2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 137 Services not covered by Not covered under any Covered only under specific Medicare condition conditions Fitness program As specifically described as a Renew Active® by covered service in the medical UnitedHealthcare. benefits chart in this chapter. Self-administered drugs in an Covered only under specific outpatient hospital conditions. We regularly review new procedures, devices and drugs to determine whether or not they are safe and effective for members. New procedures and technology that are safe and effective are eligible to become covered services. If the technology becomes a covered service, it will be subject to all other terms and conditions of the plan, including medical necessity and any applicable member copayments, coinsurance, deductibles or other payment contributions. In determining whether to cover a service, we use proprietary technology guidelines to review new devices, procedures and drugs, including those related to behavioral/mental health. When clinical necessity requires a rapid determination of the safe and effective use of a new technology or new application of an existing technology for an individual member, one of our medical directors makes a medical necessity determination based on individual member medical documentation, review of published scientific evidence, and, when appropriate, relevant specialty or professional opinion from an individual who has expertise in the technology. Section 4 Other additional benefits (not covered under Original Medicare) Introduction Your health and well-being are important to us, which is why we’ve developed the additional benefit(s) detailed in this section: · Routine hearing services · Routine vision services · Routine chiropractic services · Routine acupuncture services · Naturopathic services The benefit(s) described on the following pages are designed to help you stay healthy and provide well-rounded health coverage. Please read this section carefully, and reference it later if need be, to help you know what services are covered under your plan. If you ever have questions about what is covered, how to make a claim or about any other issue, please call Customer Service (phone numbers for Customer Service are on the cover of this booklet). We are always happy to provide answers to any questions you may have. We’re here to serve you. The information in this section describes the following benefits: · Routine eye exam and routine eyewear