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Choose where you live from the list below. |
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Compare up to 3 UPMC for Life plans by choosing plans from columns A, B, and C below. |
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Choose a plan from this column. |
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Choose a different plan from this column to compare 2 plans. |
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Choose a different plan from this column to compare 3 plans. |
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| Premium |
| Annual Maximum Out-of-Pocket Limit |
| In-Network Annual Maximum Out-of-Pocket Limit |
| Out-of-Network Annual Out-of-Pocket Deductible |
| Inpatient Hospital and Inpatient Mental Health Care |
| Skilled Nursing Facility |
| Primary Care Doctor Visit |
| Specialist Doctor Visit |
| Outpatient Rehabilitation Services (occupational, physical, speech and language therapy) |
| Outpatient Mental Health and Substance Abuse Services |
| Outpatient Services / Surgery |
| Emergency Care / Urgent Care |
| Durable Medical Equipment |
| Diagnostic Tests, X-rays, and Lab Services |
| Preventive Services |
| Routine Vision |
| Routine Hearing |
| Health & Wellness |
| Travel Assistance with Assist AmericaR |
| Personal Member Service with NEW Extended Services* |
| Prescription Drug Coverage: |
| In-Network Retail Pharmacy (1 month — 31-day supply) |
| In-Network Retail Pharmacy (3 months — 90-day supply) |
| Mail-Order Pharmacy (3 months — 90-day supply) |
| Coverage After You Reach Your Initial Coverage Limit |
| Catastrophic Coverage |
|
| You Pay: |
| $0 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $28.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$750 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| $5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $109.00 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $165.60 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-of-Network:
Same as In-Network. |
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-of-Network:
Same as In-Network. |
|
| You Pay: |
| $0 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $28.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$750 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $109.00 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $165.60 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-of-Network:
Same as In-Network. |
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-of-Network:
Same as In-Network. |
|
| You Pay: |
| $0 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $28.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$750 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| $5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $109.00 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $165.60 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-of-Network:
Same as In-Network. |
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-of-Network:
Same as In-Network. |
|
|
Compare up to 3 UPMC for Life plans by choosing plans from columns A, B, and C below. |
|
|
|
Choose a plan from this column. |
| |
|
|
|
Choose a different plan from this column to compare 2 plans. |
| |
|
|
|
Choose a different plan from this column to compare 3 plans. |
| |
|
|
|
| |
| Premium |
| Annual Maximum Out-of-Pocket Limit |
| In-Network Annual Maximum Out-of-Pocket Limit |
| Out-of-Network Annual Out-of-Pocket Deductible |
| Inpatient Hospital and Inpatient Mental Health Care |
| Skilled Nursing Facility |
| Primary Care Doctor Visit |
| Specialist Doctor Visit |
| Outpatient Rehabilitation Services (occupational, physical, speech and language therapy) |
| Outpatient Mental Health and Substance Abuse Services |
| Outpatient Services / Surgery |
| Emergency Care / Urgent Care |
| Durable Medical Equipment |
| Diagnostic Tests, X-rays, and Lab Services |
| Preventive Services |
| Routine Vision |
| Routine Hearing |
| Health & Wellness |
| Travel Assistance with Assist AmericaR |
| Personal Member Service with NEW Extended Services* |
| Prescription Drug Coverage: |
| In-Network Retail Pharmacy (1 month — 31-day supply) |
| In-Network Retail Pharmacy (3 months — 90-day supply) |
| Mail-Order Pharmacy (3 months — 90-day supply) |
| Coverage After You Reach Your Initial Coverage Limit |
| Catastrophic Coverage |
|
| You Pay: |
| $28.20 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $59.00 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$400 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $84.70 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $190.00 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-Of-Network:
Same as In-Network.
|
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply.
|
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
|
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-Of-Network:
Same as In-Network. |
|
| You Pay: |
| $28.20 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $59.00 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$400 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $84.70 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $190.00 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-Of-Network:
Same as In-Network.
|
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply.
|
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
|
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-Of-Network:
Same as In-Network. |
|
| You Pay: |
| $28.20 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $59.00 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$400 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $84.70 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $190.00 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-Of-Network:
Same as In-Network.
|
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply.
|
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
|
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-Of-Network:
Same as In-Network. |
|
|
Compare up to 3 UPMC for Life plans by choosing plans from columns A, B, and C below. |
|
|
|
Choose a plan from this column. |
| |
|
|
|
Choose a different plan from this column to compare 2 plans. |
| |
|
|
|
Choose a different plan from this column to compare 3 plans. |
| |
|
|
|
| |
| Premium |
| Annual Maximum Out-of-Pocket Limit |
| In-Network Annual Maximum Out-of-Pocket Limit |
| Out-of-Network Annual Out-of-Pocket Deductible |
| Inpatient Hospital and Inpatient Mental Health Care |
| Skilled Nursing Facility |
| Primary Care Doctor Visit |
| Specialist Doctor Visit |
| Outpatient Rehabilitation Services (occupational, physical, speech and language therapy) |
| Outpatient Mental Health and Substance Abuse Services |
| Outpatient Services / Surgery |
| Emergency Care / Urgent Care |
| Durable Medical Equipment |
| Diagnostic Tests, X-rays, and Lab Services |
| Preventive Services |
| Routine Vision |
| Routine Hearing |
| Health & Wellness |
| Travel Assistance with Assist AmericaR |
| Personal Member Service with NEW Extended Services* |
| Prescription Drug Coverage: |
| In-Network Retail Pharmacy (1 month — 31-day supply) |
| In-Network Retail Pharmacy (3 months — 90-day supply) |
| Mail-Order Pharmacy (3 months — 90-day supply) |
| Coverage After You Reach Your Initial Coverage Limit |
| Catastrophic Coverage |
|
| You Pay: |
| $36.80 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $66.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$400 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $91.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% coinsurance for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $196.10 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-of-Network:
Same as In-Network. |
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply.
|
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
|
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-of-Network:
Same as In-Network. |
| You Pay: |
| $44.10 each month |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% coinsurance for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
|
| You Pay: |
| $36.80 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $66.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$400 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $91.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% coinsurance for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $196.10 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-of-Network:
Same as In-Network. |
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply.
|
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
|
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-of-Network:
Same as In-Network. |
| You Pay: |
| $44.10 each month |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% coinsurance for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
|
| You Pay: |
| $36.80 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
| No coverage for routine hearing exams or aids. |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| This plan does not cover Medicare Part D prescription drugs. |
| You Pay: |
| $66.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$250 for each Medicare-covered stay at a network hospital.
$750 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-65.
$0 each day for days 66-100.
$3,000 maximum out-of-pocket limit. |
| $15 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
| $30 for each visit. |
$150 for each visit.
$300 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 FOR CT SCANS, MRIs, MRAs, and PET scans. |
| $0 for preventive screenings and exams. |
| $200 toward the cost of one routine eye exam and eyewear every 2 years. |
$30 copay for one routine hearing test every year.
$30 copay for one hearing aid fitting and evaluation every three years.
$400 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $91.50 each month in addition to your Medicare Part B premium. |
| $3,100 per year for all covered charges. |
| n/a |
| n/a |
$100 for each Medicare-covered stay at a network hospital.
$200 maximum out-of-pocket limit. |
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit. |
| $0 for each visit. |
| $25 for each visit. |
| $15 for each visit. |
| $25 for each visit. |
$60 for each visit.
$120 maximum out-of-pocket limit. |
| $50 for each visit. |
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Certain services require prior authorization. |
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-ray visits.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit. |
| $0 for preventive screenings and exams. |
| $250 toward the cost of one routine eye exam and eyewear every 2 years. |
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% coinsurance for Specialty drugs. |
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
| You Pay: |
| $196.10 each month in addition to your Medicare Part B premium. |
| n/a |
In-Network:
$3,100 per year for all covered charges.
Out-of-Network:
No annual maximum out-of-pocket limit for out-of-network services. |
In-Network:
No annual out-of-pocket deductible for in-network services.
Out-of-Network:
$500 per year. |
In-Network:
$100 for each Medicare-covered stay at a network hospital. $200 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each stay at an out-of-network hospital. |
In-Network:
$0 each day for days 1-15.
$60 each day for days 16-50.
$0 each day for days 51-100.
$2,100 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for services. |
In-Network:
$0 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$15 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$25 for each visit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$60 for each visit.
$120 maximum out-of-pocket limit.
Out-of-Network:
20% of the cost for each visit. |
In-Network:
$50 for each visit.
Out-of-Network:
$50 for each visit. |
In-Network:
20% of the cost for durable medical equipment.
$0 for oxygen / oxygen equipment.
Out-of-Network:
50% of the cost for each item, including oxygen and oxygen equipment.
Certain services require prior authorization. |
In-Network:
$0 for clinical / diagnostic lab services and radiation therapy.
$15 for general x-rays.
$50 for CT scans, MRIs, MRAs, and PET scans.
$200 maximum out-of-pocket limit.
Out-of-Network:
20% for clinical / diagnostic lab services, radiation therapy, and each x-ray. |
In-Network:
$0 for preventive screenings and exams.
Out-of-Network:
20% for preventive screenings and exams. |
In-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years.
Out-of-Network:
$250 toward the cost of one routine eye exam and eyewear every 2 years. |
In-Network:
$25 copay for one routine hearing test every year.
$25 copay for one hearing aid fitting and evaluation every three years.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid).
Out-of-Network:
20% coinsurance for hearing exams.
50% coinsurance for hearing aids.
$1,000 toward the cost of a hearing aid(s) every three years (cannot exceed cost of the hearing aid). |
| Silver&Fit® membership at no additional cost at a participating fitness center. |
| 24-hour worldwide emergency care at no additional cost. |
| A personal Health Care Concierge who, along with his or her team, is dedicated to helping our members understand their benefits. Concierges also aid members in using our new UPMC Resources for Life program, which offers legal and financial assistance services along with telephone counseling and other services to help you manage every day living issues. |
|
In-Network:
$5 for Generic drugs.
$25 for Preferred Brand drugs.
$75 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
Out-of-Network:
Same as In-Network. |
In-Network:
$15 for Generic drugs.
$75 for Preferred Brand drugs.
$225 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply.
|
In-Network:
$12.50 for Generic drugs.
$62.50 for Preferred Brand drugs.
$187.50 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs.
|
In-Network:
$5 for a 31-supply and $15 for a 90-day supply of generic drugs at an in-network retail pharmacy. You pay $12.50 for a 90-day supply of generic drugs through mail order. After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of preferred and non-preferred brand drug costs until you yearly out-of-pocket drug costs reach $4,350.
Out-of-Network:
$5 for a 31-day supply of generic drugs. |
In-Network:
After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance.
Out-of-Network:
Same as In-Network. |
| You Pay: |
| $44.10 each month |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
| n/a |
|
$5 for Generic drugs.
$32 for Preferred Brand drugs.
$80 for Non-Preferred Brand drugs.
33% coinsurance for Specialty drugs. |
$15 for Generic drugs.
$96 for Preferred Brand drugs.
$240 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs up to a 31-day supply. |
$12.50 for Generic drugs.
$80 for Preferred Brand drugs.
$200 for Non-Preferred Brand drugs.
33% of the cost for Specialty drugs. |
| After the total yearly drug costs (paid by both you and our plan) reach $2,700, you pay 100% of your prescription drug costs until your yearly out-of-pocket drugs costs reach $4,350. |
| After your yearly out-of-pocket drug costs reach $4,350, you pay the greater of: $2.40 for generic drugs and $6.00 for all other drugs, or 5% coinsurance. |
|
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 2009 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.
*The products and services described are neither offered nor guaranteed under contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any dispute regarding these products and services may be subject to the UPMC for Life grievance process.
|
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