cover alternative benefits through case management (see the “Care management” benefit) if the plan determines that alternative benefits are medically necessary and will result in overall reduced covered costs and improved quality of care. Before alternative benefits are covered, the plan, you (or your legal representative), and, if required by the plan, your physician or other provider, must enter into a written agreement of the terms and conditions for payment. Alternative benefits are approved on a case-specific basis only. Approval of an alternative benefit applies to only the services and member listed in the written agreement. The rest of this COC remains in effect. What the plan does not cover TIP: If you have any questions about services the plan does not cover, contact UMP Customer Service or WSRxS Customer Service. This plan covers only the services and conditions specifically identified in this COC. Unless a service or condition fits into one of the specific benefit definitions, it is not covered. You may pay all costs associated with a noncovered service. Here are some examples of common services and conditions that are not covered. Many others are also not covered — these are examples only, not a complete list. These examples are called exclusions, meaning these services are not covered, even if the services are medically necessary. 1. Activity therapy. The following activity therapy services include, but are not limited to: ◦ Aroma; ◦ Creative arts; ◦ Dance; ◦ Equine or other animal-assisted; ◦ Music; ◦ Play; ◦ Recreational or similar therapy; and ◦ Sensory movement groups. 2. Air ambulance, if ground ambulance would serve the same purpose 3. Ambulance (all types), to move you to a facility closer to your home or for purposes that are not medically necessary 4. Autologous blood and platelet-rich plasma injections 5. Bariatric surgery under the following circumstances: ◦ BMI 30 to less than 35 without Type II Diabetes Mellitus ◦ BMI less than 30 ◦ Patients younger than 18 years of age 6. Bone growth stimulators for: ◦ Nonunion of skull, vertebrae, or tumor related 106 2024 UMP CDHP (PEBB) Certificate of Coverage