What is included in the COE Program In general, all eligible expenses associated with single knee or single hip replacement surgery (if determined surgically appropriate) under the COE Program are covered. If surgery is recommended, this includes expenses from the day you arrive for your pre-operative visit through discharge, including your: • Assessment(s). • Surgery. • Hospital stay. • Hospital discharge (excluding take-home prescription drugs, which are covered under your UMP prescription drug benefit). Travel benefits Members participating in the COE Program may qualify for assistance with travel and lodging expenses. These expenses may include partial coverage by Premera for mileage, flights, parking, and lodging. To be covered by the program, all travel must be arranged through Premera. This travel may be arranged by calling Premera at 1-855-784-4563 (TRS: 711). You must have an approved adult care companion, whose travel expenses will be covered as described below. You may be partially reimbursed for expenses related to: • Mileage for driving within Washington. To qualify for reimbursement for mileage, members must live at least 60 driving miles from Virginia Mason Medical Center, located at 1100 9th Ave., Seattle, WA 98101. • Flights departing from and arriving at airports within Washington or Portland International Airport. You must depart from the airport closest to your residence. • Ground transportation from Seattle-Tacoma International Airport to Virginia Mason Medical Center. • Lodging expenses (excluding meals) at a COE-designated hotel. Premera must arrange all lodging. • Parking at Virginia Mason Medical Center and parking at your departing airport. TIP: Reimbursement for travel expenses is based on cost or current IRS rates for medical expenses, whichever is less, and may not cover all of your costs. For the IRS rates, visit the IRS website at irs.gov/tax-professionals/standard-mileage-rates. What is not included in the COE Program If you receive services outside of the COE Program, or choose to receive services at Virginia Mason Medical Center that are not related to your single knee or single hip replacement surgery, covered services will be processed at the standard rate. The following services are not included in the COE Program (but may be covered by other plan benefits): • Care received as part of the plan Virginia Mason Medical Center gives you as a condition of surgery, regardless of where you receive care. Examples include tobacco cessation and weight loss programs. • Physical therapy that is not provided during your hospitalization. • Follow-up care other than the initial postsurgical checkup at Virginia Mason Medical Center. An example of follow-up care is a visit with your regular doctor. • Prescription drugs received from a pharmacy after discharge from the hospital. • Convenience items, such as a personal phone. 58 2024 UMP Select (PEBB) Certificate of Coverage