2024 Evidence of Coverage for UnitedHealthcare® Group Medicare Advantage PEBB Balance (PPO) Chapter 4: Medical Benefits Chart (what is covered and what you pay) 122 Services that are covered for you What you must pay when you get these services in-network and out-of-network · Stress management, nutrition and physical activity content designed to help you through your quit journey *Real Weight Loss or Real Appeal Diabetes Prevention are available based on your unique needs *Real Appeal Weight Management is available to those with a BMI of 19 and higher. Real Appeal Diabetes Prevention is available to you if you have a BMI ≥ 25 (BMI ≥ 23 for Asian Americans), have Prediabetes, and no previous diagnosis of Type 1 or Type 2 Diabetes. If you are pregnant, please speak with your primary care physician before joining the program. Limitations and restrictions apply. There is no coinsurance, Screening and counseling to reduce alcohol misuse copayment, or deductible for We cover one alcohol misuse screening per year for adults the Medicare-covered screening with Medicare (including pregnant women) who misuse and counseling to reduce alcohol, but aren’t alcohol dependent. alcohol misuse preventive If you screen positive for alcohol misuse, you can get up to benefit. four brief face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting. There is no coinsurance, Screening for lung cancer with low dose computed tomography (LDCT) copayment, or deductible for For qualified individuals, a LDCT is covered every 12 the Medicare-covered months. counseling and shared decision making visit or for the LDCT. Eligible members are: people aged 50 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 20 pack-years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision making