2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 110 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Outpatient surgery or observation Please refer to Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. Please refer to Medicare Part B prescription drugs and · Outpatient infusion therapy Physician/practitioner services, including doctor’s office visits For the drug that is infused, you will pay the cost-sharing as or Outpatient surgery and other described in "Medicare Part B prescription drugs" in this medical services provided at benefit chart. In addition, for the administration of infusion hospital outpatient facilities and therapy drugs, you will pay the cost-sharing that applies to ambulatory surgical centers. primary care provider services, specialist services, or outpatient hospital services (as described under “Physician/ practitioner services, including doctor’s office visits” or “Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers” in this benefit chart) depending on where you received drug administration or infusion services. Note: Unless the provider has written an order to admit you Outpatient observation cost- as an inpatient to the hospital, you are an outpatient and pay sharing is explained in the cost-sharing amounts for outpatient hospital services. Outpatient surgery and other Even if you stay in the hospital overnight, you might still be medical services provided at considered an “outpatient.” This is called an “outpatient hospital outpatient facilities and observation” stay. If you are not sure if you are an outpatient, ambulatory surgical centers. you should ask the hospital staff. You can also find more information in a Medicare fact sheet called “Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!” This fact sheet is available on the Web at medicare.gov/sites/default/files/2021-10/11435-