2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 85 Services that are covered for you What you must pay when you get these services in-network and out-of-network lancets, and glucose-control solutions for checking the We only cover Accu-Chek® and accuracy of test strips and monitors. OneTouch® brands. UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) covers any blood glucose monitors and test Covered glucose monitors strips specified within this list. We will generally not cover include: OneTouch Verio Flex®, alternate brands unless your doctor or other provider tells us OneTouch Verio Reflect®, that use of an alternate brand is medically necessary in your OneTouch® Verio, specific situation. If you are new to UnitedHealthcare® OneTouch®Ultra 2, Accu-Chek® Group Medicare Advantage PEBB Balance (PPO) and are Guide Me, and Accu-Chek® using a brand of blood glucose monitors and test strips that Guide. is not on our list, you may contact us within the first 90 days of enrollment into the plan to request a temporary supply of Test strips: OneTouch Verio®, the alternate brand while you consult with your doctor or OneTouch Ultra®, Accu-Chek® other provider. During this time, you should talk with your Guide, Accu-Chek® Aviva Plus, doctor to decide whether any of the preferred brands are and Accu-Chek® SmartView. medically appropriate for you. If you or your doctor believe it is medically necessary for you to maintain use of an Other brands are not covered alternate brand, you may request a coverage exception to by your plan. have UnitedHealthcare® Group Medicare Advantage PEBB For cost-sharing applicable to Balance (PPO) maintain coverage of a non-preferred insulin and syringes, see product through the end of the benefit year. Non-preferred Chapter 6 - What you pay for products will not be covered following the initial 90 days of your Part D prescription drugs. the benefit year without an approved coverage exception. If you (or your provider) don’t agree with the plan’s coverage decision, you or your provider may file an appeal. You can also file an appeal if you don’t agree with your provider’s decision about what product or brand is appropriate for your medical condition. (For more information about appeals, see Chapter 9, What to do if you have a problem or complaint (coverage decisions, appeals, complaints).) · Medicare-covered continuous glucose monitors (CGMs) $0 copayment for Medicare- and supplies are covered in accordance with Medicare covered continuous glucose Guidelines. monitors (CGMs) and †† supplies.