2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 129 Services that are covered for you What you must pay when you get these services in-network and out-of-network · One pair of eyeglasses or contact lenses after each $0 copayment for one pair of cataract surgery that includes insertion of an intraocular Medicare-covered standard lens (additional pairs of eyeglasses or contacts are not glasses or contact lenses after covered by Medicare). If you have two separate cataract cataract surgery. operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery. Covered eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive lenses or anti-reflective coating). Routine vision services Eye Exam ‡ Please turn to Section 4 Routine Vision Services of this $0 copayment for 1 exam every chapter for more detailed information about this benefit. 12 months.* Eyewear Plan pays up to $300 combined allowance for eyeglasses and contact lenses every 24 months.* There is no coinsurance, “Welcome to Medicare” Preventive Visit copayment, or deductible for The plan covers the one-time “Welcome to Medicare” the “Welcome to Medicare” preventive visit. The visit includes a review of your health, as preventive visit. well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit, as