Diagnostic tests, laboratory, and x-rays You pay the standard rate for covered diagnostic tests, laboratory tests, and x-rays when medically necessary. If there are alternative diagnostic approaches with different fees, the plan will cover the least expensive, evidence-based diagnostic method. Visit the UMP Policies that affect your care webpage or contact UMP Customer Service for a list of services requiring preauthorization (see Directory for link and contact information). Covered services include: • All prostate cancer screening (prostate-specific antigen [PSA testing]), which is subject to your medical deductible and coinsurance, even if billed as preventive. • Colonoscopy performed to diagnose disease or illness. See the list on page 65 for coverage of preventive or screening colonoscopy. • Diagnostic laboratory tests, x-rays (including diagnostic mammograms), and other imaging studies. • Electrocardiograms (EKG, ECG). • Skin allergy testing. TIP: See page 61 to learn how the plan covers mammograms. The plan does not pay for the following tests (this list does not include all tests not covered by the plan): • Carotid Intima Media Thickness testing. • Computed Tomographic Colonography (CTC) (also called a virtual colonoscopy) for routine screening. • Upright Magnetic Resonance Imaging (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading.” Dialysis Inpatient Dialysis You pay the standard rate for covered inpatient dialysis services. The plan pays based on the allowed amount and the network status of the provider. Other professional providers may bill separately from the facility. Outpatient Dialysis and Supplemental Kidney Dialysis During your initial outpatient treatment period of three months (42 treatments of hemodialysis or 30 days of peritoneal dialysis), you pay the standard rate for covered outpatient dialysis services. Once the supplemental treatment period begins, you pay the special rate (0% of the allowed amount) for covered outpatient dialysis services. You will also be eligible for Medicare Part B coverage. Our care managers can help you apply for Medicare Part B. To reach a care manager, call UMP Customer Service. Once enrolled in Medicare Part B, you are eligible to get your Medicare Part B premiums reimbursed by the plan as long as you remain enrolled in Medicare Part B and are eligible under this plan. Proof of payment of your Medicare Part B premiums is required for reimbursement. If you are not enrolled in Medicare Part B and you receive outpatient dialysis from an out-of-network provider, you may be balance billed. 2024 UMP Classic (PEBB) Certificate of Coverage 47