UPMC for Life PPO Rx (PPO)
- $10 copayment for primary care doctor visits (in-network)
- Annual out-of-pocket deductible of $500 for all out-of-network services
- 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 club with our Silver&Fit fitness program at no additional cost
| Benefits: | You Pay: |
|---|---|
| High-Level Benefits: | |
| Monthly Plan Premium | $81.50 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 | $500 for out-of-network services only |
| Primary Care Doctor Visit Copay | In-network: $10 Out-of-network: $30** |
| Specialist Doctor Visit Copay | In-network: $30 Out-of-network: $50** |
| Inpatient Hospital and Mental Health Care Copay | In-network: $250 per stay; $750 maximum Out-of-network: 30% of the cost** |
| Detailed Benefits: | |
| Skilled Nursing Facility | In-network: $30 each day (days 1-10); $70 each day (days 11-54); $0 each day (days 55-100); $3,400 maximum Out-of-network: 30% of the cost** |
| Outpatient Rehabilitation Services (speech, occupational, and physical therapy) | In-network: $30 Out-of-network: $50** |
| Outpatient Services/Surgery | In-network: $150 per visit; $300 maximum Out-of-network: 30% of the cost** |
| Mental Health Services | In-network: $30 Out-of-network: $50** |
| Emergency Care | $65 (excluded from the out-of-network deductible) |
| Urgent Care | $30 (excluded from the out-of-network deductible) |
| Ambulance | In-network: $100 Out-of-network: 30% of the cost** |
| Durable Medical Equipment | In-network: 20% of the cost Out-of-network: 50% of the cost** |
| Diabetes Supplies | In-network: $10-$50 Out-of-network: 50% of the cost** |
| Lab Services, X-rays, and Advanced Imaging | In-network: $0 for lab services; $30 for general x-rays; $90 for CT scans, MRIs, MRAs, and PET scans; $25 for radiation therapy; $100 maximum for radiation therapy Out-of-network: 30% of the cost** |
| Preventive Services | In-network: $0 Out-of-network: 30% of the cost** |
| Routine Vision | You receive: a $200 allowance toward the cost of one routine eye exam and eyewear every 2 years |
| Routine Hearing | In-network: $30 for Medicare-covered hearing exams; $30 for one routine hearing test per year; $30 for one routine hearing aid fitting once every three years; Out-of-network: $50 for Medicare-covered hearing exams** Combined in- and out-of-network: $500 hearing aid allowance for use once every three years |
| Routine Chiropractic | In-network: $20; limit 8 visits Out-of-network: n/a |
| Routine Podiatry | In-network: $30; limit 8 visits Out-of-network: n/a |
| Health and Fitness Program | Silver&Fit® health and wellness program which provides membership to a local participating fitness facility 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 the 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. |
