2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 115 Services that are covered for you What you must pay when you get these services in-network and out-of-network the AT&T and Verizon wireless networks, but does not require you to have AT&T or Verizon. For additional information or to order your device, please call 1-855-595-8485 TTY 711 or visit lifeline.com/uhcgroup. Provided by: Lifeline Physician/practitioner services, including doctor’s office visits Covered services include: · Medically-necessary medical or surgical services $15 copayment for services furnished in a physician’s office. from a primary care provider or under certain circumstances, treatment by a nurse practitioner, physician's assistant or other non-physician health care professional in a primary care provider’s office (as allowed by Medicare). You pay these amounts until you reach the out-of-pocket maximum. · Medically-necessary medical or surgical services See “Outpatient surgery” earlier furnished in a certified ambulatory surgical center or in this chart for any applicable hospital outpatient department. copayments or coinsurance amounts for ambulatory surgical center visits or in a hospital outpatient setting. · Consultation, diagnosis, and treatment by a specialist. $30 copayment for services from a specialist or under