Benefits: |
You Pay: |
| High-Level Benefits: |
| Monthly Plan Premium |
$141.50 |
| Annual Maximum Out-of-Pocket Limit |
In-network: $3,400
Out-of-network: n/a |
| Primary Care Doctor Visit Copay |
$15 |
| Specialist Doctor Visit Copay |
$40 |
| Inpatient Hospital Copay |
$275 per stay; $825 maximum |
| Detailed Benefits: |
| Inpatient Mental Health Copay |
$275 per stay; $825 maximum |
| Outpatient Services/Surgery |
$175 per visit; $350 maximum |
| Outpatient Rehabilitation Services (speech, occupational, and physical therapy) |
$40 |
| Mental Health Services |
$40 |
| Emergency and Urgent Care |
$50 |
| Ambulance |
$100 |
| Routine Vision |
You receive: $150 toward the cost of one routine eye exam and eyewear every 2 years |
| Routine Hearing |
No routine hearing |
| Routine Chiropractic |
$40 per visit; limit 6 visits |
| Routine Podiatry |
$40 per visit; limit 4 visits |
| Durable Medical Equipment |
20% of the cost per item |
| Diagnostic Tests, X-rays, and Lab Services |
$0 for clinical/ diagnostic lab services and radiation
$20 for general x-rays
$60 for CT scans, MRIs, MRAs, and PET scans |
| Preventive Screenings |
$0 for preventive screenings
$0-175 for a colonoscopy
A separate office visit copay may apply. |
| Skilled Nursing Facility |
$25 each day, days 1-10
$60 each day, days 11-60
$0 each day, days 61-100;
$3,250 maximum |
| Health and Fitness Program |
Silver&Fit® fitness program which provides membership to a participating fitness club at no additional cost |
| Worldwide Emergency Travel Assistance |
Assist America® provides emergency travel assistance when you're 100 miles from home or in another country |
| Prescription Drug Coverage: |
| In-Network Retail Pharmacy (1 month - 31-day supply) |
$5 Generics
$32 Preferred Brand
$80 Non-Preferred Brand
33% of the cost for Specialty drugs |
| In-Network Retail Pharmacy (3 months - 90-day supply) |
$15 Generics
$96 Preferred Brand
$240 Non-Preferred Brand |
| Mail Order Pharmacy (3 months - 90-day supply) |
$12.50 Generics
$80 Preferred Brand
$200 Non-Preferred Brand
33% of the cost for Specialty drugs (31-day supply) |
| Coverage After You Reach Your Initial Coverage Limit |
After the total yearly drug costs (paid by both you and our plan) reach $2,830, you pay 100% of your prescription drug costs until your yearly out-of-pocket costs reach $4,550. |
| Catastrophic Coverage |
After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: $2.50 for Generics and $6.30 for all other drugs, or 5% coinsurance. |
| Extra Services and Programs: |
| Health Care Concierge+ |
A special team of Health Care Concierges who can help you understand your benefits and answer your questions. |
| UPMC Resources for Life+ |
Resources for managing life issues, like: legal guidance, financial counseling, household budgeting, and short-term telephone counseling. |
| Dental Discount Card+ |
Savings starting at 15% on dental services, such as routine cleanings and exams, x-rays and fillings, root canals and crowns, and dentures and bridges. |
| Brain Health and Fitness Program+ |
The InSight™ software program to load on your computer with exercises to help you keep your brain healthy and fit. |
| MyHealth Advice Line |
24/7 health advice from experienced, registered nurses with one phone call. |
| MyHealth OnLine+ |
An Internet-based resource that gives you access to information about your health care visits, prescription refills, membership claims, and your benefits. |
| Care Management Programs |
One-on-one support from health coaches who can help you live with chronic medical conditions, such as heart failure, asthma, diabetes, high blood pressure, depression, and more. |
Please note: Not all benefits are listed in this grid. For complete benefit information, please reference the Summary of Benefits for the plan in which you are interested. Click here to go back to our 2010 Medicare Plan Options page and review the Summaries of Benefits for each plan.
If you have any questions or would like to receive this information by mail, please call us toll-free at 1-866-400-5077 from 8 a.m. to 8 p.m., seven days a week or click on one of the links below. TTY/TDD users should call 1-800-361-2629. From March 2 through November 14, you may receive a messaging service on weekends and holidays. Please leave a message and your call will be returned the next business day.
*This cost is excluded from the annual deductible. You pay only the cost shown. The annual deductible applies to your overall costs spent, not just the amount spent on each specific benefit.
**You pay the cost shown after the annual deductible is met.
