• Have been determined to be a covered benefit by the Health Technology Clinical Committee (HTCC), if reviewed by the HTCC, and, if determined to be covered with conditions, meet the conditions of coverage established by the HTCC; and • Meet the plan’s coverage policies and preauthorization requirements. Limits and exclusions may apply to plan benefits. See both the benefit description and the “What the plan does not cover” section. Some services require preauthorization and/or notice before you receive treatment. Visit the UMP Policies that affect your care webpage for a list of these services, or contact UMP Customer Service to ask if a certain service is covered, requires preauthorization, or requires notice. See Directory for link and contact information. The following sections describe the benefits provided by this plan. Be sure to read them carefully for important information that may help you get the most from your health coverage. If you do not understand the benefits, it is your responsibility to ask for help before receiving services by contacting UMP Customer Service. UMP Plus is a self-insured ACP. UMP is offered through the Washington State HCA’s Public Employees Benefits Board (PEBB) Program. UMP is administered by Regence BlueShield, and Washington State Rx Services (WSRxS). All prescription drugs, services, or other benefit changes may require approval by the PEB Board. Approval takes place when benefits are procured for the next calendar year. For example, prescription drugs newly approved by the U.S. Food and Drug Administration (FDA) may require approval by the PEB Board before the plan will cover them. Health Technology Clinical Committee (HTCC) ALERT! HTCC determinations may be implemented by the plan at any time during the calendar year, but are often implemented the January following the HTCC’s decision. HTCC decisions are posted on the HCA website at hca.wa.gov/hta. Contact UMP Customer Service if you have questions about specific services that the HTCC has reviewed. Created by chapter 70.14 of the Revised Code of Washington (RCW), the HTCC is a committee of 11 independent health care professionals that reviews selected health technologies (services) to determine appropriate coverage, if any, for the services. These may include medical or surgical devices and procedures, medical equipment, and diagnostic tests. In public meetings, the HTCC considers public comments and scientific evidence regarding the safety, medical effectiveness, and cost-effectiveness of the services when making its determination. How HTCC decisions affect UMP benefits Under state law, the plan must comply with HTCC decisions, RCW 70.14.120 (1)(a), unless such determination conflicts with federal or state law. Services reviewed by the HTCC are either covered, covered with conditions, or not covered. The HTCC determines the conditions, if any, under which the service will be included as a covered benefit and, if covered, the criteria the plan must use to decide whether the service is medically necessary. Criteria established by the HTCC take precedence over Regence’s medical policies. When the HTCC determines that a service is not covered, then the service is not covered by the plan. Some HTCC decisions include a requirement to follow FDA or Centers for Medicare and Medicaid Services (CMS) guidelines. You may review these guidelines on the FDA website at fda.gov or CMS website at cms.gov. 38 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage