Covered preventive care services are paid at the preventive rate. You do not have to meet your medical deductible before the plan pays the allowed amount for services covered under the preventive care benefit. When you see a network provider for these services, you pay $0. If you see an out-of-network provider, you pay 50 percent of the allowed amount, and the provider may balance bill you. If you do not have access to a network provider for preventive care services, see the “Network consent for out-of- network services” section for how to request network consent. For a list of services covered as preventive, visit the HealthCare.gov website at healthcare.gov/preventive- care-benefits. This site also features links to specific preventive services covered for members based on age and other risk factors. The plan may not cover recommendations added during the calendar year as preventive until later years. For a list of immunizations covered as preventive, see the “Covered immunizations” section below. Examples of services covered under the preventive care benefit include: • Certain radiology and lab tests, such as screening mammograms (see page 46). • Certain screening tests performed during pregnancy (see page 65 for more on prenatal care). • Fluoride for prevention of dental decay when prescribed by a primary care provider to children ages 17 and under, and when the water source is fluoride deficient (see page 49 for coverage of fluoride varnish). • Hearing tests as part of a newborn screening. • Immunizations as specified under “Covered immunizations” on page 68. • Intensive behavioral counseling for adults who are overweight or obese and have additional cardiovascular disease risk factors. • Certain statin prescription drugs to adults age 40 or older (statin prescription drugs that are listed as “Preventive” in the Tier column on the UMP Preferred Drug List [see “The UMP Preferred Drug List” section]). • One-time screening by ultrasound for abdominal aortic aneurysm for men ages 65-75 who have ever smoked. • Preventive vision acuity screening from birth through 18 years of age. • Preventive visits such as well-baby care and annual physical exams. • Routine screenings for adults. • Screening for hepatitis B for adolescents and adults at high risk and those who are pregnant. • Screening procedures, such as colonoscopy (see page 51 for coverage of colonoscopy performed to diagnose or treat disease or illness). If you have a screening and the provider diagnoses and treats a condition during the colonoscopy, services will be paid at the standard rate. Note: Prostate cancer screening (prostate-specific antigen [PSA testing]) is not covered under the preventive care benefit but is covered as a medical benefit (subject to your medical deductible and coinsurance). For more information, see page 51. ALERT! Follow-up visits or tests as a result of your preventive care visit are not covered under the preventive care benefit. If the plan normally covers the test or visit and it is medically necessary, it is covered under the medical benefit. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 67