UPMC for Life PPO High Deductible with Rx (PPO)

  • $40 monthly plan premium (in addition to your Medicare Part B premium)
  • Annual out-of-pocket deductible of $1,250 for all services (unless the service is marked as "deductible does not apply")
  • Vision coverage, including a $100 allowance toward the cost of one routine eye exam and eyewear every 2 years
  • NEW fitness benefit, Fit for Life, which allows members to join any fitness facility and get reimbursed for membership
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Benefits: You Pay:
High-Level Benefits:
Monthly Plan Premium $40 in addition to your Medicare Part B premium
Annual Maximum Out-of-Pocket Limit In-network: $6,700
Combined in- and out-of-network: $10,000
Annual Out-of-Pocket Deductible $1,250 for all services (unless the service is marked as "deductible does not apply")
Primary Care Doctor Visit Copay In-network: $10 (deductible does not apply)
Out-of-network: $40 after deductible
Specialist Doctor Visit Copay In-network: $50 (deductible does not apply)
Out-of-network: $60 after deductible
Inpatient Hospital and Mental Health Care Copay In-network: $200 per stay after deductible
Out-of-network: 30% of the cost after deductible
Detailed Benefits:
Skilled Nursing Facility (SNF) In-network: $25 each day (days 1-20);
$70 each day (days 21-61);
$0 each day (days 62-100);
(deductible does not apply)
Out-of-network: 30% of the cost after deductible
Outpatient Rehabilitation Services (speech, occupational, and physical therapy) In-network: $50 (deductible does not apply)
Out-of-network: 30% of the cost after deductible
Outpatient Services (includes office/clinic visits, labs, x-rays, advanced imaging, and surgeries) In-network: $0–$50 after deductible
Out-of-network: 30% of the cost after deductible
Mental Health Services In-network: $40 (deductible does not apply)
Out-of-network: $60 after deductible
Emergency Care $65 (deductible does not apply)
Urgent Care $50 (deductible does not apply)
Ambulance In-network: $0 after deductible
Out-of-network: 30% of the cost after deductible
Durable Medical Equipment In-network: 15% of the cost (deductible does not apply)
Out-of-network: 50% of the cost after deductible
Diabetes Supplies In-network: 10% of the cost after deductible
Out-of-network: 50% of the cost after deductible
Lab Services In-network: $0–$5 (deductible does not apply)
Out-of-network: 30% of the cost after deductible
X-rays and Advanced Imaging

In-network: $10 for general x-rays (deductible does not apply);
$50 for CT scans, MRIs, MRAs, and PET scans after deductible;
$0 for radiation therapy after deductible
Out-of-network: 30% of the cost after deductible

Preventive Services In-network: $0 (deductible does not apply)
Out-of-network: 30% of the cost (deductible does not apply to all screening exams)
Routine Vision You receive: a $100 allowance toward the cost of one routine eye exam and eyewear every 2 years (deductible does not apply)
Routine Hearing No routine hearing
Routine Chiropractic In-network: $20; limit 8 visits (deductible does not apply)
Out-of-network: $40 after deductible
Routine Podiatry In-network: $50; limit 8 visits (deductible does not apply)
Out-of-network: $60 after deductible
NEW Fitness Benefit – Fit for Life Join any fitness facility you like. You pay 50% of the cost for your membership. UPMC for Life will reimburse you up to $250 annually.
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 (31-day supply) $10 generic;
$45 preferred brand;
$95 non-preferred brand;
33% specialty;
$0 select care generic
In-Network Retail Pharmacy (90-day supply) $30 generic;
$135 preferred brand;
$285 non-preferred brand;
$0 select care generic
Mail-Order Pharmacy (90-day supply) $20 generic;
$112.50 preferred brand;
$285 non-preferred brand;
$0 select care generic
Coverage After You Reach Your Initial Coverage Limit After your total yearly drug costs reach $2,850, you pay 72% of the costs for generic drugs and a discounted price for the total cost of brand-name drugs.
Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: $2.55 for generic and $6.35 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 We have specialists who can connect you to resources for: 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
Hearing Discount Program Up to 20% off hearing services at participating retail locations, including a free annual hearing screening and exam, as well as discounts on hearing aid instruments
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 information on 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

 

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