2022 Erie Mercer Venango MA Kit

UPMC for Life HMO Premier Rx Medicare-covered: $40 per visit Podiatry services Routine (4 visits per year): $40 per routine visit Facility and Testing Costs $90 per visit Emergency care $65 per visit Urgently needed services $5 per day per facility Diagnostic services/ labs* Advanced imaging (CT, MRI, and PET scans): $200 per service; Imaging* Basic imaging and X-rays: $45 per service Inpatient: $185 per day for days 1-5 and $0 per day for days 6 and beyond; Mental health services* Outpatient therapy: $40 per visit, $35 per telehealth visit $0 per day (days 1-20); Skilled nursing facility* $184 per day (days 21-100) Additional Benefits Medicare-covered: $40 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; $2,500 allowance with 50% coinsurance for comprehensive dental services per year with a $50 dental deductible Medicare-covered: $40 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: $40 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 $50 allowance per quarter to buy health care products. Over-the-counter (mail order catalog) FREE unlimited gym memberships and one FREE personal training session each year at participating fitness facilities as well as the option to work out at home with fitness kits. SilverSneakers ® Keep track of your fitness with one FREE Fitbit every two years and one-year of the Fitbit Premium app for FREE. Activity tracker Download this FREE app for help managing your mental and physical health through personalized programs, guided activities, and support from a live health coach. RxWell upmchealthplan.com/medicare 7 28 * Services with an asterisk (*) may require prior authorization.