Orthognathic and Telegnathic surgery Orthognathic and telegnathic surgery must be preauthorized by the plan. Contact UMP Customer Service if you have questions. See page 74 for treatment of temporomandibular joint (TMJ) disorder. Pain and joint management, interventional Interventional pain management is a medical subspecialty that treats pain with invasive interventions like injections, spinal cord stimulations, and implantable drug delivery systems. The purpose of interventional pain management is to help members have less pain, so they can return to normal activities, when possible. Preauthorization is required for interventional pain and joint management, such as: • Epidural injections • Radiofrequency ablations • Facet blocks • Sacroiliac joint injections • Pain pumps Preauthorization is not required for post-procedural pain management in an inpatient setting, including, but not limited to, treating acute pain due to trauma, acute post-thoracotomy pain, and acute postoperative pain. Prescription drugs See the “Your prescription drug benefit” section. Preventive care ALERT! This benefit covers only services that meet the requirements below. If you receive services during a preventive care visit that do not meet these requirements, or your provider bills your visit as medical treatment instead of a preventive service, the services are not covered as preventive. Instead, when medically necessary, they are covered under the standard rate. Covered preventive care services are paid at the preventive rate. You do not have to meet your medical deductible before the plan pays the allowed amount for services covered under the preventive care benefit. When you see a preferred or participating provider for these services, you pay $0. If you see an out-of-network provider, you pay 40 percent of the allowed amount, and the provider may balance bill you. If you do not have access to a preferred or participating provider for preventive care services, see the “When you do not have access to a preferred provider: network waiver” section for how to request a network waiver. For a list of services covered as preventive, visit the HealthCare.gov website at healthcare.gov/ preventive-care-benefits. This site also features links to specific preventive services covered for members based on age and other risk factors. The plan may not cover recommendations added during the calendar year as preventive until later years. For a list of immunizations covered as preventive, see the “Covered immunizations” section below. Examples of services covered under the preventive care benefit include: • Certain radiology and lab tests, such as screening mammograms (see page 42). • Certain screening tests performed during pregnancy (see page 64 for more on prenatal care). 2024 UMP Classic (PEBB) Certificate of Coverage 65