2022 Cumberland Dauphin Lancaste York MA Kit

UPMC for Life HMO Deductible Rx (HMO) UPMC for Life HMO Premier Rx (HMO) $22 per month $0 per month Yes, Formulary 2 Yes, Formulary 1 $0 per visit (deductible does not apply) $0 per visit $35 per visit (deductible does not apply) $40 per visit PCP: $0 per visit; PCP: $0 per visit; Specialist: $30 per visit (deductible does not apply) Specialist: $35 per visit $300 per stay after deductible $205 per day (days 1-6); $0 per day (days 7-90) $125 per surgery after deductible $350 per surgery $0 per day (days 1-20); $0 per day (days 1-20); $172 per day (days 21-100) (deductible does not apply) $160 per day (days 21-100) $90 per visit (deductible does not apply) $90 per visit $65 per visit (deductible does not apply) $65 per visit $0 per visit after deductible $40 per visit $10 per day per facility (deductible does not apply) $10 per day per facility $20 per service after deductible $50 per service $200 per service after deductible $140 per service $0 per item (deductible does not apply) 20% of the cost per item 20% of the cost per item after deductible 20% of the cost per item $750 for applicable services No deductible $7,550 for Medicare-covered services, including $7,550 for Medicare-covered services, including copays and coinsurance copays and coinsurance $20 for one hearing exam per year; $0 for one hearing exam per year; $20 for one hearing aid fitting per year; $0 for one hearing aid fitting every three years; $100 allowance for hearing aids per year $1,500 allowance for hearing aids every three years (deductible does not apply) $0 for two oral exams and cleanings per year; $0 for two oral exams and cleanings per year; $0 for one bitewing x-ray per year; $0 for one bitewing x-ray per year; $0 for one panoramic x-ray every 36 months; $0 for one panoramic x-ray every 36 months; $1,250 maximum comprehensive dental allowance with 50% coinsurance per year $250 allowance for dental services like fillings and simple tooth extractions per year (deductible does not apply) $0 for one routine vision exam every two years; $0 for one routine vision exam per year; $100 allowance for contact lenses or eyewear (all lens types) every two years (deductible does not apply) $150 allowance for contact lenses or eyewear (all lens types) per year $25 allowance per quarter Not covered