2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 84 Services that are covered for you What you must pay when you get these services in-network and out-of-network Outpatient diagnostic colonoscopy $250 copayment for each Medicare-covered diagnostic colonoscopy.†† You pay these amounts until you reach the out-of-pocket maximum. There is no coinsurance, Depression screening copayment, or deductible for an We cover one screening for depression per year. The annual depression screening screening must be done in a primary care setting that can visit. provide follow-up treatment and/or referrals. There is no coinsurance, Diabetes screening copayment, or deductible for We cover this screening (includes fasting glucose tests) if the Medicare-covered diabetes you have any of the following risk factors: high blood screening tests. pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes. Based on the results of these tests, you may be eligible for up to two diabetes screenings every plan year. Diabetes self-management training, diabetic services and supplies For all people who have diabetes (insulin and non-insulin users). Covered services include: · Supplies to monitor your blood glucose: blood glucose $0 copayment for each monitor, blood glucose test strips, lancet devices and Medicare-covered diabetes †† monitoring supply.