Hearing exam and hearing aids (instruments) This benefit is not subject to your medical deductible and includes the services and supplies outlined below. Hearing exam (routine) ALERT! The plan pays for a hearing exam performed as part of a newborn screening at the preventive rate. You pay $0 for one routine hearing exam per calendar year when you see a preferred or participating provider. However, if you see an out-of-network provider, you pay 40 percent of the allowed amount and the provider may balance bill you. Hearing aids You pay $0 of the $3,000 benefit limit per ear every 3 calendar years for prescribed hearing aids. You are responsible for hearing aid charges exceeding the $3,000 benefit limit. See the definition of “Limited Benefit”. You pay the standard rate for the following hearing-related services: ▪ Ear mold(s) ▪ Initial battery, cords, and other ancillary equipment ▪ Warranty (only as included with the initial purchase) ▪ Follow-up consultation within 30 days after delivery of hearing aid ▪ Rental charges up to 30 days if you return the rented hearing aid before actual purchase ▪ Repair of hearing aid equipment ▪ The initial assessment, fitting, adjustment, auditory training, and other ear molds as necessary to maintain an optimal fit for those who have obtained or intend to obtain a hearing aid The following hearing-related items are not covered: • Over-the-counter hearing aids that are not prescribed, except for initial assessment, fitting, adjustment, auditory training, and other ear molds as necessary to maintain an optimal fit. • Charges incurred after your plan coverage ends, unless you ordered the hearing aid before that date and it is delivered within 45 days after your coverage ended • Extended warranties, or warranties not related to the initial purchase of the hearing aid(s) • Purchase of replacement batteries or other ancillary equipment, except those covered under terms of the initial hearing aid purchase The following ancillary equipment is not covered: • Alerting devices • Assistive listening devices for FM/DM systems, receivers and transmitters • Assistive listening devices for microphone transmitters • Assistive listening devices for TDD machines • Assistive listening devices for telephones 2024 UMP Classic (PEBB) Certificate of Coverage 53