UPMC for Life PPO High Deductible with Rx (PPO)
- $0 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 excluded from the deductible)
- Low prescription drug copayments of $5 for generics and $42 for preferred-brand drugs for a 31-day supply
- Vision coverage, including a $200 allowance toward the cost of one routine eye exam and eyewear every 2 years
- Membership to a local participating fitness facility with our Silver&Fit fitness program at no additional cost
| Benefits: | You Pay: |
|---|---|
| High-Level Benefits: | |
| Monthly Plan Premium | $0 in addition to your Medicare Part B premium |
| Annual Maximum Out-of-Pocket Limit | In-network: $3,400 Combined in- and out-of-network: $5,100 |
| Annual Out-of-Pocket Deductible | $1,250 for all services (unless the service is marked as excluded from the deductible) |
| Primary Care Doctor Visit Copay | In-network: $20 Out-of-network: $30 (excluded from the yearly deductible) |
| Specialist Doctor Visit Copay | In-network: $35 Out-of-network: $50 (excluded from the yearly deductible) |
| Inpatient Hospital and Mental Health Care Copay | In-network: $0** Out-of-network: 30% of the cost** |
| Detailed Benefits: | |
| Skilled Nursing Facility (SNF) | In-network: $30 each day (days 1-10); $70 each day (days 11-54); $0 each day (days 55-100); (excluded from the yearly deductible) Out-of-network: 30% of the cost (excluded from the deductible) |
| Outpatient Rehabilitation Services (speech, occupational, and physical therapy) | In-network: $0** Out-of-network: 30% of the cost** |
| Outpatient Services/Surgery | In-network: $0** Out-of-network: 30% of the cost** |
| Mental Health Services | In-network: $35 Out-of-network: $50 (excluded from the yearly deductible) |
| Emergency Care | $65 (excluded from the yearly deductible) |
| Urgent Care | $35 (excluded from the yearly deductible) |
| Ambulance | In-network: $0** Out-of-network: 30% of the cost** |
| Durable Medical Equipment | In-network: $0** Out-of-network: 50% of the cost** |
| Diabetes Supplies | In-network: $0** Out-of-network: 30% of the cost** |
| Lab Services, X-rays, and Advanced Imaging | In-network: $0** Out-of-network: 30% of the cost** |
| Preventive Services | In-network: $0 (excluded from the deductible) Out-of-network: 30% of the cost (excluded from the deductible) |
| Routine Vision | You receive: a $200 allowance toward the cost of one routine eye exam and eyewear every 2 years |
| Routine Hearing | No routine hearing |
| Routine Chiropractic | In-network: $20; limit 8 visits Out-of-network: n/a (excluded from the yearly deductible) |
| Routine Podiatry | In-network: $35; limit 8 visits Out-of-network: n/a (excluded from the yearly deductible) |
| 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 (31-day supply) | $5 generic; $42 preferred brand; $95 non-preferred brand; 33% specialty |
| In-Network Retail and Mail-Order Pharmacy (90-day supply) | $10 generic; $105 preferred brand; $285 non-preferred brand |
| Coverage After You Reach Your Initial Coverage Limit | After your total yearly drug costs reach $2,930, you pay 86% 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 drugs costs reach $4,700, you pay the greater of: $2.60 for generic and $6.50 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. |
| 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 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. |
