2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 76 Medical Benefits Chart Services that are covered for you What you must pay when you get these services in-network and out-of-network Providers may ask you for more than one cost share payment if you get more than one service at an appointment. For example: · Your doctor will ask for a copayment for the office visit and additional copayments for each x-ray that is performed while you are there. · Your hospital will ask for separate cost-sharing for outpatient hospital medical services and any radiological tests or Medicare Part B drugs administered while you are there. · Your pharmacist will ask for a separate copayment for each prescription he or she fills. · The specific cost-sharing that will apply depends on which services you receive. The Medical benefits chart below lists the cost-sharing that applies for each specific service. There is no coinsurance, Abdominal aortic aneurysm screening copayment, or deductible for A one-time (once per lifetime) screening ultrasound for members eligible for this people at risk. The plan only covers this screening if you preventive screening. have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist.