2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 127 Services that are covered for you What you must pay when you get these services in-network and out-of-network necessary. Examples of urgently needed services that the plan must cover out of network occur if: You are temporarily outside the service area of the plan and require medically needed immediate services for an unforeseen condition but it is not a medical emergency; or it is unreasonable given your circumstances to immediately obtain the medical care from a network provider. Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished in-network. Worldwide coverage for ‘urgently needed services’ when medical services are needed right away because of an illness, injury, or condition that you did not expect or anticipate, and you can’t wait until you are back in our plan’s service area to obtain services. Services provided by a dentist are not covered. Virtual behavioral visits $30 copayment using providers UnitedHealthcare’s virtual behavioral visits lets you choose that have the ability and are to see and speak to a mental health professional using your qualified to offer virtual computer or a mobile device, like a tablet or smart phone. behavioral visits. This service can be used for initial evaluation, medication management and ongoing counseling. Providers can’t You pay these amounts until prescribe medications in all states. you reach the out-of-pocket maximum. Virtual Behavioral Health also includes cognitive behavioral health therapy. Cognitive behavioral health therapy is a type of therapy that works on your thoughts and beliefs and how they affect your actions. Virtual doctor visits $0 copayment using AmWell, UnitedHealthcare’s virtual doctor visits lets you choose to Doctor on Demand and see and speak to doctors using your computer or a mobile Teladoc.