2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Table of Contents Section 4 What if you are billed directly for the full cost of your services?.......... 66 Section 5 How are your medical services covered when you are in a “clinical research study”?.......................................................................................66 Section 6 Rules for getting care in a “religious non-medical health care institution”................................................................................................. 68 Section 7 Rules for ownership of durable medical equipment............................. 69 Chapter 4: Medical Benefits Chart (what is covered and what you pay)..............................71 Section 1 Understanding your out-of-pocket costs for covered services.............72 Section 2 Use the medical benefits chart to find out what is covered and how much you will pay..................................................................................... 73 Section 3 What Medical services are not covered by the plan?..........................131 Section 4 Other additional benefits (not covered under Original Medicare)......137 Chapter 5: Using the plan’s coverage for Part D prescription drugs.................................145 Section 1 Introduction.............................................................................................146 Section 2 Fill your prescription at a network pharmacy or through the plan’s preferred mail-order service.................................................................. 146 Section 3 Your drugs need to be on the plan’s Drug List....................................149 Section 4 There are restrictions on coverage for some drugs............................151 Section 5 What if one of your drugs is not covered in the way you’d like it to be covered?..................................................................................................153 Section 6 What if your coverage changes for one of your drugs?......................155 Section 7 What types of drugs are not covered by the plan?..............................157 Section 8 Filling a prescription...............................................................................158 Section 9 Part D drug coverage in special situations...........................................158 Section 10 Programs on drug safety and managing medications........................160 Chapter 6: What you pay for your Part D prescription drugs.............................................162 Section 1 Introduction.............................................................................................163 Section 2 What you pay for a drug depends on which “drug payment stage” you are in when you get the drug.................................................................165 Section 3 We send you reports that explain payments for your drugs and which payment stage you are in.......................................................................165 Section 4 During the Deductible Stage, you pay the full cost of your Tier 2, Tier 3 and Tier 4 drugs..................................................................................... 167 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