2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 86 Services that are covered for you What you must pay when you get these services in-network and out-of-network · For people with diabetes who have severe diabetic foot $20 copayment for each pair of disease: One pair per plan year of therapeutic custom- Medicare-covered therapeutic molded shoes (including inserts provided with such shoes.†† shoes) and two additional pairs of inserts, or one pair of You pay these amounts until depth shoes and three pairs of inserts (not including the you reach the out-of-pocket non-customized removable inserts provided with such maximum. shoes). Coverage includes fitting. · Diabetes self-management training is covered under $0 copayment for Medicare- certain conditions. Limited to 20 visits of 30 minutes per covered benefits. year for a maximum of 10 hours the initial year. Follow- up training subsequent years after, limited to 4 visits of 30 minutes for a maximum of 2 hours per year. Durable medical equipment (DME) and related supplies $20 copayment for Medicare- (For a definition of “durable medical equipment,” see covered benefits.†† Chapter 12 as well as Chapter 3, Section 7 of this Your cost-sharing for Medicare document.) oxygen equipment coverage is Covered items include, but are not limited to: wheelchairs, $20 copayment, every time you crutches, powered mattress systems, diabetic supplies, get covered equipment or †† hospital beds ordered by a provider for use in the home, IV supplies. infusion pumps, speech generating devices, oxygen Your cost-sharing will not equipment, nebulizers, and walkers. change after being enrolled for We cover all medically necessary DME covered by Original 36 months. Medicare. If our supplier in your area does not carry a If prior to enrolling in our plan particular brand or manufacturer, you may ask them if they you had made 36 months of can special order it for you. The most recent list of suppliers rental payment for oxygen is available on our website at retiree.uhc.com/wapebb. equipment coverage, your cost- sharing in our plan is $20 copayment.†† You pay these amounts until you reach the out-of-pocket maximum.