You pay the standard rate for covered DME services and supplies if they are prescribed by a provider practicing within their scope of practice, medically necessary, and used to treat a covered condition, including, but not limited to: • Artificial limbs or eyes (including implant lenses prescribed by a physician and required due to cataract surgery or to replace a missing portion of the eye). • Automatic Positive Airway Pressure (APAP) devices and related supplies. • Bi-level Positive Airway Pressure (BiPAP) devices and related supplies. • Bone growth (osteogenic) stimulators. • Breast prostheses and bras as required by mastectomy. See the “Mastectomy and breast reconstruction” benefit. • Breast pumps for pregnant and nursing members (see “Services covered as preventive” on page 64). • Casts, splints, crutches, trusses, and braces. • Compression stockings. • Continuous Positive Airway Pressure (CPAP) devices and related supplies. • Diabetic shoes, only as prescribed for a diagnosis of diabetes. See the “Foot orthotics” section below. • Elemental formulas for Eosinophilic Gastrointestinal Disorders (EGIDs). • Insulin pumps and related pump supplies (see the “Insulin pumps and related pump supplies” section below). • Ostomy supplies. • Oxygen and its equipment, such as all types of concentrators and tanks for administration, are covered on a rental basis only. • Penile prosthesis when other accepted treatment has been unsuccessful and impotence is: ▪ Caused by a covered medical condition; or ▪ A complication directly resulting from a covered surgery; or ▪ A result of an injury to the genitalia or spinal cord. • Rental or purchase (at the plan's discretion) of DME such as wheelchairs, hospital beds, and respiratory equipment. (The combined rental fees cannot exceed full purchase price.) • Wig or hairpiece to replace hair loss due to radiation therapy or chemotherapy for a covered condition, up to a lifetime maximum of $100. Wigs and hairpieces for any other reason are not covered. Some items require preauthorization. Find the list of supplies that require a preauthorization by visiting forms and publications at hca.wa.gov/ump-forms-pubs and search “durable medical equipment” or contact UMP Customer Service. The plan limits coverage of DME to one item of a particular type of equipment and the accessories needed to operate the item. If you receive a higher-cost DME item when a less expensive, medically appropriate option is available, the plan will not pay for the more expensive item. The plan also covers the repair or replacement of DME due to normal use or a change in the member’s condition (including the growth of a child). You are responsible for the entire cost of any additional pieces of the same or similar DME you purchase or rent for personal convenience or mobility. Note: The plan does not cover replacement of lost, stolen, expired, or damaged DME. 2024 UMP CDHP (PEBB) Certificate of Coverage 49