2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 79 Services that are covered for you What you must pay when you get these services in-network and out-of-network transportation could endanger the person’s health and that Authorization is required for transportation by ambulance is medically required. non-emergency Medicare- covered ambulance air transportation. Emergency ambulance does not require authorization. Annual routine physical exam $0 copayment for a routine Includes comprehensive physical examination and physical exam each year. evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit, as described for each separate service in this Medical Benefits Chart. Benefit is combined in and out-of-network. Annual wellness visit There is no coinsurance, copayment, or deductible for If you’ve had Part B for longer than 12 months, you can get the annual wellness visit. an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. You don’t have to wait a full year to get your annual wellness visit, you can get it once every calendar year. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit, as described for each separate service in this Medical Benefits Chart. Note: Your first annual wellness visit can’t take place within 12 months of your Welcome to Medicare preventive visit. However, you don’t need to have had a Welcome to Medicare visit to be covered for annual wellness visits after you’ve had Part B for 12 months.