2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 90 Services that are covered for you What you must pay when you get these services in-network and out-of-network the phone number on your UnitedHealthcare member ID card Non-emergency transportation Receive 12 one-way rides up to 50 miles per one-way trip to and from medically related appointments and to the pharmacy when referred by a UnitedHealthcare Engagement Specialist. Call the customer service number on your UnitedHealthcare member ID card for more information and to schedule your trips. · New referrals are required following each discharge. If you have been recently discharged from the hospital or a skilled nursing facility and would like a referral, call the phone number on your UnitedHealthcare member ID card. · Trips must be to or from plan-approved medically related appointments (locations); limited to ground transportation only. · Mileage reimbursement available upon request (arrangements must be set up in advance). · Each one-way trip must not exceed 50 miles. A trip is considered one way; a round trip is considered 2 trips. · The benefit cannot be used for emergency related trips. Drivers do not have medical training. In case of an emergency, call 911. · One companion per trip at least 18 years of age or older. · Cab/sedan services available. · Standard transportation services require at least 2 business days advanced notice. · Appointments can be made up to 30 days in advance. · Weekend scheduling available only for urgent requests. Non-Medical personal care