2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 140 Check the Medical Benefits Chart above for the amount of your benefit and how often you can purchase hearing aids. Limitations and exclusions The limitations and exclusions below apply to your additional hearing aid benefit: · This benefit may be changed or terminated at the end of the plan year. · Hearing aids ordered through providers other than UnitedHealthcare Hearing are not covered. · Government treatment for any services provided in a local, state or federal government facility or agency, except when federal or state law requires payment under the plan. · Any treatment or services caused by or resulting from employment, or covered under any public liability insurance, including Workers’ Compensation programs. · Covered expenses related to hearing aids are limited to the plan’s Usual and Customary (U&C) charge of a basic hearing aid to provide functional improvement. · Certain hearing aid items and services are not covered, such as: - Replacement of a hearing aid that is lost, broken or stolen if it exceeds covered rate of occurrence - Repair of the hearing aid and related services - An eyeglass-type hearing aid or additional charges for a hearing aid designed specifically for cosmetic purposes - Services, accessories, or supplies that are not medically necessary according to professionally accepted standards of practice - Replacement batteries or assistive listening devices - Services received outside of the plan’s coverage dates, warranty or trial period - Services you choose to have that are not covered under the benefit will be at your own cost - Non-prescription (over-the-counter) hearing aids purchased outside of UnitedHealthcare Hearing Routine Vision Services Vision service providers Vision coverage is through the UnitedHealthcare Medical network. Providers should contact the provider number on the back of your UnitedHealthcare member ID card to confirm eligibility and benefits. You may visit any vision service provider for routine vision services. Out-of-network vision providers may require you to pay the full cost of the service and then submit to UnitedHealthcare for reimbursement. For more information on this process, please see Chapter 7. For more information please see Access Your Benefits earlier in this section.