2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 104 Services that are covered for you What you must pay when you get these services in-network and out-of-network prevention plan. Talk to your primary care doctor or practitioner to find out more. Opioid treatment program services $0 copayment for Medicare- Members of our plan with opioid use disorder (OUD) can covered opioid treatment program services.†† receive coverage of services to treat OUD through an Opioid Treatment Program (OTP) which includes the following services: · U.S. Food and Drug Administration (FDA)-approved opioid agonist and antagonist medication-assisted treatment (MAT) medications. · Dispensing and administration of MAT medications (if applicable) · Substance use counseling · Individual and group therapy · Toxicology testing · Intake activities · Periodic assessments Outpatient diagnostic tests and therapeutic services and supplies Covered services include, but are not limited to: · X-rays $15 copayment for each Medicare-covered standard X- ray service.†† You pay these amounts until you reach the out-of-pocket maximum.