2022 Erie Mercer Venango MA Kit

UPMC for Life HMO Premier Rx (HMO) BENEFIT $0 per month Plan premium Yes, Formulary 1 Prescription drug coverage $0 per visit Primary care provider (PCP) $40 per visit Specialist PCP: $0 per visit; Telehealth Specialist: $35 per visit $185 per day (days 1-5); Inpatient hospital and inpatient mental health $0 per day (days 6-90) $350 per surgery Outpatient surgery $0 per day (days 1-20); Skilled nursing facility $184 per day (days 21-100) $90 per visit Emergency care $65 per visit Urgent care $40 per visit Physical therapy $5 per day per facility Lab services $45 per service X-rays $200 per service Advanced imaging (CT, MRI, and PET scans) 20% of the cost per item Durable medical equipment 20% of the cost per item Diabetes supplies No deductible Annual deductible $7,550 for Medicare-covered services, including Maximum out-of-pocket Your out-of-pocket spending limit for the year— this is not a deductible copays and coinsurance $0 for one hearing exam per year; Hearing 2 $0 for one hearing aid fitting per year; $500 allowance for hearing aids per year $0 for two oral exams and cleanings per year; Dental 3 $0 for one bitewing x-ray per year; $0 for one panoramic x-ray every 36 months; $2,500 maximum comprehensive dental allowance with $50 deductible and 50% coinsurance per year $0 for one routine vision exam per year; Vision 4 $300 allowance for contact lenses or eyewear (all lens types) per year $50 allowance per quarter Over-the-counter (OTC) mail-order catalog 5