2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 120 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Prostate Specific Antigen (PSA) test Diagnostic PSA exams are subject to cost-sharing as described under Outpatient diagnostic tests and therapeutic services and supplies in this chart. Prosthetic devices and related supplies $20 copayment for each Devices (other than dental) that replace all or part of a body Medicare-covered prosthetic part or function. These include, but are not limited to: device, including replacement colostomy bags and supplies directly related to colostomy or repairs of such devices, and related supplies.†† care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a $20 copayment for each mastectomy). Includes certain supplies related to prosthetic Medicare-covered orthotic devices, and repair and/or replacement of prosthetic device, including replacement devices. Also includes some coverage following cataract or repairs of such devices, and removal or cataract surgery – see “Vision services” later in related supplies.†† this section for more detail. You pay these amounts until you reach the out-of-pocket maximum. Pulmonary rehabilitation services $15 copayment for each Comprehensive programs of pulmonary rehabilitation are Medicare-covered pulmonary rehabilitative visit.†† covered for members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and an order You pay these amounts until for pulmonary rehabilitation from the doctor treating the you reach the out-of-pocket chronic respiratory disease. Medicare covers up to two (2) maximum. one-hour sessions per day, for up to 36 lifetime sessions (in some cases, up to 72 lifetime sessions) of pulmonary rehabilitation services.