screening tests” benefit for coverage of diagnostic testing other than mammograms. Massage therapy The plan covers up to 24 visits per calendar year for massage therapy (no more than 90 minutes per visit). See the definition of “Limited benefit.” You pay the special rate (a $15 copay) for up to 24 massage therapy visits per calendar year for covered diagnoses when you see a preferred provider. The copay will not apply toward your medical deductible, but the copay will apply to the out-of-pocket limit. All visits will apply to the 24-visit limit. You must have a prescription for massage therapy treatment from a covered provider type, such as a physician. The plan does not cover massage therapy when you see a participating or out-of-network provider. ALERT! The plan only covers preferred massage therapists. To find a preferred massage therapist, use the UMP Provider search or contact UMP Customer Service (see Directory for link and contact information). 60 2024 UMP Select (PEBB) Certificate of Coverage