2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 85 Services that are covered for you What you must pay when you get these services in-network and out-of-network using a brand of blood glucose monitors and test strips that OneTouch®Ultra 2, Accu-Chek® is not on our list, you may contact us within the first 90 days Guide Me, and Accu-Chek® of enrollment into the plan to request a temporary supply of Guide. the alternate brand while you consult with your doctor or other provider. During this time, you should talk with your Test strips: OneTouch Verio®, doctor to decide whether any of the preferred brands are OneTouch Ultra®, Accu-Chek® medically appropriate for you. If you or your doctor believe Guide, Accu-Chek® Aviva Plus, it is medically necessary for you to maintain use of an and Accu-Chek® SmartView. alternate brand, you may request a coverage exception to have UnitedHealthcare® Group Medicare Advantage PEBB Other brands are not covered Complete (PPO) maintain coverage of a non-preferred by your plan. product through the end of the benefit year. Non-preferred For cost-sharing applicable to products will not be covered following the initial 90 days of insulin and syringes, see the benefit year without an approved coverage exception. Chapter 6 - What you pay for If you (or your provider) don’t agree with the plan’s coverage your Part D prescription drugs. decision, you or your provider may file an appeal. You can also file an appeal if you don’t agree with your provider’s decision about what product or brand is appropriate for your medical condition. (For more information about appeals, see Chapter 9, What to do if you have a problem or complaint (coverage decisions, appeals, complaints).) · Medicare-covered continuous glucose monitors (CGMs) $0 copayment for Medicare- and supplies are covered in accordance with Medicare covered continuous glucose Guidelines. monitors (CGMs) and †† supplies. · For people with diabetes who have severe diabetic foot $0 copayment for each pair of disease: One pair per plan year of therapeutic custom- Medicare-covered therapeutic molded shoes (including inserts provided with such shoes.†† shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes). Coverage includes fitting.