January 1, 2024 - December 31, 2024 Evidence of Coverage Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of our plan This document gives you the details about your Medicare health care and prescription drug coverage from January 1, 2024 - December 31, 2024. This is an important legal document. Please keep it in a safe place. For questions about this document, please contact Customer Service at 1-855-873-3268. (TTY users should call 711). Hours are 8 a.m.-8 p.m. local time, Monday-Friday. This plan, UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO), is insured through UnitedHealthcare Insurance Company or one of its affiliates. (When this Evidence of Coverage says “we,” “us,” or “our,” it means UnitedHealthcare. When it says “plan” or “our plan,” it means UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO).) UnitedHealthcare does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities. UnitedHealthcare provides free services to help you communicate with us such as documents in other languages, Braille, large print, audio, or you can ask for an interpreter. For more information, please call Customer Service at the number on your member ID card or the front of your plan booklet. UnitedHealthcare ofrece servicios gratuitos para ayudarle a que se comunique con nosotros. Por ejemplo, documentos en otros idiomas, braille, en letra grande o en audio. O bien, usted puede pedir un intérprete. Comuníquese con nuestro número de Servicio al Cliente al número que se encuentra en su tarjeta de ID de miembro o en la portada de la guía de su plan. Benefits, deductible, and/or copayments/coinsurance may change on January 1, 2025. The formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. We will notify affected enrollees about changes at least 30 days in advance. This document explains your benefits and rights. Use this document to understand about: · Your plan premium and cost-sharing; · Your medical and prescription drug benefits; How to file a complaint if you are not satisfied with a service or treatment; · · How to contact us if you need further assistance; and, · Other protections required by Medicare law. OMB Approval 0938-1051 (Expires: February 29, 2024)