2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 118 Services that are covered for you What you must pay when you get these services in-network and out-of-network the teeth are not Medicare-covered benefits and not covered under this benefit. · Monitoring services in a physician’s office or outpatient You will pay the cost-sharing hospital setting if you are taking anticoagulation that applies to primary care medications, such as Coumadin, Heparin or Warfarin provider services, specialist (these services may also be referred to as ‘Coumadin services, or outpatient hospital Clinic’ services). services (as described under “Physician/practitioner services, including doctor’s office visits” or “Outpatient hospital services” in this benefit chart) depending on where you †† receive services. · Medically-necessary medical or surgical services that You will pay the cost-sharing are covered benefits and are furnished by a physician in that applies to primary care your home or a nursing home in which you reside. provider services or specialist physician services (as applied in an office setting, described above in this section of the benefit chart) depending on the type of physician that provides †† the services. $0 copayment for certain primary care provider, nurse practitioner, physician’s assistant, or other non-physician health care professional services furnished in the home § by designated providers