2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 117 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Virtual check-ins (for example, by phone or video chat) with your doctor for 5-10 minutes if: - You're not a new patient and - The check-in isn't related to an office visit in the past 7 days and - The check-in doesn't lead to an office visit within 24 hours or the soonest available appointment. · Evaluation of video and/or images you send to your doctor, and interpretation and follow-up by your doctor within 24 hours if: - You're not a new patient and - The evaluation isn't related to an office visit in the past 7 days and - The evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment. · Consultation your doctor has with other doctors by $0 copayment for each phone, internet, or electronic health record. Medicare-covered consultation. · Second opinion prior to surgery. You will pay the cost-sharing that applies to specialist services (as described under “Physician/practitioner services, including doctor’s office visits” †† above). · Non-routine dental care (covered services are limited to $30 copayment for each surgery of the jaw or related structures, setting fractures Medicare-covered visit.†† of the jaw for radiation treatments of neoplastic cancer You pay these amounts until disease, oral exams before a kidney transplant or you reach the out-of-pocket services that would be covered when provided by a maximum. physician). Dental services provided by a dentist in connection with care, treatment, filling, removal, or replacement of teeth or structures directly supporting