2022 Berks MA Kit

UPMC for Life PPO Rx Enhanced Out-of-Network (OUT) In-Network (IN) Inpatient: 40% of the cost per stay after deductible; Inpatient: $250 per day for days 1-5 and $0 per day for days 6 and beyond; Mental health services * Outpatient therapy: 40%of the cost after deductible Outpatient therapy: $40 per visit, $35 per telehealth visit 40% of the cost per stay after deductible $0 per day (days 1-20); $160 per day (days 21-100) Skilled nursing facility* Additional Benefits Out-of-Network (OUT) In-Network (IN) Medicare-covered: 40% of the cost per visit after deductible; Medicare-covered: $40 per visit; $0 for two cleanings per year; Dental services 3 50% of the cost for two cleanings per year (deductible does not apply); $15 for two oral exams per year; $15 for one bitewing x-ray per year; $15 for one comprehensive oral exam every 36 months; 50% of the cost for two oral exams per year (deductible does not apply); $15 for one panoramic x-ray every 36 months; 50% of the cost for one bitewing x-ray per year (deductible does not apply); 50% of the cost for one comprehensive oral exam every 36 months (deductible does not apply); 50% of the cost for one panoramic x-ray every 36 months (deductible does not apply); IN/OUT: $1,000 allowance with 50% coinsurance for comprehensive dental services per year (deductible does not apply) Medicare-covered: 40% of the cost after deductible; Medicare-covered: $40 per visit; $0 for one routine vision examevery year Vision services 4 50% of the cost for one routine vision exam every year (deductible does not apply) IN/OUT: $200 allowance for routine contact lenses or eyewear, including lens options, every year (deductible does not apply) * Services with an asterisk (*) may require prior authorization. upmchealthplan.com/medicare 8 PPO Summary of Benefits 45