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 ◦ Ultrasonic stimulator – delayed fractures and concurrent use with another noninvasive stimulator. 7. Bone morphogenetic protein-7 (rhBMP-7) for use in lumbar fusion 8. Bronchial thermoplasty for asthma 9. Carotid artery stenting of intracranial arteries 10. Carotid intima media thickness testing 11. Catheter ablation for non-reentrant supraventricular tachycardia 12. Cervical spinal fusion without evidence of radiculopathy or myelopathy 13. Complications arising directly from services that would not be covered by the plan during the current plan year. The plan will cover complications arising directly from services that a PEBB plan covered for you in the past. 14. Computed Tomographic Colonography (CTC), also called a virtual colonoscopy, for routine colorectal cancer screening 15. Corneal Refractive Therapy (CRT), also called Orthokeratology 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage 107