Exclusions

What the plans don't cover in 2018

Uniform Medical Plan covers only the services and conditions specifically identified in your plan's 2018 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. Autologous blood and platelet-rich plasma injections.
  3. Bariatric surgery under the following circumstances:
    1. BMI 30 to 34 without Type II Diabetes Mellitus.
    2. BMI less than 30.
    3. Patients younger than 18 years of age.
  4. Bone growth stimulators for:
    1. Nonunion of skull, vertebrae or tumor related.
    2. Ultrasonic stimulator – delayed fractures and concurrent use with other noninvasive stimulator.
  5. Bone morphogenetic protein-7 (rhBMP-7) for use in lumbar fusion.
  6. Bronchial thermoplasty for asthma.
  7. Cardiac nuclear imaging for:
    1. Asymptomatic patients: Does not apply to pre-operative evaluation of patients undergoing high-risk non-cardiac surgery or patients who have undergone cardiac transplant.
    2. Patients with known coronary artery disease and no changes in symptoms.
  8. Carotid artery stenting of intracranial arteries.
  9. Carotid intima media thickness testing.
  10. 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.
  11. Computed tomographic colonography (CTC), also called a virtual colonoscopy, for routine colorectal cancer screening.
  12. Corneal refractive therapy (CRT), also called orthokeratology.
  13. Coronary or cardiac artery calcium scoring.
  14. Coronary artery tomographic angiography for:
    1. Patients who are asymptomatic or at high risk of coronary artery disease;
    2. CCTA used for coronary artery disease investigation outside of the emergency department or hospital setting; and
    3. CT scanners that use lower than 64-slice technology.
  15. 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.
  16. Court-ordered care, unless determined by the plan to be medically necessary and otherwise covered.
  17. Custodial care.
  18. Deep brain stimulation and transcranial direct current stimulation when used as nonpharmacological treatments for treatment-resistant depression.
  19. Dental care for the treatment of problems with teeth or gums, other than the specific covered dental services.
  20. 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 covered by the plan).
    3. Medical foods.
    4. Minerals.
    5. Prescription or over-the-counter vitamins (see exceptions covered by the plan).
  21. Dietary programs.
  22. Discography for patients with chronic low back pain and lumbar degenerative disc disease. This does not apply to patients with the following conditions:
    1. Radiculopathy
    2. Functional neurologic deficits (motor weakness or EMG findings of radiculopathy)
    3. Spondylolisthesis greater than Grade 1
    4. Isthmic spondylolysis
    5. Primary neurogenic claudication associated with stenosis
    6. Fracture, tumor, infection, inflammatory disease
    7. Degenerative disease associated with significant deformity
  23. Drugs or medicines not covered by the plan as described in the “Your prescription drug benefit” section.
  24. Drugs or medicines obtained through mail-order pharmacies located outside the U.S.
  25. Educational programs, except as described under:
    1. Diabetes Control Program."
    2. Diabetes education."
    3. Diabetes Prevention Program.”
    4. Tobacco cessation services.”
  26. Electrical Neural Stimulation (ENS), which includes Transcutaneous Electrical Nerve Stimulation (TENS) Units.
  27. Email consultations or e-visits.
  28. 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. Residential accessibility modifications
    9. Sanitary supplies
    10. Telephone alert systems
    11. Vision aids
    12. Whirlpools, portable whirlpool pumps, or sauna baths
  29. Erectile or sexual dysfunction treatment with drugs or pharmaceuticals.
  30. Experimental or investigational services, supplies, or drugs.
  31. Extracorporeal shock wave therapy for musculoskeletal conditions.
  32. Eye surgery to alter the refractive character of the cornea, such as radial keratotomy, photokeratectomy, or LASIK surgery.
  33. Facet neurotomy for the thoracic spine or headache.
  34. Fecal microbiota transplantation for treatment of inflammatory bowel disease.
  35. Foot care not related to diabetes: cutting of toenails; treatment for diagnosed corns and calluses; or any other maintenance-related foot care.
  36. Functional neuroimaging for primary degenerative dementia or mild cognitive impairment.
  37. Headaches (for chronic migraines and tension-type headaches): Treatment of chronic tension-type headache with Botox. Treatment of chronic migraine or chronic tension-type headache with acupuncture, massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (example: chiropractic services).
  38. Hip resurfacing.
  39. Hip surgery for treatment of Femoroacetabular Impingement (FAI) Syndrome.
  40. Home health care, except as described in the "Home health care" section. 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 in the "Home health care" section or not specifically listed as covered in the certificate of coverage.
  41. Hospital inpatient charges for nonessential 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.
  42. Hyaluronic acid injections (viscosupplementation) for treatment of pain in any joint other than the knee.
  43. Hyperbaric oxygen therapy treatment for:
    1. Brain injury including traumatic (TBI) and chronic brain injury
    2. Cerebral palsy
    3. Multiple sclerosis
    4. Migraine or cluster headaches
    5. Acute and chronic sensorineural hearing loss
    6. Thermal burns
    7. Nonhealing venous, arterial and pressure ulcers
  44. Imaging of the sinus for rhinosinusitis using X-ray or ultrasound.
  45. Immunizations for the purpose of travel or employment, even if recommended by the Centers for Disease Control and Prevention.
  46. Implantable drug delivery systems (infusion pumps or IDDS) for chronic non-cancer pain.
  47. In vitro fertilization and all related services and supplies, including all procedures involving selection of embryo for implantation.
  48. Incarceration: Services and supplies provided while confined in a prison or jail.
  49. Infertility or fertility testing or treatment after initial diagnosis, including drugs, pharmaceuticals, artificial insemination, and any other type of testing, treatment, complications resulting from such treatment (e.g., selective fetal reduction), or visits for infertility.
  50. Knee arthroscopy for osteoarthritis of the knee.
  51. Late fees, finance charges, or collections charges.
  52. 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 in the "Mental health treatment" section.
  53. Lumbar artificial disc replacement.
  54. Lumbar fusion for degenerative disc disease.
  55. Magnetic resonance imaging, upright (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading.”
  56. Maintenance care.
  57. Manipulations of the spine or extremities, except as described under “Spinal and extremity manipulations.”
  58. Marriage, family, or other counseling or training services, except as provided to treat an individual member’s neuropsychiatric, mental, or personality disorder.
  59. Massage therapy services when the massage therapist is not a preferred provider.
  60. Medicare-covered services or supplies delivered by a provider who does not offer services through Medicare, when Medicare is the patient’s primary coverage.
  61. Microprocessor-controlled lower limb prostheses (MCP) for the feet and ankle.
  62. Migraine headaches (chronic migraines and tension): Treatment of chronic tension-type headache with Botox. Treatment of chronic migraine or chronic tension-type headache with acupuncture, massage, trigger point injections, transcranial magnetic stimulation, or manipulation/manual therapy (example: chiropractic services).
  63. Missed appointment charges.
  64. Noncovered provider types: Services delivered by providers not listed as a covered provider type.
  65. Novocure (tumor treating fields).
  66. Orthoptic therapy except for the diagnosis of strabismus, a muscle disorder of the eye.
  67. Orthotics, foot or shoe: Items such as shoe inserts and other shoe modifications, except as specified under "Orthotics."
  68. Osteochondral allograft/autograft transplantation for joints other than the knee.
  69. Out-of-network provider charges that are above the allowed amount.
  70. Over-the-counter contraceptive supplies intended for use by males.
  71. Pharmacogenomics testing for depression, mood disorders, psychosis, anxiety, ADHD, and substance use disorder.
  72. Positron Emission Tomography (PET) scans for routine surveillance of lymphoma.
  73. Postage and handling related to medical services and supplies.
  74. Prescription drug charges over the allowed amount, regardless of where purchased.
  75. 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.
  76. Proton beam therapy for conditions other than:
    1. Ocular cancers.
    2. Pediatric cancers (e.g., medulloblastoma, retinoblastoma, Ewing’s sarcoma).
    3. Central nervous system tumors.
    4. Other nonmetastatic cancers with the following conditions: patient has had prior radiation in the expected treatment field with contraindication to all other forms of therapy, and at agency discretion.
  77. 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.
  78. Recreation therapy.
  79. Replacement of lost, stolen, or damaged durable medical equipment.
  80. Replacement of medications that are any of the following:
    1. Confiscated or seized by Customs or other authorities
    2. Contaminated
    3. Damaged
    4. Expired
    5. Lost or stolen
    6. Ruined
  81. Residential treatment programs that are not licensed to provide residential treatment, solely to persons: Requiring residential chemical dependency treatment, or diagnosed with a mental health condition and requiring residential treatment.
  82. Reversal of voluntary sterilization (vasectomy, tubal ligation, or similar procedures).
  83. 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.
  84. Separate charges for records or reports.
  85. Service animals: Any expenses related to a service animal.
  86. 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. See "If you have other medical coverage" for details.
  87. Services delivered by providers or facilities delivering services outside the scope of their licenses.
  88. 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.
  89. Services performed during a noncovered service.
  90. 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.
  91. Services supplemental to digital mammography. When performed supplementary to digital mammography for screening purposes for women with or without dense breasts, the following procedures are not covered:
    1. Non-high-risk patients:
      1. Magnetic resonance imaging (MRI)
      2. Hand held ultrasound (HHUS)
      3. Automated breast ultrasound (ABUS)
    2. High-risk patients:
      1. Hand held ultrasound (HHUS)
      2. Automated breast ultrasound (ABUS)
  92. Services, supplies, or drugs related to occupational injury or illness.
  93. 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.
  94. 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.
  95. Sleep apnea diagnosis and treatment as indicated in referenced Medicare national and local coverage determinations.
  96. Spinal cord stimulation for chronic neuropathic pain.
  97. Spinal injections, therapeutic (except as described under “Spinal injections”) of the following types:
    1. Medial branch nerve block
    2. Intradiscal
    3. Facet injections
  98. Spinal surgical procedures known as vertebroplasty, kyphoplasty, and sacroplasty.
  99. Stereotactic radiation surgery and stereotactic body radiation therapy.
  100. Telephone or virtual consultations or appointments, except as described under “Telemedicine services."
  101. Travel, transportation, and lodging expenses, except as specified for ambulance services covered by the plan, or approved travel and lodging costs related to the Centers of Excellence (COE) Program for knee and hip replacement.
  102. Ultrasounds during pregnancy, except as described under "Obstetric and newborn care."
  103. Upright magnetic resonance imaging (uMRI), also known as “positional,” “weight-bearing” (partial or full), or “axial loading.”
  104. Vagal nerve stimulation for the treatment of depression.
  105. Vitamin D screening and testing is not covered as part of routine screening.
  106. Weight control, weight loss, and obesity treatment:
    1. Nonsurgical: 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 nonsurgical or surgical services are not covered. Such treatment is not covered even if prescribed by a provider, except as covered under “Diabetes Control Program,” “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.
  107. 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.

If you have questions about whether a certain service or supply is covered, call Customer Service at 1-888-849-3681 (TRS:711).

Contact

Medical services or supplies: UMP Customer Service
Phone: 1-888-849-3681
TRS: 711

Prescription drugs: Washington State Rx Services
Phone: 1-888-361-1611
TRS: 711