2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 139 Out-of-network benefits You can choose to use your in-network benefits with a network provider or use your out-of-network benefits with an out-of-network provider. Routine hearing services Covered Services The following services are covered under your additional hearing benefit: Routine Hearing Exam You can receive one hearing exam, every year through any hearing service provider, including a UnitedHealthcare Hearing provider. No authorization needed. For more information, see Access Your Benefits earlier in this section. Check the Medical Benefits Chart above for any copayment or coinsurance that may be due at the time of your exam. Hearing Aids Hearing aids are medical devices that fit in or near the ear. You must visit a provider in the UnitedHealthcare Hearing network or purchase through UnitedHealthcare Hearing’s website for your hearing aids to be covered. With UnitedHealthcare Hearing, you receive a broad selection of name brand and private-labeled prescription hearing aids, including some virtual appointment options. The benefit may be utilized toward the purchase of certain non-prescription (over-the- counter) hearing aids through UnitedHealthcare Hearing only. To access your hearing aid benefit, call UnitedHealthcare Hearing at 1-866-445-2071, TTY 711. A hearing counselor will verify your eligibility and help determine your hearing care needs, including if you need a routine hearing exam. Then they will help you find a convenient location and make your appointment. A prescription hearing aid purchase includes: · 1 hearing exam for evaluation and fitting of hearing aids every year · A trial period · 3 hearing aid follow-up appointments within the first year - 1 follow-up appointment for hearing aids purchased in the Silver technology level · A 3-year extended warranty The warranty for non-prescription (over-the-counter) hearing aids varies by manufacturer. Non- prescription hearing aids do not require any of the following: · A medical exam · A fitting by an audiologist · A written prescription