2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 6: What you pay for your Part D prescription drugs 165 · 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. · 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 Balance (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 you have moved from one drug payment stage to the next. In particular, there are two types of costs we keep track of: