2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 6: What you pay for your Part D prescription drugs 169 Your share of the cost when you get a covered Part D prescription drug**: Cost-Sharing $100 copayment $200 copayment $100 copayment* Tier 3 Non-preferred 1 Drug Cost-Sharing $100 copayment $100 copayment $100 copayment* Tier 4 (limited to a 30-day Specialty Tier supply) 1 1 You will pay a maximum of $35 for a 1-month supply of each Part D insulin product covered by our plan even if you haven’t paid your Part D deductible. *You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount. **For preferred insulin prescription drugs, you will pay: · $10 for a 30-day supply · $20 for a 31 to 60-day supply · $30 for a 61 to 90-day supply Check the Additional Drug List to see the preferred insulin prescription drug list. If you obtain less than a 90-day supply from the preferred mail-order pharmacy for any reason, the in-network standard retail cost-sharing amount applies. Your Pharmacy Out-of-Pocket Maximum When your total Out-of-Pocket costs (what you pay) reach $2,000 you will not pay any copayment or coinsurance. Your foreign travel prescription drug coverage After you reach your prescription deductible, you’ll pay a $45 copay for a 30-day supply. When you reach the pharmacy out-of-pocket maximum, your copay is $0. To use this benefit, you will need to pay the full cost of the service and then submit a reimbursement claim. We’ll reimburse 100% of the billed charges, minus any applicable copay for each 30-day supply. For more information on this process, please see Chapter 7. This non-Medicare drug coverage is in addition to your Medicare drug coverage. Unlike your Medicare drug coverage, you cannot file a Medicare appeal or grievance for non-Medicare drug coverage. If you have questions, please call Customer Services using the information on the cover of this booklet. Please see Section 9 of this chapter for more information on Part D vaccines and cost sharing for Part D vaccines.