UnitedHealthcare PEBB Complete EOC (2024)

Evidence of Coverage 2024 UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Group Name (Plan Sponsor): State of Washington Public Employees Benefits Board (PEBB) Program Group Number: 15994 Toll-free 1-855-873-3268, TTY 711 8 a.m.-8 p.m. local time, Monday-Friday retiree.uhc.com/wapebb Y0066_EOC_H2001_816_000_2024_C

January 1, 2024 - December 31, 2024 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of our plan This document gives you the details about your Medicare health care and prescription drug coverage from January 1, 2024 - December 31, 2024. This is an important legal document. Please keep it in a safe place. For questions about this document, please contact Customer Service at 1-855-873-3268. (TTY users should call 711). Hours are 8 a.m.-8 p.m. local time, Monday-Friday. This plan, UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO), is insured through UnitedHealthcare Insurance Company or one of its affiliates. (When this Evidence of Coverage says “we,” “us,” or “our,” it means UnitedHealthcare. When it says “plan” or “our plan,” it means UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO).) UnitedHealthcare does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities. UnitedHealthcare provides free services to help you communicate with us such as documents in other languages, Braille, large print, audio, or you can ask for an interpreter. For more information, please call Customer Service at the number on your member ID card or the front of your plan booklet. UnitedHealthcare ofrece servicios gratuitos para ayudarle a que se comunique con nosotros. Por ejemplo, documentos en otros idiomas, braille, en letra grande o en audio. O bien, usted puede pedir un intérprete. Comuníquese con nuestro número de Servicio al Cliente al número que se encuentra en su tarjeta de ID de miembro o en la portada de la guía de su plan. Benefits, deductible, and/or copayments/coinsurance may change on January 1, 2025. The formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. We will notify affected enrollees about changes at least 30 days in advance. This document explains your benefits and rights. Use this document to understand about: · Your plan premium and cost-sharing; · Your medical and prescription drug benefits; · How to file a complaint if you are not satisfied with a service or treatment; · How to contact us if you need further assistance; and, · Other protections required by Medicare law. OMB Approval 0938-1051 (Expires: February 29, 2024)

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Table of Contents 2024 Evidence of Coverage Table of Contents Chapter 1: Getting started as a member................................................................................1 Section 1 Introduction.................................................................................................2 Section 2 What makes you eligible to be a plan member?......................................3 Section 3 Important membership materials you will receive................................... 4 Section 4 Your monthly costs for the plan.................................................................5 Section 5 More information about your monthly premium...................................... 8 Section 6 Keeping your plan membership record up to date..................................8 Section 7 How other insurance works with our plan................................................ 9 Chapter 2: Important phone numbers and resources..........................................................11 Section 1 UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Contacts (how to contact us, including how to reach Customer Service)......................................................................................................12 Section 2 Medicare (how to get help and information directly from the federal Medicare program)...................................................................................17 Section 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare)...................................18 Section 4 Quality Improvement Organization......................................................... 27 Section 5 Social Security.......................................................................................... 38 Section 6 Medicaid....................................................................................................39 Section 7 Information about programs to help people pay for their prescription drugs..........................................................................................................46 Section 8 How to contact the Railroad Retirement Board.....................................59 Section 9 Do you have “group insurance” or other health insurance from an employer?..................................................................................................59 Chapter 3: Using the plan for your medical services........................................................... 61 Section 1 Things to know about getting your medical care as a member of our plan............................................................................................................ 62 Section 2 Using network and out-of-network providers to get your medical care ................................................................................................................... 63 Section 3 How to get services when you have an emergency or urgent need for care or during a disaster..........................................................................65 QuestionsQuestions?? Call Call CustomCustomer Serviceer Service at at 1-8551-855-873-32-873-326868, TTY , TTY 711711, , 8 a.m.-8 p.m8 a.m.-8 p.m. local time. local time, , Monday-FridayMonday-Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Table of Contents Section 4 What if you are billed directly for the full cost of your services?.......... 66 Section 5 How are your medical services covered when you are in a “clinical research study”?.......................................................................................66 Section 6 Rules for getting care in a “religious non-medical health care institution”................................................................................................. 68 Section 7 Rules for ownership of durable medical equipment............................. 69 Chapter 4: Medical Benefits Chart (what is covered and what you pay)..............................71 Section 1 Understanding your out-of-pocket costs for covered services.............72 Section 2 Use the medical benefits chart to find out what is covered and how much you will pay..................................................................................... 73 Section 3 What Medical services are not covered by the plan?..........................129 Section 4 Other additional benefits (not covered under Original Medicare)......135 Chapter 5: Using the plan’s coverage for Part D prescription drugs.................................143 Section 1 Introduction.............................................................................................144 Section 2 Fill your prescription at a network pharmacy or through the plan’s preferred mail-order service.................................................................. 144 Section 3 Your drugs need to be on the plan’s Drug List....................................147 Section 4 There are restrictions on coverage for some drugs............................149 Section 5 What if one of your drugs is not covered in the way you’d like it to be covered?..................................................................................................151 Section 6 What if your coverage changes for one of your drugs?......................153 Section 7 What types of drugs are not covered by the plan?..............................155 Section 8 Filling a prescription...............................................................................156 Section 9 Part D drug coverage in special situations...........................................156 Section 10 Programs on drug safety and managing medications........................158 Chapter 6: What you pay for your Part D prescription drugs.............................................160 Section 1 Introduction.............................................................................................161 Section 2 What you pay for a drug depends on which “drug payment stage” you are in when you get the drug.................................................................163 Section 3 We send you reports that explain payments for your drugs and which payment stage you are in.......................................................................163 Section 4 During the Deductible Stage, you pay the full cost of your Tier 2, Tier 3 and Tier 4 drugs..................................................................................... 165 QuestionsQuestions?? Call Call CustomCustomer Serviceer Service at at 1-8551-855-873-32-873-326868, TTY , TTY 711711, , 8 a.m.-8 p.m8 a.m.-8 p.m. local time. local time, , Monday-FridayMonday-Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Table of Contents Section 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share................................................................165 Section 6 Costs in the Coverage Gap Stage.........................................................168 Section 7 During the Catastrophic Coverage Stage, the plan pays the full cost for your covered Part D drugs.....................................................................169 Section 8 Additional benefits information............................................................. 169 Section 9 Part D Vaccines. What you pay for depends on how and where you get them.........................................................................................................169 Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs..............................................................................................172 Section 1 Situations in which you should ask us to pay our share of the cost of your covered services or drugs.............................................................173 Section 2 How to ask us to pay you back or to pay a bill you have received.....175 Section 3 We will consider your request for payment and say yes or no...........176 Chapter 8: Your rights and responsibilities....................................................................... 177 Section 1 Our plan must honor your rights and cultural sensitivities as a member of the plan............................................................................................... 178 Section 2 You have some responsibilities as a member of the plan.................. 191 Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints).......................................................................................................193 Section 1 Introduction.............................................................................................194 Section 2 Where to get more information and personalized assistance............194 Section 3 To deal with your problem, which process should you use?............. 195 Section 4 A guide to the basics of coverage decisions and appeals................. 195 Section 5 Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision.............................................................. 198 Section 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal...................................................................................... 205 Section 7 How to ask us to cover a longer inpatient hospital stay if you think you are being discharged too soon............................................................. 214 Section 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon.........................................................221 Section 9 Taking your appeal to Level 3 and beyond..........................................227 QuestionsQuestions?? Call Call CustomCustomer Serviceer Service at at 1-8551-855-873-32-873-326868, TTY , TTY 711711, , 8 a.m.-8 p.m8 a.m.-8 p.m. local time. local time, , Monday-FridayMonday-Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Table of Contents Section 10 How to make a complaint about quality of care, waiting times, customer service, or other concerns....................................................230 Chapter 10: Ending your membership in the plan............................................................... 234 Section 1 Introduction to ending your membership in our plan..........................235 Section 2 When can you end your membership in our plan?............................. 235 Section 3 Until your membership ends, you must keep getting your medical items, services and drugs through our plan.........................................235 Section 4 We must end your membership in the plan in certain situations.......236 Chapter 11: Legal notices....................................................................................................238 Section 1 Notice about governing law...................................................................239 Section 2 Notice about non-discrimination...........................................................239 Section 3 Notice about Medicare Secondary Payer subrogation rights............ 239 Section 4 Third party liability and subrogation..................................................... 239 Section 5 Member liability...................................................................................... 240 Section 6 Medicare-covered services must meet requirement of reasonable and necessary................................................................................................ 241 Section 7 Non duplication of benefits with automobile, accident or liability coverage..................................................................................................241 Section 8 Acts beyond our control........................................................................ 241 Section 9 Contracting medical providers and network hospitals are independent contractors..............................................................................................242 Section 10 Technology assessment........................................................................242 Section 11 Member statements............................................................................... 242 Section 12 Information upon request...................................................................... 242 Section 13 2024 Enrollee Fraud & Abuse Communication................................... 243 Section 14 Commitment of Coverage Decisions....................................................243 Section 15 Renew Active® Terms and Conditions................................................. 243 Chapter 12: Definitions of important words.........................................................................246 QuestionsQuestions?? Call Call CustomCustomer Serviceer Service at at 1-8551-855-873-32-873-326868, TTY , TTY 711711, , 8 a.m.-8 p.m8 a.m.-8 p.m. local time. local time, , Monday-FridayMonday-Friday

Chapter 1 Chapter 1: Getting started as a member

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 2 Section 1 Introduction Section 1.1 You are enrolled in UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO), which is a Medicare PPO You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO). We are required to cover all Part A and Part B services. However, cost-sharing and provider access in this plan differ from Original Medicare. Our plan is a Medicare Advantage PPO Plan (PPO stands for Preferred Provider Organization). Like all Medicare health plans, this Medicare PPO is approved by Medicare and run by a private company. Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at: irs.gov/Affordable-Care-Act/individuals- and-families for more information. Section 1.2 What is the Evidence of Coverage document about? This Evidence of Coverage document tells you how to get your medical care and prescription drugs. It explains your rights and responsibilities, what is covered, what you pay as a member of the plan, and how to file a complaint if you are not satisfied with a decision or treatment. When the Agreement is purchased by the Group to provide benefits under a welfare plan governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. §1001 et seq., we are not the plan administrator or named fiduciary of the welfare plan, as those terms are used in ERISA. The words “coverage” and “covered services” refer to the medical care, services and prescription drugs available to you as a member of the plan. It’s important for you to learn what the plan’s rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage document. If you are confused, concerned or just have a question, please contact Customer Service. Section 1.3 Legal information about the Evidence of Coverage This Evidence of Coverage is part of our contract with you about how the plan covers your care. Other parts of this contract include your enrollment form or your verbal or electronic election of our plan, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called “riders” or “amendments.”

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 3 The contract is in effect for months in which you are enrolled in the plan between January 1, 2024 and December 31, 2024. Each plan year, Medicare allows us to make changes to the plans that we offer. This means we can change the costs and benefits of the plan after December 31, 2024. We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, 2024. Medicare (the Centers for Medicare & Medicaid Services) must approve our plan each year. You can continue each year to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and Medicare renews its approval of the plan. Section 2 What makes you eligible to be a plan member? Section 2.1 Your eligibility requirements You are eligible for membership in our plan as long as: · You meet the eligibility requirements of your former employer, union group or trust administrator (plan sponsor - PEBB) · You have both Medicare Part A and Medicare Part B · — and — you live in our geographic service area (Section 2.2 below describes our service area). Incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. · — and — you are a United States citizen or are lawfully present in the United States Section 2.2 Here is the plan service area for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Our plan is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described below. Our service area includes the 50 United States and the District of Columbia, Puerto Rico, the United States Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. If you plan to move out of the service area, you cannot remain a member of this plan. Please contact Customer Service and your plan sponsor (PEBB) to see if we have a plan in your new area. It is also important that you call Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5. Section 2.3 U.S. Citizen or Lawful Presence A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the Centers for Medicare & Medicaid Services) will notify UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) if you are not eligible to remain a member on this

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 4 basis. UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) must disenroll you if you do not meet this requirement. Section 3 Important membership materials you will receive Section 3.1 Your UnitedHealthcare member ID card While you are a member of our plan, you must use your UnitedHealthcare member ID card whenever you get services covered by this plan and for prescription drugs you get at network pharmacies. You should also show the provider your Medicaid card, if applicable. Here’s a sample UnitedHealthcare member ID card to show you what yours will look like: Customer Service Hours: XXX - XXX, XXX - XXX, XXX XXX - XXX Health Plan (99999): 999-99999-99 For Members www.website.url Member ID: 999999999-00 Group Number: 99999 Website: Member: Customer Service: 1-999-999-9999 TTY 711 SAMPLE A MEMBER Other Number: 1-999-999-9999 TTY 711 Payer ID: Other Number: 1-999-999-9999 TTY 711 99999 RxBIN: 999999 For Providers www.website.url 1-999-999-9999 Medical Claim Address: P.O. Box 99999, XXXXXX, XX 99999-9999 RxPCN: 9999 RxGrp: XXX SAMPLE SAMPLE Copay: PCP $XX ER $XX UHC Spec $XX H9999-999-999 Plan Name For Pharmacists 1-999-999-9999 Pharmacy Claims P.O. Box 99999, XXXXXX, XX 99999-9999 Client Alts Internal & External Team Project Details Color Dimensions Client Alts Internal & External Team Project Details Color Dimensions Date: 04.26.21 Name: ID Card Template Design CMYK Flat: 3.4” x 2.15” Date: 04.26.21 Name: ID Card Template Design CMYK Flat: 3.4” x 2.15” Client Contact: Stage: FINAL Software: InDesign CC Client Contact: Stage: FINAL Software: InDesign CC 1 Art Director/Designer: catch昀椀re File Name: MAPD_ID_Card_Front_Template_Design.indd 0 Art Director/Designer: catch昀椀re File Name: MAPD_ID_Card_Back_Template_Design.indd Do NOT use your red, white, and blue Medicare card for covered medical services while you are a member of this plan. If you use your Medicare card instead of your UnitedHealthcare member ID card, you may have to pay the full cost of medical services yourself. Keep your Medicare card in a safe place. You may be asked to show it if you need hospital services, hospice services, or participate in Medicare approved clinical research studies also called clinical trials. Note: If you are not entitled to Medicare Part A coverage, hospice services are not covered by the plan or by Medicare. If your UnitedHealthcare member ID card is damaged, lost, or stolen, call Customer Service right away and we will send you a new card. Section 3.2 Provider Directory The Provider Directory lists our current network providers and durable medical equipment suppliers. Network providers are the doctors and other health care professionals, medical groups, durable medical equipment suppliers, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full. As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers, as long as the provider accepts the plan and has not opted out of or been excluded or precluded from the Medicare

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 5 Program, and the services are covered benefits and medically necessary. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information. The most recent list of providers and suppliers is available on our website at retiree.uhc.com/ wapebb. If you don’t have your copy of the Provider Directory, you can request a copy (electronically or in hardcopy form) from Customer Service. Requests for hard copy Provider Directories will be mailed to you within three business days. Section 3.3 Pharmacy Directory The pharmacy directory lists our network pharmacies. Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members. You can use the Pharmacy Directory to find the network pharmacy you want to use. See Chapter 5, Section 2.5 for information on when you can use pharmacies that are not in the plan’s network. If you don’t have the Pharmacy Directory, you can get a copy from Customer Service. You can also find this information on our website at retiree.uhc.com/wapebb. Section 3.4 The plan’s List of Covered Drugs (Formulary) The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells which Part D prescription drugs are covered under the Part D benefit included in our plan. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List. The Drug List also tells you if there are any rules that restrict coverage for your drugs. We will provide you a copy of the Drug List. The Drug List we provide you includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the provided Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact Customer Service to find out if we cover it. To get the most complete and current information about which drugs are covered, you can visit the plan’s website (retiree.uhc.com/wapebb) or call Customer Service. Section 4 Your monthly costs for the plan Your costs may include the following: · Plan Premium (Section 4.1) · Monthly Medicare Part B Premium (Section 4.2) · Part D Late Enrollment Penalty (Section 4.3) · Income Related Monthly Adjusted Amount (Section 4.4) Medicare Part B and Part D premiums differ for people with different incomes. If you have questions about these premiums review your copy of Medicare & You 2024 handbook, the section called “2024 Medicare Costs.” If you need a copy you can download it from the Medicare website

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 6 (medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. Section 4.1 Plan premium Your former employer, union group or trust administrator (plan sponsor - PEBB) is responsible for paying your monthly plan premium to UnitedHealthcare on your behalf. Your plan sponsor determines the amount of any retiree contribution toward the monthly premium for our plan. Your plan sponsor will notify you if you must pay any portion of your monthly premium for our plan. Section 4.2 Monthly Medicare Part B Premium Many members are required to pay other Medicare premiums You must continue paying your Medicare premiums to remain a member of the plan. This includes your premium for Part B. It may also include a premium for Part A which affects members who aren’t eligible for premium free Part A. Section 4.3 Part D Late Enrollment Penalty Some members are required to pay a Part D late enrollment penalty. The Part D late enrollment penalty is an additional premium that must be paid for Part D coverage if at any time after your initial enrollment period is over, there is a period of 63 days or more in a row when you did not have Part D or other creditable prescription drug coverage. “Creditable prescription drug coverage” is coverage that meets Medicare’s minimum standards since it is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. The cost of the late enrollment penalty depends on how long you went without Part D or other creditable prescription drug coverage. You will have to pay this penalty for as long as you have Part D coverage. The Part D late enrollment penalty is added to your monthly premium. (For members who must pay a late enrollment penalty, the amount of the penalty will be added to the bill we send to your plan sponsor.) When you first enroll in our plan, we let you know the amount of the penalty. Your Part D late enrollment penalty is considered part of your plan premium. You will not have to pay it if: · You receive “Extra Help” from Medicare to pay for your prescription drugs. · You have gone less than 63 days in a row without creditable coverage. · You have had creditable drug coverage through another source such as a former employer, union, TRICARE, or Department of Veterans Affairs. Your insurer or your human resources department will tell you each year if your drug coverage is creditable coverage. This information may be sent to you in a letter or included in a newsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan later. - Note: Any notice must state that you had “creditable” prescription drug coverage that is expected to pay as much as Medicare’s standard prescription drug plan pays.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 7 - Note: The following are not creditable prescription drug coverage: prescription drug discount cards, free clinics, and drug discount websites. Medicare determines the amount of the penalty. Here is how it works: · If you went 63 days or more without Part D or other creditable prescription drug coverage after you were first eligible to enroll in Part D, the plan will count the number of full months that you did not have coverage. The penalty is 1% for every month that you did not have creditable coverage. For example, if you go 14 months without coverage, the penalty will be 14%. · Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the nation from the previous year. For 2024, this average premium amount is $34.70. · To calculate your monthly penalty, you multiply the penalty percentage and the average monthly premium and then round it to the nearest 10 cents. In the example here it would be 14% times $34.70, which equals $4.86. This rounds to $4.90. This amount would be added to the plan sponsor’s monthly premium for someone with a Part D late enrollment penalty. There are three important things to note about this monthly Part D late enrollment penalty: · First, the penalty may change each year, because the average monthly premium can change each year. · Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan that has Medicare Part D drug benefits, even if you change plans. · Third, if you are under 65 and currently receiving Medicare benefits, the Part D late enrollment penalty will reset when you turn 65. After age 65, your Part D late enrollment penalty will be based only on the months that you don’t have coverage after your initial enrollment period for aging into Medicare. If you disagree about your Part D late enrollment penalty, you or your representative can ask for a review. Generally, you must request this review within 60 days from the date on the first letter you receive stating you have to pay a late enrollment penalty. However, if you were paying a penalty before joining our plan, you may not have another chance to request a review of that late enrollment penalty. Section 4.4 Income Related Monthly Adjustment Amount Some members may be required to pay an extra charge, known as the Part D Income Related Monthly Adjustment Amount, also known as IRMAA. The extra charge is figured out using your modified adjusted gross income as reported on your IRS tax return from 2 years ago. If this amount is above a certain amount, you’ll pay the standard premium amount and the additional IRMAA. For more information on the extra amount you may have to pay based on your income, visit medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug- plans. If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be. The extra amount will be withheld from your Social Security, Railroad Retirement Board, or Office of Personnel Management benefit check, no matter

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 8 how you usually pay your plan premium, unless your monthly benefit isn’t enough to cover the extra amount owed. If your benefit check isn’t enough to cover the extra amount, you will get a bill from Medicare. You must pay the extra amount to the government. It cannot be paid with your monthly plan premium. If you do not pay the extra amount you will be disenrolled from the plan and lose prescription drug coverage. If you disagree about paying an extra amount, you can ask Social Security to review the decision. To find out more about how to do this, contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778). Section 5 More information about your monthly premium Section 5.1 Can we change your monthly plan premium during the year? Monthly plan premium changes and employer-sponsored benefit changes are subject to contractual arrangements between your plan sponsor (PEBB) and us, and as a result, monthly plan premiums generally do not change during the plan year. Your plan sponsor is responsible for notifying you of any monthly plan premium changes or retiree contribution changes (the portion of your monthly plan premium your plan sponsor requires you to pay) prior to the date when the change becomes effective. However, in some cases, your plan sponsor may need to start paying or may be able to stop paying a Late Enrollment Penalty. (The Late Enrollment Penalty may apply if you had a continuous period of 63 days or more when you didn’t have “creditable” prescription drug coverage.) This could happen if you become eligible for the “Extra Help” program or if you lose your eligibility for the “Extra Help” program during the year: · If your plan sponsor currently pays the Part D late enrollment penalty and you become eligible for “Extra Help” during the year, your plan sponsor would no longer pay your penalty. · If you lose Extra Help, you may be subject to the late enrollment penalty if you go 63 days or more in a row without Part D or other creditable prescription drug coverage. You can find out more about the “Extra Help” program in Chapter 2, Section 7. Section 6 Keeping your plan membership record up to date Your membership record has information from your enrollment form, including your address and telephone number. It shows your specific plan coverage. Let us know about these changes: · Changes to your name, your address, or your phone number. · Changes in any other medical or drug insurance coverage you have (such as from your employer, your spouse or domestic partner’s employer, Workers’ Compensation, or Medicaid).

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 9 · If you have any liability claims, such as claims from an automobile accident. · If you have been admitted to a nursing home. · If your designated responsible party (such as a caregiver) changes. · If you are participating in a clinical research study. (Note: You are not required to tell your plan about the clinical research studies you intend to participate in but we encourage you to do so) If any of this information changes, please let us know by calling Customer Service. It is also important to contact Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5. Section 7 How other insurance works with our plan Other insurance Medicare requires that we collect information from you about any other medical or drug insurance coverage that you have. That’s because we must coordinate any other coverage you have with your benefits under our plan. This is called Coordination of Benefits. Once each year, we will send you a letter that lists any other medical or drug insurance coverage that we know about. Please read over this information carefully. If it is correct, you don’t need to do anything. If the information is incorrect, or if you have other coverage that is not listed, please call Customer Service. You may need to give your plan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time. When you have other insurance (like employer group health coverage), there are rules set by Medicare that decide whether our plan or your other insurance pays first. The insurance that pays first is called the “primary payer” and pays up to the limits of its coverage. The one that pays second, called the “secondary payer,” only pays if there are costs left uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs. If you have other insurance, tell your doctor, hospital, and pharmacy. These rules apply for employer or union group health plan coverage: · If you have retiree coverage, Medicare pays first. · If your group health plan coverage is based on your or a family member’s current employment, who pays first depends on your age, the number of people employed by your employer, and whether you have Medicare based on age, disability, or End-Stage Renal Disease (ESRD): - If you’re under 65 and disabled and you or your family member is still working, your group health plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan that has more than 100 employees. - If you’re over 65 and you or your spouse or domestic partner is still working, your group health plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan that has more than 20 employees. · If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you become eligible for Medicare. These types of coverage usually pay first for services related to each type:

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 1: Getting started as a member 10 · No-fault insurance (including automobile insurance) · Liability (including automobile insurance) · Black lung benefits · Workers’ Compensation Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare, employer group health plans, and/or Medigap have paid.

Chapter 2 Chapter 2: Important phone numbers and resources

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 12 Section 1 UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Contacts (how to contact us, including how to reach Customer Service) How to contact our plan’s Customer Service For assistance with claims, billing, or UnitedHealthcare member ID card questions, please call or write to our plan Customer Service. We will be happy to help you. Method Customer Service - Contact Information Call 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Customer Service also has free language interpreter services available for non-English speakers. TTY 711 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Write UnitedHealthcare Customer Service Department P.O. Box 30770, Salt Lake City, UT 84130-0770 Website retiree.uhc.com/wapebb How to contact us when you are asking for a coverage decision or appeal about your medical care A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or Part D prescription drugs. An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on asking for coverage decisions or appeals about your medical care or Part D prescription drugs, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)). You may call us if you have questions about our coverage decision process. Method Coverage Decisions for Medical Care – Contact Information Call 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday TTY 711

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 13 Method Coverage Decisions for Medical Care – Contact Information Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Write UnitedHealthcare P.O. Box 30770, Salt Lake City, UT 84130-0770 Website retiree.uhc.com/wapebb Method Appeals for Medical Care – Contact Information Call 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday For fast/expedited appeals for medical care: 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday TTY 711 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Fax 1-888-517-7113 For fast/expedited appeals for medical care only: 1-866-373-1081 Write UnitedHealthcare Appeals and Grievances Department P.O. Box 6106, MS CA124-0157, Cypress, CA 90630-0016 Website retiree.uhc.com/wapebb Method Coverage Decisions for Part D Prescription Drugs – Contact Information Call 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday TTY 711

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 14 Method Coverage Decisions for Part D Prescription Drugs – Contact Information Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Fax 1-844-403-1028 Write OptumRx Prior Authorization Department P.O. Box 25183, Santa Ana, CA 92799 Website retiree.uhc.com/wapebb Method Appeals for Part D Prescription Drugs – Contact Information Call 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday For fast/expedited appeals for Part D prescription drugs: 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday TTY 711 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Fax For standard Part D prescription drug appeals: 1-866-308-6294 For fast/expedited Part D prescription drug appeals: 1-866-308-6296 Write UnitedHealthcare Part D Appeal and Grievance Department P.O. Box 6106, MS CA124-0197, Cypress, CA 90630-0016 Website retiree.uhc.com/wapebb How to contact us when you are making a complaint about your medical care You can make a complaint about us or one of our network providers, or pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. For more information on making a complaint about your medical care, see Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 15 Method Complaints about Medical Care – Contact Information Call 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday For fast/expedited complaints about medical care: 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday TTY 711 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Fax 1-888-517-7113 For fast/expedited complaints about medical care only: 1-866-373-1081 Write UnitedHealthcare Appeals and Grievances Department P.O. Box 6106, MS CA124-0157, Cypress, CA 90630-0016 Medicare You can submit a complaint about UnitedHealthcare® Group Medicare Website Advantage PEBB Complete (PPO) directly to Medicare. To submit an online complaint to Medicare, go to medicare.gov/ MedicareComplaintForm/home.aspx. Method Complaints about Part D Prescription Drugs – Contact Information Call 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday For fast/expedited complaints about Part D prescription drugs: 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday TTY 711 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Fax For standard Part D prescription drug complaints: 1-866-308-6294 For fast/expedited Part D prescription drug complaints:

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 16 Method Complaints about Part D Prescription Drugs – Contact Information 1-866-308-6296 Write UnitedHealthcare Part D Appeal and Grievance Department P.O. Box 6106, MS CA124-0197, Cypress, CA 90630-0016 Medicare You can submit a complaint about UnitedHealthcare® Group Medicare Website Advantage PEBB Complete (PPO) directly to Medicare. To submit an online complaint to Medicare, go to medicare.gov/ MedicareComplaintForm/home.aspx. Where to send a request asking us to pay for our share of the cost for medical care or a drug you have received. If you have received a bill or paid for services (such as a provider bill) that you think we should pay for, you may need to ask us for reimbursement or to pay the provider bill. See Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs). Please note: If you send us a payment request and we deny any part of your request, you can appeal our decision. See Chapter 9 (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) for more information. Method Payment Requests – Contact Information Call 1-855-873-3268 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday TTY 711 Calls to this number are free. Hours of Operation: 8 a.m.-8 p.m. local time, Monday-Friday Write Medical claims payment requests: UnitedHealthcare P.O. Box 30995, Salt Lake City, UT 84130-0995 Part D prescription drug payment requests: OptumRx P.O. Box 650287, Dallas, TX 75265-0287 Website retiree.uhc.com/wapebb

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 17 Section 2 Medicare (how to get help and information directly from the federal Medicare program) Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant). The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes called “CMS”). This agency contracts with Medicare Advantage organizations, including us. Method Medicare – Contact Information Call 1-800-MEDICARE, or 1-800-633-4227 Calls to this number are free. 24 hours a day, 7 days a week. TTY 1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Website medicare.gov This is the official government website for Medicare. It gives you up-to- date information about Medicare and current Medicare issues. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes documents you can print directly from your computer. You can also find Medicare contacts in your state. The Medicare website also has detailed information about your Medicare eligibility and enrollment options with the following tools: · Medicare Eligibility Tool: Provides Medicare eligibility status information. · Medicare Plan Finder: Provides personalized information about available Medicare prescription drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) policies in your area. Because your coverage is provided by a plan sponsor, you will not find UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) plans listed on medicare.gov. These tools provide an estimate of what your out-of-pocket costs might be in different Medicare plans. You can also use the website to tell Medicare about any complaints you have about UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO):

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 18 Method Medicare – Contact Information · Tell Medicare about your complaint: You can submit a complaint about UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) directly to Medicare. To submit a complaint to Medicare, go to medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you don’t have a computer, your local library or senior center may be able to help you visit this website using its computer. Or, you can call Medicare and tell them what information you are looking for. They will find the information on the website and review the information with you. (You can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.) Section 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. Here is a list of the State Health Insurance Assistance Programs in each state we serve: • Alaska - Alaska Medicare Information Office • Alabama - Alabama State Health Insurance Assistance Program (SHIP) • Arkansas - Arkansas Senior Health Insurance Information Program (SHIIP) • American Samoa - American Samoa Senior Health Insurance Program • Arizona - Arizona State Health Insurance Assistance Program • California - California Health Insurance Counseling & Advocacy Program (HICAP) • Colorado - Colorado Senior Health Insurance Assistance Program (SHIP) • Connecticut - Connecticut CHOICES Senior Health Insurance Program • District of Columbia - Department of Aging and Community Living • Delaware - Delaware Medicare Assistance Bureau (DMAB) • Florida - Florida Serving Health Insurance Needs of Elders (SHINE) • Georgia - GeorgiaCares Senior Health Insurance Plan • Guam - Guam Medicare Assistance Program (GUAM MAP) • Hawaii - Hawaii SHIP • Iowa - Iowa Senior Health Insurance Information Program (SHIIP) • Idaho - Idaho Senior Health Insurance Benefits Advisors (SHIBA) • Illinois - Illinois Senior Health Insurance Program (SHIP) • Indiana - Indiana State Health Insurance Assistance Program (SHIP) • Kansas - Kansas Senior Health Insurance Counseling for Kansas (SHICK) • Kentucky - Kentucky State Health Insurance Assistance Program (SHIP) • Louisiana - Louisiana Senior Health Insurance Information Program (SHIIP) • Massachusetts - Massachusetts Serving the Health Insurance Needs of Everyone (SHINE)

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 19 • Maryland - Maryland Department of Aging - Senior Health Insurance Assistance Program (SHIP) • Maine - Maine State Health Insurance Assistance Program (SHIP) • Michigan - Michigan MMAP, Inc. Senior Health Insurance Program • Minnesota - Minnesota State Health Insurance Assistance Program/Senior LinkAge Line • Missouri - Missouri CLAIM Senior Health Insurance Program • Northern Mariana Islands - North Mariana Islands Senior Health Insurance Program • Mississippi - Mississippi Department of Human Services, Division of Aging & Adult Services • Montana - Montana State Health Insurance Assistance Program (SHIP) • North Carolina - North Carolina Seniors Health Insurance Information Program (SHIIP) • North Dakota - North Dakota Senior Health Insurance Counseling (SHIC) • Nebraska - Nebraska Senior Health Insurance Information Program (SHIIP) • New Hampshire - New Hampshire SHIP - ServiceLink Aging and Disability Resource Center • New Jersey - New Jersey State Health Insurance Assistance Program (SHIP) • New Mexico - New Mexico Benefits Counseling Program SHIP • Nevada - Nevada State Health Insurance Assistance Program (SHIP) • New York - New York Health Insurance Information Counseling and Assistance Program (HIICAP) • Ohio - Ohio Senior Health Insurance Information Program (OSHIIP) • Oklahoma - Oklahoma Medicare Assistance Program (MAP) • Oregon - Oregon Senior Health Insurance Benefits Assistance (SHIBA) • Pennsylvania - Pennsylvania Senior Health Insurance Program • Puerto Rico - Puerto Rico State Health Insurance Assistance Program (SHIP) • Rhode Island - Rhode Island State Health Insurance Assistance Program (SHIP) • South Carolina - South Carolina (I-CARE) Insurance Counseling Assistance and Referrals for Elders • South Dakota - South Dakota Senior Health Information & Insurance Education (SHIINE) • Tennessee - Tennessee Commission on Aging & Disability - TN SHIP • Texas - Texas Department of Aging and Disability Services (HICAP) • Utah - Utah Senior Health Insurance Information Program (SHIP) • Virginia - Virginia Insurance Counseling and Assistance Program (VICAP) • Virgin Islands of the U.S. - Virgin Islands State Health Insurance Assistance Program (VISHIP) • Vermont - Vermont State Health Insurance Assistance Program (SHIP) • Washington - Washington Statewide Health Insurance Benefits Advisors (SHIBA) • Wisconsin - Wisconsin State Health Insurance Plan (SHIP) • West Virginia - West Virginia State Health Insurance Assistance Program (WV SHIP) • Wyoming - Wyoming State Health Insurance Information Program (WSHIIP) Your SHIP is an independent (not connected with any insurance company or health plan) state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. SHIP counselors can help you understand your Medicare rights, help you make complaints about your medical care or treatment, and help you straighten out problems with your Medicare bills. SHIP counselors can also help you with Medicare questions or problems and help you understand your Medicare plan choices and answer questions about switching plans. Method to access SHIP and other resources

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 20 · Visit https://www.shiphelp.org (Click on SHIP LOCATOR in middle of page) · Select your STATE from the list. This will take you to a page with phone numbers and resources specific to your state. State Health Insurance Assistance Programs (SHIP) - Contact Information Alaska | Alaska Medicare Information Office 1-800-478-6065 550 W 7th Ave, STE1230 Anchorage, AK 99501 TTY 1-800-770-8973 http://dhss.alaska.gov/dsds/Pages/medicare Alabama | Alabama State Health Insurance Assistance 1-877-425-2243 Program (SHIP) TTY 711 201 Monroe ST, STE 350 Montgomery, AL 36104 www.alabamaageline.gov Arkansas | Arkansas Senior Health Insurance Information 1-800-224-6330 Program (SHIIP) TTY 711 1 Commerce Way Little Rock, AR 72202 www.shiipar.com/landing-page American Samoa | American Samoa Senior Health Insurance 1-684-699-4777 Program TTY 711 ASTCA Executive BLDG #306, P.O. Box 6101 Pago Pago, AS 96799 1-684-699-4780 Arizona | Arizona State Health Insurance Assistance Program 1-800-432-4040 1366 E Thomas RD, STE 108 ATTN: SHIP Phoenix, AZ 85104 TTY 711 https://des.az.gov/services/older-adults/medicare-assistance California | California Health Insurance Counseling & Advocacy 1-800-434-0222 Program (HICAP) TTY 1-800-735-2929 2880 Gateway Oaks Dr, STE 200 Sacramento, CA 95833 http://www.aging.ca.gov/hicap/ Colorado | Colorado Senior Health Insurance Assistance 1-888-696-7213 Program (SHIP) TTY 711 1560 Broadway, STE 850 Denver, CO 80202 https://doi.colorado.gov/insurance-products/health-insurance/ senior-health-care-medicare

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 21 State Health Insurance Assistance Programs (SHIP) - Contact Information Connecticut | Connecticut CHOICES Senior Health Insurance 1-800-994-9422 Program TTY 711 55 Farmington AVE, FL 12 Hartford, CT 06105-3730 https://portal.ct.gov/AgingandDisability/Content-Pages/ Programs/CHOICES-Connecticuts-program-for-Health-insurance- assistance-Outreach-Information-and-referral-Couns District of Columbia | Department of Aging and Community 1-202-724-5626 Living TTY 711 500 K ST NE Washington, DC 20002 https://dcoa.dc.gov/ Delaware | Delaware Medicare Assistance Bureau (DMAB) 1-800-336-9500 1351 WN ST, STE 101 Dover, DE 19904 TTY 711 https://insurance.delaware.gov/divisions/dmab/ Florida | Florida Serving Health Insurance Needs of Elders 1-800-963-5337 (SHINE) TTY 1-800-955-8770 4040 Esplanade Way, STE 270 Tallahassee, FL 32399-7000 www.floridashine.org Georgia | GeorgiaCares Senior Health Insurance Plan 1-866-552-4464 2 Peachtree ST NW, FL 33 Atlanta, GA 30303 TTY 711 https://aging.georgia.gov/georgiacares-ship Guam | Guam Medicare Assistance Program (GUAM MAP) 1-671-735-7421 130 University DR, STE 8, University Castle Mall Mangilao, GU TTY 1-671-735-7415 96913 http://dphss.guam.gov/ Hawaii | Hawaii SHIP 1-888-875-9229 No. 1 Capitol District, 250 S Hotel ST, STE 406 Honolulu, HI TTY 1-866-810-4379 96813-2831 www.hawaiiship.org Iowa | Iowa Senior Health Insurance Information Program 1-800-351-4664 (SHIIP) TTY 1-800-735-2942 1963 Bell Avenue, STE 100 Des Moines, IA 50315 shiip.iowa.gov

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 22 State Health Insurance Assistance Programs (SHIP) - Contact Information Idaho | Idaho Senior Health Insurance Benefits Advisors 1-800-247-4422 (SHIBA) TTY 711 700 W State St Boise, ID 83720 http://www.doi.idaho.gov/SHIBA/ Illinois | Illinois Senior Health Insurance Program (SHIP) 1-800-252-8966 One Natural Resources Way, STE 100 Springfield, IL 62702-1271 TTY 711 http://www.illinois.gov/aging/ship/Pages/default.aspx Indiana | Indiana State Health Insurance Assistance Program 1-800-452-4800 (SHIP) TTY 1-866-846-0139 311 W Washington ST, STE 200 Indianapolis, IN 46204-2787 http://www.in.gov/ship Kansas | Kansas Senior Health Insurance Counseling for 1-800-860-5260 Kansas (SHICK) TTY 1-785-291-3167 New England BLDG, 503 S Kansas AVE Topeka, KS 66603-3404 http://www.kdads.ks.gov/SHICK/shick_index.html Kentucky | Kentucky State Health Insurance Assistance 1-877-293-7447 Program (SHIP) TTY 1-800-627-4702 275 E Main ST, 3E-E Frankfort, KY 40621 https://chfs.ky.gov/agencies/dail/Pages/ship.aspx Louisiana | Louisiana Senior Health Insurance Information 1-800-259-5300 Program (SHIIP) TTY 711 P.O. Box 94214 Baton Rouge, LA 70804 http://www.ldi.la.gov/SHIIP/ Massachusetts | Massachusetts Serving the Health Insurance 1-800-243-4636 Needs of Everyone (SHINE) TTY 1-800-439-2370 1 Ashburton PL, RM 517 Boston, MA 02108 http://www.mass.gov/elders/healthcare/shine/serving-the-health- information-needs-of-elders.html Maryland | Maryland Department of Aging - Senior Health 1-800-243-3425 Insurance Assistance Program (SHIP) TTY 711 301 W Preston ST, STE 1007 Baltimore, MD 21201 https://aging.maryland.gov/Pages/state-health-insurance- program.aspx

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 23 State Health Insurance Assistance Programs (SHIP) - Contact Information Maine | Maine State Health Insurance Assistance Program 1-800-262-2232 (SHIP) TTY 711 11 State House Station, 41 Anthony AVE Augusta, ME 04333 https://www.maine.gov/dhhs/programs-services/health-insurance Michigan | Michigan MMAP, Inc. Senior Health Insurance 1-800-803-7174 Program TTY 711 6105 W Saint Joseph Highway, STE 204 Lansing, MI 48917 www.mmapinc.org Minnesota | Minnesota State Health Insurance Assistance 1-800-333-2433 Program/Senior LinkAge Line TTY 1-800-627-3529 540 Cedar Street St. Paul, MN 55164-0976 https://mn.gov/senior-linkage-line Missouri | Missouri CLAIM Senior Health Insurance Program 1-800-390-3330 601 W Nifong Blvd, STE 3A Columbia, MO 65203 TTY 711 www.missouriclaim.org Northern Mariana Islands | North Mariana Islands Senior 1-670-664-3000 Health Insurance Program TTY 711 P.O. Box 5795 CHRB Saipan, MP 96950 http://commerce.gov.mp/ Mississippi | Mississippi Department of Human Services, 1-601-359-4500 Division of Aging & Adult Services TTY 711 200 S Lamar ST Jackson, MS 39201 http://www.mdhs.ms.gov/adults-seniors/services-for-seniors/state- health-insurance-assistance-program/ Montana | Montana State Health Insurance Assistance 1-800-551-3191 Program (SHIP) TTY 711 1100 N Last Chance Gulch, FL 4 Helena, MT 59601 http://dphhs.mt.gov/sltc/aging/ship North Carolina | North Carolina Seniors Health Insurance 1-855-408-1212 Information Program (SHIIP) TTY 711 325 N Salisbury ST Raleigh, NC 27603 http://www.ncdoi.com/SHIIP

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 24 State Health Insurance Assistance Programs (SHIP) - Contact Information North Dakota | North Dakota Senior Health Insurance 1-888-575-6611 Counseling (SHIC) TTY 1-800-366-6888 600 E BLVD AVE Bismarck, ND 58505-0320 https://www.insurance.nd.gov/consumers/shic-medicare Nebraska | Nebraska Senior Health Insurance Information 1-800-234-7119 Program (SHIIP) TTY 711 2717 S. 8th Street, STE 4 Lincoln, NE 68508 https://doi.nebraska.gov/consumer/senior-health New Hampshire | New Hampshire SHIP - ServiceLink Aging and 1-866-634-9412 Disability Resource Center TTY 1-800-735-2964 25 Roxbury St, STE 106 Keene, NH 03431 https://www.servicelink.nh.gov New Jersey | New Jersey State Health Insurance Assistance 1-800-792-8820 Program (SHIP) TTY 711 P.O. Box 715 Trenton, NJ 08625-0715 http://www.state.nj.us/humanservices/doas/services/ship/ index.html New Mexico | New Mexico Benefits Counseling Program SHIP 1-800-432-2080 2250 Cerrillos Rd Santa Fe, NM 87505 TTY 1-505-476-4937 www.nmaging.state.nm.us Nevada | Nevada State Health Insurance Assistance Program 1-800-307-4444 (SHIP) TTY 711 3416 Goni RD, STE D-132 Carson City, NV 89706 http://adsd.nv.gov/Programs/Seniors/SHIP/SHIP_Prog/ New York | New York Health Insurance Information Counseling 1-800-701-0501 and Assistance Program (HIICAP) TTY 711 2 Empire State Plaza, FL 5 Albany, NY 12223 www.aging.ny.gov/health-insurance-information-counseling-and- assistance Ohio | Ohio Senior Health Insurance Information Program 1-800-686-1578 (OSHIIP) TTY 1-614-644-3745 50 W Town ST, STE 300, FL 3 Columbus, OH 43215 https://insurance.ohio.gov/wps/portal/gov/odi/consumers

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 25 State Health Insurance Assistance Programs (SHIP) - Contact Information Oklahoma | Oklahoma Medicare Assistance Program (MAP) 1-800-763-2828 400 NE 50th ST Oklahoma City, OK 73105 TTY 711 www.map.oid.ok.gov Oregon | Oregon Senior Health Insurance Benefits Assistance 1-800-722-4134 (SHIBA) TTY 711 350 Winter St NE Salem, OR 97309 oregonshiba.org Pennsylvania | Pennsylvania Senior Health Insurance Program 1-800-783-7067 555 Walnut ST, FL 5 Harrisburg, PA 17101-1919 TTY 711 aging.pa.gov Puerto Rico | Puerto Rico State Health Insurance Assistance 1-787-721-6121 Program (SHIP) TTY 711 Ponce de León AVE, PDA 16, EDIF 1064, 3er nivel San Juan, PR 00919-1179 www.oppea.pr.gov Rhode Island | Rhode Island State Health Insurance Assistance 1-401-462-3000 Program (SHIP) TTY 1-401-462-0740 25 Howard AVE, BLDG 57 Cranston, RI 02920 https://oha.ri.gov/ South Carolina | South Carolina (I-CARE) Insurance Counseling 1-800-868-9095 Assistance and Referrals for Elders TTY 711 1301 Gervais ST, STE 350 Columbia, SC 29201 https://aging.sc.gov/ South Dakota | South Dakota Senior Health Information & 1-877-331-4834 Insurance Education (SHIINE) TTY 711 2520 E Franklin St Pierre, SD 57501 www.shiine.net Tennessee | Tennessee Commission on Aging & Disability - TN 1-877-801-0044 SHIP TTY 711 Andrew Jackson BLDG, 502 Deaderick ST, FL 9 Nashville, TN 37243-0860 www.tn.gov/aging/our-programs/state-health-insurance- assistance-program--ship-.html

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 26 State Health Insurance Assistance Programs (SHIP) - Contact Information Texas | Texas Department of Aging and Disability Services 1-800-252-9240 (HICAP) TTY 1-512-424-6597 P.O. Box 13247 Austin, TX 78711 https://hhs.texas.gov/services/health/medicare Utah | Utah Senior Health Insurance Information Program 1-877-424-4640 (SHIP) TTY 711 195 N 1950 W Salt Lake City, UT 84116 https://daas.utah.gov Virginia | Virginia Insurance Counseling and Assistance 1-800-552-3402 Program (VICAP) TTY 711 1610 Forest AVE, STE 100 Henrico, VA 23229 https://www.vda.virginia.gov/vicap.htm Virgin Islands of the U.S. | Virgin Islands State Health Insurance 1-340-773-6449 Assistance Program (VISHIP) TTY 711 1131 King ST, STE 101 St. Croix, VI 00820 https://ltg.gov.vi/departments/vi-ship-medicare/ Vermont | Vermont State Health Insurance Assistance Program 1-800-642-5119 (SHIP) TTY 711 27 Main Street, Suite 14 Montpelier, VT 05602 www.vermont4a.org Washington | Washington Statewide Health Insurance Benefits 1-800-562-6900 Advisors (SHIBA) TTY 1-360-586-0241 P.O. Box 40255 Olympia, WA 98504-0255 www.insurance.wa.gov/statewide-health-insurance-benefits- advisors-shiba Wisconsin | Wisconsin State Health Insurance Plan (SHIP) 1-800-242-1060 1402 Pankratz ST, STE 111 Madison, WI 53704 TTY 711 www.longtermcare.wi.gov West Virginia | West Virginia State Health Insurance Assistance 1-877-987-4463 Program (WV SHIP) TTY 711 1900 Kanawha BLVD E Charleston, WV 25305 www.wvship.org

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 27 State Health Insurance Assistance Programs (SHIP) - Contact Information Wyoming | Wyoming State Health Insurance Information 1-800-856-4398 Program (WSHIIP) TTY 711 106 W Adams AVE Riverton, WY 82501 www.wyomingseniors.com Section 4 Quality Improvement Organization There is a designated Quality Improvement Organization serving Medicare beneficiaries in each state. Here is a list of the Quality Improvement Organizations in each state we serve: • Alaska - KEPRO • Alabama - KEPRO • Arkansas - KEPRO • American Samoa - Livanta BFCC-QIO Program • Arizona - Livanta BFCC-QIO Program • California - Livanta BFCC-QIO Program • Colorado - KEPRO • Connecticut - KEPRO • District of Columbia - Livanta BFCC-QIO Program • Delaware - Livanta BFCC-QIO Program • Florida - KEPRO • Georgia - KEPRO • Guam - Livanta BFCC-QIO Program • Hawaii - Livanta BFCC-QIO Program • Iowa - Livanta BFCC-QIO Program • Idaho - KEPRO • Illinois - Livanta BFCC-QIO Program • Indiana - Livanta BFCC-QIO Program • Kansas - Livanta BFCC-QIO Program • Kentucky - KEPRO • Louisiana - KEPRO • Massachusetts - KEPRO • Maryland - Livanta BFCC-QIO Program • Maine - KEPRO • Michigan - Livanta BFCC-QIO Program • Minnesota - Livanta BFCC-QIO Program • Missouri - Livanta BFCC-QIO Program • Northern Mariana Islands - Livanta BFCC-QIO Program • Mississippi - KEPRO • Montana - KEPRO

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 28 • North Carolina - KEPRO • North Dakota - KEPRO • Nebraska - Livanta BFCC-QIO Program • New Hampshire - KEPRO • New Jersey - Livanta BFCC-QIO Program • New Mexico - KEPRO • Nevada - Livanta BFCC-QIO Program • New York - Livanta BFCC-QIO Program • Ohio - Livanta BFCC-QIO Program • Oklahoma - KEPRO • Oregon - KEPRO • Pennsylvania - Livanta BFCC-QIO Program • Puerto Rico - Livanta BFCC-QIO Program • Rhode Island - KEPRO • South Carolina - KEPRO • South Dakota - KEPRO • Tennessee - KEPRO • Texas - KEPRO • U.S. Minor Outlying Islands - KEPRO • Utah - KEPRO • Virginia - Livanta BFCC-QIO Program • Virgin Islands of the U.S. - Livanta BFCC-QIO Program • Vermont - KEPRO • Washington - KEPRO • Wisconsin - Livanta BFCC-QIO Program • West Virginia - Livanta BFCC-QIO Program • Wyoming - KEPRO Your state’s Quality Improvement Organization has a group of doctors and other health care professionals who are paid by Medicare to check on and help improve the quality of care for people with Medicare. The state’s Quality Improvement Organization is an independent organization. It is not connected with our plan. You should contact your state’s Quality Improvement Organization in any of these situations: · You have a complaint about the quality of care you have received. · You think coverage for your hospital stay is ending too soon. · You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 29 Quality Improvement Organization (QIO) – Contact Information Alaska | KEPRO 1-888-305-6759 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Alabama | KEPRO 1-888-317-0751 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Arkansas | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays American Samoa | Livanta BFCC-QIO Program 1-877-588-1123 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-855-887-6668 www.livantaqio.com Arizona | Livanta BFCC-QIO Program 1-877-588-1123 10820 Guilford RD, STE 202 Annapolis Junction, KY 20701 TTY 1-855-887-6668 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays California | Livanta BFCC-QIO Program 1-877-588-1123 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-855-887-6668 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 30 Quality Improvement Organization (QIO) – Contact Information Colorado | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Connecticut | KEPRO 1-888-319-8452 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays District of Columbia | Livanta BFCC-QIO Program 1-888-396-4646 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-2660 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Delaware | Livanta BFCC-QIO Program 1-888-396-4646 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-2660 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Florida | KEPRO 1-888-317-0751 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Georgia | KEPRO 1-888-317-0751 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 31 Quality Improvement Organization (QIO) – Contact Information Guam | Livanta BFCC-QIO Program 1-877-588-1123 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-855-887-6668 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Hawaii | Livanta BFCC-QIO Program 1-877-588-1123 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-855-887-6668 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Iowa | Livanta BFCC-QIO Program 1-888-755-5580 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-9295 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Idaho | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Illinois | Livanta BFCC-QIO Program 1-888-524-9900 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-8775 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Indiana | Livanta BFCC-QIO Program 1-888-524-9900 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-8775 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 32 Quality Improvement Organization (QIO) – Contact Information Kansas | Livanta BFCC-QIO Program 1-888-755-5580 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-9295 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Kentucky | KEPRO 1-888-317-0751 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Louisiana | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Massachusetts | KEPRO 1-888-319-8452 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Maryland | Livanta BFCC-QIO Program 1-888-396-4646 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-2660 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Maine | KEPRO 1-888-319-8452 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 33 Quality Improvement Organization (QIO) – Contact Information Michigan | Livanta BFCC-QIO Program 1-888-524-9900 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-8775 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Minnesota | Livanta BFCC-QIO Program 1-888-524-9900 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-8775 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Missouri | Livanta BFCC-QIO Program 1-888-755-5580 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-9295 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Northern Mariana Islands | Livanta BFCC-QIO Program 1-877-588-1123 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-855-887-6668 www.livantaqio.com Mississippi | KEPRO 1-888-317-0751 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Montana | KEPRO 1-888-317-0891 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 34 Quality Improvement Organization (QIO) – Contact Information North Carolina | KEPRO 1-888-317-0751 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays North Dakota | KEPRO 1-888-317-0891 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Nebraska | Livanta BFCC-QIO Program 1-888-755-5580 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-9295 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays New Hampshire | KEPRO 1-888-319-8452 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays New Jersey | Livanta BFCC-QIO Program 1-866-815-5440 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-866-868-2289 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays New Mexico | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 35 Quality Improvement Organization (QIO) – Contact Information Nevada | Livanta BFCC-QIO Program 1-877-588-1123 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-855-887-6668 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays New York | Livanta BFCC-QIO Program 1-866-815-5440 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-866-868-2289 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Ohio | Livanta BFCC-QIO Program 1-888-524-9900 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-8775 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Oklahoma | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Oregon | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Pennsylvania | Livanta BFCC-QIO Program 1-888-396-4646 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-2660 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 36 Quality Improvement Organization (QIO) – Contact Information Puerto Rico | Livanta BFCC-QIO Program 1-787-520-5743 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-866-868-2289 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Rhode Island | KEPRO 1-888-319-8452 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays South Carolina | KEPRO 1-888-317-0751 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays South Dakota | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Tennessee | KEPRO 1-888-317-0751 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Texas | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 37 Quality Improvement Organization (QIO) – Contact Information U.S. Minor Outlying Islands | KEPRO 1-888-317-0891 5700 Lombardo CTR DR, STE 100 Seven Hills, FL 44131 TTY 711 www.keproqio.com Utah | KEPRO 1-888-317-0891 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Virginia | Livanta BFCC-QIO Program 1-888-396-4646 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-2660 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Virgin Islands of the U.S. | Livanta BFCC-QIO Program 1-340-773-6334 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-866-868-2289 www.livantaqio.com Vermont | KEPRO 1-888-319-8452 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Washington | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Wisconsin | Livanta BFCC-QIO Program 1-888-524-9900 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-8775 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 38 Quality Improvement Organization (QIO) – Contact Information West Virginia | Livanta BFCC-QIO Program 1-888-396-4646 10820 Guilford RD, STE 202 Annapolis Junction, MD 20701 TTY 1-888-985-2660 www.livantaqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Wyoming | KEPRO 1-888-315-0636 5201 W Kennedy BLVD, STE 900 Tampa, FL 33609 TTY 711 www.keproqio.com 9 a.m. - 5 p.m. local time, Monday - Friday; 11 a.m. - 3 p.m. local time, weekends and holidays Section 5 Social Security Social Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens and lawful permanent residents who are 65 or older, or who have a disability or End-Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office. Social Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a letter from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life-changing event, you can call Social Security to ask for reconsideration. If you move or change your mailing address, it is important that you contact Social Security to let them know. Method Social Security – Contact Information Call 1-800-772-1213 Calls to this number are free. Available 8:00 am to 7:00 pm, Monday through Friday. You can use Social Security’s automated telephone services to get recorded information and conduct some business 24 hours a day. TTY 1-800-325-0778 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 39 Method Social Security – Contact Information Calls to this number are free. Available 8:00 am to 7:00 pm, Monday through Friday. Website ssa.gov Section 6 Medicaid Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Some people with Medicare are also eligible for Medicaid. The programs offered through Medicaid help people with Medicare pay their Medicare costs, such as their Medicare premiums. These “Medicare Savings Programs” include: · Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid benefits (QMB+).) · Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).) · Qualifying Individual (QI): Helps pay Part B premiums. · Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums. To find out more about Medicaid and its programs, contact your state Medicaid agency. State Medicaid Programs – Contact Information Alaska | State of Alaska Department of Health & Social 1-800-478-7778 Services, Division of Health Care Services TTY 711 855 W.Commercial Drive, STE 131 Anchorage, AK 99654 8 a.m. - 5 p.m. AKT, http://dhss.alaska.gov/dhcs/Pages/medicaid_medicare/ Monday - Friday default.aspx Alabama | Alabama Medicaid 1-800-362-1504 P.O. Box 5624 Montgomery, AL 36103-5624 TTY 1-800-253-0799 http://www.medicaid.alabama.gov/ 8 a.m. - 4:30 p.m. CT, Monday - Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 40 State Medicaid Programs – Contact Information Arkansas | Arkansas Division of Medical Services Department 1-800-482-8988 of Human Services TTY 1-800-285-1131 Donaghey Plaza S, P.O. Box 1437 Slot S401 Little Rock, AR 8 a.m. - 4:30 p.m. CT, 72203-1437 Monday - Friday https://humanservices.arkansas.gov/divisions-shared-services/ medical-services/ American Samoa | American Samoa Medicaid State Agency 1-684-699-4777 ASCTA Executive BLDG #306, P.O. Box 6101 Pago Pago, AS TTY 711 96799 http://medicaid.as.gov/ Arizona | Arizona Health Care Cost Containment System 1-855-432-7587 (AHCCCS) TTY 1-800-367-8939 801 E Jefferson ST Phoenix, AZ 85034 8 a.m. - 5 p.m. MT, www.azahcccs.gov Monday - Friday Arizona | Arizona Department of Economic Security / Division 1-844-770-9500 of Developmental Disabilities (DDD) TTY 711 1789 W Jefferson ST Phoenix, AZ 85007 8 a.m. - 5 p.m. MT, https://des.az.gov/services/disabilities/developmental-disabilities Monday - Friday California | Medi-Cal - Managed Care Operations Division 1-800-430-4263 Department of Health Care Services TTY 1-800-430-7077 P.O. Box 989009 West Sacramento, CA 95798-9850 8 a.m. - 5 p.m. PT, https://www.healthcareoptions.dhcs.ca.gov/ Monday - Friday Colorado | Colorado Department of Health Care Policy and 1-800-221-3943 Financing TTY 711 1570 Grant ST Denver, CO 80203-1818 8 a.m. - 4:30 p.m. MT, www.healthfirstcolorado.com Monday - Friday Connecticut | Connecticut State Medicaid 1-877-284-8759 55 Farmington AVE Hartford, CT 06105-3730 TTY 1-866-492-5276 portal.ct.gov/husky 8:30 a.m. - 6:00 p.m. local time, Monday - Friday District of Columbia | DC Department of Human Services 1-202-671-4200 64 New York AVE NE, FL 6 Washington, DC 20002 TTY 711 https://dhs.dc.gov/service/medical-assistance 8 a.m. - 6 p.m. ET, Monday - Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 41 State Medicaid Programs – Contact Information Delaware | Delaware Health and Social Services 1-302-255-9040 1901 N Dupont HWY, Lewis BLDG New Castle, DE 19720 TTY 711 http://dhss.delaware.gov/dhss/ 8 a.m. - 4:30 p.m. ET, Monday - Friday Florida | Florida Medicaid Agency for Health Care 1-888-419-3456 Administration (AHCA) TTY 1-800-955-8771 2727 Mahan DR, MS 6 Tallahassee, FL 32308 8 a.m. - 5 p.m. ET, https://ahca.myflorida.com/ Monday - Friday Georgia | Georgia Department of Community Health 1-877-423-4746 1249 Donald Lee Hollowell Parkway Atlanta, GA 30318 TTY 711 https://medicaid.georgia.gov/ 8 a.m. - 5 p.m. ET, Monday - Friday Guam | Guam Department of Public Health and Social Services 1-671-735-7243 Bureau of Health Care Financing TTY 711 123 Chalan Kareta Mangilao, GU 96913-6304 8 a.m. - 5 p.m. CHT, http://www.dphss.guam.gov/ Monday - Friday Hawaii | Department of Human Services 1-808-586-5390 1390 Miller ST, RM 209 Honolulu, HI 96813 TTY 711 https://humanservices.hawaii.gov/ 7:45 a.m. - 4:30 p.m. HT, Monday - Friday Iowa | Department of Human Services (Iowa Medicaid 1-800-338-8366 Enterprise) TTY 1-800-735-2942 1305 E Walnut Street FL 5 Des Moines, IA 50319 8 a.m. - 4:30 p.m. local http://dhs.iowa.gov/ time, Monday - Friday Idaho | Idaho Department of Health and Welfare 1-877-456-1233 P.O. Box 83720 Boise, ID 83720-0026 TTY 1-888-791-3004 https://healthandwelfare.idaho.gov 7 a.m. - 7 p.m. MT, Monday - Friday Illinois | Illinois Department of Healthcare and Family Services 1-800-843-6154 100 S Grand AVE E Springfield, IL 62704 TTY 1-800-447-6404 http://www2.illinois.gov/hfs/ 8:30 a.m. - 7 p.m. CT, Monday - Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 42 State Medicaid Programs – Contact Information Indiana | Indiana Family and Social Services Administration 1-800-403-0864 FSSA Document CTR, P.O. Box 1810 Marion, IN 46952 TTY 1-800-743-3333 https://www.in.gov/medicaid/ 8 a.m. - 4:30 p.m. ET, Monday - Friday Kansas | Kansas Dept. of Health and Environment 1-800-792-4884 900 SW Jackson ST Topeka, KS 66612 TTY 711 http://www.kancare.ks.gov/ 8 a.m. - 5 p.m. CT, Monday - Friday Kentucky | Kentucky Cabinet for Health and Family Services 1-800-635-2570 275 E Main ST Frankfort, KY 40621 TTY 711 https://chfs.ky.gov/ 8 a.m. - 5 p.m. ET, Monday - Friday Louisiana | Louisiana Department of Health 1-225-342-9500 628 N. 4th Street Baton Rouge, LA 70802 TTY 711 https://ldh.la.gov/ 8 a.m. - 4:30 p.m. local time, Monday - Friday Massachusetts | Executive Office of Health and Human 1-800-841-2900 Services TTY 1-800-497-4648 100 Hancock ST, FL 6 Quincy, MA 02171 8 a.m. - 5 p.m. ET, http://www.mass.gov/eohhs/gov/departments/masshealth/ Monday - Friday Maryland | Maryland Department of Health, HealthChoice 1-877-463-3464 201 W Preston ST Baltimore, MD 21201-2399 TTY 1-800-735-2258 health.maryland.gov/mmcp/healthchoice/Pages/Home.aspx 8 a.m. - 5 p.m. ET, Monday - Friday Maine | Office of MaineCare Services 1-800-977-6740 11 State House Station Augusta, ME 04333-0011 TTY 711 https://www.maine.gov/dhhs/oms/ 8 a.m. - 5 p.m. ET, Monday - Friday Michigan | Department of Health and Human Services 1-517-373-3740 333 S Grand AVE, P.O. Box 30195 Lansing, MI 48909 TTY 1-800-649-3777 http://www.michigan.gov/mdhhs/ 8 a.m. - 5 p.m. ET, Monday - Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 43 State Medicaid Programs – Contact Information Minnesota | Minnesota Department of Human Services 1-800-657-3739 P.O. Box 64989 St. Paul, MN 55164-0989 TTY 1-800-627-3529 http://mn.gov/dhs 8 a.m. - 5 p.m. CT, Monday - Friday Missouri | MO HealthNet Division Department of Social 1-573-526-4274 Services TTY 1-800-735-2966 615 Howerton CT, P.O. Box 6500 Jefferson City, MO 65102-6500 8 a.m. - 5 p.m. CT, https://www.dss.mo.gov/mhd/ Monday - Friday Northern Mariana Islands | State Medicaid Administration 1-670-664-4880 Office TTY 711 Government BLDG # 1252, Capital Hill RD, Caller Box 100007 Saipan, MP 96950 http://medicaid.cnmi.mp/ Mississippi | State of Mississippi Division of Medicaid 1-800-421-2408 550 High ST STE, 1000 Sillers BLDG Jackson, MS 39201-1399 TTY 711 http://www.medicaid.ms.gov/ 7:30 a.m. - 5 p.m. CT, Monday - Friday Montana | Montana Healthcare Programs 1-888-362-8312 P.O. Box 202951 Helena, MT 59620-2951 TTY 1-800-833-8503 https://dphhs.mt.gov/MontanaHealthcarePrograms 8 a.m. - 5 p.m. MT, Monday - Friday North Carolina | North Carolina Deparment of Health and 1-800-662-7030 Human Services TTY 1-888-232-6348 2001 Mail Service Center Raleigh, NC 27699-2501 8 a.m. - 5 p.m. ET, https://www.ncdhhs.gov/ Monday - Friday North Dakota | North Dakota Department of Human Services 1-800-755-2604 600 E BLVD AVE, Department 325 Bismarck, ND 58505-0250 TTY 1-800-366-6888 http://www.nd.gov/dhs/services/medicalserv/medicaid 8 a.m. - 5 p.m. CT, Monday - Friday Nebraska | Nebraska Department of Health and Human 1-402-471-3121 Services TTY 1-800-471-7352 P.O. Box 95026 Lincoln, NE 68509-5026 8 a.m. - 5 p.m. CT, dhhs.ne.gov/Pages/medicaid-and-long-term-care.aspx Monday - Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 44 State Medicaid Programs – Contact Information New Hampshire | New Hampshire Department of Health and 1-844-275-3447 Human Services TTY 1-800-735-2964 129 Pleasant ST Concord, NH 03301-3852 8 a.m. - 4 p.m. ET, https://www.dhhs.nh.gov/ombp/medicaid/ Monday - Friday New Jersey | Department of Human Services Division of 1-800-701-0710 Medical Assistance & Health Services TTY 711 P.O. Box 712 Trenton, NJ 08625-0712 8 a.m. - 5 p.m. ET, https://www.state.nj.us/humanservices/dmahs/ Monday - Friday New Mexico | NM Human Services Department 1-888-997-2583 P.O. Box 2348 Santa Fe, NM 87504-2348 TTY 1-855-227-5485 https://www.hsd.state.nm.us/ 8 a.m. - 5 p.m. MT, Monday - Friday Nevada | Nevada Department of Health and Human Services 1-800-992-0900 1100 E Williams ST, STE 101 Carson City, NV 89701 TTY 711 http://dhcfp.nv.gov 8 a.m. - 5 p.m. PT, Monday - Friday New York | New York State Department of Health 1-800-541-2831 Corning Tower, Empire State Plaza Albany, NY 12237 TTY 711 http://www.health.state.ny.us/health_care/medicaid/index.htm 8 a.m. - 5 p.m. ET, Monday - Friday Ohio | Ohio Department of Medicaid 1-800-324-8680 50 W Town ST, STE 400 Columbus, OH 43215 TTY 711 https://medicaid.ohio.gov/ 7 a.m. - 8 p.m. ET, Monday - Friday; 8 a.m. - 5 p.m. ET, Saturday Oklahoma | Oklahoma Health Care Authority 1-800-987-7767 4345 N Lincoln BLVD Oklahoma City, OK 73105 TTY 711 http://www.okh 8 a.m. - 5 p.m. CT, Monday - Friday Oregon | Oregon Health Authority 1-503-947-2340 500 Summer ST, NE, E-20 Salem, OR 97301-1097 TTY 711 https://www.oregon.gov/oha/HSD/OHP 8 a.m. - 5 p.m. PT, Monday - Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 45 State Medicaid Programs – Contact Information Pennsylvania | Pennsylvania Department of Human Services 1-800-692-7462 P.O. Box 5959 Harrisburg, PA 17110-0959 TTY 1-800-451-5886 http://www.dhs.pa.gov/ 8 a.m. - 5 p.m. ET, Monday - Friday Puerto Rico | Government of Puerto Rico, Department of 1-787-765-2929 Health Medicaid Program TTY 1-787-625-6955 P.O. Box 70184 San Juan, PR 00936-8184 8 a.m. - 6 p.m. ET, https://medicaid.pr.gov Monday - Friday Rhode Island | Executive Office of Health and Human Services 1-401-462-5274 (EOHHS) TTY 711 3 West Road Cranston, RI 02920 8:30 a.m. - 4 p.m. ET, http://www.eohhs.ri.gov/ Monday - Friday South Carolina | South Carolina Department of Health and 1-888-549-0820 Human Services TTY 1-888-842-3620 P.O. Box 8206 Columbia, SC 29202-8206 8 a.m. - 6 p.m. ET, http://www.scdhhs.gov/ Monday - Friday South Dakota | South Dakota Department of Social Services, 1-800-597-1603 Division of Medical Services TTY 711 700 Governors DR Pierre, SD 57501 8 a.m. - 5 p.m. CT, http://dss.sd.gov/medicaid/ Monday - Friday Tennessee | Division of TennCare 1-800-342-3145 310 Great Circle RD Nashville, TN 37243 TTY 711 https://www.tn.gov/tenncare/ 8 a.m. - 4:30 p.m. CT, Monday - Friday Texas | Texas Medicaid Health and Human Services 1-512-424-6500 Commission TTY 1-512-424-6597 4900 N Lamar BLVD, P.O. Box 13247 Austin, TX 78751 8 a.m. - 5 p.m. CT, https://hhs.texas.gov/about-hhs/find-us Monday - Friday Utah | Utah Department of Health, Medicaid and Health 1-800-662-9651 Financing TTY 711 P.O. Box 143106 Salt Lake City, UT 84114-3106 8 a.m. - 5 p.m. MT, https://medicaid.utah.gov/ Monday - Friday; 8 a.m. - 11 a.m. MT, Thursday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 46 State Medicaid Programs – Contact Information Virginia | Department of Medical Assistance Services 1-855-242-8282 600 E Broad ST Richmond, VA 23219 TTY 711 http://www.dmas.virginia.gov/ 8 a.m. - 6 p.m. ET, Monday - Friday Virgin Islands of the U.S. | U.S. Virgin Islands Bureau of Health 1-340-715-6929 Insurance & Medical Assistance TTY 711 1303 Hospital Ground, Knud Hansen Complex, BLDG A St. Thomas, VI 00802 www.dhs.gov.vi Vermont | Department of Vermont Health Access 1-800-250-8427 280 ST DR Waterbury, VT 05671 TTY 711 http://www.greenmountaincare.org/ 8 a.m. - 5 p.m. ET, Monday - Friday Washington | Washington State Health Care Authority 1-800-562-3022 P.O. Box 45531 Olympia, WA 98504 TTY 711 hca.wa.gov 7 a.m. - 5 p.m. PT, Monday - Friday Wisconsin | Wisconsin Department of Health Services 1-800-362-3002 1 W Wilson ST Madison, WI 53703 TTY 711 https://www.dhs.wisconsin.gov/health-care-coverage/index.htm 8 a.m. - 6 p.m. CT, Monday - Friday West Virginia | West Virginia Bureau for Medical Services 1-304-558-1700 350 Capitol ST, RM 251 Charleston, WV 25301 TTY 711 http://www.dhhr.wv.gov/bms/Pages/default.aspx 8:30 a.m. - 5 p.m. ET, Monday - Friday Wyoming | Wyoming Department of Health 1-307-777-7531 122 W 25th St., 4th FL West Cheyenne, WY 82001 TTY 1-855-329-5205 http://health.wyo.gov/healthcarefin/medicaid/ 9 a.m. - 5 p.m. MT, Monday - Friday Section 7 Information about programs to help people pay for their prescription drugs The Medicare.gov website (medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/ costs-in-the-coverage-gap/5-ways-to-get-help-with-prescription-costs) provides information on how

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 47 to lower your prescription drug costs. For people with limited incomes, there are also other programs to assist, described below. Medicare’s “Extra Help” Program Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan’s monthly premium, yearly deductible, and prescription copayments. This “Extra Help” also counts toward your out-of-pocket costs. If you automatically qualify for “Extra Help” Medicare will mail you a letter. You will not have to apply. If you do not automatically qualify you may be able to get “Extra Help” to pay for your prescription drug premiums and costs. To see if you qualify for getting “Extra Help,” call: · 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week; · The Social Security Office at 1-800-772-1213, between 8 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778 (applications); or · Your State Medicaid Office (applications). (See Section 6 of this chapter for contact information.) If you believe you have qualified for “Extra Help” and you believe that you are paying an incorrect cost-sharing amount when you get your prescription at a pharmacy, our plan has a process for you to either request assistance in obtaining evidence of your proper copayment level, or, if you already have the evidence, to provide this evidence to us. · Please call the customer service number in Chapter 2 Section 1. Our Customer Service Advocates can help get your copayment amount corrected. · When we receive the evidence showing your copayment level, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn’t collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state. Please contact Customer Service if you have questions. There are programs in Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa to help people with limited income and resources pay their Medicare costs. Programs vary in these areas. Call your local Medical Assistance (Medicaid) office to find out more about their rules (phone numbers are in Section 6 of this chapter). Or call 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week and say “Medicaid” for more information. TTY users should call 1-877-486-2048. You can also visit medicare.gov for more information. What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)? Many states and the U.S. Virgin Islands offer help paying for prescriptions, drug plan premiums and/or other drug costs. If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than “Extra Help”), you still get the 70% discount on covered brand name drugs. Also, the plan may pay a portion of the costs of

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 48 brand name drugs in the coverage gap. The 70% discount and any portion paid by the plan are both applied to the price of the drug before any SPAP or other coverage. What if you have coverage from an AIDS Drug Assistance Program (ADAP)? What is the AIDS Drug Assistance Program (ADAP)? The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that are also on the ADAP formulary qualify for prescription cost-sharing assistance. Note: To be eligible for the ADAP operating in your State, individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. If you change plans please notify your local ADAP enrollment worker so you can continue to receive assistance. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call your state ADAP office listed below. AIDS Drug Assistance Program (ADAP) – Contact Information Alaska | Alaskan AIDS Assistance Association 1-800-478-2437 1057 W Fireweed LN, STE 102 Anchorage, AK 99503 9 a.m.-5 p.m. local time, http://www.alaskanaids.org/index.php/client-services/adap Monday-Friday Alabama | Alabama AIDS Drug Assistance Program 1-866-574-9964 Office of HIV Prevention and Care, 201 Monroe ST, STE 1400 8 a.m.-5 p.m. local time, Montgomery, AL 36104 Monday-Friday http://www.alabamapublichealth.gov/hiv/adap.html Arkansas | Arkansas Department of Health, Ryan White 1-501-661-2408 Program - Part B 8 a.m.-4:30 p.m. local 4815 W Markham ST, Slot 33 Little Rock, AR 72205 time, Monday-Friday https://www.healthy.arkansas.gov/programs-services/topics/ryan- white-faqs American Samoa | American Samoa Department of Health 1-684-633-1433 Faagaalu RD 1 Pago Pago, AS 96799 8 a.m.-5 p.m. local time, https://www.americansamoa.gov/departments Monday-Friday Arizona | Arizona Department of Health Services ADAP 1-800-334-1540 150 N 18th AVE, STE 110 Phoenix, AZ 85007 8 a.m.-5 p.m. local time, https://www.azdhs.gov/preparedness/epidemiology-disease- Monday-Friday control/disease-integration-services/index.php#aids-drug- assistance-program-home

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 49 AIDS Drug Assistance Program (ADAP) – Contact Information California | Department of Health Services - ADAP 1-844-421-7050 P.O. Box 997426, MS 7704 Sacramento, CA 95899-7426 8 a.m.-5 p.m. local time, https://www.cdph.ca.gov/Programs/CID/DOA/Pages/ Monday-Friday OA_adap_medpartd.aspx Colorado | Colorado State Drug Assistance Program (SDAP) 1-303-692-2716 ADAP-3800, 4300 Cherry Creek DR S Denver, CO 80246-1530 9 a.m.-5 p.m. local time, https://cdphe.colorado.gov/state-drug-assistance-program Monday-Friday Connecticut | Connecticut ADAP 1-800-424-3310 Magellan Health Services P.O. Box 9971 Glen Allen, VA 23060 8 a.m.-4 p.m. local time, https://ctdph.magellanrx.com Monday-Friday District of Columbia | District of Columbia ADAP 1-202-671-4815 AIDS Drug Assistance Program (ADAP) 899 N Capitol ST NE 8 a.m.-4:30 p.m. local Washington, DC 20002 time, Monday-Friday https://dchealth.dc.gov/node/137072 Delaware | Delaware Division of Public Health Ryan White 1-302-744-1050 Program 8 a.m.-4:30 p.m. local 540 S DuPont HWY Dover, DE 19901 time, Monday-Friday http://www.dhss.delaware.gov/dhss/dph/dpc/hivtreatment.html Florida | Florida Department of Health ADAP 1-800-352-2437 HIV/AIDS Section, 4052 Bald Cypress Way Tallahassee, FL 32399 8 a.m.-9 p.m. local time, http://www.floridahealth.gov/diseases-and-conditions/aids/adap/ Monday-Friday index.html Georgia | Georgia AIDS Drug Assistance Program (ADAP) 1-404-656-9805 200 Piedmont Ave., SE Atlanta, GA 30303-3186 8 a.m.-5 p.m. local time, https://dph.georgia.gov/health-topics/office-hivaids/hiv-care/aids- Monday-Friday drug-assistance-program-adap Guam | Bureau of Communicable Disease Control - STD/HIV/ 1-671-735-3603 Viral Hepatitis Program 8 a.m.-5 p.m. local time, 520 West Santa Monica Avenue, RM 126 Dededo, GU 96913 Monday-Friday http://www.dphss.guam.gov/document/ryan-white-hivaids- program-brochure

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 50 AIDS Drug Assistance Program (ADAP) – Contact Information Hawaii | Hawaii State Department of Health Harm Reduction 1-808-733-9360 Services Branch 7:45 a.m.-4:30 p.m. local 3627 Kilauea AVE, STE 306 Honolulu, HI 96816 time, Monday-Friday https://health.hawaii.gov/harmreduction/ Iowa | Iowa AIDS Drug Assistance Program (ADAP) 1-515-204-3746 321 E 12th ST Des Moines, IA 50319-0075 8 a.m.-4:30 p.m. local https://www.idph.iowa.gov/hivstdhep/hiv/support time, Monday-Friday Idaho | Idaho AIDS Drug Assistance Program (IDADAP) 1-208-334-5612 450 W State ST, FL 4 Boise, ID 83720-0036 8 a.m.-5 p.m. local time, https://www.idph.iowa.gov/hivstdhep/hiv/support Monday-Friday Illinois | Illinois ADAP 1-800-825-3518 525 W Jefferson ST, FL 1 Springfield, IL 62761 8:30 a.m.-4:00 p.m. local https://www.dph.illinois.gov/topics-services/diseases-and- time, Monday-Friday conditions/hiv-aids/ryan-white-care-and-hopwa-services Indiana | Indiana HIV Medical Services Program 1-866-588-4948 2 N Meridian ST, STE 6C Indianapolis, IN 46206 8 a.m.-5 p.m. local time, https://www.in.gov/health/hiv-std-viral-hepatitis/ Monday-Friday Kansas | Kansas AIDS Drug Assistance Program 1-785-296-6174 1000 SW Jackson ST, STE 210 Topeka, KS 66612 8 a.m.-5 p.m. local time, https://www.kdhe.ks.gov/355/Ryan-White-Part-B-Program Monday-Friday Kentucky | Kentucky AIDS Drug Assistance Program (KADAP) 1-502-564-6539 HIV/AIDS Branch, 275 E Main ST, HS2E-C Frankfort, KY 40621 8 a.m.-4:30 p.m. local https://chfs.ky.gov/agencies/dph/dehp/hab/Pages/services.aspx time, Monday-Friday Louisiana | Louisiana Office of Public Health 1-504-568-7474 STD/HIV Program, 1450 Poydras ST, STE 2136 New Orleans, LA 8 a.m.-5 p.m. local time, 70112 Monday-Friday http://new.dhh.louisiana.gov/index.cfm/page/1099 Massachusetts | AccessHealth MA ATTN: HDAP 1-617-502-1700 The Schrafft's City CTR, 529 Main ST, STE 301 Charlestown, MA 8 a.m.-5 p.m. local time, 02129 Monday-Friday https://accesshealthma.org/drug-assistance/hdap/

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 51 AIDS Drug Assistance Program (ADAP) – Contact Information Maryland | Maryland AIDS Drug Assistance Program 1-410-767-6536 Client Services, 1223 W. Pratt ST Baltimore, MD 21223 8:30 a.m.-4:30 p.m. local https://health.maryland.gov/phpa/OIDPCS/Pages/MADAP.aspx time, Monday-Friday Maine | Maine AIDS Drug Assistance Program 1-207-287-3747 11 State House Station, 286 Water ST Augusta, ME 04330 8 a.m.-5 p.m. local time, http://www.maine.gov/dhhs/mecdc/infectious-disease/hiv-std/ Monday-Friday services/aids-drug-assist.shtml Michigan | Michigan Drug Assistance Program 1-888-826-6565 MI Dept of Health and Human Services P.O. Box 30727 Lansing, 8 a.m.-5 p.m. local time, MI 48909 Monday-Friday https://www.michigan.gov/mdhhs/ 0,5885,7-339-71550_2955_2982_70541-456735--,00.html Minnesota | Minnesota HIV Programs 1-800-657-3761 Department of Human Services, P.O. Box 64972 St. Paul, MN 9 a.m. - 5 p.m. local time, 55164-0972 Monday - Friday http://mn.gov/dhs/people-we-serve/adults/health-care/hiv-aids/ contact-us/index.jsp Missouri | Missouri Bureau of HIV, STD and Hepatitis 1-573-751-6439 Department of Health and Senior Services, P.O. Box 570 Jefferson 8 a.m.-5 p.m. local time, City, MO 65102-0570 Monday-Friday https://health.mo.gov/living/healthcondiseases/communicable/ hivaids/casemgmt.php Mississippi | Mississippi Department of Health, STD/HIV Office 1-601-576-7723 570 E Woodrow Wilson DR, P.O. Box 1700 Jackson, MS 8 a.m.-5 p.m. local time, 39215-1700 Monday-Friday http://msdh.ms.gov/msdhsite/_static/14,0,150.html Montana | Montana AIDS Drug Assistance Program (ADAP) 1-406-444-3565 DPHHS, Cogswell BLDG C-211, 1400 Broadway ST Helena, MT 8 a.m.-5 p.m. local time, 59620-2951 Monday-Friday https://dphhs.mt.gov/publichealth/hivstd/Treatment/ mtryanwhiteprog

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 52 AIDS Drug Assistance Program (ADAP) – Contact Information North Carolina | North Carolina HIV Medication Assistance 1-919-733-3419 Program 8 a.m.-5 p.m. local time, N.C. Dept. of Health and Human Services, 2001 Mail Service Monday-Friday Center Raleigh, NC 27699-2000 https://epi.dph.ncdhhs.gov/cd/hiv/hmap.html North Dakota | North Dakota Department of Health, Division of 1-800-472-2180 Disease Control 8 a.m.-5 p.m. local time, 2635 E Main AVE, P.O. Box 5520 Bismarck, ND 58506-5520 Monday-Friday http://www.ndhealth.gov/hiv/contact/ Nebraska | Nebraska Department of Health & Human Services 1-402-471-2101 Ryan White HIV/AIDS Program, P.O. Box 95026 Lincoln, NE 8 a.m.-5 p.m. local time, 68509-5026 Monday-Friday http://dhhs.ne.gov/Pages/Ryan-White.aspx New Hampshire | New Hampshire CARE Program 1-800-852-3345 129 Pleasant ST Concord, NH 03301 8 a.m.-4:30 p.m. local https://www.dhhs.nh.gov/dphs/bchs/std/care.htm time, Monday-Friday New Jersey | New Jersey AIDS Drug Distribution Program 1-877-613-4533 (ADDP) 8 a.m.-4:30 p.m. local P.O. Box 360 Trenton, NJ 08625-0360 time, Monday-Friday http://www.state.nj.us/health/hivstdtb/hiv-aids/medications.shtml New Mexico | New Mexico Department of Health , AIDS Drug 1-505-827-2435 Assistance Program 8 a.m.-5 p.m. local time, 1190 S Saint Francis DR, STE 1200 Santa Fe, NM 87505 Monday-Friday http://nmhealth.org/about/phd/idb/hats/ Nevada | Nevada Office of HIV/AIDS 1-775-684-3499 4126 Technology Way, STE 200 Carson City, NV 89706 8 a.m.-5 p.m. local time, http://dpbh.nv.gov/Programs/HIV-Ryan/Ryan_White_Part_B_- Monday-Friday _Home/ New York | New York AIDS Drug Assistance Program 1-800-542-2437 HIV Uninsured Care Programs, Empire STA, P.O. Box 2052 8 a.m.-5 p.m. local time, Albany, NY 12220-0052 Monday-Friday http://www.health.ny.gov/diseases/aids/general/resources/adap/

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 53 AIDS Drug Assistance Program (ADAP) – Contact Information Ohio | Ohio HIV Drug Assistance Program (OHDAP) 1-800-777-4775 Ohio Department of Health 246 N High ST Columbus, OH 43215 8 a.m.-5 p.m. local time, https://odh.ohio.gov/know-our-programs/ryan-white-part-b-hiv- Monday-Friday client-services/aids-drug-assistance-program Oklahoma | Oklahoma AIDS Coordination & Information 1-405-271-5816 Services 8 a.m.-5 p.m. local time, Oklahoma Department of Health, 2400 N. Lincoln BLVD Oklahoma Monday-Friday City, OK 73111 https://oklahoma.gov/okdhs/services/health/aids-coordination- and-information-services.html Oregon | Oregon CAREAssist 1-971-673-0144 800 NE Oregon ST, STE 1105 Portland, OR 97232 8 a.m.-5 p.m. local time, http://public.health.oregon.gov/DiseasesConditions/ Monday-Friday HIVSTDViralHepatitis/HIVCareTreatment/CAREAssist/Pages/ index.aspx Pennsylvania | Pennsylvania Special Pharmaceutical Benefits 1-800-922-9384 Program 8 a.m.-4:30 p.m. local Department of Health PO Box 8808 Harrisburg, PA 17120 time, Monday-Friday https://www.health.pa.gov/topics/programs/HIV/Pages/Special- Pharmaceutical-Benefits.aspx Puerto Rico | Puerto Rico Departmento de Salud, Programa 1-787-765-2929 Ryan White Parte B 8 a.m.-4:30 p.m. local P.O. Box 70184 San Juan, PR 00936-8184 time, Monday-Friday http://www.salud.gov.pr/Dept-de-Salud/Pages/Directorio.aspx Rhode Island | Rhode Island AIDS Drug Assistance Program 1-401-222-5960 Executive Office of Health & Human Services 3 West RD 8:30 a.m.-4:30 p.m. local Cranston, RI 02920 time, Monday-Friday https://eohhs.ri.gov/Consumer/Adults/RyanWhiteHIVAIDS.aspx South Carolina | South Carolina AIDS Drug Assistance Program 1-800-856-9954 (ADAP) 8 a.m.-5 p.m. local time, DHEC, STD/HIV Division, 2600 Bull ST Columbia, SC 29201 Monday-Friday http://www.scdhec.gov/Health/DiseasesandConditions/ InfectiousDiseases/HIVandSTDs/AIDSDrugAssistancePlan/

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 54 AIDS Drug Assistance Program (ADAP) – Contact Information South Dakota | Ryan White Part B CARE Program 1-800-592-1861 South Dakota Department of Health, 615 E 4th ST Pierre, SD 8 a.m.-5 p.m. local time, 57501-1700 Monday-Friday https://doh.sd.gov/topics/diseases-conditions/communicable- infectious-diseases/reportable-communicable-diseases/hivaids/ ryan-white-part-b-program/ Tennessee | Ryan White Part B Program 1-615-741-7500 Department of Health, 710 James Robertson PKWY Nashville, TN 8 a.m.-4:30 p.m. local 37243 time, Monday-Friday https://www.tn.gov/health/health-program-areas/std/std/ryan- white-part-b-program/-tennessee-ryan-white-part-b-programs.html Texas | Texas HIV Medication Program 1-800-255-1090 ATTN: MSJA, MC 1873, P.O. Box 149347 Austin, TX 78714-9387 8 a.m.-5 p.m. local time, www.dshs.state.tx.us/hivstd/meds Monday-Friday Utah | Utah Department of Health Office of Communicable 1-801-538-6191 Diseases 8 a.m.-5 p.m. local time, 288 N 1460 W, P.O. Box 142104 Salt Lake City, UT 84114-2104 Monday-Friday http://health.utah.gov/epi/treatment/ Virginia | Virginia Medication Assistance Program (MAP) 1-800-533-4148 109 Governor ST Richmond, VA 23219 8 a.m.-5 p.m. local time, https://www.vdh.virginia.gov/disease-prevention/vamap/ Monday-Friday Virgin Islands of the U.S. | US Virgin Islands STD/HIV/TB 1-340-774-9000 Program USVI Department of Health, Old Municipal Hospital Complex, BLDG 1 St. Thomas, VI 00802 https://doh.vi.gov/programs/communicable-diseases Vermont | VT Medication Assistance Program 1-802-863-7240 Health Surveillance Division, P.O. Box 70 Burlington, VT 05402 7:45 a.m.-4:30 p.m. local http://healthvermont.gov/prevent/aids/aids_index.aspx time, Monday-Friday Washington | Washington Early Intervention Program (EIP) 1-877-376-9316 Client Services, P.O. Box 47841 Olympia, WA 98504-7841 8 a.m.-5 p.m. local time, https://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/ Monday-Friday HIV/ClientServices/ADAPandEIP

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 55 AIDS Drug Assistance Program (ADAP) – Contact Information Wisconsin | Wisconsin AIDS Drug Assistance Program (ADAP) 1-800-991-5532 Department of Health Services, 1 W Wilson ST Madison, WI 53703 8 a.m.-5 p.m. local time, https://www.dhs.wisconsin.gov/hiv/adap-consumer-client.htm Monday-Friday West Virginia | West Virginia AIDS Drug Assistance Program 1-800-642-8244 (ADAP) 8 a.m.-4 p.m. local time, 350 Capitol ST, RM 125 Charleston, WV 25301 Monday-Friday https://oeps.wv.gov/aboutus/Pages/about_dsh.aspx Wyoming | Wyoming Department of Health Communicable 1-307-777-7529 Disease Unit 8 a.m.-5 p.m. local time, HIV Treatment Program, 401 Hathaway BLDG Cheyenne, WY Monday-Friday 82002 https://health.wyo.gov/publichealth/communicable-disease-unit/ hivaids/ State Pharmaceutical Assistance Programs Many states have State Pharmaceutical Assistance Programs that help some people pay for prescription drugs based on financial need, age, medical condition or disabilities. Each state has different rules to provide drug coverage to its members. Here is a list of the State Pharmaceutical Assistance Programs in each state we serve: • California - Department of Health Services - ADAP • Colorado - Colorado Department of Health Care Policy & Financing • Connecticut - Connecticut AIDS Drug Assistance Program (CADAP) • District of Columbia - District of Columbia Department of Health • Delaware - Delaware Prescription Assistance Program • Guam - Guam Medically Indigent Program (MIP) • Idaho - Idaho AIDS Drug Assistance Program (IDADAP) • Indiana - HoosierRx • Louisiana - Louisiana Department of Health • Massachusetts - Prescription Advantage Executive Office of Elder Affairs • Maryland - Maryland Senior Prescription Drug Assistance Program (SPDAP) • Maine - Office of MaineCare Services • Missouri - MissouriRx Plan (MORx) • Montana - Montana Big Sky Rx • New Jersey - New Jersey Pharmaceutical Assistance To The Aged & Disabled (PAAD) • Nevada - Nevada Senior/Disability Rx Program • New York - New York State EPIC Program • Pennsylvania - Pennsylvania PACE • Rhode Island - Rhode Island Office of Healthy Aging • Texas - Texas HIV State Pharmaceutical Assistance Program (SPAP)

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 56 • Virginia - Virginia Medication Assistance Program (MAP) • Virgin Islands of the U.S. - US Virgin Islands Pharmaceutical Assistance Program • Vermont - Green Mountain Care Prescription Assistance • Wisconsin - Wisconsin SeniorCare Pharmaceutical Assistance Program State Pharmaceutical Assistance Programs – Contact Information California | Department of Health Services - ADAP 1-844-421-7050 Insurance Assistance Section, P.O. Box 997426, MS 7704 TTY 711 Sacramento, CA 95899-7426 8 a.m.-5 p.m. local time, https://www.cdph.ca.gov/Programs/CID/DOA/Pages/ Monday-Friday OA_adap_medpartd.aspx Colorado | Colorado Department of Health Care Policy & 1-800-221-3943 Financing TTY 711 1570 Grant ST Denver, CO 80103-1818 9 a.m.-5 p.m. local time, https://www.colorado.gov/hcpf/contact-hcpf Monday-Friday Connecticut | Connecticut AIDS Drug Assistance Program 1-800-424-3310 (CADAP) TTY 711 c/o Magellan Health, 15 Cornell RD, STE 2201 Lathan, NY 12110 8 a.m.-4 p.m. local time, https://ctdph.magellanrx.com/ Monday-Friday District of Columbia | District of Columbia Department of 1-202-671-4900 Health TTY 711 AIDS Drug Assistance Program (ADAP) 899 N Capitol ST NE 8:15 a.m. - 4:45 p.m. local Washington, DC 20002 time, Monday - Friday https://dchealth.dc.gov/node/137072 Delaware | Delaware Prescription Assistance Program 1-800-996-9969 DHSS Herman Holloway Campus, Lewis Building 1901 N. DuPont TTY 711 Highway New Castle, DE 19720 8 a.m.-4:30 p.m. local https://dhss.delaware.gov/dhss/dmma/dpap.html time, Monday-Friday Guam | Guam Medically Indigent Program (MIP) 1-671-635-7432 RAN-Care Commercial Building, CNU #207 761 South Marine TTY 711 Corps Drive Tamuning, GU 96913 8 a.m.-5 p.m. local time, http://dphss.guam.gov/bureau-of-economic-security/ Monday-Friday Idaho | Idaho AIDS Drug Assistance Program (IDADAP) 1-208-334-6657 450 W State ST, P.O. Box 83720 Boise, ID 83720-0036 TTY 711 http://www.healthandwelfare.idaho.gov/Health/ 8 a.m.-5 p.m. local time, HIV,STD,HepatitisPrograms/HIVCare/tabid/391/Default.aspx Monday-Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 57 State Pharmaceutical Assistance Programs – Contact Information Indiana | HoosierRx 1-866-267-4679 P.O. Box 6224 Indianapolis, IN 49206 TTY 711 https://www.in.gov/medicaid/members/194.htm 8 a.m.-4:30 p.m. local time, Monday-Friday Louisiana | Louisiana Department of Health 1-888-342-6207 Medicare Savings Program, P.O. Box 629 Baton Rouge, LA 70802 TTY 1-800-220-5404 http://dhh.louisiana.gov/index.cfm/page/236 8 a.m.-4:30 p.m. local time, Monday-Friday Massachusetts | Prescription Advantage Executive Office of 1-800-243-4636 Elder Affairs TTY 1-877-610-0241 P.O. Box 15153 Worcester, MA 01615-0153 9 a.m.-5 p.m. local time, https://www.prescriptionadvantagema.org/ Monday-Friday Maryland | Maryland Senior Prescription Drug Assistance 1-800-551-5995 Program (SPDAP) TTY 1-800-877-5156 c/o International Software Systems Inc. PO Box 749 Greenbriar, 8 a.m.-5 p.m. local time, MD 20768-0749 Monday-Friday www.marylandspdap.com Maine | Office of MaineCare Services 1-800-977-6740 109 Capitol ST 11 State House Station Augusta, ME 04333-0011 TTY 711 https://www.maine.gov/dhhs/oms 7 a.m.-6 p.m. local time, Monday-Friday Missouri | MissouriRx Plan (MORx) 1-800-392-2161 615 Howerton CT P.O. Box 6500 Jefferson City, MO 65102-6500 TTY 711 https://dss.mo.gov/mhd/faq/pages/faqmo_rx.htm 8 a.m.-5 p.m. local time, Monday-Friday Montana | Montana Big Sky Rx 1-866-369-1233 P.O. Box 202915 Helena, MT 59620-2915 TTY 711 www.bigskyrx.mt.gov 8 a.m.-5 p.m. local time, Monday-Friday New Jersey | New Jersey Pharmaceutical Assistance To The 1-800-792-9745 Aged & Disabled (PAAD) TTY 711 P.O. Box 715 Trenton, NJ 08625-0715 8:30 a.m.-4:30 p.m. local http://www.state.nj.us/humanservices/doas/paad/ time, Monday-Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 58 State Pharmaceutical Assistance Programs – Contact Information Nevada | Nevada Senior/Disability Rx Program 1-866-303-6323 1860 E Sahara AVE Las Vegas, NV 89104 TTY 711 http://adsd.nv.gov/Programs/Seniors/SeniorRx/SrRxProg/ 8 a.m.-5 p.m. local time, Monday-Friday New York | New York State EPIC Program 1-800-332-3742 P.O. Box 15018 Albany, NY 12212-5018 TTY 1-800-290-9138 http://www.health.ny.gov/health_care/epic/ 8:30 a.m.-5 p.m. local time, Monday-Friday Pennsylvania | Pennsylvania PACE 1-800-225-7223 P.O. Box 8806 Harrisburg, PA 17105-8806 TTY 1-800-222-9004 https://pacecares.magellanhealth.com 8:30 a.m.-5 p.m. local time, Monday-Friday Rhode Island | Rhode Island Office of Healthy Aging 1-401-462-0560 25 Howard AVE, BLDG 57 Cranston, RI 02920 TTY 1-401-462-0740 https://oha.ri.gov/what-we-do/access/health-insurance-coaching/ 8:30 a.m.-4 p.m. local drug-cost-assistance time, Monday-Friday Texas | Texas HIV State Pharmaceutical Assistance Program 1-800-255-1090 (SPAP) TTY 711 P.O. Box 149347, MC 1873 Austin, TX 78714 8 a.m.-5 p.m. local time, https://www.dshs.state.tx.us/hivstd/meds/spap.shtm Monday-Friday Virginia | Virginia Medication Assistance Program (MAP) 1-855-362-0658 P.O. Box 2448 Richmond, VA 23218-2448 TTY 711 https://www.vdh.virginia.gov/disease-prevention/vamap/ 8 a.m.-5 p.m. local time, Monday-Friday Virgin Islands of the U.S. | US Virgin Islands Pharmaceutical 1-340-774-0930 Assistance Program TTY 711 1303 Hospital Ground, Knud Hansen Complex, BLDG A St. Thomas, VI 00802 http://www.dhs.gov.vi/seniors/pharmaceutical.html Vermont | Green Mountain Care Prescription Assistance 1-800-250-8427 Department of Vermont Health Access, 280 State DR Waterbury, TTY 711 VT 05671-1020 8 a.m.-5 p.m. local time, https://dvha.vermont.gov/members/prescription-assistance Monday-Friday

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 59 State Pharmaceutical Assistance Programs – Contact Information Wisconsin | Wisconsin SeniorCare Pharmaceutical Assistance 1-800-657-2038 Program TTY 711 Department of Health Services, 1 W Wilson ST, P.O. Box 6710 8 a.m.-6 p.m. local time, Madison, WI 53716-0710 Monday-Friday http://www.dhs.wisconsin.gov/seniorcare Section 8 How to contact the Railroad Retirement Board The Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit programs for the nation’s railroad workers and their families. If you receive your Medicare through the Railroad Retirement Board, it is important that you let them know if you move or change your mailing address. If you have questions regarding your benefits from the Railroad Retirement Board, contact the agency. Method Railroad Retirement Board – Contact Information Call 1-877-772-5772 Calls to this number are free. If you press “0,” you may speak with an RRB representative from 9:00 am to 3:30 pm, Monday, Tuesday, Thursday, and Friday, and from 9:00 am to 12:00 pm on Wednesday. If you press “1”, you may access the automated RRB HelpLine and recorded information 24 hours a day, including weekends and holidays. TTY 1-312-751-4701 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are not free. Website rrb.gov/ Section 9 Do you have “group insurance” or other health insurance from an employer? If you (or your spouse or domestic partner) have medical or prescription drug coverage through another employer or retiree group, please contact that group’s benefits administrator. The benefits administrator can help you determine how your current coverage will work with our plan. You can also call Customer Service if you have any questions. You can ask about your (or your

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 2: Important phone numbers and resources 60 spouse or domestic partner’s) employer or retiree health benefits, premiums, or the enrollment period.

Chapter 3 Chapter 3: Using the plan for your medical services

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 62 Section 1 Things to know about getting your medical care as a member of our plan This chapter explains what you need to know about using the plan to get your medical care covered. It gives definitions of terms and explains the rules you will need to follow to get the medical treatments, services, equipment, prescription drugs, and other medical care that are covered by the plan. Because you are a member of the UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) plan, you can see any provider (network or out-of-network) at the same cost share, as long as they accept the plan and have not opted out of or been excluded or precluded from the Medicare Program. For the details on what medical care is covered by our plan and how much you pay when you get this care, use the benefits chart in the next chapter, Chapter 4 (Medical Benefits Chart, what is covered and what you pay). Section 1.1 What are “network providers” and “covered services”? · “Providers” are doctors and other health care professionals licensed by the state to provide medical services and care. The term “providers” also includes hospitals and other health care facilities. · “Network providers” are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment and your cost-sharing amount as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The providers in our network bill us directly for care they give you. When you see a network provider, you pay only your share of the cost for their services. · “Covered services” include all the medical care, health care services, supplies, equipment, and prescription drugs that are covered by our plan. Your covered services for medical care are listed in the benefits chart in Chapter 4. Your covered services for prescription drugs are discussed in Chapter 5. Section 1.2 Basic rules for getting your medical care covered by the plan As a Medicare health plan, UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) must cover all services covered by Original Medicare and must follow Original Medicare’s coverage rules. The plan will generally cover your medical care as long as: · The care you receive is included in the plan’s Medical Benefits Chart (this chart is in Chapter 4 of this document). · The care you receive is considered medically necessary. “Medically necessary” means that the services, supplies, equipment, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 63 · You receive your care from a provider who is eligible to provide services under Original Medicare. As a member of our plan, you can receive your care from either a network provider or an out-of-network provider (for more about this, see Section 2 in this chapter). - The providers in our network are listed in the Provider Directory. - Please note: While you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has opted out of or been excluded or precluded from the Medicare Program. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare. Section 2 Using network and out-of-network providers to get your medical care As a member of the UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) plan, you may see doctors and other health care professionals, medical groups, hospitals, and other health care facilities that are not contracted with UnitedHealthcare, as long as they accept the plan and have not opted out of or been excluded or precluded from the Medicare Program, and as long as the services are covered benefits and are medically necessary. Unlike most PPO plans, with this plan you pay the same cost share in-network and out-of-network. Section 2.1 How to get care from specialists and other network providers A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples: · Oncologists care for patients with cancer. · Cardiologists care for patients with heart conditions. · Orthopedists care for patients with certain bone, joint, or muscle conditions. How to access your behavioral/mental health benefit To directly access your behavioral/mental health benefits, please call the number on your UnitedHealthcare member ID card 24 hours a day, 7 days a week. When you call, you will speak with a representative who will check your eligibility and gather basic information about you and your situation. Depending on the help you need, a clinician may then talk with you about the problem you are experiencing and assess which provider and treatment would be appropriate for your situation. You may also ask your Primary Care Provider (PCP) to call the number on your UnitedHealthcare member ID card and arrange a referral on your behalf. You may also call to receive information about network practitioners, subspecialty care and obtaining care after normal office hours. Confidentiality is maintained, so please be assured that personal information you discuss with their staff will be kept strictly confidential.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 64 What if a specialist or another network provider leaves our plan? It is important that you know that we may make changes to the hospitals, doctors, and specialists (providers) that are part of your plan during the year. If this happens, you may continue to see the provider as long as he/she continues to accept the plan and has not opted out of or been excluded or precluded from the Medicare Program, and the care you receive is a covered service and is medically necessary. Even though our network of providers may change during the year, Medicare requires that we furnish you with uninterrupted access to qualified doctors and specialists. When possible, we will provide you with at least 30 days’ notice that your network provider is leaving our plan. You may call Customer Service for assistance at the number listed in Chapter 2 of this booklet. Some services require prior authorization from the plan in order to be covered. Obtaining prior authorization is the responsibility of the PCP or treating provider. Services and items requiring prior authorization are listed in Medical Benefits Chart in Chapter 4, Section 2.1. Section 2.2 How to get care from out-of-network providers As a member of our plan, you can choose to receive care from out-of-network providers. However, please note providers that do not contract with us are under no obligation to treat you, except in emergency situations. Our plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. Because you are a member of the UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) plan, you can see any provider (network or out-of-network) that accepts the plan and has not opted out of or been excluded or precluded from the Medicare Program, at the same cost share. Here are other important things to know about using out-of-network providers: · You can get your care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has opted out of or been excluded or precluded from the Medicare Program. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. Check with your provider before receiving services to confirm that they are eligible to participate in Medicare. · You don’t need to get a referral or prior authorization when you get care from out-of-network providers. However, before getting services from out-of-network providers you may want to ask for a pre-visit coverage decision to confirm that the services you are getting are covered and are medically necessary. (See Chapter 9, Section 4 for information about asking for coverage decisions.) This is important because: - Without a pre-visit coverage decision, if we later determine that the services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the entire cost. If we say we will not cover your services, you have the right to appeal our decision not to cover your care. See Chapter 9 (What to do if you have a problem or complaint) to learn how to make an appeal. · It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends you a bill that you think we should pay, you can send it to us

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 65 for payment. See Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs) for information about what to do if you receive a bill or if you need to ask for reimbursement. Section 3 How to get services when you have an emergency or urgent need for care or during a disaster Section 3.1 Getting care if you have a medical emergency What is a “medical emergency” and what should you do if you have one? A “medical emergency” is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent your loss of life (and, if you are a pregnant woman, loss of an unborn child), loss of a limb or function of a limb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. If you have a medical emergency: · Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to use a network doctor. You may get covered emergency medical care whenever you need it, anywhere in the world. What is covered if you have a medical emergency? Our plan covers ambulance services in situations where getting to the emergency room in any other way could endanger your health. We also cover medical services during the emergency. The doctors who are giving you emergency care will decide when your condition is stable and the medical emergency is over. After the emergency is over you are entitled to follow-up care to be sure your condition continues to be stable. Your doctors will continue to treat you until your doctors contact us and make plans for additional care. Your follow-up care will be covered by our plan. What if it wasn’t a medical emergency? Sometimes it can be hard to know if you have a medical emergency. For example, you might go in for emergency care – thinking that your health is in serious danger – and the doctor may say that it wasn’t a medical emergency after all. If it turns out that it was not an emergency, as long as you reasonably thought your health was in serious danger, we will cover your care. Section 3.2 Getting care when you have an urgent need for services What are “urgently needed services”? An urgently needed service is a non-emergency situation requiring immediate medical care but, given your circumstances, it is not possible or not reasonable to obtain these services from a network provider. The plan must cover urgently needed services provided out-of-network. Some examples of urgently needed services are i) a severe sore throat that occurs over the weekend or ii) an unforeseen flare-up of a known condition when you are temporarily outside the service area.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 66 Our plan covers worldwide emergency and urgently needed services outside the United States under the following circumstances: emergency services, including emergency or urgently needed care and emergency ambulance transportation from the scene of an emergency to the nearest medical treatment facility. Transportation back to the United States from another country is not covered. Pre-scheduled and/or elective procedures are not covered. Section 3.3 Getting care during a disaster If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan. Please visit the following website: uhc.com/disaster-relief-info or contact Customer Service for information on how to obtain needed care during a disaster. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy. Please see Chapter 5, Section 2.5 for more information. Section 4 What if you are billed directly for the full cost of your services? Section 4.1 You can ask us to pay our share of the cost of covered services If you have paid more than your plan cost-sharing for covered services, or if you have received a bill for the full cost of covered medical services, go to Chapter 7 (Asking us to pay our share of a bill you have received for covered medical services or drugs) for information about what to do. Section 4.2 If services are not covered by our plan, you must pay the full cost Our plan covers all medically necessary services as listed in the Medical Benefits Chart in Chapter 4 of this document. If you receive services not covered by our plan, you are responsible for paying the full cost of services. For covered services that have a benefit limitation, you also pay the full cost of any services you get after you have used up your benefit for that type of covered service. For example, if your plan covers one routine physical exam per year and you receive that routine physical but choose to have a second routine physical within the same year, you pay the full cost of the second routine physical. Any amounts that you pay after you have reached the benefit limitation do not count toward your annual out-of-pocket maximum. (See Chapter 4 for more information on your plan’s out-of-pocket maximum.) Section 5 How are your medical services covered when you are in a “clinical research study”? Section 5.1 What is a “clinical research study”?

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 67 A clinical research study (also called a “clinical trial”) is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. Certain clinical research studies are approved by Medicare. Clinical research studies approved by Medicare typically request volunteers to participate in the study. Once Medicare approves the study, and you express interest, someone who works on the study will contact you to explain more about the study and see if you meet the requirements set by the scientists who are running the study. You can participate in the study as long as you meet the requirements for the study and you have a full understanding and acceptance of what is involved if you participate in the study. If you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services you receive as part of the study. If you tell us that you are in a qualified clinical trial, then you are only responsible for in-network cost-sharing for the services in that trial. If you paid more, for example, if you already paid the Original Medicare cost-sharing amount, we will reimburse the difference between what you paid and the in-network cost-sharing. However, you will need to provide documentation to show us how much you paid. When you are in a clinical research study, you may stay enrolled in our plan and continue to get the rest of your care (the care that is not related to the study) through our plan. Note: If you are not entitled to Medicare Part A coverage, neither Medicare nor the plan will pay the Part A costs related to a Medicare-covered clinical research study. If you want to participate in any Medicare-approved clinical research study, you do not need to tell us or get approval from us. The providers that deliver your care as part of the clinical research study do not need to be part of our plan’s network of providers. Please note that this does not include benefits for which our plan is responsible that include, as a component, a clinical trial or registry to assess the benefit. These include certain benefits specified under national coverage determinations (NCDs) and investigational device trials (IDE) and may be subject to prior authorization and other plan rules. Although you do not need to get our plan’s permission to be in a clinical research study, covered for Medicare Advantage enrollees by Original Medicare, we encourage you to notify us in advance when you choose to participate in Medicare-qualified clinical trials. If you participate in a study that Medicare has not approved you will be responsible for paying all costs for your participation in the study. Section 5.2 When you participate in a clinical research study, who pays for what? Once you join a Medicare-approved clinical research study, Original Medicare covers the routine items and services you receive as part of the study, including: · Room and board for a hospital stay that Medicare would pay for even if you weren’t in a study. · An operation or other medical procedure if it is part of the research study. · Treatment of side effects and complications of the new care. Note: If you are not entitled to Medicare Part A coverage, neither Medicare nor the plan will pay the Part A related costs related to a Medicare-covered clinical research study.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 68 After Medicare has paid its share of the cost for these services, our plan will pay the difference between the cost-sharing in Original Medicare and your in-network cost-sharing as a member of our plan. This means you will pay the same amount for the services you receive as part of the study as you would if you received these services from our plan. However, you are required to submit documentation showing how much cost-sharing you paid. Please see Chapter 7 for more information for submitting requests for payments. Here’s an example of how the cost-sharing works: Let’s say that you have a lab test that costs $100 as part of the research study. Let’s also say that your share of the costs for this test is $20 under Original Medicare, but the test would be $10 under our plan’s benefits. In this case, Original Medicare would pay $80 for the test and you would pay the $20 copay required under Original Medicare. You would then notify your plan that you received a qualified clinical trial service and submit documentation such as a provider bill to the plan. The plan would then directly pay you $10. Therefore, your net payment is $10, the same amount you would pay under our plan’s benefits. Please note that in order to receive payment from your plan, you must submit documentation to your plan such as a provider bill. When you are part of a clinical research study, neither Medicare nor our plan will pay for any of the following: · Generally, Medicare will not pay for the new item or service that the study is testing unless Medicare would cover the item or service even if you were not in a study. · Items or services provided only to collect data, and not used in your direct health care. For example, Medicare would not pay for monthly CT scans done as part of the study if your medical condition would normally require only one CT scan. Do you want to know more? You can get more information about joining a clinical research study by visiting the Medicare website to read or download the publication “Medicare and Clinical Research Studies.” (The publication is available at: medicare.gov/Pubs/pdf/02226-Medicare-and-Clinical-Research- Studies.pdf. ) You can also call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Section 6 Rules for getting care in a “religious non-medical health care institution” Section 6.1 What is a religious non-medical health care institution? A religious non-medical health care institution is a facility that provides care for a condition that would ordinarily be treated in a hospital or skilled nursing facility. If getting care in a hospital or a skilled nursing facility is against a member’s religious beliefs, we will instead provide coverage for care in a religious non-medical health care institution. This benefit is provided only for Part A inpatient services (non-medical health care services). Section 6.2 Receiving care from a religious non-medical health care institution

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 69 To get care from a religious non-medical health care institution, you must sign a legal document that says you are conscientiously opposed to getting medical treatment that is “non-excepted.” · “Non-excepted” medical care or treatment is any medical care or treatment that is voluntary and not required by any federal, state, or local law. · “Excepted” medical treatment is medical care or treatment that you get that is not voluntary or is required under federal, state, or local law. To be covered by our plan, the care you get from a religious non-medical health care institution must meet the following conditions: · The facility providing the care must be certified by Medicare. · Our plan’s coverage of services you receive is limited to non-religious aspects of care. · If you get services from this institution that are provided to you in a facility, the following conditions apply: - You must have a medical condition that would allow you to receive covered services for inpatient hospital care or skilled nursing facility care. - and – you must get approval in advance from our plan before you are admitted to the facility or your stay will not be covered. You are covered for unlimited days in the hospital, as long as your stay meets Medicare coverage guidelines. The coverage limits are described under inpatient hospital care in the medical benefits chart in Chapter 4. Section 7 Rules for ownership of durable medical equipment Section 7.1 Will you own the durable medical equipment after making a certain number of payments under our plan? Durable medical equipment (DME) includes items such as oxygen equipment and supplies, wheelchairs, walkers, powered mattress systems, crutches, diabetic supplies, speech generating devices, IV infusion pumps, nebulizers, and hospital beds ordered by a provider for use in the home. The member always owns certain items, such as prosthetics. In this section, we discuss other types of DME that you must rent. In Original Medicare, people who rent certain types of DME own the equipment after paying copayments for the item for 13 months. As a member of our plan, however, you usually will not acquire ownership of rented DME items no matter how many copayments you make for the item while a member of our plan, even if you made up to 12 consecutive payments for the DME item under Original Medicare before you joined our plan. Under certain limited circumstances we will transfer ownership of the durable medical equipment item. Call Customer Service for more information. What happens to payments you made for durable medical equipment if you switch to Original Medicare? If you did not acquire ownership of the DME item while in our plan, you will have to make 13 new consecutive payments after you switch to Original Medicare in order to own the item. The payments made while enrolled in your plan do not count.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 3: Using the plan for your medical services 70 Example 1: You made 12 or fewer consecutive payments for the item in Original Medicare and then joined our plan. The payments you made in Original Medicare do not count. Example 2: You made 12 or fewer consecutive payments for the item in Original Medicare and then joined our plan. You were in our plan but did not obtain ownership while in our plan. You then go back to Original Medicare. You will have to make 13 consecutive new payments to own the item once you join Original Medicare again. All previous payments (whether to our plan or to Original Medicare) do not count. Section 7.2 Rules for oxygen equipment, supplies, and maintenance What oxygen benefits are you entitled to? If you qualify for Medicare oxygen equipment coverage our plan will cover: · Rental of oxygen equipment · Delivery of oxygen and oxygen contents · Tubing and related oxygen accessories for the delivery of oxygen and oxygen contents · Maintenance and repairs of oxygen equipment If you leave our plan or no longer medically require oxygen equipment, then the oxygen equipment must be returned. What happens if you leave your plan and return to Original Medicare? Original Medicare requires an oxygen supplier to provide you services for five years. During the first 36 months you rent the equipment. The remaining 24 months the supplier provides the equipment and maintenance (you are still responsible for the copayment for oxygen). After five years you may choose to stay with the same company or go to another company. At this point, the five-year cycle begins again, even if you remain with the same company, requiring you to pay copayments for the first 36 months. If you join or leave our plan, the five-year cycle starts over.

Chapter 4 Chapter 4: Medical Benefits Chart (what is covered and what you pay)

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 72 Section 1 Understanding your out-of-pocket costs for covered services This chapter provides a medical benefits chart that lists your covered services and shows how much you will pay for each covered service as a member of UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO). Later in this chapter, you can find information about medical services that are not covered. It also explains limits on certain services. Section 1.1 Types of out-of-pocket costs you may pay for your covered services To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. · A “copayment” is the fixed amount you pay each time you receive certain medical services. You pay a copayment at the time you get the medical service. (The medical benefits chart in Section 2 tells you more about your copayments.) · “Coinsurance” is the percentage you pay of the total cost of certain medical services. You pay a coinsurance at the time you get the medical service. (The medical benefits chart in Section 2 tells you more about your coinsurance.) Most people who qualify for Medicaid or for the Qualified Medicare Beneficiary (QMB) program should never pay deductibles, copayments or coinsurance for Medicare-covered services. Be sure to show your proof of Medicaid or QMB eligibility to your provider, if applicable. Section 1.2 What is the most you will pay for Medicare Part A and Part B covered medical services? · Your combined maximum out-of-pocket amount is $500. This is the most you pay during the plan year for covered Medicare Part A and Part B services received from both in-network and out-of-network providers. The amounts you pay for copayments and coinsurance for covered services count toward this combined maximum out-of-pocket amount. The amounts your plan sponsor pays for your plan premiums and the amounts you pay for your Part D prescription drugs do not count toward your combined maximum out-of-pocket amount. In addition, amounts you pay for some services do not count toward your combined maximum out-of- pocket amount. These services are marked with an asterisk in the medical benefits chart. If you have paid $500 for covered services, you will have 100% coverage and will not have any out-of- pocket costs for the rest of the plan year for Part A and Part B services. However, you must continue to pay the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party). Section 1.3 Our plan does not allow providers to “balance bill” you As a member of UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO), an important protection for you is that you only have to pay your cost-sharing amount when you get services covered by our plan and Original Medicare. Providers may not add additional separate charges, called “balance billing.” This protection applies even if we pay the provider less than the

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 73 provider charges for a service and even if there is a dispute and we don’t pay certain provider charges. Here is how this protection works. · If your cost-sharing is a copayment (a set amount of dollars, for example, $15.00) then you pay only that amount for any covered services from a network provider. · If your cost-sharing is a coinsurance (a percentage of the total charges), then you never pay more than that percentage. However, your cost depends on which type of provider you see: - If you receive the covered services from a network provider, you pay the coinsurance percentage multiplied by the plan’s reimbursement rate (as determined in the contract between the provider and the plan). - If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers. - If you receive the covered services from an out-of-network provider who does not participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers. · If you believe a provider has “balance billed” you, call Customer Service. Section 2 Use the medical benefits chart to find out what is covered and how much you will pay Section 2.1 Your medical benefits and costs as a member of the plan The medical benefits chart on the following pages lists the services UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) covers and what you pay out-of-pocket for each service. Part D prescription drug coverage is covered in Chapter 5. The services listed in the medical benefits chart are covered only when the following coverage requirements are met: · Your Medicare-covered services must be provided according to the coverage guidelines established by Medicare. · Your services (including medical care, services, supplies, equipment, and Part B prescription drugs) must be medically necessary. “Medically necessary” means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. · Some of the in-network services listed in the medical benefits chart are covered only if your doctor or other network provider gets approval in advance (sometimes called “prior authorization”) from us. - Covered services that may need approval in advance to be covered as in-network services †† are marked by a double dagger ( ) in the medical benefits chart. - Network providers agree by contract to obtain prior authorization from the plan and agree to not balance bill you. - You never need approval in advance for out-of-network services from out-of-network providers.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 74 - While you don’t need approval in advance for out-of-network services, you or your doctor can ask us to make a coverage decision in advance. Other important things to know about our coverage: · For benefits where your cost-sharing is a coinsurance percentage, the amount you pay depends on what type of provider you receive the services from: If you receive the covered services from a network provider, you pay the coinsurance - percentage multiplied by the plan’s reimbursement rate (as determined in the contract between the provider and the plan). - If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers. - If you receive the covered services from an out-of-network provider who does not participate with Medicare, you pay the coinsurance percentage multiplied by the Original Medicare Limiting Charge. · Like all Medicare health plans, we cover everything that Original Medicare covers. For some of these benefits, you pay more in our plan than you would in Original Medicare. For others, you pay less. (If you want to know more about the coverage and costs of Original Medicare, look in your Medicare & You 2024 handbook. View it online at medicare.gov or ask for a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.) · For all Preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you. However, if you also are treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care received for the existing medical condition. See the medical benefits chart for information about your share of the out-of-network costs for these services. · If Medicare adds coverage for any new services during 2024, either Medicare or our plan will cover those services. You will see this apple next to the Preventive services in the benefits chart. Medically Necessary - means health care services, supplies, or drugs needed for the prevention, diagnosis, or treatment of your sickness, injury or illness that are all of the following as determined by us or our designee, within our sole discretion: · In accordance with Generally accepted standards of medical practice. · Most appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, or illness. · Not mainly for your convenience or that of your doctor or other health care provider. · Meet, but do not exceed your medical need, are at least as beneficial as an existing and available medically appropriate alternative, and are furnished in the most cost-effective manner that may be provided safely and effectively. Generally accepted standards of medical practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 75 relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes. If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. We reserve the right to consult expert opinion in determining whether health care services are Medically Necessary. The decision to apply Physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within our sole discretion.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 76 Medical Benefits Chart Services that are covered for you What you must pay when you get these services in-network and out-of-network Providers may ask you for more than one cost share payment if you get more than one service at an appointment. For example: · Your doctor will ask for a copayment for the office visit and additional copayments for each x-ray that is performed while you are there. · Your hospital will ask for separate cost-sharing for outpatient hospital medical services and any radiological tests or Medicare Part B drugs administered while you are there. · Your pharmacist will ask for a separate copayment for each prescription he or she fills. · The specific cost-sharing that will apply depends on which services you receive. The Medical benefits chart below lists the cost-sharing that applies for each specific service. There is no coinsurance, Abdominal aortic aneurysm screening copayment, or deductible for A one-time (once per lifetime) screening ultrasound for members eligible for this people at risk. The plan only covers this screening if you preventive screening. have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 77 Services that are covered for you What you must pay when you get these services in-network and out-of-network Acupuncture for chronic low back pain $0 copayment for each Covered services include: Medicare-covered visit. Up to 12 visits in 90 days performed by, or under the supervision of a physician (or other medical provider as described below) are covered for Medicare beneficiaries under the following circumstances: For the purpose of this benefit, chronic low back pain is defined as: · Lasting 12 weeks or longer; · nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious disease, etc.); · not associated with surgery; and · not associated with pregnancy. An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing. Generally, Medicare-covered acupuncture services are not covered when provided by an acupuncturist or chiropractor. Provider Requirements: Physicians (as defined in 1861(r)(1) of the Social Security Act (the Act) may furnish acupuncture in accordance with applicable state requirements. Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa)(5) of the Act), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have: · a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 78 Services that are covered for you What you must pay when you get these services in-network and out-of-network Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and, · a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia. · Benefit is not covered when solely provided by an independent acupuncturist. Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS as required by Medicare. Acupuncture services performed by providers that do not meet CMS acupuncture provider requirements are not covered even in locations where there are no providers available that meet CMS requirements. Routine acupuncture services‡ $0 copayment for each visit. Includes 24 visits per plan year. Benefit is combined in and out- of-network. Please turn to Section 4 Routine acupuncture services of this chapter for more details about this benefit. Ambulance services $0 copayment for each one- Covered ambulance services, whether for an emergency or way Medicare-covered trip. non-emergency situation, include fixed wing, rotary wing, Authorization is not required for and ground ambulance services, to the nearest appropriate non-emergency Medicare- facility that can provide care only if they are furnished to a covered ambulance ground member whose medical condition is such that other means transportation. of transportation could endanger the person’s health or if Authorization is required for authorized by the plan. If the covered ambulance services non-emergency Medicare- are not for an emergency situation, it should be documented covered ambulance air that the member’s condition is such that other means of transportation.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 79 Services that are covered for you What you must pay when you get these services in-network and out-of-network transportation could endanger the person’s health and that Emergency ambulance does transportation by ambulance is medically required. not require authorization. Annual routine physical exam $0 copayment for a routine Includes comprehensive physical examination and physical exam each year. evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit, as described for each separate service in this Medical Benefits Chart. Benefit is combined in and out-of-network. Annual wellness visit There is no coinsurance, copayment, or deductible for If you’ve had Part B for longer than 12 months, you can get the annual wellness visit. an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. You don’t have to wait a full year to get your annual wellness visit, you can get it once every calendar year. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit, as described for each separate service in this Medical Benefits Chart. Note: Your first annual wellness visit can’t take place within 12 months of your Welcome to Medicare preventive visit. However, you don’t need to have had a Welcome to Medicare visit to be covered for annual wellness visits after you’ve had Part B for 12 months.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 80 Services that are covered for you What you must pay when you get these services in-network and out-of-network There is no coinsurance, Bone mass measurement copayment, or deductible for For qualified individuals (generally, this means people at risk Medicare-covered bone mass of losing bone mass or at risk of osteoporosis), the following measurement. services are covered every 24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician’s interpretation of the results. There is no coinsurance, Breast cancer screening (mammograms) copayment, or deductible for Covered services include: covered screening · One baseline mammogram between the ages of 35 and mammograms. 39 · One screening mammogram every 12 months for women age 40 and older · Clinical breast exams once every 24 months Cardiac rehabilitation services $0 copayment for each Comprehensive programs of cardiac rehabilitation services Medicare-covered cardiac rehabilitative visit.†† that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s order. Intensive cardiac rehabilitation services $0 copayment for each The plan covers intensive cardiac rehabilitation programs Medicare-covered intensive cardiac rehabilitative visit.†† that are typically more rigorous or more intense than cardiac rehabilitation programs.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 81 Services that are covered for you What you must pay when you get these services in-network and out-of-network There is no coinsurance, Cardiovascular disease risk reduction visit (therapy for cardiovascular disease) copayment, or deductible for We cover one visit per year with your primary care doctor to the cardiovascular disease help lower your risk for cardiovascular disease. During this preventive benefit. visit, your doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you’re eating healthy. There is no coinsurance, Cardiovascular disease testing copayment, or deductible for Blood tests for the detection of cardiovascular disease (or cardiovascular disease testing abnormalities associated with an elevated risk of that is covered once every five cardiovascular disease) covered once every 5 years (60 years. months). There is no coinsurance, Cervical and vaginal cancer screening copayment, or deductible for Covered services include: Medicare-covered preventive · For all women: Pap tests and pelvic exams are covered Pap and pelvic exams. once every 24 months · If you are at high risk of cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test within the past 3 years: one Pap test every 12 months · For asymptomatic women between the ages of 30 and 65: HPV testing once every 5 years, in conjunction with the Pap test Chiropractic services $0 copayment for each Medicare-covered visit.†† Covered services include: · Manual manipulation of the spine to correct subluxation (when one or more of the bones of your spine move out of position). Manual manipulation is a treatment that

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 82 Services that are covered for you What you must pay when you get these services in-network and out-of-network uses hands-on pressure to gently move your joints and tissues. Excluded from Medicare coverage is any service other than manual manipulation for the treatment of subluxation, including: · Maintenance therapy. Chiropractic treatment is considered maintenance therapy when continuous ongoing care is no longer expected to provide clinical improvements and the treatment becomes supportive instead of corrective. · Extra charges when your chiropractor uses a manual, hand-held device to add controlled pressure during treatment. · X-rays, massage therapy, and acupuncture (unless the acupuncture is for the treatment of chronic low back pain). Routine chiropractic services‡ $0 copayment for each visit* Includes 24 visits per plan year. Please turn to Section 4 Routine chiropractic services of this chapter for more detailed information about this chiropractic benefit. There is no coinsurance, Colorectal cancer screening copayment, or deductible for a The following screening tests are covered: Medicare-covered colorectal · Colonoscopy has no minimum or maximum age cancer screening exam, limitation and is covered once every 120 months (10 excluding barium enemas, and years) for patients not at high risk, or 48 months after a colonoscopy. previous flexible sigmoidoscopy for patients who are There is no coinsurance, not at high risk for colorectal cancer, and once every 24 copayment, or deductible for

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 83 Services that are covered for you What you must pay when you get these services in-network and out-of-network months for high risk patients after a previous screening each Medicare-covered barium colonoscopy or barium enema. enema. · Flexible sigmoidoscopy for patients 45 years and older. If you have a prior history of Once every 120 months for patients not at high risk colon cancer, or have had after the patient received a screening colonoscopy. polyps removed during a Once every 48 months for high risk patients from the previous colonoscopy, ongoing last flexible sigmoidoscopy or barium enema. colonoscopies are considered · Screening fecal-occult blood tests for patients 45 years diagnostic and are subject to and older. Once every 12 months. cost-sharing as described under · Multitarget stool DNA for patients 45 to 85 years of age the outpatient surgery cost- and not meeting high risk criteria. Once every 3 years. sharing in this chart. Therefore, the screening colonoscopy · Blood-based Biomarker Tests for patients 45 to 85 benefit is not available for years of age and not meeting high risk criteria. Once members who have signs or every 3 years. symptoms prior to the · Barium Enema as an alternative to colonoscopy for colonoscopy. patients at high risk and 24 months since the last A colonoscopy or screening barium enema or the last screening sigmoidoscopy conducted for colonoscopy. polyp removal or biopsy is a · Barium Enema as an alternative to flexible surgical procedure subject to sigmoidoscopy for patient not at high risk and 45 years the outpatient surgery cost- or older. Once at least 48 months following the last sharing described later in this screening barium enema or screening flexible chart. sigmoidoscopy. Colorectal cancer screening tests include a follow-up screening colonoscopy after a Medicare covered non- invasive stool-based colorectal cancer screening test returns a positive result. Outpatient diagnostic colonoscopy There is no copayment, coinsurance or deductible for each Medicare-covered diagnostic colonoscopy.††

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 84 Services that are covered for you What you must pay when you get these services in-network and out-of-network There is no coinsurance, Depression screening copayment, or deductible for an We cover one screening for depression per year. The annual depression screening screening must be done in a primary care setting that can visit. provide follow-up treatment and/or referrals. There is no coinsurance, Diabetes screening copayment, or deductible for We cover this screening (includes fasting glucose tests) if the Medicare-covered diabetes you have any of the following risk factors: high blood screening tests. pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes. Based on the results of these tests, you may be eligible for up to two diabetes screenings every plan year. Diabetes self-management training, diabetic services and supplies For all people who have diabetes (insulin and non-insulin users). Covered services include: · Supplies to monitor your blood glucose: blood glucose $0 copayment for each monitor, blood glucose test strips, lancet devices and Medicare-covered diabetes †† lancets, and glucose-control solutions for checking the monitoring supply. accuracy of test strips and monitors. UnitedHealthcare® Group Medicare Advantage PEBB We only cover Accu-Chek® and Complete (PPO) covers any blood glucose monitors and test OneTouch® brands. strips specified within this list. We will generally not cover alternate brands unless your doctor or other provider tells us Covered glucose monitors that use of an alternate brand is medically necessary in your include: OneTouch Verio Flex®, specific situation. If you are new to UnitedHealthcare® OneTouch Verio Reflect®, Group Medicare Advantage PEBB Complete (PPO) and are OneTouch® Verio,

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 85 Services that are covered for you What you must pay when you get these services in-network and out-of-network using a brand of blood glucose monitors and test strips that OneTouch®Ultra 2, Accu-Chek® is not on our list, you may contact us within the first 90 days Guide Me, and Accu-Chek® of enrollment into the plan to request a temporary supply of Guide. the alternate brand while you consult with your doctor or other provider. During this time, you should talk with your Test strips: OneTouch Verio®, doctor to decide whether any of the preferred brands are OneTouch Ultra®, Accu-Chek® medically appropriate for you. If you or your doctor believe Guide, Accu-Chek® Aviva Plus, it is medically necessary for you to maintain use of an and Accu-Chek® SmartView. alternate brand, you may request a coverage exception to have UnitedHealthcare® Group Medicare Advantage PEBB Other brands are not covered Complete (PPO) maintain coverage of a non-preferred by your plan. product through the end of the benefit year. Non-preferred For cost-sharing applicable to products will not be covered following the initial 90 days of insulin and syringes, see the benefit year without an approved coverage exception. Chapter 6 - What you pay for If you (or your provider) don’t agree with the plan’s coverage your Part D prescription drugs. decision, you or your provider may file an appeal. You can also file an appeal if you don’t agree with your provider’s decision about what product or brand is appropriate for your medical condition. (For more information about appeals, see Chapter 9, What to do if you have a problem or complaint (coverage decisions, appeals, complaints).) · Medicare-covered continuous glucose monitors (CGMs) $0 copayment for Medicare- and supplies are covered in accordance with Medicare covered continuous glucose Guidelines. monitors (CGMs) and †† supplies. · For people with diabetes who have severe diabetic foot $0 copayment for each pair of disease: One pair per plan year of therapeutic custom- Medicare-covered therapeutic molded shoes (including inserts provided with such shoes.†† shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes). Coverage includes fitting.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 86 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Diabetes self-management training is covered under $0 copayment for Medicare- certain conditions. Limited to 20 visits of 30 minutes per covered benefits. year for a maximum of 10 hours the initial year. Follow- up training subsequent years after, limited to 4 visits of 30 minutes for a maximum of 2 hours per year. Durable medical equipment (DME) and related supplies $0 copayment for Medicare- (For a definition of “durable medical equipment,” see covered benefits.†† Chapter 12 as well as Chapter 3, Section 7 of this Your cost-sharing for Medicare document.) oxygen equipment coverage is Covered items include, but are not limited to: wheelchairs, $0 copayment, every time you crutches, powered mattress systems, diabetic supplies, get covered equipment or †† hospital beds ordered by a provider for use in the home, IV supplies. infusion pumps, speech generating devices, oxygen Your cost-sharing will not equipment, nebulizers, and walkers. change after being enrolled for We cover all medically necessary DME covered by Original 36 months. Medicare. If our supplier in your area does not carry a If prior to enrolling in our plan particular brand or manufacturer, you may ask them if they you had made 36 months of can special order it for you. The most recent list of suppliers rental payment for oxygen is available on our website at retiree.uhc.com/wapebb. equipment coverage, your cost- sharing in our plan is $0 copayment.†† Emergency care $65 copayment for each Emergency care refers to services that are: emergency room visit. · Furnished by a provider qualified to furnish emergency You do not pay this amount if services, and you are admitted to the hospital · Needed to evaluate or stabilize an emergency medical within 24 hours for the same condition. condition. If you are admitted to a hospital, you will pay cost- A medical emergency is when you, or any other prudent sharing as described in the layperson with an average knowledge of health and “Inpatient hospital care” section medicine, believe that you have medical symptoms that in this benefit chart. require immediate medical attention to prevent loss of life

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 87 Services that are covered for you What you must pay when you get these services in-network and out-of-network (and, if you are a pregnant woman, loss of an unborn child), You pay these amounts until loss of a limb, or loss of function of a limb. The medical you reach the out-of-pocket symptoms may be an illness, injury, severe pain, or a maximum. medical condition that is quickly getting worse. Cost-sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in- network. Worldwide coverage for emergency department services. $65 copayment for worldwide · This includes emergency or urgently needed care and coverage for emergency emergency ambulance transportation from the scene of services. You do not pay this an emergency to the nearest medical treatment facility. amount if admitted to the · Transportation back to the United States from another hospital within 24 hours for the country is not covered. same condition. If you are admitted to a hospital, you will · Services provided by a dentist are not covered. pay cost-sharing as described in the Inpatient hospital care section in this benefit chart. Please see Chapter 7 Section 1.1 for expense reimbursement for worldwide services. You pay these amounts until you reach the out-of-pocket maximum.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 88 Services that are covered for you What you must pay when you get these services in-network and out-of-network Over-the-counter (OTC) card $0 copayment Healthy Benefits Plus With this benefit you will get one pre-paid card at the start of your plan year. You will get a $40 credit loaded to the card each quarter to purchase approved OTC items from network retail locations, the OTC catalog, website or mobile app. Credits are added on the first day of each quarter (in January, April, July and October) and expire at the end of the year. To access your benefit call 1-833-216-6709, TTY 711, visit HealthyBenefitsPlus.com/UHCRetiree, or download the Healthy Benefits Plus app. Renew Active is available at no Fitness program Renew Active® by UnitedHealthcare additional cost to you. Renew Active® by UnitedHealthcare is the gold standard in Call or go online to learn more Medicare fitness programs for body and mind. It's available and to get your confirmation to you at no additional cost and includes: code. Log in to your plan · A free gym membership at a fitness location you select website, go to Health & from our large nationwide network. Wellness and select Renew Active or call the number on · Thousands of on-demand workout videos and live your UnitedHealthcare member streaming fitness classes. ID card to obtain your code. · Social activities at local health and wellness classes and events. · An online Fitbit® Community. No Fitbit device is needed. · An online program offering content about brain health with exclusive content for Renew Active members through AARP® Staying Sharp.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 89 Services that are covered for you What you must pay when you get these services in-network and out-of-network Foreign travel claims^ To use this benefit, you will Worldwide coverage for non-emergency and non-urgent need to pay the full cost of the services. service and then submit a reimbursement claim. We'll reimburse 100% of the billed charges. For more information on this process, please see Chapter 7.* Foreign travel – prescription claims^ After you reach your prescription deductible (see Chapter 6), you'll pay a $45 copay for a 30 day supply. You pay this amount until you reach the out-of-pocket maximum. UnitedHealthcare Healthy at Home post-discharge $0 copayment; benefit is program available through approved With the UnitedHealthcare Healthy at Home post-discharge vendors. program, the following benefits are available to you up to 30 days following all inpatient and skilled nursing facility discharges at no cost to you: Home-delivered meals Receive 28 home-delivered meals when referred by a UnitedHealthcare Engagement Specialist. Call the number on your UnitedHealthcare member ID card to learn more or get a referral. · Restrictions, limitations and exclusions apply, including shipping and other requirements. Meals are only available through the approved vendor · If you have been recently discharged from the hospital or a skilled nursing facility and would like a referral, call

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 90 Services that are covered for you What you must pay when you get these services in-network and out-of-network the phone number on your UnitedHealthcare member ID card Non-emergency transportation Receive 12 one-way rides up to 50 miles per one-way trip to and from medically related appointments and to the pharmacy when referred by a UnitedHealthcare Engagement Specialist. Call the customer service number on your UnitedHealthcare member ID card for more information and to schedule your trips. · New referrals are required following each discharge. If you have been recently discharged from the hospital or a skilled nursing facility and would like a referral, call the phone number on your UnitedHealthcare member ID card. · Trips must be to or from plan-approved medically related appointments (locations); limited to ground transportation only. · Mileage reimbursement available upon request (arrangements must be set up in advance). · Each one-way trip must not exceed 50 miles. A trip is considered one way; a round trip is considered 2 trips. · The benefit cannot be used for emergency related trips. Drivers do not have medical training. In case of an emergency, call 911. · One companion per trip at least 18 years of age or older. · Cab/sedan services available. · Standard transportation services require at least 2 business days advanced notice. · Appointments can be made up to 30 days in advance. · Weekend scheduling available only for urgent requests. Non-Medical personal care

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 91 Services that are covered for you What you must pay when you get these services in-network and out-of-network Receive 6 hours of non-medical personal care through a professional caregiver to perform tasks such as companionship, meal prep, medication reminders and more. Call the customer service number on your UnitedHealthcare member ID card for more information and to receive non- medical personal care. · No referral required. · Unused hours do not roll over. · Caregiver hours must be scheduled in 2-hour increments. · You will typically be paired with a caregiver within 5 business days. · Some restrictions and limitations apply. You are not required to use all 3 services. New referrals for meals and transportation benefits are required after each discharge. Unused benefits do not roll over. Some restrictions and limitations may apply. Hearing services $0 copayment for each Medicare-covered exam.†† Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider. Routine hearing services Hearing exam Please turn to Section 4 Routine Hearing Services of this $0 copayment for 1 exam per chapter for more detailed information about this benefit. plan year. Hearing aids You pay any amount over $2,500 for hearing aids (combined for both ears) every 3 years years.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 92 Services that are covered for you What you must pay when you get these services in-network and out-of-network To access your hearing aid benefits, you must contact UnitedHealthcare Hearing at 1-866-445-2071, TTY 711. Hearing aids purchased outside of UnitedHealthcare Hearing’s nationwide network are not covered. There is no coinsurance, Hepatitis C screening copayment, or deductible for For people that meet one of the following conditions: beneficiaries eligible for · High risk because of current or past history of illicit Medicare-covered Hepatitis C injection drug use screening. · Had a blood transfusion before 1992 · Born between 1945 – 1965 Screening is covered annually only for high risk people with continued illicit drug use since the prior negative screening test. Screening is covered once in a lifetime for people that were born between 1945 and 1965, who are not considered high risk. There is no coinsurance, HIV screening copayment, or deductible for For people who ask for an HIV screening test or who are at members eligible for Medicare- increased risk for HIV infection, we cover: covered preventive HIV · One screening exam every 12 months screening. For women who are pregnant, we cover: · Up to three screening exams during a pregnancy Home health agency care $0 copayment for all home health visits provided by a

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 93 Services that are covered for you What you must pay when you get these services in-network and out-of-network Prior to receiving home health services, a doctor must certify network home health agency that you need home health services and will order home when Medicare criteria are †† health services to be provided by a home health agency. met. You must be homebound, which means leaving home is a Other copayments or major effort. coinsurance may apply (Please Covered services include, but are not limited to: see Durable medical equipment · Part-time or intermittent skilled nursing and home health and related supplies for aide services (To be covered under the home health applicable copayments or care benefit, your skilled nursing and home health aide coinsurance). services combined must total fewer than 8 hours per day and 35 hours per week) · Physical therapy, occupational therapy, and speech therapy · Medical and social services · Medical equipment and supplies Home infusion therapy You will pay the cost-sharing Home infusion therapy involves the intravenous or that applies to primary care subcutaneous administration of drugs or biologicals to an services, specialist physician individual at home. The components needed to perform services, or home health (as home infusion include the drug (for example, antivirals, described under “Physician/ immune globulin), equipment (for example, a pump), and practitioner services, including supplies (for example, tubing and catheters). doctor’s office visits” or “Home Covered services include, but are not limited to: health agency care”) depending on where you received · Professional services, including nursing services, administration or monitoring furnished in accordance with the plan of care services.†† · Patient training and education not otherwise covered under the durable medical equipment benefit See "Durable medical · Remote monitoring equipment" earlier in this chart · Monitoring services for the provision of home infusion for any applicable cost-sharing therapy and home infusion drugs furnished by a for equipment and supplies qualified home infusion therapy supplier related to home infusion †† therapy.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 94 Services that are covered for you What you must pay when you get these services in-network and out-of-network See "Medicare Part B prescription drugs" later in this chart for any applicable cost- sharing for drugs related to home infusion therapy.†† Hospice care When you enroll in a Medicare- You are eligible for the hospice benefit when your doctor certified hospice program, your and the hospice medical director have given you a terminal hospice services and your Part prognosis certifying that you’re terminally ill and have 6 A and Part B services related to months or less to live if your illness runs its normal course. your terminal prognosis are You may receive care from any Medicare-certified hospice paid for by Original Medicare, program. Your plan is obligated to help you find Medicare- not UnitedHealthcare® Group certified hospice programs in the plan’s service area, Medicare Advantage PEBB including those the MA organization owns, controls, or has a Complete (PPO). financial interest in. Your hospice doctor can be a network Note: If you are not entitled to provider or an out-of-network provider. Medicare Part A coverage, Covered services include: hospice services are not · Drugs for symptom control and pain relief covered by the plan or by Medicare. · Short-term respite care Note: If you need non-hospice · Home care care (care that is not related to When you are admitted to a hospice you have the right to your terminal prognosis), you remain in your plan; if you chose to remain in your plan you should contact us to arrange must continue to pay plan premiums. the services. For hospice services and for services that are covered by Medicare Part A or B and are related to your terminal prognosis: Original Medicare (rather than our plan) will pay your hospice provider for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the services that Original Medicare pays for. You will be billed Original Medicare cost- sharing.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 95 Services that are covered for you What you must pay when you get these services in-network and out-of-network For services that are covered by Medicare Part A or B and are not related to your terminal prognosis: If you need non-emergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis, you pay your plan cost-sharing amount for these services. Please refer to this Benefits Chart. For services that are covered by UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) but are not covered by Medicare Part A or B: UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) will continue to cover plan-covered services that are not covered under Part A or B whether or not they are related to your terminal prognosis. You pay your plan cost-sharing amount for these services. For drugs that may be covered by the plan’s Part D benefit: If these drugs are unrelated to your terminal hospice condition you pay cost-sharing. If they are related to your terminal hospice condition then you pay Original Medicare cost-sharing. Drugs are never covered by both hospice and our plan at the same time. For more information, please see Chapter 5, Section 9.4 (What if you’re in Medicare-certified hospice). Our plan covers hospice consultation services (one time only) for a terminally ill person who hasn’t elected the hospice benefit. Immunizations There is no coinsurance, Covered Medicare Part B services include: copayment, or deductible for · Pneumonia vaccine the pneumonia, flu, Hepatitis B, · Flu vaccine, one each flu season in the fall and winter, or COVID-19 vaccines. with additional flu vaccine shots if medically necessary There is no coinsurance, copayment, or deductible for all

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 96 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Hepatitis B vaccine if you are at high or intermediate other Medicare-covered risk of getting Hepatitis B immunizations. · COVID-19 vaccine · Other vaccines if you are at risk and they meet Medicare Part B coverage rules We also cover some vaccines under our Part D prescription drug benefit, such as shingles or tetanus booster shots. See Chapter 6 for more information about coverage and applicable cost-sharing. Inpatient hospital care $0 copayment for each Includes inpatient acute, inpatient rehabilitation, long-term Medicare-covered hospital stay each time you are admitted.†† care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally Medicare hospital benefit admitted to the hospital with a doctor’s order. The day periods do not apply. (See before you are discharged is your last inpatient day. definition of benefit periods in Covered services include, but are not limited to: the chapter titled Definitions of · Semi-private room (or a private room if medically important words.) For inpatient necessary) hospital care, the cost-sharing described above applies each · Meals including special diets time you are admitted to the · Regular nursing services hospital. A transfer to a · Costs of special care units (such as intensive care or separate facility type (such as coronary care units) an Inpatient Rehabilitation · Drugs and medications Hospital or Long Term Care Hospital) is considered a new · Lab tests admission. For each inpatient · X-rays and other radiology services hospital stay, you are covered · Necessary surgical and medical supplies for unlimited days as long as · Use of appliances, such as wheelchairs the hospital stay is covered in accordance with plan rules. · Operating and recovery room costs · Physical, occupational, and speech language therapy

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 97 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Under certain conditions, the following types of transplants are covered: corneal, kidney, kidney- pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and intestinal/multivisceral. The plan has a network of facilities that perform organ transplants. The plan’s hospital network for organ transplant services is different than the network shown in the ‘Hospitals’ section of your provider directory. Some hospitals in the plan’s network for other medical services are not in the plan’s network for transplant services. For information on network facilities for transplant services, please call UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Customer Service at 1-855-873-3268 TTY 711. If you need a transplant, we will arrange to have your case reviewed by a Medicare-approved transplant center that will decide whether you are a candidate for a transplant. Transplant providers may be local or outside of the service area. If our in-network transplant services are outside the community pattern of care, you may choose to go locally as long as the local transplant providers are willing to accept the Original Medicare rate. If UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) provides transplant services at a location outside of the pattern of care for transplants in your community and you chose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a companion. While you are receiving care at the distant location, we will also reimburse transportation costs to and from the hospital or doctor’s office for evaluations, transplant services and follow-up care. (Transportation in the distant location includes, but is not limited to: vehicle mileage, economy/coach airfare, taxi fares, or rideshare services.) Costs for lodging or places to stay such as hotels, motels or short-term housing as a result of travel

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 98 Services that are covered for you What you must pay when you get these services in-network and out-of-network for a covered organ transplant may also be covered. You can be reimbursed for eligible costs up to $125 per day total. Transportation services are not subject to the daily limit amount. · Blood - including storage and administration. Coverage begins with the first pint of blood that you need. · Physician services Note: To be an inpatient, your provider must write an order Outpatient observation cost- to admit you formally as an inpatient of the hospital. Even if sharing is explained in you stay in the hospital overnight, you might still be Outpatient surgery and other considered an “outpatient.” This is called an “outpatient medical services provided at observation” stay. If you are not sure if you are an inpatient hospital outpatient facilities and or an outpatient, you should ask the hospital staff. ambulatory surgical centers. You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web at medicare.gov/sites/default/files/2021-10/11435- Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 99 Services that are covered for you What you must pay when you get these services in-network and out-of-network Inpatient services in a psychiatric hospital $0 copayment per Medicare- covered admission.†† Covered services include: · Mental health care services that require a hospital stay. Medicare hospital benefit · Inpatient substance abuse services periods do not apply. (See definition of benefit periods in the chapter titled Definitions of important words.) For inpatient hospital care, the cost-sharing described above applies each time you are admitted to the hospital. For each inpatient hospital stay, you are covered for unlimited days as long as the hospital stay is covered in accordance with plan rules. Inpatient stay: covered services received in a hospital or When your stay is no longer skilled nursing facility (SNF) during a non-covered covered, these services will be inpatient stay covered as described in the If you have exhausted your inpatient benefits or if the following sections: inpatient stay is not reasonable and necessary, we will not cover your inpatient stay. However, in some cases, we will cover certain services you receive while you are in the hospital or the skilled nursing facility (SNF). Covered services include, but are not limited to: · Physician services Please refer below to Physician/ practitioner services, including doctor’s office visits. · Diagnostic tests (like lab tests) Please refer below to Outpatient diagnostic tests and therapeutic services and supplies.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 100 Services that are covered for you What you must pay when you get these services in-network and out-of-network · X-ray, radium, and isotope therapy including technician Please refer below to Outpatient materials and services diagnostic tests and therapeutic services and supplies. · Surgical dressings Please refer below to Outpatient · Splints, casts and other devices used to reduce diagnostic tests and therapeutic fractures and dislocations services and supplies. · Prosthetics and orthotics devices (other than dental) Please refer below to Prosthetic that replace all or part of an internal body organ devices and related supplies. (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices · Leg, arm, back, and neck braces; trusses, and artificial Please refer below to Prosthetic legs, arms, and eyes including adjustments, repairs, devices and related supplies. and replacements required because of breakage, wear, loss, or a change in the patient’s physical condition · Physical therapy, speech language therapy, and Please refer below to Outpatient occupational therapy rehabilitation services. Massage therapy $0 copayment for each visit up We cover therapeutic services from a licensed massage to 30 visit(s) per year.* therapist. There is no coinsurance, Medical nutrition therapy copayment, or deductible for This benefit is for people with diabetes, renal (kidney) members eligible for Medicare- disease (but not on dialysis), or after a kidney transplant covered medical nutrition when ordered by your doctor. therapy services.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 101 Services that are covered for you What you must pay when you get these services in-network and out-of-network We cover three hours of one-on-one counseling services during your first year that you receive medical nutrition therapy services under Medicare (this includes our plan, any other Medicare Advantage plan, or Original Medicare), and two hours each year after that. If your condition, treatment, or diagnosis changes, you may be able to receive more hours of treatment with a physician’s order. A physician must prescribe these services and renew their order yearly if your treatment is needed into the next plan year. There is no coinsurance, Medicare diabetes prevention program (MDPP) copayment, or deductible for MDPP services will be covered for eligible Medicare the MDPP benefit. beneficiaries under all Medicare health plans. MDPP is a structured health behavior change intervention that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle. Medicare Part B Prescription Drugs $0 copayment for each These drugs are covered under Part B of Original Medicare. Medicare-covered Part B drug Members of our plan receive coverage for these drugs and non-chemotherapy drugs to treat cancer.†† through our plan. Covered drugs include: · Drugs that usually aren’t self-administered by the Additionally, for the patient and are injected or infused while you are getting administration of that drug, you physician, hospital outpatient, or ambulatory surgical will pay the cost-sharing that center services applies to primary care provider · Insulin furnished through an item of durable medical services, specialist services, or equipment (such as a medically necessary insulin outpatient hospital services (as pump) described under “Physician/ practitioner services, including · Other drugs you take using durable medical equipment doctor’s office visits” or (such as nebulizers) that were authorized by the plan “Outpatient hospital services” in this benefit chart) depending on

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 102 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Clotting factors you give yourself by injection if you have where you received drug hemophilia administration or infusion · Immunosuppressive drugs, if you were enrolled in services. Medicare Part A at the time of the organ transplant · Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis, and cannot self- administer the drug · Antigens (for allergy shots) · Certain oral anti-cancer drugs and anti-nausea drugs · Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as Epogen®, Procrit®, Epoetin Alfa, Aranesp®, or Darbepoetin Alfa) · Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases · Chemotherapy Drugs, and the administration of $0 copayment for each chemotherapy drugs Medicare-covered The following link will take you to a list of Part B Drugs that chemotherapy drug to treat may be subject to step therapy: https:// cancer and the administration of that drug.†† www.medicare.uhc.com/retiree/member/documents/group- part-b-step-therapy.html You or your doctor may need to provide more information about how a Medicare Part B prescription drug is used in order to determine coverage. There may be effective, lower- cost drugs that treat the same medical condition. If you are prescribed a new Part B medication or have not recently filled the medication under Part B, you may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover the Part B drug. (For more

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 103 Services that are covered for you What you must pay when you get these services in-network and out-of-network information, see Chapter 9, What to do if you have a problem or complaint (coverage decisions, appeals, complaints).) Please contact Customer Service for more information. Chapter 5 explains the Part D prescription drug benefit, including rules you must follow to have prescriptions covered. What you pay for your Part D prescription drugs through our plan is explained in Chapter 6. Naturopathic services $30 copayment for each visit* We cover unlimited routine naturopathic visits. Naturopathic medicine is a type of alternate medicine that focuses on self-healing, as well as treating and preventing diseases without the use of drugs. It uses techniques such as diet, exercise, massage, lifestyle changes and natural therapies to improve your body's ability to prevent and fight disease. You can find more information about this benefit later in this chapter (Section 4.5, Naturopathic services) 24/7 Nurse Support Receive access to nurse consultations and additional clinical resources at no additional cost. There is no coinsurance, Obesity screening and therapy to promote sustained weight loss copayment, or deductible for If you have a body mass index of 30 or more, we cover preventive obesity screening intensive counseling to help you lose weight. This and therapy. counseling is covered if you get it in a primary care setting, where it can be coordinated with your comprehensive prevention plan. Talk to your primary care doctor or practitioner to find out more.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 104 Services that are covered for you What you must pay when you get these services in-network and out-of-network Opioid treatment program services $0 copayment for Medicare- Members of our plan with opioid use disorder (OUD) can covered opioid treatment program services.†† receive coverage of services to treat OUD through an Opioid Treatment Program (OTP) which includes the following services: · U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications. · Dispensing and administration of MAT medications (if applicable) · Substance use counseling · Individual and group therapy · Toxicology testing · Intake activities · Periodic assessments Outpatient diagnostic tests and therapeutic services and supplies Covered services include, but are not limited to: · X-rays $0 copayment for each Medicare-covered standard X- ray service.†† · Radiation (radium and isotope) therapy including $0 copayment for each technician materials and supplies Medicare-covered radiation therapy service.††

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 105 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Surgical supplies, such as dressings $0 copayment for each · Splints, casts, and other devices used to reduce Medicare-covered medical †† fractures and dislocations supply. Note: There is no separate charge for medical supplies routinely used in the course of an office visit and included in the provider’s charges for that visit (such as bandages, cotton swabs, and other routine supplies.) However, supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to cost-sharing as shown. · Laboratory tests $0 copayment for Medicare- covered lab services.†† · Blood - including storage and administration (this $0 copayment for Medicare- †† means processing and handling of blood). Coverage covered blood services. begins with the first pint of blood that you need. · In addition, for the administration of blood infusion, you will pay the cost-sharing as described under the following sections of this chart, depending on where you received infusion services: - Physician/practitioner services, including doctor’s office visits - Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 106 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Other outpatient diagnostic tests - non-radiological $0 copayment for Medicare- diagnostic services covered non-radiological diagnostic services.†† Examples include, but are not limited to EKG’s, pulmonary function tests, home or lab- based sleep studies, and treadmill stress tests. · Other outpatient diagnostic tests - radiological $0 copayment for Medicare- diagnostic services, not including x-rays. covered radiological diagnostic services, not including X-rays.†† The diagnostic radiology services require specialized equipment beyond standard X- ray equipment and must be performed by specially trained or certified personnel. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, ultrasounds, diagnostic mammograms and interventional radiological procedures (myelogram, cystogram, angiogram, and barium studies).

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 107 Services that are covered for you What you must pay when you get these services in-network and out-of-network Outpatient hospital observation Outpatient observation cost- Observation services are hospital outpatient services given sharing is explained in to determine if you need to be admitted as an inpatient or Outpatient surgery and other can be discharged. For outpatient hospital observation medical services provided at services to be covered, they must meet the Medicare criteria hospital outpatient facilities and and be considered reasonable and necessary. Observation ambulatory surgical centers. services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or order outpatient tests. Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” If you are not sure if you are an outpatient, you should ask the hospital staff. You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web at medicare.gov/sites/default/files/2021-10/11435-Inpatient- or-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7days a week. Outpatient hospital services We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Covered services include, but are not limited to: · Services in an emergency department Please refer to Emergency Care.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 108 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Laboratory and diagnostic tests billed by the hospital Please refer to Outpatient diagnostic tests and therapeutic services and supplies. · Mental health care, including care in a partial- Please refer to Outpatient hospitalization program, if a doctor certifies that mental health care. inpatient treatment would be required without it · X-rays and other radiology services billed by the Please refer to Outpatient hospital diagnostic tests and therapeutic services and supplies. · Medical supplies such as splints and casts Please refer to Outpatient diagnostic tests and therapeutic services and supplies. · Certain screenings and preventive services Please refer to the benefits preceded by the “Apple” icon. · Certain drugs and biologicals that you can’t give Please refer to Medicare Part B yourself (Note: Self-administered drugs in an outpatient prescription drugs. hospital are not usually covered under your Part B prescription drug benefit. Under certain circumstances, they may be covered under your Part D prescription drug benefit. For more information on Part D payment requests, see Chapter 7 Section 2.) · Services performed at an outpatient clinic Please refer to Physician/ practitioner services, including doctor's office visits.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 109 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Outpatient surgery or observation Please refer to Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. Please refer to Medicare Part B prescription drugs and · Outpatient infusion therapy Physician/practitioner services, including doctor’s office visits For the drug that is infused, you will pay the cost-sharing as or Outpatient surgery and other described in "Medicare Part B prescription drugs" in this medical services provided at benefit chart. In addition, for the administration of infusion hospital outpatient facilities and therapy drugs, you will pay the cost-sharing that applies to ambulatory surgical centers. primary care provider services, specialist services, or outpatient hospital services (as described under “Physician/ practitioner services, including doctor’s office visits” or “Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers” in this benefit chart) depending on where you received drug administration or infusion services. Note: Unless the provider has written an order to admit you Outpatient observation cost- as an inpatient to the hospital, you are an outpatient and pay sharing is explained in the cost-sharing amounts for outpatient hospital services. Outpatient surgery and other Even if you stay in the hospital overnight, you might still be medical services provided at considered an “outpatient.” This is called an “outpatient hospital outpatient facilities and observation” stay. If you are not sure if you are an outpatient, ambulatory surgical centers. you should ask the hospital staff. You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web at medicare.gov/sites/default/files/2021-10/11435-

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 110 Services that are covered for you What you must pay when you get these services in-network and out-of-network Inpatient-or-Outpatient.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. Outpatient injectable medications These medications may be (Self-administered outpatient injectable medications not covered under Medicare Part D. covered under Part B of Original Medicare) The list of covered drugs (Formulary) includes a list of the Part D prescription drugs that are covered by our plan. The chapter in the Evidence of Coverage titled: Using your plan’s coverage for Part D prescription drugs explains the Part D prescription drug benefit, including rules you must follow to have prescriptions covered. What you pay for your Part D prescription drugs through our plan is listed in the chapter of the Evidence of Coverage titled: What you pay for your Part D prescription drugs. Outpatient mental health care $0 copayment for each Covered services include: Medicare-covered individual therapy session.†† Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social $0 copayment for each worker, clinical nurse specialist, licensed professional Medicare-covered group counselor (LPC), licensed marriage and family therapist therapy session.†† (LMFT), nurse practitioner (NP), physician assistant (PA), or other Medicare-qualified mental health care professional as allowed under applicable state laws.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 111 Services that are covered for you What you must pay when you get these services in-network and out-of-network Please refer to virtual behavioral visits section in this chart for more information. Outpatient rehabilitation services $0 copayment for each Covered services include: physical therapy, occupational Medicare-covered physical therapy, and speech language therapy. therapy and speech-language therapy visit.†† Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, $0 copayment for each independent therapist offices, physician offices, and Medicare-covered occupational therapy visit.†† Comprehensive Outpatient Rehabilitation Facilities (CORFs). $0 copayment for each Medicare-covered comprehensive outpatient rehabilitation facility (CORF) visit.†† Outpatient substance abuse services $0 copayment for each Outpatient treatment and counseling for substance abuse. Medicare-covered individual therapy session.†† $0 copayment for each Medicare-covered group therapy session.†† Outpatient surgery and other medical services provided $0 copayment for Medicare- at hospital outpatient facilities and ambulatory surgical covered surgery or other centers services at an outpatient Note: If you are having surgery in a hospital facility, you hospital or ambulatory surgical should check with your provider about whether you will be center, including but not limited an inpatient or outpatient. Unless the provider writes an to hospital or other facility order to admit you as an inpatient to the hospital, you are an charges and physician or surgical charges.†† outpatient and pay the cost-sharing amounts for outpatient

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 112 Services that are covered for you What you must pay when you get these services in-network and out-of-network surgery. Even if you stay in the hospital overnight, you might Outpatient surgical services that still be considered an “outpatient.” This is called an can be delivered in an available “Outpatient Observation” stay. If you are not sure if you are ambulatory surgery center must an outpatient, you should ask your doctor or the hospital be delivered in an ambulatory staff. surgery center unless a hospital If you receive any services or items other than surgery, outpatient department is including but not limited to diagnostic tests, therapeutic medically necessary. services, prosthetics, orthotics, supplies or Part B drugs, there may be additional cost-sharing for those services or $0 copayment for Medicare- items. Please refer to the appropriate section in this chart for covered observation at an the additional service or item you received for the specific outpatient hospital or cost-sharing required. ambulatory surgical center.†† See “Colorectal cancer screening” earlier in this chart for screening and diagnostic colonoscopy benefit information. Partial hospitalization services and Intensive outpatient $0 copayment each day for services Medicare-covered benefits.†† “Partial hospitalization” is a structured program of active psychiatric treatment provided as a hospital outpatient service, or by a community mental health center, that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization. Intensive outpatient service is a structured program of active behavioral (mental) health therapy treatment provided in a hospital outpatient department, a community mental health center, a Federally qualified health center, or a rural health clinic that is more intense than the care received in your doctor’s or therapist’s office but less intense than partial hospitalization. Personal emergency response system (PERS) Lifeline $0 copayment; Benefit is A personal emergency response system (PERS) benefit is available through provider available to you through the provider, Lifeline. Lifeline.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 113 Services that are covered for you What you must pay when you get these services in-network and out-of-network With a PERS, help is only a button press away. A PERS can quickly connect you to the help you need, 24 hours a day in any situation. It's a lightweight, water-resistant button that can be worn on your wrist or as a pendant. Depending on the model you choose, it may even automatically detect falls. You must have a working landline or live in an area that has cellular coverage. The cellular device works nationwide with the AT&T and Verizon wireless networks, but does not require you to have AT&T or Verizon. For additional information or to order your device, please call 1-855-595-8485 TTY 711 or visit lifeline.com/uhcgroup. Provided by: Lifeline Physician/practitioner services, including doctor’s office visits Covered services include: · Medically-necessary medical or surgical services $0 copayment for services from furnished in a physician’s office. a primary care provider or under certain circumstances, treatment by a nurse practitioner, physician's assistant or other non-physician health care professional in a primary care provider’s office (as allowed by Medicare).

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 114 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Medically-necessary medical or surgical services See “Outpatient surgery” earlier furnished in a certified ambulatory surgical center or in this chart for any applicable hospital outpatient department. copayments or coinsurance amounts for ambulatory surgical center visits or in a hospital outpatient setting. · Consultation, diagnosis, and treatment by a specialist. $0 copayment for services from a specialist or under certain circumstances, treatment by a nurse practitioner, physician’s assistant or other non-physician health care professional in a specialist’s office (as allowed by Medicare).†† · Basic hearing and balance exams performed by your $0 copayment for each specialist, if your doctor orders it to see if you need Medicare-covered exam.†† medical treatment. · Some telehealth services including consultation, $0 copayment for each diagnosis, and treatment by a physician or practitioner, Medicare-covered visit.†† for patients in certain rural areas or other places approved by Medicare. · Telehealth services for monthly end-stage renal disease- related visits for home dialysis members in a hospital- based or critical access hospital-based renal dialysis center, renal dialysis facility, or the member's home. · Telehealth services to diagnose, evaluate, or treat symptoms of a stroke regardless of their location. · Telehealth services for members with a substance use disorder or co-occurring mental health disorder, regardless of their location. · Telehealth services for diagnosis, evaluation, and treatment of mental health disorders.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 115 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Telehealth services for mental health visits provided by rural health clinics and federally qualified health centers · Medicare-covered remote patient monitoring services · Virtual check-ins (for example, by phone or video chat) with your doctor for 5-10 minutes if: - You're not a new patient and - The check-in isn't related to an office visit in the past 7 days and - The check-in doesn't lead to an office visit within 24 hours or the soonest available appointment. · Evaluation of video and/or images you send to your doctor, and interpretation and follow-up by your doctor within 24 hours if: - You're not a new patient and - The evaluation isn't related to an office visit in the past 7 days and - The evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment. · Consultation your doctor has with other doctors by $0 copayment for each phone, internet, or electronic health record. Medicare-covered consultation. · Second opinion prior to surgery. You will pay the cost-sharing that applies to specialist services (as described under “Physician/practitioner services, including doctor’s office visits” †† above). · Non-routine dental care (covered services are limited to $0 copayment for each surgery of the jaw or related structures, setting fractures Medicare-covered visit.†† of the jaw for radiation treatments of neoplastic cancer disease, oral exams before a kidney transplant or services that would be covered when provided by a physician). Dental services provided by a dentist in

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 116 Services that are covered for you What you must pay when you get these services in-network and out-of-network connection with care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth are not Medicare-covered benefits and not covered under this benefit. · Monitoring services in a physician’s office or outpatient You will pay the cost-sharing hospital setting if you are taking anticoagulation that applies to primary care medications, such as Coumadin, Heparin or Warfarin provider services, specialist (these services may also be referred to as ‘Coumadin services, or outpatient hospital Clinic’ services). services (as described under “Physician/practitioner services, including doctor’s office visits” or “Outpatient hospital services” in this benefit chart) depending on where you †† receive services. · Medically-necessary medical or surgical services that You will pay the cost-sharing are covered benefits and are furnished by a physician in that applies to primary care your home or a nursing home in which you reside. provider services or specialist physician services (as applied in an office setting, described above in this section of the benefit chart) depending on the type of physician that provides †† the services.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 117 Services that are covered for you What you must pay when you get these services in-network and out-of-network $0 copayment for certain primary care provider, nurse practitioner, physician’s assistant, or other non-physician health care professional services furnished in the home § by designated providers · Certain telehealth services, including: - Virtual doctor visits See “Virtual doctor visits” in this chart for any applicable copayments or coinsurance. - Virtual behavioral visits See “Virtual behavioral visits” in this chart for any applicable copayments or coinsurance. Podiatry services $0 copayment for each Covered services include: Medicare-covered visit in an office or home setting.†† · Diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or For services rendered in an heel spurs). outpatient hospital setting, such · Routine foot care for members with certain medical as surgery, please refer to conditions affecting the lower limbs. Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. Additional routine podiatry $0 copayment per visit for Treatment of the foot which is generally considered routine podiatry visits up to 6 preventive, i.e., cutting or removal of corns, warts, calluses visits per plan year. or nails.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 118 Services that are covered for you What you must pay when you get these services in-network and out-of-network There is no coinsurance, Prostate cancer screening exams copayment, or deductible for an For men age 50 and older, covered services include the annual PSA test. following - once every 12 months: Diagnostic PSA exams are · Digital rectal exam subject to cost-sharing as · Prostate Specific Antigen (PSA) test described under Outpatient diagnostic tests and therapeutic services and supplies in this chart. Prosthetic devices and related supplies $0 copayment for each Devices (other than dental) that replace all or part of a body Medicare-covered prosthetic part or function. These include, but are not limited to: device, including replacement colostomy bags and supplies directly related to colostomy or repairs of such devices, and related supplies.†† care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a $0 copayment for each mastectomy). Includes certain supplies related to prosthetic Medicare-covered orthotic devices, and repair and/or replacement of prosthetic device, including replacement devices. Also includes some coverage following cataract or repairs of such devices, and removal or cataract surgery – see “Vision services” later in related supplies.†† this section for more detail. Pulmonary rehabilitation services $0 copayment for each Comprehensive programs of pulmonary rehabilitation are Medicare-covered pulmonary rehabilitative visit.†† covered for members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and an order for pulmonary rehabilitation from the doctor treating the chronic respiratory disease. Medicare covers up to two (2) one-hour sessions per day, for up to 36 lifetime sessions (in some cases, up to 72 lifetime sessions) of pulmonary rehabilitation services.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 119 Services that are covered for you What you must pay when you get these services in-network and out-of-network Rally Coach™ programs Rally Coach is available to you Rally Coach™ programs can help you start living a healthier at no additional cost. Call or go and happier life. These virtual coaching programs are online to get started today. available to you at no additional cost and include the rallyhealth.com/retiree following: · Real Appeal Real Appeal® is an online weight management and healthy 1-844-924-7325, TTY 711 lifestyle program proven to help you achieve lifelong results, · Rally Wellness Coaching one step at a time. It includes: 1-800-478-1057, TTY 711 · Online group sessions (and one-on-one sessions for · Tobacco Cessation those that qualify) led by a coach 1-866-784-8454, TTY 711 · A health coach who will partner with you and guide you to a healthier, happier you · A community of members to keep you motivated · Goal-setting tools, trackers and weekly content to help you learn and stay engaged · A free Success Kit with all the tools you need delivered right to your door Rally Wellness Coaching helps you get healthy your way by giving you personalized coaching support and access to digital health and wellness courses. It includes: · The ability to set your own goals—from sleeping better to eating smarter · Tailored support from a coach through online chat or a phone call · Self-paced courses and guided discussions 24/7 A tobacco cessation program providing you with the support you need to quit all types of tobacco use. It includes: · 5 sessions with a coach to support and guide you through the quitting process · Online learning that includes video, articles, quizzes and action cards

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 120 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Stress management, nutrition and physical activity content designed to help you through your quit journey *Real Weight Loss or Real Appeal Diabetes Prevention are available based on your unique needs *Real Appeal Weight Management is available to those with a BMI of 19 and higher. Real Appeal Diabetes Prevention is available to you if you have a BMI ≥ 25 (BMI ≥ 23 for Asian Americans), have Prediabetes, and no previous diagnosis of Type 1 or Type 2 Diabetes. If you are pregnant, please speak with your primary care physician before joining the program. Limitations and restrictions apply. There is no coinsurance, Screening and counseling to reduce alcohol misuse copayment, or deductible for We cover one alcohol misuse screening per year for adults the Medicare-covered screening with Medicare (including pregnant women) who misuse and counseling to reduce alcohol, but aren’t alcohol dependent. alcohol misuse preventive If you screen positive for alcohol misuse, you can get up to benefit. four brief face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, Screening for lung cancer with low dose computed tomography (LDCT) copayment, or deductible for For qualified individuals, a LDCT is covered every 12 the Medicare-covered months. counseling and shared decision making visit or for the LDCT. Eligible members are: people aged 50 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack-years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision making

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 121 Services that are covered for you What you must pay when you get these services in-network and out-of-network visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non-physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non- physician practitioner. If a physician or qualified non- physician practitioner elects to provide a lung cancer screening counseling and shared decision-making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, Screening for sexually transmitted infections (STIs) and counseling to prevent STIs copayment, or deductible for We cover sexually transmitted infection (STI) screenings for the Medicare-covered screening chlamydia, gonorrhea, syphilis, and Hepatitis B. These for STIs and counseling for STIs screenings are covered for pregnant women and for certain preventive benefit. people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to two individual 20 to 30 minute, face-to- face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. Services to treat kidney disease Covered services include: · Kidney disease education services to teach kidney care $0 copayment for Medicare- and help members make informed decisions about their covered benefits.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 122 Services that are covered for you What you must pay when you get these services in-network and out-of-network care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime. · Outpatient dialysis treatments (including dialysis $0 copayment for Medicare- covered benefits.†† treatments when temporarily out of the service area, as explained in Chapter 3, or when your provider for this service is temporarily unavailable or inaccessible) · Self-dialysis training (includes training for you and $0 copayment for Medicare- anyone helping you with your home dialysis treatments) covered benefits. · Inpatient dialysis treatments (if you are admitted as an These services will be covered inpatient to a hospital for special care) as described in the following sections: Please refer to Inpatient hospital care. · Home dialysis equipment and supplies Please refer to Durable medical equipment and related supplies. · Certain home support services (such as, when Please refer to Home health necessary, visits by trained dialysis workers to check on agency care. your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.”

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 123 Services that are covered for you What you must pay when you get these services in-network and out-of-network Skilled nursing facility (SNF) care $0 copayment each day for (For a definition of “skilled nursing facility care,” see Chapter Medicare-covered SNF care.†† 12 of this document. Skilled nursing facilities are sometimes You are covered for inpatient called “SNFs.”) services in a SNF, in Covered services include, but are not limited to: accordance with Medicare · Semiprivate room (or a private room if medically guidelines. Original Medicare necessary) benefit periods do not apply. · Meals, including special diets · Skilled nursing services · Physical therapy, occupational therapy, and speech language therapy · Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.) · Blood - including storage and administration. Coverage begins with the first pint of blood that you need. · Medical and surgical supplies ordinarily provided by SNFs · Laboratory tests ordinarily provided by SNFs · X-rays and other radiology services ordinarily provided by SNFs · Use of appliances such as wheelchairs ordinarily provided by SNFs · Physician/practitioner services A 3-day prior hospital stay is not required. There is no coinsurance, Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) copayment, or deductible for If you use tobacco, we cover two counseling quit attempts the Medicare-covered smoking within a 12-month period as a preventive service. Each and tobacco use cessation counseling attempt includes up to four face-to-face visits. preventive benefits.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 124 Services that are covered for you What you must pay when you get these services in-network and out-of-network Supervised exercise therapy (SET) $0 copayment for each SET is covered for members who have symptomatic Medicare-covered supervised exercise therapy (SET) visit.†† peripheral artery disease (PAD) and have a referral from the physician responsible for PAD treatment. Up to 36 sessions over a 12-week period are covered if the SET program requirements are met. The SET program must: · Consist of sessions lasting 30-60 minutes, comprising of a therapeutic exercise-training program for PAD in patients with claudication · Be conducted in a hospital outpatient setting or a physician’s office · Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD · Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider. Urgently needed services $15 copayment for each visit. Urgently needed services are provided to treat a non- You do not pay this amount if emergency, unforeseen medical illness, injury, or condition you are admitted to the hospital that requires immediate medical care but given your within 24 hours for the same circumstances, it is not possible, or it is unreasonable, to condition. obtain services from network providers. If it is unreasonable You pay these amounts until given your circumstances to immediately obtain the medical you reach the out-of-pocket care from a network provider, then your plan will cover the maximum. urgently needed services from a provider out-of-network. Services must be immediately needed and medically

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 125 Services that are covered for you What you must pay when you get these services in-network and out-of-network necessary. Examples of urgently needed services that the plan must cover out of network occur if: You are temporarily outside the service area of the plan and require medically needed immediate services for an unforeseen condition but it is not a medical emergency; or it is unreasonable given your circumstances to immediately obtain the medical care from a network provider. Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished in-network. Worldwide coverage for ‘urgently needed services’ when medical services are needed right away because of an illness, injury, or condition that you did not expect or anticipate, and you can’t wait until you are back in our plan’s service area to obtain services. Services provided by a dentist are not covered. Virtual behavioral visits $0 copayment using providers UnitedHealthcare’s virtual behavioral visits lets you choose that have the ability and are to see and speak to a mental health professional using your qualified to offer virtual computer or a mobile device, like a tablet or smart phone. behavioral visits. This service can be used for initial evaluation, medication management and ongoing counseling. Providers can’t prescribe medications in all states. Virtual Behavioral Health also includes cognitive behavioral health therapy. Cognitive behavioral health therapy is a type of therapy that works on your thoughts and beliefs and how they affect your actions. Virtual doctor visits $0 copayment using providers UnitedHealthcare’s virtual doctor visits lets you choose to that have the ability and are see and speak to doctors using your computer or a mobile qualified to offer virtual medical visits.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 126 Services that are covered for you What you must pay when you get these services in-network and out-of-network device, like a tablet or smart phone. These doctors are providers that have the ability to offer virtual doctor visits. During a virtual visit, you can ask questions, get a diagnosis and the doctor may be able to prescribe medication that, if appropriate, can be sent to your pharmacy. Doctors can’t prescribe medications in all states. You can find a list of participating virtual doctors online at retiree.uhc.com/ wapebb. Vision services Covered services include: · Outpatient physician services provided by an $0 copayment for each ophthalmologist or optometrist for the diagnosis and Medicare-covered exam.†† treatment of diseases and injuries of the eye, including diagnosis or treatment for age-related macular degeneration or cataracts. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts. · For people who are at high risk of glaucoma, we will $0 copayment for Medicare- cover one glaucoma screening each year. People at covered glaucoma screening. high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older. · For people with diabetes or signs and symptoms of eye $0 copayment for each disease, eye exams to evaluate for eye disease are Medicare-covered diabetic eye †† covered per Medicare guidelines. Annual examinations exam. by an ophthalmologist or optometrist are recommended for asymptomatic diabetics.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 127 Services that are covered for you What you must pay when you get these services in-network and out-of-network · One pair of eyeglasses or contact lenses after each $0 copayment for one pair of cataract surgery that includes insertion of an intraocular Medicare-covered standard lens (additional pairs of eyeglasses or contacts are not glasses or contact lenses after covered by Medicare). If you have two separate cataract cataract surgery. operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery. Covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating). Routine vision services Eye Exam ‡ Please turn to Section 4 Routine Vision Services of this $0 copayment for 1 exam every chapter for more detailed information about this benefit. 12 months.* Eyewear Plan pays up to $300 combined allowance for eyeglasses and contact lenses every 24 months.* There is no coinsurance, “Welcome to Medicare” Preventive Visit copayment, or deductible for The plan covers the one-time “Welcome to Medicare” the “Welcome to Medicare” preventive visit. The visit includes a review of your health, as preventive visit. well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit, as

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 128 Services that are covered for you What you must pay when you get these services in-network and out-of-network described for each separate service in this medical benefits chart. Important: We cover the “Welcome to Medicare” preventive visit only within the first 12 months you have Medicare Part B. When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit. Wigs^ The plan pays up to $100 for Wigs will be covered for hair loss due to chemotherapy or wigs per plan year.* radiation therapy. * Covered services that do not count toward your maximum out-of-pocket amount. †† Covered services where your provider may need to request prior authorization. ^ Coverage for these services, excluding wigs for chemotherapy, are in addition to your Medicare Advantage plan benefits. Unlike your Medicare Advantage plan medical coverage, you cannot file a Medicare appeal or grievance for non-Medicare benefits. If you have questions, please call Customer Service using the information on the cover of this booklet. § Call Customer Service at the number on your UnitedHealthcare member ID card for more details. ‡ Some services not covered by Original Medicare, such as routine vision, acupuncture and chiropractic care, will only be paid up to the Medicare allowable amount when services are from an out-of-network provider.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 129 Section 3 What Medical services are not covered by the plan? Section 3.1 Medical services we do not cover (exclusions) This section tells you what services are “excluded” from Medicare coverage and therefore, are not covered by this plan. The chart below lists services and items that either are not covered under any condition or are covered only under specific conditions. If you get services that are excluded (not covered), you must pay for them yourself, except under the specific conditions listed below. Even if you receive the excluded services at an emergency facility, the excluded services are still not covered and our plan will not pay for them. The only exception is if the service is appealed and decided upon appeal to be a medical service that we should have paid for or covered because of your specific situation. (For information about appealing a decision we have made to not cover a medical service, go to Chapter 9, Section 5.3 in this document.) Services not covered by Not covered under any Covered only under specific Medicare condition conditions Services considered not Not covered under any reasonable and necessary, condition according to Original Medicare standards. Experimental medical and May be covered by Original surgical procedures, equipment Medicare under a Medicare- and medications. approved clinical research study or by our plan. (See Experimental procedures and Chapter 3, Section 5 for more items are those items and information on clinical research procedures determined by studies.) Original Medicare to not be generally accepted by the medical community. Private room in a hospital. Covered only when medically necessary. Personal items in your room at a Not covered under any hospital or a skilled nursing condition facility, such as a telephone or a television.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 130 Services not covered by Not covered under any Covered only under specific Medicare condition conditions Full-time nursing care in your Not covered under any home. condition Custodial care. Not covered under any condition Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing. Homemaker services including Not covered under any basic household assistance, condition such as light housekeeping or light meal preparation. Fees charged for care by your Not covered under any immediate relatives or members condition of your household. Cosmetic surgery or Covered in cases of an procedures. accidental injury or for improvement of the functioning of a malformed body member. Covered for all stages of reconstruction for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. Chiropractic services Manual manipulation of the (Medicare-covered) spine to correct a subluxation is covered. Excluded from Medicare coverage is any service other than manual manipulation of the spine for the treatment of subluxation.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 131 Services not covered by Not covered under any Covered only under specific Medicare condition conditions Routine dental care, such as Not covered under any cleanings, exams or x-rays. condition Non-routine dental care. Dental care required to treat illness or injury may be covered as inpatient or outpatient care. Home-delivered meals. Not covered under any condition Orthopedic shoes or supportive Shoes that are part of a leg devices for the feet. brace and are included in the cost of the brace. Orthopedic or therapeutic shoes for people with diabetic foot disease. (As specifically described as a covered service in the medical benefits chart in this chapter.) Outpatient prescription drugs. Some coverage provided according to Medicare guidelines. (As specifically described in the medical benefits chart in this chapter or as outlined in Chapter 6.) Elective hysterectomy, tubal Your plan sponsor only covers ligation, or vasectomy, if the tubal ligations and vasectomies. primary indication for these procedures is sterilization. Reversal of sterilization procedures, penile vacuum erection devices, or non- prescription contraceptive supplies. Acupuncture (Medicare- Available for people with covered). chronic low back pain under certain circumstances. (As specifically described in the medical benefits chart in this chapter.)

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 132 Services not covered by Not covered under any Covered only under specific Medicare condition conditions All services, procedures, Not covered under any treatments, medications and condition supplies related to workers’ compensation claims. Physical examinations for the Not covered under any purpose of maintaining or condition obtaining employment, licenses, insurance, court hearings, travel, dietary counseling, weight reduction programs or for premarital and pre-adoption purposes and/or other non-preventive reasons. Abortion. Cases resulting in pregnancies from rape or incest or that endanger the life of the mother. Your plan sponsor covers elective abortions. Health services for treatment of Not covered under any military service related condition disabilities provided by the Military Health Services System (including CHAMPUS or TRICARE) under which the federal government agrees to pay for the services and supplies. Paramedic intercept service Services are only covered when (advanced life support provided the ambulance pick-up address by an emergency service entity, is located in rural New York and such as a paramedic services applicable conditions are met. unit, which do not provide Members are responsible for all ambulance transport) paramedic intercept service costs that occur outside of rural New York. Optional, additional, or deluxe Not covered under any features or accessories to condition durable medical equipment,

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 133 Services not covered by Not covered under any Covered only under specific Medicare condition conditions corrective appliances or prosthetics which are primarily for the comfort or convenience of the member, or for ambulation primarily in the community, including but not limited to home and car remodeling or modification, and exercise equipment. Immunizations for foreign travel Not covered under any purposes. condition The following services and Transplants performed Transportation services, except items are excluded from in a non-Medicare- as covered in accordance with coverage under the transplant certified transplant Medicare guidelines. program: facility. Food and housing costs except Non-Medicare-covered as covered in accordance with organ transplants. Medicare guidelines. Transplant services, Storage costs for any organ or including donor costs, bone marrow. when the transplant recipient is not a Bone marrow transplants or member. stem cell transplantation, Artificial or non-human except as a treatment for an organs. appropriate diagnosis as specifically stated in the Transportation of any Medicare coverage guidelines potential donor for or in the Evidence of Coverage. typing and matching. Services for which government funding or other insurance coverage is available. Any non-emergency care As specifically described in the received outside of the United medical benefits chart in this States and the U.S Territories. chapter.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 134 Services not covered by Not covered under any Covered only under specific Medicare condition conditions For transplants: items not Not covered under any covered include, but are not condition limited to the below. For transportation: · Vehicle rental, purchase, or maintenance/repairs · Auto clubs (roadside assistance) · Gas · Travel by air or ground ambulance (may be covered under your medical benefit). · Air or ground travel not related to medical appointments · Parking fees incurred other than at lodging or hospital For lodging: · Deposits · Utilities (if billed separate from the rent payment) · Phone calls, newspapers, movie rentals and gift cards · Expenses for lodging when staying with a relative or friend · Meals Personal emergency response As specifically described as a system (PERS) covered service in the medical benefits chart in this chapter. Rally Coach™ programs As specifically described as a covered service in the medical benefits chart in this chapter. UnitedHealthcare Healthy at As specifically described as a Home post-discharge program covered service in the medical benefits chart in this chapter.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 135 Services not covered by Not covered under any Covered only under specific Medicare condition conditions Fitness program As specifically described as a Renew Active® by covered service in the medical UnitedHealthcare. benefits chart in this chapter. Self-administered drugs in an Covered only under specific outpatient hospital conditions. We regularly review new procedures, devices and drugs to determine whether or not they are safe and effective for members. New procedures and technology that are safe and effective are eligible to become covered services. If the technology becomes a covered service, it will be subject to all other terms and conditions of the plan, including medical necessity and any applicable member copayments, coinsurance, deductibles or other payment contributions. In determining whether to cover a service, we use proprietary technology guidelines to review new devices, procedures and drugs, including those related to behavioral/mental health. When clinical necessity requires a rapid determination of the safe and effective use of a new technology or new application of an existing technology for an individual member, one of our medical directors makes a medical necessity determination based on individual member medical documentation, review of published scientific evidence, and, when appropriate, relevant specialty or professional opinion from an individual who has expertise in the technology. Section 4 Other additional benefits (not covered under Original Medicare) Introduction Your health and well-being are important to us, which is why we’ve developed the additional benefit(s) detailed in this section: · Routine hearing services · Routine vision services · Routine chiropractic services · Routine acupuncture services · Naturopathic services The benefit(s) described on the following pages are designed to help you stay healthy and provide well-rounded health coverage. Please read this section carefully, and reference it later if need be, to help you know what services are covered under your plan. If you ever have questions about what is covered, how to make a claim or about any other issue, please call Customer Service (phone numbers for Customer Service are on the cover of this booklet). We are always happy to provide answers to any questions you may have. We’re here to serve you. The information in this section describes the following benefits: · Routine eye exam and routine eyewear

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 136 · Routine chiropractic care · Routine acupuncture services · Naturopathic services Refer to the Routine hearing services benefit section below for more details on your routine hearing benefit. These are covered health services when you follow the coverage rules in the Evidence of Coverage. These services are in addition to Medicare-covered benefits outlined in the Evidence of Coverage. The provisions of this section are incorporated into and made a part of your Evidence of Coverage. Copayments or coinsurance for these covered health services do not apply toward the annual out- of-pocket maximum (if applicable to your plan) described earlier in this chapter. Further details on the benefits available as part of your additional benefit(s) (if applicable) are detailed in the section titled: Covered services. Submit a claim or request reimbursement When you obtain services, the service provider normally submits a claim on your behalf. If the service provider is unwilling to do so, you can ask us for reimbursement. Refer to Chapter 7 Section 2 How to ask us to pay you back or to pay a bill you have received. Hearing aids ordered through providers other than UnitedHealthcare Hearing are not covered. Limitation of liability We will not reduce or deny a claim for failure to furnish such proof within the time required, provided a claim is furnished as soon as reasonably possible. Except in the absence of legal capacity, we will not accept a claim more than one (1) year from the date of service. Access your benefits You may see doctors and other health care professionals, medical groups, hospitals, and other health care facilities that are not contracted with UnitedHealthcare, as long as they accept the plan, and have not opted out of or been excluded or precluded from the Medicare Program, and as long as the services are covered benefits and are medically necessary. Unlike most PPO plans, with this plan you pay the same cost share in-network and out-of-network. You may receive covered services from a provider anywhere in the United States by taking the following steps: · Locate a provider of your choice. · Call your selected provider’s office to schedule your services. · Pay the appropriate cost shares at the time of your service, if applicable. · When you go to the provider’s office for services, you may be asked to show your UnitedHealthcare member ID card. It is important to note that the provider has the right to decide whether or not he or she will agree to submit the bill for covered services directly to us for payment at the time he or she furnishes covered services to you. If the provider does not wish to submit the bill directly to us please follow the instructions under “Submit a claim or request reimbursement”.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 137 Out-of-network benefits You can choose to use your in-network benefits with a network provider or use your out-of-network benefits with an out-of-network provider. Routine hearing services Covered Services The following services are covered under your additional hearing benefit: Routine Hearing Exam You can receive one hearing exam, every year through any hearing service provider, including a UnitedHealthcare Hearing provider. No authorization needed. For more information, see Access Your Benefits earlier in this section. Check the Medical Benefits Chart above for any copayment or coinsurance that may be due at the time of your exam. Hearing Aids Hearing aids are medical devices that fit in or near the ear. You must visit a provider in the UnitedHealthcare Hearing network or purchase through UnitedHealthcare Hearing’s website for your hearing aids to be covered. With UnitedHealthcare Hearing, you receive a broad selection of name brand and private-labeled prescription hearing aids, including some virtual appointment options. The benefit may be utilized toward the purchase of certain non-prescription (over-the- counter) hearing aids through UnitedHealthcare Hearing only. To access your hearing aid benefit, call UnitedHealthcare Hearing at 1-866-445-2071, TTY 711. A hearing counselor will verify your eligibility and help determine your hearing care needs, including if you need a routine hearing exam. Then they will help you find a convenient location and make your appointment. A prescription hearing aid purchase includes: · 1 hearing exam for evaluation and fitting of hearing aids every year · A trial period · 3 hearing aid follow-up appointments within the first year - 1 follow-up appointment for hearing aids purchased in the Silver technology level · A 3-year extended warranty The warranty for non-prescription (over-the-counter) hearing aids varies by manufacturer. Non- prescription hearing aids do not require any of the following: · A medical exam · A fitting by an audiologist · A written prescription

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 138 Check the Medical Benefits Chart above for the amount of your benefit and how often you can purchase hearing aids. Limitations and exclusions The limitations and exclusions below apply to your additional hearing aid benefit: · This benefit may be changed or terminated at the end of the plan year. · Hearing aids ordered through providers other than UnitedHealthcare Hearing are not covered. · Government treatment for any services provided in a local, state or federal government facility or agency, except when federal or state law requires payment under the plan. · Any treatment or services caused by or resulting from employment, or covered under any public liability insurance, including Workers’ Compensation programs. · Covered expenses related to hearing aids are limited to the plan’s Usual and Customary (U&C) charge of a basic hearing aid to provide functional improvement. · Certain hearing aid items and services are not covered, such as: - Replacement of a hearing aid that is lost, broken or stolen if it exceeds covered rate of occurrence - Repair of the hearing aid and related services - An eyeglass-type hearing aid or additional charges for a hearing aid designed specifically for cosmetic purposes - Services, accessories, or supplies that are not medically necessary according to professionally accepted standards of practice - Replacement batteries or assistive listening devices - Services received outside of the plan’s coverage dates, warranty or trial period - Services you choose to have that are not covered under the benefit will be at your own cost - Non-prescription (over-the-counter) hearing aids purchased outside of UnitedHealthcare Hearing Routine Vision Services Vision service providers Vision coverage is through the UnitedHealthcare Medical network. Providers should contact the provider number on the back of your UnitedHealthcare member ID card to confirm eligibility and benefits. You may visit any vision service provider for routine vision services. Out-of-network vision providers may require you to pay the full cost of the service and then submit to UnitedHealthcare for reimbursement. For more information on this process, please see Chapter 7. For more information please see Access Your Benefits earlier in this section.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 139 Covered services The following services are covered under your vision benefit: Routine eye exam A routine vision exam every 12 months, through a network or out-of-network vision provider. Routine eyewear The plan provides an eyewear benefit for vision correction not related to cataract surgery. Eyewear consists of frames and lenses (eyeglasses) or contact lenses. For routine vision services from an out-of-network vision or eyewear provider, you may need to pay the full cost of the service and then submit to UnitedHealthcare for reimbursement. For more information on this process, please see 7. Please refer to the Medical Benefits Chart above for details about your routine eyewear benefit. Limitations and exclusions The limitations and exclusions below apply to your routine vision benefit: · Medically necessary services covered under Original Medicare. · Government treatment for any services provided in a local, state or federal government facility or agency, except when federal or state law requires payment under the plan. · Any treatment or services caused by or resulting from employment, or covered under any public liability insurance, including Worker's Compensation programs. · Orthoptics or vision training and any associated supplemental testing. - Plano lenses (non-prescription). - 2 pair of glasses instead of bifocals. - Subnormal (low) vision aids. - Replacement of lenses and frames which are lost or broken, except at the normal intervals when services are otherwise available. - LASIK, surgeries or other laser procedures. - Any eye exam or corrective eyewear required by an employer as a condition of employment. Routine Chiropractic Services Chiropractic service providers You may visit any chiropractor for routine chiropractic services. For more information please see Access Your Benefits earlier in this section. Covered services

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 140 The following services are covered under your additional chiropractic benefit: · A limited number of visits per year, including evaluation of X-rays. · An initial exam with a chiropractor to determine the nature of your problem and prepare a treatment plan if necessary. · Follow-up visits to chiropractors, as indicated by a treatment plan, which may include spinal and extraspinal manipulations, therapy, and X-ray procedures with the exception of those listed in the limitations and exclusions, and extraspinal manipulation when medically necessary. · Any of the following when medically necessary: radiology codes for the spine, traction, whirlpool, manual electrical stimulation, ultrasound, therapeutic exercise, neuromuscular reeducation, massage when performed by a chiropractor, attended therapy techniques, dynamic therapeutic activities, spinal manipulation, and extraspinal manipulation. · A re-evaluation to assess the need to continue, extend or change your treatment plan. If a separate appointment is made to re-evaluate your treatment plan, it will count as a visit and a copayment or coinsurance will be required. · X-rays and laboratory tests are covered in full when prescribed by a chiropractor for medically necessary services. X-ray interpretations or consultations are only covered when performed by a chiropractor or an American Radiology Association (ARA) radiologist. Please refer to the Medical Benefits Chart above for your copayment or coinsurance and the number of visits allowed under this plan. Limitations and exclusions The limitations and exclusions below apply to your additional chiropractic benefit: · Government treatment for any services provided in a local, state or federal government facility or agency, except when federal or state law requires payment under the plan. · Any treatment or services caused by or resulting from employment, or covered under any public liability insurance, including Worker’s Compensation programs. · Terms and conditions of coverage not outlined in the Evidence of Coverage. · Any accommodation, service, supply or other item determined not to be medically necessary, except for routine covered chiropractic services. · Services for an exam or treatment of strictly non-neuromuscular-skeletal disorders. · Services that are not documented as necessary and appropriate, or are experimental or investigational chiropractic care. · Diagnostic scanning, including Magnetic Resonance Imaging (MRI), CAT scans and/or other types of diagnostic scanning. · Any services or treatment for Temporomandibular Joint Disease (TMJ). TMJ is a condition of the jaw joint that commonly causes headaches, tenderness of the jaw muscles or dull aching facial pain. Treatment or service for pre-employment physicals or vocational rehabilitation. · · Thermography.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 141 · Hypnotherapy, behavior training, sleep therapy, weight programs, educational programs, non- medical self-care or self-help including any self-help physical exercise training, or any related diagnostic testing. · Air conditioners, air purifiers, therapeutic mattress supplies or any other similar devices or appliances. · Vitamins, minerals, nutritional supplements or other similar-type products. · Manipulation under anesthesia, hospitalization or any related services. · Prescription drugs or medicines, including non-legend or proprietary medicine, that don't require a prescription order. · Measurement codes, transcutaneous electrical nerve stimulator (TENS) unit for chronic low back pain and related supplies, assistant at surgery, unattended electrical stimulation, gait training, osteopathic manipulation, foot orthotics, X-rays other than for the spine, infrared and ultraviolet therapy, vertebral axial decompression, and massage not performed by a chiropractor. Routine Acupuncture Services Acupuncture service providers You may visit any acupuncturist for routine acupuncture services. For more information please see Access Your Benefits earlier in this section. Covered services The following services are covered under your additional acupuncture benefit: · Services for diagnosis and treatment to correct body imbalances and conditions such as lower back pain, sprains and strains (such as tennis elbow or sprained ankle), nausea, headaches, menstrual cramps and carpal tunnel syndrome. Please refer to the Medical Benefits Chart above for your copayment or coinsurance amount, annual maximum and number of visits allowed under this plan. Limitations and exclusions The limitations and exclusions below apply to your additional acupuncture benefit: · Government treatment for any services provided in a local, state or federal government facility or agency, except when federal or state law requires payment under the plan. · Any treatment or services caused by or resulting from employment, or covered under any public liability insurance, including Worker’s Compensation programs. · Terms and conditions of coverage not outlined in the Evidence of Coverage. · Diagnostic scanning, including Magnetic Resonance Imaging (MRI) and CAT scans. · Thermography. · Hypnotherapy, behavior training, sleep therapy, weight programs, educational programs, non- medical self-care or self-help including any self-help physical exercise training, or any related diagnostic testing.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 142 · Vitamins, minerals, nutritional supplements or other similar-type products. · Acupuncture under anesthesia, hospitalization or any related services. · Intravenous injections or solutions. · Prescription drugs or medicines, including non-legend or proprietary medication, that don't require a prescription order. Naturopathic Services You may visit any Naturopathic Provider for routine, medically related services. How to submit a claim or request reimbursement for naturopathic services If your provider doesn't submit a claim for you, you can ask us for a reimbursement. To receive a reimbursement, you must: · Get a copy of your itemized receipt(s) from the service provider · Make sure the receipt shows: - The provider’s name, address and phone number - Your name - The date the service was completed - The amount you paid (or “paid in full” if the total amount has been paid) · Send us the receipt(s) within 90 days of the date of service, or as soon as reasonably possible OptumHealth Care Solutions, LLC P.O. Box 212 Minneapolis, MN 55440-0212 We will process your reimbursement based on your benefits and send you an Explanation of Benefits (EOB). Limitations and exclusions This benefit does not cover herbs; homeopathic remedies, medications and nutritional supplements; vitamins or vitamin injections.

Chapter 5 Chapter 5: Using the plan’s coverage for Part D prescription drugs

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 144 Section 1 Introduction This chapter explains rules for using your coverage for Part D drugs. Please see Chapter 4 for Medicare Part B drug benefits and hospice drug benefits. Section 1.1 Basic rules for the plan’s Part D drug coverage The plan will generally cover your drugs as long as you follow these basic rules: · You must have a provider (a doctor, dentist, or other prescriber) write you a prescription which must be valid under applicable state law. · Your prescriber must not be on Medicare’s Exclusion or Preclusion Lists. · You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill your prescriptions at a network pharmacy or through the plan’s preferred mail-order service.) · Your drug must be on the plan’s List of Covered Drugs (Formulary) (we call it the Drug List for short). (See Section 3, Your drugs need to be on the plan’s Drug List.) · Your drug must be used for a medically accepted indication. A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain references. (See Section 3 for more information about a medically accepted indication.) Section 2 Fill your prescription at a network pharmacy or through the plan’s preferred mail-order service Section 2.1 Use a network pharmacy In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at out- of-network pharmacies.) A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. The term “covered drugs” means all of the Part D prescription drugs that are on the plan’s Drug List. Section 2.2 Network pharmacies How do you find a network pharmacy in your area? To find a network pharmacy, you can look in your Pharmacy Directory, visit our website (retiree.uhc.com/wapebb), and/or call Customer Service. You may go to any of our network pharmacies. What if the pharmacy you have been using leaves the network? If the pharmacy you have been using leaves the plan’s network, you will have to find a new pharmacy that is in the network. To find another pharmacy in your area, you can get help from

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 145 Customer Service or use the Pharmacy Directory. You can also find information on our website at retiree.uhc.com/wapebb. What if you need a specialized pharmacy? Some prescriptions must be filled at a specialized pharmacy. Specialized pharmacies include: · Pharmacies that supply drugs for home infusion therapy. · Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, a LTC facility (such as a nursing home) has its own pharmacy. If you have any difficulty accessing your Part D benefits in an LTC facility, please contact Customer Service. · Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska Natives have access to these pharmacies in our network. · Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special handling, provider coordination, or education on their use. (Note: This scenario should happen rarely.) To locate a specialized pharmacy, look in your Pharmacy Directory or call Customer Service. Section 2.3 Using the plan’s preferred mail-order service Our plan’s preferred mail-order service allows you to order up to a 90-day supply for Tiers 1, 2, and 3, and up to a 30-day supply for Tier 4. To get order forms and information about filling your prescriptions by mail you may contact our preferred mail service pharmacy, OptumRx™. OptumRx can be reached at 1-888-279-1828, or for the hearing impaired, (TTY) 711, 24 hours a day, 7 days a week. Please reference your Pharmacy Directory to find the mail service pharmacies in our network. If you use a mail-order pharmacy not in the plan’s network, your prescription will not be covered. Usually a mail-order pharmacy order will be delivered to you in no more than 10 business days. However, sometimes your mail-order may be delayed. If your mail-order is delayed, please follow these steps: If your prescription is on file at your local pharmacy, go to your pharmacy to fill the prescription. If your delayed prescription is not on file at your local pharmacy, then please ask your doctor to call in a new prescription to your pharmacist. Or, your pharmacist can call the doctor’s office for you to request the prescription. Your pharmacist can call the Pharmacy help desk at 1-877-889-6510, (TTY) 711, 24 hours a day, 7 days a week if he/she has any problems, questions, concerns, or needs a claim override for a delayed prescription. New prescriptions the pharmacy receives directly from your doctor’s office. The pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without checking with you first, if either: · You used mail-order services with this plan in the past, or · You sign up for automatic delivery of all new prescriptions received directly from health care providers. You may request automatic delivery of all new prescriptions at any time by phone or mail.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 146 If you receive a prescription automatically by mail that you do not want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund. If you used mail order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please contact us by phone or mail. If you have never used our mail-order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. It is important that you respond each time you are contacted by the pharmacy, to let them know whether to ship, delay, or cancel the new prescription. Refills on mail-order prescriptions. For refills of your drugs, you have the option to sign up for an automatic refill program. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use our auto-refill program but still want the mail-order pharmacy to send you your prescription, please contact your pharmacy 10 days before your current prescription will run out. This will ensure your order is shipped to you in time. To opt out of our program that automatically prepares mail-order refills, please contact us by calling Optum Rx at 1-877-889-5802. If you receive a refill automatically by mail that you do not want, you may be eligible for a refund. Please keep your mail order pharmacy informed about the best way(s) to contact you, so the pharmacy can reach you to confirm your order before shipping. You can do this by contacting the mail order pharmacy when you set up your auto refill program and also when you receive notifications about upcoming refill shipments. Section 2.4 How can you get a long-term supply of drugs? When you get a long-term supply of drugs, your cost-sharing may be lower. The plan offers two ways to get a long-term supply (also called an “extended supply”) of “maintenance” drugs on our plan’s Drug List. (Maintenance drugs are drugs that you take on a regular basis, for a chronic or long-term medical condition.) 1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs. Your Pharmacy Directory tells you which pharmacies in our network can give you a long-term supply of maintenance drugs. You can also call Customer Service for more information. 2. You may also receive maintenance drugs through our mail-order program. Please see Section 2.3 for more information. Section 2.5 When can you use a pharmacy that is not in the plan’s network? Your prescription may be covered in certain situations Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 147 you can get your prescriptions filled as a member of our plan. Please check first with Customer Service to see if there is a network pharmacy nearby. You will most likely be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy: · Prescriptions for a medical emergency We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care, are included in our Drug List without restrictions, and are not excluded from Medicare Part D coverage. · Coverage when traveling or out of the service area When traveling within the U.S. you have access to network pharmacies nationwide. Bring your prescriptions and medication with you and be sure to check the pharmacy directory for your travel plans to locate a network pharmacy while traveling. If you are leaving the country, you may be able to obtain a greater day supply to take with you before leaving for the country where there are no network pharmacies available. · For more information about prescriptions while you travel, refer to the Medical Benefits Chart in Chapter 4, Section 2.1. · If you are unable to obtain a covered drug in a timely manner within the service area because a network pharmacy that provides 24-hour service is not within reasonable driving distance. · If you are trying to fill a prescription drug not regularly stocked at an accessible network retail or preferred mail-order pharmacy (including high cost and unique drugs). · If you need a prescription while a patient in an emergency department, provider based clinic, outpatient surgery, or other outpatient setting. How do you ask for reimbursement from the plan? If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal cost share) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Chapter 7, Section 2 explains how to ask the plan to pay you back.) Section 3 Your drugs need to be on the plan’s Drug List Section 3.1 The Drug List tells which Part D drugs are covered The plan has a “List of Covered Drugs (Formulary).” In this Evidence of Coverage, we call it the Drug List for short. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list meets Medicare’s requirements and has been approved by Medicare. The drugs on the Drug List are only those covered under Medicare Part D. We will generally cover a drug on the plan’s Drug List as long as you follow the other coverage rules explained in this chapter and the use of the drug is a medically accepted indication. A “medically accepted indication” is a use of the drug that is either:

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 148 · Approved by the Food and Drug Administration for the diagnosis or condition for which it is being prescribed. · -- or -- Supported by certain references, such as the American Hospital Formulary Service Drug Information and the DRUGDEX Information System. The Drug List includes brand name drugs and generic drugs. A brand name drug is a prescription drug that is sold under a trademarked name owned by the drug manufacturer. Brand name drugs that are more complex than typical drugs (for example, drugs that are based on a protein) are called biological products. On the drug list, when we refer to “drugs,” this could mean a drug or a biological product. A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, generics work just as well as the brand name drug and usually cost less. There are generic drug substitutes available for many brand name drugs. What is not on the Drug List? The plan does not cover all prescription drugs. · In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more information about this, see Section 7.1 in this chapter). · In other cases, we have decided not to include a particular drug on the Drug List. In some cases, you may be able to obtain a drug that is not on the drug list. For more information, please see Chapter 9. Section 3.2 There are 4 “cost-sharing tiers” for drugs on the Drug List Every drug on the plan’s Drug List is in one of 4 cost-sharing tiers. In general, the higher the cost- sharing tier, the higher your cost for the drug: Tier 1 – Preferred Generic - All covered generic drugs. In addition, Part D eligible generic drug compound medications are covered in Tier 1. Tier 2 – Preferred Brand - Many common brand name drugs, called preferred brands. Tier 3 – Non-preferred Drug - Non-preferred brand name drugs. In addition, Part D eligible compound medications are covered in Tier 3. Tier 4 – Specialty Tier - Unique and/or very high-cost brand drugs. To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List. The amount you pay for drugs in each cost-sharing tier is shown in Chapter 6 (What you pay for your Part D prescription drugs). Section 3.3 How can you find out if a specific drug is on the Drug List? You have three ways to find out: 1. Visit the plan’s website (retiree.uhc.com/wapebb) for the most current information. 2. Call Customer Service to find out if a particular drug is on the plan’s Drug List or to ask for a copy of the list.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 149 3. Use the plan’s “Real-Time Benefit Tool” (retiree.uhc.com/wapebb or by calling Customer Service). With this tool you can search for drugs on the “Drug List” to see an estimate of what you will pay and if there are alternative drugs on the “Drug List” that could treat the same condition. Section 4 There are restrictions on coverage for some drugs Section 4.1 Why do some drugs have restrictions? For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to encourage you and your provider to use drugs in the most effective ways. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug List. If a safe, lower-cost drug will work just as well medically as a higher-cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. Please note that sometimes a drug may appear more than once in our Drug List. This is because the same drugs can differ based on the strength, amount, or form of the drug prescribed by your health care provider, and different restrictions or cost-sharing may apply to the different versions of the drug (for instance, 10 mg versus 100 mg; one per day versus two per day; tablet versus liquid). Section 4.2 What kinds of restrictions? The sections below tell you more about the types of restrictions we use for certain drugs. If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in order for us to cover the drug. Contact Customer Service to learn what you or your provider would need to do to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 9) Restricting brand name drugs when a generic version is available Generally, a generic drug works the same as a brand name drug and usually costs less. In most cases, when a generic version of a brand name drug is available, our network pharmacies will provide you the generic version instead of the brand name drug. However, if your provider has told us the medical reason that the generic drug will not work for you OR has written “No substitutions” on your prescription for a brand name drug OR has told us the medical reason that neither the generic drug nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.) What is a compounded drug? A compounded drug is created by a pharmacist by combining or mixing ingredients to create a prescription medication customized to the needs of an individual patient. Does my Part D plan cover compounded drugs? Generally compounded drugs are non-formulary drugs (not covered) by your plan. You may need to ask for and receive an approved coverage determination from us to have your compounded

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 150 drug covered. Compounded drugs may be Part D eligible if they meet all of the following requirements: 1. Contains at least one FDA, or Compendia, approved drug ingredient, and all ingredients in the compound (including their intended route of administration) are supported in the Compendia. 2. Does not contain a non-FDA approved or Part D excluded drug ingredient 3. Does not contain an ingredient covered under Part B. (If it does, the compound may be covered under Part B rather than Part D) 4. Prescribed for a medically accepted condition The chart below explains the basic requirements for how a compound with 2 or more ingredients may or may not be covered under Part D rules, as well as potential costs to you. Compound Type Medicare Coverage Compound containing a Part B eligible Compound is covered only by Part B ingredient Compound containing all ingredients eligible Compound may be covered by Part D upon for Part D coverage and all ingredients are approved coverage determination approved for use in a compound Compound containing ingredients eligible for Compound may be covered by Part D upon Part D coverage and approved for use in a approved coverage determination. However, compound, and ingredients excluded from the ingredients excluded from Part D Part D coverage (for example, over the counter coverage will not be covered and you are not drugs, etc.) responsible for the cost of those ingredients excluded from Part D coverage Compound containing an ingredient not Compound is not covered by Part D. You are approved or supported for use in a compound responsible for the entire cost What do I have to pay for a covered compounded drug? A compounded drug that is Part D eligible may require an approved coverage determination to be covered by your plan. You will pay the non-preferred drug copay or coinsurance amount for compounded drugs that are approved. No further tier cost share reduction is allowed or available. Getting plan approval in advance For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. This is called “prior authorization.” This is put in place to ensure medication safety and help guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. Trying a different drug first This requirement encourages you to try less costly but usually just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 151 plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called “step therapy.” Quantity limits For certain drugs, we limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. Section 5 What if one of your drugs is not covered in the way you’d like it to be covered? Section 5.1 There are things you can do if your drug is not covered in the way you’d like it to be covered There are situations where there is a prescription drug you are taking, or one that you and your provider think you should be taking, that is not on our drug list (formulary) or is on our formulary with restrictions. For example: · The drug might not be covered at all. Or maybe a generic version of the drug is covered but the brand name version you want to take is not covered. · The drug is covered, but there are extra rules or restrictions on coverage for that drug, as explained in Section 4. · The drug is covered, but it is in a cost-sharing tier that makes your cost-sharing more expensive than you think it should be. · There are things you can do if your drug is not covered in the way that you’d like it to be covered. If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn what you can do. · If your drug is in a cost-sharing tier that makes your cost more expensive than you think it should be, go to Section 5.3 to learn what you can do. Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way? If your drug is not on the Drug List or is restricted, here are options: · You may be able to get a temporary supply of the drug. · You can change to another drug. · You can request an exception and ask the plan to cover the drug or remove restrictions from the drug. You may be able to get a temporary supply Under certain circumstances, the plan must provide a temporary supply of a drug that you are already taking. This temporary supply gives you time to talk with your provider about the change in coverage and decide what to do. To be eligible for a temporary supply, the drug you have been taking must no longer be on the plan’s Drug List OR is now restricted in some way.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 152 · If you are a new member, we will cover a temporary supply of your drug during the first 90 days of your membership in the plan. · If you were in the plan last year, we will cover a temporary supply of your drug during the first 90 days of the plan year. · This temporary supply will be for at least a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to at least a 30-day supply of medication. The prescription must be filled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) · For those members who have been in the plan for more than 90 days and reside in a long- term care facility and need a supply right away: We will cover at least a 31-day emergency supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply. · For those current members with level of care changes: There may be unplanned transitions such as hospital discharges (including psychiatric hospitals) or level of care changes (i.e., changing long-term care facilities, exiting and entering a long-term care facility, ending Part A coverage within a skilled nursing facility, or ending hospice coverage and reverting to Medicare coverage) that can occur anytime. If you are prescribed a drug that is not on our Drug List or your ability to get your drugs is restricted in some way, you are required to use the plan’s exception process. For most drugs, you may request a one-time temporary supply of at least 30 days to allow you time to discuss alternative treatment with your doctor or to request a Drug List (formulary) exception. If your doctor writes your prescription for fewer days, you may refill the drug until you’ve received at least a 30 day supply. For questions about a temporary supply, call Customer Service. During the time when you are using a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You have two options: 1) You can change to another drug Talk with your provider about whether there is a different drug covered by the plan that may work just as well for you. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. 2) You can ask for an exception You and your provider can ask the plan to make an exception and cover the drug in the way you would like it covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception. For example, you can ask the plan to cover a drug even though it is not on the plan’s Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions. If you are a current member and a drug you are taking will be removed from the formulary or restricted in some way for next year, we will tell you about any change prior to the new year. You can ask for an exception before next year and we will give you an answer within 72 hours after we

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 153 receive your request (or your prescriber’s supporting statement). If we approve your request, we will authorize the coverage before the change takes effect. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells you what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. Section 5.3 What can you do if your drug is in a cost-sharing tier you think is too high? If your drug is in a cost-sharing tier you think is too high, here are things you can do: You can change to another drug If your drug is in a cost-sharing tier you think is too high, talk to your provider. There may be a different drug in a lower cost-sharing tier that might work just as well for you. Call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your provider to find a covered drug that might work for you. You can ask for an exception You and your provider can ask the plan to make an exception in the cost-sharing tier for the drug so that you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. Drugs in our Specialty Tier are not eligible for this type of exception. We do not lower the cost- sharing amount for drugs in this tier. Section 6 What if your coverage changes for one of your drugs? Section 6.1 The Drug List can change during the year Most of the changes in drug coverage happen at the beginning of each plan year. However, during the year, the plan can make some changes to the Drug List. For example, the plan might: · Add or remove drugs from the Drug List. · Move a drug to a higher or lower cost-sharing tier. · Add or remove a restriction on coverage for a drug. · Replace a brand name drug with a generic version of the drug. We must follow Medicare requirements before we change the plan’s Drug List. Section 6.2 What happens if coverage changes for a drug you are taking? Information on changes to drug coverage

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 154 When changes to the Drug List occur, we post information on our website about those changes. We also update our website on a regularly scheduled basis. Below we point out the times that you would get direct notice if changes are made to a drug that you are taking. Changes to your drug coverage that affect you during the current plan year · A new generic drug replaces a brand name drug on the Drug List (or we change the cost- sharing tier or add new restrictions to the brand name drug or both) - We may immediately remove a brand name drug on our Drug List if we are replacing it with a newly approved generic version of the same drug. The generic drug will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. We may decide to keep the brand name drug on our Drug List, but immediately move it to a higher cost-sharing tier or add new restrictions or both when the new generic is added. - We may not tell you in advance before we make that change—even if you are currently taking the brand name drug. If you are taking the brand name drug at the time we make the change, we will provide you with information about the specific change(s). This will also include information on the steps you may take to request an exception to cover the brand name drug. You may not get this notice before we make the change. - You or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 9. · Unsafe drugs and other drugs on the Drug List that are withdrawn from the market - Sometimes a drug may be deemed unsafe or taken off the market for another reason. If this happens, we may immediately remove the drug from the Drug List. If you are taking that drug, we will tell you right away. - Your prescriber will also know about this change, and can work with you to find another drug for your condition. · Other changes to drugs on the Drug List - We may make other changes once the year has started that affect drugs you are taking. For example, we might add a generic drug that is not new to the market to replace a brand name drug on the Drug List or change the cost-sharing tier or add new restrictions to the brand name drug or both. We also might make changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare. - For these changes, we must give you at least 30-days’ advance notice of the change or give you notice of the change and a 30-day refill of the drug you are taking at a network pharmacy. - After you receive notice of the change, you should work with your provider to switch to a different drug that we cover or to satisfy any new restrictions on the drug you are taking. - You or your prescriber can ask us to make an exception and continue to cover the drug for you. For information on how to ask for an exception, see Chapter 9. Changes to the Drug List that do not affect you during this plan year

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 155 We may make certain changes to the Drug List that are not described above. In these cases, the change will not apply to you if you are taking the drug when the change is made; however, these changes will likely affect you starting January 1 of the next plan year if you stay in the same plan. In general, changes that will not affect you during the current plan year are: · We move your drug into a higher cost-sharing tier. · We put a new restriction on the use of your drug. · We remove your drug from the Drug List. If any of these changes happen for a drug you are taking (except for market withdrawal, a generic drug replacing a brand name drug, or other change noted in the sections above), then the change won’t affect your use or what you pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any increase in your payments or any added restrictions to your use of the drug. We will not tell you about these types of changes directly during the current plan year. You will need to check the Drug List for the next plan year (when the list is available during the open enrollment period) to see if there are any changes to the drugs you are taking that will impact you during the next plan year. Section 7 What types of drugs are not covered by the plan? Section 7.1 Types of drugs we do not cover This section tells you what kinds of prescription drugs are “excluded.” This means Medicare does not pay for these drugs. If you get drugs that are excluded, you must pay for them yourself. If you appeal and the requested drug is found not to be excluded under Part D, we will pay for or cover it. (For information about appealing a decision, go to Chapter 9.) Here are four general rules about drugs that Medicare drug plans will not cover under Part D: · Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. · Our plan cannot cover a drug purchased outside the United States or its territories. · Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those indicated on a drug’s label as approved by the Food and Drug Administration. · Coverage for “off-label use” is allowed only when the use is supported by certain references, such as the American Hospital Formulary Service Drug Information and the DRUGDEX Information System. In addition, by law, the following categories of drugs are not covered by Medicare drug plans: · Non-prescription drugs (also called over-the-counter drugs). · Drugs used to promote fertility. · Drugs used for the relief of cough or cold symptoms. · Drugs used for cosmetic purposes or to promote hair growth.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 156 · Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. · Drugs used for the treatment of sexual or erectile dysfunction. · Drugs used for treatment of anorexia, weight loss, or weight gain. · Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. Please note: Your plan sponsor may have elected to offer some of the drugs listed above to you as an additional benefit. If so, you will receive additional information about the drugs they have chosen to offer to you separately, in your plan materials. In addition, if you are receiving Extra Help from Medicare to pay for your prescriptions, the Extra Help program will not pay for the drugs not normally covered. (Please refer to the plan’s Drug List or call Customer Service for more information.) However, if you have drug coverage through Medicaid, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.) Section 8 Filling a prescription Section 8.1 Provide your UnitedHealthcare member ID information To fill your prescription, provide your UnitedHealthcare member ID information, which can be found on your membership card, at the network pharmacy you choose. The network pharmacy will automatically bill the plan for our share of your drug cost. You will need to pay the pharmacy your share of the cost when you pick up your prescription. Section 8.2 What if you don’t have your UnitedHealthcare member ID information with you? If you don’t have your plan membership information with you when you fill your prescription, you or the pharmacy can call the plan to get the necessary information, or you can ask the pharmacy to look up your plan enrollment information. If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the prescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 7, Section 2 for information about how to ask the plan for reimbursement.) Section 9 Part D drug coverage in special situations Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by the plan? If you are admitted to a hospital or to a skilled nursing facility for a stay covered by the plan, we will generally cover the cost of your prescription drugs during your stay. Once you leave the hospital or skilled nursing facility, the plan will cover your prescription drugs as long as the drugs meet all of our rules for coverage described in this Chapter.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 157 Section 9.2 What if you’re a resident in a long-term care (LTC) facility? Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or uses a pharmacy that supplies drugs for all of its residents. If you are a resident of an LTC facility, you may get your prescription drugs through the facility’s pharmacy or the one it uses, as long as it is part of our network. Check your Pharmacy Directory to find out if your LTC facility’s pharmacy or the one that it uses is part of our network. If it isn’t, or if you need more information or assistance, please contact Customer Service. If you are in an LTC facility, we must ensure that you are able to routinely receive your Part D benefits through our network of LTC pharmacies. What if you’re a resident in a long-term care (LTC) facility and need a drug that is not on our Drug List or is restricted in some way? Please refer to Section 5.2 about a temporary or emergency supply. Section 9.3 What if you’re also getting drug coverage from an employer or another retiree group plan? If you currently have other prescription drug coverage through your (or your spouse’s) employer or retiree group please contact that group’s benefits administrator. He or she can help you determine how your current prescription drug coverage will work with our plan. In general, if you have employee or retiree group coverage, the drug coverage you get from us will be secondary to your group coverage. That means your group coverage would pay first. Special note about ‘creditable coverage’: Each year your employer or retiree group should send you a notice that tells if your prescription drug coverage for the next plan year is “creditable.” If the coverage from the group plan is “creditable,” it means that the plan has drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. Keep this notice about creditable coverage, because you may need it later. If you enroll in a Medicare plan that includes Part D drug coverage, you may need this notice to show that you have maintained creditable coverage. If you didn’t get the creditable coverage notice, request a copy from the employer or retiree group's benefits administrator or the employer or union. Section 9.4 What if you’re in Medicare-certified hospice? Hospice and our plan do not cover the same drug at the same time. If you are enrolled in Medicare hospice and require certain drugs (e.g., anti-nausea drugs, laxatives, pain medication or anti- anxiety drugs) that are not covered by your hospice because they are unrelated to your terminal illness and related conditions, our plan must receive notification from either the prescriber or your hospice provider that the drugs are unrelated before our plan can cover the drugs. To prevent delays in receiving these drugs that should be covered by our plan, ask your hospice provider or prescriber to provide notification before your prescription is filled.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 158 In the event you either revoke your hospice election or are discharged from hospice, our plan should cover your drugs as explained in this document. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, bring documentation to the pharmacy to verify your revocation or discharge. Section 10 Programs on drug safety and managing medications Section 10.1 Programs to help members use drugs safely We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as: · Possible medication errors · Drugs that may not be necessary because you are taking another drug to treat the same condition · Drugs that may not be safe or appropriate because of your age or gender · Certain combinations of drugs that could harm you if taken at the same time · Prescriptions for drugs that have ingredients you are allergic to · Possible errors in the amount (dosage) of a drug you are taking · Unsafe amounts of opioid pain medications If we see a possible problem in your use of medications, we will work with your provider to correct the problem. Section 10.2 Drug Management Program (DMP) to help members safely use their opioid medications We have a program that helps make sure members safely use prescription opioids and other frequently abused medications. This program is called a Drug Management Program (DMP). If you use opioid medications that you get from several doctors or pharmacies, or if you had a recent opioid overdose, we may talk to your doctors to make sure your use of opioid medications is appropriate and medically necessary. Working with your doctors, if we decide your use of prescription opioid or benzodiazepine medications may not be safe, we may limit how you can get those medications. If we place you in our DMP, the limitations may be: · Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain pharmacy(ies) · Requiring you to get all your prescriptions for opioid or benzodiazepine medications from a certain doctor(s) · Limiting the amount of opioid or benzodiazepine medications we will cover for you If we plan on limiting how you may get these medications or how much you can get, we will send you a letter in advance. The letter will tell you if we will limit coverage of these drugs for you, or if you’ll be required to get the prescriptions for these drugs only from a specific doctor or pharmacy.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 5: Using the plan’s coverage for Part D prescription drugs 159 You will have an opportunity to tell us which doctors or pharmacies you prefer to use, and about any other information you think is important for us to know. After you’ve had the opportunity to respond, if we decide to limit your coverage for these medications, we will send you another letter confirming the limitation. If you think we made a mistake or you disagree with our decision or with the limitation, you and your prescriber have the right to appeal. If you appeal, we will review your case and give you a decision. If we continue to deny any part of your request related to the limitations that apply to your access to medications, we will automatically send your case to an independent reviewer outside of our plan. See Chapter 9 for information about how to ask for an appeal. You will not be placed in our DMP if you have certain medical conditions, such as active cancer- related pain or sickle cell disease, you are receiving hospice, palliative, or end-of-life care, or live in a long-term care facility. Section 10.3 Medication Therapy Management (MTM) programs to help members manage their medications We have programs that can help our members with complex health needs. One program is called a Medication Therapy Management (MTM) program. These programs are voluntary and free. A team of pharmacists and doctors developed the programs for us to help make sure that our members get the most benefit from the drugs they take. Some members who take medications for different medical conditions and have high drug costs, or are in a DMP to help members use their opioids safely, may be able to get services through an MTM program. If you qualify for the program, a pharmacist or other health professional will give you a comprehensive review of all your medications. During the review, you can talk about your medications, your costs, and any problems or questions you have about your prescription and over-the-counter medications. You’ll get a written summary which has a recommended to-do list that includes steps you should take to get the best results from your medications. You’ll also get a medication list that will include all the medications you’re taking, how much you take, and when and why you take them. In addition, members in the MTM program will receive information on the safe disposal of prescription medications that are controlled substances. It’s a good idea to talk to your doctor about your recommended to-do list and medication list. Bring the summary with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers. Also, keep your medication list up to date and keep it with you (for example, with your ID) in case you go to the hospital or emergency room. If we have a program that fits your needs, we will automatically enroll you in the program and send you information. If you decide not to participate, please notify us and we will withdraw you. If you have any questions about these programs, please contact Customer Service.

Chapter 6 Chapter 6: What you pay for your Part D prescription drugs

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 161 Are you currently getting help to pay for your drugs? If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We sent you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert, please call Customer Service and ask for the “LIS Rider.” Section 1 Introduction Section 1.1 Use this chapter together with other materials that explain your drug coverage This chapter focuses on what you pay for Part D prescription drugs. Your Plan Sponsor has chosen to make supplemental drug coverage available to you. This coverage is in addition to your Part D prescription drug benefit. Section 5.2 of this chapter contains a table that shows your costs for a drug that is covered by both your Part D prescription drug benefit and your supplemental drug coverage. For more information about this supplemental drug coverage you can view the Certificate of Coverage at retiree.uhc.com/wapebb or call Customer Service to have a hard copy sent to you. Your plan sponsor offers additional prescription drug coverage. Please see your Additional Drug Coverage list for more information. To keep things simple, we use “drug” in this chapter to mean a Part D prescription drug. As explained in Chapter 5, not all drugs are Part D drugs – some drugs are covered under Medicare Part A or Part B and other drugs are excluded from Medicare coverage by law. To understand the payment information, you need to know what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs. Chapter 5, Sections 1 through 4 explain these rules. When you use the plan’s “Real-Time Benefit Tool” to look up drug coverage (see Chapter 5, Section 3.3), the cost shown is provided in “real time” meaning the cost you see in the tool reflects a moment in time to provide an estimate of the out-of-pocket costs you are expected to pay. You can also obtain information provided by the “Real-Time Benefit Tool” by calling Customer Service. Section 1.2 Types of out-of-pocket costs you may pay for covered drugs There are different types of out-of-pocket costs for Part D drugs. The amount that you pay for a drug is called “cost-sharing,” and there are three ways you may be asked to pay. · The “deductible” is the amount you pay for drugs before our plan begins to pay its share. · “Copayment” is a fixed amount you pay each time you fill a prescription. · “Coinsurance” is a percentage of the total cost you pay each time you fill a prescription. Section 1.3 How Medicare calculates your out-of-pocket costs

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 162 Medicare has rules about what counts and what does not count toward your out-of-pocket costs. Here are the rules we must follow to keep track of your out-of-pocket costs. These payments are included in your out-of-pocket costs Your out-of-pocket costs include the payments listed below (as long as they are for Part D covered drugs and you followed the rules for drug coverage that are explained in Chapter 5): · The amount you pay for drugs when you are in any of the following drug payment stages: - The Deductible Stage - The Initial Coverage Stage - The Coverage Gap Stage · Any payments you made during this calendar year as a member of a different Medicare prescription drug plan before you joined our plan. It matters who pays: · If you make these payments yourself, they are included in your out-of-pocket costs. · These payments are also included in your out-of-pocket costs if they are made on your behalf by certain other individuals or organizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS drug assistance programs, by a State Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian Health Service. Payments made by Medicare’s “Extra Help” Program are also included. · Some payments made by the Medicare Coverage Gap Discount Program are included in your out-of-pocket costs. The amount the manufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic drugs is not included. Moving on to the Catastrophic Coverage Stage: When you (or those paying on your behalf) have spent a total of $8,000 in out-of-pocket costs within the plan year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage. These payments are not included in your out-of-pocket costs Your out-of-pocket costs do not include any of these types of payments: · Drugs you buy outside the United States and its territories. · Drugs that are not covered by our plan. · Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements for out- of-network coverage. · Prescription drugs covered by Part A or Part B. · Payments you make toward drugs covered under our additional coverage but not normally covered in a Medicare Prescription Drug Plan. · Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 163 · Payments made by the plan for your brand or generic drugs while in the Coverage Gap. · Payments for your drugs that are made by group health plans including employer health plans. · Payments for your drugs that are made by certain insurance plans and government-funded health programs such as TRICARE and the Veterans Affairs. · Payments for your drugs made by a third-party with a legal obligation to pay for prescription costs (for example, Workers’ Compensation). Reminder: If any other organization such as the ones listed above pays part or all of your out-of- pocket costs for drugs, you are required to tell our plan by calling Customer Service. How can you keep track of your out-of-pocket total? . The Part D Explanation of Benefits (EOB) report you receive includes the · We will help you current amount of your out-of-pocket costs. When this amount reaches $8,000, this report will tell you that you have left the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage. · Make sure we have the information we need. Section 3.2 tells what you can do to help make sure that our records of what you have spent are complete and up to date. Section 2 What you pay for a drug depends on which “drug payment stage” you are in when you get the drug Section 2.1 What are the drug payment stages for our plan members? There are four “drug payment stages” for your prescription drug coverage under UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO). How much you pay depends on what stage you are in when you get a prescription filled or refilled. Details of each stage are in Sections 4 through 7 of this chapter. The stages are: Stage 1: Yearly Deductible Stage Stage 2: Initial Coverage Stage Stage 3: Coverage Gap Stage Stage 4: Catastrophic Coverage Stage Section 3 We send you reports that explain payments for your drugs and which payment stage you are in Section 3.1 We send you a monthly summary called the “Part D Explanation of Benefits” (the “Part D EOB”) Our plan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you when

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 164 you have moved from one drug payment stage to the next. In particular, there are two types of costs we keep track of: · We keep track of how much you have paid. This is called your out-of-pocket cost (what you pay including coverage gap discount program payments). · We keep track of your total drug costs. This is the amount you pay out-of-pocket or others pay on your behalf plus the amount paid by the plan. If you have had one or more prescriptions filled through the plan during the previous month we will send you a Part D EOB. The Part D EOB includes: · Information for that month. This report gives the payment details about the prescriptions you have filled during the previous month. It shows the total drug costs, what the plan paid, and what you and others on your behalf paid. · Totals for the year since January 1. This is called “year-to-date” information. It shows the total drug costs and total payments for your drugs since the year began. · Drug price information. This information will display the total drug price, and any percentage change from first fill for each prescription claim of the same quantity. · Available lower cost alternative prescriptions. This will include information about other available drugs with lower cost-sharing for each prescription claim. Section 3.2 Help us keep our information about your drug payments up to date To keep track of your drug costs and the payments you make for drugs, we use records we get from pharmacies. Here is how you can help us keep your information correct and up to date: · Show your UnitedHealthcare member ID card when you get a prescription filled. This helps us make sure we know about the prescriptions you are filling and what you are paying. · Make sure we have the information we need. There are times you may pay for the entire cost of a prescription drug. In these cases, we will not automatically get the information we need to keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs, give us copies of these receipts. Here are examples of when you should give us copies of your drug receipts: - When you purchase a covered drug at a network pharmacy at a special price or using a discount card that is not part of our plan’s benefit. - When you made a copayment for drugs that are provided under a drug manufacturer patient assistance program. - Any time you have purchased covered drugs at out-of-network pharmacies or other times you have paid the full price for a covered drug under special circumstances. - If you are billed for a covered drug, you can ask our plan to pay our share of the cost. For instructions on how to do this, go to Chapter 7, Section 2. · Send us information about the payments others have made for you. Payments made by certain other individuals and organizations also count toward your out-of-pocket costs and help qualify you for catastrophic coverage. For example, payments made by a State Pharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the Indian Health Service, and

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 165 most charities count toward your out-of-pocket costs. Keep a record of these payments and send them to us so we can track your costs. · Check the written report we send you. When you receive a Part D EOB look it over to be sure the information is complete and correct. If you think something is missing or you have any questions, please call us at Customer Service. You can also view your EOB on our website at retiree.uhc.com/wapebb. Be sure to keep these reports. Section 4 During the Deductible Stage, you pay the full cost of your Tier 2, Tier 3 and Tier 4 drugs The Deductible Stage is the first payment stage for your drug coverage. You will pay a yearly deductible of $100 on Tier 2, Tier 3 and Tier 4 drugs. You must pay the full cost of your Tier 2, Tier 3 and Tier 4 drugs until you reach the plan’s deductible amount. The deductible doesn’t apply to covered insulin products and most adult Part D vaccines. The “full cost” is usually lower than the normal full price of the drug, since our plan has negotiated lower costs for most drugs at network pharmacies. Once you have paid $100 for your Tier 2, Tier 3 and Tier 4 drugs, you leave the Deductible Stage and move on to the Initial Coverage Stage. Your plan has a deductible of $100 in Tier 2, Tier 3 and Tier 4. However, your deductible will be different if you receive Medicare’s “Extra Help” with your prescription drug costs. Depending on the level of Extra Help you receive, your deductible may be as low as $0 but not more than $100. You will get a Low Income Subsidy Rider or LIS Rider in a separate mailing. It explains Extra Help and tells you the amount of your deductible. Section 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. The plan has 4 cost-sharing tiers Every drug on the plan’s Drug List is in one of 4 cost-sharing tiers. In general, the higher the cost- sharing tier number, the higher your cost for the drug: Tier 1 – Preferred Generic - All covered generic drugs. In addition, Part D eligible generic drug compound medications are covered in Tier 1. This is the lowest cost-sharing tier. Tier 2 – Preferred Brand - Many common brand name drugs, called preferred brands. Tier 3 – Non-preferred Drug - Non-preferred brand name drugs. In addition, Part D eligible compound medications are covered in Tier 3.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 166 Tier 4 – Specialty Tier - Unique and/or very high-cost brand drugs. This is the highest cost-sharing tier. To find out which cost-sharing tier your drug is in, look it up in the plan’s Drug List. Your pharmacy choices How much you pay for a drug depends on whether you get the drug from: · A network retail pharmacy · A pharmacy that is not in the plan’s network. We cover prescriptions filled at out-of-network pharmacies in only limited situations. Please see Chapter 5, Section 2.5 to find out when we will cover a prescription filled at an out-of-network pharmacy. · The plan’s mail-order pharmacy For more information about these pharmacy choices and filling your prescriptions, see Chapter 5 and the plan’s Pharmacy Directory. Section 5.2 A table that shows your costs for a covered drug During the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or coinsurance. As shown in the table below, the amount of the copayment or coinsurance depends on which cost- sharing tier. Sometimes the cost of the drug is lower than your copayment. In these cases, you pay the lower price for the drug instead of the copayment. For some drugs, you can get a long-term supply (also called an “extended supply”). A long-term supply is up to a 90-day supply. The table below shows what you pay when you get a 30-day supply and a long-term 90-day supply of a drug. Your share of the cost when you get a covered Part D prescription drug**: Tier Standard retail cost- Preferred Mail-order Out-of-network cost- sharing (in-network) cost-sharing sharing (30-day supply) (90-day supply in Tiers (Coverage is limited to 1, 2, and 3, and 30-day certain situations; see supply in Tier 4) Chapter 5 for details.) (30-day supply) Cost-Sharing $5 copayment $10 copayment $5 copayment* Tier 1 Preferred Generic

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 167 Your share of the cost when you get a covered Part D prescription drug**: Cost-Sharing $45 copayment $90 copayment $45 copayment* Tier 2 Preferred 1 Brand Cost-Sharing $100 copayment $200 copayment $100 copayment* Tier 3 Non-preferred 1 Drug Cost-Sharing $100 copayment $100 copayment $100 copayment* Tier 4 (limited to a 30-day Specialty Tier supply) 1 1 You will pay a maximum of $35 for a 1-month supply of each Part D insulin product covered by our plan even if you haven’t paid your Part D deductible. *You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount. **For preferred insulin prescription drugs, you will pay: · $10 for a 30-day supply · $20 for a 31 to 60-day supply · $30 for a 61 to 90-day supply Check the Additional Drug List to see the preferred insulin prescription drug list. If you obtain less than a 90-day supply from the preferred mail-order pharmacy for any reason, the in-network standard retail cost-sharing amount applies. Your Pharmacy Out-of-Pocket Maximum When your total Out-of-Pocket costs (what you pay) reach $2,000 you will not pay any copayment or coinsurance. Your foreign travel prescription drug coverage After you reach your prescription deductible, you’ll pay a $45 copay for a 30-day supply. When you reach the pharmacy out-of-pocket maximum, your copay is $0. To use this benefit, you will need to pay the full cost of the service and then submit a reimbursement claim. We’ll reimburse 100% of the billed charges, minus any applicable copay for each 30-day supply. For more information on this process, please see Chapter 7. This non-Medicare drug coverage is in addition to your Medicare drug coverage. Unlike your Medicare drug coverage, you cannot file a Medicare appeal or grievance for non-Medicare drug coverage. If you have questions, please call Customer Services using the information on the cover of this booklet.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 168 Please see Section 9 of this chapter for more information on Part D vaccines and cost sharing for Part D vaccines. Section 5.3 If your doctor prescribes less than a full month’s supply, you may not have to pay the cost of the entire month’s supply Typically, the amount you pay for a prescription drug covers a full month’s supply. There may be times when you or your doctor would like you to have less than a month’s supply of a drug (for example, when you are trying a medication for the first time). You can also ask your doctor to prescribe, and your pharmacist to dispense, less than a full month’s supply of your drugs, if this will help you better plan refill dates for different prescriptions. If you receive less than a full month’s supply of certain drugs, you will not have to pay for the full month’s supply. · If you are responsible for coinsurance, you pay a percentage of the total cost of the drug. Since the coinsurance is based on the total cost of the drug, your cost will be lower since the total cost for the drug will be lower. · If you are responsible for a copayment for the drug, you will only pay for the number of days of the drug that you receive instead of a whole month. We will calculate the amount you pay per day for your drug (the “daily cost-sharing rate”) and multiply it by the number of days of the drug you receive. Section 5.4 You stay in the Initial Coverage Stage until your total drug costs for the year reach $5,030 You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filled reaches the $5,030 limit for the Initial Coverage Stage. The Part D EOB that you receive will help you keep track of how much you, the plan, and any third parties, have spent on your behalf for your drugs during the year. Many people do not reach the $5,030 limit in a year. We will let you know if you reach this amount. If you do reach this amount, you will leave the Initial Coverage Stage and move on to the Coverage Gap Stage. See Section 1.3 on how Medicare calculates your out-of-pocket costs. Section 6 Costs in the Coverage Gap Stage If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact Customer Service (phone numbers are on the cover of this booklet). After you leave the Initial Coverage Stage, we will continue to pay our share of the cost of your drugs and you pay your share of the cost. You pay these amounts until your yearly out-of-pocket costs reach a maximum amount that Medicare has set. In 2024, that amount is $8,000. Medicare has rules about what counts and what does not count toward your out-of-pocket costs (Section 1.3).

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 169 Coverage Gap Stage coinsurance requirements do not apply to Part D covered insulin products and most adult Part D vaccines. You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier. Please see Section 9 of this chapter for more information on Part D vaccines and cost sharing for Part D vaccines. Section 7 During the Catastrophic Coverage Stage, the plan pays the full cost for your covered Part D drugs · You enter the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $8,000 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year. During this payment stage, the plan pays the full cost for your covered drugs. You pay nothing. Section 8 Additional benefits information This part of Chapter 6 talks about limitations of our plan. 1. Medications will not be covered if prescribed by physicians or other providers who are excluded or precluded from the Medicare program participation. 2. You may refill a prescription when a minimum of seventy-five percent (75%) of the quantity is consumed based on the days supply. 3. Costs for drugs that are not covered under Part D do not count toward your Out-of-Pocket costs. Section 9 Part D Vaccines. What you pay for depends on how and where you get them Important message about what you pay for vaccines – Some vaccines are considered medical benefits. Other vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s Drug List. Our plan covers most adult Part D vaccines at no cost to you even if you haven’t paid your Part D deductible. Refer to your plan’s Drug List or contact Customer Service for coverage and cost sharing details about specific vaccines. There are two parts to our coverage of Part D vaccinations: · The first part of coverage is the cost of the vaccine itself. The second part of coverage is for the cost of . (This is sometimes · giving you the vaccine called the “administration” of the vaccine.) Your costs for a Part D vaccination depend on three things: 1. Whether the vaccine is recommended for adults by an organization called the Advisory Committee on Immunization Practices (ACIP).

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 170 - Most adult Part D vaccinations are recommended by ACIP and cost you nothing. 2. Where you get the vaccine. - The vaccine itself may be dispensed by a pharmacy or provided by the doctor’s office. 3. Who gives you the vaccine. - A pharmacist or another provider may give the vaccine in the pharmacy. Alternatively, a provider may give it in the doctor’s office. What you pay at the time you get the Part D vaccination can vary depending on the circumstances and what drug payment stage you are in. Below are 4 examples of ways you might get a Part D vaccine. Situation 1: You get your vaccination at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to give certain vaccines.) Your cost-share may be lower when you use a network pharmacy. · For most adult Part D vaccines, you will pay nothing. · For other Part D vaccines, you will pay the pharmacy your coinsurance OR copayment for the vaccine itself which includes the cost of giving you the vaccine. · Our plan will pay the remainder of the costs. Situation 2: You get the Part D vaccination at your doctor’s office and they submit a claim on your behalf. · For most adult Part D vaccines, you will pay nothing. · For other Part D vaccines, you will pay your doctor your coinsurance OR copayment for the vaccine itself which includes the cost of giving you the vaccine. (Your doctor is not allowed to charge you more than your plan approved cost- share.) · Our plan will pay the remainder of the costs. Situation 3: You get the Part D vaccine at your doctor's office and ask them not to submit a claim on your behalf. (Your doctor is required to submit a claim unless you ask them not to.) · Before giving you the vaccine, your doctor must tell you what your out-of-pocket costs will be. · When you get the vaccine, you may have to pay for the entire cost of the vaccine itself and the cost for the provider to give it to you. · You can then ask our plan to pay our share of the cost by using the procedures that are described in Chapter 7. · For most adult Part D vaccines, you will be reimbursed the full amount you paid. For other Part D vaccines, you will be reimbursed the amount you paid less your normal coinsurance OR copayment for the vaccine (including administration), and less any difference between the amount the doctor charges and what we normally pay. (If you get “Extra Help,” we will reimburse you for this difference.)

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 6: What you pay for your Part D prescription drugs 171 Situation 4: You buy the Part D vaccine itself at your pharmacy, and then take it to your doctor’s office where they give you the vaccine. · For most adult Part D vaccines, you will pay nothing for the vaccine itself. · For other Part D vaccines, you will have to pay the pharmacy your coinsurance OR copayment for the vaccine itself. · When your doctor gives you the vaccine, they will submit a claim for the administration of the vaccine. Depending on which drug payment stage you're in, you may have to pay an additional coinsurance OR copayment. · If you ask your doctor not to submit a claim, you will pay the entire cost for this service. You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 7. · For most adult Part D vaccines, you will be reimbursed the amount charged by the doctor for administering the vaccine less any difference between the amount the doctor charges and what we normally pay. (If you get “Extra Help,” we will reimburse you for this difference.)

Chapter 7 Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs 173 Section 1 Situations in which you should ask us to pay our share of the cost of your covered services or drugs Sometimes when you get medical care or a prescription drug, you may need to pay the full cost. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. Or you may receive a bill from a provider. In these cases, you can ask our plan to pay you back (paying you back is often called “reimbursing” you). It is your right to be paid back by our plan whenever you’ve paid more than your share of the cost for medical services or drugs that are covered by our plan. There may be deadlines that you must meet to get paid back. Please see Section 2 of this chapter. There may also be times when you get a bill from a provider for the full cost of medical care you have received or possibly for more than your share of cost-sharing as discussed in the document. First try to resolve the bill with the provider. If that does not work, send the bill to us instead of paying it. We will look at the bill and decide whether the services should be covered. If we decide they should be covered, we will pay the provider directly. If we decide not to pay it, we will notify the provider. You should never pay more than plan-allowed cost-sharing. If this provider is contracted you still have the right to treatment. Here are examples of situations in which you may need to ask our plan to pay you back or to pay a bill you have received: 1. When you’ve received medical care from a provider who is not in our plan’s network When you received services from a provider in the United States who is not part of our network, you are only responsible for paying your share of the cost. Ask the provider to bill the plan for our share of the cost. · If you pay the entire amount yourself at the time you receive the care, ask us to pay you back for our share of the cost. Send us the bill, along with documentation of any payments you have made. · You may get a bill from the provider asking for payment that you think you do not owe. Send us this bill, along with documentation of any payments you have already made. - If the provider is owed anything, we will pay the provider directly. - If you have already paid more than your share of the cost of the service, we will determine how much you owed and pay you back for our share of the cost. · Please note: While you can get your care from an out-of-network provider, the provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who has opted out of or been excluded or precluded from the Medicare Program. If the provider is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. · You can also receive emergency or urgently needed services from a provider outside the United States. If you receive emergency or urgently-needed services outside of the United States, the provider may require that you pay for the cost of the services in full. Ask for a written, detailed bill or receipt showing the specific services provided to you. Send a copy of

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs 174 the itemized bill or an itemized receipt to us to pay you back. You should be prepared to assist us in obtaining all of the information necessary to properly process your request for reimbursement, including medical records. 2. When a network provider sends you a bill you think you should not pay Network providers should always bill the plan directly and ask you only for your share of the cost. But sometimes they make mistakes and ask you to pay more than your share. · You only have to pay your cost-sharing amount when you get covered services. We do not allow network providers to add additional separate charges, called “balance billing.” This protection (that you never pay more than your cost-sharing amount) applies even if we pay the provider less than the provider charges for a service and even if there is a dispute and we don’t pay certain provider charges. · Whenever you get a bill from a network provider that you think is more than you should pay, send us the bill. We will contact the provider directly and resolve the billing problem. · If you have already paid a bill to a network provider, but you feel that you paid too much, send us the bill along with documentation of any payment you have made and ask us to pay you back the difference between the amount you paid and the amount you owed under the plan. 3. If you are retroactively enrolled in our plan Sometimes a person’s enrollment in the plan is retroactive. (This means that the first day of their enrollment has already passed. The enrollment date may even have occurred last year.) If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your covered services or drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork such as receipts and bills for us to handle the reimbursement. 4. When you use an out-of-network pharmacy to get a prescription filled If you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. Remember that we only cover out-of-network pharmacies in limited circumstances. See Chapter 5, Section 2.5 for a discussion of these circumstances. 5. When you pay the full cost for a prescription because you don’t have your UnitedHealthcare member ID card with you If you do not have your UnitedHealthcare member ID card with you, you can ask the pharmacy to call the plan or to look up your plan enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs 175 6. When you pay the full cost for a prescription in other situations You may pay the full cost of the prescription because you find that the drug is not covered for some reason. · For example, the drug may not be on the plan’s Drug List or it could have a requirement or restriction that you didn’t know about or don’t think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it. · Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost. 7. When you utilize your worldwide emergency coverage, worldwide urgently needed services, or worldwide emergency transportation benefits You will pay the full cost of emergency services received outside of the United States at the time you receive services. To receive reimbursement from us, you must do the following: · Pay your bill at the time it is received. We will reimburse you for the difference between the amount of your bill and your cost share for the services as outlined in Chapter 4 of this document. · Save all of your receipts and send us copies when you ask us to pay you back. In some situations, we may need to get more information from you or the provider who rendered services to you in order to pay you back for our share of the cost. Please see Chapter 7 Section 2.1 for expense reimbursement for worldwide services. · If you are being asked to pay your bill for worldwide emergency services and are unable to make the payment, please call Customer Service for additional assistance and we may be able to help coordinate payment for covered services on your behalf. All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 9 of this document has information about how to make an appeal. Section 2 How to ask us to pay you back or to pay a bill you have received You may request us to pay you back by sending us a request in writing. If you send a request in writing, send your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipt(s) for your records. To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment. · You don’t have to use the form, but it will help us process the information faster. · Either download a copy of the form from our website (retiree.uhc.com/wapebb) or call Customer Service and ask for the form. Mail your request for payment together with any bills or paid receipts to us at this address: Medical claims payment requests:

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs 176 UnitedHealthcare P.O. Box 30995 Salt Lake City, UT 84130-0995 Part D prescription drug payment requests: OptumRx P.O. Box 650287 Dallas, TX 75265-0287 You must submit your Part C (medical) claim to us within 12 months of the date you received the service, item, or Part B drug. You must submit your Part D (prescription drug) claim to us within 36 months of the date you received the service, item, or drug. Section 3 We will consider your request for payment and say yes or no Section 3.1 We check to see whether we should cover the service or drug and how much we owe When we receive your request for payment, we will let you know if we need any additional information from you. Otherwise, we will consider your request and make a coverage decision. · If we decide that the medical care or drug is covered and you followed all the rules, we will pay for our share of the cost. If you have already paid for the service or drug, we will mail your reimbursement of our share of the cost to you. If you have not paid for the service or drug yet, we will mail the payment directly to the provider. · If we decide that the medical care or drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. We will send you a letter explaining the reasons why we are not sending the payment and your rights to appeal that decision. Section 3.2 If we tell you that we will not pay for all or part of the medical care or drug, you can make an appeal If you think we have made a mistake in turning down your request for payment or the amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to change the decision we made when we turned down your request for payment. The appeals process is a formal process with detailed procedures and important deadlines. For details on how to make this appeal, go to Chapter 9 of this document.

Chapter 8 Chapter 8: Your rights and responsibilities

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 178 Section 1 Our plan must honor your rights and cultural sensitivities as a member of the plan Section 1.1 You have a right to receive information about the organization, its services, its practitioners and providers and member rights and responsibilities. We must provide information in a way that works for you and consistent with your cultural sensitivities (in languages other than English, in braille, in large print, or other alternate formats, etc.) Your plan is required to ensure that all services, both clinical and non-clinical, are provided in a culturally competent manner and are accessible to all enrollees, including those with limited English proficiency, limited reading skills, hearing incapacity, or those with diverse cultural and ethnic backgrounds. Examples of how a plan may meet these accessibility requirements include, but are not limited to provision of translator services, interpreter services, teletypewriters, or TTY (text telephone or teletypewriter phone) connection. Our plan has free interpreter services available to answer questions from non-English speaking members. We can also give you information in braille, in large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan’s benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Customer Service. Our plan is required to give female enrollees the option of direct access to a women’s health specialist within the network for women’s routine and preventive health care services. If providers in the plan’s network for a specialty are not available, it is the plan’s responsibility to locate specialty providers outside the network who will provide you with the necessary care. In this case, you will only pay in-network cost-sharing. If you find yourself in a situation where there are no specialists in the plan’s network that cover a service you need, call the plan for information on where to go to obtain this service at in-network cost-sharing. If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with Customer Service (phone numbers are printed on the cover of this booklet). You may also file a complaint with Medicare by calling 1-800- MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights 1-800-368-1019 or TTY 1-800-537-7697. Section 1.2 We must ensure that you get timely access to your covered services and drugs You have the right to choose an out-of-network provider that participates in Medicare. You have the right to get appointments and covered services from your providers, within a reasonable amount of time. This includes the right to get timely services from specialists when

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 179 you need that care. You also have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays. How to Receive Care After Hours If you need to talk to or see your Primary Care Provider after the office has closed for the day, call your Primary Care Provider’s office. When the on-call physician returns your call he or she will advise you on how to proceed. Because you are a member of the UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) plan, you can see any provider (network or out-of- network) at the same cost share, as long as they accept the plan and have not opted out of or been excluded or precluded from the Medicare Program. If you think that you are not getting your medical care or Part D drugs within a reasonable amount of time, Chapter 9 tells what you can do. Section 1.3 We must protect the privacy of your personal health information Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. · Your “personal health information” includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information. · You have rights related to your information and controlling how your health information is used. We give you a written notice, called a “Notice of Privacy Practice,” that tells about these rights and explains how we protect the privacy of your health information. How do we protect the privacy of your health information? · We make sure that unauthorized people don’t see or change your records. · Except for the circumstances noted below, if we intend to give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you or someone you have given legal power to make decisions for you first. · There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. - We are required to release health information to government agencies that are checking on quality of care. - Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations; typically, this requires that information that uniquely identifies you not be shared You can see the information in your records and know how it has been shared with others You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your health care provider to decide whether the changes should be made.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 180 You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Customer Service. HEALTH PLAN NOTICES OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Medical Information Privacy Notice Effective January 1, 2022 1 We are required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice. We are required by law to abide by the terms of this notice. The terms “information” or “health information” in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care. We will comply with the requirements of applicable privacy laws related to notifying you in the event of a breach of your health information. We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy practices, we will provide to you, in our next annual distribution, either a revised notice or information about the material change and how to obtain a revised notice. We will provide you with this information either by direct mail or electronically, in accordance with applicable law. In all cases, if we maintain a website for your particular health plan, we will post the revised notice on your health plan website, retiree.uhc.com/wapebb. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future. UnitedHealth Group collects and maintains oral, written and electronic information to administer our business and to provide products, services and information of importance to our enrollees. We maintain physical, electronic and procedural security safeguards in the handling and maintenance of our enrollees’ information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction or misuse. How We Collect, Use, and Disclose Information

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 181 We collect, use, and disclose your health information to provide that information: · To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice; and · To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. collect, use, and disclose health information for your treatment, to pay for We have the right to your health care and to operate our business. For example, we may use or disclose your health information: Ÿ For Payment of premiums due us, to determine your coverage, and to process claims for health care services you receive, including for subrogation or coordination of other benefits you may have. For example, we may tell a doctor whether you are eligible for coverage and what percentage of the bill may be covered. Ÿ For Treatment. We may collect, use, and disclose health information to aid in your treatment or the coordination of your care. For example, we may collect information from, or disclose information to, your physicians or hospitals to help them provide medical care to you. Ÿ For Health Care Operations. We may collect, use, and disclose health information as necessary to operate and manage our business activities related to providing and managing your health care coverage. For example, we might talk to your physician to suggest a disease management or wellness program that could help improve your health or we may analyze data to determine how we can improve our services. We may also de-identify health information in accordance with applicable laws. After that information is de-identified, the information is no longer subject to this notice and we may use the information for any lawful purpose. · To Provide You Information on Health-Related Programs or Products such as alternative medical treatments and programs or about health-related products and services, subject to limits imposed by law. · For Plan Sponsors. If your coverage is through an employer sponsored group health plan, we may share summary health information and enrollment and disenrollment information with the plan sponsor. In addition, we may share other health information with the plan sponsor for plan administration purposes if the plan sponsor agrees to special restrictions on its use and disclosure of the information in accordance with federal law. · For Underwriting Purposes. We may collect, use, and disclose your health information for underwriting purposes; however, we will not use or disclose your genetic information for such purposes. · For Reminders. We may use or disclose health information to send you reminders about your benefits or care, such as appointment reminders with providers who provide medical care to you. · For Communications to You. We may communicate, electronically or via telephone, these treatment, payment or health care operation messages using telephone numbers or email addresses you provide to us.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 182 We may collect, use, and disclose your health information for the following purposes under limited circumstances: · As Required by Law. We may disclose information when required to do so by law. · To Persons Involved with Your Care. We may collect, use, and disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity. If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests. Special rules apply regarding when we may disclose health information to family members and others involved in a deceased individual’s care. We may disclose health information to any persons involved, prior to the death, in the care or payment for care of a deceased individual, unless we are aware that doing so would be inconsistent with a preference previously expressed by the deceased. · For Public Health Activities such as reporting or preventing disease outbreaks to a public health authority. · For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency. · For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations. · For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena. · For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime. · To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster. · For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others. · For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness. · For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets federal privacy law requirements. · To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 183 · For Organ Procurement Purposes. We may collect, use, and disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation. · To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. · To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us and pursuant to federal law, to protect the privacy of your information and are not allowed to collect, use, and disclose any information other than as specified in our contract and as permitted by federal law. · Additional Restrictions on Use and Disclosure. Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. Such laws may protect the following types of information: 1. Alcohol and Substance Abuse 2. Biometric Information 3. Child or Adult Abuse or Neglect, including Sexual Assault 4. Communicable Diseases 5. Genetic Information 6. HIV/AIDS 7. Mental Health 8. Minors’ Information 9. Prescriptions 10. Reproductive Health 11. Sexually Transmitted Diseases If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law. Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you. This includes, except for limited circumstances allowed by federal privacy law, not using or disclosing psychotherapy notes about you, selling your health information to others, or using or disclosing your health information for certain promotional communications that are prohibited marketing communications under federal law, without your written authorization. Once you give us authorization to release your health information, we cannot guarantee that the recipient to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at any time in writing, except if we have already acted based on your authorization. To find out where to mail

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 184 your written authorization and how to revoke an authorization, contact the phone number listed on your health plan ID card. What Are Your Rights The following are your rights with respect to your health information: · You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction. · You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address). We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you. In certain circumstances, we will accept your verbal request to receive confidential communications, however; we may also require you confirm your request in writing. In addition, any requests to modify or cancel a previous confidential communication request must be made in writing. Mail your request to the address listed below. · You have the right to see and obtain a copy of certain health information we maintain about you such as claims and case or medical management records. If we maintain your health information electronically, you will have the right to request that we send a copy of your health information in an electronic format to you. You can also request that we provide a copy of your information to a third party that you identify. In some cases, you may receive a summary of this health information. You must make a written request to inspect and copy your health information or have your information sent to a third party. Mail your request to the address listed below. In certain limited circumstances, we may deny your request to inspect and copy your health information. If we deny your request, you may have the right to have the denial reviewed. We may charge a reasonable fee for any copies. · You have the right to ask to amend certain health information we maintain about you such as claims and case or medical management records, if you believe the health information about you is wrong or incomplete. Your request must be in writing and provide the reasons for the requested amendment. Mail your request to the address listed below. If we deny your request, you may have a statement of your disagreement added to your health information. · You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) for treatment, payment, and health care operations purposes; (ii) to you or pursuant to your authorization; and (iii) to correctional institutions or law enforcement officials; and (iv) other disclosures for which federal law does not require us to provide an accounting. · You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 185 paper copy of this notice. If we maintain a website, we will post a copy of the revised notice on our website. You may also obtain a copy of this notice on your website, retiree.uhc.com/ wapebb. · You have the right to make a written request that we correct or amend your personal information. Depending on your state of domicile, you may have the right to request deletion of your personal information. If we are unable to honor your request, we will notify you of our decision. If we deny your request, you have the right to submit to us a written statement of the reasons for your disagreement with our assessment of the disputed information and what you consider to be the correct information. We will make your statement accessible to parties reviewing the information in dispute. Exercising Your Rights · Contacting your Health Plan. If you have any questions about this notice or want information about exercising your rights, please call the toll-free member phone number on your health plan ID card or you may contact a UnitedHealth Group Customer Call Center Representative at 1-855-873-3268 (TTY/RTT 711). · Submitting a Written Request. You can mail your written requests to exercise any of your rights, including modifying or cancelling a confidential communication, requesting copies of your records, or requesting amendments to your record, to us at the following address: UnitedHealthcare Privacy Office PO Box 1459 Minneapolis, MN 55440 · Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the address listed above. You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint. 1 This Medical Information Notice of Privacy Practices applies to the following health plans that are affiliated with UnitedHealth Group: ACN Group of California, Inc.; All Savers Insurance Company; All Savers Life Insurance Company of California; AmeriChoice of New Jersey, Inc.; Arizona Physicians IPA, Inc.; Care Improvement Plus of Texas Insurance Company; Care Improvement Plus South Central Insurance Company; Care Improvement Plus Wisconsin Insurance Company; Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.; Enterprise Life Insurance Company; Freedom Life Insurance Company of America; Golden Rule Insurance Company; Health Plan of Nevada, Inc.; MAMSI Life and Health Insurance Company; March Vision Care, Inc.; MD – Individual Practice Association, Inc.; Medica Health Plans of Florida, Inc.; Medica Healthcare Plans, Inc.; National Pacific Dental, Inc.; National Foundation Life Insurance Company; Neighborhood Health Partnership, Inc.; Nevada Pacific Dental; Optimum Choice, Inc.; Optum Insurance Company of Ohio, Inc.; Oxford Health Insurance, Inc.; Oxford Health Plans (CT), Inc.; Oxford Health Plans (NJ), Inc.; Oxford Health Plans (NY), Inc.; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company; PacifiCare of Arizona, Inc.; PacifiCare of Colorado, Inc.; PacifiCare of Nevada, Inc.;

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 186 Peoples Health, Inc.; Physicians Health Choice of Texas, LLC; Preferred Care Partners, Inc.; Rocky Mountain Health Maintenance Organization, Incorporated; Rocky Mountain HealthCare Options, Inc.; Sierra Health and Life Insurance Company, Inc.; Symphonix Health Insurance, Inc.; UHC of California; U.S. Behavioral Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New York; Unison Health Plan of Delaware, Inc.; UnitedHealthcare Benefits of Texas, Inc.; UnitedHealthcare Community Plan of California, Inc.; UnitedHealthcare Community Plan of Georgia, Inc.; UnitedHealthcare Community Plan of Ohio, Inc.; UnitedHealthcare Community Plan, Inc.; UnitedHealthcare Community Plan of Texas, L.L.C.; UnitedHealthcare Insurance Company; UnitedHealthcare Insurance Company of Illinois; UnitedHealthcare Insurance Company of New York; UnitedHealthcare Insurance Company of the River Valley; UnitedHealthcare Life Insurance Company; UnitedHealthcare of Alabama, Inc.; UnitedHealthcare of Arizona, Inc.; UnitedHealthcare of Arkansas, Inc.; UnitedHealthcare of Colorado, Inc.; UnitedHealthcare of Florida, Inc.; UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of Illinois, Inc.; UnitedHealthcare of Kentucky, Ltd.; UnitedHealthcare of Louisiana, Inc.; UnitedHealthcare of the Mid-Atlantic, Inc.; UnitedHealthcare of the Midlands, Inc.; UnitedHealthcare of the Midwest, Inc.; United Healthcare of Mississippi, Inc.; UnitedHealthcare of New England, Inc.; UnitedHealthcare of New Mexico, Inc.; UnitedHealthcare of New York, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.; UnitedHealthcare of Oregon, Inc.; UnitedHealthcare of Pennsylvania, Inc.; UnitedHealthcare of Texas, Inc.; UnitedHealthcare of Utah, Inc.; UnitedHealthcare of Washington, Inc.; UnitedHealthcare of Wisconsin, Inc.; UnitedHealthcare Plan of the River Valley, Inc. This list of health plans is complete as of the effective date of this notice. For a current list of health plans subject to this notice go to uhc.com/privacy/entities-fn-v1. Financial Information Privacy Notice THIS NOTICE DESCRIBES HOW FINANCIAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY. Effective January 1, 2022 2 We are committed to maintaining the confidentiality of your personal financial information. For the purposes of this notice, “personal financial information” means information about an enrollee or an applicant for health care coverage that identifies the individual, is not generally publicly available, and is collected from the individual or is obtained in connection with providing health care coverage to the individual. Information We Collect Depending upon the product or service you have with us, we may collect personal financial information about you from the following sources: · Information we receive from you on applications or other forms, such as name, address, age, medical information and Social Security number;

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 187 · Information about your transactions with us, our affiliates or others, such as premium payment and claims history; and · Information from a consumer reporting agency. Disclosure of Information We do not disclose personal financial information about our enrollees or former enrollees to any third party, except as required or permitted by law. For example, in the course of our general business practices, we may, as permitted by law, disclose any of the personal financial information that we collect about you, without your authorization, to the following types of institutions: · To our corporate affiliates, which include financial service providers, such as other insurers, and non-financial companies, such as data processors; · To nonaffiliated companies for our everyday business purposes, such as to process your transactions, maintain your account(s), or respond to court orders and legal investigations; and · To nonaffiliated companies that perform services for us, including sending promotional communications on our behalf. Confidentiality and Security We maintain physical, electronic and procedural safeguards, in accordance with applicable state and federal standards, to protect your personal financial information against risks such as loss, destruction or misuse. These measures include computer safeguards, secured files and buildings, and restrictions on who may access your personal financial information. Questions About this Notice If you have any questions about this notice, please call the toll-free member phone number on your health plan ID card or contact the UnitedHealth Group Customer Call Center at 1-855-873-3268 (TTY/RTT 711). 2 For purposes of this Financial Information Privacy Notice, “we” or “us” refers to the entities listed in footnote 2, beginning on page four of the Health Plan Notices of Privacy Practices, plus the following UnitedHealthcare affiliates: AmeriChoice Corporation.; Dental Benefit Providers, Inc.; Ear Professional International Corporation; gethealthinsurance.com Agency, Inc.; Genoa Healthcare, LLC; Golden Outlook, Inc.; Level2 Health IPA, LLC; Level2 Health Management, LLC; Life Print Health, Inc.; Managed Physical Network, Inc.; Optum Care Networks, Inc; Optum Global Solutions (India) Private Limited; OptumHealth Care Solutions, LLC; OptumHealth Holdings, LLC; Optum Labs, LLC; Optum Networks of New Jersey, Inc.; Optum Women’s and Children’s Health, LLC; OrthoNet, LLC; OrthoNet of the South, Inc.; Oxford Benefit Management, Inc.; Oxford Health Plans LLC; Physician Alliance of the Rockies, LLC; POMCO Network, Inc.; POMCO, Inc.; Real Appeal, Inc.; Sanvello Health, Inc.; Spectera, Inc.; Three Rivers Holdings, Inc.; UHIC Holdings, Inc.; UMR, Inc.; ;United Behavioral Health; United Behavioral Health of New York I.P.A., Inc.; UnitedHealthcare, Inc.; United HealthCare Services, Inc.; UnitedHealth Advisors, LLC; UnitedHealthcare Service LLC; Urgent Care MSO, LLC;

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 188 USHEALTH Administrators, LLC; USHEALTH Group, Inc.; and Vivify Health, Inc. This Financial Information Privacy Notice only applies where required by law. Specifically, it does not apply to (1) health care insurance products offered in Nevada by Health Plan of Nevada, Inc. and Sierra Health and Life Insurance Company, Inc.; or (2) other UnitedHealth Group health plans in states that provide exceptions for HIPAA covered entities or health insurance products. This list of health plans is complete as of the effective date of this notice. For a current list of health plans subject to this notice go to uhc.com/privacy/entities-fn-v1. © 2021 United HealthCare Services, Inc. Section 1.4 We must give you information about the plan, its network of providers, and your covered services As a member of our plan, you have the right to get several kinds of information from us. We may also call you occasionally to let you know about other Medicare products and services we offer. Call Customer Service if you want to opt out of receiving these calls or want any of the following kinds of information: · Information about our plan. This includes, for example, information about the plan’s financial condition. · Information about our network providers and pharmacies. - You have the right to get information about the qualifications of the providers and pharmacies in our network and how we pay the providers in our network. · Information about your coverage and the rules you must follow when using your coverage. Chapters 3 and 4 provide information regarding medical services. Chapters 5 and 6 provide information about Part D prescription drug coverage. · Information about why something is not covered and what you can do about it. Chapter 9 provides information on asking for a written explanation on why a medical service or Part D drug is not covered or if your coverage is restricted. Chapter 9 also provides information on asking us to change a decision, also called an appeal. Section 1.5 You have a right to participate with practitioners in making decisions about your health care. We must support your right to make decisions about your care and a candid discussion of appropriate or medically necessary treatment options for your conditions, regardless of cost or benefit coverage. You have the right to know your treatment options and participate in decisions about your health care You have the right to get full information from your doctors and other health care providers. Your providers must explain your medical condition and your treatment choices in a way that you can understand.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 189 You also have the right to participate fully in decisions about your health care. To help you make decisions with your doctors about what treatment is best for you, your rights include the following: · To know about all of your choices. You have the right to be told about all of the treatment options that are recommended for your condition, no matter what they cost or whether they are covered by our plan. It also includes being told about programs our plan offers to help members manage their medications and use drugs safely. · To know about the risks. You have the right to be told about any risks involved in your care. You must be told in advance if any proposed medical care or treatment is part of a research experiment. You always have the choice to refuse any experimental treatments. · The right to say “no.” You have the right to refuse any recommended treatment. This includes the right to leave a hospital or other medical facility, even if your doctor advises you not to leave. You also have the right to stop taking your medication. Of course, if you refuse treatment or stop taking medication, you accept full responsibility for what happens to your body as a result. You have the right to give instructions about what is to be done if you are not able to make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can: · Fill out a written form to give someone the legal authority to make medical decisions for you if you ever become unable to make decisions for yourself. · Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. The legal documents that you can use to give your directions in advance in these situations are called “advance directives.” There are different types of advance directives and different names for them. Documents called “living will” and “power of attorney for health care” are examples of advance directives. If you want to use an “advance directive” to give your instructions, here is what to do: · Get the form. You can get an advance directive form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. You can also contact Customer Service for assistance in locating an advanced directive form. · Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it. · Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form who can make decisions for you if you can’t. You may want to give copies to close friends or family members. Keep a copy at home. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you to the hospital. · The hospital will ask you whether you have signed an advance directive form and whether you have it with you.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 190 · If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one. Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. What if your instructions are not followed? If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the appropriate state-specific agency, for example, your State Department of Health. See Chapter 2, Section 3 for contact information regarding your state-specific agency. Section 1.6 You have a right to voice complaints or appeals about the organization or the care it provides. You have the right to make complaints and to ask us to reconsider decisions we have made If you have any problems, concerns, or complaints and need to request coverage, or make an appeal, Chapter 9 of this document tells what you can do. Whatever you do – ask for a coverage decision, make an appeal, or make a complaint – we are required to treat you fairly. Section 1.7 What can you do if you believe you are being treated unfairly or your rights are not being respected? If it is about discrimination, call the Office for Civil Rights If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, sexual orientation, or national origin, you should call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights. Is it about something else? If you believe you have been treated unfairly or your rights have not been respected, and it’s not about discrimination, you can get help dealing with the problem you are having: · You can call Customer Service. · You can call the SHIP. For details, go to Chapter 2, Section 3. · Or, you can call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048). Section 1.8 You have a right to make recommendations regarding the organization’s member rights and responsibilities policy. How to get more information about your rights There are several places where you can get more information about your rights: · You can call Customer Service.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 191 · For information on the quality program for your specific health plan, call Customer Service. You may also access this information via the website (uhcmedicaresolutions.com/resources/ma- pdp-information-forms.html). Select, “Commitment to Quality.” · You can call the SHIP. For details, go to Chapter 2, Section 3. · You can contact Medicare. - You can visit the Medicare website to read or download the publication “Medicare Rights & Protections.” (The publication is available at: medicare.gov/Pubs/pdf/11534-Medicare-Rights-and-Protections.pdf) - Or, you can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048). Section 2 You have some responsibilities as a member of the plan Things you need to do as a member of the plan are listed below. If you have any questions, please call Customer Service. · Get familiar with your covered services and the rules you must follow to get these covered services. Use this Evidence of Coverage to learn what is covered for you and the rules you need to follow to get your covered services. - Chapters 3 and 4 give the details about your medical services. - Chapters 5 and 6 give the details about your Part D prescription drug coverage. · If you have any other health insurance coverage or prescription drug coverage in addition to our plan, you are required to tell us. Chapter 1 tells you about coordinating these benefits. · Tell your doctor and other health care providers that you are enrolled in our plan. Show your UnitedHealthcare member ID card whenever you get your medical care or Part D prescription drugs. · Help your doctors and other providers help you by giving them information, asking questions, and following through on your care. - To help get the best care, tell your doctors and other health providers about your health problems. Follow the treatment plans and instructions that you and your doctors agree upon. - Make sure your doctors know all of the drugs you are taking, including over-the-counter drugs, vitamins, and supplements. - If you have any questions, be sure to ask and get an answer you can understand. · Be considerate. We expect all our members to respect the rights of other patients. We also expect you to act in a way that helps the smooth running of your doctor’s office, hospitals, and other offices. · Pay what you owe. As a plan member, you are responsible for these payments: - You must continue to pay your Medicare Part B premium to remain a member of the plan. - For most of your medical services or drugs covered by the plan, you must pay your share of the cost when you get the service or drug.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 8: Your rights and responsibilities 192 - If you are required to pay a late enrollment penalty, you must pay the penalty to keep your prescription drug coverage. - If you are required to pay the extra amount for Part D because of your yearly income, you must continue to pay the extra amount directly to the government to remain a member of the plan. - If you move outside of our plan service area, you cannot remain a member of our plan. - If you move within our plan service area, we need to know so we can keep your membership record up to date and know how to contact you. - If you move, it is also important to tell Social Security (or the Railroad Retirement Board).

Chapter 9 Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints)

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 194 Section 1 Introduction Section 1.1 What to do if you have a problem or concern This chapter explains two types of processes for handling problems and concerns: · For some problems, you need to use the process for coverage decisions and appeals. · For other problems, you need to use the process for making complaints; also called grievances. Both of these processes have been approved by Medicare. Each process has a set of rules, procedures, and deadlines that must be followed by us and by you. The guide in Section 3 will help you identify the right process to use and what you should do. Section 1.2 What about the legal terms? There are legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to understand. To make things easier, this chapter: · Uses simpler words in place of certain legal terms. For example, this chapter generally says “making a complaint” rather than “filing a grievance,” “coverage decision” rather than “organization determination” or “coverage determination” or “at-risk determination” and “independent review organization” instead of “Independent Review Entity.” · It also uses abbreviations as little as possible. However, it can be helpful – and sometimes quite important – for you to know the correct legal terms. Knowing which terms to use will help you communicate more accurately to get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations. Section 2 Where to get more information and personalized assistance We are always available to help you. Even if you have a complaint about our treatment of you, we are obligated to honor your right to complain. Therefore, you should always reach out to customer service for help. But in some situations, you may also want help or guidance from someone who is not connected with us. Below are two entities that can assist you. State Health Insurance Assistance Program (SHIP) Each state has a government program with trained counselors. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. You will find phone numbers in Chapter 2, Section 3 of this document.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 195 Medicare You can also contact Medicare to get help. To contact Medicare: · You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. · You can also visit the Medicare website (www.medicare.gov). Section 3 To deal with your problem, which process should you use? If you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. The guide that follows will help. Is your problem or concern about your benefits or coverage? This includes problems about whether medical care (medical items, services and/or Part B prescription drugs) are covered or not, the way they are covered, and problems related to payment for medical care. Yes. Go on to the next section of this chapter, Section 4, “A guide to the basics of coverage decisions and appeals.” No. Skip ahead to Section 10 at the end of this chapter: “How to make a complaint about quality of care, waiting times, customer service or other concerns.” Coverage decisions and appeals Section 4 A guide to the basics of coverage decisions and appeals Section 4.1 Asking for coverage decisions and making appeals: the big picture Coverage decisions and appeals deal with problems related to your benefits and coverage for your medical care (services, items and Part B prescription drugs, including payment). To keep things simple, we generally refer to medical items, services and Medicare Part B prescription drugs as medical care. You use the coverage decision and appeals process for issues such as whether something is covered or not and the way in which something is covered. Asking for coverage decisions prior to receiving benefits A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical care. For example, if your plan network doctor refers you to a medical specialist not inside the network, this referral is considered a favorable coverage decision unless either your network doctor can show that you received a standard denial notice for this medical

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 196 specialist, or the Evidence of Coverage makes it clear that the referred service is never covered under any condition. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover medical care before you receive it, you can ask us to make a coverage decision for you. In limited circumstances a request for a coverage decision will be dismissed, which means we won’t review the request. Examples of when a request will be dismissed include if the request is incomplete, if someone makes the request on your behalf but isn’t legally authorized to do so or if you ask for your request to be withdrawn. If we dismiss a request for a coverage decision, we will send a notice explaining why the request was dismissed and how to ask for a review of the dismissal. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases, we might decide medical care is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. Making an appeal If we make a coverage decision, whether before or after a benefit is received and you are not satisfied, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. Under certain circumstances, which we discuss later, you can request an expedited or “fast appeal” of a coverage decision. Your appeal is handled by different reviewers than those who made the original decision. When you appeal a decision for the first time, this is called a Level 1 appeal. In this appeal, we review the coverage decision we made to check to see if we were properly following the rules. When we have completed the review, we give you our decision. In limited circumstances a request for a Level 1 appeal will be dismissed, which means we won’t review the request. Examples of when a request will be dismissed include if the request is incomplete, if someone makes the request on your behalf but isn’t legally authorized to do so or if you ask for your request to be withdrawn. If we dismiss a request for a Level 1 appeal, we will send a notice explaining why the request was dismissed and how to ask for a review of the dismissal. If we say no to all or part of your Level 1 appeal for medical care, your appeal will automatically go on to a Level 2 appeal conducted by an independent review organization that is not connected to us. · You do not need to do anything to start a Level 2 appeal. Medicare rules require we automatically send your appeal for medical care to Level 2 if we do not fully agree with your Level 1 appeal. · See Section 5.4 of this chapter for more information about Level 2 appeals. · For Part D drug appeals, if we say no to all or part of your appeal, you will need to ask for a Level 2 appeal. Part D appeals are discussed further in Section 6 of this chapter. If you are not satisfied with the decision at the Level 2 appeal, you may be able to continue through additional levels of appeal (Section 9 in this chapter explains the Level 3, 4, and 5 appeals processes).

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 197 Section 4.2 How to get help when you are asking for a coverage decision or making an appeal Here are resources if you decide to ask for any kind of coverage decision or appeal a decision: · You can call us at Customer Service. You can get free help from your State Health Insurance Assistance Program. · · Your doctor can make a request for you. If your doctor helps with an appeal past Level 2, they will need to be appointed as your representative. Please call Customer Service and ask for the “Appointment of Representative” form. (The form is also available on Medicare’s website at www.cms.gov/Medicare/CMS-Forms/CMSForms/downloads/cms1696.pdf.) - For medical care or Part B prescription drugs, your doctor can request a coverage decision or a Level 1 appeal on your behalf. If your appeal is denied at Level 1, it will be automatically forwarded to Level 2. - For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level 1 appeal on your behalf. If your Level 1 appeal is denied your doctor or prescriber can request a Level 2 appeal. · You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to ask for a coverage decision or make an appeal. - If you want a friend, relative, or another person to be your representative, call Customer Service and ask for the “Appointment of Representative” form. (The form is also available on Medicare’s website at www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1696.pdf .) The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form. - While we can accept an appeal request without the form, we cannot begin or complete our review until we receive it. If we do not receive the form within 44 calendar days after receiving your appeal request (our deadline for making a decision on your appeal), your appeal request will be dismissed. If this happens, we will send you a written notice explaining your right to ask the independent review organization to review our decision to dismiss your appeal. · You also have the right to hire a lawyer. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. Section 4.3 Which section of this chapter gives the details for your situation? There are four different situations that involve coverage decisions and appeals. Since each situation has different rules and deadlines, we give the details for each one in a separate section: · Section 5 of this chapter: “Your medical care: How to ask for a coverage decision or make an appeal”

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 198 · Section 6 of this chapter: “Your Part D prescription drugs: How to ask for a coverage decision or make an appeal of a coverage decision” · Section 7 of this chapter: “How to ask us to cover a longer inpatient hospital stay if you think you are being discharged too soon” · Section 8 of this chapter: “How to ask us to keep covering certain medical services if you think your coverage is ending too soon” (Applies only to these services: home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services) If you’re not sure which section you should be using, please call Customer Service. You can also get help or information from government organizations such as your State Health Insurance Assistance Program. Section 5 Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision Section 5.1 This section tells what to do if you have problems getting coverage for medical care or if you want us to pay you back for our share of the cost of your care This section is about your benefits for medical care. These benefits are described in Chapter 4 of this document: Medical Benefits Chart (what is covered and what you pay). In some cases, different rules apply to a request for a Part B prescription drug. In those cases, we will explain how the rules for Part B prescription drugs are different from the rules for medical items and services. This section tells what you can do if you are in any of the five following situations: 1. You are not getting certain medical care you want, and you believe that this care is covered by our plan. Ask for a coverage decision. Section 5.2. 2. Our plan will not approve the medical care your doctor or other medical provider wants to give you, and you believe that this care is covered by the plan. Ask for a coverage decision. Section 5.2. 3. You have received medical care that you believe should be covered by the plan, but we have said we will not pay for this care. Make an appeal. Section 5.3. 4. You have received and paid for medical care that you believe should be covered by the plan, and you want to ask our plan to reimburse you for this care. Send us the bill. Section 5.5. 5. You are being told that coverage for certain medical care you have been getting that we previously approved will be reduced or stopped, and you believe that reducing or stopping this care could harm your health. Make an appeal. Section 5.3. Note: If the coverage that will be stopped is for hospital care, home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services, you need to read Sections 7 and 8 of this Chapter. Special rules apply to these types of care.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 199 Section 5.2 Step-by-step: How to ask for a coverage decision Legal Terms When a coverage decision involves your medical care, it is called an “organization determination.” A “fast coverage decision” is called an “expedited determination.” Step 1: Decide if you need a “standard coverage decision” or a “fast coverage decision”. A “standard coverage decision” is usually made within 14 days or 72 hours for Part B drugs. A “fast coverage decision” is generally made within 72 hours, for medical services, or 24 hours for Part B drugs. In order to get a fast coverage decision, you must meet two requirements: · You may only ask for coverage for medical items and/or services (not requests for payment for items and/or services already received). · You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. · If your doctor tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision. · If you ask for a fast coverage decision on your own, without your doctor’s support, we will decide whether your health requires that we give you a fast coverage decision. If we do not approve a fast coverage decision, we will send you a letter that: - Explains that we will use the standard deadlines. - Explains if your doctor asks for the fast coverage decision, we will automatically give you a fast coverage decision. - Explains that you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. Step 2: Ask our plan to make a coverage decision or fast coverage decision. Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You, your doctor, or your representative can do this. Chapter 2 has contact information.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 200 Step 3: We consider your request for medical care coverage and give you our answer. For standard coverage decisions we use the standard deadlines. This means we will give you an answer within 14 calendar days after we receive your request for a medical item or service. If your request is for a Medicare Part B prescription drug, we will give you an answer within 72 hours after we receive your request. · However, if you ask for more time, or if we need more information that may benefit you we can take up to 14 more days if your request is for a medical item or service. If we take extra days, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. · If you believe we should not take extra days, you can file a “fast complaint”. We will give you an answer to your complaint as soon as we make the decision. (The process for making a complaint is different from the process for coverage decisions and appeals. See Section 10 of this chapter for information on complaints.) For Fast Coverage decisions we use an expedited timeframe A fast coverage decision means we will answer within 72 hours if your request is for a medical item or service. If your request is for a Medicare Part B prescription drug, we will answer within 24 hours. · However, if you ask for more time, or if we need more information that may benefit you we can take up to 14 more days. If we take extra days, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. · If you believe we should not take extra days, you can file a “fast complaint.” (See Section 10 of this chapter for information on complaints.) We will call you as soon as we make the decision. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. Step 4: If we say no to your request for coverage for medical care, you can appeal. · If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking again to get the medical care coverage you want. If you make an appeal, it means you are going on to Level 1 of the appeals process. Section 5.3 Step-by-step: How to make a Level 1 appeal Legal Terms An appeal to the plan about a medical care coverage decision is called a plan “reconsideration.”

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 201 A “fast appeal” is also called an “expedited reconsideration.” Step 1: Decide if you need a “standard appeal” or a “fast appeal.” A standard appeal is usually made within 30 days or 7 days for Part B drugs. A fast appeal is generally made within 72 hours. · If you are appealing a decision we made about coverage for care that you have not yet received, you and/or your doctor will need to decide if you need a “fast appeal.” If your doctor tells us that your health requires a “fast appeal,” we will give you a fast appeal. · The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision” in Section 5.2 of this chapter. Step 2: Ask our plan for an appeal or a fast appeal · If you are asking for a standard appeal, submit your standard appeal in writing. Chapter 2 has contact information. · If you are asking for a fast appeal, make your appeal in writing or call us. Chapter 2 has contact information. · You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing it, explain the reason your appeal is late when you make your appeal. We may give you more time to make your appeal. Examples of good cause may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal. · You can ask for a copy of the information regarding your medical decision. You and your doctor may add more information to support your appeal. Step 3: We consider your appeal and we give you our answer. · When our plan is reviewing your appeal, we take a careful look at all of the information. We check to see if we were following all the rules when we said no to your request. · We will gather more information if needed, possibly contacting you or your doctor.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 202 Deadlines for a “fast appeal” · For fast appeals, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to. - However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we will tell you in writing. We can’t take extra time if your request is for a Medicare Part B prescription drug. - If we do not give you an answer within 72 hours (or by the end of the extended time period if we took extra days), we are required to automatically send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 5.4 explains the Level 2 appeal process. · If our answer is yes to part or all of what you requested, we must authorize or provide the coverage we have agreed to provide within 72 hours after we receive your appeal. · If our answer is no to part or all of what you requested, we will send you our decision in writing and automatically forward your appeal to the independent review organization for a Level 2 appeal. The independent review organization will notify you in writing when it receives your appeal. Deadlines for a “standard appeal” · For standard appeals, we must give you our answer within 30 calendar days after we receive your appeal. If your request is for a Medicare Part B prescription drug you have not yet received, we will give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if your health condition requires us to. - However, if you ask for more time, or if we need more information that may benefit you, we can take up to 14 more calendar days if your request is for a medical item or service. If we take extra days, we will tell you in writing. We can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. - If you believe we should not take extra days, you can file a “fast complaint”. When you file a fast complaint, we will give you an answer to your complaint within 24 hours. (See Section 10 of this chapter for information on complaints.) - If we do not give you an answer by the deadline (or by the end of the extended time period), we will send your request to a Level 2 appeal, where an independent review organization will review the appeal. Section 5.4 explains the Level 2 appeal process. · If our answer is yes to part or all of what you requested, we must authorize or provide the coverage within 30 calendar days if your request is for a medical item or service, or within 7 calendar days if your request is for a Medicare Part B prescription drug. · If our plan says no to part or all of your appeal, we will automatically send your appeal to the independent review organization for a Level 2 appeal.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 203 Section 5.4 Step-by-step: How a Level 2 appeal is done Legal Term The formal name for the “independent review organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” The independent review organization is an independent organization hired by Medicare. It is not connected with us and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: The independent review organization reviews your appeal. · We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file. · You have a right to give the independent review organization additional information to support your appeal. · Reviewers at the independent review organization will take a careful look at all of the information related to your appeal. If you had a “fast” appeal at Level 1, you will also have a “fast” appeal at Level 2 · For the “fast appeal” the review organization must give you an answer to your Level 2 appeal within 72 hours of when it receives your appeal. · However, if your request is for a medical item or service and the independent review organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The independent review organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug. If you had a “standard” appeal at Level 1, you will also have a “standard” appeal at Level 2 · For a “standard appeal” if your request is for a medical item or service, the review organization must give you an answer to your Level 2 Appeal within 30 calendar days of when it receives your appeal. If your request is for a Medicare Part B prescription drug, the review organization must give you an answer to your Level 2 appeal within 7 calendar days of when it receives your appeal. · However, if your request is for a medical item or service and the independent review organization needs to gather more information that may benefit you, it can take up to 14 more calendar days. The independent review organization can’t take extra time to make a decision if your request is for a Medicare Part B prescription drug.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 204 Step 2: The independent review organization gives you their answer. The independent review organization will tell you its decision in writing and explain the reasons for it. · If the review organization says yes to part or all of a request for a medical item or service, we must authorize the medical care coverage within 72 hours or provide the service within 14 calendar days after we receive the decision from the review organization for standard requests. For expedited requests, we have 72 hours from the date we receive the decision from the review organization. · If the review organization says yes to part or all of a request for a Medicare Part B prescription drug, we must authorize or provide the Part B prescription drug within 72 hours after we receive the decision from the review organization for standard requests. For expedited requests we have 24 hours from the date we receive the decision from the review organization. · If this organization says no to part or all of your appeal, it means they agree with us that your request (or part of your request) for coverage for medical care should not be approved. (This is called “upholding the decision” or “turning down your appeal.”) In this case, the independent review organization will send you a letter: - Explaining its decision. - Notifying you of the right to a Level 3 appeal if the dollar value of the medical care coverage meets a certain minimum. The written notice you get from the independent review organization will tell you the dollar amount you must meet to continue the appeals process. - Telling you how to file a Level 3 appeal. Step 3: If your case meets the requirements, you choose whether you want to take your appeal further. · There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you want to go to a Level 3 appeal the details on how to do this are in the written notice you get after your Level 2 appeal. · The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter explains the Level 3, 4, and 5 appeals processes. Section 5.5 What if you are asking us to pay you for our share of a bill you have received for medical care? Chapter 7 describes when you may need to ask for reimbursement or to pay a bill you have received from a provider. It also tells how to send us the paperwork that asks us for payment.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 205 Asking for reimbursement is asking for a coverage decision from us If you send us the paperwork asking for reimbursement, you are asking for a coverage decision. To make this decision, we will check to see if the medical care you paid for is covered. We will also check to see if you followed all the rules for using your coverage for medical care. · If we say yes to your request: If the medical care is covered and you followed all the rules, we will send you the payment for our share of the cost within 60 calendar days after we receive your request. If you haven’t paid for the medical care, we will send the payment directly to the provider. · If we say no to your request: If the medical care is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the medical care and the reasons why. If you do not agree with our decision to turn you down, you can make an appeal. If you make an appeal, it means you are asking us to change the coverage decision we made when we turned down your request for payment. To make this appeal, follow the process for appeals that we describe in Section 5.3. For appeals concerning reimbursement, please note: · We must give you our answer within 60 calendar days after we receive your appeal. If you are asking us to pay you back for medical care you have already received and paid for, you are not allowed to ask for a fast appeal. · If the independent review organization decides we should pay, we must send you or the provider the payment within 30 calendar days. If the answer to your appeal is yes at any stage of the appeals process after Level 2, we must send the payment you requested to you or to the provider within 60 calendar days. Section 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal Section 6.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug Your benefits include coverage for many prescription drugs. To be covered, the drug must be used for a medically accepted indication. (See Chapter 5 for more information about a medically accepted indication.) For details about Part D drugs, rules, restrictions, and costs please see Chapters 5 and 6. This section is about your Part D drugs only. To keep things simple, we generally say “drug” in the rest of this section, instead of repeating “covered outpatient prescription drug” or “Part D drug” every time. We also use the term “drug list” instead of “List of Covered Drugs” or “Formulary.” · If you do not know if a drug is covered or if you meet the rules, you can ask us. Some drugs require that you get approval from us before we will cover it.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 206 · If your pharmacy tells you that your prescription cannot be filled as written, the pharmacy will give you a written notice explaining how to contact us to ask for a coverage decision. Part D coverage decisions and appeals Legal Term An initial coverage decision about your Part D drugs is called a “coverage determination.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. This section tells what you can do if you are in any of the following situations: · Asking to cover a Part D drug that is not on the plan’s List of Covered Drugs. Ask for an exception. Section 6.2 · Asking to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get). Ask for an exception. Section 6.2 · Asking to pay a lower cost-sharing amount for a covered drug on a higher cost-sharing tier Ask for an exception. Section 6.2 · Asking to get pre-approval for a drug. Ask for a coverage decision. Section 6.4 · Pay for a prescription drug you already bought. Ask us to pay you back. Section 6.4 If you disagree with a coverage decision we have made, you can appeal our decision. This section tells you both how to ask for coverage decisions and how to request an appeal. Section 6.2 What is an exception? Legal Terms Asking for coverage of a drug that is not on the Drug List is sometimes called asking for a “formulary exception.” Asking for removal of a restriction on coverage for a drug is sometimes called asking for a “formulary exception.” Asking to pay a lower price for a covered non-preferred drug is sometimes called asking for a “tiering exception.” If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.” An exception is a type of coverage decision. For us to consider your exception request, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make:

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 207 1. Covering a Part D drug for you that is not on our Drug List. If we agree to cover a drug not on the Drug List, you will need to pay the cost-sharing amount that applies to drugs in Tier 3. You cannot ask for an exception to the cost-sharing amount we require you to pay for the drug. 2. Removing a restriction for a covered drug. Chapter 5 describes the extra rules or restrictions that apply to certain drugs on our Drug List. If we agree to make an exception and waive a restriction for you, you can ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 3. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our plan’s Drug List is in one of 4 cost-sharing tiers. In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost of the drug. - If our Drug List contains alternative drug(s) for treating your medical condition that are in a lower cost-sharing tier than your drug, you can ask us to cover your drug at the cost-sharing amount that applies to the alternative drug(s). - If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost- sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition. - If the drug you’re taking is a generic drug you can ask us to cover your drug at the cost- sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition. - You cannot ask us to change the cost-sharing tier for any drug in Tier 4 Specialty Tier. - If we approve your tiering exception request and there is more than one lower cost-sharing tier with alternative drugs you can’t take, you will usually pay the lowest amount. Section 6.3 Important things to know about asking for exceptions Your doctor must tell us the medical reasons Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an exception. For a faster decision, include this medical information from your doctor or other prescriber when you ask for the exception. Typically, our Drug List includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception. If you ask us for a tiering exception, we will generally not approve your request for an exception unless all the alternative drugs in the lower cost-sharing tier(s) won’t work as well for you or are likely to cause an adverse reaction or other harm. We can say yes or no to your request · If we approve your request for an exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 208 · If we say no to your request, you can ask for another review by making an appeal. Section 6.4 Step-by-step: How to ask for a coverage decision, including an exception Legal Term A “fast coverage decision” is called an “expedited coverage determination.” Step 1: Decide if you need a “standard coverage decision” or a “fast coverage decision.” “Standard coverage decisions” are made within 72 hours after we receive your doctor’s statement. “Fast coverage decisions” are made within 24 hours after we receive your doctor’s statement. If your health requires it, ask us to give you a “fast coverage decision.” To get a fast coverage decision, you must meet two requirements: · You must be asking for a drug you have not yet received. (You cannot ask for fast coverage decision to be paid back for a drug you have already bought.) · Using the standard deadlines could cause serious harm to your health or hurt your ability to function. · If your doctor or other prescriber tells us that your health requires a “fast coverage decision,” we will automatically give you a fast coverage decision. · If you ask for a fast coverage decision on your own, without your doctor or prescriber’s support, we will decide whether your health requires that we give you a fast coverage decision. If we do not approve a fast coverage decision, we will send you a letter that: - Explains that we will use the standard deadlines. - Explains if your doctor or other prescriber asks for the fast coverage decision, we will automatically give you a fast coverage decision. - Tells you how you can file a “fast complaint” about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. We will answer your complaint within 24 hours of receipt. Step 2: Request a “standard coverage decision” or a “fast coverage decision.” Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. You can also access the coverage decision process through our website. We must accept any written request, including a request submitted on the

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 209 CMS Model Coverage Determination Request Form, which is available on our website. Chapter 2 has contact information. To assist us in processing your request, please be sure to include your name, contact information, and information identifying which denied claim is being appealed. You, your doctor, (or other prescriber) or your representative can do this. You can also have a lawyer act on your behalf. Section 4 of this chapter tells how you can give written permission to someone else to act as your representative. · If you are requesting an exception, provide the “supporting statement,” which is the medical reasons for the exception. Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary. Step 3: We consider your request and give you our answer. Deadlines for a “fast” coverage decision · We must generally give you our answer within 24 hours after we receive your request. - For exceptions, we will give you our answer within 24 hours after we receive your doctor’s supporting statement. We will give you our answer sooner if your health requires us to. - If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. · If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor’s statement supporting your request. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal. Deadlines for a “standard” coverage decision about a drug you have not yet received · We must generally give you our answer within 72 hours after we receive your request. - For exceptions, we will give you our answer within 72 hours after we receive your doctor’s supporting statement. We will give you our answer sooner if your health requires us to. - If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. · If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor’s statement supporting your request. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal. Deadlines for a “standard” coverage decision about payment for a drug you have already bought · We must give you our answer within 14 calendar days after we receive your request.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 210 · If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. · If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal. Step 4: If we say no to your coverage request, you can make an appeal. · If we say no, you have the right to ask us to reconsider this decision by making an appeal. This means asking again to get the drug coverage you want. If you make an appeal, it means you are going on to Level 1 of the appeals process. Section 6.5 Step-by-step: How to make a Level 1 appeal Legal Terms An appeal to the plan about a Part D drug coverage decision is called a plan “redetermination.” A “fast appeal” is also called an “expedited redetermination.” Step 1: Decide if you need a “standard appeal” or a “fast appeal.” A “standard appeal” is usually made within 7 days. A “fast appeal” is generally made within 72 hours. If your health requires it, ask for a “fast appeal” · If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.” · The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision” in Section 6.4 of this chapter. Step 2: You, your representative, doctor or other prescriber must contact us and make your Level 1 appeal. If your health requires a quick response, you must ask for a “fast appeal.” · For standard appeals, submit a written request. Chapter 2 has contact information.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 211 · For fast appeals either submit your appeal in writing or call us at 1-855-873-3268. Chapter 2 has contact information. · We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website. Please be sure to include your name, contact information, and information regarding your claim to assist us in processing your request. · You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. If you miss this deadline and have a good reason for missing it, explain the reason your appeal is late when you make your appeal. We may give you more time to make your appeal. Examples of good cause may include a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal. · You can ask for a copy of the information in your appeal and add more information. You and your doctor may add more information to support your appeal. Step 3: We consider your appeal and we give you our answer. · When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information. Deadlines for a “fast appeal” · For fast appeals, we must give you our answer within 72 hours after we receive your appeal. We will give you our answer sooner if your health requires us to. - If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 6.6 explains the Level 2 appeals process. · If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision. Deadlines for a “standard” appeal for a drug you have not yet received · For standard appeals, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. - If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. Section 6.6 explains the Level 2 appeal process.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 212 · If our answer is yes to part or all of what you requested, we must provide the coverage as quickly as your health requires, but no later than 7 calendar days after we receive your appeal. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no and how you can appeal our decision. Deadlines for a “standard appeal” about payment for a drug you have already bought · We must give you our answer within 14 calendar days after we receive your request. - If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent review organization. · If our answer is yes to part or all of what you requested, we are also required to make payment to you within 30 calendar days after we receive your request. · If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how you can appeal. Step 4: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal. · If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process. Section 6.6 Step-by-step: How to make a Level 2 appeal Legal Term The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” The independent review organization is an independent organization hired by Medicare. It is not connected with us and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: You (or your representative or your doctor or other prescriber) must contact the independent review organization and ask for a review of your case. · If our plan says no to your Level 1 appeal, the written notice we send you will include instructions on how to make a Level 2 appeal with the independent review organization. These instructions will tell who can make this Level 2 appeal, what deadlines you must follow, and how to reach the review organization. If, however, we did not complete our review within the applicable timeframe, or make an unfavorable decision regarding “at-risk” determination under our drug management program, we will automatically forward your claim to the IRE.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 213 · We will send the information about your appeal to this organization. This information is called your “case file.” You have the right to ask us for a copy of your case file. · You have a right to give the independent review organization additional information to support your appeal. Step 2: The independent review organization reviews your appeal. Reviewers at the independent review organization will take a careful look at all of the information related to your appeal. Deadlines for “fast” appeal · If your health requires it, ask the independent review organization for a “fast appeal.” · If the organization agrees to give you a “fast appeal,” the organization must give you an answer to your Level 2 appeal within 72 hours after it receives your appeal request. Deadlines for “standard” appeal · For standard appeals, the review organization must give you an answer to your Level 2 appeal within 7 calendar days after it receives your appeal if it is for a drug you have not yet received. If you are requesting that we pay you back for a drug you have already bought, the review organization must give you an answer to your Level 2 appeal within 14 calendar days after it receives your request. Step 3: The independent review organization gives you their answer. For “fast” appeals · If the independent review organization says yes to part or all of what you requested, we must provide the drug coverage that was approved by the review organization within 24 hours after we receive the decision from the review organization. For “standard” appeals · If the independent review organization says yes to part or all of your request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization. · If the independent review organization says yes to part or all of your request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization. What if the review organization says no to your appeal? If this organization says no to part or all of your appeal, it means they agree with our decision not to approve your request (or part of your request). (This is called “upholding the decision.” It is also called “turning down your appeal.”) In this case, the independent review organization will send you a letter:

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 214 · Explaining its decision. · Notifying you of the right to a Level 3 appeal if the dollar value of the drug coverage you are requesting meets a certain minimum. If the dollar value of the drug coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. · Telling you the dollar value that must be in dispute to continue with the appeals process. Step 4: If your case meets the requirements, you choose whether you want to take your appeal further. · There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). · If you want to go on to a Level 3 appeal the details on how to do this are in the written notice you get after your Level 2 appeal decision. · The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 7 How to ask us to cover a longer inpatient hospital stay if you think you are being discharged too soon When you are admitted to a hospital, you have the right to get all of your covered hospital services that are necessary to diagnose and treat your illness or injury. During your covered hospital stay, your doctor and the hospital staff will be working with you to prepare for the day when you will leave the hospital. They will help arrange for care you may need after you leave. · The day you leave the hospital is called your “discharge date.” · When your discharge date is decided, your doctor or the hospital staff will tell you. · If you think you are being asked to leave the hospital too soon, you can ask for a longer hospital stay and your request will be considered. Section 7.1 During your inpatient hospital stay, you will get a written notice from Medicare that tells about your rights Within two days of being admitted to the hospital, you will be given a written notice called An Important Message from Medicare about Your Rights. Everyone with Medicare gets a copy of this notice. If you do not get the notice from someone at the hospital (for example, a caseworker or nurse), ask any hospital employee for it. If you need help, please call Customer Service or 1-800- MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY 1-877-486-2048). 1. Read this notice carefully and ask questions if you don’t understand it. It tells you:

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 215 - Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them. - Your right to be involved in any decisions about your hospital stay. - Where to report any concerns you have about the quality of your hospital care. - Your right to request an immediate review of the decision to discharge you if you think you are being discharged from the hospital too soon. This is a formal, legal way to ask for a delay in your discharge date so that we will cover your hospital care for a longer time. 2. You will be asked to sign the written notice to show that you received it and understand your rights. - You or someone who is acting on your behalf will be asked to sign the notice. - Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date. Signing the notice does not mean you are agreeing on a discharge date. 3. Keep your copy of the notice handy so you will have the information about making an appeal (or reporting a concern about quality of care) if you need it. - If you sign the notice more than two days before your discharge date, you will get another copy before you are scheduled to be discharged. - To look at a copy of this notice in advance, you can call Customer Service or 1-800 MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also see the notice online at www.cms.gov/Medicare/Medicare- General-Information/BNI/HospitalDischargeAppealNotices.html. Section 7.2 Step-by-step: How to make a Level 1 appeal to change your hospital discharge date If you want to ask for your inpatient hospital services to be covered by us for a longer time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are: · Follow the process. · Meet the deadlines. · Ask for help if you need it. If you have questions or need help at any time, please call Customer Service. Or, call your State Health Insurance Assistance Program, a government organization that provides personalized assistance.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 216 During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It checks to see if your planned discharge date is medically appropriate for you. The Quality Improvement Organization is a group of doctors and other health care professionals paid by the Federal government to check on and help improve the quality of care for people with Medicare. This includes reviewing hospital discharge dates for people with Medicare. These experts are not part of our plan. Step 1: Contact the Quality Improvement Organization for your state and ask for an immediate review of your hospital discharge. You must act quickly. How can you contact this organization? · The written notice you received (An Important Message from Medicare About Your Rights) tells you how to reach this organization. Or, find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2. Act quickly: · To make your appeal, you must contact the Quality Improvement Organization before you leave the hospital and no later than midnight the day of your discharge. - If you meet this deadline, you may stay in the hospital after your discharge date without paying for it while you wait to get the decision from the Quality Improvement Organization. - If you do not meet this deadline, and you decide to stay in the hospital after your planned discharge date, you may have to pay all of the costs for hospital care you receive after your planned discharge date. · If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to appeal, you must make an appeal directly to our plan instead. For details about this other way to make your appeal, see Section 7.4. Once you request an immediate review of your hospital discharge the Quality Improvement Organization will contact us. By noon of the day after we are contacted, we will give you a Detailed Notice of Discharge. This notice gives your planned discharge date and explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date. You can get a sample of the by calling Customer Service or 1-800- Detailed Notice of Discharge MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY users should call 1-877-486-2048.) Or you can see a sample notice online at www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices. Step 2: The Quality Improvement Organization conducts an independent review of your case.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 217 · Health professionals at the Quality Improvement Organization (we will call them “the reviewers”) will ask you (or your representative) why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. · The reviewers will also look at your medical information, talk with your doctor, and review information that the hospital and we have given to them. · By noon of the day after the reviewers told us of your appeal, you will get a written notice from us that gives your planned discharge date. This notice also explains in detail the reasons why your doctor, the hospital, and we think it is right (medically appropriate) for you to be discharged on that date. Step 3: Within one full day after it has all the needed information, the Quality Improvement Organization will give you its answer to your appeal. What happens if the answer is yes? · If the review organization says yes, we must keep providing your covered inpatient hospital services for as long as these services are medically necessary. · You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). In addition, there may be limitations on your covered hospital services. What happens if the answer is no? · If the review organization says no, they are saying that your planned discharge date is medically appropriate. If this happens, our coverage for your inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives you its answer to your appeal. · If the review organization says no to your appeal and you decide to stay in the hospital, then you may have to pay the full cost of hospital care you receive after noon on the day after the Quality Improvement Organization gives you its answer to your appeal. Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal. · If the Quality Improvement Organization has said no to your appeal, and you stay in the hospital after your planned discharge date, then you can make another appeal. Making another appeal means you are going on to Level 2 of the appeals process. Section 7.3 Step-by-step: How to make a Level 2 appeal to change your hospital discharge date

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 218 During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at their decision on your first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay the full cost for your stay after your planned discharge date. Step 1: Contact the Quality Improvement Organization again and ask for another review. · You must ask for this review within 60 calendar days after the day the Quality Improvement Organization said no to your Level 1 appeal. You can ask for this review only if you stay in the hospital after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation. · Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 calendar days of receipt of your request for a Level 2 appeal, the reviewers will decide on your appeal and tell you their decision. If the review organization says yes: · We must reimburse you for our share of the costs of hospital care you have received since noon on the day after the date your first appeal was turned down by the Quality Improvement Organization. We must continue providing coverage for your inpatient hospital care for as long as it is medically necessary. · You must continue to pay your share of the costs and coverage limitations may apply. If the review organization says no: · It means they agree with the decision they made on your Level 1 appeal. · The notice you get will tell you in writing what you can do if you wish to continue with the review process. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further by going on to Level 3.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 219 · There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If you want to go to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision. · The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 7.4 What if you miss the deadline for making your Level 1 appeal to change your hospital discharge date? Legal Term A “fast review” (or “fast appeal”) is also called an “expedited appeal.” You can appeal to us instead As explained above, you must act quickly to start your Level 1 appeal of your hospital discharge date. If you miss the deadline for contacting the Quality Improvement Organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 alternate appeal Step 1: Contact our plan and ask for a “fast review.” · Ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Chapter 2 has contact information. Step 2: We do a “fast” review of your planned discharge date, checking to see if it was medically appropriate. · During this review, we take a look at all of the information about your hospital stay. We check to see if your planned discharge date was medically appropriate. We see if the decision about when you should leave the hospital was fair and followed all the rules. Step 3: We give you our decision within 72 hours after you ask for a “fast review”.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 220 · If we say yes to your appeal, it means we have agreed with you that you still need to be in the hospital after the discharge date. We will keep providing your covered inpatient hospital services for as long as they are medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.) · If we say no to your appeal, we are saying that your planned discharge date was medically appropriate. Our coverage for your inpatient hospital services ends as of the day we said coverage would end. - If you stayed in the hospital after your planned discharge date, then you may have to pay the full cost of hospital care you received after the planned discharge date. Step 4: If our plan says no to your appeal, your case will automatically be sent on to the next level of the appeals process. Step-by-Step: Level 2 alternate appeal process Legal Term The formal name for the “Independent Review Organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” The independent review organization is an independent organization hired by Medicare. It is not connected with our plan and is not a government agency. This organization decides whether the decision we made is correct or if it should be changed. Medicare oversees its work. Step 1: We will automatically forward your case to the independent review organization. · We are required to send the information for your Level 2 appeal to the independent review organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. Section 10 of this chapter tells how to make a complaint.) Step 2: The independent review organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. · Reviewers at the Independent review organization will take a careful look at all of the information related to your appeal of your hospital discharge.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 221 · If this organization says yes to your appeal, then we must pay you back for our share of the costs of hospital care you received since the date of your planned discharge. We must also continue the plan’s coverage of your inpatient hospital services for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover your services. · If this organization says no to your appeal, it means they agree that your planned hospital discharge date was medically appropriate. The written notice you get from the independent review organization will tell how to start a - Level 3 appeal with the review process, which is handled by an Administrative Law Judge or attorney adjudicator. Step 3: If the independent review organization turns down your appeal, you choose whether you want to take your appeal further. · There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If reviewers say no to your Level 2 appeal, you decide whether to accept their decision or go on to Level 3 appeal. · Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon Section 8.1 This section is only about three services: Home health care, skilled nursing facility care, and Comprehensive Outpatient Rehabilitation Facility (CORF) services When you are getting covered home health services, skilled nursing care, or rehabilitation care (Comprehensive Outpatient Rehabilitation Facility), you have the right to keep getting your services for that type of care for as long as the care is needed to diagnose and treat your illness or injury. When we decide it is time to stop covering any of the three types of care for you, we are required to tell you in advance. When your coverage for that care ends, we will stop paying our share of the cost for your care. If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal. Section 8.2 We will tell you in advance when your coverage will be ending

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 222 Legal Term “Notice of Medicare Non-Coverage.” It tells you how you can request a “fast-track appeal.” Requesting a fast-track appeal is a formal, legal way to request a change to our coverage decision about when to stop your care. 1. You receive a notice in writing at least two days before our plan is going to stop covering your care. The notice tells you: - The date when we will stop covering the care for you. - How to request a “fast track appeal” to request us to keep covering your care for a longer period of time. 2. You, or someone who is acting on your behalf, will be asked to sign the written notice to show that you received it. Signing the notice shows only that you have received the information about when your coverage will stop. Signing it does not mean you agree with the plan’s decision to stop care. Section 8.3 Step-by-step: How to make a Level 1 appeal to have our plan cover your care for a longer time If you want to ask us to cover your care for a longer period of time, you will need to use the appeals process to make this request. Before you start, understand what you need to do and what the deadlines are. · Follow the process. · Meet the deadlines. · Ask for help if you need it. If you have questions or need help at any time, please call Customer Service. Or call your State Health Insurance Assistance Program, a government organization that provides personalized assistance. During a Level 1 appeal, the Quality Improvement Organization reviews your appeal. It decides if the end date for your care is medically appropriate. The Quality Improvement Organization is a group of doctors and other health care experts paid by the Federal government to check on and help improve the quality of care for people with Medicare. This includes reviewing plan decisions about when it’s time to stop covering certain kinds of medical care. These experts are not part of our plan. Step 1: Make your Level 1 appeal: contact the Quality Improvement Organization and ask for a fast-track appeal. You must act quickly. How can you contact this organization? · The written notice you received (Notice of Medicare Non-Coverage) tells you how to reach this organization. Or find the name, address, and phone number of the Quality Improvement Organization for your state in Chapter 2.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 223 Act quickly: · You must contact the Quality Improvement Organization to start your appeal by noon of the day before the effective date on the Notice of Medicare Non-Coverage. · If you miss the deadline for contacting the Quality Improvement Organization, and you still wish to file an appeal, you must make an appeal directly to us instead. For details about this other way to make your appeal, see Section 8.5. Step 2: The Quality Improvement Organization conducts an independent review of your case. Legal Term “Detailed Explanation of Non-Coverage.” Notice that provides details on reasons for ending coverage. What happens during this review? · Health professionals at the Quality Improvement Organization (“the reviewers”) will ask you, or your representative, why you believe coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. · The review organization will also look at your medical information, talk with your doctor, and review the information that our plan has given to them. · By the end of the day the reviewers tell us of your appeal, you will get the Detailed Explanation of Non-Coverage from us that explains in detail our reasons for ending our coverage for your services. Step 3: Within one full day after they have all the information they need; the reviewers will tell you their decision. What happens if the reviewers say yes? · If the reviewers say yes to your appeal, then we must keep providing your covered services for as long as it is medically necessary. · You will have to keep paying your share of the costs (such as deductibles or copayments, if these apply). There may be limitations on your covered services. What happens if the reviewers say no? · If the reviewers say no, then your coverage will end on the date we have told you. · If you decide to keep getting the home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after this date when your coverage ends, then you will have to pay the full cost of this care yourself.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 224 Step 4: If the answer to your Level 1 appeal is no, you decide if you want to make another appeal. · If reviewers say no to your Level 1 appeal – and you choose to continue getting care after your coverage for the care has ended – then you can make a Level 2 appeal. Section 8.4 Step-by-step: How to make a Level 2 appeal to have our plan cover your care for a longer time During a Level 2 appeal, you ask the Quality Improvement Organization to take another look at the decision on your first appeal. If the Quality Improvement Organization turns down your Level 2 appeal, you may have to pay the full cost for your home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end. Step 1: Contact the Quality Improvement Organization again and ask for another review. · You must ask for this review within 60 days after the day when the Quality Improvement Organization said no to your Level 1 appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Step 2: The Quality Improvement Organization does a second review of your situation. · Reviewers at the Quality Improvement Organization will take another careful look at all of the information related to your appeal. Step 3: Within 14 days of receipt of your appeal request, reviewers will decide on your appeal and tell you their decision. What happens if the review organization says yes? · We must reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary. · You must continue to pay your share of the costs and there may be coverage limitations that apply.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 225 What happens if the review organization says no? · It means they agree with the decision made to your Level 1 appeal. · The notice you get will tell you in writing what you can do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by an Administrative Law Judge or attorney adjudicator. Step 4: If the answer is no, you will need to decide whether you want to take your appeal further. · There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision. · The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 8.5 What if you miss the deadline for making your Level 1 appeal? You can appeal to us instead As explained above, you must act quickly to contact the Quality Improvement Organization to start your first appeal (within a day or two, at the most). If you miss the deadline for contacting this organization, there is another way to make your appeal. If you use this other way of making your appeal, the first two levels of appeal are different. Step-by-Step: How to make a Level 1 Alternate Appeal Legal Term A “fast” review (or “fast appeal”) is also called an “expedited appeal.” Step 1: Contact us and ask for a “fast review.” · Ask for a “fast review.” This means you are asking us to give you an answer using the “fast” deadlines rather than the “standard” deadlines. Chapter 2 has contact information. Step 2: We do a “fast” review of the decision we made about when to end coverage for your services.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 226 · During this review, we take another look at all of the information about your case. We check to see if we were following all the rules when we set the date for ending the plan’s coverage for services you were receiving. Step 3: We give you our decision within 72 hours after you ask for a “fast review”. · If we say yes to your appeal, it means we have agreed with you that you need services longer, and will keep providing your covered services for as long as it is medically necessary. It also means that we have agreed to reimburse you for our share of the costs of care you have received since the date when we said your coverage would end. (You must pay your share of the costs and there may be coverage limitations that apply.) · If we say no to your appeal, then your coverage will end on the date we told you and we will not pay any share of the costs after this date. · If you continued to get home health care, or skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end, then you will have to pay the full cost of this care. Step 4: If we say no to your fast appeal, your case will automatically go on to the next level of the appeals process. Legal Term The formal name for the “independent review organization” is the “Independent Review Entity.” It is sometimes called the “IRE.” Step-by-Step: Level 2 Alternate Appeal Process During the Level 2 appeal, the independent review organization reviews the decision we made to your “fast appeal.” This organization decides whether the decision should be changed. The independent review organization is an independent organization that is hired by Medicare. This organization is not connected with our plan and it is not a government agency. This organization is a company chosen by Medicare to handle the job of being the independent review organization. Medicare oversees its work. Step 1: We automatically forward your case to the independent review organization.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 227 · We are required to send the information for your Level 2 appeal to the independent review organization within 24 hours of when we tell you that we are saying no to your first appeal. (If you think we are not meeting this deadline or other deadlines, you can make a complaint. Section 10 of this chapter tells how to make a complaint.) Step 2: The independent review organization does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. · Reviewers at the independent review organization will take a careful look at all of the information related to your appeal. · If this organization says yes to your appeal, then we must pay you back for our share of the costs of care you have received since the date when we said your coverage would end. We must also continue to cover the care for as long as it is medically necessary. You must continue to pay your share of the costs. If there are coverage limitations, these could limit how much we would reimburse or how long we would continue to cover services. · If this organization says no to your appeal, it means they agree with the decision our plan made to your first appeal and will not change it. - The notice you get from the independent review organization will tell you in writing what you can do if you wish to go on to a Level 3 appeal. Step 3: If the independent review organization says no to your appeal, you choose whether you want to take your appeal further. · There are three additional levels of appeal after Level 2, for a total of five levels of appeal. If you want to go on to a Level 3 appeal, the details on how to do this are in the written notice you get after your Level 2 appeal decision. · A Level 3 appeal is reviewed by an Administrative Law Judge or attorney adjudicator. Section 9 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. Section 9 Taking your appeal to Level 3 and beyond Section 9.1 Appeal Levels 3, 4, and 5 for Medical Service Requests This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your appeals have been turned down. If the dollar value of the item or medical service you have appealed meets certain minimum levels, you may be able to go on to additional levels of appeal. If the dollar value is less than the minimum level, you cannot appeal any further. The written response you receive to your Level 2 appeal will explain how to make a Level 3 appeal.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 228 For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 appeal: An Administrative Law Judge or an attorney adjudicator who works for the Federal government will review your appeal and give you an answer. · If the Administrative Law Judge or attorney adjudicator says yes to your appeal, the appeals process may or may not be over. Unlike a decision at a Level 2 appeal, we have the right to appeal a Level 3 decision that is favorable to you. If we decide to appeal, it will go to a Level 4 appeal. - If we decide not to appeal, we must authorize or provide you with the medical care within 60 calendar days after receiving the Administrative Law Judge’s or attorney adjudicator’s decision. - If we decide to appeal the decision, we will send you a copy of the Level 4 appeal request with any accompanying documents. We may wait for the Level 4 appeal decision before authorizing or providing the medical care in dispute. · If the Administrative Law Judge or attorney adjudicator says no to your appeal, the appeals process may or may not be over. - If you decide to accept this decision that turns down your appeal, the appeals process is over. - If you do not want to accept the decision, you can continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal. Level 4 appeal: The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the Federal government. · If the answer is yes, or if the Council denies our request to review a favorable Level 3 appeal decision, the appeals process may or may not be over. Unlike a decision at Level 2, we have the right to appeal a Level 4 decision that is favorable to you. We will decide whether to appeal this decision to Level 5. - If we decide not to appeal the decision, we must authorize or provide you with the medical care within 60 calendar days after receiving the Council’s decision. - If we decide to appeal the decision, we will let you know in writing. · If the answer is no or if the Council denies the review request, the appeals process may or may not be over. - If you decide to accept this decision that turns down your appeal, the appeals process is over.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 229 - If you do not want to accept the decision, you may be able to continue to the next level of the review process. If the Council says no to your appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 appeal and how to continue with a Level 5 appeal. Level 5 appeal: A judge at the Federal District Court will review your appeal. · A judge will review all of the information and decide yes or no to your request. This is a final answer. There are no more appeal levels after the Federal District Court. Section 9.2 Appeal Levels 3, 4, and 5 for Part D Drug Requests This section may be appropriate for you if you have made a Level 1 appeal and a Level 2 appeal, and both of your appeals have been turned down. If the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The written response you receive to your Level 2 appeal will explain who to contact and what to do to ask for a Level 3 appeal. For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level 3 appeal: An Administrative Law Judge or an attorney adjudicator who works for the Federal government will review your appeal and give you an answer. · If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that was approved by the Administrative Law Judge or attorney adjudicator within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision. · If the answer is no, the appeals process may or may not be over. - If you decide to accept this decision that turns down your appeal, the appeals process is over. - If you do not want to accept the decision, you can continue to the next level of the review process. The notice you get will tell you what to do for a Level 4 appeal. Level 4 appeal: The Medicare Appeals Council (Council) will review your appeal and give you an answer. The Council is part of the Federal government. · If the answer is yes, the appeals process is over. We must authorize or provide the drug coverage that was approved by the Council within 72 hours (24 hours for expedited appeals) or make payment no later than 30 calendar days after we receive the decision. · If the answer is no, the appeals process may or may not be over.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 230 - If you decide to accept this decision that turns down your appeal, the appeals process is over. - If you do not want to accept the decision, you may be able to continue to the next level of the review process. If the Council says no to your appeal or denies your request to review the appeal, the notice will tell you whether the rules allow you to go on to a Level 5 appeal. It will also tell you who to contact and what to do next if you choose to continue with your appeal. Level 5 appeal: A judge at the Federal District Court will review your appeal. · A judge will review all of the information and decide yes or no to your request. This is a final answer. There are no more appeal levels after the Federal District Court. Making complaints Section 10 How to make a complaint about quality of care, waiting times, customer service, or other concerns Section 10.1 What kinds of problems are handled by the complaint process? The complaint process is only used for certain types of problems. This includes problems related to quality of care, waiting times, and the customer service. Here are examples of the kinds of problems handled by the complaint process. Complaint Example Quality of your · Are you unhappy with the quality of the care you have received medical care (including care in the hospital)? Respecting your · Did someone not respect your right to privacy or share confidential privacy information? Disrespect, poor · Has someone been rude or disrespectful to you? customer service, · Are you unhappy with our Customer Service? or other negative behaviors · Do you feel you are being encouraged to leave the plan? Waiting times · Are you having trouble getting an appointment, or waiting too long to get it? · Have you been kept waiting too long by doctors, pharmacists, or other health professionals? Or by Customer Service or other staff at our plan?

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 231 Complaint Example - Examples include waiting too long on the phone, in the waiting or exam room, or getting a prescription. Cleanliness · Are you unhappy with the cleanliness or condition of a clinic, hospital, or doctor’s office? Information you · Did we fail to give you a required notice? get from us · Is our written information hard to understand? Timeliness (These If you have asked us for a coverage decision or made an appeal, and you types of think that we are not responding quickly enough, you can also make a complaints are all complaint about our slowness. Here are examples: related to the · You asked us for a “fast coverage decision” or a “fast appeal,” and we timeliness of our have said no; you can make a complaint. actions related to coverage · You believe we are not meeting the deadlines for coverage decisions decisions and or appeals; you can make a complaint. appeals) · You believe we are not meeting deadlines for covering or reimbursing you for certain medical items or services or drugs that were approved; you can make a complaint. · You believe we failed to meet required deadlines for forwarding your case to the independent review organization; you can make a complaint. Section 10.2 How to make a complaint Legal Terms A “complaint” is also called a “grievance.” “Making a complaint” is also called “filing a grievance.” “Using the process for complaints” is also called “using the process for filing a grievance.” A “fast complaint” is also called an “expedited grievance.” Section 10.3 Step-by-step: Making a complaint Step 1: Contact us promptly – either by phone or in writing.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 232 · Usually, calling Customer Service is the first step. If there is anything else you need to do, Customer Service will let you know. · If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. · We must receive your complaint within 60 calendar days of the event or incident you are complaining about. If something kept you from filing your complaint (you were sick, we provided incorrect information, etc.) let us know and we might be able to accept your complaint past 60 days. We will address your complaint as quickly as possible but no later than 30 days after receiving it. Sometimes we need additional information, or you may wish to provide additional information. If that occurs, we may take an additional 14 days to respond to your complaint. If the additional 14 days is taken, you will receive a letter letting you know. If your complaint is because we took 14 extra days to respond to your request for a coverage determination or appeal or because we decided you didn’t need a fast coverage decision or a fast appeal, you can file a fast complaint. We will respond to you within 24 hours of receiving your complaint. The address and fax numbers for filing complaints are located in Chapter 2 under “How to contact us when you are making a complaint about your medical care” or for Part D prescription drug complaints “How to contact us when you are making a complaint about your Part D prescription drugs.” · The deadline for making a complaint is 60 calendar days from the time you had the problem you want to complain about. Step 2: We look into your complaint and give you our answer. · If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. · Most complaints are answered within 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If we decide to take extra days, we will tell you in writing. · If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint”. If you have a “fast complaint,” it means we will give you an answer within 24 hours. · If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will include our reasons in our response to you. Section 10.4 You can also make complaints about quality of care to the Quality Improvement Organization When your complaint is about quality of care, you also have two extra options:

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 233 · You can make your complaint directly to the Quality Improvement Organization. · The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. Chapter 2 has contact information. Or · You can make your complaint to both the Quality Improvement Organization and us at the same time. Section 10.5 You can also tell Medicare about your complaint You can submit a complaint about UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) directly to Medicare. To submit a complaint to Medicare, go to www.medicare.gov/ MedicareComplaintForm/home.aspx. You may also call 1-800-MEDICARE (1-800-633-4227). TTY/ TDD users can call 1-877-486-2048.

Chapter 10 Chapter 10: Ending your membership in the plan

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 10: Ending your membership in the plan 235 Section 1 Introduction to ending your membership in our plan Ending your membership in the plan may be voluntary (your own choice) or involuntary (not your own choice): · You might leave our plan because you have decided that you want to leave. Section 2 provides information on ending your membership voluntarily. · There are also limited situations where you do not choose to leave, but we are required to end your membership. Section 4 tells you about situations when we must end your membership. If you are leaving our plan, our plan must continue to provide your medical care and prescription drugs and you will continue to pay your cost share until your membership ends. In the event you choose to end your membership in our plan, re-enrollment may not be permitted, or you may have to wait until your plan sponsor’s next Open Enrollment Period. You should consult with your plan sponsor regarding the availability of other coverage prior to ending your plan membership outside of your plan sponsor’s Open Enrollment Period. It is important to understand your plan sponsor’s eligibility policies, and the possible impact to your retiree health care coverage options and other retirement benefits before submitting your request to end your membership in our plan. Section 2 When can you end your membership in our plan? Section 2.1 Where can you get more information about when you can end your membership? If you have any questions about ending your membership you can: · Call your plan sponsor · Call Customer Service. · Find the information in the Medicare & You 2024 handbook. · Contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. (TTY 1-877-486-2048). Section 3 Until your membership ends, you must keep getting your medical items, services and drugs through our plan Until your membership ends, and your new Medicare coverage begins, you must continue to get your medical items, services and prescription drugs through our plan. · Continue to use our network providers to receive medical care. · Continue to use our network pharmacies or mail order to get your prescriptions filled.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 10: Ending your membership in the plan 236 · If you are hospitalized on the day that your membership ends, your hospital stay will be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins). Section 4 We must end your membership in the plan in certain situations Section 4.1 When must we end your membership in the plan? We must end your membership in the plan if any of the following happen: · We are notified that you no longer meet the eligibility requirements of your former employer, union group or trust administrator (plan sponsor). · Your former employer, union group or trust administrator’s (plan sponsor’s) contract with us is terminated. · If you no longer have Medicare Part A and Part B. · If you move out of our service area. · If you are away from our service area for more than 6 months. · If you become incarcerated (go to prison). · If you are no longer a United States citizen or lawfully present in the United States. · If you lie or withhold information about other insurance you have that provides prescription drug coverage. · If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) · If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) · If you let someone else use your UnitedHealthcare member ID card to get medical care. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) - If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General. · If you are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug coverage. Where can you get more information? If you have questions or would like more information on when we can end your membership call Customer Service. Section 4.2 We cannot ask you to leave our plan for any health-related reason Our plan is not allowed to ask you to leave our plan for any health-related reason.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 10: Ending your membership in the plan 237 What should you do if this happens? If you feel that you are being asked to leave our plan because of a health-related reason, call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week (TTY 1-877-486-2048). Section 4.3 You have the right to make a complaint if we end your membership in our plan If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can file a grievance or make a complaint about our decision to end your membership.

Chapter 11 Chapter 11: Legal notices

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 11: Legal notices 239 Section 1 Notice about governing law The principal law that applies to this Evidence of Coverage document is Title XVIII of the Social Security Act and the regulations created under the Social Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other Federal laws may apply and, under certain circumstances, the laws of the state you live in. This may affect your rights and responsibilities even if the laws are not included or explained in this document. Section 2 Notice about non-discrimination We don’t discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, sexual orientation, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. All organizations that provide Medicare Advantage plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, Section 1557 of the Affordable Care Act, all other laws that apply to organizations that get Federal funding, and any other laws and rules that apply for any other reason. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services’ Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. You can also review information from the Department of Health and Human Services’ Office for Civil Rights at hhs.gov/ocr/index.html. If you have a disability and need help with access to care, please call us at Customer Service. If you have a complaint, such as a problem with wheelchair access, Customer Service can help. Section 3 Notice about Medicare Secondary Payer subrogation rights We have the right and responsibility to collect for covered Medicare services for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, our plan, as a Medicare Advantage Organization, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any State laws. Section 4 Third party liability and subrogation If you suffer an illness or injury for which any third party is alleged to be liable or responsible due to any negligent or intentional act or omission causing illness or injury to you, you must promptly notify us of the illness or injury. We will send you a statement of the amounts we paid for services provided in connection with the illness or injury. If you recover any sums from any third party, we shall be reimbursed out of any such recovery from any third party for the payments we made on your behalf, subject to the limitations in the following paragraphs.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 11: Legal notices 240 1) Our payments are less than the recovery amount. If our payments are less than the total recovery amount from any third party (the “recovery amount”), then our reimbursement is computed as follows: a) First: Determine the ratio of the procurement costs to the recovery amount (the term “procurement costs” means the attorney fees and expenses incurred in obtaining a settlement or judgment). b) Second: Apply the ratio calculated above to our payment. The result is our share of procurement costs. c) Third: Subtract our share of procurement costs from our payments. The remainder is our reimbursement amount. 2) . If our payments equal or exceed the Our payments equal or exceed the recovery amount recovery amount, our reimbursement amount is the total recovery amount minus the total procurement costs. 3) We incur procurement costs because of opposition to our reimbursement. If we must bring suit against the party that received the recovery amount because that party opposes our reimbursement, our reimbursement amount is the lower of the following: a) Our payments made on your behalf for services; or b) the recovery amount, minus the party’s total procurement cost. Subject to the limitations stated above, you agree to grant us an assignment of, and a claim and a lien against, any amounts recovered through settlement, judgment or verdict. You may be required by us and you agree to execute documents and to provide information necessary to establish the assignment, claim, or lien to ascertain our right to reimbursement. Section 5 Member liability Note: This section only applies to you if you are required by your plan rules to obtain a referral before seeing non-network providers. Please see the chapter entitled Using the plan’s coverage for your medical services to see if your plan requires referrals to non-network providers. You will be liable if you receive services from non-network providers without authorization or a referral. In the event we fail to reimburse provider’s charges for covered services, you will not be liable for any sums owed by us. Neither the plan nor Medicare will pay for non-covered services except for the following eligible expenses: · Emergency services · Urgently needed services · Out-of-area and routine travel dialysis (must be received in a Medicare Certified Dialysis Facility within the United States) · Post-stabilization services If you enter into a private contract with a provider, neither the plan nor Medicare will pay for those services.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 11: Legal notices 241 Section 6 Medicare-covered services must meet requirement of reasonable and necessary In determining coverage, services must meet the reasonable and necessary requirements under Medicare in order to be covered under your plan, unless otherwise listed as a covered service. A service is “reasonable and necessary” if the service is: · Safe and effective; · Not experimental or investigational; and · Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: 1. Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member; 2. Furnished in a setting appropriate to the patient’s medical needs and condition; 3. Ordered and furnished by qualified personnel; 4. One that meets, but does not exceed, the patient’s medical need; and 5. At least as beneficial as an existing and available medically appropriate alternative. Section 7 Non duplication of benefits with automobile, accident or liability coverage If you are receiving benefits as a result of other automobile, accident or liability coverage, we will not duplicate those benefits. It is your responsibility to take whatever action is necessary to receive payment under automobile, accident, or liability coverage when such payments may reasonably be expected, and to notify us of such coverage when available. If we happen to duplicate benefits to which you are entitled under other automobile, accident or liability coverage, we may seek reimbursement of the reasonable value of those benefits from you, your insurance carrier, or your health care provider to the extent permitted under State and/or federal law. We will provide benefits over and above your other automobile, accident or liability coverage, if the cost of your health care services exceeds such coverage. You are required to cooperate with us in obtaining payment from your automobile, accident or liability coverage carrier. Your failure to do so may result in termination of your plan membership. Section 8 Acts beyond our control If, due to a natural disaster, war, riot, civil insurrection, complete or partial destruction of a facility, ordinance, law or decree of any government or quasi-governmental agency, labor dispute (when said dispute is not within our control), or any other emergency or similar event not within the control of us, providers may become unavailable to arrange or provide health services pursuant to this Evidence of Coverage and Disclosure Information, then we shall attempt to arrange for covered services insofar as practical and according to our best judgment. Neither we nor any provider shall have any liability or obligation for delay or failure to provide or arrange for covered services if such delay is the result of any of the circumstances described above.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 11: Legal notices 242 Section 9 Contracting medical providers and network hospitals are independent contractors The relationships between us and our network providers and network hospitals are independent contractor relationships. None of the network providers or network hospitals or their physicians or employees are employees or agents of UnitedHealthcare Insurance Company or one of its affiliates. An agent would be anyone authorized to act on our behalf. Neither we nor any employee of UnitedHealthcare Insurance Company or one of its affiliates is an employee or agent of the network providers or network hospitals. Section 10 Technology assessment We regularly review new procedures, devices and drugs to determine whether or not they are safe and efficacious for members. New procedures and technology that are safe and efficacious are eligible to become Covered Services. If the technology becomes a Covered Service, it will be subject to all other terms and conditions of the plan, including medical necessity and any applicable member copayments, coinsurance, deductibles or other payment contributions. In determining whether to cover a service, we use proprietary technology guidelines to review new devices, procedures and drugs, including those related to behavioral/mental health. When clinical necessity requires a rapid determination of the safety and efficacy of a new technology or new application of an existing technology for an individual member, one of our Medical Directors makes a medical necessity determination based on individual member medical documentation, review of published scientific evidence, and, when appropriate, relevant specialty or professional opinion from an individual who has expertise in the technology. Section 11 Member statements In the absence of fraud, all statements made by you will be deemed representations and not warranties. No such representation will void coverage or reduce covered services under this Evidence of Coverage or be used in defense of a legal action unless it is contained in a written application. Section 12 Information upon request As a plan member, you have the right to request information on the following: · General coverage and comparative plan information · Utilization control procedures · Quality improvement programs · Statistical data on grievances and appeals · The financial condition of UnitedHealthcare Insurance Company or one of its affiliates

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 11: Legal notices 243 Section 13 2024 Enrollee Fraud & Abuse Communication 2024 Enrollee Fraud & Abuse Communication How you can fight healthcare fraud Our company is committed to preventing fraud, waste, and abuse in Medicare benefit programs and we’re asking for your help. If you identify a potential case of fraud, please report it to us immediately. Here are some examples of potential Medicare fraud cases: · A health care provider - such as a physician, pharmacy, or medical device company - bills for services you never got; · A supplier bills for equipment different from what you got; · Someone uses another person’s Medicare card to get medical care, prescriptions, supplies or equipment; · Someone bills for home medical equipment after it has been returned; · A company offers a Medicare drug or health plan that hasn’t been approved by Medicare; or · A company uses false information to mislead you into joining a Medicare drug or health plan. To report a potential case of fraud in a Medicare benefit program, call UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Customer Service at 1-855-873-3268 (TTY 711), 8 a.m.-8 p.m. local time, Monday-Friday. This hotline allows you to report cases anonymously and confidentially. We will make every effort to maintain your confidentiality. However, if law enforcement needs to get involved, we may not be able to guarantee your confidentiality. Please know that our organization will not take any action against you for reporting a potential fraud case in good faith. You may also report potential medical or prescription drug fraud cases to the Medicare Drug Integrity Contractor (MEDIC) at 1-877-7SafeRx (1-877-772-3379) or to the Medicare program directly at (1-800-633-4227). The Medicare fax number is 1-717-975-4442 and the website is medicare.gov. Section 14 Commitment of Coverage Decisions UnitedHealthcare’s Clinical Services Staff and Physicians make decisions on the health care services you receive based on the appropriateness of care and service and existence of coverage. Clinical Staff and Physicians making these decisions: 1. Do not specifically receive reward for issuing non-coverage (denial) decisions; 2. Do not offer incentives to physicians or other health care professionals to encourage inappropriate underutilization of care or services; and 3. Do not hire, promote, or terminate physicians or other individuals based upon the likelihood or the perceived likelihood that the individual will support or tend to support the denial of benefits. Section 15 Renew Active®Terms and Conditions

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 11: Legal notices 244 Eligibility requirements · Only members enrolled in a participating Medicare Plan insured by UnitedHealthcare Insurance Company (“UnitedHealthcare") and affiliates are eligible for the Renew Active program (“Program”), which includes, without limitation, access to standard fitness memberships at participating gyms/fitness locations, online fitness and cognitive providers, digital communities, in-person and virtual events, clubs, classes and discounts for meal delivery at no additional cost. · By enrolling in the Program, you hereby accept and agree to be bound by these terms and conditions. Enrollment requirements · Membership and participation in the Program is voluntary. · You must enroll in the Program according to the instructions provided on this website. Once enrolled, you must obtain your confirmation code and provide it when requested to sign up for any Program services. Provide your confirmation code when requested when visiting a participating gym/fitness location to receive standard membership access at no additional cost, registering with an online fitness and/or cognitive providers, joining the Fitbit® Community for Renew Active, and to gain access to included discounts. Please note, that by using your confirmation code, you are electing to disclose that you are a Renew Active member with a participating UnitedHealthcare Medicare plan. · Program enrollment is on an individual basis and the Program's waived monthly membership rate for standard membership services at participating gyms and fitness locations is only applicable to individual memberships. · You are responsible for any and all non-covered services and/or similar fee-based products and services offered by Program service providers (including, without limitation, gym/fitness centers, digital fitness offerings, digital cognitive providers, Fitbit, and other third party service offerings made available through the Program), including, without limitation, fees associated with personal training sessions, specialized classes, enhanced facility membership levels beyond the basic or standard membership level, and meal delivery. Fitness membership equipment, classes, personalized fitness plans, caregiver access and events may vary by location. Access to gym and fitness location network may vary by location and plan. Liability waiver · Always seek the advice of a doctor prior to beginning an exercise program or making changes to your lifestyle or health care routine. · Certain services, discounts, classes, events, and online fitness offerings are provided by affiliates of UnitedHealthcare or other third parties not affiliated with UnitedHealthcare. Participation in these third-party services are subject to your acceptance of their respective terms and policies. UnitedHealthcare and its respective subsidiaries are not responsible for the services or information provided by third parties. The information provided through these services is for informational purposes only and is not a substitute for the advice of a doctor. UnitedHealthcare and its respective subsidiaries and affiliates do not endorse and are not

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 11: Legal notices 245 responsible for the services or information provided by third parties, the content on any linked site, or for any injuries you may sustain while participating in any activities under the Program. Other requirements · You must verify that the individual gym/fitness location or service provider participates in the Program before enrolling. · If a Program service provider you use, including a gym or fitness location, ceases to participate in the Program, your Program participation and waived monthly membership rate with such service provider through the Program will be discontinued until you join another service offered by a participating service provider. You will be responsible for paying the standard membership rates of the service provider should you elect to continue to receive services from a service provider once that service provider ceases to participate in our Program. If you wish to cancel your membership with such service provider, you can opt to do so per the cancellation policy of the applicable service provider, including the applicable gym or fitness location. You should review your termination rights with a service provider when you initially elect to sign up with such service provider. Data requirements · Optum (the Program administrator) and/or your service provider will collect and electronically send and/or receive the minimum amount of your personal information required in order to facilitate the Program in accordance with the requirements of applicable laws, including privacy laws. Such required personal information includes, but is not limited to, program confirmation code, gym/fitness location/provider membership ID, activity year and month, and monthly visit count. By enrolling in the Program, you authorize Optum and your service provider to request and/or provide such personal information. ©2023 United HealthCare Services, Inc. All rights reserved.

Chapter 12 Chapter 12: Definitions of important words

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 247 Chapter 12 Definitions of important words Ambulatory Surgical Center – An Ambulatory Surgical Center is an entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients not requiring hospitalization and whose expected stay in the center does not exceed 24 hours. Annual Enrollment Period –The time period of October 15 until December 7 of each year when members can change their health or drug plans or switch to Original Medicare. Appeal – An appeal is something you do if you disagree with our decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with our decision to stop services that you are receiving. Balance Billing – When a provider (such as a doctor or hospital) bills a patient more than the plan’s allowed cost-sharing amount. As a member of UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO), you only have to pay our plan’s allowed cost-sharing amounts when you get services covered by our plan. We do not allow providers to “balance bill” or otherwise charge you more than the amount of cost-sharing your plan says you must pay. Benefit period – The way that Original Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you have not received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods. For Inpatient Hospital Care, Medicare-defined hospital benefit periods do not apply. For inpatient hospital care, the cost-sharing described in the Medical Benefits Chart in Chapter 4 applies each time you are admitted to the hospital. For each inpatient hospital stay, you are covered for unlimited days as long as the hospital stay is covered in accordance with plan rules. Biological Product – A prescription drug that is made from natural and living sources like animal cells, plant cells, bacteria, or yeast. Biological products are more complex than other drugs and cannot be copied exactly, so alternative forms are called biosimilars. Biosimilars generally work just as well, and are as safe, as the original biological products. Brand Name Drug – A prescription drug that is manufactured and sold by the pharmaceutical company that originally researched and developed the drug. Brand name drugs have the same active-ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired. Catastrophic Coverage Stage – The stage in the Part D Drug Benefit that begins when you (or other qualified parties on your behalf) have spent $8,000 for Part D covered drugs during the covered year. During this payment stage, the plan pays the full cost for your covered Part D drugs. You pay nothing. Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers Medicare.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 248 Chronic-Care Special Needs Plan – C-SNPs are SNPs that restrict enrollment to MA eligible individuals who have one or more severe or disabling chronic conditions, as defined under 42 CFR 422.2, including restricting enrollment based on the multiple commonly co-morbid and clinically- linked condition groupings specified in 42 CFR 422.4(a)(1)(iv). Clinical Research Study – A clinical research study is a way that doctors and scientists test new types of medical care, like how well a new cancer drug works. They test new medical care procedures or drugs by asking for volunteers to help with the study. This kind of study is one of the final stages of a research process that helps doctors and scientists see if a new approach works and if it is safe. Coinsurance – An amount you may be required to pay, expressed as a percentage (for example 20%) as your share of the cost for services or prescription drugs. Coinsurance for in-network services is based upon contractually negotiated rates (when available for the specific covered service to which the coinsurance applies) or Medicare Allowable Cost, depending on our contractual arrangements for the service. Combined Maximum Out-of-Pocket Amount – This is the most you will pay in a year for all Part A and Part B services from both network providers and out-of-network providers. See Chapter 4, Section 1.2 for information about your combined maximum out-of-pocket amount. Compendia – Medicare-recognized reference books for drug information and medically accepted indications for Part D coverage. Complaint – The formal name for “making a complaint” is “filing a grievance.” The complaint process is used only for certain types of problems. This includes problems related to quality of care, waiting times, and the customer service you receive. It also includes complaints if your plan does not follow the time periods in the appeal process. Comprehensive Outpatient Rehabilitation Facility (CORF) – A facility that mainly provides rehabilitation services after an illness or injury, including physical therapy, social or psychological services, respiratory therapy, occupational therapy and speech-language pathology services, and home environment evaluation services. Copayment (or “copay”) – An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit, or a prescription drug. A copayment is a set amount (for example $10), rather than a percentage. Cost-Sharing – Cost-sharing refers to amounts that a member has to pay when services or drugs are received. Cost-sharing includes any combination of the following three types of payments: (1) any deductible amount a plan may impose before services or drugs are covered; (2) any fixed “copayment” amount that a plan requires when a specific service or drug is received; or (3) any “coinsurance” amount, a percentage of the total amount paid for a service or drug that a plan requires when a specific service or drug is received. Cost-Sharing Tier – Every drug on the list of covered drugs is in one of 4 cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug. Coverage Determination – A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 249 formal decision about the coverage. Coverage determinations are called “coverage decisions” in this document. Covered Drugs – The term we use to mean all of the prescription drugs covered by our plan. Covered Services – The term we use in this EOC to mean all of the health care services and supplies that are covered by our plan. Creditable Prescription Drug Coverage – Prescription drug coverage (for example, from an employer or union) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. People who have this kind of coverage when they become eligible for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll in Medicare prescription drug coverage later. Custodial Care – Custodial care is personal care provided in a nursing home, hospice, or other facility setting when you do not need skilled medical care or skilled nursing care. Custodial care, provided by people who do not have professional skills or training, includes help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving around, and using the bathroom. It may also include the kind of health-related care that most people do themselves, like using eye drops. Medicare doesn’t pay for custodial care. Customer Service – A department within our plan responsible for answering your questions about your membership, benefits, grievances, and appeals. Daily cost-sharing rate – A “daily cost-sharing rate” may apply when your doctor prescribes less than a full month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate is the copayment divided by the number of days in a month’s supply. Here is an example: If your copayment for a one-month supply of a drug is $30, and a one-month’s supply in your plan is 30 days, then your “daily cost-sharing rate” is $1 per day. Daily Cost Share applies only if the drug is in the form of a solid oral dose (e.g., tablet or capsule) when dispensed for less than a one-month supply under applicable law. The Daily Cost Share requirements do not apply to either of the following: 1. Solid oral doses of antibiotics. 2. Solid oral doses that are dispensed in their original container or are usually dispensed in their original packaging to assist patients with compliance. Deductible – The amount you must pay for health care or prescriptions before our plan pays. Disenroll or Disenrollment – The process of ending your membership in our plan. Dispensing Fee – A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription, such as the pharmacist’s time to prepare and package the prescription. Dual Eligible Special Needs Plans (D-SNP) – D-SNPs enroll individuals who are entitled to both Medicare (title XVIII of the Social Security Act) and medical assistance from a state plan under Medicaid (title XIX). States cover some Medicare costs, depending on the state and the individual’s eligibility. Durable Medical Equipment (DME) – Certain medical equipment that is ordered by your doctor for medical reasons. Examples include walkers, wheelchairs, crutches, powered mattress systems, diabetic supplies, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, or hospital beds ordered by a provider for use in the home.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 250 Emergency – A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life (and, if you are a pregnant woman, loss of an unborn child), loss of a limb, or loss of function of a limb, or loss of or serious impairment to a bodily function. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. Emergency Care – Covered services that are: 1) provided by a provider qualified to furnish emergency services; and 2) needed to treat, evaluate, or stabilize an emergency medical condition. Evidence of Coverage (EOC) and Disclosure Information – This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, what we must do, your rights, and what you have to do as a member of our plan. Exception – A type of coverage decision that, if approved, allows you to get a drug that is not on our formulary (a formulary exception), or get a non-preferred drug at a lower cost-sharing level (a tiering exception). You may also request an exception if our plan requires you to try another drug before receiving the drug you are requesting, or if our plan limits the quantity or dosage of the drug you are requesting (a formulary exception). Extra Help – A Medicare or a state program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance. Generic Drug – A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a “generic” drug works the same as a brand name drug and usually costs less. Grievance – A type of complaint you make about our plan, providers, or pharmacies, including a complaint concerning the quality of your care. This does not involve coverage or payment disputes. Home Health Aide – A person who provides services that do not need the skills of a licensed nurse or therapist, such as help with personal care (e.g., bathing, using the toilet, dressing, or carrying out the prescribed exercises). Home Health Care – Skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury. Covered services are listed in the Benefits Chart in Chapter 4, Section 2.1 under the heading “Home health agency care.” If you need home health care services, our plan will cover these services for you provided the Medicare coverage requirements are met. Home health care can include services from a home health aide if the services are part of the home health plan of care for your illness or injury. They aren’t covered unless you are also getting a covered skilled service. Home health services don’t include the services of housekeepers, food service arrangements, or full-time nursing care at home. Hospice – A benefit that provides special treatment for a member who has been medically certified as terminally ill, meaning having a life expectancy of 6 months or less. We, your plan, must provide you with a list of hospices in your geographic area. If you elect hospice and continue to pay premiums you are still a member of our plan. You can still obtain all medically necessary services as well as the supplemental benefits we offer. Hospice Care – A special way of caring for people who are terminally ill and providing counseling for their families. Hospice care is physical care and counseling that is given by a team of people

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 251 who are part of a Medicare-certified public agency or private company. Depending on the situation, this care may be given in the home, a hospice facility, a hospital, or a nursing home. Care from a hospice is meant to help patients in the last months of life by giving comfort and relief from pain. The focus is on care, not cure. For more information on hospice care visit medicare.gov and under “Search Tools” choose “Find a Medicare Publication” to view or download the publication “Medicare Hospice Benefits.” Or, call (1-800-633-4227). TTY users should call 1-877-486-2048. You may call 24 hours a day/7 days a week. Note: If you are not entitled to Medicare Part A coverage, hospice services are not covered by Medicare or the plan. Hospital Inpatient Stay – A hospital stay when you have been formally admitted to the hospital for skilled medical services. Even if you stay in the hospital overnight, you might still be considered an “outpatient.” Income Related Monthly Adjustment Amount (IRMAA) – If your modified adjusted gross income as reported on your IRS tax return from 2 years ago is above a certain amount, you’ll pay the standard premium amount and an Income Related Monthly Adjustment Amount, also known as IRMAA. IRMAA is an extra charge added to your premium. Less than 5% of people with Medicare are affected, so most people will not pay a higher premium. Initial Coverage Limit – The maximum limit of coverage under the Initial Coverage Stage. Initial Coverage Stage – This is the stage before your total drug costs including amounts you have paid and what your plan has paid on your behalf for the year have reached $5,030. Initial Enrollment Period – When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. If you’re eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-month period that begins 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65. In-Network Maximum Out-of-Pocket Amount – The most you will pay for covered Part A and Part B services received from in-network providers. After you have reached this limit, you will not have to pay anything when you get covered services from network providers for the rest of the contract year. However, until you reach your combined out-of-pocket amount, you must continue to pay your share of the costs when you seek care from an out-of-network provider. List of Covered Drugs (Formulary or “Drug List”) – A list of prescription drugs covered by the plan. Low Income Subsidy (LIS) – See “Extra Help.” Medicaid (or Medical Assistance) – A joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. State Medicaid programs vary, but most health care costs are covered if you qualify for both Medicare and Medicaid. Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. Medically Necessary – Services, supplies, or drugs that are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice. Medicare – The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End-Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant).

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 252 Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an i) HMO, ii) PPO, a iii) Private Fee-for-Service (PFFS) plan, or a iv) Medicare Medical Savings Account (MSA) plan. Besides choosing from these types of plans, a Medicare Advantage HMO or PPO plan can also be a Special Needs Plan (SNP). In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Medicare Allowable Cost – The maximum price of a service for reimbursement purposes under Original Medicare. Medicare Assignment – In Original Medicare, a doctor or supplier "accepts assignment" when he or she agrees to accept the Medicare-approved amount as full payment for covered services. For covered out-of-network services, it can save you money if your doctor or supplier accepts assignment. If a doctor or supplier accepts assignment, your cost-sharing is limited to your copayment or coinsurance amount for the covered service. Medicare Coverage Gap Discount Program – A program that provides discounts on most covered Part D brand name drugs to Part D members who have reached the Coverage Gap Stage and who are not already receiving “Extra Help.” Discounts are based on agreements between the Federal government and certain drug manufacturers. Medicare-Covered Services – Services covered by Medicare Part A and Part B. All Medicare health plans must cover all of the services that are covered by Medicare Part A and B. The term Medicare-Covered Services does not include the extra benefits, such as vision, dental or hearing, that a Medicare Advantage plan may offer. Medicare Health Plan – A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans, Special Needs Plans, Demonstration/Pilot Programs, and Programs of All-inclusive Care for the Elderly (PACE). Medicare Prescription Drug Coverage (Medicare Part D) – Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B. “Medigap” (Medicare Supplement Insurance) Policy – Medicare supplement insurance sold by private insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.) Member (Member of our plan, or “Plan Member”) – A person with Medicare who is eligible to get covered services, who has enrolled in our plan, and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS). Network – The doctors and other health care professionals, medical groups, hospitals, and other health care facilities or providers that have an agreement with us to provide covered services to our members and to accept our payment and any plan cost-sharing as payment in full. (See Chapter 1, Section 3.2) Network Pharmacy – A pharmacy that contracts with our plan where members of our plan can get their prescription drug benefits. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 253 Network Provider – “Provider” is the general term for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. “Network providers” have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. Network providers are also called “plan providers.” Non-Preferred Network Mail-order Pharmacy – A network mail-order pharmacy that generally offers Medicare Part D covered drugs to members of our plan at higher cost-sharing levels than apply at a preferred network mail-order pharmacy. Organization Determination – A decision our plan makes about whether items or services are covered or how much you have to pay for covered items or services. Organization determinations are called “coverage decisions” in this document. Original Medicare (“Traditional Medicare” or “Fee-for-service” Medicare) – Original Medicare is offered by the government, and not a private health plan such as Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see any provider (network or out-of-network) at the same cost share, as long as they accept the plan and have not opted out of or been excluded or precluded from the Medicare Program. You must pay the deductible. Medicare pays its share of the Medicare-approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States. Out-of-Network Pharmacy – A pharmacy that does not have a contract with our plan to coordinate or provide covered drugs to members of our plan. Most drugs you get from out-of-network pharmacies are not covered by our plan unless certain conditions apply. Out-of-Network Provider or Out-of-Network Facility – A provider or facility that does not have a contract with our plan to coordinate or provide covered services to members of our plan. Out-of- network providers are providers that are not employed, owned, or operated by our plan. Out-of-Pocket Costs – See the definition for “cost-sharing” above. A member’s cost-sharing requirement to pay for a portion of services received is also referred to as the member’s “out-of- pocket” cost requirement. PACE plan – A PACE (Program of All-Inclusive Care for the Elderly) plan combines medical, social, and long-term care services for frail people to help people stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high quality care they need. People enrolled in PACE plans receive both their Medicare and Medicaid benefits through the plan. PACE is not available in all states. If you would like to know if PACE is available in your state, please contact Customer Service. Part C – see “Medicare Advantage (MA) Plan.” Part D – The voluntary Medicare Prescription Drug Benefit Program. Part D Drugs – Drugs that can be covered under Part D. We may or may not offer all Part D drugs. Certain categories of drugs have been excluded as covered Part D drugs by Congress. Certain categories of Part D drugs must be covered by every plan. Part D Late Enrollment Penalty – An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 254 least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more after you are first eligible to join a Part D plan. Plan Sponsor – Your former employer, union group or trust administrator. Plan Year – The period of time your plan sponsor has contracted with us to provide covered services and covered drugs to you through the plan. Your plan sponsor’s plan year is listed inside the front cover of the Evidence of Coverage. Preferred Network Mail-order Pharmacy – A network mail-order pharmacy that generally offers Medicare Part D covered drugs to members of our plan that may have lower cost-sharing levels than at other network pharmacies or mail-order pharmacies. Preferred Provider Organization (PPO) Plan – A Preferred Provider Organization plan is a Medicare Advantage Plan that has a network of contracted providers that have agreed to treat plan members for a specified payment amount. A PPO plan must cover all plan benefits whether they are received from in-network or out-of-network providers. Premium – The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. Prior Authorization – For medical services it means a process where your PCP or treating provider must receive approval in advance before certain medical services will be provided or payable. For certain drugs it means a process where you or your provider must receive approval in advance before certain drugs will be provided or payable. Covered services that need prior authorization are marked in the Medical Benefits Chart in Chapter 4. Covered drugs that need prior authorization are marked in the formulary. In the network portion of a PPO, some in-network medical services are covered only if your PCP or other network provider gets “prior authorization” from our plan. In a PPO, you do not need prior authorization to obtain out-of-network services. However, you may want to check with the plan before obtaining services from out-of-network providers to confirm that the service is covered by your plan and what your costs-sharing responsibility is. Prosthetics and Orthotics – Medical devices including, but are not limited to, arm, back and neck braces; artificial limbs; artificial eyes; and devices needed to replace an internal body part or function, including ostomy supplies and enteral and parenteral nutrition therapy. Provider – The doctor or other provider you see first for most health problems. In many Medicare health plans, you must see your primary care provider before you see any other health care provider. Quality Improvement Organization (QIO) – A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. Quantity Limits – A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time. Real-Time Benefit Tool – A portal or computer application in which enrollees can look up complete, accurate, timely, clinically appropriate, enrollee-specific formulary and benefit information. This includes cost sharing amounts, alternative formulary medications that may be used for the same health condition as a given drug, and coverage restrictions (Prior Authorization, Step Therapy, Quantity Limits) that apply to alternative medications. Rehabilitation Services – These services include physical therapy, speech and language therapy,

2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 12: Definitions of important words 255 and occupational therapy. Retail Walk-In Clinic – A provider location that generally does not require appointments and may be a standalone location or located in a retail store, supermarket or pharmacy. Walk-In Clinic Services are subject to the same cost-sharing as Urgent Care Centers. (See the Benefit Chart in Chapter 4) Service Area – A geographic area where you must live to join a particular health plan. The plan may disenroll you if you permanently move out of the plan’s service area. Skilled Nursing Facility (SNF) Care – Skilled nursing care and rehabilitation services provided on a continuous, daily basis, in a skilled nursing facility. Examples of care include physical therapy or intravenous injections that can only be given by a registered nurse or doctor. Special Enrollment Period – A set time when members can change their health or drug plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you are getting “Extra Help” with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you. Step Therapy – A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed. Supplemental Security Income (SSI) – A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are not the same as Social Security benefits. Urgently Needed Services – Covered services that are not emergency services, provided when the network providers are temporarily unavailable or inaccessible or when the enrollee is out of the service area. For example, you need immediate care during the weekend. Services must be immediately needed and medically necessary.

UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Customer Service: Call 1-855-873-3268 Calls to this number are free. 8 a.m.-8 p.m. local time, Monday-Friday. Customer Service also has free language interpreter services available for non-English speakers. TTY 711 Calls to this number are free. 8 a.m.-8 p.m. local time, Monday-Friday. Write: P.O. Box 30770 Salt Lake City, UT 84130-0770 retiree.uhc.com/wapebb State Health Insurance Assistance Program State Health Insurance Assistance Program is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. You can call the SHIP in your state at the number listed in Chapter 2 Section 3 of the Evidence of Coverage. PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1051. If you have comments or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. UHEX24PP0107829_000