◦ Infant or adult dietary formulas ◦ Medical foods (except when prescribed for inborn errors of metabolism) ◦ Minerals ◦ Prescription or over-the-counter vitamins (see page 107) 23. Dietary programs 24. Discography for patients with chronic low back pain and lumbar degenerative disc disease. This does not apply to patients with the following conditions: ◦ Degenerative disease associated with significant deformity ◦ Fracture, tumor, infection, and inflammatory disease ◦ Functional neurologic deficits (motor weakness or Electromyography [EMG] findings of radiculopathy) ◦ Isthmic spondylolysis ◦ Primary neurogenic claudication associated with stenosis ◦ Radiculopathy ◦ Spondylolisthesis greater than Grade 1 25. Drugs or medicines not covered by the plan, as described in the “Your prescription drug benefit” section, see pages 87-108 26. Drugs or medicines obtained through mail-order pharmacies located outside the U.S. 27. Educational programs, except as described under: ◦ “Diabetes Control Program” on page 46 ◦ “Diabetes education” on page 46 ◦ “Diabetes Prevention Program” on page 46 ◦ “Tobacco cessation services” on page 75 28. Electrical Neural Stimulation (ENS), which includes Transcutaneous Electrical Nerve Stimulation (TENS) units, outside of medically supervised facility settings (e.g., in-home use). 29. Email consultations or e-visits, except as described under the telemedicine benefit. 30. Equipment not primarily intended to improve a medical condition or injury, including, but not limited to: ◦ Air conditioners or air purifying systems ◦ Residential accessibility modifications ◦ Arch supports ◦ Sanitary supplies ◦ Communication aids ◦ Telephone alert systems ◦ Elevators ◦ Vision aids except when covered ◦ Exercise equipment through VSP ◦ Massage devices ◦ Whirlpools, portable whirlpool pumps, ◦ Overbed tables or sauna baths 31. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals 32. Experimental or investigational services, supplies, or drugs (see page 187) 2024 UMP Classic (PEBB) Certificate of Coverage 113