Premera will help you understand how the COE Program works, what is covered under the Program, connect you with Virginia Mason Medical Center providers if you are eligible, and work to resolve any questions or issues you may have. If you receive services related to joint replacement that are not covered under the COE Program, but are covered under the plan, you will pay your normal UMP cost-share, depending on the services received and the network status of the provider(s). This may be a deductible, coinsurance, copay, or amounts not covered by the plan. Services billed to the plan outside of the COE Program are subject to the plan’s preauthorization requirements. COE for knee and hip joint replacement: Virginia Mason Medical Center Virginia Mason Medical Center is the only provider approved to perform single knee and single hip replacement under the COE Program. Virginia Mason Medical Center has proven that it provides high- quality joint replacements using the most up-to-date medical guidelines and services. Who is eligible to participate in the COE Program? You are eligible to participate in the COE Program if you are: • A member enrolled in UMP Select. • Not enrolled in Medicare as your primary coverage. • Age 18 or older. How to apply to participate in the COE Program If you are interested in participating in the COE Program: • You may self-refer by calling Premera at 1-855-784-4563 (TRS: 711). • Your regular provider may refer you. You may receive information in the mail about the COE Program, which will explain how the program works and whom to contact for more information. Premera will screen applicants to initially determine whether they are eligible to participate in the COE Program. What happens after you are approved to participate After you are approved to participate in the program, Premera will: • Provide a booklet to participants describing their journey through the program. • Assign participants a dedicated case manager who will walk participants through each step of the journey. • Gather relevant medical records to supply to the participant’s COE care team as part of the referral process. This information helps the care team assess next steps. After Premera’s referral, Virginia Mason Medical Center will: • Review the participant’s medical records and schedule an evaluation appointment to determine whether the surgery is medically appropriate for the participant under the COE Program. • Provide a list from which participants may select their surgeon if the participant is approved for surgery. Virginia Mason Medical Center must determine if surgery for joint replacement is appropriate based on established medical guidelines. You may find these guidelines on the Policies that affect your care webpage (see Directory for link). 2024 UMP Select (PEBB) Certificate of Coverage 57