• On request, receive information from the plan about: ▪ How new technology is evaluated for inclusion as a covered service. ▪ How the plan reimburses providers. ▪ Preauthorization review requirements. ▪ Providers you select and their qualifications. ▪ Services and treatments that have completed HTCC review and how that affects coverage by UMP. ▪ Technologies and treatments currently under review by the HTCC. ▪ The plan and network providers. ▪ Your covered expenses, exclusions, reductions, and maximums or limits. • Receive: ▪ A written explanation from the plan about any request to refund an overpayment. ▪ All covered services and supplies determined to be medically necessary as described in this COC, subject to the maximums, limits, exclusions, deductibles, coinsurance, and copays. ▪ Courteous, prompt answers from the plan. ▪ Timely, proper medical care without discrimination of any kind — regardless of health status or condition, sex, ethnicity, race, marital status, color, national origin, age, disability, or religion. As a plan member, you have the responsibility to: • Comply with requests for information by the date given. • Confirm provider and facility network status before every visit. • Contact the plan as soon as possible if you do not understand what is covered, if you have any questions, or if you need information. • Enroll in Medicare Part A and Part B if you are currently retired, or are in the process of retiring, and become eligible for Medicare. You must notify the PEBB Program when you enroll in Medicare Part A and Part B. Call 1-800-200-1004 (TRS: 711) to speak with a customer service representative for the PEBB Program. • Follow your providers’ instructions about your health care. • Give your providers complete information about your health to get the best possible care. • Keep your mailing address current by reporting changes as follows: ▪ Employees: To your payroll or benefits office. ▪ Retirees, PEBB Continuation Coverage members, and retired employees of a former employer group: To the PEBB Program. Send your address changes to: Health Care Authority PEBB Program PO Box 42684 Olympia, WA 98504 • Know how to access emergency care. • Not engage in fraud or abuse in dealing with the plan or your providers. • Participate with your providers in making decisions about your health care. 134 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage