33. Extracorporeal shock wave therapy for musculoskeletal conditions 34. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy, photokeratectomy, or LASIK surgery 35. Facet neurotomy for headache 36. Facet neurotomy for thoracic spine 37. Fecal microbiota transplantation for treatment of inflammatory bowel disease 38. Foot care not related to diabetes: Toenail cutting; diagnosed corns and calluses treatment; or any other maintenance-related foot care 39. Functional neuroimaging for primary degenerative dementia or mild cognitive impairment 40. Gene expression profile testing for multiple myeloma or colon cancer 41. Headaches: ◦ Treatment of chronic tension-type headache with Botox or acupuncture ◦ Treatment of chronic migraine or chronic tension-type headache with massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (e.g., chiropractic services) Note: For chronic migraines and tension-type headaches, see page 52 42. Hearing aid items: ◦ Over-the-counter hearing aids that are not prescribed, except for initial assessment, fitting, adjustment, auditory training, and 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 types of ancillary equipment not covered are: ◦ 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 ◦ Assistive listening devices for televisions (including amplifiers and caption decoders) ◦ Assistive listening devices for use with cochlear implants ◦ Assistive listening devices, supplies, and accessories not otherwise specified 43. Hip resurfacing 44. Hip surgery for treatment of Femoroacetabular Impingement (FAI) Syndrome 45. Home health care, except as described on page 54. The plan does not cover the following services: ◦ Housekeeping or meal services 114 2024 UMP Classic (PEBB) Certificate of Coverage