2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (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 · 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 $30 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. You pay these amounts until you reach the out-of-pocket maximum. Additional routine podiatry $30 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. 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: · Digital rectal exam