2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 102 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Clotting factors you give yourself by injection if you have where you received drug hemophilia administration or infusion · Immunosuppressive drugs, if you were enrolled in services. Medicare Part A at the time of the organ transplant · Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis, and cannot self- administer the drug · Antigens (for allergy shots) · Certain oral anti-cancer drugs and anti-nausea drugs · Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as Epogen®, Procrit®, Epoetin Alfa, Aranesp®, or Darbepoetin Alfa) · Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases · Chemotherapy Drugs, and the administration of $0 copayment for each chemotherapy drugs Medicare-covered The following link will take you to a list of Part B Drugs that chemotherapy drug to treat may be subject to step therapy: https:// cancer and the administration of that drug.†† www.medicare.uhc.com/retiree/member/documents/group- part-b-step-therapy.html You or your doctor may need to provide more information about how a Medicare Part B prescription drug is used in order to determine coverage. There may be effective, lower- cost drugs that treat the same medical condition. If you are prescribed a new Part B medication or have not recently filled the medication under Part B, you may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover the Part B drug. (For more