2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 105 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Surgical supplies, such as dressings $0 copayment for each · Splints, casts, and other devices used to reduce Medicare-covered medical †† fractures and dislocations supply. Note: There is no separate charge for medical supplies routinely used in the course of an office visit and included in the provider’s charges for that visit (such as bandages, cotton swabs, and other routine supplies.) However, supplies for which an appropriate separate charge is made by providers (such as, chemical agents used in certain diagnostic procedures) are subject to cost-sharing as shown. · Laboratory tests $0 copayment for Medicare- covered lab services.†† · Blood - including storage and administration (this $0 copayment for Medicare- †† means processing and handling of blood). Coverage covered blood services. begins with the first pint of blood that you need. · In addition, for the administration of blood infusion, you will pay the cost-sharing as described under the following sections of this chart, depending on where you received infusion services: - Physician/practitioner services, including doctor’s office visits - Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers