2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 1: Getting started as a member 4 UnitedHealthcare® Group Medicare Advantage PEBB Balance (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