2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 6: What you pay for your Part D prescription drugs 173 · For other Part D vaccines, you will have to pay the pharmacy your coinsurance OR copayment for the vaccine itself. · When your doctor gives you the vaccine, they will submit a claim for the administration of the vaccine. Depending on which drug payment stage you're in, you may have to pay an additional coinsurance OR copayment. · If you ask your doctor not to submit a claim, you will pay the entire cost for this service. You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 7. · For most adult Part D vaccines, you will be reimbursed the amount charged by the doctor for administering the vaccine less any difference between the amount the doctor charges and what we normally pay. (If you get “Extra Help,” we will reimburse you for this difference.)

UnitedHealthcare PEBB Balance EOC (2024) - Page 179 UnitedHealthcare PEBB Balance EOC (2024) Page 178 Page 180