2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 123 Services that are covered for you What you must pay when you get these services in-network and out-of-network visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non-physician practitioner. For LDCT lung cancer screenings after the initial LDCT screening: the member must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non- physician practitioner. If a physician or qualified non- physician practitioner elects to provide a lung cancer screening counseling and shared decision-making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits. There is no coinsurance, Screening for sexually transmitted infections (STIs) and counseling to prevent STIs copayment, or deductible for We cover sexually transmitted infection (STI) screenings for the Medicare-covered screening chlamydia, gonorrhea, syphilis, and Hepatitis B. These for STIs and counseling for STIs screenings are covered for pregnant women and for certain preventive benefit. people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy. We also cover up to two individual 20 to 30 minute, face-to- face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office. Services to treat kidney disease Covered services include: · Kidney disease education services to teach kidney care $0 copayment for Medicare- and help members make informed decisions about their covered benefits.