Exclusions

What the plan doesn't cover

Uniform Medical Plan covers only the services and conditions specifically identified in your plan's 2017 Certificate of Coverage. Unless a service or condition fits into one of the specific benefit definitions, it is not covered. You may pay all costs for a noncovered service.

Here are 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. Air ambulance, if ground ambulance would serve the same purpose.
  2. Arthroscopic knee surgery (lavage and debridement of the knee) for the diagnosis of osteoarthritis.
  3. Bariatric surgery for members under age 18.
  4. Cardiac Artery Calcium Scoring.
  5. Carotid Intima Media Thickness testing.
  6. Complications arising directly from services that would not be covered by the plan during the current plan year. The plan will, however, cover complications arising directly from services that a PEBB plan paid for you in the past.
  7. Computed Tomographic Colonography (CTC) (also called a virtual colonoscopy) for routine colorectal cancer screening.
  8. Corneal Refractive Therapy (CRT), also called Orthokeratology.
  9.  Cosmetic services or supplies, including drugs and pharmaceuticals. However, the plan does cover:
    1. Reconstructive breast surgery following a mastectomy necessitated by disease, illness, or injury.
    2. Reconstructive surgery of a congenital anomaly, such as cleft lip or palate, to improve or restore function.
  10. Court-ordered care, unless determined by the plan to be medically necessary and otherwise covered.
  11. Custodial care.
  12. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services listed under dental services.
  13. Dietary or food supplements, including but not limited to:
    1. Herbal supplements, dietary supplements, medical foods, and homeopathic drugs.
    2. Infant or adult dietary formulas (see exceptions).
    3. Medical foods.
    4. Minerals.
    5. Prescription or over-the-counter vitamins (see exceptions).
  14. Dietary programs.
  15. Drugs or medicines not covered by the plan as described in the "Guidelines for drugs not covered" section in your plan's 2017 certificate of coverage.
  16. Drugs or medicines obtained through foreign (non-United States) mail-order pharmacies.
  17. Educational programs, except as described under:
    1. Diabetes education
    2. Diabetes Prevention Program
    3. Tobacco cessation services
  18. Email consultations or e-visits.
  19. Electrical Neural Stimulation (ENS), which includes Transcutaneous Electrical Nerve Stimulation (TENS) Units.
  20. Equipment not primarily intended to improve a medical condition or injury, including but not limited to:
    1. Air conditioners or air purifying systems
    2. Arch supports
    3. Communication aids
    4. Elevators
    5. Exercise equipment
    6. Massage devices
    7. Overbed tables
    8. Sanitary supplies
    9. Telephone alert systems
    10. Vision aids
    11. Whirlpools, portable whirlpool pumps, or sauna baths
  21. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals.
  22. Experimental or investigational services, supplies, or drugs.
  23. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy, photokeratectomy, or LASIK surgery.
  24. Foot care not related to a medical condition: Cutting of toenails; treatment for diagnosed corns and calluses; or any other maintenance-related foot care.
  25. Hip surgery for treatment of Femoroacetabular Impingement (FAI) Syndrome.
  26. Home health care, except as described under Home health care. The plan does not cover the following services:
    1. Private duty or continuous care in the member's home.
    2. Housekeeping or meal services.
    3. Care in any nursing home or convalescent facility.
    4. Care provided by or for a member of the patient's family.
    5. Any other services provided in the home that do not meet the definition of skilled home health care as described under Home Health Services or not specifically listed as covered in your plan's 2017 Certificate of Coverage.
  27. Hospital inpatient charges for non-essential services or features such as:
    1. Admissions solely for diagnostic procedures that could be performed on an outpatient basis.
    2. Reserved beds.
    3. Services and devices that are not medically necessary.
    4. Personal or convenience items.
  28. Hyaluronic acid injections (viscosupplementation) for treatment of pain in any joint other than the knee.
  29. Immunizations for the purpose of travel or employment, even if recommended by the Centers for Disease Control and Prevention.
  30. Implantable drug delivery systems (infusion pumps or IDDS) for chronic non-cancer pain.
  31. In vitro fertilization and all related services and supplies, including all procedures involving selection of embryo for implantation.
  32. Incarceration: Services and supplies provided while confined in a prison or jail.
  33. Infertility or fertility testing or treatment, including drugs, pharmaceuticals, artificial insemination, and any other type of testing, treatment, complications resulting from such treatment (for example, selective fetal reduction), or visits for infertility.
  34. ate fees, finance charges, or collections charges.
  35. Learning disabilities treatment after diagnosis, except as covered under the following benefits:
    1. Applied Behavior Analysis (ABA) Therapy,
    2. Physical, occupational, speech, and neurodevelopmental therapy; or
    3. When part of treating a mental health disorder as described under mental health treatment.
  36. Magnetic Resonance Imaging—Upright MRIs (uMRI), also known as "positional," "weight-bearing" (partial or full), or "axial loading."
  37. Maintenance care.
  38. Manipulations of the spine or extremities, except as described under Spinal and extremity manipulations.
  39. Marriage, family, or other counseling or training services, except as provided to treat an individual member's neuropsychiatric, mental, or personality disorder.
  40. Massage therapy services when the massage therapist is not a preferred provider (network provider for UMP Plus).
  41. Missed appointment charges.
  42. Noncovered provider types: Services delivered by providers not listed as a covered provider type.
  43. Orthoptic therapy except for the diagnosis of strabismus, a muscle disorder of the eye.
  44. Orthotics, foot or shoe: Items such as shoe inserts and other shoe modifications, except as specified under orthotics.
  45. Out-of-network provider charges that are above the allowed amount.
  46. Over-the-counter contraceptive supplies intended for use by males.
  47. Postage and handling related to medical services and supplies.
  48. Prescription drug charges over the allowed amount, regardless of where purchased.
  49. Prescription drugs that require preauthorization unless the request is:
    1. Supported by medical justification from a clinician other than the patient or member of the patient's family.
    2. Approved by the plan.
  50. Provider administrative fees—Any charges for completing forms, copying records, or finance charges, except for records requested by the plan to perform retrospective (postpayment) review.
  51. Recreation therapy.
  52. Replacement of lost, stolen, or damaged durable medical equipment.
  53. Replacement of medications that are any of the following:
    1. Confiscated or seized by Customs or other authorities
    2. Contaminated
    3. Damaged
    4. Lost or stolen
    5. Ruined
  54. Residential treatment programs that are not solely for chemical dependency treatment or a mental health condition requiring inpatient treatment. Examples include, but are not limited to, schools, wilderness programs, and behavioral programs.
  55. Reversal of voluntary sterilization (vasectomy, tubal ligation, or similar procedures).
  56. Riot, rebellion, and illegal acts: Services and supplies for treatment of an illness, injury, or condition caused by a member's voluntary participation in a riot, armed invasion or aggression, insurrection or rebellion, or sustained by a member arising directly from an act deemed illegal by a court of law.
  57. Separate charges for records or reports.
  58. Service animals: Any expenses related to a service animal.
  59. Services covered by other insurance, including but not limited to motor vehicle, homeowner's, renter's, commercial premises, personal injury protection (PIP), medical payments (Med-Pay), automobile no-fault, general no-fault, underinsured or uninsured motorist coverage.
  60. Services delivered by providers delivering services outside the scope of their licenses.
  61. Services or supplies:
    1. That are not medically necessary for the diagnosis and treatment of injury or illness or restoration of physiological functions, and are not covered as preventive care. This applies even if services are prescribed, recommended, or approved by your provider.
    2. For which no charge is made, or for which a charge would not have been made if you had no health care coverage.
    3. Provided by a family member or any household member.
    4. Provided by a resident physician or intern acting in that capacity.
    5. That are solely for comfort.
    6. For which you are not obligated to pay.
  62. Services performed during a noncovered service.
  63. Services performed primarily to ensure the success of a noncovered service, including but not limited to a hiatal hernia repair done to ensure the success of a noncovered Laparoscopic Adjustable Gastric Banding surgery.
  64. Services, supplies, or drugs related to occupational injury or illness.
  65. Services, supplies, or items that require preauthorization unless the request is:
    1. Supported by medical justification from a clinician other than the patient or member of the patient's family.
    2. Approved by the plan.
  66. Skilled nursing facility services or confinement:
    1. When primary use of the facility is as a place of residence.
    2. When treatment is primarily custodial.
  67. Spinal cord stimulator for chronic neuropathic pain.
  68. Spinal injections, therapeutic (except as described under spinal injections) of the following types:
    1. Medial branch nerve block
    2. Intradiscal
    3. Facet neurotomy
  69. Spinal surgical procedures known as vertebroplasty, kyphoplasty, and sacroplasty.
  70. Telephone or virtual consultations or appointments, except as described under telemedicine services.
  71. Travel, transportation, and lodging expenses, except as specified for ambulance services covered by the plan, or approved travel and lodging expenses related to the Center of Excellence (COE) Program for knee and hip joint replacement surgery.
  72. Ultrasounds during pregnancy, except as described under "Limitations on Ultrasounds During Pregnancy" in the Obstetric and newborn care benefit.
  73. Weight control, weight loss, and obesity treatment:
    1. Non-surgical: Any program, drugs, services, or supplies for weight control, weight loss, or obesity treatment. Exercise or diet programs (formal or informal), exercise equipment, or travel expenses associated with non-surgical or surgical services are not covered. Such treatment is not covered even if prescribed by a provider, except as covered under Diabetes Prevention Program, Nutrition counseling and therapy, or Preventive care.
    2. Surgical: Any bariatric surgery procedure, any other surgery for obesity or morbid obesity, and any related medical services, drugs, or supplies, except when approved by preauthorization review.
  74. Workers' compensation: When a claim for workers' compensation is accepted as being caused by a work-related injury or illness, all services related to that injury or illness are not covered, even if some services are denied by workers' compensation.

Contact

For more about coverage of medical services or supplies: UMP Customer Service
Phone: 1-888-849-3681

For more about coverage of prescription drugs: Washington State Rx Services
Phone: 1-888-361-1611