2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 106 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Blood - including storage and administration (this $0 copayment for Medicare- †† means processing and handling of blood). Coverage covered blood services. begins with the first pint of blood that you need. · In addition, for the administration of blood infusion, you will pay the cost-sharing as described under the following sections of this chart, depending on where you received infusion services: - Physician/practitioner services, including doctor’s office visits - Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers · Other outpatient diagnostic tests - non-radiological $15 copayment for Medicare- diagnostic services covered non-radiological diagnostic services.†† Examples include, but are not limited to EKG’s, pulmonary function tests, home or lab- based sleep studies, and treadmill stress tests. You pay these amounts until you reach the out-of-pocket maximum.