2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 1: Getting started as a member 5 Program, and the services are covered benefits and medically necessary. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information. The most recent list of providers and suppliers is available on our website at retiree.uhc.com/ wapebb. If you don’t have your copy of the Provider Directory, you can request a copy (electronically or in hardcopy form) from Customer Service. Requests for hard copy Provider Directories will be mailed to you within three business days. Section 3.3 Pharmacy Directory The pharmacy directory lists our network pharmacies. Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members. You can use the Pharmacy Directory to find the network pharmacy you want to use. See Chapter 5, Section 2.5 for information on when you can use pharmacies that are not in the plan’s network. If you don’t have the Pharmacy Directory, you can get a copy from Customer Service. You can also find this information on our website at retiree.uhc.com/wapebb. Section 3.4 The plan’s List of Covered Drugs (Formulary) The plan has a List of Covered Drugs (Formulary). We call it the “Drug List” for short. It tells which Part D prescription drugs are covered under the Part D benefit included in our plan. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the plan’s Drug List. The Drug List also tells you if there are any rules that restrict coverage for your drugs. We will provide you a copy of the Drug List. The Drug List we provide you includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the provided Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact Customer Service to find out if we cover it. To get the most complete and current information about which drugs are covered, you can visit the plan’s website (retiree.uhc.com/wapebb) or call Customer Service. Section 4 Your monthly costs for the plan Your costs may include the following: · Plan Premium (Section 4.1) · Monthly Medicare Part B Premium (Section 4.2) · Part D Late Enrollment Penalty (Section 4.3) · Income Related Monthly Adjusted Amount (Section 4.4) Medicare Part B and Part D premiums differ for people with different incomes. If you have questions about these premiums review your copy of Medicare & You 2024 handbook, the section called “2024 Medicare Costs.” If you need a copy you can download it from the Medicare website