Spinal and extremity manipulations The plan covers up to 24 visits per calendar year for manipulations (adjustments) of the spine and extremities (arms and legs). See the definition of “Limited benefit.” You pay the special rate (a $15 copay) for up to 24 visits for spinal and extremity manipulations 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 apply to the 24-visit limit. You may receive an office visit (see the “Office visits” benefit for more details) and/or x-ray (see the “Diagnostic tests, laboratory, and x-rays” benefit for more details) at the time of your spinal and extremity manipulation service. Note: For participating providers and out-of-network providers, services are paid at the standard rate up to 24 visits per calendar year. Spinal injections The plan must preauthorize some spinal injections (see the “Limits on plan coverage” section for how this works). The following therapeutic injections are covered for treatment of chronic pain: • Cervical-thoracic epidural injections • Lumbar epidural injections • Sacroiliac joint injections Note: See page 119 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 FOR MEDICARE RETIREES: The COE Program is not available to UMP Classic members enrolled in Medicare as their primary coverage (see the “For retirees enrolled in Medicare and UMP Classic” section). Medicare members still have access to covered services related to spine care separate from the COE Program. Those services are paid at the standard rate. 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. 70 2024 UMP Classic (PEBB) Certificate of Coverage