2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 101 Services that are covered for you What you must pay when you get these services in-network and out-of-network This benefit is for people with diabetes, renal (kidney) members eligible for Medicare- disease (but not on dialysis), or after a kidney transplant covered medical nutrition when ordered by your doctor. therapy services. We cover three hours of one-on-one counseling services during your first year that you receive medical nutrition therapy services under Medicare (this includes our plan, any other Medicare Advantage plan, or Original Medicare), and two hours each year after that. If your condition, treatment, or diagnosis changes, you may be able to receive more hours of treatment with a physician’s order. A physician must prescribe these services and renew their order yearly if your treatment is needed into the next plan year. There is no coinsurance, Medicare diabetes prevention program (MDPP) copayment, or deductible for MDPP services will be covered for eligible Medicare the MDPP benefit. beneficiaries under all Medicare health plans. MDPP is a structured health behavior change intervention that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle. Medicare Part B Prescription Drugs $0 copayment for each These drugs are covered under Part B of Original Medicare. Medicare-covered Part B drug Members of our plan receive coverage for these drugs and non-chemotherapy drugs to treat cancer.†† through our plan. Covered drugs include: · Drugs that usually aren’t self-administered by the Additionally, for the patient and are injected or infused while you are getting administration of that drug, you physician, hospital outpatient, or ambulatory surgical will pay the cost-sharing that center services applies to primary care provider · Insulin furnished through an item of durable medical services, specialist services, or equipment (such as a medically necessary insulin outpatient hospital services (as pump) described under “Physician/ practitioner services, including