2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Table of Contents Section 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share................................................................167 Section 6 Costs in the Coverage Gap Stage.........................................................170 Section 7 During the Catastrophic Coverage Stage, the plan pays the full cost for your covered Part D drugs.....................................................................171 Section 8 Additional benefits information............................................................. 171 Section 9 Part D Vaccines. What you pay for depends on how and where you get them.........................................................................................................171 Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs..............................................................................................174 Section 1 Situations in which you should ask us to pay our share of the cost of your covered services or drugs.............................................................175 Section 2 How to ask us to pay you back or to pay a bill you have received.....177 Section 3 We will consider your request for payment and say yes or no...........178 Chapter 8: Your rights and responsibilities....................................................................... 179 Section 1 Our plan must honor your rights and cultural sensitivities as a member of the plan............................................................................................... 180 Section 2 You have some responsibilities as a member of the plan.................. 193 Chapter 9: What to do if you have a problem or complaint (coverage decisions, appeals, complaints).......................................................................................................195 Section 1 Introduction.............................................................................................196 Section 2 Where to get more information and personalized assistance............196 Section 3 To deal with your problem, which process should you use?............. 197 Section 4 A guide to the basics of coverage decisions and appeals................. 197 Section 5 Your medical care: How to ask for a coverage decision or make an appeal of a coverage decision.............................................................. 200 Section 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal...................................................................................... 207 Section 7 How to ask us to cover a longer inpatient hospital stay if you think you are being discharged too soon............................................................. 216 Section 8 How to ask us to keep covering certain medical services if you think your coverage is ending too soon.........................................................223 Section 9 Taking your appeal to Level 3 and beyond..........................................229 QuestionsQuestions?? Call Call CustomCustomer Serviceer Service at at 1-8551-855-873-32-873-326868, TTY , TTY 711711, , 8 a.m.-8 p.m8 a.m.-8 p.m. local time. local time, , Monday-FridayMonday-Friday