2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Complete (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 117 Services that are covered for you What you must pay when you get these services in-network and out-of-network $0 copayment for certain primary care provider, nurse practitioner, physician’s assistant, or other non-physician health care professional services furnished in the home § by designated providers · Certain telehealth services, including: - Virtual doctor visits See “Virtual doctor visits” in this chart for any applicable copayments or coinsurance. - Virtual behavioral visits See “Virtual behavioral visits” in this chart for any applicable copayments or coinsurance. Podiatry services $0 copayment for each Covered services include: Medicare-covered visit in an office or home setting.†† · Diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or For services rendered in an heel spurs). outpatient hospital setting, such · Routine foot care for members with certain medical as surgery, please refer to conditions affecting the lower limbs. Outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. Additional routine podiatry $0 copayment per visit for Treatment of the foot which is generally considered routine podiatry visits up to 6 preventive, i.e., cutting or removal of corns, warts, calluses visits per plan year. or nails.