2022 Berks MA Kit

UPMC for Life PPO Rx Enhanced Out-of-Network (OUT) In-Network (IN) IN: $0 per service; for your annual wellness visit, preventive screenings, and flu and pneumonia vaccines Preventive care OUT: 40% of the cost per service (deductible does not apply) 40% of the cost after deductible $40 per visit Physical therapy* 40% of the cost after deductible $50 for treat and no transport; Ambulance* $200 per one-way trip 40% of the cost after deductible 20% of the cost Medicare Part B drugs* 50% of the cost per item (deductible does not apply) 18% of the cost per item Durable medical equipment* 50% of the cost per item after deductible 20% of the cost per item (limited to specific suppliers, products, and brands. Quantity limits apply.) Diabetes supplies Medicare-covered: 40% of the cost after deductible; Medicare-covered: Tier 1: $18 per service Tier 2: $20 per service; Chiropractic care* 2 Routine (8 visits per year): 40% of the cost (deductible does not apply) Routine (8 visits per year): Tier 1: $18 per service Tier 2: $20 per service Medicare-covered: 40% of the cost after deductible; Medicare-covered: $40 per visit; Podiatry services Routine (8 visits per year): Routine (8 visits per year): 40% of the cost per routine visit (deductible does not apply) $40 per routine visit Facility and Testing Costs Out-of-Network (OUT) In-Network (IN) IN/OUT: $90 per visit (deductible does not apply) Emergency care IN/OUT: $65 per visit (deductible does not apply) Urgentlyneededservices 40% of the cost after deductible $5 per day per facility Diagnostic services/ labs* Advanced imaging (CT, MRI, and PET scans): 40% of the cost after deductible; Advanced imaging (CT, MRI, and PET scans): $150 per service; Basic imaging and X-rays: $20 per service Imaging* Basic imaging and X-rays: 40% of the cost after deductible upmchealthplan.com/medicare 7 44