2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 1: Getting started as a member 2 Section 1 Introduction Section 1.1 You are enrolled in UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO), which is a Medicare PPO You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO). We are required to cover all Part A and Part B services. However, cost-sharing and provider access in this plan differ from Original Medicare. Our plan is a Medicare Advantage PPO Plan (PPO stands for Preferred Provider Organization). Like all Medicare health plans, this Medicare PPO is approved by Medicare and run by a private company. Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at: irs.gov/Affordable-Care-Act/individuals- and-families for more information. Section 1.2 What is the Evidence of Coverage document about? This Evidence of Coverage document tells you how to get your medical care and prescription drugs. It explains your rights and responsibilities, what is covered, what you pay as a member of the plan, and how to file a complaint if you are not satisfied with a decision or treatment. When the Agreement is purchased by the Group to provide benefits under a welfare plan governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. §1001 et seq., we are not the plan administrator or named fiduciary of the welfare plan, as those terms are used in ERISA. The words “coverage” and “covered services” refer to the medical care, services and prescription drugs available to you as a member of the plan. It’s important for you to learn what the plan’s rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage document. If you are confused, concerned or just have a question, please contact Customer Service. Section 1.3 Legal information about the Evidence of Coverage This Evidence of Coverage is part of our contract with you about how the plan covers your care. Other parts of this contract include your enrollment form or your verbal or electronic election of our plan, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called “riders” or “amendments.”