• Total knee arthroplasty performed with computer navigation is covered. • For individuals with unicompartmental disease, unicompartmental partial knee arthroplasty is covered. • Multi-compartmental partial knee arthroplasty (including bicompartmental and bi-unicompartmental) is not covered. Mammogram and Digital Breast Tomosynthesis (DBT) ALERT! Not all mammograms are paid at 100 percent (preventive rate). Only screening mammograms are considered preventive. Diagnostic mammograms are subject to your medical deductible and coinsurance. Claims are paid based on how your provider bills the service. Screening (preventive) • For members age 40 or older, with or without a clinical breast exam, the plan covers screening mammograms and Digital Breast Tomosynthesis (DBT) every year, and they are not subject to your medical deductible. • For members under age 40, the plan covers screening mammograms and DBT for members who are at an increased risk for breast cancer. A covered health care provider must order the service, and the claim must be billed with an “at risk” diagnosis to be covered under the preventive care benefit. Note: Digital Breast Tomosynthesis (DBT) is only covered when you receive it along with a screening mammogram. How much you will pay For all members, services are covered at the preventive rate. Diagnostic (medical) You pay the standard rate for medically necessary mammograms to diagnose a medical condition under the “Diagnostic tests, laboratory, and x-rays” benefit. There are no age requirements for diagnostic mammograms and DBT. A covered health care provider must order the service, and the claim must be billed as a diagnostic mammogram. ALERT! See the “Breast health screening tests” benefit for coverage of diagnostic testing other than mammograms. Massage therapy Support network provider type: You must use a UMP Plus–PSHVN provider or a covered provider within the support network to receive network level benefits (see description in the “Support network providers” section). The plan covers up to 24 visits per calendar year for massage therapy (no more than 90 minutes per visit). See the definition of “Limited benefit”. You pay the special rate (a $15 copay) for up to 24 massage 62 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage