2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (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 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 $30 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 $15 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 You pay these amounts until other Medicare-qualified mental health care professional as you reach the out-of-pocket allowed under applicable state laws. maximum.