2022 Erie Mercer Venango MA Kit

UPMC for Life HMO Salute (HMO) UPMC for Life HMO Rx (HMO) $0 per month; $50 Part B premium reduction per month $81 per month No prescription drug coverage Yes, Formulary 2 $20 per visit $0 per visit $50 per visit $35 per visit PCP: $15 per visit; PCP: $0 per visit; Specialist: $45 per visit Specialist: $30 per visit $250 per day (days 1-7); $295 per stay $0 per day (days 8-90) $275 per surgery $225 per surgery $0 per day (days 1-20); $0 per day (days 1-20); $184 per day (days 21-100) $100 per day (days 21-100) $90 per visit $90 per visit $50 per visit $65 per visit $40 per visit $35 per visit $5 per day per facility $5 per day per facility $30 per service $35 per service $250 per service $200 per service 20% of the cost per item 20% of the cost per item 20% of the cost per item 20% of the cost per item No deductible No deductible $6,700 for Medicare-covered services, including $7,550 for Medicare-covered services, including copays and coinsurance copays and coinsurance $0 for one hearing exam per year; No routine hearing benefits $0 for one hearing aid fitting per year; $1,000 allowance for hearing aids per year $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; $3,000 maximum comprehensive dental allowance with $50 deductible and 50% coinsurance per year $3,000 maximum comprehensive dental allowance with 50% coinsurance per year $0 for one routine vision exam per year; $0 for one routine vision exam every two years; $300 allowance for contact lenses or eyewear (all lens types) per year $200 allowance for contact lenses or eyewear (all lens types) every two years $50 allowance per quarter $50 allowance per quarter