2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (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 · Radiation (radium and isotope) therapy including $30 copayment for each technician materials and supplies Medicare-covered radiation therapy service.†† You pay these amounts until you reach the out-of-pocket maximum. · Surgical supplies, such as dressings $20 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 You pay these amounts until routinely used in the course of an office visit and included in you reach the out-of-pocket the provider’s charges for that visit (such as bandages, maximum. 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 $15 copayment for Medicare- covered lab services.†† You pay these amounts until you reach the out-of-pocket maximum.