2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 130 Services that are covered for you What you must pay when you get these services in-network and out-of-network described for each separate service in this medical benefits chart. Important: We cover the “Welcome to Medicare” preventive visit only within the first 12 months you have Medicare Part B. When you make your appointment, let your doctor’s office know you would like to schedule your “Welcome to Medicare” preventive visit. Wigs^ The plan pays up to $100 for Wigs will be covered for hair loss due to chemotherapy or wigs per plan year.* radiation therapy. * Covered services that do not count toward your maximum out-of-pocket amount. †† Covered services where your provider may need to request prior authorization. ^ Coverage for these services, excluding wigs for chemotherapy, are in addition to your Medicare Advantage plan benefits. Unlike your Medicare Advantage plan medical coverage, you cannot file a Medicare appeal or grievance for non-Medicare benefits. If you have questions, please call Customer Service using the information on the cover of this booklet. § Call Customer Service at the number on your UnitedHealthcare member ID card for more details. ‡ Some services not covered by Original Medicare, such as routine vision, acupuncture and chiropractic care, will only be paid up to the Medicare allowable amount when services are from an out-of-network provider.