2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 128 Services that are covered for you What you must pay when you get these services in-network and out-of-network device, like a tablet or smart phone. These doctors are $15 copayment using other providers that have the ability to offer virtual doctor visits. providers that have the ability During a virtual visit, you can ask questions, get a diagnosis and are qualified to offer virtual and the doctor may be able to prescribe medication that, if medical visits. appropriate, can be sent to your pharmacy. Doctors can’t You pay these amounts until prescribe medications in all states. You can find a list of you reach the out-of-pocket participating virtual doctors online at retiree.uhc.com/ maximum. wapebb. Vision services Covered services include: · Outpatient physician services provided by an $30 copayment for each ophthalmologist or optometrist for the diagnosis and Medicare-covered exam.†† treatment of diseases and injuries of the eye, including You pay these amounts until diagnosis or treatment for age-related macular you reach the out-of-pocket degeneration or cataracts. Original Medicare doesn’t maximum. cover routine eye exams (eye refractions) for eyeglasses/contacts. · For people who are at high risk of glaucoma, we will $0 copayment for Medicare- cover one glaucoma screening each year. People at covered glaucoma screening. high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older, and Hispanic Americans who are 65 or older. · For people with diabetes or signs and symptoms of eye $30 copayment for each disease, eye exams to evaluate for eye disease are Medicare-covered diabetic eye †† covered per Medicare guidelines. Annual examinations exam. by an ophthalmologist or optometrist are recommended You pay these amounts until for asymptomatic diabetics. you reach the out-of-pocket maximum.