2022 Beaver Butler Washington MA Kit

UPMC for Life HMO Access Rx Medicare-covered: $35 per visit Podiatry services Routine (4 visits per year): $35 per routine visit Facility and Testing Costs $90 per visit Emergency care $65 per visit Urgently needed services $0 per day per facility Diagnostic services/ labs* Advanced imaging (CT, MRI, and PET scans): $245 per service; Imaging* Basic imaging and X-rays: $25 per service Inpatient: $360 per stay; Mental health services* Outpatient therapy: $35 per visit, $30 per telehealth visit $0 per day (days 1-20); Skilled nursing facility* $184 per day (days 21-100) Additional Benefits Medicare-covered: $35 per visit; Dental services 3 $0 for two cleanings per year; $0 for two oral exams per year; $0 for one bitewing x-ray per year; $0 for one comprehensive oral exam every 36 months; $0 for one panoramic x-ray every 36 months; $3,000 allowance with 50% coinsurance for comprehensive dental services per year with a $50 dental deductible Medicare-covered: $35 per visit; Vision services 4 $0 for one routine vision exam every year; $300 allowance for routine contact lenses or eyewear, including lens options, every year. Medicare-covered: $35 per visit; Hearing services 5 $0 for one hearing exam per year; $0 for one hearing aid fitting every year; $500 allowance for hearing aids every year $40 allowance per quarter to buy health care products. Over-the-counter (mail order catalog) You can customize your plan with a choice of even more coverage for dental, vision, or OTC health care products, You can chooseONE benefit below to enhance when you apply for enrollment: Choice of Supplemental Benefits $600 more for comprehensive dental - $3,600 total per year $100 more for contact lens or eyewear - $400 total per year $10 more for OTC health care products - $50 total per quarter * Services with an asterisk (*) may require prior authorization. upmchealthplan.com/medicare 7 44