2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 7: Asking us to pay our share of a bill you have received for covered medical services or drugs 177 6. When you pay the full cost for a prescription in other situations You may pay the full cost of the prescription because you find that the drug is not covered for some reason. · For example, the drug may not be on the plan’s Drug List or it could have a requirement or restriction that you didn’t know about or don’t think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it. · Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost. 7. When you utilize your worldwide emergency coverage, worldwide urgently needed services, or worldwide emergency transportation benefits You will pay the full cost of emergency services received outside of the United States at the time you receive services. To receive reimbursement from us, you must do the following: · Pay your bill at the time it is received. We will reimburse you for the difference between the amount of your bill and your cost share for the services as outlined in Chapter 4 of this document. · Save all of your receipts and send us copies when you ask us to pay you back. In some situations, we may need to get more information from you or the provider who rendered services to you in order to pay you back for our share of the cost. Please see Chapter 7 Section 2.1 for expense reimbursement for worldwide services. · If you are being asked to pay your bill for worldwide emergency services and are unable to make the payment, please call Customer Service for additional assistance and we may be able to help coordinate payment for covered services on your behalf. All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 9 of this document has information about how to make an appeal. Section 2 How to ask us to pay you back or to pay a bill you have received You may request us to pay you back by sending us a request in writing. If you send a request in writing, send your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipt(s) for your records. To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment. · You don’t have to use the form, but it will help us process the information faster. · Either download a copy of the form from our website (retiree.uhc.com/wapebb) or call Customer Service and ask for the form. Mail your request for payment together with any bills or paid receipts to us at this address: Medical claims payment requests: