2022 Lycoming Tioga MA Kit

UPMC for Life PPO Flex Rx (PPO) BENEFIT $0 per month Plan premium Yes, Formulary 1 Prescription drug coverage IN: $0 per visit; Primary care provider (PCP) OUT: 30% per visit after deductible IN: $30 per visit; Specialist OUT: 30% per visit after deductible IN: PCP: $0 per visit; Telehealth Specialist: $25 per visit; OUT: Not covered IN: $400 per stay; Inpatient hospital and inpatient mental health OUT: 30% per stay after deductible IN: $275 per surgery; Outpatient surgery OUT: 30% per surgery after deductible IN: $0 per day (days 1-20) and $184 per day (days 21-100); Skilled nursing facility OUT: 30% of the cost per stay after deductible IN/OUT: $90 per visit (deductible does not apply) Emergency care IN/OUT: $65 per visit (deductible does not apply) Urgent care IN: $30 per visit; Physical therapy OUT: 30% of the cost after deductible IN: $10 per day per facility; Lab services OUT: 30% of the cost after deductible IN: $30 per service; X-rays OUT: 30% of the cost after deductible IN: $275 per service; Advanced imaging (CT, MRI, and PET scans) OUT: 30% of the cost after deductible IN: 20% of the cost per item; Durable medical equipment OUT: 30% of the cost (deductible does not apply) IN: 20% of the cost per item; Diabetes supplies OUT: 30% of the cost after deductible IN: No deductible; Annual deductible OUT: $400 for applicable services IN: $7,550 for Medicare-covered services, including copays and coinsurance; IN/OUT: $11,300 for Medicare-covered services, including copays and coinsurance Maximum out-of-pocket Your out-of-pocket spending limit for the year— this is not a deductible IN: $0 for one hearing exam per year and Hearing 2 $0 for one hearing aid fitting per year; OUT: 30% of the cost; IN/OUT: $500 allowance for hearing aids per year (deductible does not apply) IN: $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; OUT: 30% of the cost (deductible does not apply); IN/OUT: $2,500 maximum comprehensive dental allowance with $50 deductible and 50% coinsurance per year IN: $0 for one routine vision exam per year; Vision 4 OUT: 30% of the cost for one routine vision exam per year; IN/OUT: $150 allowance for contact lenses or eyewear (all lens types) per year (deductible does not apply) $50 allowance per quarter Over-the-counter (OTC) mail-order catalog 5