2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 95 Services that are covered for you What you must pay when you get these services in-network and out-of-network For services that are covered by Medicare Part A or B and are not related to your terminal prognosis: If you need non-emergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis, you pay your plan cost-sharing amount for these services. Please refer to this Benefits Chart. For services that are covered by UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) but are not covered by Medicare Part A or B: UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) will continue to cover plan-covered services that are not covered under Part A or B whether or not they are related to your terminal prognosis. You pay your plan cost-sharing amount for these services. For drugs that may be covered by the plan’s Part D benefit: If these drugs are unrelated to your terminal hospice condition you pay cost-sharing. If they are related to your terminal hospice condition then you pay Original Medicare cost-sharing. Drugs are never covered by both hospice and our plan at the same time. For more information, please see Chapter 5, Section 9.4 (What if you’re in Medicare-certified hospice). Our plan covers hospice consultation services (one time only) for a terminally ill person who hasn’t elected the hospice benefit. Immunizations There is no coinsurance, Covered Medicare Part B services include: copayment, or deductible for · Pneumonia vaccine the pneumonia, flu, Hepatitis B, · Flu vaccine, one each flu season in the fall and winter, or COVID-19 vaccines. with additional flu vaccine shots if medically necessary There is no coinsurance, copayment, or deductible for all