16. Coronary or cardiac artery calcium scoring 17. Cosmetic services or supplies, including drugs and pharmaceuticals, unless part of the following care: ◦ Reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury ◦ Reconstructive surgery of a congenital anomaly, such as cleft lip or palate, to improve or restore function 18. Court-ordered care, unless determined by the plan to be medically necessary and otherwise covered 19. Custodial care (see definition on page 172) 20. Deep brain stimulation and transcranial direct current stimulation when used as nonpharmacological treatments for treatment-resistant depression 21. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services (see pages 48–49) 22. Dietary/food supplements, including, but not limited to: ◦ Herbal supplements, dietary supplements, and homeopathic drugs ◦ Infant or adult dietary formulas ◦ Medical foods (except when prescribed for inborn errors of metabolism) ◦ Minerals ◦ Prescription or over-the-counter vitamins (see page 103) 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 85–104 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 50 ◦ “Diabetes education” on page 50 ◦ “Diabetes Prevention Program” on page 51 ◦ “Tobacco cessation services” on page 73 108 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage