72. Noncovered provider types: Services delivered by providers not listed as a covered provider type (see page 19) 73. Novocure (i.e., Optune) (tumor treating fields) 74. Orthoptic therapy except for the diagnosis of strabismus, a muscle disorder of the eye 75. Orthotics, foot or shoe: Items such as shoe inserts and other shoe modifications, except as specified on page 53 76. Osteochondral allograft/autograft transplantation for joints other than the knee 77. Out-of-network provider charges that are above the allowed amount 78. Peripheral nerve ablation, using any technique, to treat limb pain for adults and children, including for knee, hip, foot, or shoulder due to osteoarthritis or other conditions 79. Pharmacogenetic testing for patients being treated with oral anticoagulants 80. Pharmacogenomics testing for depression, mood disorders, psychosis, anxiety, attention deficit hyperactivity disorder (ADHD), and substance use disorder 81. Positron Emission Tomography (PET) scans for routine surveillance of lymphoma 82. Prescription drug charges over the allowed amount, regardless of where purchased 83. Prescription drugs that require preauthorization, unless the request is: ◦ Approved by the plan ◦ Supported by medical justification from a clinician other than the member or the member’s family 84. Printing costs for medical records 85. Private duty nursing or continuous care in the member's home, except as described on pages 61 and 69 86. Proton beam therapy for individuals age 21 or older for conditions other than: ◦ Brain/spinal ◦ Hepatocellular carcinoma ◦ Esophageal ◦ Ocular ◦ Head/neck ◦ Skull-based ◦ Other primary cancers where all other treatment options are contraindicated after review by a multidisciplinary tumor board 87. Provider administrative fees: Any charges for completing forms, copying records, or finance charges, except for records requested by the plan to perform retrospective (i.e., post-payment) review 88. Repetitive transcranial magnetic stimulation for tinnitus 89. Replacement of lost, stolen, or damaged durable medical equipment (DME) 90. Replacement of prescription drugs that are any of the following: ◦ Confiscated or seized by Customs or ◦ Expired other authorities ◦ Lost or stolen ◦ Contaminated ◦ Ruined ◦ Damaged 91. Residential treatment programs offered at facilities that do not meet the definition of Residential Treatment Facility (see definition of “Residential treatment facility”) 112 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage